I am currently training two clients who have recently undergone therapy for L4-L5 herniations. I have only been working with them for a couple of weeks, and they are making good progress. My question is, how much time should I give them before starting any exercises/activities that require spinal flexion, or working in the tranverse plane (i.e., woodchoppers, twists, etc.)? Both of these clients have medical clearance, I am just looking for some general guidelines of how best to progress their programs.
Thank you for your question. Unfortunately, disc herniations are very common especially in the L4-L5 region. Research has shown most adults are walking around with herniations, however, asymptomatic (no pain is felt). Moreover, it is often found that the disc is NOT the main source of pain; it’s actually the neural and active structures (muscle, fascia). This is why resting hasn’t proved positive results.
With respect to your question, it is imperative you start moving the spine in ALL planes as soon as possible. Although very non-traditional, this approach is critical to your clients' function. However, please follow the points/guidelines and adapt to your clients individually:
- One of the main reasons for disc herniations is excessive repetitive micro trauma. This micro trauma means neighboring structures are not helping to absorb and transfer forces (in simple terms). Therefore, you must check the thoracic spine (above the problem area) and the hips, knees, ankles (below the problem) for optimal tissue extensibility in all three planes of motion and for strength in all three planes of motion. Once you have found the restrictions, develop a plan to mobilize the restricted areas, followed by functionally strengthening the entire chain.
- Assess your clients' lifestyle. This means all movements they perform throughout the day. For example, analyze the complexity of getting in and out of a car – the spine must flex, extend, laterally bend and rotate. Therefore, the question is, how are they performing the movement? If poorly, then you must improve it seeing as it happens daily. Point: don’t be overly cautious. Just be smart and never allow a movement to take place if it causes pain; yet remember, pain is your best coach as it will direct you, if you listen.
- Start movements (exercises) with bodyweight with an understanding that an exercise (although we have placed “special” names to it) is nothing more than a movement performed repetitively with load. The goal is to challenge movements in a conditioning program, so when a movement is performed in life, it can be easily tolerated. Therefore, your program must be functional, which translates to the spine moving in all planes of motion – the way it’s designed to.
- Although structural changes have occurred in your clients, you will still apply the aforementioned tips as everyone’s function should be defined individually (work with what you have to improve one's life movement).
For more information on this subject, please see Gary Gray’s Functional Video Digest on the Lumbar Spine – well worth your time and money!