Physical Therapy for Herniated Discs: How To Get Back On Your Feet Without Surgery
Have you recently discovered that you have one or more herniated discs in your low back?
If so, you may have excruciating pain in your back and down one leg first thing in the morning, which then subsides after standing and walking for about an hour. You may feel sharp, stabbing muscle spasms in your back every time you attempt bending and lifting. You also may notice a dull, aching pain in your back and down one leg when sitting, which increases the longer you sit.
Whether you experience all or only some of these symptoms, pain from herniated discs can result in significant difficulty with daily activities.
Here’s the good news: most cases of disc herniation resolve on their own. For cases that don’t, there are several conservative treatment options available for treating the pain without surgery.
Physical therapy is an effective first-line treatment for herniated discs. When used alone or in conjunction with other conservative treatments, physical therapy can relieve pain just as well as surgery, without the same risks and long-term consequences.
Table of contentsWhat Is a Herniated Disc?Risk Factors for Disc HerniationHow Physical Therapy HelpsThe McKenzie MethodOther Conservative Treatments That Support Physical TherapyHow Effective Is Conservative Treatment for Herniated Discs?Physical Therapy After SurgeryBest Exercises for Herniated DiscsTakeaways
What Is a Herniated Disc?
There are 33 vertebrae that together form the spinal column. In between each pair of consecutive vertebrae sits a cushion made of cartilage and a gel-like substance. These cushions are called intervertebral discs.
In each disc, the cartilage is thicker around the outside of the disc. This cartilage ring is called the annulus fibrosus. The annulus contains the inner water-based gel portion of the disc called the nucleus pulposus. In a normal disc, the annulus successfully contains the nucleus so that the nucleus acts as a shock absorber and disperser, protecting the spinal cord and spinal nerves from compression (1).
Sometimes, as a result of an injury or from repeated torsion from daily movement, the outer cartilage begins to tear (1). When this happens, the inner nucleus will start to protrude or bulge through the tear.
Once the tear extends through the full thickness of the cartilage, the nucleus will start to leak, or herniate, out of the disc. When a disc becomes herniated, the portion of the nucleus leaking out can compress spinal nerve roots around the spinal canal, resulting in either low back pain or sciatica (radiating pain down the sciatic nerve).
When a disc is healthy, it functions as a shock absorber, protecting spinal nerves from compression and damage. When a disc becomes herniated, part of the disc leaks out and results in nerve root compression.
Risk Factors for Disc Herniation
A number of factors can place you at increased risk for developing herniated discs.
- Smoking and cardiovascular disease: Smoking results in changes to arteries and veins, which ultimately decreases blood flow throughout the body. Since spinal discs already don’t receive much blood flow under typical circumstances, smoking will increase the odds of developing a herniated disk (1, 2).
- Weight: Obesity increases the amount of stress on spinal discs and joints in routine movements, making them more prone to degeneration (3).
- Nutrition and water intake: Unlike most anatomical structures in the body, spinal discs don’t receive nutrition via blood vessels. Instead, the discs absorb water during moments when the spine is unweighted (such as when you lay down at night to sleep) (4, 5). All the nutrients needed by the discs are brought in with the water. This makes water intake critical for healthy spinal discs. Without proper water intake, the discs will not consistently receive the nutrition they need to function properly.
Posture and Movement Abnormalities
- Repeated Bending and Lifting: Forward bending and twisting movements stress the spine more than other movements do (6). This stress increases if you’re simultaneously lifting a heavy object. Jobs or recreational activities that involve repeated bending, twisting, and lifting therefore put spinal discs at greater risk of injury (1).
- Poor Posture: Regularly sitting or standing with your shoulders slumped forward pushes the inner nucleus of each disc outward against the outer cartilage ring. Over time, sustained pressure can result in degeneration of the cartilage ring and cause herniation.
- Prolonged Sitting: Sitting can damage your spinal discs even if you sit with good posture. Therefore, sitting for prolonged periods of time without taking standing and walking breaks will increase your chances of developing spinal disc problems (1, 7).
Age and Genetics
There are a number of risk factors for developing spinal disc herniation. While some of them can’t be controlled (age, genetics), others are related to lifestyle and can be influenced. Being physically active, drinking plenty of water, avoiding smoking, and maintaining good posture can all help mitigate the likelihood of disc herniation.
How Physical Therapy Helps
Physical therapists help people suffering with back pain by analyzing movement abnormalities, determining which musculoskeletal structures may be causing the abnormalities through various tests, and then designing treatment plans to address impairments.
When you first consult a physical therapist for your back pain, your therapist will assess your range of motion and pain response with different movements (such as bending forward, bending backward, and bending side to side). They’ll look for which motions aggravate pain and which reduce it. They’ll also assess your strength, leg reflex responses, and possibly the results of auxiliary tests to rule out any non-musculoskeletal pathology that may be contributing to your pain.
Based on these findings, your therapist will select an appropriate set of interventions to address your pain and improve your range of motion.
Interventions that can relieve pain resulting from herniated lumbar discs include:
- Manual therapy (direct hands-on treatment from the therapist)
- Heat or cold therapy (promotion of blood flow or reduction of inflammation, respectively)
- TENS (gentle electrical stimulation to the muscles to promote relaxation)
- Traction therapy (reduction of weight on spinal discs)
- Ultrasound (application of gentle sound waves to the reactive tissues to promote healing)
In conjunction with these interventions, your physical therapist will also incorporate different exercises to improve your range of motion. Typical exercises include:
- Stretching exercises to improve flexibility of the back muscles
- Strengthening and stabilization exercises to improve core muscle strength and support for the back
- Balance exercises to improve awareness of how your back is moving during various activities
- Posture exercises to improve any postural abnormalities
Throughout the treatment, your therapist will also instruct you in proper form for daily maneuvers to avoid disc re-injury. As your pain subsides, they’ll incorporate specific exercises and training methods to get you back to your usual routine, including your favorite leisure activities and sports.
Physical therapists are experts in movement analysis and the treatment of musculoskeletal conditions, including low back pain caused by herniated lumbar discs. Their skills allow them to assess whether your pain is musculoskeletal in nature. If your pain is due to a musculoskeletal cause like a disc herniation, physical therapists have a variety of treatment techniques they can implement to relieve your pain and get you moving again. If they notice any abnormalities indicative of a non-musculoskeletal pathology, they’ll refer you to the appropriate physician to investigate further.
The McKenzie Method
Some physical therapists have advanced training in a diagnostic and treatment approach called the McKenzie method. While this method can be used for generalized back, knee, shoulder, or neck pain, it’s most commonly known for its use with radiculopathy symptoms (pain down the leg) associated with spinal disc bulges or herniations (8).
The McKenzie method involves assessing the presence of a radiculopathy based on whether a specific, repeated movement makes the pain go farther down the leg, and if another movement centralizes the pain to the back (in other words, eliminates the leg pain). Based on these findings, the therapist may incorporate a specific set of movement exercises into the exercise program with the goal of eliminating radicular pain down a leg (8).
Physical therapists fully trained in the McKenzie method take several additional courses to build proficiency with the method, then undergo specialized examination. Once they pass the exam, they’re given the MDT certification. If you're interested in an evaluation from a McKenzie certified physical therapist, you can Google McKenzie certified therapists in your area, or go to the McKenzie Institute USA's website and click on their "Find a Provider" tab.
The McKenzie method is an advanced diagnostic and treatment approach best known for its success in treating radiculopathy from bulging or herniated spinal discs. Physical therapists are required to earn additional certification in order to integrate this approach in their clinical practice.
Other Conservative Treatments That Support Physical Therapy
In certain cases, physical therapy alone may not be enough to completely resolve low back and radiating leg pain caused by herniated discs. In these cases, physicians will likely recommend additional treatments in conjunction with physical therapy to maximize the benefits of both.
Other common conservative treatments used to manage herniated disc pain include:
- NSAIDs: Non-steroidal anti-inflammatory drugs such as ibuprofen or naproxen have been proven effective in reducing inflammation which is often associated with acute pain (1). Some research has found NSAIDs and physical therapy to be equally effective when used individually. However, when used excessively, NSAIDs often result in cardiovascular gastrointestinal complications (9). Consequently, NSAIDs are typically recommended during the acute phase of pain, to reduce inflammation so the physical therapist can progress their treatment plan more quickly, and then phased out as the therapy ramps up.
- Nerve pain medications: For individuals suffering from sciatica symptoms, nerve pain medications such as gabapentin or pregabalin may be prescribed, as these medications target nerve pain specifically, unlike NSAIDs which confer more general anti-inflammatory benefits (1). They may help take the edge off the nerve pain while physical therapy is just beginning to take effect.
- Epidural steroid injections: If pain doesn’t respond to NSAIDs or physical therapy initially, the physician may inject a steroid medication such as cortisone into the spinal space where the disc herniation is pinching a nerve. The injection allows the steroid, which is a strong anti-inflammatory medication, to target the inflamed nerve root more quickly than oral medications. Sometimes, one or two of these injections numbs the pain long enough for physical therapy to resolve the underlying cause of pain (10).
Physicians have several interventions which they may recommend ancillary to physical therapy to maximize pain reduction. All of them involve some type of medication, so it’s important to receive medical advice from your physician about each of them to determine which may be best for you.
How Effective Is Conservative Treatment for Herniated Discs?
As discussed, most cases of disc herniation resolve on their own without additional treatment, anywhere from 2 to 12 weeks after pain onset (11).
Studies comparing the results of surgical and non-surgical treatment have found surgery to be more effective than conservative care in the short-term (within a month of treatment), but not in the long-term (six months out) (12, 13).
This is important to keep in mind when considering potential risks and complications of each treatment method. While studies report very minimal side effects from physical therapy, surgical procedures carry significant risk of complications (14, 15, 16).
While you may be tempted to consider surgery for a herniated disc, it’s important to keep in mind that surgery comes with an elevated risk of complications (including disc re-herniation) and often doesn’t outperform conservative care in the medium and long-term.
Physical Therapy After Surgery
In severe cases of disc herniation, surgery may be needed to prevent permanent neurological damage. Surgery may also be necessary if conservative treatments are unsuccessful in resolving the pain. Under these circumstances, the surgeon may still suggest physical therapy after the surgery.
Physical therapy still plays a role in post-surgery recovery, because it helps manage post-operative pain and reduces the time needed for recuperation. It also allows the therapist to instruct in proper movement form following surgery, to reduce the chances of disc reherniation and other complications that could arise following surgery.
Research has found that initiating exercise as soon as possible after lumbar spine surgery resulted in positive outcomes regarding return to function (17). Additional studies have found that initiating walking within a week after surgery carries benefits that continue for months after surgery, as opposed to being on bed rest (18).
Even when surgery is used to treat herniated discs, physical therapy is still beneficial after surgery for alleviating pain and improving recovery time.
Best Exercises for Herniated Discs
While a physical therapy treatment program can include a number of different exercises, the following exercises are particularly effective in managing pain caused by herniated discs. I’ve used these exercises frequently in my own clinical practice with significant success, as have several of my colleagues.
Lying on your stomach with your palms flat against a mat on either side of you, gently push yourself up onto your hands while keeping your hips down on the mat. If you can’t push all the way up onto your hands, you can try pushing up onto your elbows instead. Only go as far as you can without increasing any pain or discomfort. Return to the starting position and repeat 10 times.
Hanging On Pull-Up Bar
The goal of this exercise is to gently reduce pressure on the discs and joints in your back, essentially producing your own form of traction that you can perform at home. Hold the pull-up bar with both hands, then gently pull up through your arms to unweight your lower back. If you can successfully hold your weight with your feet completely off the floor, then do so. If not, just pull as much weight as you can and hold for as long as possible before taking a break. Repeat 5 - 10 times.
Lie on your back with your knees bent and feet flat on the mat. Cross your right leg over the left leg, so your right foot is resting on your left knee. Using your right hand, gently push your right knee down towards the mat, until you feel a stretch deep in the right hip. Hold this stretch for up to 10 seconds. Repeat 5 - 10 times, as tolerated. Then switch to your left leg.
You should work closely with your physical therapist in designing the best care program for your particular case. Strive to put together a routine that incorporates a range of different exercises that you can do regularly over a treatment course of several weeks.
Physical therapy is one of the front-line treatments for herniated discs and has been shown to be effective in achieving pain relief and eliminating the need for surgery. Physical therapy also carries limited side effects and entails minimal risk of long-term complications. Although surgery may reduce pain more in the short-term, it comes with greater risk of reherniation and recurrent back pain, which will often require another surgery.
If you’ve been struggling with pain caused by herniated lumbar discs and you want to avoid surgery, consult a physical therapist. They’ll not only help you resolve your pain and get back to the active lifestyle you, but they’ll also teach you how to protect your back from re-injury so you can stay healthy!