All posts in Arthritis

Acoustic Wave Therapy – Hip & Groin Pain

Hip and groin pain are among the more common problems I see in my practice.

‘Sports hernia’, sacroiliac joint dysfunction, adductor muscle strain, hip osteoarthritis and impingement syndrome are all common diagnosis patients present with. Before presenting to me some patients have tried cortisone shots, platelet-rich plasma (PRP) injections, stem cell injection, physical therapy and exercise.

It is not unusual to find the pain or symptoms in the hip and groin pain being referred pain from the lumbar spine, lower abdomen, and pelvis 1, 2, 3. Figuring this out is all part of making the proper diagnosis.

I will sit and talk to my patients and get a good history, provide a quality physical examination, identify pain causing generators, and come up with a working diagnosis.

Here is what the research tells us:
• The pain at the front of the hip and groin pain is commonly associated with osteoarthritis and hip labral tears.
• Rear hip pain is associated with piriformis syndrome, sacroiliac joint dysfunction, lumbar radiculopathy, and less commonly ischiofemoral impingement and vascular claudication.
• Lateral hip pain occurs with greater trochanteric pain syndrome.4
• Patients may also have hip and groin back from a herniated disc without back pain.5
• I often see tight hips that cause low back pain 6

The beneficial effects of Acoustic therapy for the above conditions are often experienced after only 3-6 treatments. Acoustic therapy is safe and non-invasive.
Please call the office at 310-444-9393 for more information.

1 Tan EW, Schon LC. Mesenchymal Stem Cell-Bearing Sutures for Tendon Repair and Healing in the Foot and Ankle. Foot Ankle Clin. 2016 Dec;21(4):885-890. doi: 10.1016/j.fcl.2016.07.015.
1 St-Onge E, MacIntyre IG, Galea AM. Multidisciplinary approach to non-surgical management of inguinal disruption in a professional hockey player treated with platelet-rich plasma, manual therapy and exercise: a case report. The Journal of the Canadian Chiropractic Association. 2015;59(4):390-397.
2. McSweeney SE, Naraghi A, Salonen D, Theodoropoulos J, White LM. Hip and groin pain in the professional athlete. Can Assoc Radiol J. 2012 May;63(2):87-99.
3. Holmich P, Dienst M. Differential diagnosis of hip and groin pain. Symptoms and technique for physical examination. Orthopade. 2006 Jan;35(1):8, 10-5.
4. Wilson JJ, Furukawa M. Evaluation of the patient with hip pain. Am Fam Physician. 2014 Jan 1;89(1):27-34.
5. Oikawa Y et al. Lumbar disc degeneration induces persistent groin pain. Spine (Phila Pa 1976). 2012 Jan 15;37(2):114-8. doi: 10.1097/BRS.0b013e318210e6b5.
6. Suarez JC, Ely EE, Mutnal AB, Figueroa NM, Klika AK, Patel PD, Barsoum WK. Comprehensive approach to the evaluation of groin pain.J Am Acad Orthop Surg. 2013 Sep;21(9):558-70. doi: 10.5435/JAAOS-21-09-558.

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EPAT Shockwave – Los Angeles

If you’re suffering from a soft tissue ailment or looking for an alternative, holistic approach to pain reduction, and want overall healthy joint aging, EPAT shockwave and laser may be an effective option. Dr. Jeffrey Tucker says “The results from EPAT (shockwave) and laser are promising for acute pain, chronic pain conditions and regenerative medicine.”

Frequently asked questions about EPAT:

Is deep tissue massage similar to EPAT Shockwave? No, EPAT shockwave penetrates much deeper than hands can get. EPAT goes beyond muscles treating the underside of muscles, bones, and joints to work on a deeper level.

EPAT Shock wave sessions usually last thirty minutes! True, they normally take about 20-30 minutes depending on the number of impulses and the number of areas we are intending to apply to a given area.

Some patients describe the EPAT as a ‘Jack hammer’. Why? The overall feeling is a combination of gliding, kneading, percussion, vibration, deep friction massage, and rolling of the soft tissue and joints.

EPAT is often used in combination with other therapies including laser, deep muscle stimulator (DMS) and cupping.

Like most massage, EPAT is traditionally practiced on exposed skin surfaces. You should wear loose, comfortable clothing to ensure the doctor can have skin exposure and be able to move your joints through the full range of motion. During EPAT therapy, ultrasound gel is used on treatment surfaces.

Dr. Tucker’s philosophy treats patients holistically, focusing on physical, mental, nutritional and healthy aging wellness. “I help achieve joint and muscle balance using a blend of modern technology like the Deep Muscle Stimulator (DMS), Laser, EPAT (shock wave) and therapies that have stood the test of time like cupping and transverse friction massage.

“I have every intention of helping patients detect and correct where they may be blocking recovery by mental and physical tension, bad habits, and the poor health they showed up with if that is the case.”

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Hip & Low Back pain

In a recent study in the journal PMR, (June 2017) a Washington University School of Medicine team found links between the hip and the spine affecting pain and function. The key finding was that hip disease, before it was even evident on an MRI as osteoarthritis, could cause problems in the lower back.The hip was the true disguised pain generator in back pain patients. This is no surprise to me and my patients. Every patient in my office has had a hip evaluation if they present with low back pain. This truly is a case where the science is catching up with what active practitioners have known for years.

What is this research telling us? If you had an MRI of your hip, and nothing presented itself as obvious, then the doctor may chase something in the spine that is not causing the pain.

The link that the researchers are still missing is that tight and immobile hips cause increased dysfunctional motion in the lower lumbar spine and this causes excess rubbing and irritation in the low back.

The same team of researchers, publishing earlier in February 2017 were also able to conclude that physical examination findings indicating hip osteoarthritis (loss of range of motion and acute pain) are common in patients who also have low back pain. A patient presenting with low back pain should be examined for hip osteoarthritis).2

1 Prather H, Cheng A, May KS, Maheshwari V, VanDillen L. Association of Hip Radiograph Findings with Pain and Function in Patients Presenting with Low Back Pain. PM&R. 2017 Jun 16.

2. Prather H, Cheng A, May KS, Maheshwari V, VanDillen L. Hip and Lumbar Spine Physical Examination Findings in People Presenting With Low Back Pain With or Without Lower Extremity Pain. J Orthop Sports Phys Ther. 2017 Feb 3:1-36. doi: 10.2519/jospt.2017.6567.

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Is Sockwave therapy and laser therapy the right treatment for damaged discs and bulges?

Both Shockwave and laser help damaged disc and bulges by:

  • Stem cell activation: Stem cells are effective in inhibiting disc degeneration and disc herniation. It’s a pretty complex interplay between the stem cells and the immune system cells but the result can be disc tissue regeneration.
  • Stem cell activation: This will promote regeneration of the outer tissue of the disc and help contain and lessen the bulge (scar tissue formation).
  • Stem cell activation:The increased number of cells to the area brings more oxygen to the damaged disc and accelerates healing by reversing the low-oxygen (degenerative or dying) environment in the spine. Everything heals better and faster with increased oxygen.
  • Stem cell activation reduces and prevents herniation by suppressing the non-healing inflammation.

Office phone 310-444-9393

References: Cunha C, Almeida CR, Almeida MI, Silva AM, Molinos M, Lamas S, Pereira CL, Teixeira GQ, Monteiro AT, Santos SG, Gonçalves RM, Barbosa MA. Systemic Delivery  of Bone Marrow Mesenchymal Stem Cells for In Situ Intervertebral Disc Regeneration. Stem Cells Transl Med. 2016 Oct 11. pii: sctm.2016-0033.

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Knee Osteoarthritis – Brentwood Chiropractor

  • Arthroscopy Journal 2015 – doctors concluded that PRP injections are a viable treatment for knee osteoarthritis and should be considered in patients with knee osteoarthritis.6 Studies like these add to the accumulating evidence that PRP can halt and reverse meniscus degeneration.7,8
  • J Orthop Res. 2016 – doctors confirm that stem cell therapy stimulates the regeneration of meniscal tissue. Specifically with regard to post-meniscectomy meniscus growth (with stem cells).9 This means we can use the PIEZOWAVE and EnPuls to stimulate regeneration even after surgery.
  • Doctors at the University of Iowa found that stem cells and cartilage cells could be influenced to migrate to the site of “white-zone” where the most difficult meniscus tears are. I use Laser therapy, PiezoWave Pulse Therapy and EnPuls shockwave to do just that!
  • I do think stimulating the tissues with PiezoWave and EnPuls shockwave can promote regeneration and is a promising new strategy in meniscus repair.10
  • Stimulating stem cell based strategies for meniscus tissue is a fundamental role in meniscal regeneration.
  1. Pihl K, Roos EM, Nissen N, JøRgensen U, Schjerning J, Thorlund JB. Over-optimistic patient expectations of recovery and leisure activities after arthroscopic meniscus surgery. Acta Orthop. 2016 Sep 13:1-7.
  2. Brelin AM, Rue JP. Return to Play Following Meniscus Surgery. Clin Sports Med. 2016 Oct;35(4):669-78. doi: 10.1016/j.csm.2016.05.010. Epub 2016 Jul 9. Review.
  3. Noyes FR, Barber-Westin SD. Long-term Survivorship and Function of Meniscus Transplantation. Am J Sports Med. 2016 Sep;44(9):2330-8.
  4. Niu W, Guo W, Han S, Zhu Y, Liu S, Guo Q. Cell-Based Strategies for Meniscus Tissue Engineering. Stem Cells International. 2016;2016:4717184. doi:10.1155/2016/4717184.
  5. Blanke F, Vavken P, Haenle M, von Wehren L, Pagenstert G, Majewski M. Percutaneous injections of Platelet rich plasma for treatment of intrasubstance meniscal lesions. Muscles Ligaments Tendons J. 2015 Oct 20;5(3):162-166.
  6. Campbell KA, Saltzman BM, Mascarenhas R, Khair MM, Verma NN, Bach BR Jr, Cole BJ. A Systematic Review of Overlapping Meta-analyses. Arthroscopy. 2015 Nov;31(11):2213-21. doi: 10.1016/j.arthro.2015.03.041. Epub 2015 May 29.
  7. Wu CC, Chen WH, Zao B, Lai PL, Lin TC, Lo HY, Shieh YH, Wu CH, Deng WP. Regenerative potentials of platelet-rich plasma enhanced by collagen in retrieving pro-inflammatory cytokine-inhibited chondrogenesis. Biomaterials. 2011 Sep;32(25):5847-54. Epub 2011 May 25.
  8. van Buul GM, et al. Platelet-Rich Plasma Releasate Inhibits Inflammatory Processes in Osteoarthritic Chondrocytes. Am J Sports Med. 2011 Nov;39(11):2362-70. Epub 2011 Aug 19.
  9. Seol D, Zhou C, Brouillette MJ, Song I, Yu Y, Choe HH, Lehman AD, Jang KW, Fredericks DC, Laughlin BJ, Martin JA. Characteristics of meniscus progenitor cells migrated from injured meniscus. J Orthop Res. 2016 Nov 3. doi: 10.1002/jor.23472.
  10. McCrum CL, Vangsness CT. Postmeniscectomy Meniscus Growth With Stem Cells: Where Are We Now? Sports Med Arthrosc. 2015 Sep;23(3):139-42.  PUBMED Meniscus Growth With Stem Cells
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Shockwave Therapy for Knee Pain

  • Arthroscopy Journal, doctors concluded that PRP injections are a viable treatment for knee osteoarthritis and should be considered in patients with knee osteoarthritis.6 Studies like these add to the accumulating evidence that PRP can halt and reverse meniscus degeneration.7,8
  • J Orthop Res. 2016 Nov 3. doi: 10.1002/jor.23472 they confirm that stem cell therapy stimulates the regeneration of meniscal tissue. Specifically with regard to post-meniscectomy meniscus growth (with stem cells).9 This means we can use the PIEZOWAVE and EnPuls to stimulate regeneration even after surgery.
  • Doctors at the University of Iowa found that stem cells and cartilage cells could be influenced to migrate to the site of “white-zone” where the most difficult meniscus tears are. I use Laser and PiezoWave and EnPuls to do just that!
  • I do think stimulating the tissues with PiezoWave and EnPuls shockwave can promote regeneration and is a promising new strategy in meniscus repair.10
  • Stimulating stem cell based strategies for meniscus tissue is a fundamental role in meniscal regeneration. 11
  1. Campbell KA, Saltzman BM, Mascarenhas R, Khair MM, Verma NN, Bach BR Jr, Cole BJ. A Systematic Review of Overlapping Meta-analyses. Arthroscopy. 2015 Nov;31(11):2213-21. doi: 10.1016/j.arthro.2015.03.041. Epub 2015 May 29.
  2. Wu CC, Chen WH, Zao B, Lai PL, Lin TC, Lo HY, Shieh YH, Wu CH, Deng WP. Regenerative potentials of platelet-rich plasma enhanced by collagen in retrieving pro-inflammatory cytokine-inhibited chondrogenesis. Biomaterials. 2011 Sep;32(25):5847-54. Epub 2011 May 25.
  3. van Buul GM, et al. Platelet-Rich Plasma Releasate Inhibits Inflammatory Processes in Osteoarthritic Chondrocytes. Am J Sports Med. 2011 Nov;39(11):2362-70. Epub 2011 Aug 19.
  4. Seol D, Zhou C, Brouillette MJ, Song I, Yu Y, Choe HH, Lehman AD, Jang KW, Fredericks DC, Laughlin BJ, Martin JA. Characteristics of meniscus progenitor cells migrated from injured meniscus. J Orthop Res. 2016 Nov 3. doi: 10.1002/jor.23472.
  5. McCrum CL, Vangsness CT. Postmeniscectomy Meniscus Growth With Stem Cells: Where Are We Now? Sports Med Arthrosc. 2015 Sep;23(3):139-42.  PUBMED Meniscus Growth With Stem Cells
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Meniscus Tears – Research suggests the ‘White Zone’ can heal (Los Angeles Chiropractor)

 

  • FACT: Regeneration of meniscus and cartilage is difficult to heal especially in the ‘white zone’ where there is a lack of blood vessels and therefore deprives the meniscus of healing nutrients and oxygen.
  • FACT: Stem cell injections and PRP injection treatments are in the infancy stages of research. These treatment options are as controversial as surgery.
    • New York Times, Dr. Gordon H. Guyatt, a professor of medicine at McMaster University in Hamilton, Ontario states: Meniscus surgery is expensive and has potential complications (British Medical Journal even agrees with this).
    • FACT: I want patients to return to sport or leisure activity as fast as possible.
    • Researchers in Denmark have published: “patients undergoing arthroscopic meniscus surgery were too optimistic regarding their recovery time and postoperative participation in leisure activities. This highlights the need for shared decision making which should include giving the patient information on realistic expectations of recovery time and regarding participation in leisure-time activities after meniscal surgery.”1
  • Can PIEZOWAVE Pulse Therapy and ENPULS Radial Shockwave Therapy regrow meniscus tissue? What about stem cell therapy and PRP? Is one more successful at treating meniscal damage? All of these treatments are very promising! I have not seen 80-100% predictable positive clinical outcomes yet with any of these! So far I see stimulation of stem cells (either non-invasive therapy or injections) as promising for meniscus repair and regeneration.4
  • We need more University and Hospital based studies to confirm this trend.
  • Again, everyone agrees that Meniscus injuries remain a significant challenge due to the poor healing potential of the inner avascular zone (the inner portion of the meniscus that lacks a blood supply).
  • I use the non-invasive and less expensive EnPuls and PiezoWave therapy instead of PRP to achieve pain relief and attempt to halt the progression of meniscal damage. More time and research is required to see if this is the way to regenerate tissue.5
  1. Pihl K, Roos EM, Nissen N, JøRgensen U, Schjerning J, Thorlund JB. Over-optimistic patient expectations of recovery and leisure activities after arthroscopic meniscus surgery. Acta Orthop. 2016 Sep 13:1-7.
  2. Brelin AM, Rue JP. Return to Play Following Meniscus Surgery. Clin Sports Med. 2016 Oct;35(4):669-78. doi: 10.1016/j.csm.2016.05.010. Epub 2016 Jul 9. Review.
  3. Noyes FR, Barber-Westin SD. Long-term Survivorship and Function of Meniscus Transplantation. Am J Sports Med. 2016 Sep;44(9):2330-8.
  4. Niu W, Guo W, Han S, Zhu Y, Liu S, Guo Q. Cell-Based Strategies for Meniscus Tissue Engineering. Stem Cells International. 2016;2016:4717184. doi:10.1155/2016/4717184.
  5. Blanke F, Vavken P, Haenle M, von Wehren L, Pagenstert G, Majewski M. Percutaneous injections of Platelet rich plasma for treatment of intrasubstance meniscal lesions. Muscles Ligaments Tendons J. 2015 Oct 20;5(3):162-166.
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Degenerative Disc Disease – Shockwave Treatments

Shock wave or radial pulse therapy (PiezoWave, EnPuls) is effective in “kick-starting” the healing process to treat degenerative disc disease. Radial (EnPuls) and acoustic (PiezoWave) pulse waves have been used for Achilles tendinopathy, plantar fasciitis, calf strains, and even cellulite. Pulse wave therapy is non-invasive and stronger than percussion treatments such as the Deep Muscle Stimulator (DMS). By stimulating the skin and muscles adjacent to the spine with pulse wave therapy we are doing two things 1) breaking up tight spasm and hard fibrotic tissue, 2) releasing the spasm allows the paraspinal muscles to be less dampened and work more efficiently again. In this way regeneration begins because the discs are indirectly treated and the discs show an increase in disc height.

Exercise is used along with the PiezoWave or EnPuls impulse treatment to address the problems of spinal ligament instability. The sooner you catch the degeneration, the better the results with pulse wave treatment and exercise. Stability exercise training has a protective effect on damaged discs. In the acute phase we may start with the pulse therapy and or laser to decrease the pain and inflammation. Dr. Tucker uses various isometric exercises in his practice. Clinical outcomes and patient satisfaction with these types of treatments is very high. We can use this model of therapy in the early treatment phase and in late stages of the degenerative process. “Earlier intervention in the disease process is more beneficial than later treatment of an already severely degenerated discs”, says Tucker.

“I think most people understand the repair process that the body naturally goes through after an injury but they do not understand how the body can also regenerate a degenerated discs”.  These newer treatments (PiezoWave, EnPuls, and Lasers) are able to recover the mechanical properties of denatured discs, thereby providing a promising effective therapeutic modality.

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Disc Pain: Non-invasive therapy

Does shockwave therapy such as EnPuls and PiezoWave stimulate stem cells in inhibiting disc degeneration and disc herniation? The research and my clinical experience suggest the answer is ‘Yes’. Stem cells can be injected into the area of local damage but this is invasive and costly. We are using EnPuls and PiezoWave pulse therapy and laser (all non-invasive) to stimulate stem cells to interact with the local stem cells and immune system cells to achieve successful disc pain relief and tissue regeneration.

 

The current theory is that the combination of these non-invasive deep tissue treatments stimulates stem cells that are able to bring more oxygen to the damaged disc and accelerate healing by reversing the low-oxygen (degenerative or dying) environment in the spine. Also inflammation comes in many forms. To keep it simple one type is healing and another type is non-healing inflammation. Research supports stem cells are able to reduce or prevent herniation by suppressing the non-healing inflammation.

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Stem Cell Therapy Alternatives

Here’s what we think is happening when a shock wave and laser treatment is applied to a damaged joint causing you (in your joints):

  • Stem cell stimulation occurs which sends signals to the local stem cells and other growth factors to regroup and begin repairing damaged joints.
  • Mesenchymal stem cell (MSCs – connective tissue stem cells) suppress inflammatory T–cell proliferation and provide anti-inflammatory effects. Applying these (Piezo Wave, EnPuls, TheraLase, Light Force) treatment modalities inhibits damaging chronic inflammation.
  • Mesenchymal stem cells express various growth factors – these are active molecules that stimulate local tissue repair. These growth factors, and the direct cell to cell contact between MSCs and chondrocytes (the present remaining cartilage cells in the joint), have been observed to influence chondrogenic differentiation and cartilage matrix formation – in simple terms – stem cells regenerated cartilage.

Can shock wave repair disc lesions and other degenerated joints? We are seeing clinical outcomes that suggest it does. Do I think you should try this before more expensive and risky injections of stem cells? The answer is Yes!

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