Georgio Baylouny, PT, DPT, OCS
Physical Therapist, New York City
Have you ever bent down to pick something up around the house and felt a sudden, sharp pain in your lower back? Or maybe that last rep with the barbell got the best of you, causing a “tweak” in the low back. Your first thought might be “Uh oh, is it a herniated disc?”
If any of these things have happened to you, you’re not alone! Two out of every three adults experience low back pain at some point in their lives, with some studies even bringing this number up to 80% of adults having experienced back pain. Here’s one more interesting stat – 10% of the population is experiencing low back pain right now as you read this blog!
So, now what? Get an x-ray or MRI? Make an appointment with your primary care doctor? This blog will tell you why running to get imaging may not be necessary, why staying active is key, and why your chances of making a full recovery are good. And, while a herniated disc could certainly be the diagnosis, I’m writing to tell you that this issue is very common and it can improve. Here’s what you should know about the infamous herniated disc.
What is a Herniated Disk?
Intervertebral discs are thick, fibrous, and sturdy, and sit between each vertebrae (bone) throughout the spine. They function to create a joint between each vertebrae, act a shock absorber, and help with allowing movement through the spine.
A herniated disc refers to the displacement of disc material outside of the normal margins of the disk space. This disk material can come in contact with a nerve root, which can cause pain down the leg. A herniated disc is the cause of 85% of cases of sciatica.
While what I just described sounds pretty scary, it’s actually quite common in people who have no pain at all. Just because there is a herniated disk, does not mean there will be pain. The finding of a herniated disc on MRI can be totally incidental, meaning it’s actually not the cause of pain. MRI commonly shows disc herniations in asymptomatic individuals, and the prevalence of a disk herniation finding actually increases with age.
Do I Need an X-ray or MRI After I Hurt My Back?
If you’ve ever “thrown out your back,” you know the pain can be pretty significant at first. Your instinct may be to think you need an x-ray or MRI to show you what’s wrong. Believe it or not, in most cases, imaging is actually not helpful in determining the cause of the pain, or even guiding what the treatment should be. Here are some quick facts regarding imaging of the lower back.
X-ray does not show a herniated disc, and clinical guidelines say that x-rays for acute back pain is only recommended for patients who have history of systemic disease, like cancer, or a history of using injected or oral steroids.
By the way, your x-ray might show arthritis or something called “degenerative disc disease.” This is just evidence that you are a human being who has been alive for 25 years+. Don’t panic if your doc says you have degenerative disc disease (I hate that name – it should be renamed “normal age related changes”). We all have it!
MRI can visualize a herniated disc. But, remember what we said above about incidental findings. Just because it’s there, doesn’t mean it’s relevant to what you’re feeling.
MRI isn’t recommended until a patient hasn’t made improvements after 4-6 weeks of conservative treatment, or if the patient is showing severe neurological deficits (meaning you can’t pick up your foot, trip when walking, losing sensation in the groin area, etc).
So, if you hurt your back, there’s rarely a need to run and get imaging. A Physical Therapist will be able to assess the situation and refer you to the appropriate medical professional in the rare case that it’s truly necessary.
Current practice guidelines do not recommend the routine use of MRI. Disc herniation is common among asymptomatic people (about 60% of people over 50). Therefore, there’s a risk of misleading MRI findings, which can lead to a cascade of overmedicalization and chronic pain.
The best thing to do when you hurt your back is to try and keep moving. Get some guidance on conservative treatment that includes a more active approach for best outcomes early on.
Do Herniated Disks Heal or Get Better?
The natural history of a lumbar herniated disc is favorable. Meaning, if you hurt your back, prognosis is good! One study showed that without surgery, pain improved in 87% of people within 3 months (and that’s without PT).
36% of patients report an improvement in symptoms within 2 weeks, and that only gets better as time goes on.
In fact, large cohort studies show that the condition of patients with low back herniated disc improves with 6 weeks of conservative care.
Still thinking surgery is the only option? Studies show that at 1 year, there is no difference between those who got surgery early and those who only stuck to conservative measures.
Here’s a pretty promising stat… MRI shows shrinkage of most herniated discs over time, and 76% partially or completely resorbed by 1 year! Your herniated disc can heal. The human body is pretty amazing (and resilient)!
Physical Therapy for a Herniated Disc
So, what’s PT look like for a herniated disc? Well, as always, there is no black and white answer, and this varies from individual to individual. But there are some key themes when it comes to rehab.
Education is important in the rehab process! Your PT should be able to tell you exactly what’s going on in a way that’s easy to understand. You should also get clear instructions on what movements or positions to temporarily avoid while in pain, as well as what positions or movements to do a bit more of.
Attitude matters! Studies show that a patient’s attitudes, beliefs, and outlook can play a role in the prognosis of back pain. Your PT should be helping the cause by avoiding scary language that you don’t understand, providing education and a solid game plan, and promoting an active recovery (rather than making you rely on things like massage, or laying around with a heating pad).
Exercise early and often. Yes, believe it or not we want to get you moving! Studies show time and time again that an active rehab process is far superior than bed rest or “watchful waiting.” Exercise is better than just guidance when it comes to short term pain relief and functional improvement.
Returning to full function is the final step. That means reintroducing the motions or positions that used to hurt, as well as the higher level activities you love to do. For example, your PT should slowly reintroduce bending forward (if that’s what used to hurt). Another example would be working towards your favorite exercise class, or getting back to the gym, or running.
Deyo et al. Herniated Lumbar Intervertebral Disk. New England Journal of Medicine 2016.