The disc herniation and corrective exercise article sparked some discussion, which is great to see.
I wanted to respond back right away but I took so long to reply because I did not want to start an argument or come across as being defensive.
After reading things and letting everything sit for a few days, here are a few things that came to mind.
Before I get to the stuff, just a reminder that this month’s Injury of the Month is ready to go. It is Piriformis Syndrome. You can check it out here.
Now back to disc herniations.
Most People Have Disc Herniations
Let’s face it, a lot of people have disc hernations. The chances are good you have one.
Here is some research that highlights this:
Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994 Jul 14;331(2):69-73.
- Thirty-six percent of the 98 asymptomatic subjects had normal disks at all levels.
- With the results of the two readings averaged, 52 percent of the subjects had a bulge at at least one level, 27 percent had a protrusion, and 1 percent had an extrusion.
- Thirty-eight percent had an abnormality of more than one intervertebral disk.
- The prevalence of bulges, but not of protrusions, increased with age. The most common nonintervertebral disk abnormalities were Schmorl’s nodes (herniation of the disk into the vertebral-body end plate), found in 19 percent of the subjects; annular defects (disruption of the outer fibrous ring of the disk), in 14 percent; and facet arthropathy (degenerative disease of the posterior articular processes of the vertebrae), in 8 percent.
- The findings were similar in men and women.
A little more research.
Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. (1990). Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8.
- One-third of the subjects were found to have a substantial abnormality.
- Of those who were less than sixty years old, 20 per cent had a herniated nucleus pulposus and one had spinal stenosis.
- In the group that was sixty years old or older, the findings were abnormal on about 57 per cent of the scans: 36 per cent of the subjects had a herniated nucleus pulposus and 21 per cent had spinal stenosis.
- There was degeneration or bulging of a disc at least one lumbar level in 35 per cent of the subjects between twenty and thirty-nine years old and in all but one of the sixty to eighty-year-old subjects.
I know you are thinking, “Man, my back must be messed up”.
Let’s talk about your neck now.
Boden SD, McCowin PR, Davis DO, Dina TS, Mark AS, Wiesel S. (1990). Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Sep;72(8):1178-84.
- Abnormality in 19 per cent of the asymptomatic subjects
- Of the 19 per cent, 14 per cent of those who were less than forty years old and 28 per cent of those who were older than forty
- Of the subjects who were less than forty, 10 per cent had a herniated nucleus pulposus and 4 per cent had foraminal stenosis.
- Of the subjects who were older than forty, 5 per cent had a herniated nucleus pulposus; 3 per cent, bulging of the disc; and 20 per cent, foraminal stenosis.
- Narrowing of a disc space, degeneration of a disc, spurs, or compression of the cord were also recorded.
- The disc was degenerated or narrowed at one level or more in 25 per cent of the subjects who were less than forty years old and in almost 60 per cent of those who were older than forty.
- VERY IMPORTANT, AND THIS APPLIES AS WELL TO EXERCISE PRESCRIPTION – The prevalence of abnormal magnetic-resonance images of the cervical spine as related to age in asymptomatic individuals emphasizes the dangers of predicting operative decisions on diagnostic tests without precisely matching those findings with clinical signs and symptoms.
If 52% of People Have a Disc Herniation, What Are We Doing to Keep Them Out of Lumbar Flexion?
My life in lumbar flexion:
- When I go to my family doctor, I sit on my bicycle and bike there. Sitting on my bike puts me into lumbar flexion.
- When I go to the Chiropractor, I drive there. My truck seat puts me into lumbar flexion.
- When I go to the physical therapist, I sit on the edge of the treatment bed and this puts me into lumbar flexion.
- When I go to the massage therapist, I sit in the waiting room on a firm hard chair, which puts me into lumbar flexion.
- If you do what Dr. Stu McGill calls the “Midnight Mambo”, this put you into lumbar flexion.
It is nearly impossible to avoid lumbar flexion and a lot of what we do on a day-to-day basis puts us into it.
It is probably more important to look at duration, frequency and load compared to the act of lumbar flexion.
Plus, it is tough to think all of the above is okay, but doing 30 seconds to 60 seconds of exercise is going to be the thing that slips your disc or causes a disc herniation.
What Kind of Client do You See?
The setting I work in will affect the type of disc herniation client that I would see.
When I worked in a Medical Rehabilitation Program (MRP), I would see the worst of the worst. The ones that tried Physical Therapy, Chiropractics, Massage Therapy, etc but did not get better. The disc herniation clients that I would see had all kinds of symptoms and limitations.
How the MRP worked was, each client would be seen by the sports medicine doctor, he would let me know what the medical findings were and then provided direction for the exercise program. Then I would design, implement, supervise and progress the exercise program.
Looking at all the settings I have worked in, the type of disc herniation client varied. The client differed depending if they were in a Work Hardening Program, Occupational Rehabilitation Program, Chronic Pain Program, Physical Therapy Clinic, Community Based Rehab, Personal Training Studio, Gym or Recreation Centre.
I think we see or hear something and think of the typical client that we see or that we come across in our work environment.
Now I see clients that have finished their medical care and have been cleared to start an exercise program. They have an injury, limitations and an area that I need to focus in on. Based on their injury, function and goals, I need to know which exercises will help or make things worse.
We Like to Focus on What Not to Do
When I go to the doctor, my list of what I should not be doing is a lot longer than my list of what I should be doing.
Many times I leave with the fear that if I do anything, I am going to make it worse.
I feel I should lie on the floor and not move.
I wonder if I breathe too hard it that will make things worse.
I very much felt this way after my car accident or after I saw my physical therapist when I flared up my back and had all kinds of neurological signs.
Now my guidelines are simple.
- Movement is good for you.
- Focus in on the movements you can do.
- Work around the movements you can’t do.
- Do what you can with the movement you have.
- Work on constantly improving your movements.
Have We Drunk To Much of the McGill Cool-Aide?
I remember when Paul Hodges came out with his research on transverse abdominis activation and how this was now going to save the world from back pain.
I remember when Paul Chek came out with his concept of core training and how this was going to save the world from back pain.
I remember when Juan Carlos Santana did all kids of core exercises with the stability ball and now this was going to save the world from back pain.
Now everyone is quoting Dr. Stu McGill on bits and pieces of his research and how this is going to save the world from back pain.
I wonder what will be next.
Hodges, Chek and Santana were in very 1990’s. McGill was very 2000, let’s see what comes up in the rest of this decade.
Stu McGill’s Research Says…
I have two of Stu’s books.
I have organized a conference and brought him to Vancouver. I have attended his course.
I have heard him talk at another conference. I have read a few of his research articles of his 147 that are on PubMed.
I use his information as a piece of my core exercise continuum.
I can’t say that I have read and know all of his research.
He has probably forgotten more about the back and his research than I know about the back.
Corrective Exercise is Not For Acute Clients
Corrective exercise has a lot of misconceptions around it.
One of them is what an acute client should be doing it.
When I worked with acute clients, I never did any corrective exercise stuff.
I use corrective exercise for healthy individuals who need to have specific movements restored.
- Stage of Recovery – This will play a role in deciding the exercise. Whether they are acute, sub-acute or chronic will play a role when it comes to the exercises they need to do.
- Guest Blog Posts – I like to let guests speak their minds. I don’t like censoring them. I like to hear their perspective because their education, learning and experience is different than mine. Many times this leads to discussion, which is great.
- McKenzie Protocol – I do like this system and have hosted them in Vancouver before. I find it very effective for SI Joint pain.
I am getting a little long with this post.
I will cut it off here and pass it onto you.
One last thing. I had a reader email me and say now they are confused on what to do about exercise and a disc herniation. I will be back next week with some clear guidelines on what to do.
Let me know what you think.
Rick Kaselj, MS