|11-19-2007, 06:18 AM||#1|
Disc Hernitation / Prolapse Thoughts and Suggestions
I notice that there is another question on disc-ey stuff that showed up recently...
Since questions about this seem to come up fairly frequently on the boards… I will do my best to relate my experience:
I am currently 15 months out from a fairly severe L5-S1 prolapse, and 10 months out from a completely debilitating re-injury of the original herniation. In January of 07, I couldn’t walk, work, sleep, or sit for almost 1 month. I was offered surgery in Febuary, due to progressive bilateral symptoms and some symptoms of cauda equina syndrome. In consultation with the surgeon, I aggressively pursued non-surgical rehab, and am currently stronger than before (although not symptom, nor activity restriction free!)
The following is my suggestion for non-surgical re-hab, based on my experience. Surgery has it’s place, has helped many people, and in a study of professional atheletes in the US… showed a 92%!! Return to competetion rate, post surgery. Familerize yourself with the symptoms of cauda equina syndrome, and if you start to experience any of them… GO TO THE EMERGENY ROOM, IMMEDIATELY!
However, take note of what one of our Spinal Neuro-surgeons in Calgary told me: “If you come in at 3am, screaming in intractable pain, I can make you feel better the next day. Anything less, and it’s a crap shoot as to whether or not I can help you.”
NOTE: If your lower back hurts… THIS IS NOT FOR YOU. A symptomatic prolapsed disk, will display shooting LEG PAIN (ie. Sciatica). You will have a positive straight leg raise (S.L.R.) test. If you have that, read on.
1. No sitting.
2. No, really… NO sitting. NONE.
3. Spinal extension good. Compression bad.
4. Spend a lot of time at the swimming pool.
5. Anything involving increasing intra-abdominal pressure (ie. Valsava manuver), bad. Forget about weighted squats or deads for a while. Try not to sneeze, cough or laugh.
6. Glutes and hams are really going to tighten up from this… try to streach as much as possible without aggrevating the area… ie. NO compression.
7. ALWAYS pain free range of motion, with exercise / activity. NOTE: With disc stuff this means the day after too. If you feel worse on day 2, back off.
So. You “tweaked” your lower back… and now you have shooting leg pain with anything approaching a forward bend.
What to do?
1. You may ONLY operate in the pain free range of motion. If it hurts, even a bit, you can’t do it. This may mean eliminating ALL of your workouts.
2. No sitting.
3. Spend as much time in spinal extension as possible. If you work on the computer… you are now doing it from the floor, on your belly.
4. Do multiple sets of “sloppy push-ups” / upward dogs / cobras / spinal extensions each day.
5. Consider a steroid injection (nerve root block) into the affected nerve root, if your symptoms are severe enough.
6. NSAID’s are your friend. Take as many as you need, and can tolerate, to control symptoms. Max daily dosage of Ibuprofen is 3200mg, not the 1200mg they put on the bottle… consult on this with your physican. Keep in mind, that these things are BAD for you in the long term… but can be very helpful with your injury in the short term.
Semi Acute Phase
So, you are feeling a bit better, can get around ok, still hurts to sit, still positive S.L.R., but impoving in your ability to do daily tasks.
1. The swimming pool just became your best friend. Yes, the chlorine stinks. Yes, every old and pregnant lady in town is faster than you are… learn to love it. 1 hr or more / day. Try pool running. Don’t forget PAIN FREE RANGE OF MOTION! …some of the pool running strides can incur leg pain… don’t.
2. You can now start to stretch… again, pain free. Standing glute stretches should be well tolerated. Standing or lying single leg hamstring stretches are more troublesome, but do your best. NO spinal compression.
3. Gym stuff. Again, pain free. Try air squats, overhead squats with PVC, deadlifts with PVC. KB swings with VERY light weights… ie. 5 – 8 lbs. Toe hops, if you are having weakness in your calfs (to force the neurological pathway to fire, not to stress the actual muscles). Ab exercises to enfore the use of the the lower abs, pelvic floor, and multifidus… this will be a lot of bridgeing / planking exercise, and lateral stabilization on swiss balls. NO spinal compression. Try DB / KB toss and catches to get your multifidus working. While we are at it, learn to find and fire your multifidus.
4. Still no sitting.
1. Minimal sitting. Hard chair and lumbar roll if necessary. An ice pack in the small of the back works wonders for driving.
2. Yoga. Yes, yoga. Xfit folks disparage it. Ignore them, and become a member at your local studio. HOWEVER, keep a few things in mind: As always, pain free range of motion. Your lower back MUST NEVER ROUND. Looking around the room at your local yoga studio… you will see 90+% of the students, with rounded lower backs. You CANNOT do this. Much of yoga involves forward bending. However, it only involves forward FLEXION of the spine, when it preformed improperly (with the exception of some poses, which you will avoid). You will always bend forward from the hips, with a flat lower back.
a. So, why yoga, seeing as it will be a hassle to do it in a manner not further injurious to yourself? Because it is going to help to expand your by-now severely curtailed range of motion. You need to GENTLY push youself back into full, symmetrical movement. Yoga will help (with a flat back! And lots of modifications to poses as necessary)
3. Gym & Other activity. Start working on those squats and deads. Add weight. Keep a lordotic arch. Avoid ballistic exercises. Get lots of exercise in general, but avoiding spinal flexion (biking, rowing) and ballistics (oly lifts, running). Add weight to you KB swings. Do lots of swings. Investigate you movement asymmetries. Work to reduce them. Try a one legged, straight leg, deadlift, with a 5 lb dumbbell. Keep the un-weighted leg in line with your body as you rotate forward around your hip. Keep your hips flat. Can’t do it? You are esstentially doing a S.L.R. test while standing, in the guise of a deadlift. Bend the supporting leg and try it. Keep working on it, and get it symmetrical.
4. Did I mention lots of KB swings?
1. Lots of activity
2. Lots of yoga or streaching. Your preference… but as with x-fit exercise, be sure to expand yourself into ROM’s that you don’t “like”.
3. Add ballistics back into the exercise program. Add plyometics, if you are going to be doing high impact things (skiing, mtn biking) to get your body “ready” for the impacts. Don’t forget all of that lower abdominal, core bracing stuff. Not everyday, just occasionally.
4. Still reducing sitting, lots of attention to posture, and a lumbar roll.
In no order…
Things that I KNOW really helped (at the appropriate time):
1. No sitting
2. Steriod injection.
3. KB swings
5. Front / OH squats & lighter DL’s
7. Very painful Japanese acupressure massage.
8. Some serious introspection as to the underlying emotional / psychological causes. (Seriously. Try John Sarnos book, Understanding Back Pain, for starters.)
Things that helped a bit, but not tons:
5. Active Release (this should go at the top end of this category)
This injury can be completely debiliatating, and VERY scary.
Let me assure you, that you will get better. Follow a few rules, treat yourself gently at the beginning, learn to lie on the couch (with a lumbar roll), and gradually start to push yourself as you get better.
Good luck all.
|11-19-2007, 06:19 AM||#2|
Re: Disc Hernitation / Prolapse Thoughts and Suggestions
The following is posted in for interest. I wrote it prior to my visit with the spine surgeon, ~4 weeks after the re-injury.
Lumbar Disc Herniation History
➢ Bilateral Numbness (parasthesia), on outside soles of feet, outside posterior calves and hamstrings, and posterior buttocks
➢ No (or severely reduced) reflexes in both legs.
➢ “Soreness” in right calf and back of right knee
➢ Weakness in both calves, particularly the right
➢ Sciatic pain in right hamstring on forward flexion.
➢ Sciatic pain in both hamstrings on sneezing or violent coughing.
➢ Pain on extreme extension, as well as flexion.
➢ Comfort in “neutral” position: slight flexion to slight extension
➢ Improved mobility & reduced pain over last 2 weeks, from prior L leg only symptoms, increasing numbness and weakness, and symptoms in R leg.
➢ If we treat conservatively (without surgery) what are the chances of me suffering permanent damage (weakness / numbness) if I do not improve swiftly?
➢ Given that I can GUARENTEE that I will encounter impacts, and lumbar flexion in the future, due to my lifestyle… what is the best treatment option?
➢ If we do perform surgery, what sort of permanent inhibitions can I expect due to the materials (disk, bone) that you will remove? … Do I lose “shock absorption” from the removal of disk, and protection from the removal of bone?
➢ For this surgery, why should I choose an orthopedic vs. a neuro- surgeon?
➢ Procedure? Microdiscectomy, Laminectomy, Chemonucleosis, Percutaneous discectomy, Endo / Athroscopic discectomy?
Previous Injuries to the region:
• Summer 1999, Sciatia from tree planting / overuse (repetitive bending over). Rehabbed over summer, no further symptoms by Winter
• June 2002, violent flexion of lumbar spine, caused by under-rotation of a front flip on trampoline. Landed on shoulder blades with legs folding down violently. Sciatic symptoms in left leg & buttock. Minor sciatic symptoms from long periods of sitting for ~10months.
• July 2003, VERY hard forward flexion from paraglider crash, thought I broke lower back at the time, no- long lasting symptoms.
• June 2005, fracture of transverse process of L5 RHS, from paraglider crash. Force equivalent to jumping off the roof of a vehicle moving at 40km/hr & landing on one buttock.
Aug 21 – 24: Repeated poor parachute landings onto L leg, resulting in a feeling of “shock” to the L hip and low back. Similar to the feeling of stepping off a moving vehicle from a 3 – 4 foot height, into a run, and “jamming” the hip into it’s socket.
Aug 25 – 29: Saw chiropractor & massage, had X-rays taken, only minor relief. Noticeable relief from ibuprofen. Sciatic symptoms on SLR @ ~20deg. Discomfort while seated or in one position for too long. Noticeable spinal curve to L. Responds positively to ice.
Sept 1 – Oct 15: Saw chiropractor, physiotherapist, massage therapist, acupuncturist, and family physician. Generally told to “take it easy” and work on movement re-patterning to increase “firing” of L posterior chain muscles during movement. Best relief from some ART of hip flexors & glutes. Activity gives relief, especially in extension (ie. Climbing), as long as it does not involve twisting. Gait and posture noticeable altered, with favoring of L side. Strong, sharp sciatic pain to back of L knee, on sneezing or coughing. Gait & posture gradually begin to correct. Sitting becomes more comfortable with lumbar roll. Flexion ability in Lumbar, still minimal, and zero under load. Streching painful, and only seems to make symptoms worse.
Oct 15: CT scan of Lumbar Spine—Degeneration seen in L4/L5 and L3/L4… radiologist notes nothing significant.
Oct 15 – Dec 1: gradually begin to increase demands with weight movement & stretching. Sitting still aggravates, coughing and sneezing still VERY painful. Begin working with muscles of LHS posterior chain, to increase “firing” and strength. Stretching still painful.
Dec 1- Jan 7, Increasing activity level, skiing painful with lateral movement, no pain while up-tracking. Pain decreasing overtime. Begin regular stretching of piriformis, & glute. Hamstring still difficult & painful to stretch on LHS. Still Neurological impingement on SLR @ 30deg, will increase with muscle warmth and activity.
Jan 7 – Jan 11: Stretching and “firing” exercises for glutes appear to have increase functional strength. Begin Squatting & dead lifting again. Weights to ~ 30 – 40% of pre-injury values, before form breakdown. Still very limited lumbar flexion. Still sciatic pain on SLR.
Jan 12: RE-Injury while skiing @ Lake Louise: Land in some softer snow, flex forward slightly at waist… feel a muscular “tweak” in L sacral area. Able to continue skiing, albeit at lesser intensity and increasing discomfort. Upper glute area sore & spasming on drive home.
Jan 13 – 22: Rest. Usually prone on floor in slight extension. Standing and walking for more than short periods is difficult. Sitting is not possible without rapidly increasing pain. Pain always present, variable from slight (and therefore ignorable) to severe and debilitating.
Jan 22 – 24, Complete rest, prone position, ice, anti-inflammatories.
Jan 24 – 29, Gradually increasing activity, swimming from 30mins/day to 1hr / day, walking increasing from nil to 1 – 2 hrs / day. Epidural cortisone shot into L S1 neural foramen on Friday Jan 26. Increased effectiveness & pain-relief from diclofenac since.
Condition improved with extension, rest with mild activity, short use of stationary bike while standing, core stabilization exercises NOT involving truck flexion (variations on planking), light stretching, SWIMMING, WALKING.
Condition worsted by long periods standing, lying on side, any flexion, and SITTING (including with good lumbar lordosis).
Diclofenac… positive, but mild effect, increasing effect since cortisone shot.
T3’s… used VERY occasionally to aid sleep. I have never used painkillers before in adult life.
Massage… positive relaxation effect, little ongoing effect. Therapist found no “spasmed” muscles, only general (and slight) tightness.
Acupuncture… positive relaxation effect, little ongoing effect.
Physiotherapy… Negative effect from “needling” for muscle relaxation, negative effect from aggressive neuro-dynamic tests. Recommended to continue core stabilization work, light activity, and light stretching… plus regular extension exercises throughout day.
Energy Therapy… positive relaxation effect, no noticeable ongoing effect.
Cortisone / Anesthetic… Neural root block @ S1 level, immediate positive effect from anesthetic, ongoing positive effect, especially in combination with NSAID’s.
X-rays (from time of original accident… Aug 2006)
CT Scan (Oct 2006)
Bone Scan (Jan 2007)
MRI (Jan 2007)
Questions for Physio
1. What exercises should I be doing right now? How often? Can I do “too much” of them?
2. Given the size of the bulge / herniation does this make it more probable that surgery is necessary, and I am potentially doing damage by waiting longer?
3. When is it realistic to forsee returning to:
a. Work (sitting for long drive required, sitting at computer can be minimized)
b. Core Exercises & Weight training, not directly involving the back.
c. Back training (Squats, deadlifts, etc.)
d. Dynamic extensional exercise (climbing)
e. Dynamic compressive exercise (skiing, mtn biking.)
|04-24-2008, 09:03 AM||#5|
Re: Disc Hernitation / Prolapse Thoughts and Suggestions
As someone who has tweaked my back several times including again last week, I'm grateful for your post. In the past I've managed to always make a full recovery but this time I really wanted to avoid as much loss of fitness as possible. I know most of these techniques work from my own experience, especially the yoga. As boring as most Crossfitters find it (and I'm no exception), it is extremely helpful but you have to ease into it.
I thought I'd clarify some of those phases with general time lines.
Acute Phase: Days 1-4 post injury
Sub-acute (semi-acute) Phase: Days 4-21 post injury
Recovery/Chronic Phase: Days 21+
These are guidelines and there's no reason force your body into a schedule in can't keep. Too much too soon will mean starting from square one again or worse like never really recovering, ever.
I would also emphasize the importance of sticking with the program in the recovery/chronic phase. This is when the body will be sculpting scar tissue for practical use. If you skip your air squats, low weight deadlifts, etc. the scar tissue may restrict your range of motion and lead to more trouble down the line. Also think of this phase as a great time to build up those oft neglected core muscles--back extensions, bridges, crunches but no twisting until you're 100%
I've also found I can still do non-kipping pull ups and dips starting in the sub acute phase provided I can lower myself gently to the ground after the last rep.
|04-24-2008, 09:28 AM||#6|
Re: Disc Hernitation / Prolapse Thoughts and Suggestions
Here are a few other things that help me as well.
For the first day or two inflammation is the enemy. Lie on you belly. Keep ice on your back in 15-20 min on/off cycles. If you have to lie on your back keep your knees up, even then only for short periods.
After the first day or two, I find a heat pad works wonders. Most of the worst inflammation is over and the heat will accelerate the healing by stimulating blood flow to the area. I start with the same 15-20 min on/off cycle. Then once I'm regaining some motion I will add some gentle yoga stretches after warming up my back with the pad.
NSAID's are good. I like Naproxen better than Ibuprofen. I also up my supplement intake to include a little extra fish oil and the maximum recommended dosage of glucosamine/chondroitin.
At night, I sleep on my side with my knees bent. A skinny pillow between my kness also eases pressure on my back.
Get a little sunlight too. If you're like me and you've done this before once you get past the anger and humiliation and accepted your helplessness some mild depression will settle in. This is to a large degree a healthy body's response to lack of exercise. Sunlight will help. So will the DHA in the fish oil.
Watch some movies but don't get addicted to TV. Reread a favorite book, guilty pleasures especially. If you find you can't do the things you really want to be doing, do something else. Just doing something rather than thinking about what you can't do will have a big effect on your morale.
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