14 Nov Herniated…Slipped…buldging discs…THE TRUTH
Perhaps the subject I’ve most been asked about are herniated discs… from family, friends or many strangers after they find out I am a physical therapist. It seems to be the most popular ‘oh, I have a question for you since you are a physical therapist’ moment at dinner parties and meeting new strangers once they know what I do for a living.
The funny part is, they actually rarely listen and heed the advice I give them.
They ask, they seem to want advice and answers, but they don’t take it. Instead they use it as a platform to complain, talk about their pain, and tell me how it wont get better, they need surgery, their friend says it’s the worst thing ever, their doctor said it’s the worst they have seen….the list goes on. It seems like more of a conversation piece than someone in pain genuinely wanting the right answer.
This actually plays into the causes and problems with herniated discs: the personality.
Its been said many times that back pain is all in the head. While this isn’t fully true, there is a very large psychological component to the problem that also needs to be addressed.
But lets back up. What is a herniated or bulging or protruding disc?
No matter what word you use to describe the disc physical movement, they are all actually the same thing. Thus, just the terminology alone does not tell us the extent of the injury or which are worse than others.
Nor does an MRI.
Let me say that again: an MRI also DOES NOT tell us the extent of the injury. Thus it does not tell us anything about which are more serious than others. It gives us some anatomical consideration, but not in terms of severity to the patient. And this is the most important factor. It also doesn’t tell us a lot about how to treat it.
In general, if we look at MRI’s of many low backs, we will see a larger percentage have what looks to be severe disc herniations that even seem to be hitting the nerves…yet they have no pain. And we see a good percentage of patients who complain of severe pain that have nothing at all on their MRI’s.
So what does tell us about the extend of the injury and the way we should treat it? The symptoms.
Why? The symptoms tell us how the condition has progressed if it has, how severe it is, and what we can likely do to get rid of it.
Why is this?
Imagine you have a pebble in your shoe. Now imagine if that pebble is sitting right under your big toe. Every time you walk, you will hit down on your big toe and feel the discomfort. Now imagine its under your heel…a wider surface. You are still going to feel the pebble but likely a little less since the surface area of your heel is larger than the pad under your big toe. Simple physics tells us this. The pressure is equal to the force acting over the area. Smaller area, bigger force.
Now imagine the pebble is pushed to the side of your shoe where you don’t feel it at all or between the toes or in front of the toes or on top of the toes. You may not feel it at all.
The same is true of herniated discs. Just because you see one on an MRI does not mean the patient feels it as if the pebble is under the heel, toe or somewhere outside the foot. It is not possible to know if that disc is severe or not. The only way to know is to ask the patient about their symptoms and put them through a series of movements to ascertain how that disc is acting.
Thus the physical exam and asking pertinent questions is the most important part of assessing and treating a herniated disc!!
So what are the symptoms of a more severe herniated disc? In general back pain alone does not indicate a severe disc problem. In fact, it generally means it is not severe at all.
What does determine if the disc is more of a problem is the presence of pain in areas other than the back.
Lets say back pain puts us at a 1 out of 10 in terms of severity. Then mild to moderate pain puts us at a 3-4/10. Severe pain or pain radiating into the glute/butt puts us at a 5/10. Still not a very severe disc problem if we are at 50%.
When the pain starts to travel down the leg, we are getting up to the 6 range. Down the knee and into the foot lets say 7. If that pain is there most of the day, not just with certain movements we have moved to 8.
Last and the most severe type is losing muscle strength in the leg and inability to move the ankle up and down. This is a 9 or 10.
So now you can see that simple back pain puts us at a 3 or lower in order of severity. Not much at all to be worried about. This is why the vast majority of herniated discs are non surgical and can be treated by physical therapy.
In general, muscle weakness in the foot or even knee is a need for surgery. However this is the only type of herniated disc that is and should be a clear surgical indicator (in most cases). Anything else, therapy must and should be tried first unless there are other comorbid factors at play.
Thus, when we talk about low back pain, no matter the severity, surgery should not be the option in the absence of lack of muscle control. Nor when we see pain down the leg. A good physical therapist should be able to get rid of both most of the time. However, this only works when the patient: 1. Wants to get better and believes he will get better and 2. Does what he is supposed to do at home every day, several times a day.
If you have seen a therapist, done all your homework several times a day, stayed away from the positions that cause more discomfort, ask yourself first…am I wanted to get better? As I have mentioned a large part of this problem is psychological. The back is deeply emotional and I will tell you after seeing hundreds of these patients over 15 years, personality and will to get better is a huge factor. The other main factor is whether you have found a good physical therapist.
Do you have a good physical therapist? A good physical therapist works on you with their hands. They move things around, loosen things up, give you repetitive stretches and movements to do at home, and spend more than 20 minutes with you. They don’t leave you to an aide or assistant to go exercise. They ask you with every exercise and every manual treatment about your symptoms. They monitor the nerve involvement as you move. They do not let you do any movements or exercises that cause numbness and pain. They don’t watch you do a hundred movements, they help move you, and give you afew pieces of homework.They will also let you know that treatment is also up to you: your attitude and your commitment to the stretches and movements while avoiding the aggravating factors. This is why most people don’t want to listen to my advice. Most are looking for a ‘quick fix’ like surgery and don’t want to hear that it can be a month or two of persistent work on stretches and modifying your lifestyle, and going to a therapist. Its actually a life long commitment to doing the work on your own!
Along with the treatment, the activity modification they teach is imperative. This does not give you the right to be a couch potato. It does mean that any and all positions and exercises and movements that cause any pain or nerve symptoms must be avoided. Even if it is simple sitting (the most common cause of herniated discs!). Good posture and avoidance of certain positions while adding the movements your therapist supplies, is the only way to get better. You must give in…give your back what it needs and wants.
Yes, most doctors will tell you to have surgery. Why? Because they don’t know how to rehab it. Why is that? Because they were not trained in rehab. They don’t know a good therapist. Or because they will make more money on the surgery…way more money than writing you a prescription for physical therapy. And because by doing so they will create a long term patient!
Why else should you not have surgery if it is not indicated? Because you are not fixing the source of the problem. You are taking out the pebble but not teaching the body how to keep more pebbles from forming. You can be sure more will take their place. Your problem will not end with surgery because you do not learn what you did to get the problem in the first place. Thus, the chance for recurrence the next level up on the spine is likely. And pain is also likely as well. Not to mention the trauma of surgery causes inflammation and scar tissue…two things that are exactly the reason why the disc is bothering you in the first place. This is why alot of surgeries don’t work and why a good therapist is paramount!
So if considering your options, consider searching for a physical therapist who is not in your network. In-network therapists are constrained by time. They will not have enough time to get you better. They will have assistants and aides who are not skilled. They will not offer you what you need. Seek an out of network or cash based therapist. I know spending money is not what you want to do, but they are the only ones that can spend time one on one to do manual therapy, what you really need. And afterall, its your back…you have it for life. Investing in it is one of the best things you can do for yourself.
Sure sometimes injections and medications are needed to aid the healing. A good doctor will actually recommend therapy, followed by drugs and then injections in that order if things are slow to improve.
And most of all, relax. You may think its a horrible problem, feel anxious and stressed and like it is never going to get better. These feelings are unfounded. It is actually one of the most common ailments of American society. Your anxiety and drama is actually doing more to hurt than help! Know that relief is available, you just have to find the right medical team to do it. If your doctor recommends surgery without any of the above, especially if the pain is confined to your back only, you can be almost certain he is not the doctor you are looking for. He feeds into the drama and anxiety as well. This is not promoting health, only fear.
Disc problems are fixable. We do it every day in my office, and we aren’t just magicians. We work with patients who want to get better and we give them all the tools they need to do so.