Advice on disc protrusion

[Sonj]

Hi there. I'm not actually a physio, but am working towards getting into Uni to study physio. Came across this site and thought I'd ask for some advice about a problem I am having with my back.

9 months ago I was out hill-walking and experienced tightness in my left buttock, and back of knee (lateral side), as I walked downhill I experienced a nerve type pain in the inguinal area also. This pain came on and off over the next month but I just thought I'd strained a muscle or something and kind of ignored it. Then I drove to the Lakes (5hr) did some rock climbing (carrying lots of gear!) and drove back home. 3 days later was VERY sore in left leg, stabbing in bum and radiating pain down back of thigh to knee.

Went to GP who thought I'd poss torn a ligament and he put my down for some NHS physio. While waiting, I booked in for some private physio. She thought I'd fatigued deep muscle in back which was irritating sciatic nerve and causing radiating pain. Had massage and Ultasound which greatly helped but the pain returned a few days later. On second visit, nothing she did helped. She said that my nerves were extremely sensitized at that point and there wasn't much more she could do and recommended I go see an Osteopath. I wasn't too keen on this, so waited for my NHS appointment.

When this came, they diagnosed a slight bulge in disc (L5 I think) and gave me back extension exercises to do (cobra pose- 10 reps every hour) This helped and I was in much less pain. The therapist said I could continue with my hillwalking. I went down to Wales to do some walking and 3 days there I became very painful again so came home. I hadn't been doing my extensions as much as I should have either, naughty!!! By the time I got home, I was in excruciating pain, evil stabbing from buttock right down to toes. Therapist said to continue with the extension exercises. Only problem was these exercises now caused MORE pain. Even moving back ever so slightly sent the stabbing pain down my leg. This went on for a few weeks with the therapist insisting this was the right exercise for me, and me trying my best to do it, but suffering much pain. Got fed up, as it seemed to be making things worse, and I booked an appointment with a Chiropracter.

By this point as well as stabbing pains down my leg, I was getting a stabbing in the sole of my foot and an intense gripping pain in my lower calf. The chiro diagnosed bulge in the disc, inflammation of the facet joint and tightness in my SI joint, he thought that the SI prob had probably caused the disc problem. After just one manipulation the stabbing pain down my leg disappeared. I was left with just the calf pain, foot pain and a burning in my thigh. The calf pain would be very bad at times, like something was twisting inside. On a scale of 1-10 it was around 7ish. Now, I have been seeing the Chiro for around 5 months now and the calf pain has gone and the pain is now focused mainly deep in my bum.

He thinks that Piriformis is very tight, and also TLF is tight but doesn't seem to be doing much to be trying to release them. I have started to do stretches at home and over the past week have got much relief. I am still sore and tight in my bottom when I walk, tho it does ease after a short time. And during the night, I wake in pain every few hours. I'm sore first thing in the morning but it eases as the day goes on, only to get sore again at night. Pain is now at a level of between 2 when good and up to 5ish when bad. I still cannot hillwalk or climb without it flaring up, and when it does flare, the calf pain comes back again. I have recently been for an MRI and am waiting for an appointment with the Ortho consultant. My GP had a nosey at the results on his pc and says that I have a large disc protrusion but there is no evidence of it compressing the nerve root. Now it seems to me, that my muscles are possibly spasming to protect my nerve root from being compressed. Am I correct in assuming this???

What my query is, is that I am wondering what will happen to the protruding disc? Will it eventually go back into place or will it continue to degenerate. If it is the case where the disc is beyond healing, then does this mean that I will continue to suffer until it degenerates completely??? 9 months seems an awful long time to be having this problem for, esp when the 'experts' keep telling me I will be better in 6wks, then a couple of months, then perhaps half a year. Sometimes it seems that the pain is only better because I am avoiding doing things. I never sit down, I eat lying down, I study lying down. The only time I sit is to drive my car. And to drive any distance longer than 20mins in the car I have to take 30mg of dehydracodeine to cope. I cannot hill walk or climb without a flare up of the pain. And I have not slept properly for the past half year and this is affecting my studying now. Any advice??? Do you think the Ortho will want to operate if there is no evidence of nerve compression? And I think the main thing I'd like to know, is will this blasted disc ever heal or will I just have to put up with it and manage the pain until it has degenerated completely. I will put these questions to the Ortho and to the chiro when I see him next, but just after some more opinions really, though I do know you can't really give me much advice over an internet forum! Oh, should also add, that I go for an hour long walk in the morning, followed by 2more 20min walks during the day and eve. When I am lying down to study, I get up and stretch and move around every half hour also. And I try to stretch out my piriformis, TLF, gluteals, hamstring and calf 3x a day. Hamstring on affected leg is VERY tight.

Phew, sorry for long winded post!

Thanks in advance for any tips on what will become of my disc

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[alophysio]

Hi,

Thank you for the informative post. I wish more people put as much history down as you did...don't apologise for it! The more info the better.

A few things.

1. The disc doesn't actually have to be touching the nerve to make it sensitive. The chemicals from the NP do a great job of doing that.
2. There is evience that disc resorption occurs in disc bulges that are trans-ligamentous (that that go thru the posterior longitudinal lig).
3. This is now a chronic problem and research has shown that central sensitisation has occurred.
4. Leaving the NHS physio was a good thing - If the treatment is making you worse, why keep doing it. The same goes for the chiro. Was able to relieve some pain but not the back pain and 5 months of treatment is a long time. I would say you need a change in treatment approach (IMO).
5. Physio at NHS gave you MacKenzie exercises but probably wasn't trained in it because extension pain is not an indication for extension exercise.
6. You are spot on in assuming that the muscles are trying to protect you. They are sensitised and you probably have changed your motor patterns to accomodate this problem.
7. You have a loding problem because you avoid sitting so much (loading the spine into flexion). Does it hurt to cough or sneeze?
8. is hamstring on affected leg actually tight or is it neurological tensioning - i.e.do you get more hamstring length if you plantarflex your foot? What is your SLR like?

Lastly, I think there is help available for you but you will need to find someone who can do motor control retraining. I believe Mark Comerford is someone from the UK. Otherwise, anyone trained by Peter O'Sullivan, Paul Hodges +co, or Diane Lee's courses should be able to nail it.

Out of interest, are you able to fill out your history based on the form attached and post it with the headings? A comprehensive subjective is always helpful...

Thanks

Thanks

[Sonj]

Thankyou for the reply.

To be honest, I'm not really after any diagnosis of problem, or advise on problem as such, it was more that I was wondering what would happen to the disc itself. But if there is evidence that protrusions can go back into place then this is good.

Am not sure, but am assuming that as it is a protrusion I have, and not an extrusion, then the NP will be contained and not able to cause irritation to nerve. But the stabbing pains in bum and leg were def caused by something irritating the nerve/root, wether from the protrusion itself which has now started to 'go back into place' or wether due to irratation from surrounding structures, ie tight muscles etc, I am unsure.

After a week now of doing my stretches the pain relief is astounding!!! And I managed a 45minute drive yesterday with no painkillers needed and no flare up of symptoms which is a great improvement.

The Chiro did advise that I start stretching the piriformis and gluteal muscles, he just didn't advise me what exercises to do, but in his defence, I had a muddle with my appointment time that day and he just managed to squeeze me in as he is very busy, and perhaps there wasn't time for him to go over which exercises I should do. He did say, that any I do should cause a stretching type feeling in the muscle but should cause no pain to my back or SI. The stretches I am doing are just ones that I found on the internet. For the past couple of days I have now managed to try doing some back extensions and can manage them now pain free, but not full extension, just partly.

I tried to sit again last night on a firm chair with good posture and back support, but after 5mins the pressure became too much so I had to get up and had pain down to knee. Coughing used to be painful but is now just more uncomfortable. Sneezing is evil, LOL!! I have to brace myself for the stab of pain that it will cause. Stab of pain is in the sacral area. Infact majority of pain is around here I think, it is hard to tell at times, as the pain is deep. I feel no pain whatsoever in the L5 area, just a slight bruised kind of feeling if I push into that area with my fingers.

I agree that 5months seems a long time for treatment, but I do feel loathe to part with the Chiro as he has helped ALOT, even if there is not much focus on my muscles. And I have to admit, that over the course of seeing him, I havn't always heeded his advice. He has told me that I can continue climbing (he is a climber himself, and understands the physiology of climbing) but that I must be very aware and careful of how I move. Climbing involves certain moves to scale up the rock or wall face. Now, he has advised that I keep my moves small and fluid, avoiding any jerky moves, any lunging and scrunched up movements, or any high steps with the affected leg, bearing weight onto this leg. Basically any type of movement which compresses my back. This is why the hillwalking is so bad just now, as the downhill walking, causes too much compression. If I climb in the manner advised then all is fine, but I have often found myself pushing it, and going for harder moves, which result in flare up of pain. I have subsequently been going climbing less as pushing myself in my sport is one of the joys of climbing and I soon become bored doing easy moves. I am thinking that the time length of my recovery is due to my own fault in pushing myself too much, rather than anything the Chiro does, or doesn't do. Also, as I am lacking in sleep, I have become somewhat run down, and have had the flu twice in the past 5months, coming from rarely ever having any infections of any sort. The flu, both times put me to bed, and unable to exercise, and this, with all the coughing and sneezing at the time, made things flare up badly and set me back. I think I will continue with the Chiro for the time being but if my condition does not improve in the next couple of months then I shall research this 'Motor Control Training'. Thanks for the tip, re that.

Yes, I get more hamstring length with plantar flexion. SLR used to cause a violent stabbing sciatic like pain, but now just causes a tight, stretching type pain in bum, hard to pinpoint from where exactly.

Anyway, thanks again for the reply and like I said, I was more just curious as to what was going to happen to my disc. And I have many queries for the Ortho in a couple of weeks and for my next appointment at the chiro, just impatient for the answer I guess.

[alophysio]

Hi Sonj,

Your irritated nerve root is sensitised by the nucleus pulposus - apparently the chemicals can exit via fissures in the disc. It is unlikely that the bulge itself is the cause of the irritated nerve root because it has been shown that asymptomatic people can have apparent bulges onto nerve roots without pain. Mechanical stimulation of the nerve root is also fairly benign but when it is sensitised, this is when problems occur.

As for resorption of the disc, it will need to be transligamentous to occur. Now a protrusion can be transligamentous just like a gloved finger can go thru cling wrap. Once past the PLL, an inflammatory process occurs which begins the process of resorption..

I am glad to hear you are doing well. You will now have first hand knowledge of why listening to your therapist will be something your patients will have to learn to do!!! As they say in the classics..."Physician heal thyself!".

As for the motor control thing...There is no reason why you can't research it now and use it to complement your treatment from the chiro. It sounds like your chiro is doing a good job and giving the right advice but you still have pain on sneezing 5 months down the track. This seems to indicate to me that you are unable to control the intraabdominal pressure generated during the sneeze. An intact "core" or "inner unit" or "local system" is required to help in this area. Developing your coordination and endurance in your "core" ill help dissipate the forces generated. At present when you sneeze, the force is being sent thru the weakest part of you abdominal cavity - the injured disc.

In my honest opinion, waiting to see if just the good chiro treatment alone will help this problem before trying the exercises seems to be like saying "I will learn to kick a football with my left leg after i have mastered scoring goals with my right". You can get away with just having chiro treatment but wouldn't your body appreciate the extra help that the exercises will give you?

Anyway, I think your chiro sounds like what a good physio should be doing for you. They have really started to embrace the whole rehab side of things and if we as physios don't stay on our toes, we will become obsolete.

Good luck and let us know what the doc says - please note he is an orthopaedic SURGEON so by definition he prefers to cut. If you are not a "cutting case", he may not be interested in you, especially if his waiting list is 3 months long!

[Sonj]

Thankyou again for your thorough reply.

Yes, the Chiro seems very good. I must admit to being very hesitant in seeing him at first as I had heard alot of bad stories of chiropracters previously along with some good stories too of course. And this one was recommended to me by several people who had suffered from back problems. Seems to be that just about every one either has had or knows someone who has had a back problem.

I understood that some folk could have a protrusion and have no symptoms but didn't realise that it could press on nerve and there be no pain. The private physio that I originally saw did say that it was very sensitised. At the beginning the pain seemed to be very 'exagerated' ie - one time my friend just barely touched my hip and it sent me into spasms of agony, she was quite bemused as she had really just brushed past me nothing more, lol!

I take it by resorption, you mean the disc protrusion going back into place as it were, as opposed to reabsorption, where perhaps the disc degenerates and is reabsorbed by the body???

Aye, guess it will do no harm to research the Motor Control thing just now. I have never heard of it before, hopefully there will be someone in Scotland, nearby who practises this!

Yes, my core is pretty weak just now. I used to do alot of pilates, as core strength is very important to climbing to keep you close to the wall when on steep or overhanging ground. The pilates was really helping there, but then I got lazy and out of the habit of doing it so regularly. I hadn't done any core exercises for around a year before my disc going and I do wonder if this, along with the very heavy weights you have to carry when winter climbing in Scotland and the often very steep ground you have to cover, contributed to my disc going in the 1st place.

As for the surgeon, the Chiro knows him and says he values his opinion greatly as he is very good. He says he is not 'scissor happy' as it were, and will not choose to operate unless it is 100% necessary and as there is no nerve root compression and I am alot better, I am confident I shall escape his knife! Hopefully he will not be too brusque with me, as many ortho's can be, having had experience of them after breaking my wrist a few years back. Ended up with extensor tendinitis which physio cured a treat and made me develop an interest in it. The human body, muscular and neurological is such a fascinating and complex subject. How one disorder in some part of the body, can effect a multitude of different parts elsewhere, so much to learn........

I also had an appointment at a pain clinic recently, where I had a loan of a TENS machine. Found it helpful but a real hassle to use and the electrodes didn't seem to stick well to my skin, so I gave up on it. The pain specialist I saw also does Acupuncture and has booked me in for a course of that, but my appointments aren't until June (blasted NHS waiting times!) and I'm hoping that I will be all better by then!!! She has also made an appointment for me to see about having an epidural, which I am none too sure about. I detest taking drugs of any kind and it was months before I had to relent and start taking painkillers, the physio I was seeing said she had never had a patient not take painkillers for nerve pain before, and I should not be so stoical, hehe! So the thought of pumping drugs into my spine, does make me shudder somewhat. And I have heard stories of steroid injections weaking joints in the long term, wether this is true or not though, I do not know. That was another thing, she prescribed me Amytriptyline to see if it would help me to sleep better and said I would probably need to work my way up to 50g a night before it would be effective for pain relief. I have been on 50mg for the past week now, and I'm wondering if it is this or the exercises and stretches I am doing that is giving me relief, or a mix of both. I'm highly tempted to stop taking the Amytriptyline to see if the pain comes back as it is making no difference whatsoever in helping me get a good nights sleep and that's why I was willing to try it in the 1st place.

Aye, I will post again once I have seen the Ortho and let you know how I got on. Thanks again

[sdkashif]

According to Melzack and wall depression has been mentioned as a concomitant of chronic pain and it is therefore natural that many types of antidepressant drugs should be prescribed. They help the patient natural depression but they also sometimes have a surpringly powerful effect on pain which appears to be independent of their action on the depression. These drugs act by increasing the concentration in brain and spinal cord of the amine transmitters such serotonin. These amines are thought to play a role in inhibitory mechanisms, especially the descending controls. It may therefore be that the antidepressant drugs have a double action, one to help depression and one to increase the effectiveness of existing inhibatory mechanisms. So it is a possibility that you may getting the benefit of analgesia by antidepressant amytriptyline. Although the exercises have also a role in pain relief as aerobic exercises are thought to increase the endogenous opioids resulting in the pain relief.

[Sonj]

Hi there.

Yes, I finally succumbed to trying Amytriptyline a couple of months ago. I have always been able to 'grit my teeth' and just get on with things regardless of the pain, only using codeine when really bad, or during the night. But I thought the Amytriptyline might help me sleep better. So far it has been of no help whatsoever for sleep. Taking codeine before bedtime, I can fall asleep fine, the problem is that I wake a couple of hours later in pain and then have to wait an hour or so before I can take more painkillers because of the paracetemol. Last night I got just over 3hrs sleep, yawn!! I have tried Tramadol also but found it useless and all it did was make me feel like a zombie.

It actually dawned on me last night that the therapist at the pain clinic said I would need to work up to 50mg of the Amytriptyline before I found any pain relief from it. Now, I have been on 50mg for a couple of weeks now and it crossed my mind that perhaps I have been feeling alot less pain over the past week due to the Amytriptyline rather than the stretches I am doing, or perhaps a mix of both. I am curious to know which it is that is helping so I stopped taking the Amytriptyline last night. It will be interesting to see if there is a return of worse pain or not. If there isn't then I won't be taking it any more, as it does nothing whatsoever in helping me sleep through the night.

[gogo girl]

Why didn't you ask your chiro these questions? If you did what was his/ her answer? It is very dangerous to diagnose and treat over the web/phone or by mail

[Sonj]

Firstly can I say AGAIN that I was not after a diagnosis and yes it isn't good to try and get a diagnosis over internet etc. I was merely wondering what happens to a disc once it has prolapsed and this question has been answered. I wasn't seeing the Chiro for another few weeks, and the question just popped into my head, hence the post. I saw the Chiro Wed past and he said that there will more than likely be some resorption but that disc would continue to degenerate but once I am sorted it should hopefully be pain free! It has been explained to me that once a nerve has been irritated or damaged it can take anything up to 18 months to be symptom free.

To sdkashif, I seem to have anterior, posterior and static sensitive type pain. The pain is relieved upon movement but ONLY if I walk for over half an hour. And walking downhill makes things worse.

I stopped taking the Amytriptyline and the pain came back straight away so I have started taking it again. The Chiro said to keep taking it as it is calming down the pain enough for me to exercise more thoroughly and to do the stretches and we are hoping that we can break this cycle of flare up and inflammation irritating the nerve, which causes muscles to tighten, which further irritates nerve etc etc etc. He reckons that another month or so and perhaps this cycle will be broken and get me moving properly.

I went for a 6 hour walk yesterday with a gentle incline and decline but over fairly rough ground. Going up was no problem but coming down there was alot of tightness in the SI area and my stride was very shortened (which caused alot of problems trying to ford a river!!! ) but there was no pain whatsoever and once down and on the flat it loosened off again and I was able to walk at a very fast pace. Hoping now, that there is no flare of symptoms building up over a few days which there has been in the past after downhill walking.

To Aisha. Yes, I have found that if I follow advice and instruction to the letter that things start improving and I think that the symptoms have lasted for so long because I push myself too much too quickly at the slightest sign of improval. If I do too little things flare up but if I do too much things flare up also, it's hard to find the right balance at times and probably doesn't help that my personality type is one that likes to push my boundaries. But I am slowly learning to listen to my body more when it's telling me ENOUGH, ease off!

Anyway, here's hoping that the continuing exercises will benefit. After a week and half I can now straighten and lift my affected leg to knee level when lying down and plantar flexed, and can almost fully dorsi flex the foot in same position. Can now do a back extension with arms almost straight and can now nearly touch my knees when flexing forward. This is all relatively pain free

[Yarok]

Hi
hope you are getting better.
We need ask questions, why a young active person have the protruded disc?
i think the herniation is only the symptom of imbalance in mechanism(YOU).
somewhere is the weak link which led to it.

is importent to identify the problem, because from my point of view the same weak link hinder your recovery

thanks
Yaro

[Sonj]

Hi, the Chiropracter reckons the problems originated with my SI. I had sciatic type symptoms years back after giving birth to my daughter and have fallen when climbing many times onto my bum. He reckons that problems with SI and L5 often go hand in hand. After trying another gentle hillwalk I had a major flare up of symptoms and was in agony, so much so that the codeine did abs nothing for the pain and I am now on Tramadol instead.

Anyway, latest news is that my GP read my notes WRONG on his computer and he said the protrusion doesn't touch the nerve when infact it should have read DOES touch the nerve!!!!! Went to see the Ortho consultant on Thursday past and he said the nerve is being compressed quite badly, there is barely any room for it!!! They recommended surgery and I was pretty gobsmacked after being told by my doctor there was no nerve compression so was feeling a bit confused. The consultant saw my confusion and said to come back in 4weeks after I have the Steroid injection and if that doesn't work then he will operate to remove the disc.

[alophysio]

Hi Sonj,

Thanks for the update.

Firstly, I know that you that you aren't after a diagnosis but some of the following might help those who read your story and do want some informatino ona diagnosis...again, i appreciate the fact that you have kept us updated.

SIJ as the first reason why your L5 disc may have been affected is definitely a possibility. The SIJ dysfunction can cause altered load transfer from the lower limbs thru the pelvis and into the trunk. The disc at L5/S1 then cops it and the stress gets moved further up the chain (spine).

That said, the current pain is still possibly from the disc. Whether your nerve is compressed or not is not too big a deal (believe it or not!). It is when the nerve gets sensitised that it causes pain.

I am not saying that nerve compression is not dangerous or serious, it is just a fact that there are people walking around today without ever having back pain who have nerve compressions. The noxious nature of the disc sensitises the nerve to physical stimuli.

To differentiate between the two, a compressed nerve should show signs of:
1. decreased reflexes for that nerve root
2. decreased muscle power for that nerve root
3. Altered sensation for that nerve root

Other important questions to ask is if you have had any changes in bladder or bowel function, sexual function or any numbness in the genital region. This is a sign of cauda equina compresison

The steroid injection has a postulated mechanism of helping resolve the initial stages of the inflammatory process to facilitate the resorption of the disc. This won't happen immediately but over the next 2 months following the injection, it should help. It has been some time now but i am assuming that the recurrent flare ups are like an acute injury

It has also been shown that an acute episode of pain in the L/S can cause unilateral segmental multifidus atrophy and is prognostic for further back pain episodes. My advice on this area is that you find someone who is skilled at training your multifidus and transversus abdominis. Preferably with an Ultrasound.

I don't think i mentioned that the treatment for a sensitised nerve is different for a compressed nerve. Make sure whoever treats you knows the differrence.

Lastly, You do have a chronic condition in that the pain has been there for more than 3 months. There are central changes - these are changes that happen at the spinal cord and brain level - that can make things difficult. In these people, pain can persist even after the offending lesion has changed/reomved/etc. Now obviously there may be a very big physical reason for your pain at the moment but even if you have it reomved, the pain be persistent. The current popular treatment for centrally mediated pain is called Cognative Behavioural Therapy. You may have to look into it eventually.

Anyway, all the best for what is going on. I hope things improve for you. Please keep us informed on how you are going. No doubt your story will resonate with a lot of the back pain population!!

[gogo girl]

what country do you live in? you describe a typical picture of disc protrusion and it sounds like it is resolving somewhat. Perhaps it would be helpful if you found a physio who can assess you correctly and advise on the correct/appropriate exercises

At this stage you may need some motor retraining (of the muscles) as the pain will have affected the way your muscles are firing and therefore not supporting or stabilising your spine well enough. this seems to be what is happening when you start walking over rough ground or downhill - possibly not sufficient stability leading to pain

I always warn my cients that they may think some of the exercises i prescribe for them are a bit woosy but they are needed to retrain the function (or even get them activating correctly) before strengthening and building endurance.

In my experience, Cortisone can be (1) helpful, (2) not make any change or (3) can make the problem worse. occasionally it "fixes " the pain for a signifiicant time but often the pain comes back if nothing else is done and repeated C injections have less effect and the relief period is shorter. there is some controversy as to how many one can have - one school says as many as make you comfortable, others say the minimum number due to side effects and/or damage to tissue. there have been promising studies done on animals where they have shown therapeutic ultrasound hastens healing whilst cortisone delays healing.

If a physio near you has an ATM2, this may be of benefit to you to - it is a machine whish fixes the pelvis and allows pain free movement.

A disc protrusion usually results from a damaged disc but significant studies show thta exercise can help if given and practiced correctly - good luck! If you have no pain, loss of reflexes or numbness you could hold off the surgery until you try a course of appropriate exercise

[Sonj]

Hi there.

I def have symptoms of nerve root compression esp the altered sensation. I used to get pins and needles and numbness alot, also pins and needles in groin area but that resolved itself. No change it bladder/bowel function though I did have a fright a few months back when I had the sensation of a full bladder but unable to urinate and had to sit for around 5mins or so before bladder would empty. This was put down to the codeine and also due to the fact that I was getting constipated, again due to the codeine. I now make sure I drink plenty water and this is all ok now. Re the altered sensation, my foot still goes numb and I get an odd thing happening when I walk sometimes. It's very weird. Normally you don't have to think about moving your leg yeah, you just do it. Well sometimes it was like it took all my concentration and will to be able to move my leg to walk. It wasn't paralysis as I could feel my leg no problem and it did move no problem,it was just that I had to conciously really think to move it. Most odd feeling. The chiro explained why that happened and it made sense, can't remember exactly what he said but it was something to do with the different kind of sensory nerve cells being effected. I also have muscle weakness in my foot and I did lose my ankle reflex at one point but it seemed to come back again and I did wonder if the Doctor who tested my reflexes at that point was just not very good at finding them because the Chiro was able to get it straight away.

Yes, the recurring flare ups are acute in nature and always seem to occur a few days after over exerting myself or walking downhill. Suggests to me that this is due to inflammation and swelling building up over the course of 2-4 days as the flare ups never occur until after a few days of over activity.

The Chiro has said that the SI problem needs to be sorted or else the disc problems and other back problems will keep reoccuring. He also said that I have a slight lumbar lordosis. Funny that cos I always wondered about my shape as my bum always seems to stick out too much and my belly is always protruding too much also (and it's not fat cos I'm slim!!) He also said that my upper spine was flatter than it should be. I think the main aim of his treatment is to get my spine and pelvis moving properly and to alter the shape of my back. Certainly, my back looks different to me when I look at it in the mirror. He says that I have problems which won't be corrected overnight. With you saying that the treatment is different for nerve compression and nerve sensitisation I wonder if the Chiro has been treating me differently as I had told him that the nerve was NOT compressed as that is what my GP had said to me.

Re Neuro Linguistic Programming, it is something I've heard of, sound interesting and my mother has just bought a CD about it as she is very interested in finding out more about it to help her, as she has Fibromyalgia.

Multifudis is the deep muscle in the back right? When I used to do Pilates I just bought a pilates video and did that and it seem to help my core but I do wonder if I didn't do things properly and possibly set myself up for future trouble. The Pilates type breathing that you have to do, I find very difficult. The Chiro has given me a static abdominal exercise to do. Hard to explain but you pull in the muscle just above the pubic area but you don't hold your breath but keep breathing in and out whilst just pulling in the muscle here. And you feel a tightning there and also a tightnigh in the mid back. He felt that I wasn't ready for any non static abdominal exercises. But for the past week I've been doing Pilates type sit ups where you flex your knees and hips at 90degrees and just lift your upper back slightly off the floor and it is causing no pain to my back or down leg but maybe I should stop cos there is always the possibility that I'm not doing it correctly.

I would like to go back to see a Private Physio but at the moment I just can't afford it as I'm not working. The Chiro is giving me treatment at a reduced price as I'm unemployed and I have a membership to a Health Trust which pays for half of the treatment. But yes, I'm quite worried that if I did decide to go for surgery that it wouldn't resolve my pain but at this point I do feel like I'm running out of options. As for the Cortisone injection I'm only going to get one. I'm of the school of thought that thinks that too many can weaken joints in the long term. And I do also believe that inflammation is part of the healing process and shouldn't be supressed but I'm getting to the point where I'm desperate to get my life back!

PS - I'm in Angus area in Scotland.

[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.

[junior_physiotherapist]

Hallo Sonj:

after along describtions and advices to ur steps u'll be the the head of ur desicion regarding ur patient as every one in medical fields should have a practice and a clinical sense..

this link really is very intersting u can search more and u'll find more through this link
www.spine-health.com

Beat of luck

[sdkashif]

Dear Sonj I giving you some information of management of musculoskeletal pain which contain some basic points while managing the disc related pain and other musculoskeletal painful problems of the spine.

You need to determine whether you are suffering from anterior element pain, posterior element pain, movement related pain or mechanical pain without postures or movement exacerbation (static sensitive).

Anterior element pain

Anterior element pain has been defined as pain made worse by sustained flexion of lumbar spine. Anterior element pain is made worse by sitting and is relieved by standing. Patients assume hyperlordotic posture to relieve their pain. Fracture of vertebral bodies and prolapsed intervertebral discs produce anterior element pain. Extension exercises and press ups are more likely to produce remission than flexion exercises. This is because flexion exercises increase the intradiscal pressure whereas extension exercises unload the discs. Therefore, extension exercises advocated by Cyriax and McKenzie are logical for patients with anterior element pain. Lesions resulting in chronic anterior element pain are obscure; it is tempting to assume that anterior element pain is discogenic in origin, but there is no evidence for this. Unlike the acute group, the patients with chronic anterior element pain may respond to manipulative techniques.

Posterior element pain

Pain is worse by increasing the lumbar lordosis, standing and walking. It is eased by maintained forward flexion, sitting and hip flexion (with or without knee extended). Patients who have structural or postural hyperlordosis, who have facet arthropathy, and who suffer from foraminal stenosis show features of posterior element pain. Pain from rotation and extension is usually of facet origin. Flexion treatment frequently improves the facet disease, spondylolysis, flexion dysfunction and certain types of derangement. Prescription of hyperextension exercises may make the condition worse.

Movement related pain

Patients with movement related pain are most comfortable at rest; pain is precipitated only by activity and jarring. Heavy manual work, repeated twisting, fast walking and running (especially on hard surfaces) and traveling in car on rough grounds all precipitate pain. Movement related pain occurs in traumatic fracture dislocations, in symptomatic spondylolysis or spondylolisthesis and as a result of chronic degenerative segmental instability. Diagnosis may be confirmed by lateral flexion and extension roentengenograms of the lumbar spine and noting abnormal translational movement. A basic scheme of progressive stabilization by strengthening regional and segmental musculature isometrically should be considered. According to Grieve mature patients and those in most pain may need to start abdominal exercises with knee bent and progress more slowly. Side lying stabilization techniques and dynamic abdominal bracing may also be used. Home exercises should be efficiently monitored and the patient taught avoidance of posture and activities known to constitute his specific additional stimuli.

Mechanical pain without posture and movement exacerbation ( Static Sensitive)
Patient with static sensitive low back pain have the have an inability to maintain any one position ( other than lying) for a normal length of time and obtain relief by changing position and moving. Many of these patients appear to have a discrete structural disease, such as scoliosis.

Altered pattern of muscle recruitment have been clearly delineated. One of the most common of those is overuse and early recruitment of low back muscles. Another pattern associated with low back pain is over use of hip flexor (iliopsoas) and weakness of abdominals. It is frequently important to retrain the gluteal muscles and inhibit overuses of lumbar extension, a maladaptive pattern.

Dynamic trunk stabilizers, aside from gluteal maximus which originates or inserts into the lumbodorsal fascia, are the latissimus dorsi, transversus abdominis and internal obliques muscles. The main purpose of strengthening these muscles is to produce a forceful couple that is designed to stabilize the trunk and effectively controls the antigravity weight line or the way in which this area bears weight.

There are many types of isometrics exercises and Grieve provides some good examples to improve power of gluteal and abdominal muscles in the treatment of chronic low back pain, including abdominal wall and abdominal bracing exercises. These exercises avoid the higher intradiscal pressure and emphasize the eccentric control, free breathing and maintenance of functional position of spine. When performing exercises for upper abdominals, the feet should be plantar flexed to inhibit action of psoas.

Isotonic exercises can be helpful for some patients and may be used in all patients as progression of exercise programme, with or without manual or mechanical resistance.

Spinal Bracing:

A number of mechanical supports have been advocated. Spinal bracing seems justified in patients with osteoporotic compression fractures, spondylolisthesis, or segmental instability and in some patients with spinal stenosis- although no controlled studies have demonstrated its efficacy precisely. Approximately 80 to 90 % patients wearing a simple support describe some benefit. The mechanical effect includes prevention of excessive motion and a reminder to wearer not to exaggerate the lumbar load. Thoracolumbosacral corset has been prescribed in spondylolisthesis patients for a period of 3-6 months. This decreases pain in many patients during the acute episodes. In the mean time exercise programme to stretch the lumbar extensors, hamstrings, psoas, lumbodorsal fascia, teach pelvic tilting and strengthening programme for abdominals and avoidance of lumbar extension helps in relieving the condition.

References:

1-Management of Common musculoskeletal disorders, Physical therapy Principles and methods, 2nd edition, By Darlene Hertling and Randolph M. Kessler

2-Tidy's Physiotherapy, 12th Edition, By Ann Thomson, Alison Skinner, Joan Piercy

3- Textbook of Orthopaedic Medicine, Volume 1, Diagnosis of Soft Tissue Lesions, By James Cyriax

4-Mobilisation of Spine, A primary handbook of clinical methods, By Gregory P. Grieve, Fifth Edition

[Aisha_kb]

Hey Sonj,

I have found your posts and the replies that you have gotten very interesting and especially the last post by sdkashif was very informative.

I was just wondering what is the latest on your condition thus far? Any changes? Have you found any new information regarding your condition?

I would like to make an observation for you... having treated quite a number of patients with disc protrusion, there is a good relieve of symptoms with physiotherapy, and on the long run, with continued followups, i have found that those who FOLLOWED THE GIVEN ADVICES and CONTINUED with exercises moving gradually on to more difficult ones, have gotten great relief, no pain symptoms AND no further problems.
They do admit only when they do the wrong position or discontinue exercises end up feeling similar symptoms but not as severe on initial diagnosis.

Sadly, they have not bothered to take another MRI to see what has happened to the disc, so there is no idea what has happened to the disc and i have not gotten a satisfactory answer from anyone.

So please if there is anyone out there who can shed some light to this issue.. Let us know.

Yours,
Aisha.

[stevehalt]

When I had an active neurology practice I focused on nutritional and alternative treatments to disc protrusions and disc dessication.

1. One of the main things to do is to stay well hydrated and to use methods that may specifically improve disc hydration
2. I would check out the use of hydrolyzed collagen - I am including some sections of a book I am writing on the benefits of hydrolyzed collagen. The idea is to use a nutritional supplement that provides the raw materials for connective tissue repair.

Why hydrolyzed collagen affects the electrical properties of the body
• The collagen in everyone’s body declines with age and collagen loss is accelerated in disease. This means the conductive pathways in acupuncture meridians will also become impaired. In addition toxins that accumulate also disrupt the structure and function of collagen. Collagen molecules in the connective tissues such as skin, ligaments, tendons, discs and bones are constantly being broken down and regenerated. This process is called remodeling. However the regeneration of collagen requires an adequate supply of the basic dietary amino acid building block of collagen. Both poor dietary habits and excessive physical stress can result in a situation where collagen breakdown exceeds collagen synthesis, which will result in structural instability as well as degradation in the bioelectric circuits. In addition, trauma and inflammatory processes damage collagen and cause dehydration in the connective tissues and correspondingly can impair transmission of signals in the acupuncture meridians.
• If you want to improve the hydration of the connective tissues and their function as bioelectric circuits it is important to provide dietary materials that will support the structure and function of the connective tissues. Therefore the best source of nutrition would be a food product that provides the raw material for collagen synthesis.


Hydrolyzed Collagen may help osteoarthritis pain and disc pain
• Hydrolyzed collagen improves joint function, and leg strength in individuals with osteoarthritis.
• Some studies also show that hydrolyzed collagen improves pain in arthritic joints Adam, 1991; Moskowitz, 2000).
• Hydrolyzed collagen contains the same amino acid composition as joint cartilage and disc material. Hydrolyzed collagen when given orally to mice will lead to the accumulation of collagen material in cartilage (Oesser et al., 1999). Hydrolyzed collagen has been demonstrated to stimulate cartilage cells to produce cartilage (Oesser et al., 2003).
• Daily use of a dietary supplement of hydrolyzed collagen may help increase strength and decrease pain in the knees and other major joints in individuals with arthritis who experience pain when they are doing repetitive activities (Zukley et al., 2004).
• Hydrolyzed collagen like gelatin contains significant amounts of the amino acids Proline and Glycine. The body uses these and other amino acids to rebuild damaged collagen. These two amino acids are found in high amounts in joints and cartilage and are required by the body to replace collagen when it is broken down by wear and tear (Carpenter et al., 2004).
• James M. Rippe, MD published a book in 2001 titled The Joint Health Prescription. In this book he reported the results of a study that he and his associates performed at the Rippe Lifestyle Institute in Shrewsbury, Massachusetts. This double-blind controlled study involved 175 patients with osteoarthritis between the ages of 40 and 85 who used either a gelatin supplement or a placebo over a 14-week period. The participants in the study consumed either 10 grams of gelatin (Knox Nutra-Joint) or a placebo before breakfast in a glass of water or juice. After 14 weeks the participants who used the gelatin supplement had improved joint mobility, improved knee strength and decreased symptoms of pain and stiffness compared to those individuals who received the placebo (McCarthy et al., 2000).

• While there are no absolute recommendations on the therapeutic intake of collagen hydrolysate, however studies in arthritic patients suggest a 10 g daily dose may be beneficial. The treatment period should not be less than three months. However, as symptoms tend to return after discontinuation of treatment, long-term administration may be prudent. Collagen hydrolysate has no side effects beyond digestive issues (loose bowels at high doses in a few individuals); therefore long-term regular use is safe and may serve as preventive measure.

3. Also check out the use of IceWave patches for pain control. Information on pain control using these nontransdermal patches can be found at www.lifewave.com.

[Aisha_kb]

Another neural stretch position for stretching the sciatic nerve is when hook lying, place one foot over the opposite knee and passively flexing the opposite hip (either by someone doing it for you or by grabbing onto the thigh and pulling it towards your chest). A stretch should be felt over the posterior thigh.

I teach this to many of my patients with sciatica and they feel very good relief after a few sessions.

[Sonj]

Hi thanks, shoulder is much better after doing stretches of the rotator cuff, a sublime (but painful) massage from the chiro and massaging it myself also. Shoulder impingement is one of the most common climbers injury but it wasn't really proper impingement but def felt like the start of something, thankfully nipped in the bud!!

When the chiro examines my back each session he has me do certain movements as he palpates up my spine. In simple terms he likens the joints to hinges on a door and when all is well they move smoothly. He said that with a protrusion or inflammation etc it feels more akin to a door with rusty hinges, not smooth and all jerky like I guess. So he's been saying it feels much much better and movement is good. The Ortho said that as well as reducing the inflammation the steroid jab would reduce the swelling so I guess that is why he is saying it is no longer compressed. It's def not healed as I can still feel it not quite right but it's a great improvement and the way things are going, even though symptoms are not 100% resolved I don't think I'll get another jab, even if they recommend one cos the side effects from it have been a bit horrible.

Thanks for the post on the neural tensioning stuff. The stretches sound similar to what I'm doing already, ie lying supine and doing SLR both plantar and dorsi flexed and holding for 20-30 secs. In dorsi flexion I can almost lift my leg as high as my good leg now with no pain, but still get a little neurological symptoms in plantar flexion and I seem to hit a barrier, where it feels tight in the lumbrosacral area, but not painful. Also the knee stretche lying prone doesn't produce any pain whatsoever and never would have.

Aisha, that stretch you recommended is one that I have doing for a while now and is def very very soothing, esp to my bum. Another one which is good that is soothing is lying supine, flexing good knee but with foot on floor, then placing bad foot on the outside of good thigh and pulling knee on bad leg up to the opposite shoulder.

[alophysio]

Hi Sonj,

Thanks for the update

Just a few things.

1. It is good to hear you are doing well. You probably had a strained shoulder which will usually cause you to use the shoulder differently and then it leads to things like impingement etc. So dealing with it quickly was good.

2. Your joints should move smoothly. However, there are a number of factors that make up smooth movement.
- You can have "form closure" problems - where the joints, ligaments etc don't work properly - swelling can affect this.
- You can have "Force Closure" problems where the muscles don't support the joints properly - like in muscle strains and tears.
- You can have "motor control" problems where the brain doesn't coordinate the muscles properly in sequence leading to incorrect support for the joints - this is a very common problem.
- Lastly, you can have your "Emotions" that can control what is going on, especially in persistent pain (Chronic pain). This is often the pyschosocial aspect of chronic pain - read G Waddell - the back pain revolution for more information.

3. It has been months now since your problem started so central sensitisation has probably occurred - what this means is that pain can be perceived without nociception - that is pain is sensed by the brain without there actually something causing the pain physically. This is a bit hard for people to understand (even physios!!). Try Google for "central sensitization" - i found this one at the start of the list... <click here>

4. Keep going with the neurodynamic self treatment. The "stretch" shouldn't be strong as the blood supply to the nerve is easily compromised under slight strain. They (the experts in this field) are recommending more "neural flossing" type techniques where the motion is continuous rather than sustained stretching. It would be like doing your current exercise10 times instead of holding it for 60secs

Good luck!

[monkey]

Hi Sonj,
I have recently joined this forum and only skimmed through the thread. I am not sure whether the original question on natural resolution of a disc prolapse has been dealt with. I have always advised patients that natural resolution does occur and surgery is simply a means to alleviate present symptom levels. Patients often feel they should have surgery to stop them having problems in the future but having spinal surgery now actually makes you more likely to require surgery in the future. Of course there are cases where surgery has to be performed but if symptoms are resolving then leave to a natural recovery.
I have MRI scans of patients with large disc prolapses who have had repeat scans a year later and the disc prolapse has shrunk to a small bulge. The way I usually explain this is in laymans terms: when the disc first prolapses it is full of fluid, like a grape, with time it loses its water content and becomes more like a raisin (due to proteoglycan deterioration and dehydration).
So yes disc prolapses do resolve but disc degeneration will remain.
The problem is there is poor correlation between size of disc prolapse and symptoms and virtually no correlation between disc degeneration and symptoms.
The good news is that a huge proportion of the elderly population are walking around with severely degenerate discs which are not causing them any problems. This is why the epidural is useful, very often the symptoms are due to chemical rather than mechanical factors.
The best evidence for self care is try and gradually return to normal activity, try not to worry. Fear of re injury is a big barrier to recovery.
Good luck with your shoulder, I can't help you with this, except being a spinal specialist I would probably put it down to a C5 nerve root problem.

[Sonj]

Thanks for that. Aye, fear of re injury was strong at first (you keep expecting the pain) but once I got back into climbing I don't tend to think about it anymore. The pain is now all but gone with just the occasional flicker and occasional numb foot and a bit sore first thing in the morning which resolves as soon as I'm up and moving. The one thing that's still bothering me though is that I still can't sit down for very long or I get a pain in my bum (piriformis?) but this again resolves as soon as I get up and move about. I'm still doing all my stretches daily and there def helping. I still havn't had a big long day on the hill yet with going down steep ground but hoping to shortly to see how my back copes with it. Couple of weeks ago I did go down some pretty steep ground carrying a pretty heavy sack and there was no problems but I was only going down for around 5mins as opposed to the hour or so that I was used to before.

Re the shoulder thing, been no more twinges but it does ache a little sometimes when I'm climbing so I'm just continuing with the rotator cuff stretches as they seem to do the trick. Lol, I abs refuse to have another nerve root problem going on!