Print Handout Dr. Ramin Safakish, MD, FRCPC Allevio Pain Management 240 Duncan Mill Road #101 Toronto, Ontario M3B 3S6 P: 416-840-5990 F: 647-427-4100 www.raminsafakish.com www.allevioclinic.com Patient Name: Special Instructions: Follow Up: Herniated Disk with Rehab Between each vertebrae of the spine exists a disk. These disks contain a jelly-like material that helps cushion the spinal column. Occasionally, damage to the supportive ligaments of the vertebrae causes a disk to shift from its normal alignment and place pressure on surrounding structures, such as the spinal cord. This is called a herniated (ruptured) disk. SYMPTOMS Pain in the back, that often affects one side. Pain that gets worse with movement, sneezing, coughing, or straining. Muscle spasms in the back. Pain, numbness, or weakness affecting one arm or leg (depending on whether injury is in the neck or low back). Muscle loss (if the condition has become chronic). Loss of stool (bowel) or urine (bladder) function. http://www.mdconsult.com/das/patient/body/437616202-3/1505977361/10089/56270.html 1/14
CAUSES Herniated disks result when a disk becomes weak. The disk eventually ruptures and places pressure on the spinal cord. Herniated disks may occur from sudden injury (acute trauma) such as heavy labor, or from ongoing (chronic) stress, such as obesity. RISK INCREASES WITH: Sports that involve downward or twisting pressure on the neck or spine (football, weightlifting, horseback riding competition, bowling, tennis, jogging, track, racquetball, gymnastics). Poor strength and flexibility. Failure to warm up properly before activity. Family history of low back pain or disk disorders. Previous back surgery (especially fusion). Preexisting forward displacement of a vertebra (spondylolisthesis). Poor technique when lifting. Prolonged sitting, especially with poor posture. PREVENTION Learn and use proper technique when sitting or lifting. Warm up and stretch properly before activity. Maintain physical fitness: Strength, flexibility, and endurance. Cardiovascular fitness. Maintain a healthy body weight. If previously injured, avoid any intense physical activity that requires twisting of the body under uncontrollable conditions. PROGNOSIS If treated properly, herniated disks are usually curable within 6 weeks. Sometimes, surgery is required. RELATED COMPLICATIONS Permanent numbness, weakness, or paralysis and muscle loss. Chronic back pain. Loss of bowel or bladder function. Decreased sexual function. Risks of surgery: infection, bleeding, injury to nerves (persistent or increased numbness, weakness, or paralysis), persistent back pain, and spinal headache. http://www.mdconsult.com/das/patient/body/437616202-3/1505977361/10089/56270.html 2/14
TREATMENT Treatment first involves resting from any aggravating activities and the use of ice and medicine to reduce pain and inflammation. As muscle spasms begin to decrease, it is important to perform strengthening and stretching exercises of the back muscles. These will help teach and reinforce proper body posture. These exercises may be performed at home, or with a therapist. A therapist may complete a further evaluation and recommend additional treatments, such as ultrasound, traction (for herniated disks of the neck), a cervical collar (for herniated disks of the neck), or a corset or back brace (for herniated disks of the low back). Prolonged rest may do more harm than good. Your therapist will teach you proper techniques for performing simple activities, such as lifting an object off the floor or using proper posture while sitting. At night, it is advised that you sleep on your back, on a firm mattress, and place a pillow under your knees. Your caregiver may recommend oral steroids or an injection of corticosteroids in the space around the spinal cord (epidural space) in order to reduce pain and inflammation. For severe cases, surgery is recommended. MEDICATION If pain medicine is needed, nonsteroidal anti-inflammatory medicines (aspirin and ibuprofen), or other minor pain relievers (acetaminophen), are often advised. Do not take pain medicine for 7 days before surgery. Prescription pain relievers may be given if your caregiver thinks they are needed. Use only as directed and only as much as you need. Ointments applied to the skin may be helpful. Corticosteroid injections may be given. These injections should be reserved for the most serious cases, as they can only be given a certain number of times. Oral steroids may be given to reduce inflammation, although not usually for severe (acute) injuries. HEAT AND COLD Coldtreatment (icing) relieves pain and reduces inflammation. Cold treatment should be applied for 10 to 15 minutes every 2 to 3 hours, and immediately after activity that aggravates your symptoms. Use ice packs or an ice massage. Heattreatment may be used before performing stretching and strengthening activities prescribed by your caregiver, physical therapist, or athletic trainer. Use a heat pack or a warm water soak. SEEK MEDICAL CARE IF: Symptoms get worse or do not improve in 2 to 4 weeks, despite treatment. You develop loss of bowel or bladder function. New, unexplained symptoms develop. (Drugs used in treatment may produce side effects.) EXERCISES RANGE OF MOTION (ROM) AND STRETCHING EXERCISES - Herniated Disk (Ruptured Disk) http://www.mdconsult.com/das/patient/body/437616202-3/1505977361/10089/56270.html 3/14
Most people with low back pain will find that their symptoms get worse with excessive bending forward (flexion) or arching at the low back (extension). The exercises that will help resolve your symptoms will focus on the opposite motion. Your physician, physical therapist or athletic trainer will help you determine which exercises will be most helpful to resolve your low back pain. Do not complete any exercises without first consulting with your caregiver. Discontinue any exercises that make your symptoms worse, until you speak to your caregiver. If you have pain, numbness or tingling that travels down into your buttocks, leg or foot, the goal of this therapy is for these symptoms to move closer to your back and to eventually go away. Sometimes, these leg symptoms will get better, but your low back pain may get worse. This is typically an indication of progress in your rehabilitation. Be sure to be very alert to any changes in your symptoms and to the activities you have done in the 24 hours prior to the change. Sharing this information with your caregiver will allow him or her to best treat your condition. These exercises may help you when beginning to rehabilitate your injury. Your symptoms may go away with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember: Restoring tissue flexibility helps normal motion to return to the joints. This allows healthier, less painful movement and activity. An effective stretch should be held for at least 30 seconds. A stretch should never be painful. You should only feel a gentle lengthening or release in the stretched tissue. FLEXION RANGE OF MOTION AND STRETCHING EXERCISES: STRETCH Flexion, Single Knee to Chest Lie on a firm bed or floor, with both legs extended in front of you. Keeping one leg in contact with the floor, bring your opposite knee to your chest. Hold your leg in place by either grabbing behind your thigh or at your knee. Pull until you feel a gentle stretch in your low back. Hold for seconds. Slowly release your grasp and repeat the exercise with the opposite side. Repeat times. Complete this exercise times per day. STRETCH Flexion, Double Knee to Chest Lie on a firm bed or floor, with both legs extended in front of you. Keeping one leg in contact with the floor, bring your opposite knee to your chest. Tense your stomach muscles to support your back and then lift your other knee to your chest. Hold your legs in place by either grabbing behind your thighs or at your knees. Pull both knees toward your chest until you feel a gentle stretch in your low back. Hold for seconds. Tense your stomach muscles and slowly return one leg at a time to the floor. http://www.mdconsult.com/das/patient/body/437616202-3/1505977361/10089/56270.html 4/14
Repeat times. Complete this exercise times per day. STRETCH Low Trunk Rotation Lie on a firm bed or floor. Keeping your legs in front of you, bend your knees so they are both pointed toward the ceiling and your feet are flat on the floor. Extend your arms out to the side. This will stabilize your upper body by keeping your shoulders in contact with the floor. Gently and slowly drop both knees together to one side, until you feel a gentle stretch in your low back. Hold for seconds. Tense your stomach muscles to support your low back as you bring your knees back to the starting position. Repeat the exercise while dropping both knees to the other side. Repeat times. Complete this exercise times per day http://www.mdconsult.com/das/patient/body/437616202-3/1505977361/10089/56270.html 5/14
EXTENSION RANGE OF MOTION AND FLEXIBILITY EXERCISES: STRETCH Extension, Prone on Elbows Lie on your stomach on the floor. (A bed will be too soft.) Place your palms about shoulder width apart. Place your elbows under your shoulders. If this is too painful, stack pillows under your chest. Allow your body to relax so that your hips drop lower and make contact more completely with the floor. Hold this position for seconds. Slowly return to lying flat on the floor. Repeat times. Complete this exercise times per day. RANGE OF MOTION Extension, Prone Press Ups Lie on your stomach on the floor. (A bed will be too soft.) Place your palms about shoulder width apart and at the height of your head. Keeping your back as relaxed as possible, slowly straighten your elbows while keeping your hips on the floor. You may adjust the placement of your hands to maximize your comfort. As you gain motion, your hands will come more underneath your shoulders. Hold this position for seconds. Slowly return to lying flat on the floor. Repeat times. Complete this exercise times per day. RANGE OF MOTION- Quadruped, Neutral Spine Assume a hands and knees position on a firm surface. Keep your hands under your shoulders and your knees under your hips. You may place padding under your knees http://www.mdconsult.com/das/patient/body/437616202-3/1505977361/10089/56270.html 6/14
for comfort. Drop your head and point your tail bone toward the ground below you. This will round out your low back like an angry cat. Hold this position for seconds. Slowly lift your head and release your tail bone so that your back sags into a large arch, like an old horse. Hold this position for seconds. Repeat this until you feel limber in your low back. Now, find your "sweet spot." This will be the most comfortable position somewhere between the two previous positions. This is your neutral spine. Once you have found this position, tense your stomach muscles to support your low back. Hold this position for seconds. Repeat times. Complete this exercise times per day. STRENGTHENING EXERCISES - Herniated Disk (Ruptured Disk) These exercises may help you when beginning to rehabilitate your injury. These exercises should be done near your "sweet spot." This is the neutral, low-back arch, somewhere between fully rounded and fully arched, that is your least painful position. When performed in this safe range of motion, these exercises can be used for people who have either a flexion or extension based injury. These exercises may resolve your symptoms with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember: Muscles can gain both the endurance and the strength needed for everyday activities through controlled exercises. Complete these exercises as instructed by your physician, physical therapist or athletic trainer. Increase the resistance and repetitions only as guided. You may experience muscle soreness or fatigue, but the pain or discomfort you are trying to eliminate should never worsen during these exercises. If this pain does get worse, stop and make sure you are following the directions exactly. If the pain is still present after adjustments, discontinue the exercise until you can discuss the trouble with your clinician. STRENGTHENING Deep Abdominals, Pelvic Tilt Lie on a firm bed or floor. Keeping your legs in front of you, bend your knees so they are both pointed toward the ceiling and your feet are flat on the floor. Tense your lower abdominal muscles to press your low back into the floor. This motion will rotate your pelvis so that your tail bone is scooping upwards rather than pointing at your feet or into the floor. With a gentle tension and even breathing, hold this position for seconds. http://www.mdconsult.com/das/patient/body/437616202-3/1505977361/10089/56270.html 7/14
Repeat times. Complete this exercise times per day. STRENGTHENING Abdominals, Crunches Lie on a firm bed or floor. Keeping your legs in front of you, bend your knees so they are both pointed toward the ceiling and your feet are flat on the floor. Cross your arms over your chest. Slightly tip your chin down without bending your neck. Tense your abdominals and slowly lift your trunk high enough so that your shoulder blades are just off the floor. Lifting higher can put too much stress on the low back and does not further strengthen your abdominal muscles. With control, return to the starting position. Repeat times. Complete this exercise times per day. STRENGTHENING Quadruped, Opposite UE/LE Lift Assume a hands and knees position on a firm surface. Keep your hands under your shoulders and your knees under your hips. You may place padding under your knees for comfort. Find your neutral spine and gently tense your abdominal muscles so that you can maintain this position. Your shoulders and hips should form a rectangle that is parallel with the floor and is not twisted. Keeping your trunk steady, lift your right hand no higher than your shoulder. Then lift your left leg no higher than your hip. Make sure you are not holding your breath. Hold this position for seconds. http://www.mdconsult.com/das/patient/body/437616202-3/1505977361/10089/56270.html 8/14
Continuing to keep your abdominal muscles tense and your back steady, slowly return to your starting position. Repeat with the opposite arm and leg. Repeat times. Complete this exercise times per day. STRENGTHENING Lower Abdominals, Double Knee Lift Lie on a firm bed or floor. Keeping your legs in front of you, bend your knees so they are both pointed toward the ceiling and your feet are flat on the floor. Tense your abdominal muscles to brace your low back and slowly lift both of your knees until they come over your hips. Be certain not to hold your breath. Hold for seconds. Using your abdominal muscles, return to the starting position in a slow and controlled manner. Repeat times. Complete this exercise times per day. POSTURE AND BODY MECHANICS CONSIDERATIONS - Herniated Disc (Ruptured Disk) Keeping correct posture when sitting, standing or completing your activities will reduce the stress put on different body tissues, allowing injured tissues a chance to heal and limiting painful experiences. The following are general guidelines for improved posture. Your physician or physical therapist will provide you with any instructions specific to your needs. While reading these guidelines, remember: The exercises prescribed by your provider will help you build the flexibility and strength to maintain correct postures. The correct posture provides the best environment for your joints to work. All of your joints have less wear and tear when properly supported by a spine with good posture. This means you will experience a healthier, less painful body. Correct posture must be practiced with all of your activities, especially prolonged sitting and standing. Correct posture is as important when doing repetitive low-stress activities (typing) as it is when doing a single heavy-load activity (lifting). RESTING POSITIONS Consider which positions are most painful for you when choosing a resting position. If you have pain with http://www.mdconsult.com/das/patient/body/437616202-3/1505977361/10089/56270.html 9/14
flexion-based activities (sitting, bending, stooping, squatting), choose a position that allows you to rest in a less flexed posture. You would want to avoid curling into a fetal position on your side. If your pain gets worse with extension-based activities (prolonged standing, working overhead), avoid resting in an extended position such as sleeping on your stomach. Most people will find more comfort when they rest with their spine in a more neutral position, neither too rounded nor too arched. Lying on a non-sagging bed on your side, with a pillow between your knees, or on your back with a pillow under your knees will often provide some relief. Keep in mind, being in any one position for a prolonged period of time, no matter how correct your posture, can still lead to stiffness. PROPER SITTING POSTURE In order to minimize stress and discomfort on your spine, you must sit with correct posture. Sitting with good posture should be effortless for a healthy body. Returning to good posture is a gradual process. Many people can work toward this most comfortably by using various supports until they have the flexibility and strength to maintain this posture on their own. When sitting with proper posture, your ears will fall over your shoulders and your shoulders will fall over your hips. You should use the back of the chair to support your upper back. Your low back will be in a neutral position, just slightly arched. You may place a small pillow or folded towel at the base of your low back for support. When working at a desk, create an environment that supports good, upright posture. Without extra support, muscles tire, which leads to excessive strain on joints and other tissues. Keep these recommendations in mind. CHAIR A chair should be able to slide under your desk when your back makes contact with the back of the chair. This allows you to work closely. The chair's height should allow your eyes to be level with the upper part of your monitor and your hands to be slightly lower than your elbows. BODY POSITION Your feet should make contact with the floor. If this is not possible, use a foot rest. Keep your ears over your shoulders. This will reduce stress on your neck and low back. http://www.mdconsult.com/das/patient/body/437616202-3/1505977361/10089/56270.html 10/14
INCORRECT SITTING POSTURES If you are feeling tired and unable to assume a healthy sitting posture, do not slouch or slump. This puts excessive strain on your back tissues, causing more damage and pain. Healthier options include: Using more support, like a lumbar pillow. Switching tasks, to something that requires you to be upright or walking. Talking a brief walk. Lying down to rest in a neutral-spine position. PROLONGED STANDING WHILE SLIGHTLY LEANING FORWARD When completing a task that requires you to lean forward while standing in one place for a long time, place either foot up on a stationary 2-4 inch high object, to help maintain the best posture. When both feet are on the ground, the low back tends to lose its slight inward curve. If this curve flattens (or becomes too large), the back and your other joints will experience too much stress, tire more quickly and can cause pain. CORRECT STANDING POSTURES Proper standing posture should be assumed with all daily activities, even if they only take a few moments, like when brushing your teeth. As in sitting, your ears should fall over your shoulders and your shoulders should fall over your hips. You should keep a slight tension in your abdominal muscles to brace your spine. Your tailbone should point down to the ground, not behind your body, resulting in an over-extended swayback posture. INCORRECT STANDING POSTURES http://www.mdconsult.com/das/patient/body/437616202-3/1505977361/10089/56270.html 11/14
Common incorrect standing postures include a forward head, locked knees or an excessive swayback. WALKING Walk with an upright posture. Your ears, shoulders and hips should all lineup. PROLONGED ACTIVITY IN A FLEXED POSITION When completing a task that requires you to bend forward at your waist or lean over a low surface, try finding a way to stabilize 3 out of 4 of your limbs. You can place a hand or elbow on your thigh, or rest a knee on the surface you are reaching across. This will provide you more stability so that your muscles do not tire as quickly. By keeping your knees relaxed, or slightly bent, you will also reduce stress across your low back. CORRECT LIFTING TECHNIQUES DO : Assume a wide stance. This will provide you more stability and the opportunity to get as close as possible to the object you are lifting. Tense your abdominals to brace your spine. Then, bend at the knees and hips. Keeping your back locked in a neutral-spine position, lift using your leg muscles. Lift with your legs, keeping your back straight. Test the weight of unknown objects before attempting to lift them. Try to keep your elbows down by your sides, in order get the best strength from your shoulders when carrying an object. Always ask for help when lifting heavy or awkward objects. INCORRECT LIFTING TECHNIQUES DO NOT: Lock your knees when lifting, even if it is a small object. http://www.mdconsult.com/das/patient/body/437616202-3/1505977361/10089/56270.html 12/14
Bend and twist. Pivot at your feet or move your feet when needing to change directions. Assume that you can safely pick up even a paper clip, without proper posture. Document Released: 12/18/2006 Document Revised: 03/11/2013 Document Reviewed: 04/01/2010 ExitCare Patient Information 2013 ExitCare, LLC. Copyright MD Consult 2013 Adult Health Advisor Copyright 2013 Elsevier Inc. All rights reserved. - www.mdconsult.com Client IP Address: 76.10.173.185 DAS Host: isis http://www.mdconsult.com/das/patient/body/437616202-3/1505977361/10089/56270.html 13/14
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