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Corrective Exercises for Herniated Disc

23

Filed Under (Fitness, Low Back Pain) by Rick Kaselj



I always get great feedback on back pain articles and today I have one on herniated discs.

Enjoy and make sure to Facebook like this and leave us a comment or question.

A herniated disc, also referred to as a bulging or slipped disc, is an injury that can set back even the most highly trained individual. It can result from the effects of aging (as in degenerative disc disease), cumulative and repetitive disc trauma over time, or a specific, traumatic event.

The information presented in this article will focus on the lumbar region. If a herniated disc presses on a nerve, it can cause back pain or sciatica. If you are experiencing low back pain and/or pain down one or both legs, it is advised that you seek the help of a licensed health-care provider.

The goal of herniated disc treatment is to decrease stress on the spine. This is typically done utilizing exercises that improve core stability and posture, as well as those which correct muscle imbalances. Manual therapy and other modalities are often used in combination with an exercise plan.

Corrective Exercises for Disc Herniations

 

#1 – Hip Flexor Stretch
Kneel on a soft surface and bring one leg in front, placing the foot flat on the ground so the knee, positioned over the ankle, is bent at about a 90-degree angle. The back knee should remain on the cushioned surface and should be bent at a 90-degree angle as well. Slide the front foot forward a few inches. Brace the abs and squeeze the glute of the side that is being stretched. Shift the hips forward. The angle of the back knee should now be slightly greater than 90 degrees. Hold for 10 seconds and perform 5-10 repetitions, then switch sides.

For a version of the stretch that’s easier on the knees, try starting from a standing position. Take a big step backwards with one leg. Bend the front knee until it’s over the front foot while simultaneously shifting the hips forward. Keep the back leg straight throughout. Hold for 10 seconds and perform 5-10 repetitions, then switch sides.

#2 – Ham Stretch
Stand next to a bench or table. Lift your leg up onto the table so it is fully extended and straight. Rest your hands on the top of your upper leg for stability. Slowly lean forward, keeping your leg and back straight until you feel a stretch in your hamstring area. Hold the stretch for 10 seconds, then stand back up and rest. Perform 5-10 repetitions and switch sides.

#3 – Bilateral Knee to Chest
Lie on the floor, arms out to the side and knees bent. Slowly bring one knee toward the chest, then the other, aided by placing both hands on the back of thighs. Hold for 10 seconds and perform 5-10 repetitions.

#4 – Single Knee to Chest
From the initial position for the Bilateral Knee to Chest, slowly bring one knee close to the chest, aided by pulling with both hands. Hold for 10 seconds and perform 5-10 repetitions. Switch sides.

#5 – Pelvic Tilts
Lay on your back with your arms by your sides, your knees bent and feet flat. There should be a space between the floor and your low back. Inhale first, and then initiate the pelvic tilt movement as you exhale. When you let your breath out, your belly button should come toward your spine as you tilt the bottom of your pelvis up. This will result in your low back gently stretching and reaching in the direction of the floor. Inhale to come back to starting position. Perform 10 repetitions.

#6 – Bridges
Lay on your back with your arms by your sides, your knees bent and feet flat. Make sure your feet are hip-width apart. Push through your heels to raise your hips up, creating a straight line from your knees to shoulders. Squeeze your glutes and brace your core. If your hips sag or drop, lower yourself back on the floor. The goal is to maintain a straight line from your shoulders to your knees and hold for 20-30 seconds. You may need to begin by holding the bridge position for five-second repetitions as you build your strength.

(Above is a more advanced bridging version with the foam roller)

#7 – Iso Hip Flexion
Start in the same position as the Knee to Chest stretch. Draw both knees toward your chest until your thighs and torso form a 90-degree angle. Place your hands on your knees and try to move them closer to your chest, but resist with your hands so no actual movement occurs. Hold for 10 seconds and then relax, and perform 10 repetitions.

 

#8 – Safe Crunch
Lie on your back with your left leg extended. Your right knee should be bent and your right foot flat. Place your hands palms down on the floor underneath the natural arch in your lower back. Slowly raise your head and shoulders off the floor without bending your lower back or spine, and hold this position for 5 seconds as you exhale. Perform 5-10 repetitions and then switch legs.

#9 – Bilateral Knee Raise
Sit on the edge of a chair or bench with your knees and feet together. Lean slightly backward, keeping shoulders pulled back and chest up. Bring your knees towards your chest then extend them back out towards the ground. Perform 10 repetitions.

#10 – Air Bike (more advanced progression)
Sit on the edge of a chair or bench with your knees and feet together. Lean slightly backward, keeping shoulders pulled back and chest up. Bring your knees towards your chest then perform a pedaling motion. Make sure that you aren’t simply pushing the feet in and out, but forming a circular motion with them. Perform 10 repetitions pedaling away from you, and 10 repetitions pedaling toward you.

#11 – Accordions (most advanced progression)
Sit on the ground with your knees bent and feet flat. Your hands should be extended out to the sides and parallel to the ground. Raise your feet off the ground and bring your knees toward your chest. At the same time, bring your hands toward one another and exhale, pretending you are squeezing an accordion. Then extend legs out straight and parallel to the ground and extend arms out to the sides.

 

Rick Kaselj, MS

Here are some other exercises that may be of benefit to you:

Now if you are looking for something to help you over come your back pain and get you back to pain-free workouts, then check out Fix My Back Pain.

Fix My Back Pain

Facebook comments:

Comments posted (23)

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Hi Rick and Sarah.

I hope you take this constructively but I believe many of the exercises you described are contraindicated not only in the acute/subacute low back pain population but especially in discogenic cases.

Naturally, it is important in such cases to identify, through a clinical audit, both aggravating and relieving movements, positions and loads, but more often than not, flexion based exercises (loaded and unloaded) are harmful for hot discs.

Here are some resources:

http://www.youtube.com/watch?v=kukmaW9CmSU

http://www.youtube.com/watch?v=033ogPH6NNE

Jeff

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Rick Kaselj Reply:

I agree. I would focus more on pain management, decreasing muscle tension, activating inner unit and hip movement.

Sarah explains her situation below.

Rick

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Hi,

I just wanted to point out that many of these exercises, and especially those involving hip flexion with movement on the lower extremity will create a flexion moment in the spine. Almost all disc herniation in the lumbar spine are posterior slips. Flexion moments in the lumbar spine will exacerbate acute discal presentations and are not advised. Perhaps these exercises would be suitable for those who have managed to get out of an acute exacerbation with sufficient bracing but are not advisable for those in acute situations.

Tom

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Rick Kaselj Reply:

I view corrective exercise for someone that is outside of the acute phase.

If they are in the acute phase or get symptoms with any of the above, I would regress, modify or eliminate the exercise.

Rick

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Correction, that should read with movements of the lower extremity, not “on”

Tom

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Hi Rick,

I want to start off by saying, as Jeff did, that I hope you take my response as constructive feedback. A lot of the exercises that you have demonstrated would involve putting a flexion intolerant patient through lumbar flexion. Stu McGill has published a lot of research on this topic and thus it would be my recommendation to avoid these types of movements. You are on the right track in understanding that creating core stability is very important for a disc patient; however it is my belief that when we are trying to accomplish this by using flexion based movements we are working against our-self. In these types of movements, it will be common for the hip flexors to do a lot of the actual gross movement, leading to less optimal activation of the global core system. This leads to hip flexors that were perhaps already tonic continuing that trend. Likewise, the amount of compression and shear force that will be placed on the lumbar spine is very high. Again, for a disc patient (or even a healthy patient) I think this is something that we should avoid. One last thought to perhaps think of; in these types of exercise it is very common to see anterior head carriage. If we follow a joint by joint approach, we know that the neck should provide stability. When we train movements that have the potential to compromise a “packed” neck position we are only cementing a dysfunction. Allow the cervical spine may not be directly involved with a disc herniation, it is my belief that it can effect what is going on at the lumbar region.

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Bilateral knees to chest? Air bike? If you have a true lumbar disc insult, these movements will exacerbate your condition.

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Having dealt with over 100 cases of acute disc herniation in the last 15 years I would say that you would want to reconsider the level of spinal flexion in this program for acute herniations which may be obvious but even for those where the bulge has apparently returned to normal. . So if there is a herniation that has ‘corrected’ itself the outer cartilage of the disc(laminae) can remain damaged for up to two years post injury. IF THE damage is on the posterior aspect of the disc, as most are, there will be risk for re herniation, or worse, for sequestration IMO. For this reason I wouldn’t include much for lumber flexion that may cause the nucleus pulposus to push outward on the damaged laminae, while possibely including flexion exercises that don’t flex the lumbar spine.

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Agreed with Thomas and Lance. Typically you want to avoid flexion based exercises. No offense but some of these exercises would be aptly coined exercises you do not want to do for disc herniations.

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Hi Sarah and Rick,

I think it’s great that you are working hard to educate the public, but I would have to agree with the other commenters about avoiding flexion. When dealing with a herniated disc it’s just a bad idea. Bringing the knee to the chest will often cause pain when someone has a severe herniation.

I can think of 2 situations where you could apply your exercises and get a positive result.
1. If a herniation is very small, you can probably get away with the things you mentioned without the client noticing. However, the larger the herniation, the more likely it is to bother them.
2. If you are dealing with someone with a weak core musculature (but not a herniation) I think the exercises are great. It will definitely help them get back on track and pain free.

I know of times in the past where I did the things you mentioned, and it worked with clients. But I also realize that there are times that I really lucked out and they ended up getting better despite some of the mistakes I made. The research shows that flexion on a herniated disc is not a good idea, and the reason physical therapists use that rule is due to the physiology associate with the anatomy and the thousands of patients they treat every year that confirms it. Also, because physical therapists are dealing with more severe cases, their patients are going to be hypersensitive to the wrong movement. In personal training, the clients are not dealing with a severe herniation.

I really believe your heart is in the right place, but I have to respectfully disagree with some of the exercises.

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Same as written above by others.

Some of these exercises specially in acute cases as knee to chest, even pelvic tilts could cause increase of the symptoms due to pressure placed on the disc and pushing nucleus out.

I completely agree with opinions on fb that is important to get full ROM in spine, just acute phase of herniation might not be the best time to do that.

It’s just my opinion but clients with disc pathologies should be first trained how to not hurt themselves (hip hinge, sitting, lifting…) Then work on spinal stability (adequate to their level) and increase of distal mobility

exercise like bilateral knee raise will help to strengthen ,,core,, but will also work even harder (psoas) which might cause increased shear on the spine if not stabilized properly as in disc pathologies common.

I think that variations of planks, chop and lift (core work with extended hips) and even lower variations as a dead bug could be more appropriate choices.

Rick and Sarah no offense and if that program worked/works for you and your clients that’s great. Above are just my opinions
TJ

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My two cents-
I totally agree with everything that has been said above. I am suprised to not see any planks, side planks or bird dogs…the basics that McGill recommends. I also wanted to add that I have had wonderful results with Mackenzie (Protocol )extensions for relief of disc pain, both with clients and myself. Always get them out of flexion and into some gentle extension and teach NEUTRAL spine. On the other hand, if back pain/radiating pain is from spinal stenosis- if you have that diagnosis- flexion can make things feel better- so having the right diagnosis is key to know what exercises help or hurt. I have also found that tight ITB’s can produce pain that mimics radiating nerve pain, so if foam rolling lessens pain- you have a clue as to that involvement in the pain syndrome which is very common.

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I have always read and been taught that you should NOT stretch the hamstrings if a patient has a herniated disc in the lumbar spine??

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Jan- totally agree. IN my experience, hamstring stretching ellicits radiating pain in many cases as hams are so tight, client flexes spine during stretch. Hamstring stretching is way down the line of things to be done … only once acute incident has subsided. In fact, this brings up a great point… No trainer should even be trying to treat disc herniations with exercise- that’s not our job. So even the name of the original article is a bit misleading. Since 80% of us have some disc issues- we will see many clients with DJD that are asymptomatic. But any one with symptoms that are acute and undaignosed should see their MD or a PT or a chiro etc. first of course.

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@Jeff Cubos
I agree with Jeff. Flexion based exercises would probably aggravate a disc-lesion. Corrective exercises for disc-problems would include good core stabilization from the inside out ( by activating proper diaphragm function), off-loading the lumbar spine by learning better hip-hinge patterns and by improving the cortical control of the movement patterns.

Hans

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I would agree with avoiding flexion exercises for disc herniations. Using the diaphragm to start stabilization first, most people cannot even breathe properly! Even when clients get better I believe there are much better ways to train the hip flexors without calling it an ab exercise.

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The blog post was actually based on my own experience. I went through 5 months of PT twice a week to rehab my herniation and resultant foot drop from the affected nerve. This is part of my explanation (copied from email I sent to Rick earlier this week):

When I put together what I wrote, I was drawing on my own herniated disc experience. I worked with a PT for five months and I realize no two cases are the same. In addition to my going through PT for that 5 months, I have volunteered with a PT and in an orthopedic clinic, and worked for two chiropractors. I’m no stranger when it comes to spine-related issues! I now realize that I should have been more specific in explaining what kind of herniation the advanced exercises are appropriate for.

My diagnosis was herniation at L5-S1 (slightly at L4-5 as well), with a fragment pressing on nerves which affected my left leg. When viewing the MRI films, the herniation was not posterolateral but lateral. I had L5 root involvement resulting in foot drop.

Perhaps I should preface the post with this information? I don’t have to say that “I” was the affected person, but perhaps point out that in the case of a posterolateral herniation, things would be different? In the exercises that involve flexion, the ROM is so small that it seems ridiculous to try and prove my point.

I honestly found it counter-intuitive that my PT prescribed flexion exercises, but when realizing that in my case, I have always dealt with excessive lumbar extension, it made sense. I even asked him about this because an “uh-oh” went off in my head when he first demonstrated the air bike. I thought “isn’t it bad to do an exercise that puts the lumbar spine into flexion?” He showed me my MRI CD again and it made sense when I viewed the lateral films of my lumbar spine. Both the “air bike” exercise and the “accordion” are basically static holds with hip involvement. I wasn’t prescribed tons of reps of flexion.

I have dealt with back issues since the age of 12. I was a gymnast and have always wrestled with a persistent anterior pelvic tilt! Perhaps being a gymnast set me up for issues down the road. My herniation was most likely a long time coming, and the slip and fall that resulted in the nerve involvement was what sent me to PT. Because of my low back issues, I know how important it is to stay on top of core stabilization “homework.” As you know, a low back injury shuts down the functionality of the core musculature, so it can be a vicious cycle maintaining the integrity of the region. I was not surprised to see how weak my core was when I started PT. It was definitely an eye-opener! Prior to the advanced exercises that were implemented towards the end of my therapy, they had me do a lot of manual therapy/isometrics just to get those muscles firing. I was never prescribed exercises such as the McKenzie press-up, etc, which serve to “re-seat” the lumbar curve.

Putting me into further extension would have been a nightmare!

So, I feel 100% confident backing up my post, but perhaps all that is necessary is a preface which lays out the specifics of the herniation.

Thank y’all for the feedback and for being part of the intelligent side of the fitness community. Not to hijack the comments thread, but I would love to see a discussion about Crossfit & injuries related to what has become such a big presence in our field. I am not on the CF bandwagon and (of course), whenever I speak my mind about it, I get flamed by a defensive CF proponent. 😀

Anyhow, have a great weekend!
Yours in Health,
Sarah

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Hi Sarah,

I think it completely depends on the stage of your exacerbation. If you are acute, there is no way that your back is going to tolerate any amount of flexion whatsoever, whether it’s negligible as you contend or not. It’s basic mechancis. The anterior longitudinal ligament is big and fat in the lumbar spine which makes anterior herniations very very rare. Hip flexion does cause a certain degree of a flexion moment in your spine. There are a dozen other factors at work as well, such as how well your inner core is already functioning, the degree of “sloppiness” in the back that is existent and so forth, so you may have been one of the lucky few that survived something of this nature and actually benefitted from it.

On the other hand, when publishing something that is very generic in nature, as the title suggests itself you have to be very cautious giving this type of information out because as a clinician that see’s MANY herniation patients weekly I can tell you that nearly 90%+ of my patients would scream in agony if I prescribed anything near that level of load and flexion for them.

I think you agree by stating this in your article above:

“Prior to the advanced exercises that were implemented towards the end of my therapy, they had me do a lot of manual therapy/isometrics just to get those muscles firing.”

Evidently there was a lot of prep work going into it before loading you in the manner those exercises do. And that is precisely what most of the critics have been alluding to. You can’t just put someone who is in an acute exacerbation into those positions and expect them to work. In most cases you are going to do more damage. That’s not just my clinical opinion. It is backed up with hundreds of peer reviewed articles and basic understanding of biomechanics of the spine as well as stages of the injury (acute, sub acute, chronic, etc)!

Just throwing a cautionary note out there, not suggesting that you weren’t meaning well.

Tom

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This one definitely struck a nerve, with some strong although constructive opinions. Let’s add some facts.

1. Some people can be helped with lumbar flexion, the McKenzie system (MDT) has differentiation rules for this possibility, literature supports it, as well as my own clinical experience
2. This also states that the remark ‘McKenzie extension’ does not do justice to the MDT for it contains flexion and lateroflexion tests (and exercises) as well
3. A bulge laterally does not indicate flexion, extension intolerance as a symptom on the other hand, may well indeed

It is more than likely that the author has recovered with these kind of exercises and that the bulge may in fact had no stake in her symptoms.

In the light of this, I believe that this article is justified, reminding us that there is nothing generic to non specific low back pain and we need to differentiate. We have a phase 0 classification system called MDT and it does prescribe flexion in rare cases.

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Can anyone please tell me what to do for those you have flexion tolerant back…. please … As far as I’m concerned, one has said anything about the right exercises to be done if you have a flexion tolerant back…

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Rick Kaselj Reply:

Please provide more details.

Rick

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I totally agree with everything that has been said above. and according to my experience ,pain management is the first step before starting any exercise protocal .next we can think about McKenzie level one . next im looking for further discussion on ” NOT stretch the hamstrings if a patient has a herniated disc in the lumbar spine” can anybody tell me why? next can we give piriformis stretch ?? if yes then , why not hamstrings. thank you

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@Baneet sharma – You need to be cautious of it as it could stretch the sciatic nerve and irritate things in people with back pain due to disc herniation.

Rick

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