PT on the Net Research

Degenerative Disc Disease


Question:

I am currently training a 40-year-old female who weighs approximately 180 pounds at 32% BF. She has degenerative disc disease of her L3 L4 vertebrae. She is able to do a seated cable row, kneeling opposite arm and leg reach and hold and prone superman exercises without any problem, but she feels slight pain in her lower back when doing two leg planks. However, when we alternate from leg to leg on the plank, she feels no pain. Can you please suggest any other lower back strengthening/endurance type exercises that will not further aggravate her condition? Thanks.

Answer:

First, degenerative disc disease is a term that is used in a variety of ways. I will assume that you mean the natural fluid loss of the nucleus pulposus and associated drying out of the annulus fibrosis, starting around age 30 and leading to an eventual disc herniation and subsequent spinal nerve compression compounded by osteoarthritis. If it is specifically a painful disc herniation causing the problem, your client’s physiotherapist/physician will have a full report for you on the status and severity of the disease (hate that term). He will most likely have done an assessment (including a straight leg test to confirm it) and possible X-rays to look for further fractures and osteophytes.

Next, let’s address the main question: why does your client experience lower back pain during the two leg plank and not on the one leg plank, which has a higher level of difficulty and increased core demand? Without seeing your client do the one leg version, it seems likely that she is shifting the effort to the hip and/or laterally tilting her pelvis to avoid direct gravitational load through her core and lumbar spine. This compensatory pattern is common for those who lack strength in their core and hip stabilizers. If she is weak in her external rotators and lateral/posterior hip stabilizers (glute med, etc.), she will tend to rely on her illiacus as she shifts her weight laterally. Two signs to look for on the one leg plank are 1) see if her pelvis hikes, twists or swings out laterally, beyond her knee and foot and 2) ask her at the end of the exercise if she feels burning through the front of the hip and thigh. If so, chances are she is compensating, and the initial purpose of the exercise is lost.

If she feels pain during the two leg plank, it could be that she cannot activate her deep layer abdominals (TVA) and glutes effectively. In this case, her psoas muscles will try to pull the pelvis into an anterior pelvic tilt, causing inferior initiated lumbar spine extension and creating stress and compression to the associated structures. Even if the pelvis doesn’t tilt anteriorly, that doesn’t mean that there is not serious tension in the muscle and possible strain on the structures of the spine as it slowly loses the fight to resist extension.

As far as the other exercises you mentioned, they don’t bother her because she is either weight supported or has a base of support that is closer to her spine, therefore drastically reducing the forces acting on the core.

Remember

There are many people who have painful degenerative disc disease whose symptoms get better with age and some who never experience back pain. Further, just because she has this problem does not mean her plank pain is disc related. When you describe slight pain, it sounds mild in comparison to a disc or spur compressing a nerve. It could simply be muscular, stemming from an illio-psoas irritation/strain, or it could be from an existing condition of facet joint irritation, which will present primarily during extension of the spine, especially under a substantial load.

What really must be considered is the amount of mechanical load that is put on the lumbar spine in a horizontal position. This combined with your client’s high body weight and excessive percentage of non functional tissue leads me to believe that she simply is not ready to properly do the plank yet!

What I would initially recommend is the following:

Then

  1. Avoid all planks for now.
  2. Keep the supermans if there continues to be no pain.
  3. TVA breathing in four positions. During supine position, put a hockey puck or circular air freshener just below the belly button. On the exhale, your client should be able to tip the puck by simply drawing in her belly button. On all other positions, you should have one finger on the belly button and one at the same height but on the lumbar spine.
  4. Supine alternating single knee lifts with TVA activation and puck or freshener. Start with both feet on the ground and eventually progress to both feet up. Make sure she doesn’t flex the spine and lose her lumbar curvature during the concentric portion of the movement. Also, make sure that eccentrically she doesn’t move into excessive lumbar lordosis. (If done correctly, she should be shaking.)
  5. Prone cobra holds progressing to bent over diver holds with TVA activation. (See my two-part article series on Lateral Epicondylitis for a picture and description.)
  6. SB straight arm walkouts and holds, with monitored TVA activation and video for progress. Ideally use even a video phone to record the various positions on the ball as she moves further out over the ball each week. Only let her go as far as she can while being able to draw her belly button in to her spine 15 times. That is the goal needed for two sets before she can progress.
  7. Mc Kenzie method movement (Use only if she has no facet pain or other).

Also it is important to train any weak links in the extensor chain using NO momentum!

  1. Side lying single leg abduction with holds. Have her bring her bottom knee up towards her chest using only a range she can comfortably do. Hold at peak contraction for four to six seconds and repeat six times to start.
  2. Supine hip extension on BOSU if no pain is present. Make sure her feet are balanced, she can keep a neutral spine and she draws her belly button in effectively.
  3. Assisted single leg knee lifts while standing on the BOSU (psoas and hip musculature). You will need to help her a lot at first. Make sure her hip does not swing out beyond her base of support. If it does, go back and start with her standing on floor with two feet.
  4. Progressing to single leg SB toe touch with neutral spine. One foot on the ball, she rolls it back behind her as she bends at the waist and touches her front toe.
  5. Finally, work on one leg step ups on step and eventually bench. Research this one and pay attention to the subtleties, which are too numerous to list!

As a trainer, don’t forget to asses all areas of the involved kinetic chains for flexibility deficits and imbalances. This is extremely important in preventing future breakdown and in allowing access to the muscles you need to strengthen. And remember, it is not the exercises that make the trainer good and the results effective, it is the subtleties and details of each exercise that define whether it achieves its purpose.