Herniated Disc Injury

This was emailed to us and we thought others might be interested!

Hi,
I wanted to ask about herniated disks. I have a client who has a herniated disk between L4 & L5, she does not currently have pain. Is it correct to not do any kind of lumbar flexion with thorasic rotation(i.e. short box round back with twist or mat obliques roll back), just rotation of thorasic with lumbar in neutral to avoid any further herniation?
Thanks,
Deanna Murray

Response from Leslie Braverman:

Hello Deanna:
Thanks for emailing. When the disc ruptures or herniates, a portion of the spinal disc pushes outside its normal boundary. When a herniated disc bulges out from between the vertebrae, the spinal nerves and/or spinal cord can become compressed. So depending on where this is happening will determine which movements to avoid. Typically, it is recommended that people avoid spinal flexion and rotation, because the disc most frequently herniates posterior-laterally and flexion and rotation would exacerbate the problem and/or create pain. To be perfectly sure which movements are to be avoided, it is best to speak with a physician or physical therapist that has worked with your client and has seen the notes from an MRI and knows exactly where the bulge is occurring. Unfortunately, as a pilates teacher, it is often hard to get this information.

If your client were still having a lot of pain, I would suggest that he/she consult with a doctor and, ideally, work with a physical therapist before doing pilates.

Since your client is no longer having pain it is possible that the disc problem has been resolved and the annulus is no longer irritable and pushing on the nerves. In this case, you can progress your client through all exercises and use her symptoms as a guide. Initially, be cautious of lumbar flexion and rotation. On the other hand, your client may have lost a lot of disc height and have too much segmental mobility and/or  instability where the disc was herniated. Progress slowly and be cautious of too much flexion load on her lumbar spine. Be very conscious of her ability to sit in neutral lumbar position. Most likely,  your client will need to sit on a box or cushion to have a proper position without stressing the lumbar area.

I would recommend that you focus your programming on work that encourages your client to become very stable in neutral positions. Really monitor what is happening at L4-L5. You may need to place your hand on her back to really be sure that she is not flexion or extending, even minutely, at this level. Often people with L4-L5 herniations will not know how to sit properly in neutral position, so really check that her lumbar and sacrum are absolutely correct.

Giving your client lots of exercising that challenge stability in neutral positions will be key to her avoiding future herniations or other deterioration of the spine. Here are some examples. Use these ideas with discretion-depending on the clients level and innate strength at this time- use your professional judgment:

1.) Cat position exercises- all variations to build stability in neutral:
-picking up one hand at a time
-sliding one leg out at at time
-alternating opposite arms and legs (i.e. swimming prep on hands and knees)

2.) Shoulder Bridges- Glut strength is paramount for people that have lower back instability
-advance to picking one leg up at a time
Make sure she is getting Glut medius and deep fibers of Glut Max- not just her deep rotators and hamstrings- watch she doesn’t tuck her sacrum under. Keep your hand on L4-L5 to maintain neutral.

3.) Leg Pull Front Prep

4.) Reformer- Footwork- keep your hand on L4-L5- maintain neutral

5.) Short Box- Straight back
You could do this on the reformer too with the arm straps (like roll back with a straight back) add bicep curls if able

6.) In kneeling positions, make sure that her hips are open enough to get head of femur over the knee so her spine can stay neutral. Her hips may be tight and not allow her to do this.

7.) Extension work is great- my guess is that it was a posterior herniation- if there is any pain avoid it. You can definitely do things like breast stroke that encourage upper back extension. If things like Swan Dive feel good, then do them. As usual, check that she is not hyper-extending at any one spinal level.

8.) Lateral flexion- watch alignment is excellent.

Hopefully, this gives you some good ideas. Challenge her in standing, kneeling and sitting positions- as long as there is no pain. Add upper body and lower body resistances to challenge her ability to stabilize her back against rotational pulls. Side lying work would be great too.

Then, once she is really strong this way, I would begin to introduce more flexion and rotation. Make sure that she is getting movement in all segments of the spine, and she is distributing and translating movement throughout the spine and not giving in at one level.

Some clients will fully recover from disc issues and some will always have a degree of vulnerability. You will have to find out slowly over time and with thoughtful progressions. When in doubt, be open to consult with your clients’ other health advisors and clinicians.

I hope this helps!

Best, Leslie Braverman