This condition is something most people fear in a very real context. A condition that often causes awfully unreliable pain that can range from niggling at times to excruciating pain that radiates across the lower spine and sometimes down the leg and into the calf. The pain can range depending on how much nerve impingement is present or how much muscular tension is involved. You can be fine for days, then unable to stand up straight at any point. It's unpredictable and accounts for some of the 'sore lower back' tension that many people feel but don't do anything about - until they go to lift something and then BAM, you're stuck in an uncompromising position and unable to move.
Anatomy
Commonly referred to as a disc bulge, a herniated disc is an issue where the intevertebral disc loses it's integrity and the nucleus pulposus or annulus fibrosis (soft squidgy bit in the middle) is unable to maintain the load and its structure and herniates (pops out) from the surrounding tissue. It's essentially like squeezing a Monte Carlo biscuit together. The cream on the inside cannot withstand the pressure and so it ruptures out the side of the biscuit. A good analogy of exactly what happens in the spine.
The annulus fibrosis is made up of fibres that actually act like cords that surround a soft centre, the nucleus polposus. These fibres are stronger in structure when they are extended, like a netting that is pulled tight the more weight that is inside it. When the intevertebral disc weakens or deteriorates with age the amount of tension that this netting is able to exert decreases which then weakens the strength of the nucleus pulposus. This 'squidgy bit' relies on the hard outer fibres to be strong and resilient to maintain its structure. Our discs begin to degnerate as early as 25 years old. So it isn't uncommon for people in their 30's to suffer from this condition. What exacerbates the condition moreso, is the shrinking and 'drying' of the nucleus pulposus which is made up of 80% water when we are younger and then by 60-70 years old, the disc becomes mainly fibrous in structure and not as malleable or 'cushion-like'.
This situation occurs early on in the neck where the disc space is already shortened, and then goes on to affect the larger lumbar discs in the lower spine. The disc space is vital and you can actually have a herniated disc without any symptoms of pain if there is no palpation of the nerve. The trauma of an accident is often a major cause but genetic contributions of weak ligaments in the spine make disc damage more prevalent in a person under 50yo.
Often it is the dreaded combination of lifting with rotation that causes a disc bulge, such as reaching for a gardening tool, or picking something up off the floor - a cause all too often seen in the clinic. The disc bulge is most common at the posterior aspect of the vertebrae which comes from spinal flexion (bending forward). When this is combined with even the slightest bit of rotation, this targets the weakest aspect of the vertebrae being the posteroalateral (to the back and the side) aspect of the joint space. Commonly this will occur at L4/L5 whilst impact injuries such as a car crash will occur in the cervical spine.
Treatment
A herniated disc will create muscle seizures and locking. This is to reduce movement in the area and to maintain structural integrity of the spine. What must occur is the reabsorption of the herniated disc into the annulus fibrosis. This is a waiting game and often needs rest and patience to occur. The bony alignment of spinal segments needs to be realigned to create the best positon for this to occur. When the spine is in acute flare and the pain is very real, pressure on the disc is not warranted. Working on the areas 'around' the affected disc will help to create space and movement of fibres the influence disc alignment. Getting the spine back into the 'base' position with a good lumbar curve and consequent cervical curve is ideal . SO depending on where the bulge is located, a therapist can still work on the body to influence the spinal alignment. Sometimes working on the legs makes a difference to the pelvic alignment which in turn makes a difference to the alignment of the lumbar spine. So a good therapist can always find a way to influence movement, alignment and pain reduction via a more appropriate postural position.
Being able to extend without pain and without irritation of the bulge is desirable and a good base to start from. Having a neutral curve in the lumber spine and a consequent alignment of the rest of the spine is vital. This is the basis for soft tissue/bodywork therapists. We get you in the right position. We create space. We get the basic postural alignment correct via techniques that work beyond the symptom and beyond the area of pain.
Working on the legs creates space in the back as does working on the ribs. Oddly enough, in disc bulge, the ribs help to reinforce the thoracic vertebrae so a disc bulge in this location is not necessarily common. However the ribs are vital to maintaining spinal alignment and the complimentary nature of curves throughout the spine. All these areas can contribute to assisting with neutralising disc bulge pain symptoms and creating space to assist with recovery.
“So a good therapist can always find a way to influence movement, alignment and pain reduction via a more appropriate postural position.”
Flexion and extension movements in a neutral non weight bearing position is key. Then introducing lateral flexion is the next step. All this is to be done in a neutral, supported position - ie non weight bearing. In this instance the Erector Spinae group of muscles that run along the spine like two thin fillets of lamb are vital to ensuring the individual rotation of each vertebrae are released and active to influence support for rotation. These muscles form an integral 'group' of muscles that all act together to facilitate rotation and help to reinforce the strength and integrity of the spine when it is 'in motion'. This helps to avoid the 'oh I reached for something' pain that so many people suffer from.
Prognosis
A herniated disc can take up to 12 months to recover from depending on the severity of the bulge, the impingement of associated nerves and the amount of anatomical strength/fitness going into the injury. Some minor cases can be treated in a manner of weeks but it really does depend on the impact that the bulge has on other structures. Rest is always the best form of recovery as you wait for the bulge to be reabsorbed into the spinal segment. Maintaining flexibility is important and securing a good postural base is vital. Anything that assists with this without irritating the bulge is an advocate for recovery.
Ascertaining the herniation is primary. Often indications of a disc bulge can be misconstrued by other symptoms. The situations that mimic the disc herniation are spondylosis (refer to previous article) and irritation of the spinal ligaments that irritate the radiating symptoms that occur along other areas of the body. In this case you need to understand how ligament issues differ from Disc herniations in assessment of muscular weakness and recovery from soft tissue bodywork. A therapist getting temporary results from treatment can sometimes mean that the disc herniation is actually the primary cause. Only an MRI can give you a qualitative assessment of the disc issue. So if you are unsure - PUSH FOR THE FULL SCAN.
Recovery/Rehabilitation
Along with getting soft tissue treatment, as mentioned before the postural integrity is of primary importance. If you have a strong base to start from then recovery is faster and more rapid. Your body knows the position it is meant to be in. Having a good postural position and strong muscular balance of stabilisers is all important to speedy recovery. Generating basic and functional extension of the spine is primary.
Introducing basic movements of flexion and extension are vital. As is rotation of the spine. This should be localised and minimal in the initial stages of recovery and with any instance of sharp pain, the protocol should be abandoned immediately. Basic movement patterning of this nature will help to re-introduce the body to movements that are vital to reactivating the spine and the disc into movement.
Everyone believes that core activation is the key to keeping the lower back in check. Yes - to a degree. In this instance, you need to make sure your core is active "in rotation" to really be strong and supple. It is one thing to practice core activation in a flexion/extension relationship but as is writ previously 'rotation' is the key. Use movements that twist you to maintain your core in this way and ensure good control and stability in the core whilst rotating!
The spine is a complex structure that relies on complete co-operation of all it's parts. So never underestimate the value and importance of complete spinal integrity. A disc bulge is concerned with one articulation, but there is so much involved in strengthening/maintaining ALL the contributing parts that make the structure work cohesively and harmoniously together. This is where a good therapist can always make a difference. There is always a way to treat the condition without always being focussed on the symptom.
