Still Got Disc? : Part 2- Functional and Structural Diagnosis and Management of Lumbar Disc Injury

Still Got Disc? : Part 2- Functional and Structural Diagnosis and Management of Lumbar Disc Injury
May 18, 2012 Dr. Phillip Snell

Part 1 of this multi-part posting on lumbar disc injury diagnosis and management discussed identification of the structural issues associated with the injury. Next post we’ll look at some of the finesse points that trainers and clinicians can address to improve long term function in the lumbar spine. Today we’ll look at the functional aspects.  How do we see a disc injury before it manifests as a fully blown sciatica/radiculopathy event or,…

 

What are the functional clues to impending disc injury?

Lab studies show that endrange loading of the lumbar discs into flexion in the presence of compression is the quickest way to cause a disc to herniate in the low back. More often than not in my experience, this represents the end result of long term habitual lumbar hinging, until the fateful day when the patient bent forward to pick up ___________(fill in the blank) and felt the searing pain in the butt and leg. Single injury events do occur, usually as a slip and fall onto the butt or as a poorly executed heavy lift. I can’t tell you how many initial onset histories in guys start with, “My first back injury occurred in high school in the weight room after football practice when me and 2 friends (always 2 friends, and poor grammar) decided to see who could back squat the most weight.” Often, they remember a ‘pop’, and back pain, with some sciatica later. Some researchers have said they can hear that ‘pop’ in the lab as the endplate fractures when they load the motion segments to failure in flexion/compression in pig spines. The research of spine biomechanist, Michael Adams, PhD suggests that that endplate failure is frequently the cause of the altered motion in the vertebral segment over time that results in disc degeneration.

 

If this patient walks into your clinic, studio or gym, that lumbar hinge is what you’re looking for. If they are acute with radicular symptoms and you try a multisegmental flexion assessment per SFMA, you’re a cruel bastard. The seated slump test from the previous post, and the quadruped sit back assessment as in the photos below from Stu McGill’s Low Back Disorders will yield your lumbar hinge under less provocative loading.

Start in quadruped

 

Look for the hinge as they sit back toward the heels.

Fix that hinge by quickly training them to hip hinge and box squat so that they don’t hurt getting up and down from the chair to the exam table. Video tutorials for these are available to subscribers of MyRehabExercise.com to send to their patients or clients. If you don’t feel comfortable in your clinic setting or your bodywork studio confidently instructing your patients or clients how to do this, I’ve uploaded these as free material on the FixYourOwnBack.com site. Use that as a resource for your patients or clients to learn more about their disc injury.

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If you’re a trainer and your client has this history, put down your cell phone and stop texting while your client is squatting, rowing, deadlifting, etc and make sure that they aren’t hinging in the lumbar spine while performing those movements. If you’re doing Boot Camp types of movements like Burpees, Mountain Climbers and Squat Tosses with medicine balls, make sure they don’t hinge with these movements. (I think Boot Camp exercise vigilance might require a separate post now that I think of it). Trainers can help buttress the lumbar spine during squatting by cueing the client to use the lats by ‘bending the bar’  and cueing the glutes by pushing their knees in and having the client resist strongly by pushing the knees out (As of November 2014, we’ve updated these cues after seeing them more effective in one of the best powerlifting gyms in the world. Find that info on Chapter 9 of The Plan, available to subscribers of FixYourOwnBack.com). If this info is new to you, then you need Stu McGill’s other book, Ultimate Back Fitness and Performance. Seriously…go now and get it…we’ll wait until you get back!

 

The typical disc presentation is flexion-intolerant, but many of these folks also complain that extension hurts too when you stand them up and ask them to bend backwards. This is important to know because you need to repeat that extension in the prone position. You also need to repeat it several times and ask if the repetitions are less painful.

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If they are, you’re on the right track and need to continue the extensions with McKenzie protocols. Does that mean you’re done with the rehab? NO!

The following quotes are from member feedback at FixYourOwnBack.com in the Discussion Forum:

 

“I now understand why 3 months of McKenzie exercises (post position) 8×10 reps a day prescribed by my last PT caused new pain and symptoms.”

 

“I have been taught to do the Dead Bug by four physical therapists over the past three and a half years. Doing it the way you explained in your video is a completely different experience and makes it a completely different exercise. Thank you for the in-depth explanation.”

 

I’ll also share a recent patient presentation too: 29 y.o. female 2nd year med student and former Division 1 soccer player presented with low back and leg pain 3 weeks after discharge from PT where she received McKenzie (MDT) therapy. Once her pain improved, she was discharged to normal ADLs. Her first rec league soccer match ended early with raging leg pain and weakness after a long cross field kick.

 

I’m a huge fan of MDT and use it daily in my own practice, and that approach did not fail with any of these cases. It did fall short of rehabilitating the injuries of these patients. To paraphrase the common question in all of these individuals:

 

Is There Life After McKenzie?

Full disclosure, I am not MDT certified but learned this approach in my DC training, through reading the literature concerning it and I employ it daily with my cervical and lumbar disc patients. The way I use MDT and frame it to my patients is as a first aid kit. I know of nothing else that allows a lumbar disc patient quicker self help pain relief for disc pain and sciatica. To my mind though, it only gets the patient to Square 1 of the rehab process.

 

Once the person is out of pain, that’s when the fun starts! I break out McGill’s rehab protocols, Janda’s Movement Pattern Assessments,  DNS assessment, SFMA algorithms, Liebenson’s Mag 7, etc and customize an exercise program for them that borrows from all of these schools of thought.  Once your toolbox is deep and you’re familiar with these methods they blend wonderfully for the lumbar disc patient. Despite all of these customizations though, probably 90% of these lumbar disc patients have a very similar take home plan.

  1. Use McKenzie prone press up to control pain
  2. Correct transitional movement flaws and posture faults to stop ‘picking the scab’
  3. Stabilize the lumbar spine by building endurance in sagittal and frontal planes/incorporating proper breathing stereotype
  4. Correct mobility deficits that likely exist in the T-spine and hips, possibly ankle
  5. Build strength
  6. Build agility
  7. Build power
  8. Address sport specific issues pertaining to the lumbar disc
Most of my patient base might get up to some of level 5-7, but mostly need help from a trainer or PT in a gym environment to really get into the deeper levels well because my office is more set up to manage pain than performance. The similarity between most of these lumbar disc patients means that much of their treatment could be standardized, in my opinion, to help more people. Which brings us to another question:

Does Everyone Need An Individual Assessment?

Wouldn’t that be nice? While I would love to see everyone receive an excellent functional assessment,  but so many folks are suffering from lumbar disc injury and it is responsible for such a drain on public health that I think we need to address this from a public health perspective.  We need  low cost ways to get most of the people suffering from disc injury educated about what not to do, what they should do more of, and how to incorporate exercise into their self treatment without hurting themselves. Once folks get feeling better, they will need guidance and excellent exercise instruction. Are you qualified? If not, why not? And that leads us to another important question:

 

What Will You Do In Your Next Career When Your Patients Find Out That They Feel Better After Working Out Than After Leaving Your Office?

 

Those of you who are savvy to Functional Rehab and who are members of MyRehabExercise.com, know that all of those approaches above are already available to you on that website to prescribe those tutorials by sending your patients an email link to their customized prescription.  However, what if you’re a bodyworker, or massage therapist and you don’t feel comfortable taking your relaxed, naked patients through rehab exercise instruction after a massage? I just released another site to help those folks distinguish your services by including exercise. Refer your clients and patients to FixYourOwnBack.com where they can get free education and for much less than they would pay for an office call, they can get the exercise plan above laid out for them as video tutorials. Next post, I’ll cover deeper functional approaches to managing the lumbar disc patient by decoupling the hip movement from spine movement, and improving mobility in key areas. Cheers!