Disc prolapse, disc bulge, herniated discs, or slipped disc whichever term you know, is in my opinion the most common cause of low back pain. People often worry when they hear the words disc prolapse but there are many different levels of injury. Also, what we will see in the following case is that the level of injury may not be representative of the patient’s symptoms.
David came to see me back in February this year with a persistent back pain. He had started to feel it a few months after starting to commute to work on a bike. Back then it was just an ache and things took a turn for the worse when he had to move offices and lifted some heavy equipment.
Then his back became more painful and he started experiencing right leg pain. This started as pain and then gradually he became aware of numbness and even some weakness in that leg. He kept on just trying to live with it. His work life was really busy and as a result had not been able to go to the gym. The back pain started giving him problems down both legs for a while and this is when he came to see me.
When we first met, David had been suffering with these symptoms for 6 months, trying to push on through and keep going. He had however decided to change jobs so was actually in between jobs on our first meeting.
David’s case is fairly typical of many disc prolapse patients that I see. What is interesting for me with back pain is firstly how long it takes for you to decide to take action, we push our selves to get to work or through our sports until it actually becomes so painful that we have to take notice.
The other common similarity is that our backs often cope with a fair amount but when we add in something like 2 hours of cycling per day, it can tip the problem over the edge. So, for David who spent 8 hours a day sat at work and then added it 2 hours of cycling a day which is in that same bent position the back started to complain.
24 Hour Pattern
Looking at your 24 hour pattern is always the first task we do to help identify what loads (mechanical or otherwise) we are putting our backs under.
YOUR 24 hour pattern is looking at all the activities that involve your back, this includes how much sitting you are doing, how much walking, bending, and other exercise or sport. This will give you an idea as to whether you are doing too much of one thing or whether just everything together is too much for your back.
Following chatting about David’s symptoms and asking in detail as to whether he had any cauda equina symptoms, we took a look at how he moved and did many tests to see if we could work out the extent of the injury. David did seem to be weaker on his right leg than his left and he also had some changes in sensation. He also had a very positive nerve test on his left leg as well as his right.
A thorough physiotherapy assessment
A thorough physiotherapy assessment involves getting you to move and see what movement are limited or painful. This will give us an idea of what your back doesn’t enjoy. We also test your strength and sensation- this tells us whether the sciatic nerve maybe compressed and reducing its ability to do its job (supply your legs with power and feeling). We also can test the spinal reflexes which can tell us if there are some connection errors.
David’s weakness and sensation changes or numbness were not alarming we just needed to make note of it and most importantly make sure that these symptoms DID NOT GET WORSE. When working with a physio this is important.
What was something to be noted was that David was getting bilateral pain. Now most times bilateral pain on its own is just worth monitoring but on occasion bilateral pain may indicate a central disc prolapse.
Discs are spongy like material that sit between 2 vertebrae, these discs act like brake discs to cushion and allow fluid movements in between the bones, but too much repetitive or sustained positions can gradually load up that disc until it bulges almost like a balloon between your hands. If you squeeze it down it will start to bulge. This bulge can happen either straight behind or on one side or the other. The problem is when its straight behind your spinal cord is in the way so its really important that the disc prolaspe doesn’t squash in to the cord.
We discussed at length what this meant to David and gave him all the info to help identify if he felt things were getting worse.
With all this in the first session, I sent David away to with some basic advice which boiled down to….
- Reduce your sitting time!
- Get moving.
David’s disc was a reasonable size on the MRI and I thought it useful to get a surgical opinion on his back and on seeing the surgeon, he said the disc was large but his symptoms were under control so no need to consider surgery as yet.
If however David’s symptoms did not continue to improve or he kept getting set backs or flare ups then perhaps this would be a case for surgical intervention.
As it happened… David continued to make good and steady progress.
Over the coming weeks, David assessed how much sitting he did, returned to work and had a graduated return to full time hours and his office had also invested in some standing desks which made a big difference.
Once his disc prolapse had settled and were controlled, we begun a strengthening routine. This started gently to begin until we progressed him always baring in mind what his goals were to get back to.
He started working with one of our physio’s doing some weighted work and now the plan is to get back to snowboarding.
Strength and Exercises to good health
What we went through with David is pretty common and the process of keeping up with the strength and exercises, being aware of what may aggravate his symptoms but in no way avoiding anything and understanding how to manage his back has meant that David is now in control and no longer sees the exercises as rehab but actually getting stronger and fitter.
What a great case to work with.