Back Clinic Lower Back Pain Chiropractic Team. More than 80% of the population suffers from back pain at some point in their lives. Most cases can be linked to the most common causes: muscle strain, injury, or overuse. But it can also be attributed to a specific condition of the spine: Herniated Disc, Degenerative Disc Disease, Spondylolisthesis, Spinal Stenosis, and Osteoarthritis. Less common conditions are sacroiliac joint dysfunction, spinal tumors, fibromyalgia, and piriformis syndrome.
Pain is caused by damage or injury to the muscles and ligaments of the back. Dr. Alex Jimenez compiled articles outline the importance of understanding the causes and effects of this uncomfortable symptom. Chiropractic focuses on restoring a person’s strength and flexibility to help improve symptoms of lower back pain.
The back and spine are bound to the musculoskeletal system, where they work together to keep the entire body moving and upright. The back muscles surround the spine along with the nerve roots, blood vessels, and tissues that help the back to be able to bend, twist, sit, and stand without any injuries or feeling pain. However, as the body ages naturally, so do the back muscles. They are strained and overused from strenuous activities that can injure the back muscles and pressure the nerve roots, causing them to be irritated. Fortunately, some treatments can help alleviate the stress of the nerve roots and relax the back muscles by loosening them up. Today’s article will focus on the lumbar pinched nerves, their symptoms, and how decompression therapy can help alleviate the symptoms of lumbar pinched nerves for many individuals. By referring patients to qualified and skilled providers specializing in spinal decompression therapy. To that end, and when appropriate, we advise our patients to refer to our associated medical providers based on their examination. We find that education is the key to asking valuable questions to our providers. Dr. Alex Jimenez DC provides this information as an educational service only. Disclaimer
Feeling a sharp, sudden pain in your lower back? How about stiff muscles that feel overused after just picking something heavy? How about burning throbbing pain that travels down the legs? You might be suffering from lumbar pinched nerves, which can affect your quality of life. Research studies have mentioned that lumbar pinched nerves are primarily associated with low back pain and are among the most common complaints about many suffering individuals. Low back pain can cause degeneration of the vertebrae disc and constantly irritate the nerve roots spread out on the lumbar area in the spine. The lumbar spinal nerve roots will experience uncomfortable signals like pain, numbness, and tingling sensations that can cause on and off signals that irritate the nerve roots to cause radicular symptoms. Other research studies have found that radicular pain can cause irritating pain alongside the lumbar nerve root without any neurological involvement causing the sensory fibers to be numb. This will cause unwanted sensations to the lower back down the legs.
Research studies have stated that since radicular pain is one of the many reasons for low back pain, it can affect the nerve roots, depending on the severity. When the nerve roots are being compressed and start by sending on again off again signals, it can range from mild numbing pain that can cause numbing sensations to burning stinging pain that can cause motor dysfunction in the lower back. Some of the other symptoms that are caused by lumbar pinched nerves can include:
Numbness around the area where the nerve is located
Feeling a sharp burning pain radiating from the lower back down to the leg? How about feeling your foot has fallen asleep, and you can’t shake it off? Or have you lost the sensation in your lower back? These are all symptoms of lumbar pinched nerves that are associated with chronic low back pain. The best way to take the pressure off these irritated nerves is spinal decompression. The video explained how there are many techniques that spinal decompression has to offer when dealing with a variety of back issues like herniated discs, sciatica, low back pain, and even pinched nerves in the lumbar area of the spine. Spinal decompression can help relieve the pressure off the nerve roots that are branched out of the spine and relieve the symptoms causing pain. Suppose you want to learn more about decompression and how it can benefit you in alleviating pinched nerves on the lower back? This link will explain what it does for the lumbar area in the spine and provide relief to the back nerve roots.
How Decompression Therapy Can Help Lumbar Pinched Nerves
Since low back pain is associated with lumbar pinched nerves, various treatments can help take the painful symptoms away, and one of these treatments is spinal decompression. Research studies have mentioned that spinal decompression is a type of traction treatment that follows the fundamental goal and principle of relieving pain by using negative pressure. What this negative pressure does is that it causes any herniated or bulging discs to be repositioned and causes an influx of healing substances to come back to the compressed discs and take the pressure off the lumbar nerve roots that are causing the radiating pain. Other research studies have found that decompression therapy can significantly improve lumbar spinal stenosis that also causes lumbar pinched nerves to emit pain by relieving it and bringing physical function back to the legs and back. This will cause significant relief for many suffering individuals suffering from having lumbar pinched nerves.
Overall the lower back has nerves that are spread out and can provide a motor function for the back to move around while keeping the upper body upright. When these nerves are pinched or irritated constantly, they can cause unwanted back issues like low back pain, sciatica, or loss of all sensory and motor functions. When this happens, many individuals won’t have to worry about feeling low back pain or lumbar pinched nerves stopping them from daily activities. Spinal decompression therapy helps the individual gently take the pressure off the irritated nerve roots and causes relief to the lower back and legs. Spinal decompression therapy also allows the beneficial healing nutrients to restore the compressed spinal discs to the spine.
Alexander, Christopher E, and Matthew Varacallo. “Lumbosacral Radiculopathy – Statpearls – NCBI Bookshelf.” In: StatPearls [Internet]. Treasure Island (FL), StatPearls Publishing, 12 Feb. 2022, https://www.ncbi.nlm.nih.gov/books/NBK430837/.
Allegri, Massimo, et al. “Mechanisms of Low Back Pain: A Guide for Diagnosis and Therapy.” F1000Research, F1000Research, 28 June 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926733/.
Anjarwalla, N K, et al. “The Outcome of Spinal Decompression Surgery 5 Years On.” European Spine Journal : Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, Springer-Verlag, Nov. 2007, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223332/.
Dydyk, Alexander M, et al. “Radicular Back Pain – Statpearls – NCBI Bookshelf.” In: StatPearls [Internet]. Treasure Island (FL), StatPearls Publishing, 2 Nov. 2021, https://www.ncbi.nlm.nih.gov/books/NBK546593/.
As the body’s central support structure in the musculoskeletal system, the spine ensures that the body can do everything without feeling discomfort or pain. The spine has three sections in an S-shaped curve known as the cervical, thoracic, and lumbar. Each section helps keep the body upright and is composed of ligaments, soft tissue muscles, and nerve roots spread out all over the back. The spine and sections suffer the most from neck or back pain when the back becomes injured. When this happens, non-surgical treatments can help alleviate the painful symptoms and cause relief for many individuals. Today’s article gives an overview of lumbar traction therapy, how it can help with low back pain, and how it differs from decompression therapy. By referring patients to qualified and skilled providers specializing in spinal decompression therapy. To that end, and when appropriate, we advise our patients to refer to our associated medical providers based on their examination. We find that education is the key to asking valuable questions to our providers. Dr. Alex Jimenez DC provides this information as an educational service only. Disclaimer
Feeling your muscles become stiff on your lower back? Does your back hurt after picking up something heavy? How about a mild ache on your lower back that won’t disappear? Why not try lumbar traction therapy to alleviate these symptoms. Research studies have mentioned that lumbar traction has been used to alleviate symptoms of low back pain. What lumbar traction therapy does is that it allows the extension of soft tissue muscles that are around the facet joints while decreasing the pressure off the intervertebral discs of the lumbar spine. This allows the anterior and posterior ligaments to be extended while stretching and relaxing the muscle to stop them from spasming, improving blood circulation around the spine. Other research studies have found that lumbar traction has helped reduce the pain intensity and disability for many individuals suffering from chronic low back pain. Traction therapy gently relieves the pressure off the spine and helps bring the nutrients back to the spinal discs to promote relief to the individual.
How Does It Help With Low Back Pain?
Since chronic low back pain is common worldwide, many individuals try to alleviate low back pain without going to surgery. Some will try medication to reduce severe pain; others will do light physical activities like yoga or meditation to stretch out the tense muscles. Traction therapy can help alleviate low pain symptoms and prevent other chronic conditions from progressing even further. Research studies have stated that traction therapy can help increase the spinal disc height and reduce internal pressure. This allows the irritated pain-sensitive fibers around the outer layer of the spinal discs to relax and relieve the spinal joints to be put back into normal position. Fortunately, traction therapy and even decompression therapy for low back pain can work together with other non-surgical treatments to help decompress the spine and lower the effects of chronic low back pain.
Lumbar Traction Overview-Video
Feeling mild to severe pain in your lower back? How about tenderness on certain parts of your back? Do your muscles ache and become stiff when carrying or lifting heavy items? Suffering from low back pain can hinder your daily activities and make you feel miserable. Like the video above, utilizing lumbar traction therapy can help relax the back muscles and provide relief to the compressed spinal discs that are pressing on the nerve roots. Traction therapy is a non-surgical treatment that allows individuals to lay down on a traction machine and be strapped in. The traction machine begins to slowly pull on the spine, causing the intervertebral disc to increase its height in the spine and any nerve roots that were being irritated to stop sending pain signals to and from the brain. Suppose you want to learn more about lumbar traction and how it can benefit you? In that case, this link will explain what traction does for the lumbar area in the spine and provide relief to the back.
How Is Traction Different Than Decompression?
Research studies show that lumbar traction therapy immediately improved the pain and functional status of many individuals suffering from chronic low back pain. Since traction therapy help with chronic low back pain, how is it different when individuals use decompression therapy? Traction therapy is performed mechanically or manually to help widen the spaces between the spinal vertebrae. In contrast, decompression therapy helps relieve the pressure of irritated nerve roots that are causing pain along the spinal column. Research studies have found that decompression uses negative pressure to reduce spinal disc protrusion and intradiscal stress off the spinal nerve roots. Traction and decompression therapy have one thing in common: relieve pressure off the spine and alleviate low back pain. These two therapies can also be combined with physical therapy that allows the individual to reduce the stress of the nerve roots and strengthen the back muscle tissues. Incorporating traction or decompression therapy will benefit anyone on their wellness journey by providing relief to chronic low back pain.
Therefore, as part of the musculoskeletal system, the spine can be injured in various scenarios that cause low back pain. Incorporating lumbar traction therapy can help alleviate low back pain either manually or mechanically, stretching the spine to help widen the spaces in the spinal column to relieve compressed spinal discs and loosen up the stiff back muscle to promote blood circulation to the back. Since decompression and traction are different forms of therapy, they do have something in common when it comes to low back pain: to relieve the symptoms of the individual. Once people start incorporating traction therapy as part of their journey to a healthy lifestyle, they can feel relieved and become pain-free from chronic low back pain.
Borman, Pinar, et al. “The Efficacy of Lumbar Traction in the Management of Patients with Low Back Pain.” Rheumatology International, U.S. National Library of Medicine, Mar. 2003, https://pubmed.ncbi.nlm.nih.gov/12634941/.
Koçak, Fatmanur Aybala, et al. “Comparison of the Short-Term Effects of the Conventional Motorized Traction with Non-Surgical Spinal Decompression Performed with a DRX9000 Device on Pain, Functionality, Depression, and Quality of Life in Patients with Low Back Pain Associated with Lumbar Disc Herniation: A Single-Blind Randomized-Controlled Trial.” Turkish Journal of Physical Medicine and Rehabilitation, Bayçınar Medical Publishing, 16 Feb. 2017, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6709608/.
Oh, Hyunju, et al. “The Impact of Manual Spinal Traction Therapy on the Pain and Oswestry Disability Index of Patients with Chronic Back Pain.” Journal of Physical Therapy Science, The Society of Physical Therapy Science, Dec. 2018, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6279706/.
Tadano, Shigeru, et al. “Lumbar Mechanical Traction: A Biomechanical Assessment of Change at the Lumbar Spine.” BMC Musculoskeletal Disorders, BioMed Central, 9 Apr. 2019, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6454715/.
Tanabe;Akai M;Doi T;Arai S;Fujino K;Hayashi K; ;, Hideki. “Immediate Effect of Mechanical Lumbar Traction in Patients with Chronic Low Back Pain: A Crossover, Repeated Measures, Randomized Controlled Trial.” Journal of Orthopaedic Science: Official Journal of the Japanese Orthopaedic Association, U.S. National Library of Medicine, 27 Mar. 2021, https://pubmed.ncbi.nlm.nih.gov/33785233/.
Disc bulge and disc herniation are some of the most common conditions affecting the spine of both young and middle-aged patients. It is estimated that approximately 2.6% of the US population annually visits a clinician to treat spinal disorders. Roughly $ 7.1 billion alone is lost due to the time away from work.
Disc herniation is when the whole or part of the nucleus pulposus is protruded through the torn or weakened outer annulus fibrosus of the intervertebral disc. This is also known as the slipped disc and frequently occurs in the lower back, sometimes also affecting the cervical region. Herniation of the intervertebral disc is defined as a localized displacement of disc material with 25% or less of the disc circumference on an MRI scan, according to the North American Spine Society 2014. The herniation may consist of nucleus pulposus, annulus fibrosus, apophyseal bone or osteophytes, and the vertebral endplate cartilage in contrast to disc bulge.
There are also mainly two types of disc herniation. Disc protrusion is when a focal or symmetrical extension of the disc comes out of its confines in the intervertebral space. It is situated at the intervertebral disc level, and its outer annular fibers are intact. A disc extrusion is when the intervertebral disc extends above or below the adjacent vertebrae or endplates with a complete annular tear. In this type of disc extrusion, a neck or base is narrower than the dome or the herniation.
A disc bulge is when the outer fibers of the annulus fibrosus are displaced from the margins of the adjacent vertebral bodies. Here, the displacement is more than 25% of the circumference of the intervertebral disc. It also does not extend below or above the margins of the disc because the annulus fibrosus attachment limits it. It differs from disc herniation because it involves less than 25% of the disc’s circumference. Usually, the disc bulge is a gradual process and is broad. The disc bulge can be divided into two types. In a circumferential bulge, the whole disc circumference is involved. More than 90 degrees of the rim is involved asymmetrically in asymmetrical bulging.
Normal Intervertebral Disc Anatomy
Before going into detail about the definition of disc herniation and disc bulge, we need to look at the standard intervertebral disc. According to spine guidelines in 2014, a standard disc is something that has a classic shape without any evidence of degenerative disc changes. Intervertebral discs are responsible for one-third to one-fourth of the height of the spinal column.
One intervertebral disc is about 7 -10 mm thick and measures 4 cm in anterior-posterior diameter in the lumbar region of the spine. These spinal discs are located between two adjacent vertebral bodies. However, no discs can be found between the atlas and axis and the coccyx. About 23 discs are found in the spine, with six in the cervical spine, 12 in the thoracic spine, and only five in the lumbar spine.
Intervertebral discs are made of fibro cartilages, forming a fibrocartilaginous joint. The outer ring of the intervertebral disc is known as the annulus fibrosus, while the inner gel-like structure in the center is known as the nucleus pulposus. The cartilage endplates sandwich the nucleus pulposus superiorly and inferiorly. The annulus fibrosus comprises concentric collagen fiber sheets arranged in a radial tire-like structure into lamellae. The fibers are attached to the vertebral endplates and oriented at different angles. With their cartilaginous part, the endplates anchor the discs in their proper place.
The nucleus pulposus is composed of water, collagen, and proteoglycans. Proteoglycans attract and retain moisture, giving the nucleus pulposus a hydrated gel-like consistency. Interestingly, throughout the day, the amount of water found in the nucleus pulposus varies according to the person’s level of activity. This feature in the intervertebral disc serves as a cushion or a spinal shock-absorbing system to protect the adjacent vertebra, spinal nerves, spinal cord, brain, and other structures against various forces. Although the individual movement of the intervertebral discs is limited, some form of vertebral motion like flexion and extension is still possible due to the features of the intervertebral disc.
Effect of Intervertebral Disc Morphology on Structure and Function
The type of components present in the intervertebral disc and how it is arranged determine the morphology of the intervertebral disc. This is important in how effectively the disc does its function. As the disc is the most important element which bears the load and allows movement in the otherwise rigid spine, the constituents it is made up of have a significant bearing.
The complexity of the lamellae increases with advancing age as a result of the synthetic response of the intervertebral disc cells to the variations in the mechanical load. These changes in lamellae with more bifurcations, interdigitation and irregular size and number of lamellar bands will lead to the altered bearing of weight. This in turn establishes a self-perpetuated disruption cycle leading to the destruction of the intervertebral discs. Once this process is started it is irreversible. As there is an increased number of cells, the amount of nutrition the disc requires is also increasingly changing the normal concentration gradient of both metabolites and nutrients. Due to this increased demand, the cells may also die increasingly by necrosis or apoptosis.
Human intervertebral discs are avascular and hence the nutrients are diffused from the nearby blood vessels in the margin of the disc. The main nutrients; oxygen and glucose reach the cells in the disc through diffusion according to the gradient determined by the rate of transport to the cells through the tissues and the rate of demand. Cells also increasingly produce lactic acid as a metabolic end product. This is also removed via the capillaries and venules back to the circulation.
Since diffusion depends on the distance, the cells lying far from the blood capillaries can have a reduced concentration of nutrients because of the reduced supply. With disease processes, the normally avascular intervertebral disc can become vascular and innervated in degeneration and in disease processes. Although this may increase the oxygen and nutrient supply to the cells in the disc, this can also give rise to many other types of cells that are normally not found in the disc with the introduction of cytokines and growth factors.
The morphology of the intervertebral disc in different parts of the spine also varies although many clinicians base the clinical theories based on the assumption that both cervical and lumbar intervertebral discs have the same structure. The height of the disc was the minimum in the T4-5 level of the thoracic column probably due to the fact that thoracic intervertebral discs are less wedge-shaped than those of cervical and lumbar spinal regions.
From the cranial to caudal direction, the cross-sectional area of the spine increased. Therefore, by the L5-S1 level, the nucleus pulposus was occupying a higher proportion of the intervertebral disc area. The cervical discs have an elliptical shape on cross-section while the thoracic discs had a more circular shape. The lumbar discs also have an elliptical shape though it is more flattened or re-entrant posteriorly.
What is a Disc Bulge?
The bulging disc is when the disc simply bulges outside the intervertebral disc space it normally occupies without the rupture of the outer annulus fibrosus. The bulging area is quite large when compared to a herniated disc. Moreover, in a herniated disc, the annulus fibrosus ruptures or cracks. Although disc bulging is more common than disc herniation, it causes little or no pain to the patient. In contrast, the herniated disc causes a lot of pain.
Causes for Disc Bulging
A bulging disc can be due to several causes. It can occur due to normal age-related changes such as those seen in degenerative disc disease. The aging process can lead to structural and biochemical changes in the intervertebral discs and lead to reduced water content in the nucleus pulposus. These changes can make the patient vulnerable to disc bulges with only minor trauma. Some unhealthy lifestyle habits such as a sedentary lifestyle and smoking can potentiate this process and give rise to more severe changes with the weakening of the disc.
General wear and tear due to repeated microtrauma can also weaken the disc and give rise to disc bulging. This is because when the discs are strained, the normal distribution of weight loading changes. Accumulated micro-trauma over a long period of time can occur in bad posture. Bad posture when sitting, standing, sleeping, and working can increase the pressure in the intervertebral discs.
When a person maintains a forward bending posture, it can lead to overstretching and eventually weakness of the posterior part of the annulus fibrosus. Over time, the intervertebral disc can bulge posteriorly. In occupations that require frequent and repetitive lifting, standing, driving, or bending, the bulging disc may be an occupational hazard. Improper lifting up of items, and improper carrying of heavy objects can also increase the pressure on the spine and lead to disc bulges eventually.
The bulging intervertebral discs usually occur over a long period of time. However, the discs can bulge due to acute trauma too. The unexpected sudden mechanical load can damage the disc resulting in micro-tears. After an accident, the disc can become weakened causing long-term microdamage ultimately leading to bulging of the disc. There may also be a genetic component to the disc bulging. The individual may have a reduced density of elastin in the annulus fibrosus with increased susceptibility to disc diseases. Other environmental facts may also play a part in this disease process.
Symptoms of Disc Bulging
As mentioned previously, bulging discs do not cause pain and even if they do the severity is mild. In the cervical region, the disease will cause pain running down the neck, deep pain in the shoulder region, pain radiating along the upper arm, and forearm up to the fingers.
This may give rise to a diagnostic dilemma as to whether the patient is suffering from a myocardial infarction as the site of referred pain and the radiation is similar. Tingling feeling on the neck may also occur due to the bulging disc.
In the thoracic region, there may be pain in the upper back that radiates to the chest or the upper abdominal region. This may also suggest upper gastrointestinal, lung, or cardiac pathology and hence need to be careful when analyzing these symptoms.
The bulging discs of the lumbar region may present as lower back pain and tingling feeling in the lower back region of the spine. This is the most common site for disc bulges since this area holds the weight of the upper body. The pain or the discomfort can spread through the gluteal area, thighs, and to the feet. There may also be muscle weakness, numbness or tingling sensation. When the disc presses on the spinal cord, the reflexes of both legs can increase leading to spasticity.
Some patients may even have paralysis from the waist down. When the bulging disc compresses on the cauda equine, the bladder and bowel functions can also change. The bulging disc can press on the sciatic nerve leading to sciatica where the pain radiates in one leg from the back down to the feet.
The pain from the bulging disc can get worse during some activities as the bulge can then compress on some of the nerves. Depending on what nerve is affected, the clinical features can also vary.
Diagnosis of Disc Bulging
The diagnosis may not be apparent from clinical history due to similar presentations in more serious problems. But the chronic nature of the disease may give some clues. Complete history and a physical examination need to be done to rule out myocardial infarction, gastritis, gastro-oesophageal reflux disease, and chronic lung pathology.
MRI of Disc Bulge
Investigations are necessary for the diagnosis. X-ray spine is performed to look for gross pathology although it may not show the bulging disc directly. There may be indirect findings of disk degeneration such as osteophytes in the endplates, gas in the disc due to the vacuum phenomenon, and the loss of height of the intervertebral disc. In the case of moderate bulges, it may sometimes appear as non-focal intervertebral disc material that is protruded beyond the borders of the vertebra which is broad-based, circumferential, and symmetrical.
Magnetic resonance imaging or MRI can exquisitely define the anatomy of the intervertebral discs especially the nucleus pulposus and its relationships. The early findings seen on MRI in disc bulging include the loss of normal concavity of the posterior disc. The bulges can be seen as broad-based, circumferential, and symmetrical areas. In moderate bulging, the disc material will protrude beyond the borders of the vertebrae in a non-focal manner. Ct myelogram may also give detailed disc anatomy and may be useful in the diagnosis.
Treatment of Disc Bulging
The treatment for the bulging disc can be conservative, but sometimes surgery is required.
When the disc bulging is asymptomatic, the patient does not need any treatment since it does not pose an increased risk. However, if the patient is symptomatic, the management can be directed at relieving the symptoms. The pain is usually resolved with time. Till then, potent pain killers such as non-steroidal anti-inflammatory drugs like ibuprofen should be prescribed. In unresolved pain, steroid injections can also be given to the affected area and if it still does not work, the lumbar sympathetic block can be tried in most severe cases.
The patient can also be given the option of choosing alternative therapies such as professional massage, physical therapy, ice packs, and heating pads which may alleviate symptoms. Maintaining correct posture, tapes, or braces to support the spine are used with the aid of a physiotherapist. This may fasten the recovery process by avoiding further damage and keeping the damaged or torn fibers in the intervertebral disc without leakage of the fluid portion of the disc. This helps maintain the normal structure of the annulus and may increase the recovery rate. Usually, the painful symptoms which present initially get resolved over time and lead to no pain. However, if the symptoms get worse steadily, the patient may need surgery
If the symptoms are resolved, physiotherapy can be used to strengthen the muscles of the back with the use of exercises. Gradual exercises can be used for the return of function and for preventing recurrences.
When conservative therapy does not work with a few months of treatment, surgical treatment can be considered. Most would prefer minimally invasive surgery which uses advanced technology to correct the intervertebral disc without having to grossly dissect the back. These procedures such as microdiscectomy have a lower recovery period and reduced risk of scar formation, major blood loss, and trauma to adjacent structures when compared to open surgery.
Previously, laminectomy and discectomy have been a mainstay of treatment. However, due to the invasiveness of the procedure and due to increased damage to the nerves these procedures are currently abandoned by many clinicians for disc bulging.
Disc bulging in the thoracic spine is being treated surgically with costotransversectomy where a section of the transverse process is resected to allow access to the intervertebral disc. The spinal cord and spinal nerves are decompressed by using thoracic decompression by removing a part of the vertebral body and making a small opening. The patient may also need a spinal fusion later on if the removed spinal body was significant.
Video-assisted thoracoscopic surgery can also be used where only a small incision is made and the surgeon can perform the surgery with the assistance of the camera. If the surgical procedure involved removing a large portion of the spinal bone and disc material, it may lead to spinal instability. This may need bone grafting to replace the lost portion with plates and screws to hold them in place.
What is a Disc Herniation?
As mentioned in the first section of this article, disc herniation occurs when there is disc material displaces beyond the limits of the intervertebral disc focally. The disc space consists of endplates of the vertebral bodies superiorly and inferiorly while the outer edges of the vertebral apophyses consist of the peripheral margin. The osteophytes are not considered a disc margin. There may be irritation or compression of the nerve roots and dural sac due to the volume of the herniated material leading to pain. When this occurs in the lumbar region, this is classically known as sciatica. This condition has been mentioned since ancient times although a connection between disc herniation and sciatica was made only in the 20th century. Disc herniation is one of the commonest diagnoses seen in the spine due to degenerative changes and is the commonest cause of spinal surgery.
Classifications of Disc Herniation
There are many classifications regarding intervertebral disc herniation. In focal disc herniation, there is a localized displacement of the disc material in the horizontal or axial plane. In this type, only less than 25% of the circumference of the disc is involved. In broad-based disc herniation, about 25 – 50 % of the disc circumference is herniated. The disc bulge is when 50 – 100 % of the disc material is extended beyond the normal confines of the intervertebral space. This is not considered a form of disc herniation. Furthermore, the intervertebral disc deformities associated with severe cases of scoliosis and spondylolisthesis are not classified as a herniation but rather adaptive changes of the contour of the disc due to the adjacent deformity.
Depending on the contour of the displaced material, the herniated discs can be further classified as protrusions and extrusions. In disc protrusion, the distance measured in any plane involving the edges of the disc material beyond intervertebral disc space (the highest measure is taken) is lower than the distance measured in the same plane between the edges of the base.
Imaging can show the disc displacement as a protrusion on the horizontal section and as an extrusion on the sagittal section due to the fact that the posterior longitudinal ligament contains the disc material that is displaced posteriorly. Then the herniation should be considered an extrusion. Sometimes the intervertebral disc herniation can occur in the craniocaudal or vertical direction through a defect in the vertebral body endplates. This type of herniation is known as intravertebral herniation.
The disc protrusion can also be divided into two focal protrusion and broad-based protrusion. In focal protrusion, the herniation is less than 25% of the circumference of the disc whereas, in broad-based protrusion, the herniated disc consists of 25 – 50 % of the circumference of the disc.
In disc extrusion, it is diagnosed if any of the two following criteria are satisfied. The first one is; that the distance measured between the edges of the disc material that is beyond the intervertebral disc space is greater than the distance measured in the same plane between the edges of the base. The second one is; that the material in the intervertebral disc space and material beyond the intervertebral disc space is having a lack continuity.
This can be further characterized as sequestrated which is a subtype of the extruded disc. It is called disc migration when disk material is pushed away from the site of extrusion without considering whether there is continuity of disc or not. This term is useful in interpreting imaging modalities as it is often difficult to show continuity in imaging.
The intervertebral disc herniation can be further classified as contained discs and discs that are unconfined. The term contained disc is used to refer to the integrity of the peripheral annulus fibrosus which is covering the intervertebral disc herniation. When fluid is injected into the intervertebral disc, the fluid does not leak into the vertebral canal in herniations that are contained.
Sometimes there are displaced disc fragments that are characterized as free. However, there should be no continuity between disc material and the fragment and the original intervertebral disc for it to be called a free fragment or a sequestered one. In a migrated disc and in a migrated fragment, there is an extrusion of disc material through the opening in the annulus fibrosus with a displacement of the disc material away from the annulus.
Even though some fragments that are migrated can be sequestered the term migrated means just to the position and it is not referred to the continuity of the disc. The displaced intervertebral disc material can be further described with regard to the posterior longitudinal ligament as submembranous, subcapsular, subligamentous, extra ligamentous, transligamentous, subcapsular, and perforated.
The spinal canal can also get affected by an intervertebral disc herniation. This compromise of the canal can also be classified as mild, moderate, and severe depending on the area that is compromised. If the canal at that section is compromised only less than one third, it is called mild whereas if it is only compromised less than two-thirds and more than one third it is considered moderate. In a severe compromise, more than two-thirds of the spinal canal is affected. For the foraminal involvement, this same grading system can be applied.
The displaced material can be named according to the position that they are in the axial plane from the center to the right lateral region. They are termed as central, right central, right subarticular, right foraminal, and right extraforaminal. The displaced intervertebral disc material’s composition can be further classified as gaseous, liquefied, desiccated, scarred, calcified, ossified, bony, nuclear, and cartilaginous.
Before going into detail on how to diagnose and treat intervertebral disc herniation, let us differentiate how cervical disc herniation differs from lumbar herniation since they are the most common regions to undergo herniation.
Cervical Disc Herniation vs. Thoracic Disc Herniation vs Lumbar Disc Herniation
Lumbar disc herniation is the most commonest type of herniation found in the spine which is approximately 90% of the total. However, cervical disc herniation can also occur in about one-tenth of patients. This difference is mainly due to the fact that the lumbar spine has more pressure due to the increased load. Moreover, it has comparatively large intervertebral disc material. The most common sites of intervertebral disc herniation in the lumbar region are L 5 – 6, in the Cervical region between C7, and in the thoracic region T12.
Cervical disc herniation can occur relatively commonly because the cervical spine acts as a pivoting point for the head and it is a vulnerable area for trauma and therefore prone to damage in the disc. Thoracic disc herniation occurs more infrequently than any of the two. This is due to the fact that thoracic vertebrae are attached to the ribs and the thoracic cage which limits the range of movement in the thoracic spine when compared to the cervical and lumbar spinal discs. However, thoracic intervertebral disc herniation can still occur.
Cervical disc herniation gives rise to neck pain, shoulder pain, pain radiating from the neck to the arm, tingling, etc. Lumbar disc herniation can similarly cause lower back pain as well as pain, tingling, numbness, and muscle weakness seen in the lower limbs. Thoracic disc herniation can give rise to pain in the upper back radiating to the torso.
Although disc herniation can occur in all age groups, it predominantly occurs between the fourth and fifth decade of life with the mean age of 37 years. There have been reports that estimate the prevalence of intervertebral disc herniation to be 2 – 3 % of the general population. It is more commonly seen in men over 35 years with a prevalence of 4.8% and while in women this figure is around 2.5%. Due to its high prevalence, it is considered a worldwide problem as it is also associated with significant disability.
In most instances, a herniated disc occurs due to the natural aging process in the intervertebral disc. Due to the disc degeneration, the amount of water that was previously seen in the intervertebral disc gets dried out leading to the shrinking of the disc with the narrowing of the intervertebral space. These changes are markedly seen in degenerative disc disease. In addition to these gradual changes due to normal wear and tear, other factors may also contribute to increasing the risk of intervertebral disc herniation.
Being overweight can increase the load on the spine and increase the risk of herniation. A sedentary life can also increase the risk and therefore an active lifestyle is recommended in preventing this condition. Improper posture with prolonged standing, sitting, and especially driving can put a strain on the intervertebral discs due to the additional vibration from the vehicle engine leading to microtrauma and cracks in the disc. The occupations which require constant bending, twisting, pulling and lifting can put a strain on the back. Improper weight lifting techniques are one of the major reasons.
When back muscles are used in lifting heavy objects instead of lifting with the legs and twisting while lifting can make the lumbar discs more vulnerable to herniation. Therefore patients should always be advised to lift weights with their legs and not the back. Smoking has been thought to increase disc herniation by reducing the blood supply to the intervertebral disc leading to degenerative changes of the disc.
Although the above factors are frequently assumed to be the causes for disc herniation, some studies have shown that the difference in risk is very small when this particular population was compared with the control groups of the normal population.
There have been several types of research done on genetic predisposition and intervertebral disc herniation. Some of the genes that are implicated in this disease include vitamin D receptor (VDR) which is a gene that codes for the polypeptides of important collagen called collagen IX (COL9A2).
Another gene called the human aggrecan gene (AGC) is also implicated as it codes for proteoglycans which is the most important structural protein found in the cartilage. It supports the biochemical and mechanical function of the cartilage tissue and hence when this gene is defective, it can predispose an individual to intervertebral disc herniation.
Apart from these, there are many other genes that are being researched due to the association between disc herniation such as matrix metalloproteinase (MMP) cartilage intermediate layer protein, thrombospondin (THBS2), collagen 11A1, carbohydrate sulfotransferase, and asporin (ASPN). They may also be regarded as potential gene markers for lumbar disc disease.
Pathogenesis of Sciatica and Disc Herniation
The sciatic pain originated from the extruded nucleus pulposus inducing various phenomena. It can directly compress the nerve roots leading to ischemia or without it, mechanically stimulate the nerve endings of the outer portion of the fibrous ring and release inflammatory substances suggesting its multifactorial origin. When the disc herniation causes mechanical compression of the nerve roots, the nerve membrane is sensitized to pain and other stimuli due to ischemia. It has been shown that in sensitized and compromised nerve roots, the threshold for neuronal sensitization is around half of that of a normal and non-compromised nerve root.
The inflammatory cell infiltration is different in extruded discs and non-extruded discs. Usually, in non-extruded discs, the inflammation is less. The extruded disc herniation causes the posterior longitudinal ligament to rupture which exposes the herniated part to the vascular bed of the epidural space. It is believed that inflammatory cells are originating from these blood vessels situated in the outermost part of the intervertebral disc.
These cells may help secrete substances that cause inflammation and irritation of the nerve roots causing sciatic pain. Therefore, extruded herniations are more likely to cause pain and clinical impairment than those that are contained. In contained herniations, the mechanical effect is predominant while in the unconfined or the extruded discs the inflammatory effect is predominant.
Clinical Disc Herniation and What to Look for in the History
The symptoms of the disc herniation can vary a great deal depending on the location of the pain, the type of herniation, and the individual. Therefore, history should focus on the analysis of the main complaint among the many other symptoms.
The chief complaint can be neck pain in cervical disc herniation and there can be referred pain in the arms, shoulders, neck, head, face, and even the lower back region. However, it is most commonly referred to as the interscapular region. The radiation of pain can occur according to the level at the herniation is taking place. When the nerve roots of the cervical region are affected and compressed, there can be sensory, and motor changes with changes in the reflexes.
The pain that occurs due to nerve root compression is called radicular pain and it can be described as deep, aching, burning, dull, achy, and electric depending on whether there is mainly motor dysfunction or sensory dysfunction. In the upper limb, the radicular pain can follow a dermatomal or myotomal pattern. Radiculopathy usually does not accompany neck pain. There can be unilateral as well as bilateral symptoms. These symptoms can be aggravated by activities that increase the pressure inside the intervertebral discs such as the Valsalva maneuver and lifting.
Driving can also exacerbate pain due to disc herniation due to stress because of vibration. Some studies have shown that shock loading and stress from vibration can cause a mechanical force to exacerbate small herniations but flexed posture had no influence. Similarly, activities that decrease intradiscal pressure can reduce the symptoms such as lying down.
The main complaint in lumbar disc herniation is lower back pain. Other associated symptoms can be a pain in the thigh, buttocks, and anogenital region which can radiate to the foot and toe. The main nerve affected in this region is the sciatic nerve causing sciatica and its associated symptoms such as intense pain in the buttocks, leg pain, muscle weakness, numbness, impairment of sensation, hot and burning or tingling sensation in the legs, dysfunction of gait, impairment of reflexes, edema, dysesthesia or paresthesia in the lower limbs. However, sciatica can be caused by causes other than herniation such as tumors, infection, or instability which need to be ruled out before arriving at a diagnosis.
The herniated disc can also compress on the femoral nerve and can give rise to symptoms such as numbness, tingling sensation in one or both legs, and a burning sensation in the legs and hips. Usually, the nerve roots that are affected in herniation in the lumbar region are the ones exiting below the intervertebral disc. It is thought that the level of the nerve root irritation determines the distribution of leg pain. In herniations at the third and fourth lumbar vertebral levels, the pain may radiate to the anterior thigh or the groin. In radiculopathy at the level of the fifth lumbar vertebra, the pain may occur in the lateral and anterior thigh region. In herniations at the level of the first sacrum, the pain may occur in the bottom of the foot and the calf. There can also be numbness and tingling sensation occurring in the same area of distribution. The weakness in the muscles may not be able to be recognized if the pain is very severe.
When changing positions the patient is often relieved from pain. Maintaining a supine position with the legs raised can improve the pain. Short pain relief can be brought by having short walks while long walks, standing for prolonged periods, and sitting for extended periods of time such as in driving can worsen the pain.
The lateral disc herniation is seen in foraminal and extraforaminal herniations and they have different clinical features to that of medial disc herniation seen in subarticular and central herniations. The lateral intervertebral disc herniations can when compared to medial herniations more directly irritate and mechanically compress the nerve roots that are exiting and the dorsal root ganglions situated inside the narrowed spinal canal.
Therefore, lateral herniation is seen more frequently in older age with more radicular pain and neurological deficits. There is also more radiating leg pain and intervertebral disc herniations in multiple levels in the lateral groups when compared to medial disc herniations.
The herniated disc in the thoracic region may not present with back pain at all. Instead, there are predominant symptoms due to referred pain in the thorax due to irritation of nerves. There can also be predominant pain in the body that travels to the legs, tingling sensation and numbness in one or both legs, muscle weakness, and spasticity of one or both legs due to exaggerated reflexes.
The clinician should look out for atypical presentations as there could be other differential diagnoses. The onset of symptoms should be inquired about to determine whether the disease is acute, sub-acute, or chronic in onset. Past medical history has to be inquired about in detail to exclude red flag symptoms such as pain that occurs at night without activity which can be seen in pelvic vein compression, and non-mechanical pain which may be seen in tumors or infections.
If there is a progressive neurological deficit, with bowel and bladder involvement is there, it is considered a neurological emergency and urgently investigated because cauda equine syndrome may occur which if untreated, can lead to permanent neurological deficit.
Getting a detailed history is important including the occupation of the patient as some activities in the job may be exacerbating the patient’s symptoms. The patient should be assessed regarding which activities he can and cannot do.
Degenerative disc disease
Myofascial pain leading to sensory disturbances and local or referred pain
Cyst leading to occasional motor deficits and sensory disturbances
Spondylosis or spondylolisthesis
Discitis or osteomyelitis
Malignancy, neurinoma or mass lesion causing atrophy of thigh muscles, glutei
Spinal stenosis is seen mainly in the lumbar region with mild low back pain, motor deficits, and pain in one or both legs.
An epidural abscess can cause symptoms similar to radicular pain involving spinal disc herniation
Aortic aneurysm which can cause low back pain and leg pain due to compression can also rupture and lead to hemorrhagic shock.
Hodgkin’s lymphoma in advanced stages can lead to space-occupying lesions in the spinal column leading to symptoms like that of intervertebral disc herniation
Lumbar nerve root schwannoma
Herpes zoster infection results in inflammation along with the sciatic or lumbosacral nerve roots
Examination in Disc Herniation
Complete physical examination is necessary to diagnose intervertebral disc herniation and exclude other important differential diagnoses. The range of motion has to be tested but may have a poor correlation with disc herniation as it is mainly reduced in elderly patients with a degenerative disease and due to disease of the joints.
A complete neurological examination is often necessary. This should test muscle weakness and sensory weakness. In order to detect muscle weakness in small toe muscles, the patient can be asked to walk on tiptoe. The strength of muscle can also be tested by comparing the strength to that of the clinician. There may be dermatomal sensory loss suggesting the respective nerve root involvement. The reflexes may be exaggerated or sometimes maybe even absent.
There are many neurologic examination maneuvers described in relation to intervertebral disc herniation such as the Braggart sign, flip the sign, Lasegue rebound sign, Lasegue differential sign, Mendel Bechterew sign, Deyerle sign both legs or Milgram test, and well leg or Fajersztajin test. However, all these are based on testing the sciatic nerve root tension by using the same principles in the straight leg raising test. These tests are used for specific situations to detect subtle differences.
Nearly almost all of them depend on the pain radiating down the leg and if it occurs above the knee it is assumed to be due to a neuronal compressive lesion and if the pain goes below the knee, it is considered to be due to the compression of the sciatic nerve root. For lumbar disc herniation detection, the most sensitive test is considered to be radiating pain occurring down the leg due to provocation.
In the straight leg raising test also called the Lasegue’s sign, the patient stays on his or her back and keeps the legs straight. The clinician then lifts the legs by flexing the hip while keeping the knee straight. The angle at which the patient feels pain going down the leg below the knee is noted. In a normal healthy individual, the patient can flex the hip to 80- 90? without having any pain or difficulty.
However, if the angle is just 30 -70? degrees, it is suggestive of lumbar intervertebral disc herniation at the L4 to S1 nerve root levels. If the angle of hip flexion without pain is less than 30 degrees, it usually indicates some other causes such as tumor of the gluteal region, gluteal abscess, spondylolisthesis, disc extrusion, and protrusion, malingering patient, and acute inflammation of the dura mater. If pain with hip flexion occurs at more than 70 degrees, it may be due to tightness of the muscles such as gluteus maximus and hamstrings, tightness of the capsule of the hip joint, or pathology of sacroiliac or hip joints.
The reverse straight leg raising test or hip extension test can be used to test higher lumbar lesions by stretching the nerve roots of the femoral nerve which is similar to the straight leg raising test. In the cervical spine, in order to detect stenosis of the foramina, the Spurling test is done and is not specific to cervical intervertebral disc herniation or tension of the nerve roots. The Kemp test is the analogous test in the lumbar region to detect foraminal stenosis. Complications due to the disc herniation include careful examination of the hip region, digital rectal examination, and urogenital examination is needed.
Investigation of Disc Herniation
For the diagnosis of intervertebral disc herniation, diagnostic tests such as Magnetic resonance imaging (MRI), Computed tomography (CT), myelography, and plain radiography can be used either alone or in combination with other imaging modalities. Objective detection of disc herniation is important because only after such a finding the surgical intervention is even considered. Serum biochemical tests such as prostate-specific antigen (PSA) level, Alkaline phosphatize value, erythrocyte sedimentation rate (ESR), urine analysis for Bence Jones protein, serum glucose level, and serum protein electrophoresis may also be needed in specific circumstances guided by history.
Magnetic Resonance Imaging (MRI)
MRI is considered the best imaging modality in patients with history and physical examination findings suggestive of lumbar disc herniation associated with radiculopathy according to North American Spinal Society guidelines in 2014. The anatomy of the herniated nucleus pulposus and its associated relationships with soft tissue in the adjacent areas can be delineated exquisitely by MRI in cervical, thoracic, and lumbosacral areas. Beyond the confines of the annulus, the herniated nucleus can be seen as a focal, asymmetric disc material protrusion on MRI.
On sagittal T2 weighted images, the posterior annulus is usually seen as a high signal intensity area due to radial annular tear associated with the herniation of the disc although the herniated nucleus is itself hypointense. The relationship between the herniated nucleus and degenerated facets with the nerve roots which are exiting through the neural foramina are well-demarcated on sagittal images of MRI. Free fragments of the intervertebral disc can also be distinguished from MRI images.
There may be associated signs of intervertebral disc herniation on MRI such as radial tears on the annulus fibrosus which is also a sign of degenerative disc disease. There may be other telling signs such as loss of disc height, bulging annulus, and changes in the endplates. Atypical signs may also be seen with MRI such as abnormal disc locations, and lesions located completely outside the intervertebral disc space.
MRI can detect abnormalities in the intervertebral discs superiorly to other modalities although its bone imaging is a little less inferior. However, there are limitations with MRI in patients with metal implant devices such as pacemakers because the electromagnetic field can lead to abnormal functioning of the pacemakers. In patients with claustrophobia, it may become a problem to go to the narrow canal to be scanned by the MRI machine. Although some units contain open MRI, it has less magnetic power and hence delineates less superior quality imaging.
This is also a problem in children and anxious patients undergoing MRI because good image quality depends on the patient staying still. They may require sedation. The contrast used in MRI which is gadolinium can induce nephrogenic systemic fibrosis in patients who had pre-existing renal disease. MRI is also generally avoided in pregnancy especially during the first 12 weeks although it has not been clinically proven to be hazardous to the fetus. MRI is not very useful when a tumor contains calcium and in distinguishing edema fluid from tumor tissue.
Computed Tomography (CT)
CT scanning is also considered another good method to assess spinal disc herniation when MRI is not available. It is also recommended as a first-line investigation in unstable patients with severe bleeding. CT scanning is superior to myelography although when the two are combined, it is superior both of them. CT scans can show calcification more clearly and sometimes even gas in images. In order to achieve a superior imaging quality, the imaging should be focused on the site of pathology and thin sections taken to better determine the extent of the herniation.
However, a CT scan is difficult to be used in patients who have already undergone laminectomy surgical procedures because the presence of scar tissue and fibrosis causes the identification of the structures difficult although bony changes and deformity in nerve sheath are helpful in making a diagnosis.
The herniated intervertebral discs in the cervical disc can be identified by studying the uncinate process. It is usually projected posteriorly and laterally to the intervertebral discs and superiorly to the vertebral bodies. The uncinate process undergoes sclerosis, and hypertrophy when there is an abnormal relationship between the uncinate process and adjacent structures as seen in degenerative disc disease, intervertebral disc space narrowing, and general wear and tear.
Myelopathy can occur when the spinal canal is affected due to disc disease. Similarly, when neural foramina are involved, radiculopathy occurs. Even small herniated discs and protrusions can cause impingement of the dural sac because the cervical epidural space is narrowed naturally. The intervertebral discs have attenuation a little bit greater than the sac characterized in the CT scan.
In the thoracic region, a CT scan can diagnose an intervertebral disc herniation with ease due to the fact that there is an increased amount of calcium found in the thoracic discs. Lateral to the dural sac, the herniated disc material can be seen on CT as a clearly defined mass that is surrounded by epidural fat. When there is a lack of epidural fat, the disc appears as a higher attenuated mass compared to the surrounding.
Plain radiography is not needed in diagnosing herniation of the intervertebral discs, because plain radiographs cannot detect the disc and therefore are used to exclude other conditions such as tumors, infections, and fractures.
In myelography, there may be deformity or displacement of the extradural contrast-filled thecal sac seen in herniation of the disc. There may also be features in the affected nerve such as edema, elevation, deviation, and amputation of the nerve root seen in the myelography image.
In this imaging modality, the contrast medium is injected into the disc in order to assess the disc morphology. If pain occurs following injection that is similar to the discogenic pain, it suggests that that disc is the source of the pain. When a CT scan is also performed immediately after discography, it is helpful to differentiate the anatomy and pathological changes. However, since it is an invasive procedure, it is indicated only in special circumstances when MRI and CT have failed to reveal the etiology of back pain. It has several side effects such as headache, meningitis, damage to the disc, discitis, intrathecal hemorrhage, and increased pain.
Treatment of Herniated Disc
The treatment should be individualized according to the patient-guided through history, physical examination, and diagnostic investigation findings. In most cases, the patient gradually improves without needing further intervention in about 3 – 4 months. Therefore, the patient only needs conservative therapy during this time period. Because of this reason, there are many ineffective therapies that have emerged by attributing the natural resolution of symptoms to that therapy. Therefore, conservative therapy needs to be evidence-based.
Since the herniation of the disc has a benign course, the aim of treatment is to stimulate the recovery of neurological function, reduce pain, and facilitate early return to work and activities of daily living. The most benefits of the conservative treatment are for younger patients with hernias that are sequestered and in patients with mild neurological deficits due to small disc hernias.
Bed rest has long been considered a treatment option in herniation of the disc. However, it has been shown that bed rest has no effect beyond the first 1 or 2 days. The bed rest is regarded as counterproductive after this period of time.
In order to reduce the pain, oral non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen can be used. This can relieve the pain by reducing inflammation associated with the inflamed nerve. Analgesics such as acetaminophen can also be used although they lack the anti-inflammatory effect seen in NSAIDs. The doses and the drugs should be appropriate for the age and severity of the pain in the patient. If pain is not controlled by the current medication, the clinician has to go one step up on the WHO analgesics ladder. However, the long-term use of NSAIDs and analgesics can lead to gastric ulcers, liver, and kidney problems.
In order to reduce the inflammation, other alternative methods such as applying ice in the initial period and then switching to using heat, gels, and rubs may help with the pain as well as muscle spasms. Oral muscle relaxants can also be used in relieving muscle spasms. Some of the drugs include methocarbamol, carisoprodol, and cyclobenzaprine.
However, they act centrally and cause drowsiness and sedation in patients and it does not act directly to reduce muscle spasm. A short course of oral steroids such as prednisolone for a period of 5 days in a tapering regime can be given to reduce the swelling and inflammation in the nerves. It can provide immediate pain relief within a period of 24 hours.
When the pain is not resolved adequately with maximum effective doses, the patient can be considered for giving steroid injections into the epidural space. The major indication for the steroid injection into periradicular space is discal compression causing radicular pain that is resistant to conventional medical treatment. A careful evaluation with CT or MRI scanning is required to carefully exclude extra discal causes for pain. The contraindications for this therapy include patients with diabetes, pregnancy, and gastric ulcers. Epidural puncture is contraindicated in patients with coagulation disorders and therefore the foraminal approach is used carefully if needed.
This procedure is performed under the guidance of fluoroscopy and involves injecting steroids and an analgesic into the epidural space adjacent to the affected intervertebral disc to reduce the swelling and inflammation of the nerves directly in an outpatient setting. As much as 50% of the patients experience relief after the injection although it is temporary and they might need repeat injections at 2 weekly intervals to achieve the best results. If this treatment modality becomes successful, up to 3 epidural steroidal injections can be given per year.
Physical therapy can help the patient return to his previous life easily although it does not improve the herniated disc. The physical therapist can instruct the patient on how to maintain the correct posture, walking, and lifting techniques depending on the patient’s ability to work, mobility, and flexibility.
Stretching exercises can improve the flexibility of the spine while strengthening exercises can increase the strength of the back muscles. The activities which can aggravate the condition of the herniated disc are instructed to be avoided. Physical therapy makes the transition from intervertebral disc herniation to an active lifestyle smooth. The exercise regimes can be maintained for life to improve general well-being.
The most effective conservative treatment option that is evidence-based is observation and epidural steroid injection for the relief of pain in the short-term duration. However, if the patients so desire they can use holistic therapies of their choice with acupuncture, acupressure, nutritional supplements, and biofeedback although they are not evidence-based. There is also no evidence to justify the use of trans electrical nerve stimulation (TENS) as a pain relief method.
If there is no improvement in the pain after a few months, surgery can be contemplated and the patient must be selected carefully for the best possible outcome.
The aim of surgical therapy is to decompress the nerve roots and relieve the tension. There are several indications for surgical treatment which are as follows.
Absolute indications include cauda equina syndrome or significant paresis. Other relative indications include motor deficits that are greater than grade 3, sciatica that is not responding to at least six months of conservative treatment, sciatica for more than six weeks, or nerve root pain due to foraminal bone stenosis.
There have been many discussions over the past few years regarding whether to treat herniation of intervertebral disc disease with prolonged conservative treatment or early surgical treatment. Much research has been conducted in this regard and most of them show that the final clinical outcome after 2 years is the same although the recovery is faster with early surgery. Therefore, it is suggested that early surgery may be appropriate as it enables the patient to return to work early and thereby is economically feasible.
Some surgeons may still use traditional discectomy although many are using minimally invasive surgical techniques over recent years. Microdiscectomy is considered to be the halfway between the two ends. There are two surgical approaches that are being used. Minimally invasive surgery and percutaneous procedures are the ones that are being used due to their relative advantage. There is no place for the traditional surgical procedure known as a laminectomy.
However, there are some studies suggesting microdiscectomy is more favorable because of its both short-term and long-term advantages. In the short term, there is a reduced length of operation, reduced bleeding, relief of symptoms, and reduced complication rate. This technique has been effective even after 10 years of follow-up and therefore is the most preferred technique even now. The studies that have been performed to compare the minimally invasive technique and microdiscectomy have resulted in different results. Some have failed to establish a significant difference while one randomized control study was able to determine that microdiscectomy was more favorable.
In microdiscectomy, only a small incision is made aided by an operating microscope and the part of the herniated intervertebral disc fragment which is impinging on the nerve is removed by hemilaminectomy. Some part of the bone is also removed to facilitate access to the nerve root and the intervertebral disc. The duration of the hospital stay is minimal with only an overnight stay and observation because the patient can be discharged with minimal soreness and complete relief of the symptoms.
However, some unstable patients may need more prolonged admission and sometimes they may need fusion and arthroplasty. It is estimated that about 80 – 85 % of the patients who undergo microdiscectomy recover successfully and many of them are able to return to their normal occupation in about 6 weeks.
There is a discussion on whether to remove a large portion of the disc fragment and curetting the disc space or to remove only the herniated fragment with minimal invasion of the intervertebral disc space. Many studies have suggested that the aggressive removal of large chunks of the disc could lead to more pain than when conservative therapy is used with 28% versus 11.5 %. It may lead to degenerative disc disease in the long term. However, with conservative therapy, there is a greater risk of recurrence of around 7 % in herniation of the disc. This may require additional surgery such as arthrodesis and arthroplasty to be performed in the future leading to significant distress and economic burden.
In the minimally invasive surgery, the surgeon usually makes a tiny incision in the back to put the dilators with increasing diameter to enlarge the tunnel until it reaches the vertebra. This technique causes lesser trauma to the muscles than when seen in traditional microdiscectomy. Only a small portion of the disc is removed in order to expose the nerve root and the intervertebral disc. Then the surgeon can remove the herniated disc by the use of an endoscope or a microscope.
These minimally invasive surgical techniques have a higher advantage of lower surgical site infections and shorter hospital stays. The disc is centrally decompressed either chemically or enzymatically with the use of chymopapain, laser, or plasma (ionized gas) ablation and vaporization. It can also be decompressed mechanically by using percutaneous lateral decompression or by aspirating and sucking with a shaver such as a nucleosome. Chemopapin was shown to have adverse effects and was eventually withdrawn. Most of the above techniques have shown to be less effective than a placebo. Directed segmentectomy is the one that has shown some promise in being effective similar to microdiscectomy.
In the cervical spine, the herniated intervertebral discs are treated anteriorly. This is because the herniation occurs anteriorly and the manipulation of the cervical cord is not tolerated by the patient. The disc herniation that is due to foraminal stenosis and that is confined to the foramen are the only instances where a posterior approach is contemplated.
The minimal disc excision is an alternative to the anterior cervical spine approach. However, the intervertebral disc stability after the procedure is dependent on the residual disc. The neck pain can be significantly reduced following the procedure due to the removal of neuronal compression although significant impairment can occur with residual axial neck pain. Another intervention for cervical disc herniation includes anterior cervical interbody fusion. It is more suitable for patients with severe myelopathy with degenerative disc disease.
Complications of the Surgery
Although the risk of surgery is very low, complications can still occur. Post-operative infection is one of the commonest complications and therefore needs more vigorous infection control procedures in the theatre and in the ward. During the surgery, due to poor surgical technique, nerve damage can occur. A dural leak may occur when an opening in the lining of the nerve root causes leakage of cerebrospinal fluid which is bathing the nerve roots. The lining can be repaired during the surgery. However, headache can occur due to loss of cerebrospinal fluid but it usually improves with time without any residual damage. If blood around the nerve roots clots after the surgery, that blood clot may lead to compression of the nerve root leading to radicular pain which was experienced by the patient previously. Recurrent herniation of the intervertebral disc due to herniation of disc material at the same site is a devastating complication that can occur long term. This can be managed conservatively but surgery may be necessary ultimately.
Outcomes of the Surgery
There has been extensive research done regarding the outcome of lumbar disc herniation surgery. Generally, the results from the microdiscectomy surgery are good. There is more improvement of leg pain than back pain and therefore this surgery is not recommended for those who have only back pain. Many patients improve clinically over the first week but they may improve over the following several months. Typically, the pain disappears in the initial recovery period and it is followed by an improvement in the strength of the leg. Finally, the improvement of the sensation occurs. However, patients may complain of feeling numbness although there is no pain. The normal activities and work can be resumed over a few weeks after the surgery.
Although conservative therapy is the most appropriate therapy in treating patients, the current standard of care does not address the underlying pathology of herniation of the intervertebral discs. There are various pathways that are involved in the pathogenesis such as inflammatory, immune-mediated, and proteolytic pathways.
The role of inflammatory mediators is currently under research and it has led to the development of new therapies that are directed at these inflammatory mediators causing damage to the nerve roots. The cytokines such as TNF ? are mainly involved in regulating these processes. The pain sensitivity is mediated by serotonin receptor antagonists and ?2 adrenergic receptor antagonists.
Therefore, pharmacological therapies that target these receptors and mediators may influence the disease process and lead to a reduction in symptoms. Currently, cytokine antagonists against TNF ? and IL 1? have been tested. Neuronal receptor blockers such as sarpogrelate hydrochloride etc have been tested in both animal models and in clinical studies for the treatment of sciatica. Cell cycle modifiers that target the microglia that are thought to initiate the inflammatory cascade have been tested with the neuroprotective antibiotic minocycline.
There is also research on inhibiting the NF- kB or protein kinase pathway recently. In the future, the treatment of herniation of the intervertebral disc will be much more improved thanks to the ongoing research. (Haro, Hirotaka)
Dr. Alex Jimenez DC, MSACP, RN, CCST
A disc bulge and/or a herniated disc is a health issue that affects the intervertebral discs found in between each vertebra of the spine. Although these can occur as a natural part of degeneration with age, trauma or injury as well as repetitive overuse can also cause a disc bulge or a herniated disc. According to healthcare professionals, a disc bulge and/or a herniated disc is one of the most common health issues affecting the spine. A disc bulge is when the outer fibers of the annulus fibrosus are displaced from the margins of the adjacent vertebral bodies. A herniated disc is when a part of or the whole nucleus pulposus is protruded through the torn or weakened outer annulus fibrosus of the intervertebral disc. Treatment of these health issues focuses on reducing symptoms. Alternative treatment options, such as chiropractic care and/or physical therapy, can help relieve symptoms. Surgery may be utilized in cases of severe symptoms. – Dr. Alex Jimenez D.C., C.C.S.T. Insight
Curated by Dr. Alex Jimenez D.C., C.C.S.T.
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Gruenhagen, Thijs. Nutrient Supply And Intervertebral Disc Metabolism. The Journal Of Bone And Joint Surgery (American), vol 88, no. suppl_2, 2006, p. 30. Ovid Technologies (Wolters Kluwer Health), doi:10.2106/jbjs.e.01290.
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Lieberman, Isador H. Disc Bulge Bubble: Spine Economics 101. The Spine Journal, vol 4, no. 6, 2004, pp. 609-613. Elsevier BV, doi:10.1016/j.spinee.2004.09.001.
Lappalainen, Anu K et al. Intervertebral Disc Disease In Dachshunds Radiographically Screened For Intervertebral Disc Calcifications. Acta Veterinaria Scandinavica, vol 56, no. 1, 2014, Springer Nature, doi:10.1186/s13028-014-0089-4.
Moazzaz, Payam et al. 80. Positional MRI: A Valuable Tool In The Assessment Of Cervical Disc Bulge. The Spine Journal, vol 7, no. 5, 2007, p. 39S. Elsevier BV, doi:10.1016/j.spinee.2007.07.097.
Lumbar Disc Disease: Background, History Of The Procedure, Problem. Emedicine.Medscape.Com, 2017, http://emedicine.medscape.com/article/249113-overview.
Vialle, Luis Roberto et al. LUMBAR DISC HERNIATION. Revista Brasileira de Ortopedia 45.1 (2010): 1722. PMC. Web. 1 Oct. 2017.
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Jacobs, Wilco C. H. et al. Surgical Techniques For Sciatica Due To Herniated Disc, A Systematic Review. European Spine Journal, vol 21, no. 11, 2012, pp. 2232-2251. Springer Nature, doi:10.1007/s00586-012-2422-9.
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Squat exercises are highly effective, as they strengthen the back and core muscles, helping the prevention of injury. They can be done anywhere with or without equipment like weights and resistance bands and can be part of an aerobic workout. Squatting requires following proper form and posture. Using the improper form, adding too much weight too soon, overdoing it without enough recovery time can cause soreness, back pain, and injury. Having muscle soreness after performing squats is expected; however, if symptoms like chronic soreness, tingling, numbness, or sharp aches that come and go, begin to appear, it is recommended to consult a medical trainer, chiropractor, doctor, or spine specialist to evaluate the symptoms, and if necessary develop a treatment plan, as well as a prevention plan to continue exercising safely.
Squatting is a highly beneficial form of exercise. Athletes, trainers, coaches, and individuals just staying healthy use the technique as a part of their training and workouts. This is because squatting increases core muscle strength, increasing body power. Squat exercises benefits include:
Improved strength and a range of motion allow the body to move flawlessly in various directions with minimal effort.
Increased Core Strength
All major muscles work together during a squat.
This increases muscle stabilization, maintains body balance, increasing core strength.
Squats work all leg muscles simultaneously, synchronizing the body.
This increases body stability decreasing the risk of injury.
Back Pain and Potential Injury
The spine is exposed and unprotected during a squat. This is where back pain and injury can happen. Potential causes include:
A chiropractor or physical therapist will be able to evaluate spinal health, exercise form, and advise if there is an issue.
Achieve Health and Fitness Goals By Doing What You Enjoy
Don’t engage in workouts or fitness programs that make you miserable. Do workouts/activities that you enjoy and have fun doing. Exercise for the love of the body, keeping it healthy and in shape, not because there is a feeling of obligation.
Individuals who don’t like lifting weights try using resistance bands or bodyweight exercises.
The same goes for nutrition. Don’t base diet and supplement choices on misperceptions about health.
Calatayud, Joaquín et al. “Tolerability and Muscle Activity of Core Muscle Exercises in Chronic Low-back Pain.” International journal of environmental research and public health vol. 16,19 3509. 20 Sep. 2019, doi:10.3390/ijerph16193509
Clark, Dave R et al. “Muscle activation in the loaded free barbell squat: a brief review.” Journal of strength and conditioning research vol. 26,4 (2012): 1169-78. doi:10.1519/JSC.0b013e31822d533d
Cortell-Tormo, Juan M et al. “Effects of functional resistance training on fitness and quality of life in females with chronic nonspecific low-back pain.” Journal of back and musculoskeletal rehabilitation vol. 31,1 (2018): 95-105. doi:10.3233/BMR-169684
Donnelly, David V et al. “The effect of the direction of gaze on the kinematics of the squat exercise.” Journal of strength and conditioning research vol. 20,1 (2006): 145-50. doi:10.1519/R-16434.1
Zawadka, Magdalena et al. “Altered squat movement pattern in patients with chronic low back pain.” Annals of agricultural and environmental medicine: AAEM vol. 28,1 (2021): 158-162. doi:10.26444/aaem/117708
Today, more than ever, individuals are less physically active and sitting down for more extended periods causing the gluteus muscles to be used less and weaken. Weak, inactive, or tightening glutes can cause instability in the lower spine, the hips, and the pelvis to shift out of alignment. This leads to low back and buttock pain. The pain is constantly dull, aching, pulsating, then when moving, getting up, it throbs and stings. Gluteal strengthening exercises can strengthen the muscles and alleviate the pain.
Every individual has a unique physiology. The body develops asymmetrically as the individual favors one side or area of the body over another. This can cause imbalances in the muscular system, leading to awkward positioning that causes pain. The muscle groups that support the lower back consist of the:
The gluteal muscle group includes:
In some cases, the development or lack of level of an individual’s upper back strength can also affect the amount of strain on the lower back.
Gluteal Strengthening Difference
Many joints connect in this area that can have functional problems. The muscles within the lower back need:
Stretching allows the body to enhance the limits of its flexibility and mobility. Most of the stretches are involve the hip joint, as this is one of the most effective ways to loosen the gluteal regions. It’s essential to warm the muscles slightly with a light activity while stretching them to elongate naturally.
Seated Figure 4 Stretch
Sitting in a chair.
Cross the right leg over the left.
With the right ankle resting on the left knee.
It should resemble the number 4.
Bend forward at the hip, placing slight pressure onto the left leg.
Hold this stretch for ten-twenty seconds.
Stretch the other side.
Placing the left foot on the right knee.
Repeat this three times.
This yoga pose engages all the muscles along the back. With the glutes at the top in this position, it forces them to activate, allowing them to stretch fully.
Hold this pose and focus the attention on the glutes.
Squats naturally engage the glutes. This is a variation on a squat that focuses on developing gluteal strength.
Stand with the back facing the wall.
Place a Swiss stability ball between the wall and the back.
Lean back into the ball for balance.
Lower the torso until the knees reach 90 degrees.
Return to standing.
Repeat for ten reps.
Do three sets.
Analysis An Effective Tool
Opportunities to increase physical activity lead individuals in a positive direction. The most common reason for reducing and stopping healthy changes is a lack of motivation and feedback. Strategies that provide immediate feedback are essential to:
Monitor progress for establishing a baseline.
Set appropriate and attainable goals.
Track changes over time.
Monitoring changes with a simple weight scale or Body Mass Index calculator provides limited ability to accurately track changes that only highlight weight changes and not track progress in muscle gain or fat loss. In less than 45 seconds, the InBody Test provides doctors, trainers, and physical therapists with easy-to-understand, accurate and objective measurements to evaluate body composition that includes:
Assessing muscle distribution.
Target areas weakened by condition or injury.
Identify muscle and fat imbalances in each area of the body.
Monitor changes to determine the efficacy of the treatment plan, exercise program, and diet plan to ensure long-term success.
Akuthota, Venu et al. “Core stability exercise principles.” Current sports medicine reports vol. 7,1 (2008): 39-44. doi:10.1097/01.CSMR.0000308663.13278.69
Distefano, Lindsay J et al. “Gluteal muscle activation during common therapeutic exercises.” The Journal of orthopedic and sports physical therapy vol. 39,7 (2009): 532-40. doi:10.2519/jospt.2009.2796
Glaviano, Neal R et al. “Gluteal muscle inhibition: Consequences of patellofemoral pain?.” Medical hypotheses vol. 126 (2019): 9-14. doi:10.1016/j.mehy.2019.02.046
Jeong, Ui-Cheol et al. “The effects of gluteus muscle strengthening exercise and lumbar stabilization exercise on lumbar muscle strength and balance in chronic low back pain patients.” Journal of physical therapy science vol. 27,12 (2015): 3813-6. doi:10.1589/jpts.27.3813
Macadam, Paul et al. “AN EXAMINATION OF THE GLUTEAL MUSCLE ACTIVITY ASSOCIATED WITH DYNAMIC HIP ABDUCTION AND HIP EXTERNAL ROTATION EXERCISE: A SYSTEMATIC REVIEW.” International Journal of sports physical therapy vol. 10,5 (2015): 573-91.
Individuals believe that maintaining a straight/flat back is healthy. However, the back is made up of natural curves that allow flexibility and optimal movement. If there is a lack of these curves, it can lead to spine issues, discomfort, and pain. A common problem to develop from a spine lacking natural curvature is abnormal kyphosis. This is when the natural curve in the thoracic spine – mid-back or lumbar spine – low back disappears, which results in a flat back. Restoring the curvature can be challenging, as flatback syndrome requires chiropractic adjustments to gently shift and realign the spine back into a healthy curve and re-train the spine to maintain the curve.
Causes of Flat Back Syndrome
Flatback syndrome is usually a result of muscle tightness in the lower back muscles, specifically in the psoas muscle. Or it could be degenerative disc disease, where the cartilage supporting the spine begins to weaken. Other causes include arthritis and osteoporosis. Practicing unhealthy posture habits can worsen these conditions, speeding up the loss of the spine’s curvature. Loss of spinal curvature does not occur rapidly, as the body will begin to present with symptoms. The following symptoms could be an indication:
Fatigue when trying to stand upright
Chronic low back pain
Back pain and problems with balance are the earliest warning signs of flatback syndrome.
Flatback symptoms usually get worse as the day progresses, with a sense of fatigue and increasing difficulty to stand upright. Individuals tend to flex or bend their hips and knees to get into an upright position. This can become an exhausting process as the day progresses. Individuals can also have symptoms of sciatica and/or spinal stenosis with leg pain and weakness that gets worse when walking. Neck and upper back pain can begin to present while straining to align themselves. The symptoms become disabling, often requiring pain medications that limit the individual’s ability to perform daily activities.
A chiropractor must determine the severity of the deviation through a thorough assessment and examination. This shows the loss of curvature to help a chiropractor plan a realignment/remodeling adjustment schedule. Restoring a natural kyphosis is done through a combination of adjustments and bracing. Scheduled spinal adjustments will realign and shift the vertebrae back to neutral, while a back brace supports to prevent any deviation. Stretching and exercising relevant muscle groups is also part of a chiropractic treatment plan. An example is core exercises for strengthening the muscles supporting the spine.
Because the body is so complex and dynamic, there is no perfect fit when it comes to diet, exercise, or a combination. Fad diets typically recommend that individuals adhere to the same eating guidelines, indicating they will reach an expected result like fat loss. These diets work because they focus on a simple reduction in calorie intake, especially processed and fast foods. The problem is that some of these fad diets can restrict critical nutrients that negatively affect an individual’s health. More information about an individual’s body and how it works is an excellent resource in improving body composition and overall health. Personalized nutrition is an innovative and favorable approach to preventing and treating obesity and related conditions. This approach identifies:
Educated recommendations can be made based on these factors.
Drabsch, Theresa, and Christina Holzapfel. “A Scientific Perspective of Personalised Gene-Based Dietary Recommendations for Weight Management.” Nutrients vol. 11,3 617. 14 Mar. 2019, doi:10.3390/nu11030617
Farcy, J P, and F J Schwab. “Management of flatback and related kyphotic decompensation syndromes.” Spine vol. 22,20 (1997): 2452-7. doi:10.1097/00007632-199710150-00025
Lee, Chang-Hyun, et al. “‘Lumbar Degenerative Kyphosis’ Is Not Byword for Degenerative Sagittal Imbalance: Time to Replace a Misconception.” Journal of Korean Neurosurgical Society vol. 60,2 (2017): 125-129. doi:10.3340/jkns.2016.0607.001
Lu, Daniel C, and Dean Chou. “Flatback syndrome.” Neurosurgery clinics of North America vol. 18,2 (2007): 289-94. doi:10.1016/j.nec.2007.01.007
Wiggins, Gregory C et al. “Management of iatrogenic flat-back syndrome.” Neurosurgical focus vol. 15,3 E8. 15 Sep. 2003, doi:10.3171/foc.2003.15.3.8
The pelvic floor is essentially the spine, and when pain presents, it can be mistaken for back pain. However, these two conditions are frequently linked. The National Institutes of Health- NIH reported that a quarter of women are impacted by pelvic floor disorders and up to 16% of men. The pelvic floor is made up of muscles. If the muscles begin to spasm, they can spread pain upwards and even downwards. This is where the misdiagnosis of lower back pain comes in.
The Pelvic Floor
The pelvic floor is comprised of muscles and connective tissue, known as fascia. The muscles and fascia intertwine, creating a support system for the pelvic organs. The pelvic floor muscles act as a spring system that supports the organs. When downward pressure is applied, and the spring system is working correctly, they push back up to support the muscles. These muscles create the base known as the core. The core muscles support the abdomen, diaphragm, and back muscles, supporting the spine. This is why back, pelvic pain is prevalent as these muscles are interconnected.
Pelvic Floor Dysfunction and Back Pain
If there is pelvic floor dysfunction, there is an inability to control the muscles. There can be too much or insufficient tension, resulting in urinary incontinence or inability to complete bowel movements. It can also be mistaken for back pain or contributes to pelvic and low back pain. The core muscles support the torso and promote stabilization during movement. If they are not working correctly, the torso and pelvis become unstable. The SI – sacroiliac joints linked with the pelvis and the lower spine can begin to present with posterior pelvic and back pain.
Dysfunction can present in several ways, including:
Vaginal dryness by a lack of estrogen during menopause.
Tight inner thigh muscles.
Back pain itself can cause dysfunction.
Women make up the majority of cases that result from:
Endometriosis – a condition in which uterine tissue grows outside the uterus.
Men can also develop problems. As a man’s body ages, prostate problems can cause urinary leakage and frequency problems. It can develop from activities like bicycling. The seat can compress the pudendal nerve, causing pain and dysfunction.
Retraining the Muscles
The dysfunction can be helped by reactivating and strengthening the pelvic and core muscles. Training the pelvic floor and the core muscles will help boost support for the spine and alleviate discomfort and pain. First, it is recommended to get a physical evaluation by a chiropractor or physical therapist to determine if the pelvic floor muscles are too tight or weak. The objective is to improve the strength of the pelvic floor muscles or relax them if they are too tight. A chiropractor and physical therapist can work on the muscles, educate on stretches, exercises, nutrition, and offer additional help and support.
The point of resistance training is to get the muscles to function more effectively. It begins with the contractile proteins that control muscle shortening and lengthening. Resistance exercise can cause some of the proteins to get pulled apart. The stress the muscles experience is the stimulus for the muscles to rebuild bigger, stronger, or more powerful. After resistance exercise, the muscle synthesizes proteins helped by nutritional stimuli and protein consumption. Satellite cellsalso activate to help build up the broken-down muscle. Resistance exercise causes activation.
National Institutes of Health. (September 2008) “Roughly One-Quarter of U.S. Women Affected by Pelvic Floor Disorders” https://www.nih.gov/news-events/news-releases/roughly-one-quarter-us-women-affected-pelvic-floor-disorders
Smith, Christopher P. “Male chronic pelvic pain: An update.” Indian journal of urology: IJU: journal of the Urological Society of India vol. 32,1 (2016): 34-9. doi:10.4103/0970-1591.173105
World Health Organization. (2013) “Low back pain” https://www.who.int/medicines/areas/priority_medicines/Ch6_24LBP.pdf
The body is a connected whole and more than just separate parts and regions. When back pain presents, it might not be the back muscles or spine but could be tense, tight hips, and hamstrings causing low back pain. How it happens, how to stretch and loosen up, and target these areas could help alleviate the pain.
The Hips and Hamstrings
When the hip flexors and hamstrings become tense, the tightness can alter the pelvic alignment. This affects spinal alignment leading to discomfort and low back pain. The hip flexors are a group of muscles around the front of the hips, and they activate when moving the leg and knee upward. The hamstrings are the muscles in the back of the thighs that allow for flexion of the knees and hip extension. Muscle tightness in the hips and/or hip joint stiffness can also contribute to low back pain. Not being able to rotate, flex, or extend the hip forward or backward can affect:
This increases mechanical strain on the lower back.
Losing the ability to function through the entire length of motion can also indicate muscle weakness and a lack of joint movement where the joint around the muscle becomes stiff. This can be caused by:
A lack of movement
Stretching and Treatment
Stretching exercises can be the first line of treatment. It is recommended to start with gentle stretches targeting these areas. What works best for the individual is the stretch they are comfortable repeating enough to make a difference. Warming up the muscles first will generate the best results. An easy place to begin is a gentle forward fold stretch.
Stand up straight, or sit with the legs extended out in front.
Then, reach with the fingers toward the toes. Don’t worry if you can’t reach them.
If the stretching does not bring relief, it is recommended to progress to a personalized treatment and stretching program with a chiropractor or physical therapist. Chiropractic and physical therapy can relieve the problems without medication, injections, or surgery and provide lifelong techniques for maintaining optimal flexibility, mobility, and strength. The hands-on treatment loosens and relieves the tense tightness, reinforcing the flexibility and range of motion. Treatment includes:
Joint mobilization to the hips and spine.
Soft tissue mobilization.
A personalized strengthening program with stretches and exercises that target the specific muscles.
Anti-inflammatory diet recommendations.
Monounsaturated fat is considered healthy fat. This type of fat makes up a significant component of the Mediterranean diet. Studies have shown monounsaturated fats like extra-virgin olive oil can help prevent adverse events related to cardiovascular disease. A meta-analysis evaluating diets high in monounsaturated fats indicated a significant reduction in:
Systolic blood pressure in individuals with type II diabetes.
A significant increase in HDL or good cholesterol.
Another study showed the protective effects of monounsaturated fatty acids reduced the risk factors associated with metabolic syndrome and cardiovascular disease. Monounsaturated fats can have a positive impact on overall health. Monounsaturated fat sources include:
Olive, peanut, and canola oil
Sesame and pumpkin seeds
Estruch, Ramón et al. “Retraction and Republication: Primary Prevention of Cardiovascular Disease with a Mediterranean Diet. N Engl J Med 2013;368:1279-90.” The New England journal of medicine vol. 378,25 (2018): 2441-2442. doi:10.1056/NEJMc1806491
Gillingham, Leah G et al. “Dietary monounsaturated fatty acids are protective against metabolic syndrome and cardiovascular disease risk factors.” Lipids vol. 46,3 (2011): 209-28. doi:10.1007/s11745-010-3524-y
American College of Physicians. (February 2017) “American College of Physicians issues guideline for treating non-radicular low back pain” https://www.acponline.org/acp-newsroom/american-college-of-physicians-issues-guideline-for-treating-nonradicular-low-back-pain
MedlinePlus. (2019) Hip flexor strain – aftercare https://medlineplus.gov/ency/patientinstructions/000682.htm
The low back is made up of five vertebrae, L1 to L5. Pain in the low back is common, specifically because of all the sitting at work, school, and home. Individuals dealing with low back pain know how difficult it can be to sit without discomfort and have found that a low back support pillow can help.
Low Back Support Pillow
A lumbar pillow is a pillow that supports the low back region of the spine. Different types include:
Specially shaped pillows made from materials like memory foam.
Lumbar pillows can be used on any chair at the office or home.
They are also helpful for travel with small-sized versions that can be packed and easy to carry.
How Lumbar Pillows Help
According to the CDC, the average adult spends around 6.5 and 8 hours a day sitting. Constant sitting hurts the body, specifically the spine and the back muscles, and is a significant cause of muscle stress. Properly supporting the low back helps remove the stress and strain. A low back support pillow can help correct sitting posture.
There are plenty of options for low-back support pillow shapes, sizes, fillings, and materials. These include:
Some look like a half-cylinder in shape, rectangular, and curved.
Personal preference and comfort are different for everybody, and it could take some trial and error to find the right lumbar pillow. Some pillows are customizable, allowing the ability to add or remove filling as needed. Talking with a spine specialist, orthopedist or chiropractor can help in figuring out what type is best. Pillows come in various price ranges, with some at $10-15, while others can cost $100 or more. However, any pillow that provides enough support for the low spine’s natural curvature can work. It is important to be comfortable and supported to prevent pain and injury no matter where you sit.
Fermentable and Nonfermentable Fiber
The entire body can host trillions of beneficial bacteria. The majority live in the intestines and are referred to as the gut microbiome. Also known as the forgotten organ, these bacteria have a say in the body’s composition and overall health. The beneficial bacteria thrive on fermentable fiber, and fermentation in the gut produces short-chain fatty acids like:
These help suppress gut inflammation and can reduce the risk of various digestive disorders like:
Irritable bowel syndrome
Foods that are rich in fermentable fibers include:
Cereal fibers that are rich in cellulose, like wheat bran, are nonfermentable.
“What is Memory Foam?” Sleep Foundation, Seattle, WA. August 2020. https://www.sleepfoundation.org/mattress-information/what-is-memory-foam
“Association Between Sitting Time and Cardiometabolic Risk Factors After Adjustment for Cardiorespiratory Fitness, Cooper Center Longitudinal Study, 2010–2013.” Centers for Disease Control, Atlanta, GA. December 2016. https://www.cdc.gov/pcd/issues/2016/16_0263.htm
“Ergonomics for Prolonged Sitting.” The University of California at Los Angeles, Los Angeles, CA. https://www.uclahealth.org/spinecenter/ergonomics-prolonged-sitting
“Workplace sitting is associated with self-reported general health and back/neck pain: a cross-sectional analysis in 44,978 employees.” BMC Public Health, London, UK. May 2021. https://pubmed.ncbi.nlm.nih.gov/33957889/
Kettlebell training for the back muscles and back pain prevention can be part of a recommended treatment plan. When experiencing low back pain, many sports medicine experts recommend kettlebell exercise to strengthen the core and posterior chain. However, if not used correctly, kettlebell exercises can worsen back pain.
They are made of cast iron or steel and are named for resembling a tea kettle with an oversized handle. They can be used in one and two-handed movements.
Exercises and Movements for Back Pain
For individuals that are not experiencing back pain, kettlebell training can be excellent for maintenance and injury prevention. They strengthen the core and back muscles.
The kettlebell swing is an essential exercise and is one of the most important exercises when dealing with back pain issues.
A kettlebell is placed on the floor about 12 inches in front while standing with the feet a little wider than hip-distance.
The hips become the hinge.
Extend the arms down to the bell and grip it.
Begin swinging it up and down through the legs and then upward and outward to chest level.
The shoulders are to stay relaxed.
The hips are used to thrust and create momentum to swing the kettlebell.
Keep the spine neutral throughout the exercise to prevent injury.
The arms are to hold the bell only.
Don’t swing with the arms or shoulders, but push through with the hips.
The exercise can be swung up over the head but is not recommended for those with back pain.
They are portable and don’t require a lot of space.
With kettlebells, an individual can train more easily than with barbells.
Kettlebell workouts provide strength training and cardiovascular fitness.
Once the proper technique is learned, individuals can set up a regular regimen at home.
Proper Form and Mistakes
Proper form is crucial. The primary movement most individuals have difficulty with is getting the proper hinging motion at the hip. Most individuals flex at the lower back and place increased pressure on the discs. Proper hip hinge motion means:
Keeping the low back straight
Flexing at the hip
Pushing back out with the buttocks when performing the swing motion.
When done correctly, an individual should be able to stop at any stage and hold that position.
Posture Form Tips
Form issues with kettlebells include:
When picking up the kettlebell, remember to hip hinge instead of squatting to maintain the back in a neutral position.
Drive the hips back in the same way when sitting down on a low chair.
Arching the back
If the pelvis is tilted too far forward, the back arches a lot.
This can narrow where the nerves leave the spine in the low back.
Keep the abdominals tight to prevent the pelvis from tilting forward.
Using the incorrect weight can also cause problems; this could be going too heavy or too light.
Too heavy increases the risk of straining the body and back.
A kettlebell that is too light does not provide the correct resistance to strengthen the muscles.
Another common mistake is overtraining. Specifically, individuals over 50 whose bodies don’t recover as quickly.
Individuals over 50 are recommended to spread out the workout days with more than one rest day.
Proper training before working with kettlebells is highly recommended, especially for those already dealing with back pain. Individuals are encouraged to work with a physical therapist, sports chiropractor, or personal trainer who can teach proper techniques and specific exercises, observe the individual’s process, and make corrections. Improper technique can lead to:
Start in a pushup position with the arms on the floor in front.
Lift the legs, so the tops of the feet rest on the exercise/stability ball.
Knees should be bent to start the movement.
Extend the legs out as straight as possible.
Hold the position for a few seconds.
Return to the starting position.
Common Injuries Associated with Kettlebells: ACSM’s Health & Fitness Journal (March/April 2017) “Managing Risks of Training with Kettlebells to Achieve Optimum Benefits.” https://journals.lww.com/acsm healthfitness/Fulltext/2017/03000/MANAGING_RISKS_OF_TRAINING_WITH_KETTLEBELLS_TO.6.aspx
We see it on all types of athletes nowadays. They are wearing tape that looks like it’s for an injury. It is for injuries, but it can also be used as a preventative measure to avoid injuries. It is known as Kinesiology, Kinesio, KT, and elastic tape. It reduces swelling, increases mobility, and expedites recovery. It can be beneficial with back soreness/pain.
When it comes to Kinesio tape for back pain, medical professionals reported the tape is most effective when incorporated with other pain treatments. A study found that taping various areas of the body safely relieved knee pain and reduced the need for pharmacological treatment for knee osteoarthritis. It is applied to the body to support a joint, improve circulation, or provide proprioception feedback to the brain. The tape can help increase awareness of a specific painful area, reminding the individual to maintain proper posture and not move in a way that causes pain. Online videos can teach how to tape a particular area of the body. Examples include:
Each joint and muscle requires various tapings or different patterns and directions. Applying the tape to body areas that an individual can reach and access, like the knee and ankle, can be simple. But it can be a challenge to apply it to the shoulder or back. This is when a physical therapist, chiropractor, medical clinician, partner, family member, or friend can help with the application. Kinesiology tape is designed to adhere for an average of three to four days, even when bathing.
Kinesio taping for low back pain with help should be done in a shortened muscle position, meaning the person helping should apply the tape while the person experiencing back pain stands up straight. The taping can be two stripes going up and down, or it can be done with strips fanning out towards the buttocks. This gives support to the spine/back muscles and decreases pain.
Recovery and Prevention
Recovery from a spine condition or injury prevention, kinesiology tape can be used without any risk. It can help reduce pain, improve circulation, and provide muscle support. For a minor sprain or strain, the tape could help on its own. But for an individual experiencing severe back pain, it is recommended to seek professional medical care along with a stretching and strengthening regimen. The tape is recommended to be used as part of a complete treatment plan.
Five-Day Training Plan
The idea of training five times a week can be pretty intimidating. This is not about pushing yourself to your breaking point Monday through Friday. The objective of working out this frequently is about exercising normally, not like a professional athlete. That’s why many individuals divide up the areas they work out each day. Particular attention is given to one muscle group or system, letting the others rest and recover. This workout strategy is called a split and is favored by the bodybuilding community. Five-day splits are utilized to target different major muscle group/s every day. A standard training plan includes:
This is just one of the many programs that trainers, athletes, and fitness individuals have developed. Some individuals replace shoulders day with cardio; some do abs every day; it depends on what fitness goal the individual is going for.
Journal of Bodywork and Movement Therapies. (April 2016) “Kinesio taping for chronic low back pain: A systematic review” https://pubmed.ncbi.nlm.nih.gov/27634093/
Therapeutic Advances in Musculoskeletal Disease. (August 2019) “The effectiveness of Kinesio Taping® for pain management in knee osteoarthritis: a randomized, double-blind, controlled clinical trial” https://journals.sagepub.com/doi/full/10.1177/1759720X19869135
What are the potential benefits for back pain?: Asian Journal of Sports Medicine. (June 2015) “Low Back Pain in Athletes” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4592766/
Relaxing the low back muscles. The low back supports the weight of the upper body and provides mobility. The lumbar spine/low back is a complex structure of interconnecting:
All work together to provide support, strength, and flexibility.
However, this complex structure is highly susceptible to injury and pain. The muscles in the low back support the spinal column and are responsible for flexing, rotating the hips when walking. The nerves in the low back supply sensation and power the muscles in the pelvis, legs, and feet. The most common acute low back pain cases are brought on from injury to the:
The body also reacts to injury by triggering an inflammatory response. Inflammation can cause severe pain. The key is relaxing the muscles and keeping them loose.
Lower back pain causes
The most common cause is muscle spasms, which can be triggered by:
Quick awkward movements like twisting, reaching, and/or bending at the wrong angle can set off pain symptoms.
If the same back muscles are getting strained and/or pulled continuously, this could indicate an underlying problem with a misaligned vertebra.
Correct improper postures
Improper posture and body positioning eventually present with discomfort and pain. Individuals are constantly hunched over and slumped in front of computers and devices, along with sitting with crossed legs, sleeping on a non-supportive mattress, and there is a perfect recipe for low back pain. Adjusting sitting, desk, and computer ergonomics and using smart devices with posture awareness will go a long way to correct improper posture.
Cramped or pulled muscles need time to recover. Too much rest or being completely inactive makes sense but is not recommended. Light movement keeps the blood flowing, especially in and around the injured/sore area. This increases healing and shortens recovery time. Just some light walking is recommended. Getting up and moving while relaxing around the house will get the muscles back in shape.
Benefits of collagen
Collagen generates a protective barrier effect on the intestinal mucosa that lines the digestive tract. One study found that collagen supplementation protects against the breakdown of the intestinal wall after a burn injury. A lack of collagen from aging or other factors could impair the structure of the intestinal mucosa. This could lead to digestive problems like leaky gut syndrome and irritable bowel syndrome.
Joint Health and Mobility
Collagen provides structure and cushion in the joints. As the body ages, the cushion wears down, and joint mobility decreases. This increases the risk of injury. Taking collagen supplements can help improve symptoms of osteoarthritis, rheumatoid arthritis, and other conditions.
Finta, Regina et al. “The effect of diaphragm training on lumbar stabilizer muscles: a new concept for improving segmental stability in the case of low back pain.” Journal of pain research vol. 11 3031-3045. 28 Nov. 2018, doi:10.2147/JPR.S181610
Lugo, James P et al. “Efficacy and tolerability of an undenatured type II collagen supplement in modulating knee osteoarthritis symptoms: a multicenter randomized, double-blind, placebo-controlled study.” Nutrition journal vol. 15 14. 29 Jan. 2016, doi:10.1186/s12937-016-0130-8
National Institute of Neurological Disorders and Stroke. Pain: Hope Through Research. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Pain-Hope-Through-Research. June 9, 2017.
Recent studies have begun to show that back pain apps can enhance the body’s recovery when combined with conservative treatments and physical activity/exercise. Low back pain – LBP can interfere with everyday activities, work, school, and sleep making life miserable. All around the world low back pain is one of the leading causes of disability. Studies have shown how physical activity/exercise, mindfulness, and spinal manipulation can reduce symptoms more effectively. Exercise has been shown to reduce anxiety and increase positive outlook/mood. However, the biggest problem for individuals is finding activities/exercises that they can enjoy and sticking with them. Individuals that use back pain apps have reported the benefits of being guided through the exercises and meditation that help decrease their pain.
Back Pain Apps
Several back pain apps utilize the brain and body connection. They provide exercises for the body and meditation to help the mind relax and work out and through the pain. The brain is the computer, the software is the mind and the hardware is the body. The brain is linked to the nervous system. Apps that help with psychosocial and behavioral issues have shown the ability to reverse the negative thinking of individuals with chronic pain. For individuals that don’t like exercising, there are apps to help address various barriers and obstacles.
They’re ready when and where you are
They track progress
They match guidance messages based on responses
They provide positive reinforcement
Before starting, if the answer is yes to any of the following questions consult with a physician first:
Is leg pain presenting?
Is there constant pain at night?
Is there a history of a recent accident or injury?
Effectiveness of Apps
A 12-week controlled trial in 2019, of individuals with low back pain, found that those who used an app did statistically better, in reducing their pain compared to the control group. The trial consisted of:
Those in the treatment group that completed the program found their pain level (based on a 100-point scale) had reduced 62% from a level of 44 to 14. Compared to an 8% reduction in the control group. However, scientific evidence on specific apps is limited and requires further research. However, the apps that scientists studied include:
A review of 25 apps for low back pain found the higher the price, the higher the app scored in the scientific study. The apps with the top scores included:
Core stability exercises
The Lower Back Pain App, developed by a physiotherapist, scored the highest. It is a 10-week program where users are directed each week to perform three exercises twice daily. The exercises focus on:
Instructions are given through videos and writing.
Back Pain Specific Apps
A variety of back pain-specific applications are available. Try them out and see which fits your style. They are there to guide, strengthen the body, help relax, and lessen the pain.
Chronic stress is like poison to the body. It negatively impacts every aspect of the body’s health and is more dangerous because of its ability to present without realizing it. One of the body’s systems responsible for handling difficult situations is the immune system. Specifically, cells of the immune systems have receptors that recognize stress hormones like cortisol. Acute stress can cause immune system problems by increasing the release of inflammatory cytokines that are a special type of immune cell. Stress, immunity, and disease can affect each other. But these relationships can be moderated by:
What is important is to develop a healthy strategy to relieve the symptoms of stress like meditating, exercising, and spending time with friends/family.
Best Evidence Rehabilitation for Chronic Pain Part 3: Low Back Pain https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6679058/
Current Directions in Stress and Human Immune Function. Current opinion in psychology vol. 5 (2015): 13-17. doi:10.1016/j.copsyc.2015.03.007 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4465119/
The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain https://pubmed.ncbi.nlm.nih.gov/27586832/#affiliation-1
Assessment of the Quality of Mobile Applications (Apps) for Management of Low Back Pain Using the Mobile App Rating Scale (MARS) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763508/#B12-ijerph-17-09209
Surgical versus nonsurgical treatment of chronic low back pain: A meta-analysis based on current evidence https://pubmed.ncbi.nlm.nih.gov/26406211/
Randomized controlled trial of a 12-week digital care program in improving low back pain https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6550254/#CR8
Evaluation of Self-Management Support Functions in Apps for People With Persistent Pain: Systematic Review https://mhealth.jmir.org/2019/2/e13080/
App-based multidisciplinary back pain treatment versus combined physiotherapy plus online education: a randomized controlled trial https://www.nature.com/articles/s41746-019-0109-x
Tennis is a sport that can be enjoyed by individuals of all ages and provides optimal physical activity and cardiovascular exercise. Although it can be leisurely, it does require being light on the feet with quick, starting, stopping, turning, and twisting movements for those new to playing tennis. If back pain is present, playing can be difficult. One study showed almost 40% of tennis players missed one or more tournaments because of low back pain/problems. A 2016 study found that tennis players with low back pain have difficulty moving their muscles with ease.
Know and Understand the Risks
Playing tennis has its risks when it comes to back pain. What can bring on or worsen back pain are the repetitive motions, like swinging, serving, volleying, and the uneven force placed on the body. This force is the power and momentum that is used for certain swings like serving and forehands. What happens is it does not evenly distribute through the body, increasing the potential to cause strains and sprains. For example, the serving motion repeatedly puts a hyperextension force through the spine. The result is overuse injuries.
No one wants to injure their back for those new to tennis and those who have been playing for years. This is where off-court conditioning comes in and preventive measures. This includes:
Trying to smash the ball too soon can result in a rotator cuff injury.
Stay Aware of Your Body
Playing tennis can cause an individual to become distracted; however, it’s crucial to be mindful of the body and what’s going on.
Pay attention to the heat.
Proper rest between games
Hydration to prevent muscle cramping
Stretching before and after playing
Warming up and cooling down
Take a break and stretch out if pain symptoms present.
Never play through the pain that could result in worsening or creating new injuries.
Pay attention to proper form.
Apply modifications to prevent and avoid worsened back pain. This could be serving more simply or hitting around a stroke that generates pain symptoms.
After a match, rehydrate the body and cool down. This could be a little walking around the court, if possible getting in a pool or water splash park, and let the musculoskeletal system recover. Do some spinal exercises afterward, like yoga poses. Applying anti-inflammatory creams or gels can help keep the muscles loose and promote circulation. Anti-inflammatory foods can help with pain and inflammation.
There are individuals with spinal conditions that should not play tennis. These include:
Acute disc herniation
Active bone injury/s – fractures and stress fractures
Spinal instability – spondylolisthesis
A spinal condition involving nerves and/or the spinal cord
Consult a doctor before adding tennis to a physical regimen. Tennis is an aerobic activity that has several benefits. It keeps the body physically active for mental and physical wellness. The hormones released can help mitigate musculoskeletal pain and negative emotions like depression and anxiety that can come from experiencing back pain.
Magnesium supports a healthy immune system. It helps maintain:
Aids muscle relaxation after exercise/physical activity
Magnesium is essential in several biochemical reactions; a slight deficiency can increase cardiovascular disease risk. Deficiency can also lead to an increased risk of insulin resistance. Magnesium-rich foods are also high fiber foods. Dietary fiber helps with:
Helps control weight
Stabilizes blood sugar
Recommended sources of Magnesium include:
Green vegetables – spinach, swiss chard, and turnip greens
Nuts – almonds and cashews
Clinics in Sports Medicine. (April 1988) “Low back pain in the competitive tennis player.” https://europepmc.org/article/med/2968850
Journal of Science and Medicine in Sport. (April 2016) “Trunk muscle activation, fatigue and low back pain in tennis players” https://www.sciencedirect.com/science/article/abs/pii/S1440244015000845
Jahnen-Dechent, Wilhelm, and Markus Ketteler. “Magnesium basics.” Clinical kidney journal vol. 5,Suppl 1 (2012): i3-i14. doi:10.1093/ndtplus/sfr163
Katz, David L et al. “Cocoa and chocolate in human health and disease.” Antioxidants & redox signaling vol. 15,10 (2011): 2779-811. doi:10.1089/ars.2010.3697
Wang, Jinsong, et al. “Dietary magnesium intake improves insulin resistance among non-diabetic individuals with metabolic syndrome participating in a dietary trial.” Nutrients vol. 5,10 3910-9. 27 Sep. 2013, doi:10.3390/nu5103910
Many doctors/surgeons rely on the widely adopted lumbar spinal fusion. However, experts have asserted that lumbar total disc replacement or TDR should be made available and increased for treating degenerative disc disease and other spinal conditions. Individuals interested in total disc replacement, the ability to have it done, and if insurance will pay? What to know about TDR and fusion before deciding and moving forward.
Total Disc Replacement
Spinal fusion has been the traditional approach for relieving lower back pain. In this procedure, a bone graft is inserted between two or more vertebrae. This eliminates movement that causes pain or could be dangerous to the individual. Total disc replacement demands more on a technical level than spinal fusion. However, the worn-out, injured, or damaged disc is fully replaced, even a completely degenerated disc, with a metal and/or plastic one. Benefits from lumbar TDR surgery include:
Shown to be a safe procedure with minimal complications
Significant improvement in health and quality of life
High rates of successful outcomes
Mobility is preserved
Who Needs Disc Replacement?
Low back problems affect more than a third of the population. This can come from:
All are risk factors
Fusion or Total disc replacement
Fusion reduces and eliminates motion around the affected area which also changes with the spine’s mechanics. It can also place increased stress on the surrounding segments. However, the lack of motion is to eliminate the pain. Total disc replacement does increase mobility, but it can’t fully relieve the pain. It can relieve pain generated from the disc but not from other causes. TDR has been shown to:
Provides motion preservation
Reduces staying at the hospital
Provides long-term durability
Lower reoperation rates compared to fusion
Total disc replacement issues:
The procedure is more time-consuming
A lot of time making decisions
A lot of time preparing
An example could be the patient has a narrow disc space. Looking at the X-rays of the discs above and below, the surgeon has to make sure they choose the right size. Next, the narrow space needs to be mobilized back to a normal height that cannot be too high or too short. Finally, the surgeon has to make sure that the disc is anchored and fits properly.
Why Surgeons Still Choose Fusion?
Despite the benefits, there are reasons why surgeons still choose fusion.
There are strict rules as to when TDR can be used. This means insurers are prone only to approve fusion procedures.
The surgical technique is challenging. TDR surgery is a highly demanding procedure. As a result, many doctors specializing in fusion for 20 years or more can be reluctant to perform the procedure.
Complications and revision surgeries. Reoperations are sometimes necessary, but this happens in both fusion and TDR.
Fortunately, most individuals with lower back problems never need total disc replacement. And those that do have severe pain/conditions are recommended to try non-invasive/surgical treatment. This ranges from:
Imaging and lab tests will be required. However, if an operation is necessary, ask questions about both procedures. For example, if a surgeon insists that fusion is the only option, ask why total disc replacement is not an option?
Body Composition Testing
Protein and Weight Loss
Protein is one of three basic macronutrients found in food. Proteins are made up of smaller units called amino acids. There are 22 amino acids, with 9 of these being essential. This means the body needs them, as the body cannot produce them. These essential amino acids can be obtained by eating protein-rich foods like:
Vegetarian/vegan options include:
Generally, all the essential amino acids cannot be obtained from just one food. Therefore it is recommended to eat a variety of animal and plant-based proteins. Protein is in almost every structure and function of the body.
These proteins fight off any infections, bacteria, etc.
Repair, maintenance, and structural
Proteins are the building blocks of the body’s muscles, bones, skin, and hair.
Chemical messenger proteins are how cells and organs communicate. For example, Growth Hormone affects muscle gain and fat loss.
Not all proteins are enzymes; however, all enzymes are proteins. These proteins are catalysts or starters for chemical reactions in the body.
Transportation and storage
Some proteins carry molecules where they are needed. For example, hemoglobin or the red blood cells carry oxygen to cells, then transport carbon dioxide away.
Not getting enough protein in one’s diet can have serious consequences on the body’s health. Without enough protein, the muscles can begin to atrophy or waste away, taking Lean Body Mass, strength, and energy away as well.
The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make your own health care decisions based on your research and partnership with a qualified health care professional. Our information scope is limited to chiropractic, musculoskeletal, physical medicines, wellness, sensitive health issues, functional medicine articles, topics, and discussions. We provide and present clinical collaboration with specialists from a wide array of disciplines. Each specialist is governed by their professional scope of practice and their jurisdiction of licensure. We use functional health & wellness protocols to treat and support care for the injuries or disorders of the musculoskeletal system. Our videos, posts, topics, subjects, and insights cover clinical matters, issues, and topics that relate to and support, directly or indirectly, our clinical scope of practice.* Our office has made a reasonable attempt to provide supportive citations and has identified the relevant research study or studies supporting our posts. In addition, we provide copies of supporting research studies available to regulatory boards and the public upon request.
We understand that we cover matters that require an additional explanation of how it may assist in a particular care plan or treatment protocol; therefore, to further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.
Salzmann, Stephan N et al. “Lumbar disc replacement surgery-successes and obstacles to widespread adoption.” Current reviews in musculoskeletal medicine vol. 10,2 (2017): 153-159. doi:10.1007/s12178-017-9397-4
Hopkins overview of Lumbar TDR (for consumers) https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/lumbar-disk-replacement
“Comparison of Lumbar Total Disc Replacement With Surgical Spinal Fusion for the Treatment of Single-Level Degenerative Disc Disease: A Meta-Analysis of 5-Year Outcomes From Randomized Controlled Trials”, Zigler J, et al., Global Spine Journal, June 2018, PMC602295 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6022955/
“Overview of Lumbar TDR” (for consumers); Johns Hopkins Medical Center https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/lumbar-disk-replacement
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