If you are suffering from a known knee meniscus tear get out your MRI report…
If you have a meniscus tear the radiologist probably used phases or words like located in the “White Zone” and/or “Red Zone” meniscus tears. The “Red Zone” refers to the outer edges of the meniscus and has a fair amount of blood vessel in it. Areas that have a good blood supply typically heal better than those areas without good blood flow. If the radiologist describes your tear as being in the “White Zone” that refers to the center of the meniscus which has a poor network of blood flow. White zone tears are often recommended to have surgery.
The red zone (good blood flow) is known to contain regenerative cells, (cells that stimulate stem cell activity) and those of us using Shockwave Therapies (Zimmer EnPuls, EPAT, Acoustic Wave Therapy, Gaines Wave), hypothesize that shockwave treatments to the knee can help stimulate migration of the regenerative cells in the red zone to the site of meniscal injury in the white zone. Shock wave practitioners know the meniscus is capable of healing tear defects that occur in the white zone (the area without circulation).
Shockwave Therapies (Zimmer EnPuls, EPAT, Storz, Acoustic Wave Therapy, Miracle Wave, Gaines Wave) is a non-invasive alternative to shots and surgical treatment. Shockwave therapy may act as a spark to mobilize the body’s own stem cells to facilitate healing.
Findings in the Journal of Orthopaedic Research demonstrate that articular cartilage and injuries to the meniscus mobilize an intrinsic progenitor cell population with strong reparative potential, even into the white zone area (2).
1 Matar HE, Dala-Ali B, Atkinson HD. Meniscal regeneration: a cause of persisting pain following total knee arthroplasty. Case reports in medicine. 2011;2011.
2 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. Journal of Orthopaedic Research. 2016 Nov 1.
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.”
What I do as a practitioner is provide the kind of care I want for myself and my family. My practice style is interactive, meaning we make decisions together, co-decide treatment options for pain relief, and I will help you achieve new range of motion. If you need weight loss I have very successful practical plans, and if you want to improve your fitness I can help guide you along. I’m formally trained in pain reduction strategies, flexibility and mobility training, weight loss, strength training, cardio and all its many forms, nutritional supplements, diets, and stress reduction. I have studied all of these concepts for 35 years. The things I continue to do and use are methods I know have worked for other people. I have stayed at the top of my game by staying in active practice, I’ve continued learning, I am an instructor to other Doctors around the world, I enjoy writing, sharing, and I continue to learn my craft.
I have been challenged by difficult patients with chronic pain, over-achievers with lots of stress, and patients with crazy character. I’ve learned and tried many different techniques, studied with masters and put together my own processes based on what works. For example if you ask me “What’s a good exercise?” I will say ‘One the patient does’ – I teach the ones I know patients do because I live it every day. As I have gotten older I have become more direct, a no nonsense style, and I have applied ‘healthy aging’ knowledge to myself and my patients. I am more serious about helping people regain lost range of motion in the neck, shoulders and back and then it is up to you to never lose it. That is my ‘healthy aging’ program for patients.
A session with me starts with getting to know you. Then we make a plan or program. Maybe you will need to schedule twice a week, once a week, once every two weeks. I don’t know that answer until we meet. I will teach you what you can do at home on your own. The truth is that what we do in the office is 10-20% of your change, the other 80-90% is what you do at home. Please call my West Los Angeles office 310-444-9393 for an appointment.
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.
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.1 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.
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
Research suggests the White Zone can heal
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! So far I see stimulation of stem cells (either non-invasive therapy or injections) as promising for meniscus repair and regeneration.
- 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.
- 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.
You probably have knee pain and then you got an MRI and the doctor said “You have a meniscus tear and you’ll need surgery”. Do you have other options? YES!
First off, let me tell you that research suggests the meniscus is always trying to heal itself. The length of time it takes to heal can depend on the location of the tear. The “Red Zone” part of the meniscus which is the outer edges, contain areas that have a blood supply and can receive oxygen and nutrients that help heal. This ‘Red Zone’ has a better opportunity than the “White Zone” which is more in the center of the meniscus to heal. The ‘White Zone’ does not have a well-organized blood supply which is required to bring oxygen and nutrients into damaged areas. If you are one of those people with a meniscus tear and your pain and dysfunction is not that great, meaning you can do most of the stuff you want to do, and you can live with the pain, I would recommend a trail of PiezoWave, EnPuls and laser. The research studies comparing people who had surgery and those who did not have surgery show that the outcomes are about the same after two years in those who did not go through a costly and invasive surgery! Acoustic Pulse Wave (PiezoWave) therapy and radial pulse therapy (EnPuls) is changing the healing pace – results of healing are quicker in the “White Zone” damaged tissue. I suspect it’s increasing the blood flow to these deeper tissues and improving the healing nutrient supply to the damaged ‘White Zone’ tissue and people feel better, faster.