Written by jason reynolds
Low back pain is the #1 cause of doctor visits in the U.S. aside from the common cold. Low back pain is an epidemic and it will affect 85% of us at some stage of our life and to varying degrees. “Low back pain” is a garbage can term, though; it is both ambiguous and useless if we do not define the specific pathophysiology that would manifest the label of “back pain.” One thing that needs clarification is that the chronicity of low back pain seen in the average American is often different than the acutely episodic low back pain an athlete may encounter. While some of the same anatomical, physiological, and biomechanical principals are true of all lumbopelvic injuries or “back pain,” still it remains that the etiology and prognosis will vary from an athlete to an unfit individual. A perfect working example of this is my recently injured yet fast-healing patient and colleague, Chad Smith the juggernaut. This three-part article serves as a journey and case study into the cause, management, and prognosis of “back pain,” the often elusive, multifaceted, #1 cause of disability in the US. Hopefully we can unravel some truths about the causation, progression, and appropriate therapies in dealing with such a menace to our society.
I recommend you read my article from last month Lumbar Spine Rehab-Part 1 before reading on. In part one, I dissect the epidemiology of “back pain,” and explain the importance of movement preparation and functional integrity of the lumbar spine. It won’t be a waste of time, I promise, and it will create a good knowledge base for this article and next month’s article.
What is the first thing you think of when you hear the words “herniated disc?” How about we spare the negatives and just say what you don’t think of: being back to pre-injury status in eight weeks. I may be embellishing a bit, and quite honestly, I am inflating that statement by about 3-4 weeks, but let me explain. When Chad sustained his MRI-confirmed multilevel herniation with clinically correlated findings (meaning what we saw on the MRI matched what my orthopedic and neurologic testing presumed and confirmed symptomatically what you would have expected symptomatically), we knew this would set him back from his record-setting squatting, pushing, and pulling. The structural severity of Chad’s injury would have had spinal orthopedists licking their chops and prepping for operation day. For reasons more than Chad’s stubborn, hard-working, alpha male mentality, we decided that surgery was a last resort and even a consult would have to wait. This was a tough decision, but I had a feeling of optimism and assuredness that conservative care was the best option. Back to the four/eight-week pre-injury status comment: this is an embellished statement because of the human being we are talking about. Remember, Chad has squatted 905. It would take 16 weeks of solid programming for a healthy Chad to achieve that feat again, let alone coming off an injury that has put many people onto surgeon’s tables and others onto disability for life. That is not the path Chad is on, and to validate my eight weeks comment, just take a look at his training log. Chad is doing things that any normal human could not be doing at eight weeks post-injury, and even at four weeks post-injury, Chad was doing much more than the average patient. He was marching through his rehab, and while much of his success is due to his dedication to the rehab plan, I am confidant a big chunk can be credited to the passive care he was receiving.
Passive care is defined as a treatment or modality used to correct, alleviate, or act as a support to the body’s normal healing and recovery processes, where the body is not acting or performing to assist the recovery. Good examples are chiropractic manipulation, soft tissue mobilization, pain medication, laser therapy, ultrasound, electric stimulation, kinesiological tape, massage, ice packs, heat packs, spinal decompression, acupuncture, etc. Anything where the patient does nothing and someone or something is facilitating the care. If you are reading this and are just now finding out that I am a chiropractor, I suggest you connect with me via the links below so you can see that not all doctors are created equal and that a provider should be defined by what they know and how they manage care, not the alphabet soup behind their name. Nonetheless, I am a chiropractor and due to that I have certain philosophical beliefs, but those beliefs do not preclude me from being a responsible healthcare provider. I like to make mention of this professional affiliation because I occasionally still get the ignorant patient, fellow chiropractor, physical therapist, medical doctor, or orthopedist who learns that I am a chiropractor and has some preconceived idea of what I do or should be doing. Lest I start a civil war with my chiropractic and orthopedic colleagues, any other comments regarding my philosophical belief and my simultaneous trust in medicine will be left to your imaginative, ambiguous thoughts.
The passive care plan for Chad’s herniations was simple: use all methods that had any supportive research. Time and money were not an issue for this patient; the issue was getting our Juggernaut back to being unstoppable. In no way am I directly stating that these passive care protocols, techniques, machines, and tools are exclusive to the type of care Chad received, nor am I endorsing any one of them. They are the preferred method for me as a practitioner and I encourage you to seek out these therapies and other therapies associated with the treatment of lumbar spine pathology. In the acute phase of care (in this instance 2-3 weeks), we focused on spinal decompression therapy and class IV laser therapy. The theory behind implementing these two modalities early was to unload the discs with the decompression machine, allowing for better inflammatory cell exchange through improved circulation of water and blood, and structurally permit the herniated material to be resorbed into the disc and off of Chad’s nerves and nerve sheath, which is prolonged when a constant axial load is present. The laser served as a cellular metabolism accelerator. The process of cellular exchange from healthy cell to inflammatory cell can be sped up with laser therapy. After the first two weeks with plateauing effects we moved to mostly manual therapy procedures. These consisted of chiropractic manipulation, myofascial mobilization techniques like Active Release Therapy (ART), instrument-assisted soft tissue therapies like Graston Technique (GT), muscle energy techniques like Post-Isometric Relaxation (PIR), proprioceptive neuromuscular facilitation stretches (PNF), and lastly joint mobilizations with and without movement. These are the bread and butter of a passive care plan. We also utilized ice and electrical stimulation concurrently with the manual therapy but the manual therapy is my trump card in the passive care approach that I take. All therapies listed can be effectively executed in a 10-20 minute session. When dealing with tissue change and receptivity, frequency is key. Another important note is that just because we took a holistic approach to his lumbar spine injury, that doesn’t mean we needed to look at Chad’s diet, social health, and mental state (although, yes, that is encompassed in holistic). The term “holistic” here means from a biomechanical standpoint, think “comprehensive.” The holistic approach with this manual therapy in the sub-acute phase (weeks 3-8), was to steer our focus away from the lumbosacral region and explore other dysfunctions up and down the chain. This included lower extremities, thoracic spine, and even the shoulder girdle. I do not want to be laborious in my treatments from day to day, but below is a sample treatment Chad may have received, complete with the corresponding functional and biomechanical reasoning.
Manipulation of the thoracic spine: Attempt to restore any lost range of motion that could lead to a propensity for increased activation of the erector spine musculature, which act as posterior shear forces on the lumbar spine.
ART and Graston of bilateral latissimus dorsi (both lats), lumbopelvic fascia, and lumbar spine erector musculature: The linkage between the lats, the fascia in the lumbar spine, and the pelvis has been shown to relate directly to each other’s dysfunction. Tissue immobility, tightness, or irregularity in the normal function of these regions can cause imbalance at the lumbopelvic region.
ART and PIR of the Illiopsoas (hip flexors): A mentor of mine once said that if he could treat only one muscle in the human body it would be the psoas, because of the impact they play on the lumbar spine. The psoas muscles attach to the spine and stretch past your hip and onto your upper leg. They are responsible for flexing your hip, but more importantly for stabilizing your lumbar spine through heavy torque and loads. Overly shortened psoas can cause undue compression on the lumbar spine and undue shearing forces.
Mobilization with movement, bilateral femoral acetabular joints (both hips): These joint mobilizations aim to provide a stretch in the capsule of our joints. Many stretching and soft tissue procedures will not address the capsular tissue and capsular ligaments of a joint. A mob (pronounced MŌB), as it is called, allows you to gain increases in range of motion that other passive modalities cannot. When addressing low back injuries, often the lack of hip range of motion causes compensatory motion in the lumbar spine, which can lead to increased shear and load to the soft tissue in the spine.
Ice and stim of the lumbar spine (electrical stimulation): A big part of me is attached to the novelty of this training room classic. Heck, I grew up with one of these practically attached to my hamstring throughout the end of high school and into my college career. Stim and static stretching were the main passive care modalities used to treat injuries. In all fairness, I do use it for a pain modulating effect and the ice helps to quickly rush out the increased inflammation that I caused earlier in the session with all the ART and Graston.
That is a general visit in the manual therapy protocol for disc herniation. I would like you to keep in mind that the aim of passive care is to holistically restore any compensatory patterns that were developed during the acute phase as Chad’s body was trying to operate but stay away from pain. Concurrently, Chad had homework: there were active care procedures that were being done to preserve his neurologic mapping of what a squat pattern is, breathing under load, or what it feels like to have the hamstring activate – and not from a nerve root-provoked radicular shock type of activation. It is a holistic, comprehensive plan that you can see has brought us to the light at the end of the tunnel. We cannot say we are victorious until Chad steps onto that stage again and tries for another American or world record, but I would like to claim a victory for Chad, conservative care, and myself. Although Chad still has 2-3 months before most would claim pre-injury status, he was squatting his body weight for high volume by week eight and yoke carrying 125% of his body weight, all asymptomatically. We took what could have been a surgical case and turned it into a success by any normal man’s measure: No surgery, back to normal daily activities in four weeks, and back to intense exercise at eight weeks. So for most of us, I wasn’t embellishing at all. Eight weeks to pre injury status after a severe back injury? Sure it’s possible. Check back for part three and discover the keystone piece to Chad’s miraculous rehab: the active care.
Dr. Jason Reynolds is 1 of 206 board-certified Chiropractic Sports Physicians, a small portion of the chiropractic field that is dedicated to the conservative management of sports injuries and enhancement of sports performance. He is a partner at Body Dynamix Chiropractic and Performance, operator and practitioner of Body Dynamix OC, Professor of Emergency Procedures and Physiotherapy II Active Care at Southern California University of Health Sciences, and Adjunct Medical Director and provider for USA Men’s Field Hockey.
Contact Jason at [email protected]
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