Physical Therapist's Guide to Herniated Disk
A herniated disc occurs when the cushion-like cartilage (the disc) between the bones of the spine is torn, and the gelatin-like core of the disc leaks. Often mistakenly called a slipped disc, a herniated disc can be caused by sudden trauma or by long-term pressure on the spine. This condition most often affects people aged 30 to 50 years; men are twice as likely to be diagnosed as women. Repeated lifting, participating in weight-bearing sports, obesity, smoking, and poor posture are all risk factors for a herniated disc. The majority of herniated discs do not require surgery, and respond best to physical therapy. Physical therapists design individualized treatment programs to help people with herniated discs regain normal movement, reduce pain, and get back to their regular activities.
What is a Herniated Disk?
The spine is made up of 33 vertebrae (bones) stacked on top of each other. Between each vertebra is a cushion-like piece of cartilage called an "intervertebral disc." Imagine the disc as a jelly donut:
- The outer portion of the donut is a rubbery substance (the "annulus fibrosus" or AF).
- A gelatin-like substance fills the "hole" in the donut (the "nucleus pulposus" or NP).
In people younger than 30 years of age, the disc is soft, flexible, and absorbs shock extremely well. As individuals age, however, the disc can lose some flexibility. If stress is applied to the spine, the outer part of the disc (AF) can tear, and the gelatin-like core (NP) leaks through the tear. This leaking, or bulging, of the gelatin is called a herniated disc. In more severe cases, the leaked NP can seep outside the spinal column.
Injuries that cause herniation can occur rapidly, or develop slowly over time.
- A sudden injury can occur when an individual lifts something while in a poor position. This action strains the spine, and causes the outer part of a disc to suddenly tear.
- A slow injury can occur as the result of sitting or standing with poor posture (slumped forward) for hours, weeks, or years, slowly overstretching or tearing the outer part of a disc.
The most common area of the spine to experience a herniated disc is the low back, just below waist level. Herniated discs also commonly occur in the neck.
How Does it Feel?
A herniated disc can cause pain, tightness, numbness, weakness, or tingling in the neck, back, arms, or legs. If the bulging or leaking disc pushes on a nearby nerve, pain or muscle weakness may result. If the bulging or leaking disc does not push on a nerve, pain or disability may not occur. Although back or neck pain can be caused by a herniated disc, other factors may be involved. Your physical therapist can test for and rule out other possible conditions.
If a herniated disc is severely pressing on a nerve, or is pressing on the spinal cord, surgery may be needed to immediately relieve that pressure. Your physical therapist can help determine whether either of these conditions is occurring, and will work closely with your physician and surgeon to determine the correct treatment.
Signs and Symptoms
The type and location of your symptoms depend on the location and direction of the herniated disc, and the amount of pressure on nearby nerves.
A herniated disc may cause no pain at all. Or, it can cause any of the following symptoms:
- Pain in the neck, back, low back, arms, or legs
- Inability to bend or rotate the neck or back
- Numbness or tingling in the neck, shoulders, arms, hands, hips, legs, or feet
- Weakness in the arms or legs
- Limping when walking
- Increased pain when coughing, sneezing, reaching, or sitting
- Inability to stand up straight; being "stuck" in a position, such as stooped forward or leaning to the side
- Difficulty getting up from a chair
- Inability to remain in 1 position for a long period of time, such as sitting or standing, due to pain
- Pain that is worse in the morning
In individuals older than 50 years, the gelatin-like core of the disc (NP) can become dry and less soft, making it less likely to leak, or herniate. This deterioration, however, can lead to other conditions that cause pain, such as degenerative disc disease, and degenerative joint disease. Your physical therapist will work with other health care professionals to determine your correct diagnosis.
How Is It Diagnosed?
Your physical therapist will conduct a thorough evaluation that includes taking your health history. Your physical therapist will also ask you detailed questions about your injury, such as:
- How and when did the pain start?
- At what time of day is it worse?
- What type of discomfort do you feel, and where do you feel it?
- What can’t you do right now, in your daily life, due to the pain?
Your physical therapist will perform tests on your body to find physical problems, such as:
- Difficulty moving
- Weakness or tightness in the muscles
- Loss of skin sensation in some areas (numbness)
- Loss of reflexes
- Joint stiffness
- Poor posture
- Difficulty walking
If your physical therapist finds any of the above problems, physical therapy treatment may begin right away, to help get you on the road to recovery and back to your normal activities.
If more severe problems are found with any of the testing, your physical therapist may collaborate with a physician or surgeon to obtain special diagnostic testing, such as an MRI. Physical therapists work closely with physicians and other health care providers to ensure that you receive an accurate diagnosis and the treatment and care you need.
How Can a Physical Therapist Help?
In all but the most extreme cases, conservative care (such as physical therapy) often produces better results in treating a herniated disc than surgery or pain medications, such as opioids.
Your physical therapist will work with you to design a specific treatment program that will speed your recovery, including exercises and treatments that you can do at home. Physical therapy will help you return to your normal lifestyle and activities. The time it takes to heal the condition varies, but results can be achieved in 2 to 8 weeks or less, when a proper posture, pain-reduction, stretching, and strengthening program is implemented.
During the first 24 to 48 hours following your diagnosis of a herniated disc, your physical therapist may advise you to:
- Rest the area by avoiding any activity that causes worsening symptoms in the arms or legs.
- Avoid bed rest.
- Stay active around the house, and go on short walks several times per day. Movement will decrease pain and stiffness, and help you feel better.
- Apply ice packs to the affected area for 15 to 20 minutes every 2 hours.
- Sit in firm chairs. Soft couches and easy chairs may make your problems worse.
- Consult with a physician for further services, such as medications or diagnostic tests.
Some exercises are better for individuals with herniated discs. Your physical therapist will educate you about them. For example:
- Exercising in water can be a great way to stay physically active when other forms of exercise are painful.
- Exercises that involve lots of twisting and bending may or may not benefit you. Your physical therapist will design an individualized exercise program to meet your specific needs.
- Weight-training exercises, though very important, need to be done with proper form to avoid stress to the back and neck.
Your physical therapist will work with you to:
Reduce pain and other symptoms. Your physical therapist will help you understand how to avoid or modify the activities that caused the injury, so healing can begin. Your physical therapist may use different types of treatments and technologies to control and reduce your pain and symptoms.
Improve posture. If your physical therapist finds that poor posture has contributed to your herniated disc, the therapist will teach you how to improve your posture so that pressure is reduced in the injured area, and healing can begin and progress as rapidly as possible.
Improve motion. Your physical therapist will choose specific activities and treatments to help restore normal movement in any stiff joints. These might begin with "passive" motions that the physical therapist performs for you to move your spine, and progress to “active” exercises and stretches that you do yourself. You can perform these motions at home and in your workplace to help hasten healing and pain relief.
Improve flexibility. Your physical therapist will determine if any of the involved muscles are tight, start helping you to stretch them, and teach you how to stretch them at home.
Improve strength. If your physical therapist finds any weak or injured muscles, your physical therapist will choose, and teach you, the correct exercises to steadily restore your strength and agility. For neck and back disc herniations, “core strengthening” is commonly used to restore the strength and coordination of muscles around your back, hips, abdomen, and pelvis.
Improve endurance. Restoring muscular endurance is important after an injury. Your physical therapist will develop a program of activities to help you regain the endurance you had before the injury, and improve it.
Learn a home program. Your physical therapist will teach you strengthening, stretching, and pain-reduction exercises to perform at home. These exercises will be specific for your needs; if you do them as prescribed by your physical therapist, you can speed your recovery.
Return to activities. Your physical therapist will discuss your activity levels with you and use them to set your work, sport, and home-life recovery goals. Your treatment program will help you reach your goals in the safest, fastest, and most effective way possible. For spine injuries like a herniated disc, your physical therapist may teach you proper “body mechanics”—correct ways to perform tasks and lift heavy objects—that will help protect your spine from further injury.
Once your pain is gone, it will be important for you to continue your new posture and movement habits to keep your back healthy and pain free.
Can this Injury or Condition be Prevented?
To prevent experiencing a herniated disc, individuals should:
- Use proper body mechanics when lifting, pushing, pulling, or performing any action that puts extra stress on your spine.
- Maintain a healthy weight. This will reduce the stress on your spine.
- Stop smoking.
- Discuss your occupation with a physical therapist, who can provide an analysis of your job tasks and offer suggestions for reducing your risk of injury.
- Keep your muscles strong and flexible. Participate in a consistent program of physical activity to maintain a healthy fitness level.
Many physical therapy clinics offer “back schools,” which teach people how to take care of their backs and necks and prevent injury. Ask your physical therapist about programs in your area. If you don't have a physical therapist, click on Find a PT to find a certified professional in your immediate area.
To prevent recurrence of a herniated disc, follow the above advice, and:
- Continue the new posture and movement habits that you learned from your physical therapist, to keep your back healthy.
- Continue to do the home-exercise program your physical therapist taught you, to help maintain your improvements.
- Continue to be physically active and stay fit.
Real Life Experiences
Jeff is a 42-year-old maintenance supervisor at an office park. He sometimes experiences back pain at work when he lifts heavy objects. He recently volunteered to help build a community playground. Last Saturday, he lifted a number of heavy bags of sand to create a sandbox. He felt a sharp pain in his lower back that has been getting worse all week.
Today, the pain is extending down his leg. Jeff knows people who have taken opioid pain medication for their back pain, but he really wants to avoid opioid drugs. His neighbor recommends a visit to her physical therapist, who specializes in treating people with back pain.
At Jeff’s first visit, his physical therapist takes his health history, and learns about his repeated episodes of pain at work. She performs a full physical examination. Jeff notes his pain is now traveling down the back of his leg into his calf and foot. He says the pain is worse with sitting and bending; he is unable to sit for more than 10 minutes without having both back and leg pain.
Jeff's physical therapist conducts a series of physical tests to determine the severity of the condition, the strength of his muscles, the movement of the joints in his back, and the skin sensation in his legs. She is able to identify a specific movement that relieves his leg pain.
She concludes that Jeff has a herniated disc in his lower back. She explains that with physical therapy over the next few weeks, the bulging gelatin-like core of the disc (NP) will likely shrink back into its proper position, which will relieve his pain and allow healing to occur.
During Jeff's first treatment session, his physical therapist performs a manual (hands-on) therapy treatment for his low back that relieves both his back and leg pain. She also teaches him how to perform a specific movement that reduces the pain in his legs after a few repetitions. She instructs Jeff to perform this movement each day at home, and whenever the pain seems worse.
Over the next few weeks, Jeff learns strengthening exercises for his core muscles to better support his back when he lifts heavy objects. His physical therapist shows him how to manage his pain by making simple changes to how he performs his daily activities, such as correcting his own posture and movements when on the job.
She encourages Jeff to begin a daily walking program, like going on neighborhood outings with his daughter after school.
Jeff follows the advice of his physical therapist, and, after 4 weeks, he is pain free and symptom free. He walks with his daughter to her new local playground several times a week, and sticks to his program of regular exercise.
At his 6-week checkup, Jeff is happy to report that he feels stronger than he has in years!
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat people who have low back pain as a result of a herniated disc. You may want to consider:
- A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, problems.
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you’re looking for a physical therapist:
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists’ experience in helping people with a herniated disc. During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of a herniated disk. The articles report precent research and give an overview of the standards of practice for treatment both in the United States and internationally. The article titles are listed by year and linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Apeldoorn AT, van Helvoirt H, Meihuizen H, et al. The influence of centralization and directional preference on spinal control in patients with nonspecific low back pain. J Orthop Sports Phys Ther. 2016;46(4):258–269. Free Article.
Langevin P, Desmeules F, Lamothe M, Robitaille S, Roy JS. Comparison of 2 manual therapy and exercise protocols for cervical radiculopathy: a randomized clinical trial evaluating short-term effects. J Orthop Sports Phys Ther. 2015;45(1):4-17. Free Article.
VanGelder LH, Hoogenboom BJ, Vaughn DW. A phased rehabilitation protocol for athletes with lumbar intervertebral disc herniation. Int J Sports Phys Ther. 2013;8(4):482–516. Free Article.
Di Ciaccio E, Polastri M, Gasbarrini A. Cervical disc herniation: is the regression flawed by age: a case report. Int J Ther Rehabil. 2013;20(12):612–616. Abstract Not Available.
Keramat KU, Gaughran A. Safe physiotherapy interventions in large cervical disc herniations. BMJ Case Rep. 2012;2012:bcr2012006864. Free Article.
Albert HB, Hauge E, Manniche C. Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions? Eur Spine J. 2012;21(4):630–636. Free Article.
Boyles R, Toy P, Mellon J Jr, Hayes M, Hammer B. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. J Man Manip Ther. 2011;19(3):135–142. Free Article.
Cook C, Hegedus EJ, Ramey K, Physical therapy exercise intervention based on classification using the patient response method: a systematic review of the literature. J Man Manip Ther. 2005;13:152-162. Abstract Not Available.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Authored by Chris Bise, PT, DPT. Reviewed by the MoveForwardPT.com editorial board.
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