Extracorporeal Shock Wave Therapy for Chronic Low Back Pain

Despite LBP being an international health menace, medical doctors continue to treat pain symptoms while ignoring the underlying causes. But new research and advanced technologies are changing the game for back pain sufferers, providing innovative solutions for diagnosis, treatment and rehabilitation.

Learn about the causes and types of low back pain, and how extracorporeal shockwave therapy can play a key role in restoring pain-free functional mobility for LBP patients.

What Causes Chronic Low Back Pain?

The lumbopelvic region is the site of load transfer between the upper and lower body during any type of physical activity. To effectively mediate forces, the muscles of the core are activated to stabilize the region and protect the spine. Additional stability is provided by the fascia – a tough thin network of connective tissue that encases and connects muscles and organs, providing elastic tension and enabling tissue gliding.

But weakened and imbalanced muscles can fail to protect other structures, shifting force loads to fascia, tendons, ligaments and joints, and causing tissue damage and pain. Low back pain can arise from multiple causes, and patients often have more than one contributing factor.

Factors that contribute to low back pain include:

• Acute trauma that damages multiple structures and tissue types
• Repetitive overuse from sports, exercise, or occupation
• Excessive sitting that weakens muscles and causes imbalances
• Poor posture that causes misalignment of the spine
• Lack of regular physical activity
• Injuries of the lower extremities that create inefficient compensation patterns
• Obesity and metabolic disorders
• Chronic dehydration and poor diet

With the exception of traumatic injuries, low back pain typically has a gradual onset. In many cases, pain arises from a bulging spinal disc that compresses a nerve, and such cases often self-resolve over a few days or weeks. LBP that persists for 3 months or longer and progressively worsens is considered a chronic condition.

What Tissues and Structures Involved in Chronic Low Back Pain?

The lumbopelvic region houses a complex network of organs, muscles, joints, bones, nerves, blood vessels, connective tissue and fascia, and chronic LBP rarely arises from a single structure. For example, a bulging disc might irritate a nerve root while at the same time causing muscle spasms and placing stress on a facet joint.

Tissues and structures involved in LBP include:

• Intervertebral Discs – fibrocartilaginous structures that act as shock absorbers between the vertebrae. Discs can degenerate or become inflamed, creating pressure on nerve roots that causes pain.
• Facet Joints – synovial joints that connect adjacent vertebrae and help control spinal motion. Facet joints can degenerate and cartilage can break down, resulting in inflammation and reduced spinal range of motion.
• Paraspinal muscles and fascia – these tissues provide spinal stability and protect the spine from damaging forces. Strains, imbalances and spasms can cause pain, and myofascial trigger points can develop, interfering with muscle action. Damaged fascia can thicken (densify), entrapping nerves and blood vessels and preventing them from gliding among other structures.
• Spinal Ligaments – the posterior longitudinal ligament and ligamentum flavum provide spinal support and stability. Ligaments can develop sprains, and they can thicken and calcify from disuse or misuse. Thickening of the ligamentum flavum is associated with spinal stenosis.
• Vertebral bones – the vertebrae form the spinal column, and they can be affected by conditions like spondylolisthesis, osteoarthritis, and microfractures from osteoporosis, causing chronic pain.
• Nerves and nerve roots – nerves exit the lower spine through the spinal foramina to innervate the body’s periphery. Nerve roots can be irritated by herniated discs, spinal stenosis, or scar tissue, or compressed by densified fascia, bones or muscles along their path to peripheral tissues.
• Sacroiliac joint (SIJ) – the sacroiliac (SI) joints connect the sacrum – the triangular bone at the base of the spine – to the ilium of the pelvis, providing a bridge between the upper body and the lower limbs. The SIJ plays a critical role in stability, load transfer, and force distribution. Inflammation or dysfunction of the SIJ can refer pain to the lower spine, accounting for up to 30% of LBP cases.

What are the Different Categories of Chronic Low Back Pain?

Central Sensitization

The spinal column houses nerve roots that affect every part of the body, providing a conduit for messaging between the brain and peripheral tissues. In some chronic LBP cases, central sensitization can arise – a condition where pain perception is amplified in the central nervous system (CNS), even in the absence of ongoing tissue damage. Sensitization is often tied to psychological factors like stress or depression, and can prolong and exaggerate pain associated with chronic LBP.

Enthesopathic Pain

Enthesopathy is a condition of the lower spine affecting the entheses—the attachment points of tendons, ligaments, or joint capsules to bones. It may involve inflammation, structural degeneration, or other changes that cause pain and reduced mobility. Enthesopathy is marked by pain or tenderness in the lower back at points where ligaments and tendons attach, along the vertebrae or near the iliac crest.

Radicular Pain

Radicular pain is caused by irritation or compression of a spinal nerve root, often from a herniated disc pressing against the nerve. Sciatica is a type of radicular pain caused by compression of the sciatic nerve that travels from the low back, all the way to the legs and feet. Spinal stenosis – a narrowing of the spinal canal – can also cause radicular pain as nerve roots are compressed within the narrowing space.

Inflammatory Pain

Inflammation in the low back caused by various types of arthritis can create non-mechanical LBP. Inflammatory low back pain is usually worse in the morning or after prolonged inactivity, causing stiffness that improves with movement.

Neuropathic Low Back Pain

Neuropathic LBP is caused by nerve damage, rather than direct structural issues. Post surgical nerve damage often appears after spinal procedures, caused by fibrosis or scar tissue. Nerve damage can also arise from diabetic neuropathy.

Referred Pain

Pain felt in the lower back can sometimes originate from an internal organ or other non-spinal structure. Potential causes include kidney stones or infection, pelvic conditions, and rare but serious abdominal aortic aneurysm.

Non-Specific Low Back Pain

Pain with no identifiable structural or pathological cause accounts for about 85% of chronic LBP cases, leaving doctors baffled and patients frustrated. Potential causes are muscle tension, poor posture, stress, or minor biomechanical issues that are not visible with imaging.

How is Chronic LBP Diagnosed?

Sadly, most medical doctors paint low back pain with a broad brush, relying on one-size-fits-all pain management strategies without differentiating between different types of pain. When pain persists or intensifies, MRI may be recommended to look for structural issues that can be surgically resolved. But MRI is costly and inconvenient for patients, and results are limited to static images that take days to process and analyze. In many cases, MRI fails to provide any insight at all into the cause of a patient’s LBP.

High-resolution diagnostic ultrasonography presents a less costly and more patient-friendly imaging alternative to MRI. Dynamic ultrasound images appear on a monitor in real time, allowing patient and clinician to view the various structures as they interact. Ultrasound allows for differentiation between various structures and tissue types, giving clinicians the ability to examine long structures like nerves, fascia, muscles and bones along their entire path.

Ultrasound imaging can be performed in-office, with portable and affordable equipment that takes up a fraction of the space of MRI. Unlike other imaging modalities, ultrasonography does not emit harmful radiation, and is considered safe for most patients. When administered by a skilled and experienced clinician, diagnostic ultrasound can provide invaluable information about the exact causes of low back pain, empowering doctors to go beyond pain management, to actually treating and healing the underlying mechanisms of LBP.

What is Shockwave Therapy for Chronic Low Back Pain?

Conventional medical treatment of low back pain typically involves rest, ice and heat in the early stages, with the use of over-the-counter NSAIDs to treat pain and inflammation. When pain persists, anti-inflammatory drugs, opioids and antidepressants may be introduced, along with corticosteroid injections at the locus of pain.

Patients can suffer for years with flare-ups or unrelenting pain that requires increasing amounts of drugs to relieve symptoms. Surgery is usually reserved for structural issues like severe disc herniation and spinal stenosis, but doctors may turn to surgery as a last resort when other treatments fail. But back surgery poses high risks for the patient, with no guarantee of success.

Today, new advancements in research and technology are offering holistic alternatives to conventional LBP care that do not involve drugs or surgery, with the potential to reverse chronic low back pain and eliminate it for good. ESWT is an evidence-based, non-invasive technology that is revolutionizing LBP treatment. It uses high-frequency sound waves to trigger a cascade of biological reactions that promote tissue repair at the cellular level.

What Makes Multimodal Shockwave Therapy Superior for LBP Treatment?

Chronic low back pain often involves more than one tissue type, and different tissues respond to specific types of shockwaves. Multimodal shockwave therapy uses a variety of shockwaves for optimal results. Advanced equipment allows clinicians to vary the depth and width of penetration, zoom in on specific tissues, and zoom out to cover larger areas. When applied under ultrasound guidance by an experienced clinician, ESWT provides an evidence-based methodology for fine-tuning LBP treatment.

Advantages of ESWT for chronic low back pain include:

• Effective treatment of enthesopathies of the paraspinal muscles.
• Improved tensegrity by treating fascial attachments at the hip muscle lumbodorsal insertion.
• Superior to steroid injections for treating facet joints by targeting inflammation and bony osteophytes, and releasing facet capsules.
• Improves the function of medial nerve branches that innervate the multifidus muscles.
• Improves foraminal stenosis.
• Eliminates myofascial trigger points.
• Eradicates fascial densifications that reduce mobility.
• Helps to release fixated sacroiliac joints.
• Decreases pain by addressing TRPV receptors in lumbodorsal fascia.

ESWT for LBP has been shown to improve functional mobility, with minimal side effects and long-term benefits. It addresses the underlying mechanisms of chronic low back pain, providing relief without drugs or surgery. ESWT can help to prepare tissues for additional treatments like physical therapy, aimed at restoring pain-free functional mobility.

What New Research Supports the Use of ESWT for LBP?

A growing body of research is discovering innovative ways to combine ESWT with other methodologies for LBP diagnosis and treatment.

ESWT for Degenerative Disc Disease

One study published in the Spine Journal explored the efficacy of shockwave therapy combined with low tension traction to regenerate and repair moderately and severely degenerated discs, and to explore its possible mechanisms of action. Since the intervertebral discs are avascular – meaning they have no blood supply – there is a limited flow of oxygen and nutrients to the discs, making it difficult to halt the degenerative process. In order to self-repair, discs are dependent on the exchange of nutrients and metabolites via molecular dispersion fluid from bony endplates.

The study combined ESWT with low tension traction to create a stable intervertebral environment for the repair and regeneration of degenerative discs. The researchers concluded that low energy ESWT combined with low tension traction provided a more stable intervertebral environment for the regeneration and repair of moderate and severe degenerative discs. This evidence holds great promise for a condition that was previously thought irreversible.

ESWT as a Superior Non-Invasive Treatment for Facet Joint Pain

Pain generated from the lumbar facet joints account for up to one-third of LBP. Conventional treatment involves corticosteroid injections and medial branch radiofrequency neurotomy, both invasive therapies that carry the risk of complications, including infections and damage to the nerve roots or medial branch structures.

A Canadian study published in Neuroendocrinology Letters set out to explore the effectiveness of ESWT compared to both steroid injections and radiofrequency neurotomy. Results showed that ESWT had better long-term effects than steroid injections, and only slightly inferior efficacy compared to neurotomy. The shockwave group exhibited no adverse effects or complications, and patients reported significant long-term improvements in daily mobility.

ESWT as a Diagnostic Tool for Myofascial Pain

Another study published in Biomechanics asserts that most back pain is caused by myofascial pain syndrome (MPS) – a chronic pain condition characterized by pain in the muscles and surrounding fascia. MPS typically involves the presence of trigger points—tight, sensitive spots in the muscle that can cause localized pain or refer pain to other areas of the body when pressed.

The researchers set out to demonstrate that ESWT can be used as a diagnostic tool for MPS when focused waves are directed at trigger points to provide a non-invasive mechanical stimulus. The objective was to produce referred pain patterns that implicate myofascial pain as the underlying cause of LBP. They concluded that focused ESWT provides ” a precise, reproducible, and non-invasive diagnostic approach for MPS in chronic LBP.”

Efficacy of Ultrasound Guidance of ESWT for Neuromuscular Pain

In a 2022 study published in Neuromodulation, NYDNRehab clinical director Dr. Lev Kalika and his colleague, Dr. Bubnov set out to establish the efficacy of multimodal ESWT under ultrasound guidance, The aim of the study was to compare the effectiveness of US guidance for enhancing ESWT treatment of neuromusculoskeletal pathologies, muscle pain, and dysfunction.

In 2024, Dr. Kalika presented the results of a second study to the 26th World Congress of the International Society for Medical Shockwave Treatment. The study’s stated objective was to “investigate the impact of ultrasound guidance on the precision, direction, and depth of ESWT.” Results showed significant enhancement of subjective symptoms when precision adjustments were made based on ultrasound findings. They concluded that ultrasound guidance enhanced the functional application of ESWT, providing a more nuanced approach that rendered superior results.

Where Can I Get Multimodal Shockwave Therapy in NYC?

Back pain sufferers often go from one doctor to the next, seeking long-term solutions to restore their functional mobility. However, conventional medicine is oriented to pain management, with surgery as a last resort when all else fails. At NYDNRehab, we take a more holistic approach to chronic low back pain, seeking to identify the underlying cause and eliminating pain at its source.

We use the highest-resolution ultrasound imaging to diagnose your condition and guide our procedures, for precise and effective treatment. Our high-grade multimodal shockwave equipment is second to none. When combined with Dr. Kalika’s 20+ years of clinical experience and professional expertise, ESWT at NYDNRehab provides low back pain sufferers with the most evidence-based and effective treatment options in NYC.

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