Advice on disc protrusion

[alophysio]

Hi,

Just briefly...

1. one cortisone injection won't hurt (except the risk of infection because it is piercing the skin etc etc). Just make sure it gets done under fluroscopy

2. You have chronic low back pain. I don't think anyone would dispute that. The evidence is in favour of an active rehabilitation model. It sounds like your chiro is on track. You need to get MOVING.

3. If it doesn't hurt, don't worry. If you have been doing the back exercise for a week now and it doesn't hurt, keep going.

4. The worst thing you can do is decrease your activity. You should know your limits by now - do as much as you can without aggravating the back.

5. www.back-exercises.com has a good explanation on stability. Don't have to buy their stuff ok! It is for knowledge about stability etc.

6. At this stage, repeated manipulations won't help. You have had the chiro for some time now and your problem still exists. I wouldn't worry about him treating you differently - he sounds good and will have noted the compression signs anyway - and yes, physios and chiros are usually much better at reflex testing than doctors!

7. Get active, get active, get active. Just need to do it with caution. It is called "pacing".

Hope this helps. I would definitely see the surgeon though. All those pain and nerve signs are not good.

[Sonj]

Fascinating stuff, thanks for the link. As for keeping active, I think my main danger has been that I keep trying to be too active rather than under active. I've not been very good at pacing myself and have a tendency to do too much too soon. And also a tendency to keep on going and pushing through pain.

It's highly possible that my 'outer' muscles are overcompensating. Certainly when I do high load stuff such as the walking down hill I can feel my superficial muscles tightening up esp a band of muscle running down my mid and lower spine and in my bum and thigh.

[sdkashif]

Apart from the advice that you have taken from a number of contributors on your case discussion, let me add further. Please, also start a course of endurance training like using the stationary bicycling to do the aerobic exercise will increase your stamina and will do your cardiovasular conditioning improving the performance of your musculoskeletal system. That helps a lot in chronic pain states. For bladder problems, if there is any muscles weakness, it is better to strengthen the pelvic floor muscles. You must do the execises for pelvic floor muscles. Please, consult a urologist if the bladder and bowl problems worsen. In addition, you must try the spinal traction procedures and they have certain efficacy regarding pain and root compression symptoms. Let me tell you the detail of spinal traction as under so that you may get these session from your local clinician or physiotherapist there. Have a look on the over view upon the spinal traction procedures.
Spinal traction has effects of mechanical elongation of spine, facet joint mobilization, promoting muscle relaxation, reduction of pain. Spinal traction is indicated for spinal nerve root impingement, hypomobility of joints from dysfunction or degenerative changes, joint pain from symptomatic facet joints, muscle spasm or guarding, meniscoid blocking, discogenic pain, post compression fracture.
Continuous or prolonged traction is an effective mode of therapy. In it a static traction force is applied for several hours to several days usually in bed. Only small amount of weight is tolerable.
The effective force is influenced by the body position, weight of the part, friction of the treatment table, method of traction used and the equipment itself. Generally for vertebral separation:

In lumbar spine a minimum friction free force of half the body weight is necessary for mechanical separation. Some authorities suggest that 1/3 of the body weight should be used for lumbar traction. While some suggests that 60 percent of the body weight should be used for lumbar traction. Generally lumbar traction should be applied in range of 18 to 45KG. To avoid treatment soreness, the first treatment should not exceed half the patient weight. Progression of dosage at succeeding treatment will depend upon the goals and patient’s reaction.

There are controversies that exist between different literatures regarding the dosage applied for the spinal traction. Opinions vary among different authorities.

Have a look over a very useful article on Lumbar Traction.

http://www.thesaundersgroup.com/lumbar.pdf

I think that it will be of help to you. Please feel free to discuss more ideas or views in this regard.

[alophysio]

Hi Sonj,

Good advice above from sdkashif.

As much as i hate traction, this is one circumstance that i would use it.

Now, about keeping active - and you said it yourself - the problem is NOT keeping too active, the problem is that you don't know how to pace.

Pacing is simple. Start with walking 5 mins. That should be non-threatening for you. Then increase it s l o w l y.

Can do the same for other activities. Like you said, pacing is the problem.

And don't worry. Things will settle down.

I had a patient who strained his back at the gym. He felt it whenever he FF and did a certain move to stress it.

Anyway, we diagnosed the problem, outlined the solution and gave him the right exercises etc and sent him off.

We reviewed him 2 weeks later and found that the pain was just the same. He was doing his exercises properly. He had eased back at the gym, he was doing everything technically perfect but he STILL had the pain.

I personally was baffled so i asked him what he had been doing in his every day life, work, school, etc. After a while, he told me that he tested the back every 15-30 mins to see how it was going! In other words, he kept straining it to pain!

Needless to say, when i got him to stop that, he got better within the next 2 weeks. I wouldn't let him test it for at least a week!

The moral of the story is that once you stop aggravating your back, the pain will start to get better. Learn to pace yourself to give yourself the best chance. It is much better to stay active. If you become less active, you will become even more deconditioned and lose muscle mass and mke things worse.

Hope it helps...

[Sonj]

Hi first of all I can't afford to go back to a private physio for traction and it's not something that was offered to me on the NHS. I did try hanging off a pull up bar (and I know that's not the same) but it was too painful.

Re the walking, 5mins is nowhere near enough!! I could walk all day with no problems whatsoever but walking downhill is the killer. Before this injury I was used to walking out in the hills, carrying heavy weights for 10-12hrs in extreme weather! So 5mins is nothing for me even in my injured state. I try to test myself every so often as if I don't then how am I to guage how my recovery is going? But ANYTHING I do that causes compression, causes pain. Even when I tried to stay away from climbing and hillwalking and just concentrating on light walking and my stretching, the pain would still flare up from time to time.

Went for the steroid jab yesterday and great so far. Pretty much no pain left and even managed to sleep all night long, it was heavenly bliss!! So, now I just wait for the analgesic they injected to wear off and the steroid to kick in to see if it will help. If not I am going for the surgery as from what I can gather I could spend years trying various different therapies and get limited results.

[alophysio]

Fair enough.

I hope it all goes well for you.

maybe try the nhs again?

I think you have the answers - it is a matter of doing what is required. How? I don't know.

Again, it is hard to give advice without seeing you.

Let us know how things are going.

Thanks for the updates

[Sonj]

Hi, thankyou for all your replies.

Think I forgot to mention above that my GP had read out my results wrong from his PC. I went to see the Ortho consultant about my results before I had the injection. He said there is a large protrusion and it is def compressing the nerve root, quite badly infact! There is also some acute endplate something or other. He said that basically the way the disc was displaced it was nudging against the end plate and denting it. He said he wanted to operate. My chiropracter knows the consultant and says he's one of the best and he actually turns away over a third of people and sends them back to their GP without operating, so only operates when he deems it 100% necessary. The chiro also said that there is a high success rate with surgery where the disc protrusion protrudes into the lateral recess (I'm sure he said recess, but it was def lateral something or other) but conversely a low success rate with the steroid injections. 3 days now and the analgesic they injected into my spine is starting to wear off, so waiting to see if the steroid kicks in and helps now.

Thanks everyone for all your replies.

[Sonj]

Well, I took a very bad reaction to the steroid injection. The Thursday after the jab, my leg gave way and I collapsed in a heap of screaming pain and couldn't move for around 15mins and have been in worse pain than before the injection ever since. Then at the weekend after the injection, I had a full on panic attack which was abs terrifying. My GP told me, that some people react badly (though it is rare) to the steroid causing mood changes etc and this was made worse by the fact that I'm taking Amytriptyline. Would have been nice to have told of the possibility of this beforehand!! I'm still getting palpatations but the anxiety levels have dropped thanks to the use of herbal preperations of Valerian and Passiflora. Interestingly, now that I'm not taking 50mg of the Amytriptyline, I'm sleeping much better!!! My appointment with the Ortho has been moved forward to this Thurs and it looks like I will be having the operation.

Thanks for all the interest and replies to this thread.

[MrPhysio+]

Hi all,
Very interesting reading, and good histories. The problem with scanning over the years is that as scan resolutions become better, more 'problems' are discovered. Recent evidence indicates that between 67% & 75% of people aged between 30 - 80 years of age will have degenerative changes evident on scanning. These changes include disc bulges and spinal cord / nerve root compressions. What is even more interesting is that mild to moderate degenerative changes can be completely symptom free, also including spinal stenosis, nerve compressions.
Therefore a person may have had a disc disruption / compression for years without knowing, hurt their back in another way, have a scan, and find out information that is completely useless to the current new problem. This explains why many treatments, including surgery. Therapists are trying to fix something that is not broken.

Forgive the simplicity of this next suggestion, but I believe that the majority of your symptoms can be explained by a tethering of your piriformis muscle to your sciatic nerve. Stretches can sometimes improve this condition, but can also worsen the irritation. Your sciatica is explained by tethering, as are the exercise induced symptoms, as well as the problem caused by sitting.Lumbar muscle spasms are due to the erector spinae muscles spasming or tightening to act as a splint, which then decreases your mobility further, and increases compression forces.

I believe that you need a very deep piriformis friction massage, then gluteal / sciatic exercises over two days. If the treatment is not firm enough, it will fail. Your previous history of severe pain in the gluteals should not preclude this deep type of treatment, but it will hurt!
I carry out such treatments all the time, and they are safe, and usually unmask the nature of symptoms, and often provide information as to whether tethering or the disc is the major contributing factor to the pain.
As other writers have suggested, you are now in the chronic pain category, therefore compensatory changes will have occurred with the failed treatments and time eg further tethering, muscle imbalances.

As you cannot readily access your physio, you could try the following:
1. To find the correct area, place your little finger on the top portion of the gluteal cleft, and your thumb of the same hand onto your greater trochanter
(bump on your upper thigh bone).
2. A third of the way between your little finger and thumb is likely to be a tender point.
3. Find the sharp edge of a cupboard or table top, and back your buttock onto the sore area very firly, to the point of deep pain.
4. Do the same thing 25 mm (1 inch) above and below the first point, on a curve. The areas are probably sore.
5. Do a stretch either in standing or laying down, where you pull the affected side knee towards the opposite shoulder, hold the stretch without bouncing, for 15 seconds. Repeat 10 times, 3 to 4 times daily.
6. Do a hamstring stretch for the affected side with the same directions as for the gluteals.Do not bounce any stretches - have a sustained hold to the point of discomfort, not pain.
7. Morning and night lay on your back, knees bent,with your heel a comfortable distance from your buttocks, knees and ankles pressed together, and rock your knees gently side to side for 5 minutes, not into pain.

Do the above exercises for at least 2 days, even if the buttocks are sore. The pressure against the table top edge can be sufficient to cause bruising, if done correctly. If you do not do the exercises, the treatment is a waste of time, as is a gentle treatment.
Do not increase your daily activity levels within the first two days, no matter how much better you feel.

Note, if any of the exercises cause increased true neural signs such as loss of strength, or numbness beyond what you already experience, decrease the intensity of the hamstring stretches.This is unlikely if you take the exercises gently. The friction massage for the priformis cannot worsen any spinal stenosis, and is therefore safe.

Hope the above helps. It is certainly worth a try, especially as surgery is being viewed as an option.Do not sit for greater than 20 minutes for the first two days, without doing glteal stretches (one for 15 seconds), or better still walk a little (couple of minutes change of position).
Goodluck
MrPhysio+

[Sonj]

Sorry for not replying sooner, I've been out rock climbing nearly every day for the past week, yeeha!!!!

It's 3 weeks since the steroid injection and after the initial horrible reactions in the 1st week I am completely pain free, the difference is astounding!!!

I'm still doing all my stretches and going walking though. The only thing I'm left with is that I'm still waking in the morning a bit tender in my bum and behind me knee and down the lateral side of my thigh. I remember the 1st private physio I went to see massaging into my bum at the painful point as yes it was VERY sore when she did it but effective (if only for a couple of days). I mentioned to the Chiropracter about doing the thing where you use a tennis ball to reach the Piriformis but he reckoned there was too much irritation and inflammation present and this would just irritate it further. I ignored what he said, curious to see if it would help or not but he was right and the deep pressure caused spasms of agony and much nerve pain. But a while back, after being on the Amytriptyline for a couple of months and the pain had subsided enough for me to be able to start doing more stretches without causing too much pain I was able to do several Piriformis stretches which were very soothing to do and he did say that it was then ok to use the tennis ball. I think he thought that Piriformis was going into spasm because of the irritation to the nerve and not the other way around.

Certainly, all the pain was most def coming from the nerve compression as the steroid injection was injected into the right place and has removed all the painful symptoms. Interestingly though, when I do any back extension exercises they still cause my leg to go numb. Probably the disc bulge has not fully retracted and my bending backwards causes it to get squished out more? But all the flexion type exercises are fine. Tho I can seem to do the exercise know as The Cat in yoga fine tho with just not as much flexibility as before. The 2 stretches which still cause problems are lying prone and doing a Cobra type stretch and lying prone and keeping chest and head on floor but lifting leg up. Both of these make my leg go numb and if held in position for too long leg goes a bit sore. But I'm still doing them, but only to the point where they don't cause symptoms.

[Sonj]

PS - the tender point you mention between the gluteal cleft and the trochanter is still a tad tender, certainly even when I press into there with my fingers I can feel a tender spot. How long should I sit on the sharp corner bit of a desk etc?? Cos you are right, it is bloody painful to do that!!! (Excuse my language!)

[alophysio]

Hi,

it is good that you are feeling better.

However, please listen to your body...it is telling you that extension is no good! Numbness is not a 'normal' sign for anything. It would seem to me that you are compressing the nerve root.

Any good Mackenzie therapist worth their salt will tell you that extension is not the only way to treat discs. In fact, there are 7 derangements described by Mackenzie so please don't get caught up on only one of them!

I would still think that the nerve is sensitising the piriformis...but only my opinion! L/S extension, unless you are severely overactivating your hip muscles, doesn't cause leg numbness from an overactive piriformis.

Staying within the symptom range as you are is the smart thing to do! Don't keep reassessing it! Do it once a week only. I had a patient who kept testing his L/S - he was doing it every hour or so - he didn't get better until he stopped testing his L/S!!

Good luck!