Herniated discs in the lower back, or disc injuries in general are one of those injuries that often inspires a degree of worry and concern but is it something we can recover from? In this week’s newsletter we’re going to be discussing disc injuries in general, whether it’s a minor disc strain, a slipped disc, a bulging disc or a full blown herniated disc.
The first and most important thing to note is that this really is a spectrum of disc injuries rather than a series of separate diagnoses. Given this in mind, let us begin by stating that our spinal discs, can be very strong, strong enough to withstand 100’s of pounds of load, and they can be very weak at the same time. One important fact you must remember is that just like everything in our body, these discs respond to how we use our bodies. They can get stronger and improve their ability to bear load, and they can get weaker with inactivity and disuse. The time frames over which positive and negative changes can take place (injuries aside) are much slower than that of muscles, tissues that respond relatively quickly to use or disuse. One thing is clear however, the rate at which our tissues weaken with a lack of stimulation, is ALWAYS faster than the rate at which they strengthen with concerted effort.
We thought it best to cover the above fact first, as the tendency to view your back, once diagnosed with some form of disc injury as a “glass back”, is common. The important takeaway is that it might feel like glass right now, but it can be steel again in the future!
What is a spinal disc?
It is helpful to begin by identifying what the intervertebral discs are and how they function. These have dual function, they firstly create a separation between two adjacent vertebra. This “spacer” allows for a nice large exit hole (Foramina) through which the corresponding spinal nerves can exit the spine. For example, the space formed between your L5 vertebra and your S1 vertebra by the largest disc in your spine allows for the exit of the L5 nerve root which goes on to contribute to the sciatic nerve in the pelvis – a nerve some of you will be all too familiar with. Coincidentally this is the largest nerve in your body providing a neural pathway to the lower body.
The disc’s themselves form an extension in the footprint of the vertebral body – the larger front portion of the vertebra, with the smaller portion being on the back where the facet joints are located. The discs have a highly fluid central core called the Nucleus Pulposus – think of this as the “jam” in the doughnut. Fluid is non compressible and therefore it is this central fluid-containing core that retains the height of your disc when held in place by the Annulus Fibrosus. This part of the disc forms the bulk and is a layer of many ligamentous-type fibers running from one vertebral body to the other, diagonally, not vertically. Every other layer as you move from the inside of the disc next to the central nucleus, to the outermost layer is arranged roughly perpendicular to the next. This provides additional strength and forms somewhat of a mesh to hold that fluid-based nucleus in place.
It is worth noting that much of the internal portion of this Annulus, the part closest to the central Nucleus, does not have much in the way of a nerve supply. That is to say, we are not particularly aware or pain sensitive to the goings on in this region. It is not until you reach the outer third or so of the Annulus that we start to become a little more “innervated” – having a larger nerve supply. This will become relevant later.
Disc Herniation, a slow injury to your back
As mentioned earlier, it is best to view a disc injury as a scale, first the disc becomes strained and slightly symptomatic, perhaps barely perceptible. Perhaps the constant strain on the disc allows for some of the internal layers of the Annulus to become compromised and invaded by the nucleus as it tries to escape the center of the disc under load. Remember the fluid is non-compressible and relies on the intact Annulus to hold it in its central location. Slowly and over time repeat injuries create more and more disruption in the disc’s fibers and more become slightly damaged, perhaps not healing completely from one flare to the next.
Very often, the compression happens to be on the front of the vertebral body. An easy visualization here is to imagine squeezing the front of a doughnut, the jam being driven backwards. Our daily lives are full of flexion, forward bending. Not just for shorter periods of time, but for longer ones too. 6 hours or more sat at the desk, day in day out, only to go home and do more sitting, slouched, on the front of that doughnut.
We mentioned in the earlier section that the disc is primarily ligamentous in nature and their important role in holding that Nucleus in place in the center of your disc. Well ligaments are interesting structures, they don’t tend to stretch too much, we can see this in the joints of our bodies, for example finger joints and knee joints, the strong ligaments here don’t allow much movement at all in certain directions. This is very similar to tendons.
There are certain ways in which the stability of ligaments can be manipulated, and therefore their integrity interfered with.
It is very rare that you bend your knee to the side for 20 minutes, stressing the ligaments that support the one side of your knee continuously. However when it comes to your back, you’ll regularly spend well in excess of 20 minutes stressing the ligaments (including the back of your disc) that support the natural curve and normal neutral position of your spine.
Under this repeated stress and stretch the ligaments that make up the back of your disc start to become somewhat slackened, along with the ligaments on the back of our spine, and thus our natural and normal position starts to change – “remodeling of your spine alignment”. Not only do these changes make the ligaments that make up the disc less efficient and effective, they also allow you to naturally put more pressure through the front of that disc. This makes it easier to create the necessary forces that drive that Nucleus into the wall of the annulus.
Now you’ve created a vulnerable bulging disc
Through consistent work and effort, the discs’ internal structures have now been altered making them less effective and creating weaknesses. These weaknesses under load create the environment necessary for the Nucleus to move significantly backwards starting to create the bulge or slip. Now because the fibers on the back have become more lax the Nuclear material is able to spread out, meaning it’s role of separating the two vertebra is compromised, therefore the two vertebrae move closer, further enhancing the degree to which the disc as a whole “bulges” in a normal load bearing scenario.
At this point the disc itself has much more available movement as the internal pressure begins to dissipate. When everything was nice and tight and in the proper place, there was integrity, now, things are loose.
Think of your seatbelt in the car being nice and tight. When the car moves suddenly one way or another, the compression of the seat belt holds you tight to the seat. If we loosen the seat belt an inch or two, the sudden movements that ordinarily might be easily handled without too much discomfort become problematic. As the car applies the brakes fast but in a particularly reasonable manner, you have the room to shunt forwards in the seat, that inch or two. Then all of a sudden the seatbelt reaches tension and you abruptly stop, and feel rather sore because of it – perhaps a little bruised.
This is similar to the disc that’s become loosened, the internal pressure it once had with everything held nicely in place meant that the whole system of your spine helped dissipate forces, now all of a sudden there is a particular area that has a fraction more movement than everywhere else, creating a focal point for stress to be dissipated. Thus a focal point for a normal stress, like bending to put your socks on, to exploit.
Most herniated discs were injured before
You can see how the circumstances that lead to a compromised disc can take place creating the propensity for a seemingly insignificant movement to exploit a background weakness. It is these cases that are so very common – the norm. It is very rare that a severe one off trauma injures the disc so dramatically that herniation is the outcome. These scenarios are usually reserved for car accidents, falls off ladders and other extreme and unfortunate events.
Modern life and the way we use our bodies habitually puts abnormal use through our lower lumbar spine. There is a reason that the L4, L5 and L5, S1 discs are so commonly injured. They’re the regions so commonly abused in regards to our day-to- day use. Writing the first draft of this email, I’m literally spending hours sat working on it! This is just a small example, how do you fare with your day to day, herniated disc or not?
So what can we do to help our lumbar discs?
The good news, as we mentioned earlier on, is that our bodies adapt. The lack of productive attention on our back health by way of physical exercises, coupled with poor day-to-day habits created the weaknesses, vulnerabilities and injuries in your lower back. Good habits, the proper strengthening work consistently applied can lead to changes in the opposite direction too! Just remember, it takes less time to demolish a house than it does to build a one! The same goes for our bodies – and not just our back – our health in general.
Many of you reading this will be in the Back In Shape Program, and considering this article is already well over 1500 words, we’ll spare the breakdown. Suffice to say, working to correctly rehabilitate your back, modify your daily activities and consistently progress with your strengthening over the days, weeks, months and years ahead is the correct course of action.
Can you really get back in shape after a herniated disc?
The short answer is yes. Know that the vulnerabilities in the region can be worked around by providing external support through strong core muscles and an education in the maintenance of a neutral spine. Steadily over time building the muscles of the back and core, you’ll be able to further increase the strength of the supporting structures in the immediate vicinity of the spine.
Secondly you’ll work on strong and mobile hips, the hips as a region being vital for your good mobility. Good strong hip and leg muscles allow for you to have safe and competent movement through a mobile hip joint. Note that we said strong hips allow for mobile hips. Too many work on mobility first or in isolation – a big mistake.
These two goals allow for you to provide protection whilst the body is undergoing the healing process, and the more recent flare or injury starts to settle and “scab over”.
Building strength in your discs
Your body responds to strain, and in the case of the collagen fibers that form the annulus, and surrounding ligaments, they are no different. This is one of the reasons bed rest and inactivity is such a fatal error. As the injury moves into the remodelling phase, the “scab” that formed where the disc was specifically exploited and injured, needs the stimulation necessary to understand how this disc is used. So steady application of load starts to inform your tissues how they need to repair and reorganize these fibers to rebuild stronger than before.
Quite often people will shy away from objective loading of the discs in the lower back, opting for body weight only or nominal weights. Failing to recognise that “life” will often require the lifting and moving of a 20kg holiday suitcase, a heavy sofa or overgrown plant pot. All significantly heavier than the 10lb kettlebell that you might consider is “enough for me”.
Heal your lumbar disc for the long term
By continuing to SLOWLY challenge yourself with more load on choice exercises you can help the remodelling process that’s taking place in your spine. Rebuilding the tissues, to be stronger than they were before! This is the secret – it’s not sexy, it’s not quick, but it is simple! And we’re here to help you each step of the way to get your discs Back In Shape!
Comment of the week – Ola
“Back in Shape is the best thing that has ever happened to me in my over a decade living with pain“
3 Practical Steps To Heal Your Herniated Disc:
- Knowledge helps tremendously!
Understanding that there are many activities and movements that may provide momentary relief but are making the underlying issue worse is key, we have many videos in addition to this article to help you understand the role of your spinal discs and how they get injured. We also have material explaining why the commonly prescribed exercises, such as knee hugs fall into the category of “exercises that are not helpful”. Once you have a basic appreciation for the discs and how they often become injured, and how they can heal and adapt, moving forward is a common sense process. The inevitable bumps in the road to recovery are also much more manageable – mentally.
- Regularly relieve your discs in the short, medium and long term:
Providing a regular respite from the stresses of everyday life helps your early recovery and long term condition no end. This is by way of relieving the way in which your discs are stressed. Compression (front loaded) from sitting for extended periods – very difficult to avoid in modern life. Hip stiffness, which is a consequence of the injury. Our Phase 1 routine is exactly the remedy to help you provide a daily dose of spine health movements.
- Make a commitment to strengthening your back and guiding recovery:
This is the all important final step in the process. Working through resistance based exercises with great technical form, will help you safely learn the right movement patterns, as well as expose your spine to graded load over the long term. This graded load helps your back know where additional strength is required as the damaged tissue is rebuilding!
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