Guest Post By Perry Nickelston, DC, NKT, FMS, SFMA
Lower back pain can be debilitating. It can affect every aspect of your quality of life and functional daily activities. I have experienced terrible episodes of lower back pain from disc herniations that literally brought me to my knees. I know the pain! The one modality that made the biggest changes and lasting results for me was deep tissue laser therapy. So much so, that I purchased my own unit and have been using it for the last ten years helping other people feel better. Some people may have heard of laser for back pain and wanted to learn more, others don’t even know it’s an option. This article is designed to help both of you learn more and know there is always hope using wonderful devices based in science and research that can be helpful.
Effective rehabilitation protocols require a strategic and comprehensive approach integrating soft tissue techniques, fascial manipulation, joint manipulation, and functional movement patterning. Restoring optimal range of motion and reducing pain by transitioning a client from passive to active care should be the primary goal. Decreasing the time a client spends in the passive phase of care and teaching painless functional active rehab of the kinetic chain will help improve compliance. Using therapeutic modalities to significantly increase recovery times and heal chemically damaged cells while strengthening surrounding tissue can decrease passive therapy and accelerate the natural regeneration process of injured areas.
Laser therapy for back pain is the modality you have been searching for to enhance recovery and regeneration. Understanding the therapeutic mechanisms of action involved with laser therapy and treatment protocols are essential. Successful use of any modality in clinical practice ultimately depends on the expertise and skill of the practitioner. Let’s take an in depth look at the physiological benefits of laser therapy and how it can be integrated into rehabilitation programs.
The US Food and Drug Administration (FDA) approved the first low level Class III laser (LLLT) in 2002 and the first Class IV therapy laser in 2003. The most significant clinical and therapeutic difference between Class IV lasers and Class III is the Class IV higher power output may produce a primary bio-stimulative effect on deeper tissues. Reaching deep tissue structures is critical to rehabilitation and recovery. If you cannot reach the intended target tissue with adequate therapeutic laser dosages overall clinical results will diminish. Laser therapy excites the kinetic energy within cells by transmitting healing energy known as photons. The skin absorbs these photons via a photo-chemical effect, not photo-thermal; therefore it does not cause heat damage to tissues. As such, laser can be safely used on patients who have metal joint replacements without the risk of injury.
Laser light does not excite or interact with the molecules in metal or plastic. Once photonic energy reaches damaged cells of the body, they promote a cascade of cellular activities. It can ignite the production of enzymes, stimulate mitochondria, increase vasodilation and lymphatic drainage, ATP synthesis, and elevate collagen formation substances to prevent the formation of scar tissues. This is a critical step in reducing long term disabling chronic myofascial pain syndromes and joint restrictions.
Photobiomodulation, otherwise known as laser biostimulation, is the medical term in which exposure to laser light enhances tissue growth and healing. Photobioregeneration is also used as a term in describing laser therapy because of the cellular healing effects.
Here is a partial list of positive effects of Photobiomodulation on the body, all of which are a crucial part of long term healing:
• Increased leukocyte activity (acceleration of tissue repair and decrease of pain)
• Increased neovascularization (new vessel growth and increase oxygenation)
• Increased fibroblast production (speeds tissue repair)
• Increased tensile strength (helps prevent re-injury)
• Stabilization of cellular membrane of damaged cells
• Enhancement of ATP production and synthesis
• Decreased C-Reactive protein Neopterin and acceleration of leukocytic activity
• Enhanced lymphocyte response with reduction of Interleukin 1 (IL-1)
• Increased prostaglandin synthesis
• Enhanced superoxide dismutase (SOD) levels
• Stimulation of vasodilation with increased angiogenesis (new blood vessels)
Principle factors of success with laser therapy for fascial restrictions and joint rehabilitation include; optimal dosage, power, wavelength, and accurate clinical diagnoses.
Maintaining or restoring movement of specific segments is the key to preventing or correcting musculoskeletal pain. Fundamentally, rehabilitation is about movement, and lots of it. The base foundation of functional movement is proper joint mobility and stability. Without adequate mobility and stability of joints in the kinetic chain you end up with dysfunctional movement. Activities of daily living are then built on dysfunctional movement patterns, resulting in compensation, and injury. Microtrauma results from small amounts of stress imposed on the body over time caused by poor biomechanics and the body compensates with suboptimal joint alignment, muscle coordination, and posture. Joints begin approximating in an effort to gain stability lost from muscular weakness and compensation. This process known as ‘Joint Centration’ is an inherent protective mechanism of the body which if left uncorrected may cause osteoarthritis, degeneration, and decreased mobility.
Postural movement patterns are learned early in life by the central nervous system (CNS). However, structural or functional body stressors (tension, trauma, genetics, etc.), may prevent achievement of optimum posture. Faulty postures from physical compensations alter joint mechanical behavior, flexibility and range of motion. The increase in mechanoreceptor stimulation from chronically locked joints results in neuro-reflexive muscular changes, i.e., protective muscle guarding. Long-standing over-activation of abnormal joint reflexes causes changes in spinal cord memory that eventually “burns a neural groove” in the CNS as the brain and cord are unknowingly saturated with a constant stream of inappropriate proprioceptive information.
Inherently, the brain comes to rely on this faulty information about where it is in space to determine how to establish perfect posture. The brain simply forgets what its alignment should be. In other words, the body now makes the abnormal its new normal. Neurology wins every time. The silent progression of faulty postures and dysfunctional movement patterns are part of the reflexogenic relationship between muscles and joints. Neurogenic muscle activation patterning by combining laser therapy and functional movement rehabilitation is an effective way to ‘reprogram’ the CNS for optimal function and reverse abnormal patterning.
Laser affected areas prior to active movement patterning to accelerate the metabolic rate of deep tissue structures. Laser therapy on muscle attachment sites can increase a cascade of neurological input to the CNS enhancing proprioceptive awareness. Most rehabilitation cases require 6-10 laser therapy sessions for maximum benefit depending on the individual and Class of laser used for treatment. Laser affected joint and surrounding tissue with a therapeutic dose following current research of (4-12 J/cm2) depending on depth of tissue. (Joules is the measurement of photon energy in J/cm2).
Each therapy program is different depending on the unique circumstances of each movement pattern dysfunction. There is no baseline laser therapy program for pain syndromes. The history of each patient determines the laser therapy protocols. The above mentioned dosage range is a benchmark foundation for treatment. When administered correctly, deep tissue laser therapy for back pain can have significant and profound positive impact on healing.
Learn more about Dr. Nickelston and Laser Therapy For Back Pain at: http://www.stopchasingpain.com
The Stabilizer Biofeedback cuff is a great device to use to monitor the changes in spinal motion when performing lower abdominal exercises. Too often I see individuals with back pain going way beyond their ability to stabilize their spine when attempting to strengthen their abs. Here is a short video of how the Phase 1 exercise can be done with the feedback unit.
Pretty nifty, right?
The Stabilizer Biofeedback exercises build a solid foundation to work from with regard to abdominal training. It allows a lot of variation, especially if your back pain is bad enough that doing anything other than laying on your back makes you hurt more. In fact, I’ve found that in many cases when someone told me that “any exercise I do causes me pain”, I was able to at bare minimum assign the Stabilizer exercises without any problem.
Stabilizer Cuff Settings
There are a number of different methods for setting up the stabilizer biofeedback tool. In the instruction manual for the tool, they recommend setting the cuff at 40 mmHg of pressure, then performing the exercise while attempting to hold that pressure. There are times when I do recommend this setting, mostly for back pain sufferers that can’t move very much without agitating something.
One problem with this setting, however, is that very often the lower back extensors are facilitated (hyperactive) and the lower abdominals need to be encouraged to work a bit more to counteract this hyperactivity. This can be done by doing a posterior pelvic tilt to increase the pressure in the cuff a bit before starting the exercise. Adding about 20 mmHg usually does the trick.
The other problem I have with the standard setting is the starting pressure of 40 mmHg. This is a problem for many people because of excessive thoracic kyphosis. If the spine is rigid in the lower thoracic/upper lumbar region, the 40 mmHg + 20 mmHg pelvic tilting is going to be difficult to hold without compensating using larger muscles. Therefore, I recommend the starting cuff pressure to be set to 60 mmHg to get around this issue.
So, I recommend STARTING the cuff at 60 mmHg, then performing a posterior pelvic tilt to 80 mmHg, and performing the exercise while holding at 80. Got it?
Strengthening the lower back needs to be done with a focus on connecting all of the muscles that extend the hips. Very frequently, focusing on activating and strengthening the glutes will reduce and in some cases, completely alleviate lower back pain. I find this exercise works particularly well for sacroiliac joint problems. The reverse hyperextension is one of the top exercises I use for this. You can perform reverse hyperextensions without a bench. In the video below, I will show you how to do this with a swiss ball.
Watch this video to learn how to perform it. Be sure to pay attention to the details, as they make ALL the difference!
Did you notice the focus on STARTING the movement from the Glutes??
Seriously, this can mean the difference between the reverse hyper extension causing lower back discomfort and it being a great exercise for your lower back pain. What we are trying to correct here is called Faulty Hip Extension. This is were you are turning on the muscles in your posterior chain in an inappropriate order. This movement is distinctly different from the 45 degree hyperextension bench, and I prefer to start with the reverse version first.
Using a Reverse Hyperextension Machine or Bench
The bench version is commonly done with a unit designed by Louie Simmons. It has a pendulum that attaches to the bench so that you can add weight as the exercise becomes easy. Its really great if you have one, but if not, a high bench can be used with the same results.
Setting Up On the Reverse Hyper Bench
When setting yourself up on the bench, you will want to make sure that your ASIS bones (which are the bones on the front of your pelvis) are just AT the edge of the bench. This will allow for a bit of traction on the lumbar spine as your legs drop straight down. You will get a gentle stretch of the lumbar muscles at L-5/S-1 by doing this.
To initiate the movement, as stated in the video above, start by squeezing your glutes as you lift your legs in the air. You should think about pushing those ASIS bones into the bench, which will automatically help you use your glutes. You will ONLY go as high as you can extend your hips, which will be determined by how much psoas tension you have.
As an additional tip to make the reverse hyperextension more effective, allow your legs to turn outward slightly. This is a natural motion the glutes perform, and will enhance the contraction and improve range of motion. Avoid letting your knees bend. This encourages the hamstrings, and reduces focus on the glutes. Do NOT force them straight, just avoid deliberately contracting your hamstrings to bend your knees.
While its not very hard to finding information on how to stretch your hip flexors on the web, it IS common to find this stretch performed incorrectly! When stretching the hip flexors, you MUST pay very close attention to the pelvic tilting. If you do not, its very easy to agitate the lower segments of the spine, especially when they are degenerative.
Why Stretch Hip Flexors?
First, I hope you have read a few of my previous posts on the topic of muscle imbalances! If not, make sure you do so. The primary hip flexor muscles we are concerned with, the Psoas Major, Iliacus, and the Rectus Femoris, will cause the pelvis to tip forward (called anterior pelvic tilt). If excessive, it can contribute to lower back pain.
This anterior tilt is a problem because it not only increases lumbar lordosis (the inward arch in the spine), but also distorts the position of the hips. In short, it induces all sorts of biomechanical mess!
Positive Effects of Hip Flexor Stretching
Based on the above, the anterior tilt of the pelvis causes the hamstrings to lengthen, as they attempt to stop the pelvis from going forward. As you can imagine, this is exhausting for a set of muscles to do for any length of time. This leads to fatigue, tension, and weakness of the hamstrings.
In addition, due to neurological laws (Reciprocal inhibition in particular), the glute muscles will become weakened. Of course this is a problem because your glutes are the largest hip extensor muscle. If they are not doing their job, then your lower back muscles and hamstrings take a beating as they attempt to compensate for the workload.
I’m frequently asked if one can exercise with a disc bulge. Assuming clearance has been attained from a physician, then YES. However, you must be super careful, and a very specific set of exercises may need to be done prior to moving forward with correcting muscle imbalances with a program such as my End Your Back Pain Now! program. Here is a free downloadable PDF that you must check out:
Are there really Disc Bulge Exercises that are beneficial?
First of all, let me answer that question by generally saying, YES. We have to define what an exercise actually is. By my definition, its any movement with the intention of improving movement ability or any movement quality. This could mean coordination, strength, flexibility, endurance, or anything else.
Since discs don’t contain any muscles, they cannot contract, so technically any exercise that is aimed at helping reduce a disc bulge problem is NOT directly impacting the disc itself, but rather reducing the potential movement problems that may be agitating the disc issue.
What the heck do I mean by that??
Well, when we consider that the vast majority of disc bulges are POSTERIOR in nature, it would mean that any pressure on the front side of the disc (toward the abdomen) would exacerbate disc problems. Therefore, wouldn’t it make sense to address the muscle imbalances that make this situation worse?
This means stretching any tight abdominal muscles, loosening the tight hamstrings (not necessarily by stretching!), or any other muscle that causes the lumbar spine to flatten. So…YES. This is how you perform exercises for a disc bulge. INDIRECTLY.