L5/S1 disc protrusion treatment options help

[Ashraf M]

Dear All;

First, I would like to express my thanks to all of you for the very kind help and advice you give to your colleagues and patient (like me).

I am a 43 yrs old male – overweight (L=1.66 m – W=88 Kg) and working – since the last three years as a design engineer and my job requests me to stick to the computer for 8 to 9 hours / day and unfortunately I rarely practice any type of sports.

Long ago when I was at the end of my college stage I started to suffer low back pain but that was not a serious concern to me although annoyed me for a lot of times.

After graduation and working as a site engineer – pain episodes started to decrease and felt happy with my back.

Since I switched my career (actually developed my career) – back pain episodes (about : once every two months) started to attack me again and at that time a short course of anti-infalmatory drugs (Viox tablets) – for two or three days was enough to relief my pain and let me back to work.

An important point to mention here is that as I had suffered from gastric ulcer, gastritis , and excess of acid secretion – doctors tried to avoid giving me strong anti inflammatory and at that time (Viox ) was a good solution.(unfortunately – it has been withdrawn).

Three years ago (April – 2005) – while I was walking I suffered a strong pain in my right bottom calf (achilles tendon area – if I were right) and I went to an orthopedic who did a lot of tests to me (including straight leg raise test) and he diagnosed my case as a problem in the lumbar spine and ordered a lumbar spine MRI.

The finding of the MRI was as follows:
Straightened lumbar lordotic curve – normal sagittal diameter of the bony lumbar spine – degeneration of the L5/S1 disc – L5/S1 central posterior disc protrusion seen affecting the anterior epidural fat and indenting the ventral aspect of the theca – mild diffuse L4/L5 diffuse posterior disc bulde.

The orthopedic prescribed complete bed rest for a week and a an inti-inflamatory injection and to walk after that week at least one hour / day for the next week.

I took the medications (minimal effective dose) as I was very afraid from GIT complications and after the two weeks period healing occurred – though I suffered some tolerable pain from time to time.

A year later I have got diabetes and since that time I am on a combination of insulin (in the morning) and tablets (in the evening) – an added problems to the nerves – and I do my best to keep blood glucose under control – though sometimes it gets out of control.

Since that time I suffered a problem while setting at work or home to the computer chair and I was not able to set comfortable unless I put one of my legs under my thigh – and it became a strange habit : as soon as I reach my disk at work, take off my shoes and put one leg under my other thigh and start working

I went to two orthopedics – they mentioned that I might have an inflammation in the coccyx and prescribed some medications to me – but unfortunately – that did not help much – and I kept that habit till now.

Three months ago – I got a new job abroad and as I were having a minor pain episode (that time it was in my left side accompanied with a burning sensation in the back of my left thigh) – I went to a neurologist and he ordered another MRI to me and the findings was as the first one.

He commented that this is due my disk herniation – but I do not have a sensory defect and if things went very bad I can go for a disc surgery.

I went to my new job – and working there was very tense – long time setting to the computer chair – about 11 hours/ day – no time for any sport and I started to suffer serious back problems.

It started by not being able to extend my back or walk after long setting (every two hours) till I lay down onto the floor for 5 or 10 minutes – try to stand up very slowly and step by step I can walk and return to my computer disk.

I had a very strong pain in my buttocks (around the coccyx area ) as if I felt on my buttocks on a hard ground and pain in the back of my left thigh extending to my foot.

The case developed seriously and I was not able to walk more than 5 minutes as I was getting very strong tightness in buttocks, thighs and I became semi disabled (but the pain was manageable with minimum dose of pain killers – morphine derivatives) so I decided to return home seeking family care and treatment.

I went to the following orthopedic – and after investigation he mentioned that this is due my disc heniation – he prescribed complete bed rest, anti-inflamatory drugs injection, cortisone injection – and to evaluate the case after two weeks.

Fortunately – after two weeks – progress was occurring and the doctor asked me to go for physical therapy and not to set to the computer chair for another two weeks.

I started physical therapy at a clinic which gave me: infrared heating, wax heat, electricity, ultrasound in 15 minutes sessions and hydro therapy (some exercises in the swimming pool – with O3) plus manual massage.

The problem is that I have to return to work as soon as possible (no medical insurance covers my sick leave or treatment cost) – and I am afraid that I might expedite my healing process so that the problem relapses and I will be forced to have a surgery.

I read in your forum – that there might be other options which seems to be very efficient – so I appreciate very much if some one can guide me about the proper physical therapy, exercise, stretches I can do or have.

Finally, thank you all again and I apologize for that long post.

Similar Threads:

• Advice on disc protrusion
• Muscle Tear And mild Disc Protrusion
• Spondylolisthesis and disc protrusion
• L5/S1 disc protrusion ???
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[ben]

hi there
well it would be a good idea if a physio has a look at you to start off, things like how your lumbar movement , core muscle strength , neuro dynamics need to be evaluated .
if its purely discogenic then a mckenzie extension ex prog would help you , also a work area evaluation is needed. i personally would not advise ultrsound for 15 minutes !! over the area , though moist heat does help if you have muscle spasm . with mckenzie ,you should on some spinal stabilisation ex prog ,if a physio can mobilise the l5 s1 then you probably will have better results
hope this helps
cheers
ben

[Ashraf M]

Dear Bin;

First - thank you for your kind reply

The guys I am having treatment with right now are physiospecialists - but you know as I am out of the medical field I cannot judge the professionality of them.

As I read the name of Mckenzi a lot in the forum posts - I searched on the net and found that he has a book : Treat Your Own Back - so I just ordered a book from Amazon - I think I might receive it after 10 days.(I also ordered two other books : 8 steps for Pain Free Back - Treat your back without surgery) - unfortunately - this is the best I can do for now.

You mentioned that an evaluation of the work environment should be made - to me With no doubt - I think it is a hositle one - LoL - could you please explain more ?

If there is a source to know more about those exercises - may you kindly inform me or send it to me (till I receive the books - if you think they are useful).

Finally, thank you again for your help.

cheers.

Ashraf

[msk101]

Hi,
As far as managing a discogenic back problem, a physiotherapist should assess your range of movement, and have a good feel of your spine (that's like localising a bone in your spine and testing it for movement) it to assess the movement of the segments... this will give an indication of tight/loose structures, tension in musculature, inflammation, pain response, and normal/abnormal movements around the joints. They may also assess your spine in different postural positions which allows them to isolate problems or movement patterns that need addressing. The physio should also assess your core strength (through activation of your transversus abdominus muscle - your core acts to support your lower spine in every day activities), and other muscle strength around your pelvis which supports your spine.

Treatment with electrotherapy such as ultrasound and heat can be useful in some amounts but it should not be your whole treatment. With all respect to honest physios out there, i would be very dubious about a physio that just plugs you into a few machines for 15 minutes as the main part of your treatment program.(!!)

From your explanations it sounds like you need an exercise program to regain normal lumbar spine movement patterns, work on your core strength and continue this as a maintenance program long-term.

As for a workplace assessment, this means looking at the workstation set up you have such as chair suitability and size, lumbar support, computer monitor height, keyboard reach distance, mouse reach, phone reach... etc etc. Your chair at work should be wide enough in the seat to accommodate your bottom without oozing over the edges, but nor should you be swimming in the middle of the chair. The back support on your chair should be fitted into the curve of your back and the seat tilt should be level or slightly tipped forwards. your feet should be able to be flat to the floor comfortably with your bottom back in the seat. If your chair isn't adjustable to suit, i would suggest taking a towel and rolling it up to put into your lumbar spine when you are sitting for support. it will help prevent you from slouching (slouching will exacerbate the disc problem).

May I suggest seeing an alternative physiotherapist for second opinion - try one who is trained in McKenzie and pilates (core strength).

Good Luck
msk101

[Ashraf M]

Dear MSK 101

Thanks a lot for your suggestions and help - I really appreciate that very much.

Just to give some background : At the first visit to the clinic they asked me to do some tests - I was already out of the acute phase - and was able to walk a little bit, sit to a soft sofa and have food.

They asked me to walk on my feet toes (passed) - stand on them for a bout 5 seconds (passed) - walk on my heels (passed) – stand up right and bend forward slowly while legs stretched till I feel pain and stop (bent at approx 40 degrees from vertical position) – lay down on my back and do straight leg raise slowly till I feel pain / one by one (achieved only 30-40 degrees).

By today session – I have taken 6 sessions

Today as I was having the session a new physio therapist came and started to do some strange stretches to me – he asked me to lay on my side at the edge of the table (right side here), swing my left leg forward - straight in the air - and he positioned himself between the too legs, starting to push my left leg outward while pressing on my right leg – till I feel pain and hold for 5 to 10 seconds – repeated for three times for the left leg , then he did the same for the right leg.

I was surprised to see my leg could be stretched to reach approx 90 degrees.

He then asked me to lay on face on the table and started to do some pushing on some points – and he said that I had also a problem in the sacro iliac joints – and he applied some pressure on some points – after that I felt some pain relief.

As I concluded that he is doing something good – I asked him if he knows something about Mckenzi stretches and if it is suitable in my case – he replied that why not to think about William flexion – and he added sometimes they get him confused as they prescribe complete different treatment scenarios for the same case !!

I hope that you can kindly have some advise on that?

After the session today – I started to try walking and I was able to walk 10 minutes without a spasm (only some pain in my left leg calf - for which I had taken 200mg Celprex to tolerate) and I was very happy to be able do that.

I am annoyed by that pain – and it might be away from my disk problem – as I still not able to sit on my computer chair (at home) unless I bring my left (or sometimes right) leg and fold it on the chair near or under my other thigh !! – and that pain is only from the calf to the knee frontal side (not coming from the back of the thigh)

Do you have any explaination to that strange way to be able to sit ?

Finally, thanks MSK for your help.

Cheers

Ashraf

[Ashraf M]

Any other opinions or help please - appreciate that very much.

Thanks in advance.

Ashraf

[linbin]

hi dude
as suggested core spinal exercise help you.there might be some changes in the way your spine might be moving.so correcting of movement deviations is also a part of it.
you need a combination of motor contol training and coorrection of movement impairment approach

[bikelet]

Also if you have a chance read Lower Back Disorders by Stuart McGill and colleagues. It is based in a lot of research but quite easy to read for non medical people. It's available on the net and there is a DVD based on it just out too. As a non physio exercise professional i found it very helpful.

On the work station note, there is research (forgive me for not having the ref on hand) that says that leaning back in the chair (as if putting your feet up on the desk) actually reduces disc pressure and that the 'best' sitting posture is one that changes often. McGill's book discusses this in more detail. Sitting puts a lot of force through the back so it is good to alter your position regularly and get up and stretch at least every hour.

Beware of lumbar flexion stretches 1-2 hours after waking up in the morning. Discs soak up fluid over night and are vunerable to injury in this time.

[Ashraf M]

Thank Bikelet you for your advice – by today; it is about one month and half (about 6 ‎weeks) from my last back pain episode and disability.(also 6 weeks of my sick leave)‎

From the pain point of view , I can say that after medications and physical therapy – I ‎am much much better – pain is mild and tolerable such that I do not need to take ‎strong medications (sometimes one celebrex tablet in a week span).‎

I am on my diabetes medications – and there is a strong request from my doctors to ‎take a medication called Alpha Lipoic Acid (300 mg / day) – although I do not follow ‎their advice.‎

Actually it is a food supplement as a powerful antioxidant – and they say to me that as ‎I am diabetic then this medication is a must – especially if I have problems with the ‎nerves (I do not mind to take that medication – it has very excellent effect – but it ‎needs a good or healthy stomach : which I do not have )‎

From the functional point of view (if I can say something like that) - I am suffering ‎from mild numbness in my left foot – it might be from the nerve compression, might ‎be from diabetes, might be from both.‎

I can walk now (for about twenty minutes) – drive my car (for about half an hour) ‎without complains – it is only hard to stand still for more than five minutes.‎

I can sit to my computer chair for about three to four hours/day – but of course not ‎continuous.‎

Unfortunately till now – I do not have a clear and fixed or exercise program – as the ‎books I ordered from Amazon – did not arrive yet !!! – so I picked some exercises ‎from the net from ChiroGeek website (Dr. Gerald website) – which is called dynamic ‎lumbar stabilization (level one exercises) – I think this site is an excellent one.‎
I will place an order for the book you mentioned Bikelet – but I expect one month to ‎receive it !!!‎

I do hope that some body can kindly reply to some of my questions which is :‎

If that numbness in my foot is due to the nerve compression – is it possible that it will ‎heal by physical therapy and exercises ?‎

I am still on my sick leave (my initial physical therapy program still have about two ‎weeks to finish ) and eager to return to my job (please remember it is unpaid sick ‎leave) – but I am quite afraid that a relapse might occur – it was a really horrible ‎experience to me – so does any body have suggestions to how long should I stick to ‎sick leave or just ignore my fears and go back to work ? ‎

Please remember that my work is very tense and usually I stick to my computer chair ‎for a bout 10 or 11 working hours/ day – 5 days/ week and by working hours here – I mean ‎really performing hours not attendance hours.‎

Finally, thank you all for your kind help.‎

Best Regards

Ashraf

[Ashraf M]

Sorry - I forgot to mention an important point regarding returning back to the work.

My job is not in the same city or country where I live - it's abroad - I have to take a flight (4 hours) - move to a different country, search for an apartment, buy furniture, ... etc - and it is very difficult there to find a proper treatment (according to my past experience) - a relapse here means a big loss of money as well.

Any suggestions Please ?

Thanks in advance

Ashraf

[Ashraf M]

Just another simple question: till my last post - about a hundred person read my post - but they did not comment or reply - they might were scanning the forum posts - or did not have time to reply or simply they did not care.

My question is - might be another reason ? - and if so - what it would be ?

Thanks and best regards

[bikelet]

This is my two cents worth- i think some feel that there are more qualified people to answer so they leave it to them (or perhaps the other way, that the answer is obvious so they wait for someone else to spell it out. Don't think this applies in your case so much). Also people scanning and not commenting probably see the title and read it in hope of finding answers not just the initial problem. Or they are afraid of not being smart enough/knowing enough (esp around some very smart physios in here!) to make some sort of reply. Just how i see it

[Ashraf M]

Thanks Bikelet again - it was just a question came up to my mind. And I appreciate very much your contribution.

In matter of fact - by participating in such forums - like this - I do not expect that very highly qualified specialits will read carefully my post/s and write highly qualified treatment options and advices !!! - that would be very foolish thinking for me !!

It is simply a way to communicate, getting more info, sharing, community interaction, ..... with, from and to others.

Those others most propably might be paitents like me had a past similar prroblems - they can just tell about their past experience, treatment worked for them, treatment that did not work for them and might be it might be discussion for a general life issue - like that last one I asked about.

In some cases - it might be a specialist can quickly write a short advice (he thinks that it might work) - but of course without any sort liability or responsibility - even inner (I mean selfone) responsibilty.

In general - I thought it is some sort of communication and interaction - not treatment !! - that's why I thought their might be something wrong in my posts doesn't encourage others to communicate.

Thanks Bikelet

[ben]

dear ashraf

first of all sorry fr the delay in reply , was on vacations!!

-well your question - - do you think that any physio specialist can do mobilization to the disc - or that needs and extremely professional one and expert in that (as it might be very dangerous)

1- my honest answer would be that you need a good physio to treat you but a really good physio to assess you and chart out the actual problem. i was going thru things you wrote
2- william flex ion ex would be a definite no from me if its a true disc, now early morning lumbar fascia stretch as mentioned in sturt mcgill is a different story,that does not involve lumbar movement
3- most physio do a maitland mobs on the spine this shud not be misunderstood with FIXING THE SPINE theory like chiro or osteos, it is mainly targeted at improving the range of movement ,
4 - core muscles like your trans.rectus abd , multifidus, iliopoas , are important to stabilize the spine and hold in right position
5 - work station evaluation is generally done by physios specialised in ergnomics and work place safety , in general the most important thing is to know if you are having proper weight distribution thru your body ,also the golden rule is not to sit for more than 30 min . thats my advise to everyone , also if u can replace the chair with a swiss ball it works well....

hope i ve of help
regards

ben

[Ashraf M]

Dear Ben, Bikelet;

Thanks for your replies and help, it was really very helpful as I discussed your suggestions and advices with the treating physio and though I am not a medical specialist – it seemed to me that he benefit very much from your suggestions.

Now – after about two months and ten days (total of 9 weeks) – from returning back home and starting the medical treatment - it seems that I am much much better.

I can walk for an hour without problem – I can stand for half an hour without problem – I can sit to my computer disk for about 4 or 5 hours (on one hour cycles without a problem)

I still remember that when I felt that sort of disability I was quite afraid to go for surgery – though – I think that we have very good neuro-spinal surgeons in Egypt (may be because of the very high number of population and practice )

However – I think that :the advice to wait at least 6-8 weeks and give other treatments an opportunity is very practical and clever.

The only problem I had (or sometimes have) is that a mild feeling of numbness in my left foot or extra weight – but it is not persistent – it comes and goes.

It also started to be less annoying after I had been put onto a course of vitamin B injections.

Doctors also advised to be on alpha lipoic acid (food supplement) – 600 mg / day
Taking into account the adoption of diabetes medication – as it increases the efficiency of insulin absorption (to avoid hypoglycemia) – but it is not an easy medication for people who have GIT problems.

I also got McKenzie book: Treat Your Own Back – and I read through it and started to do the exercises as advised: extension in laying down – but I soon gave up after I felt a pain in my upper thoracic back area.

- The exercise is a three phase – sleep on the ground face down – breath steady for
three min.
- Do semi extension by putting by raising the back while elbows are semi bent.
- Then extend the elbows and raise the back as much as possible 10 or 15 min each 2
sec.

I do not know what happens but of course I am quite afraid to cause any harm to my back – any advice regarding that.

Also, is that numbness of feel of heaviness in my left foot (which is causal) is something serious or I should neglect and it will completely disappear.

However – thanks all for your help and advice e.

[arkesh_physio]

Hi
U are diagnosed with a Posterior herniation & u have a flattened lumbar curvature,
So i think Mckenzie's therapy for Derangement is best suited for you.
Find out the grade of derangement in the book & start the appropriate exercise.

[Laura01]

you can do core exercises until you blue in the face but your therapy needs to address functional things like sitting. Your sitting posture needs to be assessed so that you can learn the optimal posture for your back. the chances are you may never be able to sit for 10 hours a day at the computer but who can? your back is designed to moved therefore you must allow yourself regular breaks when at work where you change position. I wouldn't be jumping into surgery lightly either as it doesn't always help.
developing a fear of movement is very common so your physio should be giving you graded exercise to prevent potential abnormal movement patterns.
consider whether your back is shifted (do you lean a certain way to avoid pain). this can be adaptive- your bodies was of trying to protect the structure or maladaptive- that youve done it for a while and you body forgets wherw it should be in space.
maybe you should get someone on here to recommend a therapist. I would deinately be suspicious of a therapist who hooks you up to machines for therapy and doesn't look at your movement etc.
good luck

[talhaphysio]

assalamualaikum

have u received lumbar traction by any physiotherapist & if yes what did u feel.

[Ashraf M]

Dear All;

Thank you all for your advices - I missed the forum for about one month and half - so please accept my apology -but I did not receive any replies in my mail or mail notification for any reply)

I was seeking a job at my home country - as I decided to stay home to have a better medical and family care and finally I managed to get a good job in these difficult days.

However, there was a very interesting instances I would like to share with you and really need your opinion.

As I have been again into work - slowly - I started to forget the good exercises which I should follow and suddenly the dull and continuous pain in my buttocks returned back - but not very intense.

I immediately booked at one of the top orthopedic surgeons in Egypt who is MD, Prof or Orth. and had been graduated from UK.

He investigated my last MRI - which has been taken in the GULF area - for the coccyx and the pelvic area and directed me to another highly qualified radiology specialist asking for his opinion too.

Later, he informed me that he is quite sure that there is no problem from the structural point of view in my coccyx - and those pains might be of mechanical nature which do not appear in the MRI and the only solution he had is to give a local cortisone injection.

I had the local cortisone injection - Diprofose ( Betamethazone ) - note : this is the second time - after about 6 months from the first to have local cortisone injection.

Surprisingly - things went bad !!! - it did not improve at all !! - more ever as cortisone elevates blood glucose levels very high for me as diabetic person - that caused nerve inflamation and pain in my back area !!!

As I returned back to the doctor (after two weeks ) - he also was surprised but firmly he mentioned: this pain or its source is out of his coverage area and better to seek the diagnosis in a another medical coverage area and to cope with this pain with anti-inflamatory drugs.

I was very disappointed and suddenly I had an idea - why not to use the sitting cusion again - at least - it is a solution - even if it is temporary.

I started to use it and started to cope with it during my work

One day while I was surfing the net - I read an article about a lady had a very severe problem while setting and she visited a lot of medical specialists - till one day she meet with a very clever doctor - who investigated her and mentioned that she had a problem with her pelvic floor muscle and it is stuck ( sorry I do not know what is meant by stuck here !!)

I tried to find more about this pelvic floor muscle and found that it is correlated also with some problems during going to the toilet ( I guess you know what I mean ) - as I had problems in that !!

There was no good advice regarding that just some extensions - I tried to do some of them- and it was very surprising to me that with no anti-infalmatory drugs - no muscle relaxants, no cortisone injection - pain decreased dramatically such that I threw the sitting cusion !!!!

But still I have the back pain from time to time - and still have to put my leg under my thigh.

Oh - sorry - that was a long post - but at the end : does any one know about how to take care of this pelvic floor muscle - and if it is the main cause for the pain in the coccyx area - how to trat it.

One more thing - I learned that the human body is not like an engineering system -

In many instances - You cannot pin point the source of the problem - there might be small diverse things which build up the problem and really it needs a very professional person to investigate and find a suitable cure.

Waiting for your suggestions.

Best Regards

[Ashraf M]

Oh - sorry - as a reply for the question - if I had a traction before ?

No - unfortunately I did not - however due to my last experience I prefer to wait till I see a very professional one in that traction - and as I read on the net - with very good equipmet.

Best Regards

[cathy29]

hi
as suggested core spinal exercise help you.there might be some changes in the way your spine might be moving.so correcting of movement deviations is also a part of it.
you need a combination of motor contol training and coorrection of movement impairment approach

[Tarni j]

Hello , after reading all ur posts wat I would like to suggest you for the numbness that you feel in your calf is stretching of calves , pyriformis muscles and if any physio near by you knows the SNAGS of lumbar spine that will be of great help .. try it

[junior_physiotherapist]

Dear Ashraf,


Let us at first hope to u fast full recovery......

In addition to above,may here I can suggest to read the follwing article that in relevant to office ergonomics..........

Thibodeau PL and Melamut SJ. Ergonomics in the electronic library. Bull Med Libr Assoc. 1995, 83(3): 322–329.

*Free soft ware for stretching:
Stretch Break for Kids - Pre Download Form

Hope this could help.............

[gensurfer]

Try reading articles in this link: Causes of Sciatica Pain and Sciatica Symptoms with Info On Sciatic Nerve Involvement.

I am wondering if the problems are still due to your disks, inflammation and the particular areas of nerves it is affecting. This book; Do You Really Need Back Surgery, by Aaron Filler; has a great deal of explanatory information on the back and nerves.

[adopastos]

Hello to all,
Very interesting discussion so allow me to jump in and share my case withyou. I believe through such discussions we can help each other, although eachcase is different from the other.
My clinical view: Strong pain in the rightleg only during some activities (bending or sitting for long time)
The finding of my MRI was as follows:
Right posterilateral disc protrusion at the L5/S1disc level with moderate compression of theright descending S1 nerve root.

I am 2 months after the origin of the problem and i am following theconservative method of treatment with laser and electrotherapy.
My question is how long it takes for a disc like thisto be healed?