Herniated disc and frustration

[berkeley]

I have a L4/L5 herniation and a L5/S1 bulging disc. I did 8 months of PT (2/3 times a week) last year, but while it got me out of that "OMG pain!!" state, I was still having enough pain that was I pretty miserable.

They had tried me on oral prednisone and gabapentin when I was first diagnosed and both had horrible side effects, and after the PT, I ended up getting the series of three cortisone shots. The cortisone shots worked wonders - it was so amazing to not have pain day in and day out. That was 6 months ago... and I think it's worn off.

For the last 6 months, I've concentrated on getting stronger. Without pain, it's obviously so much easier to get through exercises. I felt good and really tried to pay attention to my posture, etc.

So now I don't know what to do. My pain is almost exactly where it was pre-cortisone shots. And when I look at other's experiences, it's all over the place. I've read through some of the old threads, and of course, everyone's experiences are different. Some do well with surgery, some with PT, inversion tables, yoga, etc.

I'm utterly confused and frustrated!

[KnottedYet]

Please don't be upset.

The shot masks the pain by deadening the nerves, but the mechanical cause of the pain (bulge and herniation) remain.

60% of bulges and herniations are directed posteriorly. They can be pushed back into place with some variation of spinal extension. (standing back bends, yoga "cobra", etc.)

40% are directed laterally or anteriorly. They will be pushed back into place with pelvic side glides combined with some amount of extension, or with flexion (like bending forward).

Once you figure out which direction you need to move the spinal segments above and below the herniations/bulges to correct them, then you keep doing that corrective motion every couple hours until you've been pain free for a week.

The spine is self correcting. We only go with corrective motions to help it do what it wanted to do all along. (a little more "oomph" as it were)

Hit up your library for "Treat Your Own Back" by Robin McKenzie, or find a certified or diplomate MDT physical therapist in your area.

I've treated patients who've had chronic pain for 20 years, yet they only needed 6 visits to learn how to fix themselves so they can finish healing. It's never too late to fix yourself. The PT is only there to teach you how. You are the power!

[berkeley]

Thanks I have the McKensie neck book, but I have this lower back book, which is very similar to the workouts the PT had me doing:

http://www.amazon.com/Spinal-Stabili...dp/0968871518/

I will order the other McKensie, thanks for the rec.

I've been doing the cobra stretches since the very beginning. It gives me only some temporary relief, but better than nothing. I did them probably once or twice a day when I wasn't in terrible pain, and for the last week, probably 5-6 times a day.

My herniation is posterior and center, which I guess can cause more problems, but all of my symptoms are on the right side. The bulge is to the left, but seems to be asymptomatic at this point.

And my understanding though is that you can't push the disc "back in" (nor can it "slip")... the herniation results in the disc nucleus busting out of the outer layer, which results in the inflammatory response (which is relieved with the steroids). In the end, the terminology means little, as the therapy is still the same.

I am keeping on with the PT but like today... I did my full set of exercises, and felt worse afterwards. So it's hard to see the light at the end of the tunnel, kwim?

[KnottedYet]

A posterior bulge is pushed back into place with extension.

If extension (cobra) feels better and lets you move better, you do it 10 times every couple hours. AND every time you feel your symptoms. So, at least 8 sessions a day.

The relief will be temporary, because it isn't a "slipped disc." It's a bulge. It will bulge back out again an hour or so later as your body puts pressure on the disc and the goo moves back out to where it's been busting loose. Your job is to keep shoving that bulgy bit back into place over and over and over again so the collagen your body is desperately throwing at it has a chance to reinforce the outer wall of the disc. Every time the bulge bulges out, it shreds the collagen your body just laid down.

Imagine a pair of old underwear. As you sit, your butt stretches out the backside of the underwear. It gets saggy-baggy. Your bulging disc wall is saggy-baggy, too. Your body is trying to reinforce the elastic of your disc wall so it won't bulge as you move, just like reinforcing the saggy butt of your underwear would keep it from wrinkling up as you move.

Inflammation is your body's response to injury. Every time you rip up the little bit of repair your body has managed to accomplish, you kick the inflammation up a notch.

The doc who does our ESIs includes lidocaine with the steroids, which is standard-of-care. Once the over enthusiastic inflammatory cycle has been interrupted you can begin focussing on what to do mechanically to shove things back where they belong. You can shove 'em out (pain) and you can shove 'em back (no pain).

Please please tell me your PT exercises do not include any forward flexion or lying on your back lifting legs or arms or flattening back into the floor. Those are for anterior herniations, not for posteriors.

Doing anything that puts the lumbar segments into flexion (crunch, pelvic tilt, pelvic stability, cat-cow, etc, and all but one of the exercises on the cover of that book) will increase pain because they will shove the bulgy bit out farther. They are for anterior bulges, not posterior bulges.

[berkeley]

Please please tell me your PT exercises do not include any forward flexion or lying on your back lifting legs or arms or flattening back into the floor. Those are for anterior herniations, not for posteriors.

Doing anything that puts the lumbar segments into flexion (crunch, pelvic tilt, pelvic stability, cat-cow, etc, and all but one of the exercises on the cover of that book) will increase pain because they will shove the bulgy bit out farther. They are for anterior bulges, not posterior bulges.

We were working mostly on things to strengthen the multifidus and transverse abdominals - and lots of working in the other planes of motion. I can't really do anything that requires bending forward at the waist anyway. We did much the flexion work you mentioned (the cobra pose, standing back bends etc) and one of the therapists I worked with is a McKenzie practitioner. I don't really know how much of what we did was in line with it, though.

The cover of the book shows the more 'interesting' of the exercises, I suppose. I haven't done any of them but the transverse abs activation one.

[daisylubob]

A posterior bulge is pushed back into place with extension.

Please please tell me your PT exercises do not include any forward flexion or lying on your back lifting legs or arms or flattening back into the floor. Those are for anterior herniations, not for posteriors.

Doing anything that puts the lumbar segments into flexion (crunch, pelvic tilt, pelvic stability, cat-cow, etc, and all but one of the exercises on the cover of that book) will increase pain because they will shove the bulgy bit out farther. They are for anterior bulges, not posterior bulges.

I am back, after being gone for awhile...Bulges at L4-5 L5-S1.

Update. I went to MCKenzie therapy, was RXd basic cobra to get the discs back in place. I went 5 times w/ no relief, therapist was surprised/dumbfounded and had no other answers. Went to more PT (9wks, 1-3x/wk), had 2 injections w/ no relief. Had 2 private lessons w/ Pilates instructor (DR recommended) on correct method of doing the exercises. Which included pushing low back into the floor and sucking the belly towards the floor. Are you saying that all the exercises I have done have basically negated all of the cobra/standing back bends???? I am considering doing 1 more injection (3 strikes and you're out), and doing decompression on a specific machine at PT rehab.

My chiro, DR, physical therapists, and massage therapist all have said this can heal......in 1-3 years.

[OakLeaf]

My chiro, DR, physical therapists, and massage therapist all have said this can heal......in 1-3 years.

Everyone I've known who's had back surgery has said it takes about two years to reach maximum recovery, with diligent PT. So that part at least isn't any different.

Sounds like your Pilates instructors weren't well versed in dealing with back injuries. As we've talked about here before, there are a lot of fly-by-night Pilates certifications out there. You'll want to interview instructors to make sure they have a "real" certification requiring hundreds of hours of training. They may have you use some equipment to prevent your back from going fully into imprint. Ideally a lot of Pilates maneuvers are done in neutral spine anyway, but beginners who can't stabilize their spines in neutral are ordinarily taught to do the moves in imprint, to avoid destabilizing their spines during the move. That's obviously not what you want to be doing.

[KnottedYet]

Are you saying that all the exercises I have done have basically negated all of the cobra/standing back bends???? .

Nope.

You tried cobra and backbends, and said it gave you no relief and did you no good.

So, there's no good from them for you to negate with other movements, anyway.

[daisylubob]

Everyone I've known who's had back surgery has said it takes about two years to reach maximum recovery, with diligent PT. So that part at least isn't any different.

Sounds like your Pilates instructors weren't well versed in dealing with back injuries. As we've talked about here before, there are a lot of fly-by-night Pilates certifications out there. You'll want to interview instructors to make sure they have a "real" certification requiring hundreds of hours of training. They may have you use some equipment to prevent your back from going fully into imprint. Ideally a lot of Pilates maneuvers are done in neutral spine anyway, but beginners who can't stabilize their spines in neutral are ordinarily taught to do the moves in imprint, to avoid destabilizing their spines during the move. That's obviously not what you want to be doing.

I have not had any surgery yet. This time line was given for healing the disc non-surgically.

She has been teaching Stott Pilates for 10 yrs, is the best in town. It is who my Neuro DR recommended, he has been to her also. She had me try the reformer, which I also used at PT. SHe was actully the 1st Pilates instructor who taught me about the imprint. No one in classes I have taken before has ever mentioned it. Do you teach Pilates?

Part of my furstration is all of the different opinions and recommendations I get from everyone. It is very confusing to know who is right, who has the best solutions....especially since I have not had a whole lot of improvement.

[OakLeaf]

She has been teaching Stott Pilates for 10 yrs, is the best in town. It is who my Neuro DR recommended, he has been to her also. She had me try the reformer, which I also used at PT. SHe was actully the 1st Pilates instructor who taught me about the imprint. No one in classes I have taken before has ever mentioned it. Do you teach Pilates?

Part of my furstration is all of the different opinions and recommendations I get from everyone. It is very confusing to know who is right, who has the best solutions....especially since I have not had a whole lot of improvement.

That's got to be frustrating. Hope you find a solution soon.

It does sound like your Pilates instructor is well qualified. I have one of those fly-by-night certifications - I know just enough to know that I'm not really qualified to teach Pilates. Anything I post here is from my personal experience and that of people I know, not from any real expertise.

I think the term "imprint" may be specific to Stott Pilates, but the concept is common to every Pilates method I know of, whether it's called the "C-curve" or whatever - reversing the natural lumbar curve to use the floor to stabilize the spine. It's actually one of the reasons I've grown to prefer yoga to Pilates ... in my limited experience with Pilates, backbends and movements outside the sagittal plane are de-emphasized, whereas it's really those two things that cyclists and runners tend to need most.