SpineFITyoga

Massive Herniated Discs and Low Back Pain, the Good News

Conservatively treated massive prolapsed discs: a 7-year follow-up. Benson RT, Tavares SP, Robertson SC, Sharp R, Marshall RW. Ann R Coll Surg Engl. 2010 Mar;92(2):147-53.

Abstract
INTRODUCTION:
The natural history of a lumbar hernia of the nucleus pulposus (HNP) is not fully known and clear indications for operative intervention cannot be established from the literature. Several studies have shown that the largest discs appear to have the greatest tendency to resolve. The aim of this study was to investigate whether massive prolapsed discs can be safely managed conservatively once clinical improvement has occurred.

PATIENTS AND METHODS:
Thirty-seven patients were studied by clinical assessments and serial magnetic resonance imaging (MRI) over 2 years. Patients had severe sciatica at first, but began to show clinical improvement despite the large disc herniations. Clinical assessment included the Lasegue test and neurological appraisal. The Oswestry Disability Index was used to measure function and changes in function. Serial MRI studies allowed measurement of volume changes of the herniated disc material over a period of time.

RESULTS:
Initial follow-up at an average of 23.2 months revealed that 83% had a complete and sustained recovery at the initial follow-up. Only four patients required a discectomy. The average Oswestry disability index improved from 58% to 15%. Volumetric analysis of serial MRI scans found an average reduction of 64% in disc size. There was a poor correlation between clinical improvement and the extent of disc resolution.

CONCLUSIONS:
A massive disc herniation can pursue a favourable clinical course. If early progress is shown, the long-term prognosis is very good and even massive disc herniations can be treated conservatively.

My comments:

The entire article above is worth reading, and fortunately a free full text is available. I have a read a lot of case reports and observations of both cervical and lumbar disc herniations (prolapsed discs) healing or reabsorbing on their own and thought it would be good to know both how often and to what extent this was occurring. This paper with its 7 year follow up was the best one I found and it fits with my experience pretty well with low back pain patients showing or reporting poor looking MRIs but still progressing very well with their exercise program, often with a full resolution of symptoms with strength, endurance and function returning to better than they were pre-injury.

Interesting factoids and comments from the paper were as follows:

  • Massive herniated discs were defined as those for which the extruded disc material occupied 50% or more of the anteroposterior diameter of the spinal canal. I’d agree that’s big.
  • 83% of the 37 patients reported complete and sustained recovery 7 years after the injury.
  • The average reduction in the size of the disc prolapse was 64% most of which occurred in the first 6 months after the initial scan at which point they were only one third of their original size. They slightly better at 6-12 months after which point reduction volume was relatively unchanged.
  • They cited another paper that found that with herniated disc larger than 6 mm, that that on average they improved 36% in 6 weeks, and 60% at 6 months, which closely agrees with the 6 month outcome of this study.
  • Four of the 37 patients went on to have surgery and their average volume reduction was less at 47%.
  • Seven years later 90% of the conservatively treated patients were satisfied with their outcome, while with only 50% of those having surgery being satisfied, though the difference was not statistically significant.
  • In the discussion they cited other research that surprisingly found the worst discs had greatest ability to improve (on a percent of initial injury) over time, speculating that it was due to increased immune/inflammatory response with macrophages and neovascularization playing a role.
  • They cited two additional studies indicating similar outcomes with herniated discs in the cervical spine, aka, neck.
  • The noted the degree of disc resorption was not always correlated with symptoms as they cited several papers where patients showed considerable improvement in symptoms even when MRI changes were minimal.
  • They thought, and I agree, that patients with sciatica should be initially treated with conservative treatment and that early access to surgeons and diagnostic can result in unnecessary surgery.

The authors said that only four of the patients had surgery. However there was no mention regarding what types of therapy, exercises, postural advice, etc, was or wasn’t utilized as part of the conservative course of treatment. Also there was no mention as to what caused the herniated discs, which seem often the case from the point of view from a lot of practitioners. Often a person will complain of severe back or neck pain, go to their doctor, get an MRI, see a herniated disc, and there’s the cause. However physical therapists who want to more effectively treat spine pain, need to look further back than that.

I’ve read a fair number of philosophy books and it seems there are very few uncaused events, and vertebral discs don’t herniate by magic. While there often isn’t a specific injury, it is known that most disc bulges and herniations are caused by repeated spine flexion, which is exacerbated by sustained flexion loads, with rotational stresses not doing the discs a lot of good either. So sufferers of back pain (and neck too) should keep this in mind, and should probably avoid a lot of spine stretching, and sustained poor postures, or else what happened to the disc in question will likely happen to neighboring discs either above or below. As many pain sufferers can tell you, a good number of spine injuries result in recurrent and chronic pain, then is only eliminated when bad habits are eliminated and strength increased. Still the good news from this study is that even with the worst of herniated discs generally respond very well to treatment without the need of surgery.

Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember SpineFit Yoga for you or someone you know in the future.

Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed Yoga Teacher Training at Sampoorna Yoga in Goa, India.

Comments

15 responses to “Massive Herniated Discs and Low Back Pain, the Good News”

  1. Rishi Verma

    I read your article regarding your critique of the McKenzie ideology, and was very interested in speaking to you more about this. To keep it as short as possible, I am a 22 year old athletic young man who has suffered two back injuries in the past year and a half. I have always been a natural athlete (basketball and football) and had plans on walking on my university’s football team, but nagging injuries always held me back. I began having back spasms at 18/19 but ignored them. In retrospect, I wish I hadn’t because accumulating injuries can be very telling and reveal muscular imbalances and incorrect movement patterns. I didn’t care much about lifting weights, until about last year. Around June of 2014, I was pulling a deadlift and heard the infamous pop in my lower back. I was in pain, but didn’t think I was in any danger. I had no sciatic pain or anything extreme so it was evident that I would heal. Upon consulting an ortho, I resumed training and playing basketball regularly. After the first injury, is when I started to take strength training more seriously, and I amassed good strength within 5 months. I began powerlifing and by March of 2014, my total was 1,015lbs at 161lbs 5’9 (Long torso, hence weaker pull). Further, my athletic performance was increasing as well as my speed and sheer explosiveness. While I was performing exercises correctly, what I didn’t realize, was that I was feeding my muscular imbalances as I became a quad dominant squattter. To combat, I would train front squats equally to I guess mitigate the issue. April 2015, the same exact injury happened at the same location. Again, no sciatic pain. I thought all was well and the same would happen, but it didn’t. I healed very very very fast the first time, and initially, after the second injury it seemed as if I would again. Two weeks post injury, I was running sled weighted sprints again, front squatting (not back yet I wasn’t comfortable) and playing basketball. Everything seemed fine until I came home from college. I’m not sure what happened, but one day while playing basketball I think I got nudged in a weird way but felt fine at the time. When I went home, my legs when numb, and that’s when I got scared. I consulted the ortho again and upon the MRI, I received the horrible news that I had two large herniations at L4/5S1. The doctor hit me with the “your days of squatting are over” and “everything is risk management from here on out”. I was upset but I refused to accept this answer. So I read, and read some more and became educated on the matter. Foundation Training by Dr. Eric Goodman has shown me great results. It’s premise is to strengthen the smaller multifidus and to correctly engage the posterior chain. This along with spine elongation and decompression breathing. I have been pain free, completely for about 2 months, no significant stiffness in the morning and almost full range of motion. I have this nagging issue when I curl my toes up and push my neck down while lifting my leg that causes a pinch at the base of the left spine. That is way too specific to be caught up over, yet here I am writing you. Since late October, I abandoned playing basketball and upper body weight training (squats and pulls stopped in May) to expedite the healing process. I cut my carbs, took out the excess sugar (which was not much to begin with) out of my diet and started to take turmeric powder to squash the inflammation. Earlier this week I started to look into McKenzie therapy to fully heal my spine, and “turn back on muscles that had not been working post injury”. Today was my second day of the stretches and while it feels great while doing them, at night, the tingling begins in my right leg which is raising the red flag for me. I am going to stop doing these stretches, because although there is absolutely no pain associated during performing these stretches, or after, I don’t believe that there should be any nuerological symptoms as a result of these stretches. When I read your article, it was an absolute revelation because when you mentioned L5/S1 and potentially worsening your condition my eyes lit up. It would appear, from a objective opinion that the excess flexion of the spine is causing this. If this is the case, what do you recommend? I have decided to forgo heavy lifting until at least a full year post injury, but I feel my explosiveness returning but am also hesitant to return to playing ball either. Thank you so much for your time if you have read this, I hope this message finds you well.

    Reply
    1. Chad Reilly

      Hi Rishi,

      I’m sorry to hear about your back. 22 is too young to be having to deal with herniated discs already. Back in my bodybuilding days (before I got into Olympic lifting) a number of my friends were competitive powerlifters, and I used to train with them often. At the time I adopted the low bar “power” squat technique and did a lot of deadlifting, so I think I can relate to the training you were doing. Also, you give a lot of information in your reply worth commenting on, so I’ll try and unpack it some. Please feel free to hit me up with follow-up questions if I miss anything or didn’t explain something well.

      For a powerlifter with back pain, what I would be worried most about would be the deadlifts. You saying your hurt your back deadlifting is a big clue. During squats, most powerlifters keep their backs very neutral and thus relatively safe. However, when deadlifting they will often have some degree of spine flexion, which in competition is advantageous. Some spine flexion when deadlifting helps you lift more by being able to reach the bar while keeping your hips higher. Full spine flexion combined with compression (like when powerlifting) I would think is one of the worst things you can do for your spine. However, I have not seen any data that indicates powerlifters have inordinately high rates of low back injuries. So I think powerlifters get a fair degree of protection from the fact that powerlifters usually only partially flex their spine, deadlift repetitions are usually low, often infrequent, and powerlifters have a great deal of muscle mass that helps stabilize the spine. How much spine flexion when deadlifting is OK, is a good question for which I don’t think anyone has a good answer. I recall seeing a study that found you could get away with 50% flexion before posterior disc stress became significant. However, in my patients with already existent back pain, my general answer is, “none.”

      Given you have two herniations, no spine flexion when lifting sounds like the safest answer going forward. I think your one doctor had a point in saying you are on risk management going from here on out, but I don’t know if things are so bad as to say you can never squat again. I get the vast majority of my low back pain patients squatting, and I consider squats a tremendous rehabilitation exercise for low back pain. However, I have them work up to doing them, and I have them start with no weight, I use high reps (15s), and I make sure they keep their chest high, spine neutral, and I limit their depth in the squat, stopping them just before their hips tuck under (thus flexing the lumbar spine). Some people have the hip mobility to do rock bottom squats and keep their spines neutral; however, some can’t even break parallel with a neutral spine. Low back pain/spine researcher Stuart McGill says this is a genetic thing based on how deep your hip sockets are, and I think he is correct. If your hip sockets (acetabulum) are deep, there likely will be some limitation in how deep you can squat and still keep your spine neutral. Front squats usually help, such that with the more upright torso, you can squat deeper before hips run out of range of motion. So that might be a reason you had good luck with front squats before.

      Romanian Deadlifts (RDLs) are another favorite low back rehab exercise of mine. Again, I almost never start my patients with them, but I try to work all of my patients up to them over maybe 3-5 treatments. RDLs are great for motor control, teaching people to bend though the hips (while keeping the spine neutral) they help to stretch out the hamstrings. Plus, RDLs strengthen the hamstrings and low back better than any exercise I can think of. So I think perfecting your form on RDLs would do you a lot of good. Whenever I hear about people being quad dominant, I think they should do more RDLs. Perfecting your RDL technique might get you able to do deadlifts from the floor, using an RDL like low back position but I would be slow and cautious going there.

      In your case I think you really have to think about what, besides lifting, led to your disc herniations. I would expect the lifting was just the straw (in this case a heavy straw) that broke the camel’s back. It’s probable that your discs were progressively bulging over the years, likely by how you sit when you watch TV, how you sit in school or driving your car, all causing hours of sustained spine flexion. Also, how you move when you sit and stand, get in and out of your car, and how you are training your abdominals contributed to the herniations. Most abdominal exercises are terrible for the spine because they combine spine flexion with lots of repetitions. Plank type exercises are usually better way to train abdominals and electric muscle stimulation (EMS) is way better still. EMS done right makes for more intense abdominal training than any exercise I have ever seen, by a lot. Everyone who tries it agrees immediately if I’m setting up their machine. EMS also has cool side effect of immediately decreasing pain, so it’s well worth looking into.

      How much should you lift? Nobody knows. I usually have my patients keep their reps high (15s) and their spine positions as close to perfect as I can get. Also I have them stop immediately, if there is any increase in pain or symptoms (like numbness). If they are going for 15 reps and they have pain on 14, I want them to stop on 14, and not do 15. Are sets of 15s the best reps for performance? I’m pretty sure they are not, but combined with good form and good spine posture during the rest of the day they are a pretty good insurance policy against reinjury.

      As for that chiropractor Eric Goodman, I checked out his website and it looks like he is teaching people to exercise with their chest out and back straight, which is good because that’s pretty much the neutral spine posture you should be hoping to maintain. However, I didn’t think his explanations for what he was doing were very accurate, at least not in the couple short videos I watched. It didn’t look like he was isolating the multifidus in any way, not that one would even want to, and his spine elongation/decompression exercises didn’t look like they were elongating or decompressing the spine at all. However, much like mild Mckenzie type stretches I think his stuff could bring some relief, mostly because he’s bringing the spine out of flexion, and in holding in mild extension. It looks like Goodman was increasing spine extensor endurance, which is more than Mckenzie stretches can offer. So aside from his explanations, I didn’t see anything that looked bad; however, I only gave his stuff a quick look.

      I think you are correct in stopping the Mckenzie stretches. Your discs have already herniated. If you had a mild disc bulge, mild Mckenzie stretches might help some. However, with disc material being in the vertebral canal, it’s too late for extension to push that material forward. You are likely getting some numbness with the extension stretching, especially if you are doing a full prone push-up, because spine extension decreases vertebral and intervertebral disc space. Also the herniated disc takes up vertebral and/or intervertebral space. The herniated discs result in decreased disc height (aka degenerative disc disease) which also decreases intervertebral disc space. So the combination is a triple whammy, hence the numbness you feel afterwards.

      Flexion most assuredly caused your injury. The key is simply to avoid flexion, through good posture, good motor control, good fitness, and good exercise technique. It’s already too late to push that material forward with extension, but the good news is that the body generally reabsorbs much of that material anyway on it’s own, you just have to stop hurting it.

      I hope that helps and again, feel free to ask follow-up questions.

      Reply
  2. Rishi Verma

    Wow.. Thank you so much for taking the time to write out this detailed explanation. Ironically enough, I just watched the video where Dr. McGill goes over the genetic potential for squat depth and found that pretty interesting. I’ve been putting off RDL’s and Front Squats for some time just to let everything run its course, and now with the numbness a few nights back, I wont be doing them any sooner than I had planned. Since, I have corrected most of my movement patterns, and like you said, it has been an injury in the making because of how poor my movement had been before, albeit I hadn’t known that I was breaking my body down instead of building it back up. I have no pain while performing squats or pulls so I’m confident that I will return even stronger (also staying positive which is important). In terms of spine flexion, I have completely eliminated it and don’t plan on lifting with any degree of flexion anymore, as I find it would adversely affect my spine. I have a handfull of friends my age, some even younger that have had disc issues that had much, much worse nuerological symptoms who have made full recoveries and have gone on to PR in both olympic and powerlifting. I consulted two physicians, one who told me to stop everything and go into management, and another who told me I don’t have to quit anything. Both looked over my MRI, so I’m not too sure which one to believe haha.

    Few questions on my mind:

    I find that olympic lifting does MUCH MORE to help build the core and remain injury-free. Although there are injuries in the sport, I find that these athletes are more explosive and functional. Are power-cleans off the table for me in your opinion?

    My goal is to get into some fronts and RDL’s by mid December, probably very very light at first. My depth has not really been an issue but to be safe i’ll stay wide and go to parallel and not full depth. Should I start with seated squats (sitting onto a base then just standing up), or go straight into regular squats?

    Backsquat: Low-bar is not something I will do for at least another year, is highbar the way to go for backsquat, or should I wait?

    Most important: I just want to play ball again, I don’t really care about slapping plates on a bar, I would like to have both but if I had to chose, it would be to play. Is this in jeopardy, and if so is just having an overall stronger body the solution to getting back into competitive sports?

    Thank you so much for clearing up a lot of issues for me man, you really know your stuff and I’m glad theres trainers out there like you helping athletes all over the world.

    Reply
    1. Chad Reilly

      Hi again Rishi,

      Regarding the contradictory advice between your two physicians, the truth is probably somewhere in the middle. Most docs just don’t know that much about how exercise affects the body, they (even spine specialists) just don’t get that much education in regards to the effects of exercise on the spine. Unfortunately physical therapists, who you would think should know better, generally get that much education in exercise, at least exercise that matters, either. That’s why you often see them using therabands, swiss balls, and wasting a lot of time with Williams or Mckenzie stretches, massage, needle poking, foam rolls, etc., I digress…

      I think what you want to do is an experiment of one (on yourself), gradually working yourself back, listen to you body and easing up as needed if symptoms return. Generally for strength and conditioning, if in doubt I increase the weights and see what happens. For rehabilitation, if in doubt I go easy and take my time, you just have more to lose by going too fast. Definitely keep checking out the Stuart McGill material.

      So as for you and power cleans I really couldn’t say. My competitive weightlifting experience was almost all before I was a PT, so I’ve never tried to get anyone with disc herniations back to doing cleans. I’m sure I’m considered aggressive returning people to squats and RDLs, and for my usual back pain population that’s generally enough. If I had a younger patient like yourself, they would probably have been pain free for some time before starting cleans again, and either their insurance would have run out, or they would be happy enough to go it alone and skip the co-pays before I progressed them to cleans. I wouldn’t say never though. Generally I start my patients with standing cable rows and presses, if those go well I’ll add the McGill big three exercises and lat pulldowns. If that goes well bodyweight squats, then have them start squatting with dumbbells, until they can do 15 reps without pain with 25 lb dumbbells. At which point I let them do back squats with the bar and progress slowly from there. RDLs I start a day or two after squats with no weight either and work it up with either dumbbells or a light bar. Beyond that I would would maybe start doing clean deadlifts from the floor, and if those do well try clean pulls, progressing to power cleans. All those progressions are tentative, and in rehab I always keep my reps high. I’m not sure how your back would take it with the low reps and high accelerations you get with power cleans. You would have both the weight and speed potentially working against you. The faster lifts should increase power for sports, but it’s iffy for your back. I’d definitely EMS those abs. Here’s an example of one of my stereotypical low back therapy sessions in someone who had no lifting experience, two years of chronic low back pain, on her 6th session.

      I do have a lot of people start with box squats if they need help with form and breaking their hips back. If they already have decent technique I’ll skip them ahead to free squats.

      As for high bar vs low bar, I have been thinking a lot about that lately. I think a lot of it has to do with your build. If you are naturally able to squat with a more erect torso then some people prefer high bar squats. Some people, who have a lot of forward lean feel a lot better doing low bar squats. It shortens their lever arm which should lessen lumbar stress. So that depends, try both and see which feels better. I don’t think one is inherently better than the other. I’ve done both, and I teach both.

      As for returning to basketball, increased strength, power, increased endurance, spine stiffness and improved motor control is what you want and should give you the best shot at recovery. And when you rest, you want to rest your spine in good postures. So when you are seated and relaxing, you want your back relaxed but neutral. That might mean shoving a couple throw pillows behind your back when you are watching TV. Sports will always be high stress and will often put your spine in compromising positions. Your back is better able to tolerate those stresses and positions if you weren’t sitting in flexion for hours studying or watching TV for hours earlier in the day.

      And you’re more than welcome. I think I write my best material when I’m answering questions, and it makes me think about things differently when trying to figure out new problems, so if you have more questions let me know.

      Reply
    2. Tim

      Wow this is great info as I am a pain sufferer with a disc extrusion of the s1-L5 and broad based disc of the L4-L5. I have been told by multiple Pts,Chrios that it is not the disc causing my upper glute pain that spans from the left of the si joint upper and over to the hip along the Glute MEd(told it is muscle. Also I have been told it is absolutely the disc from PTs and Chiros. My Doctor wants me to get a Cortisone shot, what are your thoughts on this?? My pain goes from right to left across to hip and not down the leg. The discomfort drives me crazy some days and I hope to be pain free someday. I have been doing the MK extensions but I am finding that I am more irritated after I do them. I have been told so many different things from Pts , so overwhelmed in what to do and not to do . I cant avoid sitting at work so I feel that I am screwed from life. Wish my spine was not the way it is and I fixed my posture many years ago along with everything else. When your in your 30s and your not in pain, your not thinking about your spine.

      Reply
      1. Chad Reilly

        Hi Tim. I’m against the cortisone shot. It will sometimes decrease inflammation, but the body should do that anyway. And, though rare there have been some very bad reactions (like put you in a wheelchair permanently) reactions to cortisone to the spine. The FDA now discourages them because of it.

        I would avoid the McKenzie extensions too if it were me. A meta-analysis that I blogged on found they don’t help either.

        My advice is to read about the causes of spine pain. I think that will make sense of the problem. A good chair at work (I love my Herman Miller Aeron) will help immensely. Putting the right size pillow behind your back when sitting on sofas at home helps a TON. Exercise wise I think SC5 would get you started, and as you start feeling better work into SF5. Described here, and a years membership is only $20. Less than most physical therapy copays, and my instagram shows SF5 builds muscle too.

        Reply
  3. Rishi

    Thank you so much man, I’ll keep in touch and let you know how I progress!

    Reply
  4. Rishi Verma

    UPDATE: lesson learned the hard way for me. Overworking the piraformis muscle can very well replicate the symptoms of sciatic pain. The sciatic nerve runs directly under the piraformis, and in some, may run through the muscle itself, thus if it is too tight, or overworked it could cause nerve irritation. From my understanding this is not a muscle that should be very large. Chad feel free to drop some knowledge if you would like. Thus far, in my recovery process I haven’t had sciatic pain ever so to think that I’m going backwards while having no back pain is counterintuitive. Trying to retrace my steps I think I’ve put two and two together.

    Reply
    1. Chad Reilly

      I wouldn’t pay any mind to the piriformis muscle, at least not nominally. “Piriformis syndrome” is a pretty sketchy diagnosis and one that I don’t personally believe in. Rather I think you just have a herniated disc, which is either directly compressing a nerve root causing the pain going down your leg, or the resulting inflammation from the disc material is irritating the nerve root, causing sciatic pain. It would be very coincidental that all of a sudden after herniating your discs, your piriformis started to act up and pinch the sciatic nerve. So I don’t think a tight piriformis is your problem. Back when I used to believe in piriformis syndrome, I would stretch it on my patients and they never felt better afterwards. Rather laying on your back, and stretching your knee up to the opposite shoulder generally results in more spine flexion further irritating the back, discs, and sciatic nerve.

      That said, I think hip abductor, adductor, and external rotators (for which the piriformis muscle is just one of several) are often relatively weak in people with back pain. Which is one of the reasons I generally have my patients do the hip abductor/adductor machine, even if it’s traditionally a girl exercise. However, I think the piriformis muscle, and later the multifidus and transverse abdominis get entirely too much press in comparison to their importance in relation to low back and sciatic pain. Rather I think all the muscles are important, you just want to avoid what irritates your symptoms, and get EVERYTHING as fit as you can, but using exercises that don’t cause harm.

      Reply
  5. Ben

    Hi Chad, I live in south Australia and unfortunately there are a lot of physio’s with a lot of different ideas, I’ve been diagnosed with a L4/5 mild posterior disc bulge and a L5/s1 focal posterior disc protrusion with an annular tear, it’s been nearly 6 months since this has happened and have seen a physio since but unfortunately no real results, if anything I have lost a lot of lower back muscle which I would think would not help, I am so unsure as to what steps to take next, was considering seeing a new physio that uses the Mackenzie method but am unsure if this would be the right move. I’m 35 and have always been very physical including a very physical job, I feel I have lost a lot of lower back strength and stability and have started back extensions hoping this might build up lower back strength, any advice would be much appreciated.

    Reply
    1. Chad Reilly

      Hi Ben, no worries, there are a lot of physio’s with different ideas here too. Most want to lay you on your back, stretch your knees to your chest, twist you back and forth, and then have you balance on a swiss ball. As if any of that will do any good.

      I agree it doesn’t help to lose muscle and definitely I think you want to get it back. However, having one herniated disc and another bulging, you should really look at motor control. If the discs are bulging and herniated posteriorly, which I’m sure they are, that means you are getting too much spine flexion either during your job, home, or recreational activities, but likely all three. If you were stronger before, that strength didn’t prevent the rearward migration of your disc material in the first place, so by itself it won’t be enough to prevent it going forward. There is actually research which shows people with strong backs are at just as high a risk of disc herniation as those with weaker muscle, because they use their backs more. Stronger hips and legs however, plus an awareness to move and lift in such a way as to keep the spine neutral should help to prevent further injury while your body heals itself. A strong back is good, but it doesn’t help prevent disc herniations if it doesn’t OCCUR TO YOU TO KEEP FROM FLEXING YOUR SPINE REPEATEDLY during the day. The good news is that the best exercises increase back, hip and leg strength all at the same time, while helping grove good motor control patterns but you will have to be very diligent about learning good exercise technique.

      A couple of blogs I have written discuss motor control exercise for prevention of further injury, another about reverse ergonomics, aka fitting the worker to the job, and what I think about McKenzie method. In the latter, I talk at length about exercises are good or not after herniated discs. I think McKenzie method has some good points to it and he teaches a lot of good stuff, however I think there is some bad in there too, which on whole would explain why overall that meta-analysis found it was of little benefit. On my low back pain page I have a video of a sample workout of what I think are some of the best exercises for low back pain. My treatments aren’t exactly like current spine researcher Stuart McGill’s but they are heavily influenced by him and generally follow the principles he outlines. He just came out with a book, Back Mechanic, on treating back pain that’s supposed to be in layman’s language. I haven’t read it yet but I just ordered a copy. If it’s as good as his other books, minus the medical jargon, I expect it would be $35 well spent.

      I don’t know if you can find a good physical therapist in your area or not. A relative of mine on the other side of the country had a lumbar fusion and her physical therapist kept stretching her in spite of the fact that it gave her more pain and defeats the purpose of the procedure she just underwent. She didn’t have any other physio options, so I told her to stop going and do home exercise. I hope that helps! Let me know if you have any other questions.

      Reply
  6. Ben

    Thankyou very much for your advice it’s much appreciated, it sounds like the Mckenzie method does have some benefits as long as it’s not over done and to listen to your body very carefully but the exercises you have given me through your video makes so much more sense in strengthening any weekness my body might have, unfortunately I haven’t worked for 6 months since the injury and haven’t made any progress since so it’s pretty disheartening, the problem I seam to have is any wrong move ( even in the shower) feels like it inflames the back muscles and then pulls to one side which then puts my lower back out of line and the only way to rectify this is seeing my chiro! but hopefully by doing these exercises I can start to make progress by
    building strength up in the lower back and hold my back in place. I don’t actually get a lot of pain more high discomfort it just feels like everything is extremely delicate and that my back will go at anytime, hence the reason I’m on the couch most of the time. Most probably the reason I’ve lost a lot of lower back muscle and support. Being that I’m home all the time would u recommend these exercises 2-3 times a day with low reps or only once a day only? Thankyou once again for ur time and advice, it’s so good of u to put time aside to help people and answer there questions. Hopefully I can get back to a normal life soon.

    Reply
    1. Chad Reilly

      Yeah, the wrong move in the shower is probably some kind of spine twisting, flexion or extension. The idea with the motor control exercises is to learn to get more motion through your hips, keeping your spine neutral, thus decreasing the number and severity of incidents that ‘light you up’ so to speak.

      FYI, I’d save money on the chiro; a number of studies (for which the authors are chiropractors) are finding manipulation just doesn’t work. Well it works better than a waiting list, but no better than placebo/sham treatments so it’s thought to have psychological benefits at best.

      Besides the exercise, EMS makes a HUGE difference in low back pain outcomes. With the right parameters, it very often shocks out the pain pretty quick while increasing core strength and endurance. Good machines can be had for a low as $150, and top of the line for $500-600 depending on your source. When I added the EMS to my program a couple years ago, I would say it improved my back pain outcomes a full 100%. It helps to knock out the pain, so you can train harder on the exercises, and the core strength you get from it seems to help people progress faster on the real exercises.

      As for the back exercises on my back pain page, the model in the video did not start out with that much weight. That weight was what she worked up to by about workout six or so. I’ll often start with the standing rows and presses, all of which I think are minimally likely to increase pain. Then if things are going well, I’ll add 1-2 exercises per day, with squats and RDL’s being the last exercises added due to the higher level of strength and motor control needed in order to be performed correctly. The isometric hold stuff on the mat table is done 1 set of 10 reps with 10 second holds, while the weight training exercises I usually do 3 sets of 15, easy medium and hard, progressing the weights the following session, only if they can do all 3 sets, pain free with good technique. You got me thinking I should do a blog just one my weight progressions for rehab.

      Reply
  7. Suz

    I came across your site looking for helpful answers to get me back to life again. On Thanksgiving last year I was goofing off with my 11 year old son and long story made short, I took the full force of his 85lbs while I was hunched over. Felt an immediate pop in my lower back and was in major discomfort right away. Went home, nursed my back with ice, got to the chiropractor who usually helps resolve immediate pains.. I had another back episode several years before that with a couple of chiropractic treatments and a few weeks I was up and going like normal again. Obviously that should have been a wake up call then, and I never should have put myself in a position where my son would drop his weight in my arms and I didn’t expect he would.

    I think I originally had sciatica but attributed it to the stiffness in my back muscles more than nerve pains… too much discomfort at first to really pick out what I was feeling. 2 weeks after the injury I started feeling like someone was splashing cold water on the top of my right foot, and the bottom of my left foot began to feel tingly/numb, not pins and needles, but not right. My chiro had told me not to bend forward, not to lift anything over 25 lbs, and no twisting.

    Fast forward. Back pain slowly subsided. Stopped chiro, started to feel like it was irritating my nerve symptoms in my feet. Saw my reg. Dr. who did an MRI, told me I had no disk problems but a cyst in my thoracic T12-L1. Picked up the report and read otherwise… L4-L5 broad based moderate posterior disc bulging causing mild central canal effacement, L5-S1 Broad-based mild posterior disc bulging. My chiro saw the report and says I shouldn’t have the symptoms I’m having from what’s on my report. Got the flu bug one day and was in excruciating pelvic pain for two evenings which I’m starting to think were related to my back as well.

    Started massage therapy to try and help relax muscles in my back and legs to further calm any issues ongoing and try and relieve symptoms. Felt so much better after the first massage. Symptoms slowly creep back in. Continuing to go as it seems to continue to help some, but I can’t afford to continue going at the rate I am now.

    Changed regular Drs. because we weren’t happy where we were anyway. Showed him the report. He too says I shouldn’t have the symptoms I have. Would write for PT to try and help if I wanted. My symptoms at that time were tingling/numb bottom of left foot. Back feels tight. He did check my reflexes, only person to do that, all normal. Said I shouldn’t worry because I’m not going to further hurt anything, my back is strong. (I had told him I’m not someone who normally has back pain after a hard day of manual work).

    Evaluation at PT, the therapist hardly looked at my report. Told her I wanted to work on core strengthening because I had once before stumbled upon your site and thought it a good approach. She said we would work on core strengthening, stretching my hamstrings as they are too tight because of the injury, and we would mildly work on some back exercises. The first session her assistant put me through McKenzie and the “floppy push ups” as I think you call them and my symptoms flaired in my feet and added mild sciatic back to the list. I called and she said to back down on intensity, not reps. She consulted with another assistant in the office and they didn’t seem to know what to do with me since my injury is straight and affects both legs. Her assistant asked what my pain level was and she didn’t know what to do with zero. Told her I’m not here for pain but symptoms and she looked at me like I had two heads. I backed their exercises down even further and wasn’t feeling too bad until Tues when the assistant decided traction was going to be it, sent me back to ice packs that evening as my lower back was in a flair of tenderness that I haven’t experienced in a long time. Now I’m paying for her guess and I feel like a lab experiment, sciatica in buttocks and off and on in legs. Each day is a little better, but they aren’t doing that again! Weird that the right foot splashing has seemed to stop again. I see the original therapist tomorrow and I’m about to the point of telling her if she won’t read over your site and follow your lead, I’m done.

    I’m 41 years old and my husband and I have a zest for life. We are active people who garden, heat our home with wood (read lots of days splitting (with a mechanical splitter) & loading firewood), play racquetball and pickleball, and my husband has been trying to get me biking or running/jogging with him. We had recently decided we weren’t going to let age take us down and we want to stay active. I so want to get back to life and not feel like every move I make will put me that much closer to surgery, and I hate not being able to do the things I love. I feel so fragile and want so much to get back to a full life without feeling strange things going on reminding me that I’m broken.

    If you have an outline of your system, or what you would recommend for me, please let me know. Any help is appreciated! Thanks so much for being open about your program online and giving people hope that life continues.. I’m ready to get a handle back on mine!

    Reply
    1. Chad Reilly

      Hi Suz,

      I’m sorry you had to go through all of that. My program is tough to put in an outline form but I’m actually giving it a go because I hear a lot about stories like yours. The tough part is that my methods aren’t just core strengthening but more total body strengthening to include hips and legs, minus all the exercises with high potential to irritate the back. Also tricky is that I use a fair amount of gym equipment that most people don’t have at home. On my back pain page, I have a video of what’s a typical program for people with chronic low back pain. I start people with just a few exercises, usually standing cable rows, and presses and maybe single leg press or hip in-out machine, generally performed three sets of 15 reps with easy-medium-hard weights (all the weights are kept relatively easy for the first 3 or so treatments) and I’ll add an exercise or two every day until the total body is being worked. Also EMS for back pain with the Globus Genesy 10-50-10 program and rubber carbon electrodes to the core is a BIG part of my treatment.

      Probably most important is knowing that the exercises you do, and even the EMS, is SECONDARY to learning how not to hurt your back during the day. You really need to practice keeping your spine neutral (through the use of lumbar supports when sitting and better motor control when moving) during daily activities to lessen the disc bulging stresses. In the meantime it’s probably worth reading Stuart McGill’s Back Mechanic. My program is largely based on his research, with EMS on top but his book gives great advice and is more home exercise friendly than mine if you don’t have a gym nearby. I hope that helps get you started.

      Reply

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