What is a Herniated Disc?
An intervertebral disc is a cushion between the vertebrae (or spine bones) in our backs. There are a total of 23 discs in our spine: 6 in the neck, 12 in the middle back and 5 in the lower back. Although the discs are like tires – resilient and pliable – they are not hollow in the middle like tires but contain a gelatinous middle – like a jelly donut. The outside fibers of the disc are made out of annulus fibers and are rubbery, the inside gelatinous material is called the nucleus. These intervertebral discs act very much like a cushion pad for the spine during compressive axial forces, and also allow for flexible movement of the back.
Up to the age of 30 years old, the disks are very gelatinous and malleable. As we age, the gelatinous material starts to harden and desiccate (dry up). Because of this loss of moisture, they flatten and become less flexible, making them more prone to injury. In more severe cases of strain, the gelatinous nucleus may burst out through the annulus fibers – much like the jelly pushing out of the donut – and result in a herniation bulge of a tear in the outer fibers.
Below are the risk factors in developing a herniated disc:
- Age – the disc is at its most strain and weakened state when it starts to become more desiccated. This tends to happen between the ages of 30 and 50 years old. This is also known as disc degeneration. Bulging discs are less common in folks above 50 because of a more complete desiccation of the disc and therefore much less fluidity of material pushing out of the outer annulus fibers.
- Obesity – increased weight means increased axial loading on the discs and therefore more strain.
- Occupation – jobs that are physically strenuous and involve a lot of carrying, pushing and pulling can strain the discs and spine more.
- Sedentary behaviors – conversely, folks who do not regularly engage themselves in strengthening activities and lead very sedentary lives tend to have weaker core muscles the support the trunk. Less support almost always means more pressure and strain on the bony spine and discs.
It is found that up to 50% of the whole population in the world have some form of discogenic pain or dysfunction. The good news is that not all of these populations have symptoms. Their disk problems may not be severe enough to cause nerve pain – though their risk of future rupture could be higher. At the first sign of a back injury or neck injury, physical therapy can very much help with preventing already-weak structures getting weaker, and potentially prevent future severe disk herniations.
Additionally, evidence and outcomes have shown that a good majority of patients with disk herniations recover well with physical therapy intervention – with and without surgical intervention.
Signs and Symptoms of Disc Herniations
The tricky part about disc herniations actually lie in its symptoms. Patients may have mild to intense spine pain – or no pain at all. As mentioned earlier, there is a large portion of the population who present with asymptomatic disc herniations.
For those who do have symptoms, the slipped disc herniation is likely protruding out into the spinal canal and exerting pressure on spinal nerves or the spinal cord. This pressure on the nerves can feel like neck or back pain (depending on the location of herniation on the spine), numbness/tingling sensation to the arms or legs, or electrical/burning pain down the arms or hips and legs. These nerve sensations are called radiculopathy. Usually, nerve symptoms only affect one side of the body.
Following are the pain behaviors of a disc herniation:
- Pain is aggravated by prolonged sitting, bending over and reaching to the side.
- Pain is typically worse when staying in one position for too long, so the patient will feel the need to switch positions frequently.
- Standing is usually preferred over sitting because intradiscal pressure is less than in sitting positions.
- Pain alleviating positions include lying down with legs bolstered up with a large cushion underneath the knees.
Diagnosing a Disc Herniation
Your physical therapist can conduct an evaluation that consists of several key tests that would imply a bulging disc herniation. The evaluation consists of a thorough inquisition as the behavior of the pain including but not limited to:
- Location of the pain and its radiating qualities
- Times and activities that cause pain aggravation and alleviation
- How much your endurance is with different activities like standing, walking, sitting and sleeping.
The physical examination will encompass:
- A posture assessment to observe how you stand, bend over, walk and perform daily functional activities – particularly those that elicit pain
- Measure range of motion of your spine
- Test strength of extremity muscles groups that correspond to specific spinal levels that could hint of any severe abnormalities in neuromuscular connection
- Special tests that ascertain the likelihood of a slipped disc. One example if the Straight Leg Raise test to diagnose lumbar disc herniation.
- Assess joint mobility manually by gently touching and mobilizing muscles and joints of your spine
If the patient experiences severe and profound weakness, loss of sensation, or severe pain (greater than 8 out of 10 on a visual analog scale), then further diagnostics such as magnetic resonance imaging (MRI), or nerve conduction tests may be warranted. This would allow your healthcare team to hone in on exactly the location of the damage and the severity of it.
It is important to note that there is a reliable outcome data and research that supports physical therapy as a successful intervention for discal pain and can produce better long-term results than surgery. The cases where this is not true is in extreme cases of disk herniations involving high levels of pain, disability and profound muscle weakness, and loss of bowel/bladder control. ***
If the above severe symptoms are not happening to you, physical therapy treatment can commence immediately to help you with your pain relief. If the evaluation indicates that the slipped disc is causing severe nerve symptoms, your physical therapist should refer you out to a neurosurgeon or a physician.
What physical therapy treatments are there for disc pain?
After your physical therapist determined the etiology of your pain, they will form a treatment plan of care for you with the goal to help you resume your daily activities and sports. This plans of care will involve:
- Exercises that move you in such a manner that is decreased nerve impingement and pressure. Gentle exercises to help decrease pain and improve range of motion.
- Stretching exercises to improve muscle and joint mobility so spasms and joint lock-up is minimized
- Core strengthening exercises that promote trunk stability so that the skeletal system is less vulnerable to compression and shear forces. Strengthening extremities is also very important as squatting and using your legs more can take the place of lumbar spine forward bending (a usual aggravating factor).
- Aerobic exercise which helps to increase blood flow and healing. In addition to helping the body lose some weight that is contributing to spinal loading.
There is a lot of research proving that exercise is the crux to rehabilitating disc herniations. Besides exercise, there are also other techniques your physical therapist can do to relieve some of your discal pain:
- Manual joint mobilization and soft tissue mobilization to help with stiff areas of your back/neck.
- Posture - education and cueing to avoid positions of aggravation. Changes to way you sit, stand, bend over and carry objects can significantly help with pain relief and decrease discal pressure.
- Pain modulation via ice, traction and electrical stimulation.
It is vital to understand that physical therapy does not end with your last visit – posture re-education and core strengthening must resume to promote a healthy back and prevent recurrence of injury.
Can disc herniations be preventable?
Though bulging discs can occur as a result of aging, there are some key lifestyle habits you can adopt to prevent injuries from happening to your discs:
- Maintaining a healthy weight will prevent overloading of your spine
- Being cognizant of posture at all times – maintaining a proper alignment already requires core strength and back strength. Continuously being cognizant about this in life will also help maintain this core strength.
- Use good body mechanics — being cognizant of static posture is not enough. Life throws challenges to your body and you need to be aware of what is and isn't safe to do. If you are cognizant of good posture, this should not waver when doing activities like when you move homes or when you do sports.
- Also, a number of disc injuries occur at the workplace, when you are told to complete a task. If you sense that it involves an unsafe maneuver on your back – speak up to make a change in your work environment.
Come visit us and get your herniated disc treatment at one of our Portland Therapy Clinics today!