Lumbar Disc Herniation - A Multidisciplinary Approach

[Mark Baer]

Hi good people of ATUNE,

I thought I would start a thread here to gather ideas and workshop different approaches to treating a lumbar disc bulge to include input from all disciplines.

Just in short, a common presentation of a lumbar disc bulge is irritable low back pain with or without sciatica where pain runs down the leg, and possibly numbness/pins and needles in leg/foot. A typical way to test for lumbar disc bulge is with a straight leg raise or slump test. Confirmation of a disc bulge is done with CT scan or MRI (as Xrays only show bones, not discs). Please let me know if you want me to go into more detail about presentation, examination, and diagnosis. If diagnosed, treated and managed well, what has the potential to be a chronic life long issue can be minimised into a 6-12 week recovery (a gross generalisation, but an illustration of both ends of the spectrum). So lets hear from y'all. Ill go first....

A few pics:

[Mark Baer]

In Osteopathy, I have seen the best results in my patients with acute disc injuries from a combination of the following:

- A good explanation of the issue to the patient
- A persistent/consistent motivation by the patient to follow protocol
- Good management of required lifestyle changes, eg expectations of self/pacing, adjusting schedules, not 'pushing through' the pain, dealing with frustration.
- Good balance of resting the area and movement/stretching/activity
- NSAIDs as per diections on the packet for 2 weeks (no longer), then decrease to aim for use only when necessary. Herbal anti-inflammatories worked well for me also.
- McKenzie method - (backwards bending to compress the disc back under the vertebrae)
- Swimming 3x/week or hydrotherapy if swimming is difficult
- Core strengthening
- Weekly decompression of the affected area with physical manipulation/ treatment
- General treatment of other areas for assisting compensatory patterns and general comfort eg stiff thoracics
- Reviewing and adjusting approaches as necessary.
- Simon would add "DRINK PLENTY OF WATER!!!" and also take glucosamine and condroitin.

Again, this is general and not a research based article, so feel free to add, critique, expand etc.... I think most modalities here at ATUNE have something to offer here. Please add your perpectives!

[Mark Baer]

A quick explanation of the McKenzie Technique....

This revolutionary development in treating disc injuries comes from the notion that the disc isn't bone or concrete, so why don't we just squeeze it back in? and it attempts this by applying forwards pressure to it in end range lumbar extension, that is, bending backwards as far as you can comfortably go (in a nutshell). Once the size of the disc bulge is reduced, pressure on the sciatic nerve is also reduced and the distribution of sciatic pain down the leg will go less and less further down the leg until it centralises in the lower back. There is a lot of variation on this theme you will find on YouTube for example. I have heard physios say that once the bulge (annulus) is retracted, the torn disc cartilage may actually mend with scar tissue and seal the tear in the cartilage. Again, a generalisation and theres more to it, but you get the picture.

This is the book behind the approach, but there is also the McKenzie Institute for the research and development behind it. Follow the link below the pic for a online copy of the book.

Online ebook: http://ebookbrowsee.net/treat-your-own-back-by-robin-mckenzie-pdf-d209505030
(I'm personally unsure of the legalities/ethics of this, and cant assure this link is virus free etc etc etc. Take precaution just in case)

McKenzie Institute & Research links: http://www.mckenziemdt.org/libresearchlist.cfm?section=int

Australian McKenzie Institute: http://www.mckenziemdt.org.au/

[Josh Laurie]

On the whole I follow a very similar protocol to Mark. I don't typically recommend the McKenzie exercises just simply because I'm not well versed in them beyond the basic theory of them. I focus a lot on gentle AROM for the lumbar spine early in the management - supine with knees bent rocking side to side within pain free range/single leg hip flexion exercises/supine hip wiggle for lumbar side bending. I also have a strong focus on icing the injured area each evening for the first 1-2 weeks and then after any flare ups or aggravating activities there on. I recommend the client avoids 'dosing up' too much on pain killers during the day early in the injury process as it can mask the pain to an extent where the client is not able to tell whether they are aggravating their complaint or not. I recommend they do use them to get a restful sleep if required as I feel it is important for the recovery of the area that the client is able to regenerate and heal while sleeping. I will give advice on the best sleeping positions for minimise risk or aggravation in bed.

Treatment wise, my first couple of sessions focus heavily on decompression of the lx spine and pelvis and particularly on removing any rotational strain patterns within (or originating from) the sacrum/pelvis. I find this very effective in unloading the injured site. My initial treatment focus tends to be on the hips/SIJs/sx/lowertx/dia/ql/glutes/psoas. I generally wont use any rotational lumbar techniques until the sharp pain as subsided. As the sharp pain subsides I will gradually introduce more directly therapy to the lumbar spine.

My shift towards long term management always begins with the introduction of basic core activation and postural awareness education, building up to pilates/yoga/hydro/water aerobic/low impact aerobic exercise as the client's ability and confidence improves.

[Mark Baer]

Yep, good point about being too 'dosed up' on medication to sense if they are aggravating things Josh!

Ill just post things while they are in my mind (before my mind goes on holidays...)

- Great resting position commonly called "The Astronaught" where the patient lies on the floor with their legs up on the couch placing the spine in a neutral position. It is the same position as they would be in if they were sitting upright in a chair, except facing the ceiling.
- Sleeping positions with pillows underneath knees if supine, or a pillow between knees and ankles if lying on side helps support the back from strain
- Some Lumbar mobilisation exercises for self management 1) with patient lying supine and bringing knees up to about 90*, and rocking them back and forth only about an inch so that it hinges at the lumbosacral (LS) joints specifically. It should feel soothing if everything but the arms are relaxed and the movement is well localised. 2) in the same position, swinging feet side to side and in turn, rocking the hips towards the head and away resulting in lumbosacral joint sidebending mobilisation. There are many other ways to get these LS joints mobilised in sidebending- the hip wiggle being an easier one for the patient to achieve too. 3) Supine with knees bent and patient rocking their knees side to side gently for rotational lumbar mobilisation (Are these along the lines of what you do Josh?)
- I have 3 easy stretches that I give out with the patient in a cross legged supine position.
The first is a piriformis stretch you are probably all familiar with.



The second is in the same position, but pushing the crossed knee away from the chest till it brings the hip lower as well. A resisted stretch (MET) pushing the knee up towards the chest against resistance from this position will traction the LS in sidebending when released. Activating transverse abs during this will help.



If comfortable with rotation, from the same starting position as above, rolling the crossed leg to the opposite side will not only stretch the gluts/piriformis, but also the lumbar joints in rotation.





Hope that made sense, been typing in between patients. Again, feel free to critique, compare, contrast, contribute etc etc etc. But for now.... Im outta here! See you in a few weeks!

[Nicola Tonson]

I use a combination of a lot of what Mark & Josh have suggested.

As with all conditions, but particularly with discs I think its helpful to set the patient up with a realistic recovery time frame. I find advising them that it might take 6-8 weeks to settle aids compliance with further advice given.

Rest is obviously important initially, (but not too much of course). I encourage the patient to try and find their own line of rest versus activity as it is different for everyone.

Definitely lots of icing, anti-inflammatories in the first week in particular, trying to taper off in the second. Pain meds only as need as they don't actually help the healing process. Josh I like what you said about day/night time use.

I don't tend to give any exercises in the first 1-2 weeks; probably because I'm tentative about causing a reaggravation. Once things settle a little though I suggest the same lumbar flexion/extension/rotation exercises in minimal range. I don't use the McKenzie technique.

I have suggested glucosamine on occasions, usually if the disc is taking longer to settle than I would suspect and I think that they need a continuous mild anti-inflammatory. I have also found it helpful in a few cases of radiating pain caused by osteophytic spurring rather than disc prolapse.

Once everything has settled I definitely try to give core exercises. For interested and compliant patients I have spent sessions just doing rehab exercises with minimal or no treatment - (look at the physio in me coming out!) I teach them to contract their core initially and then progress to basic swiss ball exercises (lumbar seated flexion/extension/side bending/rotations). I find building strength and increasing stability with the proprioceptive challenge beneficial. Finally I progress to more body weight bearing exercises.

If I proscribe glut stretches I usually suggest it seated. One ankle rests on the opposite knee and then leaning 5-10 degrees forward with a straight back. I think its an easier position for them to get into.

Osteo treatment wise - I tend to treat very indirectly the first couple of sessions. Lots of sacral float, TL balances and counterstrain through the lumbars and psoas. I tend to avoid massage until later on too.

[Anna Kurth]

I use a mix of the above procedures described by Mark, Josh and Nicola.
I tend to really lay on the advice in the first session (nothing different to what is mentioned above) and find that they are a lot more interested in this if I'm one of the first people they've seen. I agree that it's super important to get the client "on board" and having realistic expectations. I don't tend to offer exercises for the first 1-2 sessions, generally because the are so acute. When I do it's mainly seated piriformis and some supine knee hugging.
Treatment tends to be really indirect - sacral floats, lumbar BLT, diaphragms, SNS etc. When they're doing a bit better I tend to introduce some basic Ayle Ledderman muscular reAbilitation techniques.

[Nicola Tonson]

When they're doing a bit better I tend to introduce some basic Ayle Ledderman muscular reAbilitation techniques.

I'd love to know more about those Ayle Ledderman techniques... that's not something I've come across, though the name rings a bell.

[Mark Baer]

Thanks for some great insight fellow osteos! Do we have some more tips or advice from any of ATUNE's other wonderful modalities?