PT on the Net Research

Herniated Discs


Question:

Could you please offer some suggestions about training people with herniated L4 and L5? I have a client who has a number of issues, but the most pronounced is his herniated L4 and L5. Plus, as a child, he had abdominal surgery. The incision was similar to the one used for Cesarean sections. Therefore, he has a constant pelvic tilt, which then adds to his back pain. Oh, and he's about 50 pounds overweight. Help!

Answer:

This is a complex issue and to make it sound too simple would be to fall prey to the weaknesses of the exercise industry. I will give some general indicators, but what is more important is that you study the relevant materials. According to Serge Gracovetsky, Ph.D., about 76 percent of the population at large - who do not currently have back pain - have an undiagnosed disc bulge (herniation if you prefer; not a sequestration). The point being, any trainer in a gym without significant knowledge of how to exercise correctly to prevent unnecessary disc stress or to manage an existing condition is in a sense working in a mine field! The condition you have described in your client above is the most common orthopaedic injury today.

Some clinical guidelines for this type of client/patient (someone with an injury is actually a patient!):

  1. The further from the back the client has symptoms (pain, numbness, tingling, motor weakness, circulatory/temperature changes, hair loss, trophic changes in skin and nails, etc.), the greater the magnitude of the injury and the more careful you must be! If the body has a shift (shoulders lateral to pelvis), the condition is again significantly greater in magnitude, and no attempt at exercise or centralization in the sagittal plane should be made until the shift is corrected. When working with such a client, always begin the session by asking the client to rate his pain or symptoms on a scale of 10 (i.e., "My pain is a 7/10 at present."). If his pain or symptoms increase in magnitude anywhere peripheral to the segment of injury, such as in the hip, knee, foot or ankle, you are making the condition worse and should stop that procedure immediately!
  2. If your approach is causing the symptoms in the legs to reduce, this is good. It is common that the pain becomes worse in the injured segment as it decreases in the more distal regions. This event is called "centralization."
  3. The safest and most common approach to this condition is the prone lying McKenzie press up, which is basically like performing a push-up but leaving your lower body as relaxed as possible. As your client pushes his upper body upward, arcing his low back into an exaggerated lordosis, it is important that he:
    • Not tighten the butt muscles or spinal muscles.
    • Breathe out (exhale).
    • Allow the head and neck to extend naturally with the rest of the spine. Don't allow the client to look down.
    • Go to an end range position that is uncomfortable but only therapeutically so. Forcing the end range position can cause the bulge to worsen if forced, but not coming up high enough will give poor results.
    • Stay in the extended position for as long as he can, coming down when he needs to inhale.
  4. Perform 10 repetitions every hour or as needed to control pain and pripherailization (travelling away from spine) of symptoms.
  5. Avoid any axial loading of the spine with your exercises until you have had a comprehensive evaluation performed. Any C.H.E.K Certified Level 1 or higher is trained to perform a comprehensive evaluation of this condition and can coach you and the client as to what exactly should be done to restore function! The Swiss Ball is your method of choice for such a client. I recommend a skilled evaluation to exclude any exercises that may decentralize the disc, though.
  6. Your client will need the following to properly recover function:
    • A corrective stretching program that targets all tonic muscles that have shortened (in facilitation).
    • A corrective joint mobilization program for any region of restriction in the entire kinetic chain; the back injury is commonly an injury of decomposition; this means the back was compensating for other problems and could no longer take the stress, thus the bulging disc.
    • A comprehensive corrective exercise program with all the necessary precautions taken to avoid exacerbating the disc injury.
    • An assessment of the client's ergonomics at home and work.
    • An evaluation of the client's diet and lifestyle factors; they dramatically influence the rate of healing!

Suggested Resources:

  1. I strongly suggest you get the book Treat Your Own Backby Robin McKenzie. You and your client should study it carefully.
  2. Much vital information is available to you in my programs titled Scientific Core Conditioning and Scientific Back Training. In these programs, you will find many necessary testing and corrective procedures outlined.
  3. I have produced two handouts that will benefit you: "10 Tips for a Healthy Back" will show your client how to manage an acute back injury while in the healing phase (it takes about 500 days for most disc injuries to fully stabilize under correct guidance from a skilled therapist), while "10 Tips for a Healthy Workplace" will show your client how to properly set up his desk or work station to prevent ergonomic insults on the injured spinal column. (These handouts are available on the C.H.E.K Institute web site.)
  4. I suggest you read my article series on PTontheNet.com titled Scientific Balance Training and pay special attention to the section on the survival totem pole. Here you will get an idea of all the body systems that can use the back to compensate for malfunction, leading to a disc injury as an indicator of decompensation – the body has worn out that compensatory mechanism. I also suggest you read the three-part article series on both PTontheNet.com titled Back Strong and Beltless because it will improve your comprehension of spinal stabilization mechanisms and functional anatomy, as well as the common abuses of belts and their proper use (as a lumbar corset when needed, not a weight belt!).

I hope you find this information useful, and I strongly suggest you take advantage of this learning experience so that you can prepare for a future of more of the same! Once you learn to perform a skilled orthopaedic assessment, you will be shocked to find that both the gym and your own clientele are probably littered with disc injuries and other spinal injuries that have been either mismanaged or misdiagnosed. It will probably shock you somewhat when you realize the danger most trainers expose their clients to out of ignorance.