What do you do if you have continued pain after ROTATOR CUFF SURGERY
Continued shoulder pain even after a surgery for tears does happen. When complaints persist and have become an unresolved shoulder pain, I am called upon to help patients make decisions what to do next. Helping patients learn about the available treatment options and understand their choices is a discussion that needs to take place. When I discuss Rotator cuff surgery I refer to Lädermann A, et al. from the University Hospitals of Geneva. They state that “Tear recurrence can be related to various factors such as:
(1) Inadequate strength of the initial repair construct
(2) Biological failure to heal despite strong initial fixation (hardware and suture) and
(3) inappropriate postoperative rehabilitation causing structural failure of the repair” (1).
We always hope for good outcomes after a surgery but “The results of (rotator cuff) treatment are not as predictable as the patient (family, trainer, coach and doctor) would like to think” says Nickolas G et al. in the Physical Medicine and Rehabilitation Clinics of North America journal.
I talk to patients about the concept of cellular communication and how there could be a breakdown in the local tissue area and even the brain to stimulate proper healing. We have learned that certain therapies such as stem cell injections, shockwave, and laser can seem to jump start a non-healing area within a damaged shoulder or knee joint. The current thinking is that these therapies change the joint environment from non-healing (diseased) to healing by signaling the local native resident healing cells to get ready to rebuild.
How, can I as a Chiropractor change the joint environment from not healing to healing and working better?
- By inducing gentle non-painful motion into a poorly functioning joint.
- By re-awakening stem cells to change (plasticity) and activate (multipotency – the ability to change/morph into other cell types and multiply). I use shockwave to do this.
- Get the surrounding healthy cells to send signals to suppress inflammatory T–cell proliferation (inflammation) and provide an anti-inflammatory effect. I use laser to do this.
Maybe the above 3 points help activate stem cells to express various growth factors – it takes a lot of reawakening of molecules to stimulate local tissue repair. I like the concept of getting cells to communicate directly cell to cell (even to the resident remaining cartilage cells) in the joint. Seol et al did a study to show that stem cell activation regenerated cartilage in knees, why not the shoulders! (3)
- Lädermann A, Denard PJ, Burkhart SS. Management of failed rotator cuff repair: a systematic review. Journal of Isakos. 2016;1(1):32-37. doi:10.1136/jisakos-2015-000027.
- Nickolas G. Garbis, Edward G. McFarland. Understanding and Evaluating Shoulder Pain in the Throwing Athlete. Physical Medicine and Rehabilitation Clinics of North America, 2014; 25 (4): 735 DOI:10.1016/j.pmr.2014.06.009
- Seol D, Zhou C, et al. Characteristics of meniscus progenitor cells migrated from injured meniscus. J Orthop Res. 2016 Nov 3. doi: 10.1002/jor.23472.
Can you stop the pain of diabetic peripheral neuropathy? It is worth doing a trial of laser and vitamin B12. Both are safe and effective treatments.
B12 supplements are known as one of the easiest and safest ways to help relieve this problem – could utilizing laser coupled with supplements increase the results?
Julie Waldfogel, a Johns Hopkins doctor of pharmacy, authored a paper specifically referring to those diabetics who suffer from the excruciating shooting and burning pain of peripheral neuropathy – here’s what we know: The common drugs prescribed for neuropathy come with some serious side effects.
Duloxetene (better known as Cymbalta) also used to treat fibromyalgia, can cause difficulty breathing, swelling of your face, lips, tongue, or throat, anxiety and panic attacks, depression and suicidal thoughts.
Pregabalin, which goes under the brand name Lyrica and is already prescribed for nerve pain from shingles and diabetes, can cause things such as agitation, aggression, and “dangerous impulses.” As if that wasn’t enough, some of the more common side effects are dizziness, blurry vision, weight gain, and swelling of your hands and feet. It has also been linked to the development of blood vessel tumors.
Duloxetene and venlafaxine are said to potentially increase serotonin levels in the blood — something that can be life-threatening.
On the good side, Vitamin B12 is non-toxic, and has been proven to be effective in helping diabetics with this kind of nerve pain. Doctors learn in medical school that a classic symptom of a B12 deficiency is peripheral neuropathy! And guess what has been found to be “unequivocally demonstrated as the prime factor” linked to a B12 deficiency? None other than the popular diabetes medication called metformin.
A study done at Bethesda Diabetes Research Center in the Netherlands, found using metformin could increase the risk of a B12 deficiency by 19 percent. On top of that, around 25 percent of people in the U.S. are deficient in B12, whether they’re diabetic or not.
Another group of drugs draining your B12 are the acid-suppressing meds called proton pump inhibitors (PPI) like Nexium and Prilosec. So, if you have neuropathy please get your B12 levels checked and make sure you don’t have B12 deficiency. If you’ve been on metformin for any length of time, or have been taking one of those PPI drugs, it makes perfect sense to have your B12 levels checked.
And since we know there is plenty of research that laser helps peripheral neuropathy, do a trial of the TheraLase class 3B laser on the feet, legs and lower lumbar spine. It makes sense to take a B12 supplement and try the TheraLase laser!
Dr. Tucker is the first Chiropractor to use virtual reality (VR) in a private practice setting. This demonstrates his willingness to embrace new technology and constantly look for new pain relief strategies. VR offers an immersive, realistic, three-dimensional experience that patients describe as pleasant and capable of reducing pain and anxiety. VR is feasible, tolerated, and well-liked by patients, especially for breathing exercises and relaxation.
Dr. Tucker is a Los Angeles based Chiropractor who sees this emerging technology for his patients in acute and chronic pain. Use of VR has been researched in Cedars Sinai Hospital Los Angeles and has been shown to help reduce pain and is a controlled distraction. VR is an effective and safe therapy for pain management. Call 310-444-9393 to make an appointment and find out if VR can help your care.
Chronic low back pain is the most common and important clinical, social, economic, and public health problem of all chronic disorders. There is a need for improvement to help reduce chronic pain and learn how to manage it. Contemporary pain neuroscience that I use to help persistent chronic low back pain includes
- Identification of central nervous system pain (brain memories of pain) vs actual lower back region pain
- Decreasing chronic inflammation in the body and in the brain itself (Glia cell activation or gliopathy) using laser therapy, extracorporal shockwave therapy and nutrition;
- Improving sleep (poor sleep can increase pain and anxiety);
- Optimize gentle movement therapy to your capacity
My main goals for you include decreasing pain, improvements in coping with pain symptoms, decrease the threatening nature of pain, anxiety, and cognitive speed. I am a specialist in teaching patients how to move again without that “dangerous’ or fear-memory taking over.
If you suffer from chronic low back pain feel free to call for an appointment at 310-444-9393
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.”
In this study patients with chronic low back pain who followed cognitive intervention and exercise programs (versus surgery) improved signi?cantly in muscle strength compared with patients who underwent lumbar fusion. In the lumbar fusion group, muscle density (meaning ‘weak muscles’) decreased signi?cantly at L3–L4 compared with the exercise group.1
In addition to exercise therapy for chronic low back pain, current treatments include laser therapy and shockwave therapy for spinal problems, especially when scar tissue has formed. If you have damaged spinal ligaments causing spinal instability or ‘Enthesopathy’ (areas of irritable ligament attachment to bone) a trial of exercise and laser is highly recommended.
Dr. Jeffrey Tucker has created new treatments combining laser therapy, shockwave therapy and exercise to stimulate stem cell activity. Most up-to-date doctors agree that treating back pain patients with conservative care is better than injections or surgery. Doctors that understand how to treat chronic low back pain such as degenerative disc disease, address the problems of spinal ligament instability and scar tissue formation by stimulating the body’s natural ability to regenerate the discs indirectly – decrease spinal stiffness, increase paraspinal muscle activation/strength, and increase hydration in the discs.2 This approach helps decrease pain in the low back.
Please feel free to call my office for a consultation 310-444-9393
- Keller A, Brox JI, Gunderson R, Holm I, Friis A, Reikerås O. Trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain randomized to lumbar fusion or cognitive intervention and exercises. Spine (Phila Pa 1976). 2004 Jan 1;29(1):3-8.
- Röllinghoff M, Schlüter-Brust K, Groos D, et al. Mid-range outcomes in 64 consecutive cases of multilevel fusion for degenerative diseases of the lumbar spine. Orthopedic Reviews. 2010;2(1):e3.
West Los Angeles Chiropractor
Patients who are thinking about spinal injections or surgery, or have had spinal surgery (fusion, disc procedure, etc.) should see a Chiropractor trained in proper exercise therapy and who uses laser therapy and other new technology such as acoustic wave therapy to improve spinal strength and stability. In addition, scar tissue and muscle atrophy needs to be evaluated and treated. This can help prevent costly and risky injections and surgery.
Why is failed back surgery syndrome so common? Researchers at the Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University in Japan:
Up to 25% of patients report unimproved or worse pain and up to 40% are not happy with the outcome of lumbar fusion.
The possible reasons for poor results include instrumentation failure, inadequate surgical technique, and poor patient selection.
In patients who had continued pain after back surgery, muscle biopsies revealed:
Atrophy of paraspinal muscles
Loss of muscular support leading to disability and increased biomechanical strain and possibly failed back syndrome.1
In another study researchers found that the muscles adjacent to the fusion (the paraspinal muscles of the lumbar spine) play an important role in recovery. The muscles become weak and unstable after a spinal fusion.2 If those muscles remain damaged or weakened, the spine is unstable and pain persists.2
I can’t say enough about this…Doctors at Oslo University Hospital examined patients who had continued pain 7 to 11 years after spinal fusion. They found reduced muscle strength and density of tissue one year after lumbar fusion: 27% reduction in muscle density.3 Again, patients need a skilled practitioner like myself to help them properly build strength and stability…but I recommend doing this before injections or surgery if at all possible.
1 Ohtori S, Orita S, Yamauchi K, et al. Classification of Chronic Back Muscle Degeneration after Spinal Surgery and Its Relationship with Low Back Pain. Asian Spine Journal. 2016;10(3):516-521.
2 Malakoutian M, Street J, Wilke HJ, Stavness I, Dvorak M, Fels S, Oxland T. Role of muscle damage on loading at the level adjacent to a lumbar spine fusion: a biomechanical analysis. Eur Spine J. 2016 Sep;25(9):2929-37.
3 Froholdt A, Holm I, Keller A, Gunderson RB, Reikeraas O, Brox JI. No difference in long-term trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain 7 to 11 years after lumbar fusion versus cognitive intervention and exercises. Spine J. 2011 Aug;11(8):718-25.
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.
One of the therapies I find useful for DDD is shock wave therapy. PiezoWave Pulse Therapy and EnPuls are two of the top brand names in this type of non-invasive treatment. Shock wave therapy changes the degenerative disease environment of the inner spine to a healing environment.
Shock wave therapy stimulates stem cells. When stem cells are stimulated towards the spine or a targeted joint they initially start a line of new communication with the immune system and begin exchanging messages. The stem cells tell the immune cells to call healing factors to the site of damage and to meet them at the points where repair is needed. This is when healing begins.
Using the current research to explain how this change of environment works: When introduced into a diseased joint or spine, stem cells display plasticity and multipotency. This is the ability to change/morph into other cell types and multiply. One of the specific cell types is called Mesenchymal stem cell (MSCs) or connective tissue stem cells. These suppress inflammatory T–cell proliferation and provide an anti-inflammatory effect. The shockwave treatment actually stimulates a ‘controlled irritation’ or ‘controlled injury’ that leads to the beginning of the bodies dampening effect on the chronic inflammation.1
Shockwave therapy also signals the native stem cells and other growth factors to regroup and begin repairing damaged joints.
Stem cells and the herniated disc
A bulging disc bulges because the soft jelly like nucleus (inner colloid substance of the disc) are able to push through the weakened, damaged outer wall of the disc.
New research suggests that stem cells, without direct injection to the site of disc lesions in the spine, can repair disc lesions by changing the healing environment of the spine.
1 Davatchi F, et al. Mesenchymal stem cell therapy for knee osteoarthritis: 5 years follow-up of three patients. Int J Rheum Dis. 2016 Mar;19(3):219-25
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.