A disc prolapse or disc herniation is one of the most common spinal abnormalities leading to back pain. Herniated or slipped disc is a condition where the intervertebral disc bulges out into the spinal canal, causing pressure on the spinal cord and the associated nerve roots.
The condition is extremely common, and most people may have it without even knowing about it. For some, the condition may not be painful, while for others, it may cause discomfort and pain.
Anatomy of spine and disc
Our spine is made up of blocks of bones called vertebras. Between two vertebra lies a disc which is similar to a rubber washer, and it allows movement in the spinal column. In the center, the disc contains a jelly-like substance known as Nucleus Pulposus, which is surrounded by a fibrous ring called Annulus Fibrosus. When the annulus fibrosus becomes damaged or diseased, the nucleus pulposus is pushed out into the spinal canal, causing pressure to the nerve roots.
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Some facts about nucleus pulposus:
1. Initially,the nucleus pulposus is made up of synovial fluid, and later it gets replaced by Gallert tissue.
2. With aging, the Gallert tissue starts to lose its elasticity.
3. Nucleus pulposus transmits 75% of the body weight.
4. Nucleus pulposus is the only part of the intervertebral disc that is non-innervated.
5. Nucleus pulposus is made of 80% of water and works as a shock absorber during movements of the spine.
6. Aging reduces the water content of the nucleus pulposus.
Some facts about Annulus Fibrosus:
1. There are two layers of Annulus Fibrosus – an outer collagenous layer and an inner fibrocartilaginous layer.
2. The oblique fibers of collagenous fibers help in the rotational movement of the spine.
3. The Oblique fibers provide stability and flexibility to the disc.
4. Annulus Fibrosus transmits 25% of the body weight.
Stages of disc prolapse
As mentioned earlier, the spinal disc has two parts – the annulus fibrosus and the nucleus pulposus. The disc can bulge, remain intact, or the nucleus can leak from the torn Annulus. Here are the stages of Disc prolapse:
a. Bulging Disc – This is the first stage of the disc prolapse. There is no rupture of the annulus fibrosus. A patient can complete all his day-to-day activities pain-free, but intense activities like running, jogging, and walking may cause the symptoms.
b. Disc protrusion – In this stage, the disc further bulges, forcing the outer layer of the annulus fibrosus to move outwards. However, there is no rupture of the annulus fibrosus, and the nucleus pulposus remains within the annulus fibrosus. As the bulging proceeds in this stage, the compression on the nerve increases, and the condition becomes more painful.
The patient complains of a tingling sensation on the back and the thigh. Walking and prolonged standing also become painful. A patient may also complain of pain during sleeping, and to get relief, he may have to change the posture repeatedly.
c. Disc extrusion – In this stage, the annulus fibrosus may rupture, and the nucleus pulposus moves out, which causes compression of the spinal nerve resulting in pain in the back.
The patient feels sharp, unbearable pain even with the slightest movement of the leg and trunk.
In this stage, it becomes nearly impossible to reverse the hernia using only conservative treatment. Surgical treatment is much recommended at this stage.
d. Disc sequestration– This is a stage where the detached part of the disc becomes free. It may act as a free fragment in the spinal canal.
Risk factors of Disc herniation
Various factors increase the risk of the herniated disc, including:
a. Lifestyle factors
i. Smoking – Smoking causes changes in arteries and veins, resulting in their hardening and reduced blood flow. With reduced blood flow to the spinal disc, smoking may increase the chances of a herniated disc. Smokers may have an increased risk of back pain due to early disc degeneration (Fogelholm, 2001).
ii. Obesity – Being overweight increases the amount of stress on the spinal disc during the movement increasing the chance of disc degeneration (USA spine care and orthopedics, n.d.).
b. Posture abnormalities
i. Heavy lifting and excessive bending –Lifting heavyweight and excessive twisting and bending movement put a lot of stress on the spine. So, the jobs that include a lot of bending, lifting, and twisting activities can increase the risk of disc injury.
ii. Bad posture – Sitting and standing with bad posture can push the nucleus pulposus outwards against the annulus fibrosus. When the pressure continues, it causes disc herniation.
iii. Sitting – Prolonged sitting may also damage your intervertebral discs. So, take a break after a certain period of time to reduce your chances of disc prolapse.
c. Genetics and age
i. Disc problems are commonly seen in people who are over 45 years.
ii. People who have a family history of disc problems are more prone to developing the condition in themselves(Ala-Kokko, 2002).
Causes of intervertebral disc prolapse
There are various causes of a herniated disc, including:
a. Aging causes degenerative changes in the disc, which results in a herniated disc.
b. Any injury like a fall on the back can also result in disc prolapse.
c. Heavy lifting also puts pressure on the back, causing disc prolapse.
d. A sports injury may also result in disc prolapse.
How physical therapy helps?
Physical therapy can be highly beneficial in back pain by helping in determining the abnormalities in various musculoskeletal structures using different tests and analyzing the abnormalities in the movement.
A physical therapist firstly analyses the range of motion, which elicits the pain in the patient. He will also assess the reflexes, strength and perform various tests to find out any underlying pathology contributing to the pain.
Based on all the findings, a physical therapist will formulate a treatment protocol to manage the pain and increase the range of motion of the patient.
Physical therapy treatment for a herniated disc may include:
a. Manual Therapy
e. Heat and cold therapy
f. Stretching exercises
g. Strengthening and stabilizing exercises
h. Posture correction exercises
i. Balance exercises
A physical therapist will also advise the patient about ways to avoid disc injury in the future. As and when a patient finds relief in the pain, a physical therapist will incorporate the specific exercises to let him get back into the routine activities.
The McKenzie method
McKenzie method (Szulc, 2015) is one of the common treatment approaches that many physiotherapists opt for. This is best suited to relieve the symptoms related to radiculopathy caused due to disc herniation.
Exercises for herniated discs
While a patient with a herniated disc may find relief from various exercises, there are a few ones that are especially effective in managing the symptoms of disc prolapse.
a. Prone press up – The patient is asked to lie down on his stomach on a mat keeping his palms flat on either side of him. Now he is asked to gently push himself up using his hands. He is instructed to go as far as he can without exaggerating the pain. Repeat the process for few times.
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b. Piriformis stretch – While lying on the back, the patient crosses his right leg over his left leg while keeping his right ankle over his left knee. Now he is asked to lift the left foot from the floor and pull it towards his body. He is asked to hold it for few seconds and repeat on the other side.
c. Pull-ups – The aim of this exercise is to reduce the stress on the joints and the discs of the back. A patient holds the pull-up bar and pulls his body up using his arms to unweight the back. If a patient is not able to lift his feet completely from the floor, then he should aim for the maximum weight that he can hold for as long as possible. Repeat the exercise multiple times.
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Effectiveness of conservative treatment for the herniated disc
Most of the mild cases of herniated disc resolve on their own from 2-12 weeks. Conservative treatment is best suited when the pain doesn’t resolve on its own. A structured physiotherapy treatment model (Svensson, 2014)can resolve the symptoms within 3-6 months without any need for surgery.
Few studies (Abou-Elroos, 2017) show that for the short-term, surgical treatment is more effective, while for the long-term, conservative treatment is most suited (Gugliotta, 2016).
Physical therapy is one of the best conservative treatments for herniated disc, and studies have proved its effectiveness in managing pain and eliminating the need for surgery.
If you are experiencing any symptoms associated with disc herniation, then you should consult a physiotherapist from Progressive Physiocare. The experts will not only reduce your pain but will also teach you how to prevent the symptoms in the future.
1. Fogelholm, R. R. (2001, April). Smoking and intervertebral disc degeneration. PubMed. https://pubmed.ncbi.nlm.nih.gov/11339862/
2. USA spine care and orthopedics. (n.d.). Causes of a herniated nucleus pulposus — excess body weight | USA Spine Care | Laser Spine Surgery. USA Spine Care. https://www.usaspinecare.com/back_problems/hnp/weight/
3. Ala-Kokko, L. (2002). Genetic risk factors for lumbar disc disease. PubMed. https://pubmed.ncbi.nlm.nih.gov/12014433/
4. Szulc, P. (2015, September). Impact of McKenzie Method Therapy Enriched by Muscular Energy Techniques on Subjective and Objective Parameters Related to Spine Function in Patients with Chronic Low Back Pain. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4596425/
5. Svensson, G. L. (2014, March). A structured physiotherapy treatment model can provide rapid relief to patients who qualify for lumbar disc surgery: a prospective cohort study. PubMed. https://pubmed.ncbi.nlm.nih.gov/24336970/
6. Abou-Elroos, D. A. (2017, August 1). Prolonged Physiotherapy versus Early Surgical Intervention in Patients with Lumbar Disk Herniation: Short-term Outcomes of Clinical Randomized Trial. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573846/
7. Gugliotta, M. (2016, December). Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5223716/
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