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    Move Forward Guide

    Physical Therapist's Guide to Herniated Disk

    It's estimated that as many as 75% of us will have some form of back or neck pain at some point in our lifetime. The good news is that most of us will recover without the need for surgery—and conservative care such as physical therapy usually gets better results than surgery. A herniated disk is one cause of neck and back pain.


     

    What is a Herniated Disk?

    Your spine is made up of 33 vertebrae (bones) that are stacked on top of one another. Between each vertebra is a cushion-like piece of cartilage called an "intervertebral disk." Imagine the disk as a tire, with gelatin filling the hole in the tire. The rubbery outer part is called the "annulus,” and the gelatin is called the "nucleus." When we're young—under 30 years of age—the disk is made mostly of gelatin. As we age, we start to lose some of that gelatin. The disk becomes flatter and less flexible, making it easier to injure. In some cases, the gelatin can push out through a crack in the rubbery exterior and lead to a herniation (bulge) or rupture (tear).

    Herniated disks are most common in the neck (cervical spine) and low back (lumbar spine). In the low back, disks may become damaged by excessive wear and tear or an injury.

    Your risk for developing a herniated disk increases due to:

    • Age – most herniated disks occur in people who are 30 to 50 years of age as a result of age-related disk degeneration. Herniated disks are less common after the age of 50, however, because with aging there is less fluid to push out of the disk
    • Obesity – increased weight results in increased pressure on the disks
    • Occupation – jobs that are physically demanding and involve repetitive tasks such as lifting, pushing, pulling, and twisting place additional stress on the disks
    • Low levels of physical activity – people who are not physically active are less able to handle physical demands
    Herniated Disk
     

    Signs and Symptoms

    You might have mild to intense neck or back pain—or no pain at all. Herniated disks sometimes show up on the diagnostic images of people who have no symptoms.

    When the disk ruptures ("herniates") and a portion of the disk pushes outside its normal boundaries, it can "pinch" or press on spinal nerves or the spinal cord. This condition is called "radiculopathy." The pressure can lead to back pain or to pain, numbness, or weakness in the legs.

    The type and location of your symptoms depends on the location and the amount of pressure on the nerves:

    • If you have a herniated disk in the cervical spine, you may have pain, tingling, numbness, weakness, or any combination of these symptoms in the arm, shoulder, or neck
    • If you have a herniated disk in the lumbar spine, you may have pain, tingling, numbness, weakness, or any combination of these symptoms in the back, buttocks, or legs; most likely, your symptoms will be on only one side of your body

    Often, symptoms from herniated disks are made worse by certain activities or positions. If you have a herniated disk in the lumbar spine:

    • Pain may get worse with sitting, bending, and reaching
    • Pain may be worst first thing in the morning and after staying in one position for a long time
    • You may need to switch positions frequently
    • You may prefer to stand rather than sit

    If you have a herniated disk in the neck, symptoms are often worse with prolonged sitting and when lying down.

     

    How Is It Diagnosed?

    Your physical therapist will conduct a thorough evaluation that includes a review of your medical history and will use screening tools to determine the likelihood of a herniated disk. For example, the therapist will:

    • Ask you very specific questions about the location and behavior of your pain, weakness, and other symptoms
    • Ask you to fill out a body diagram to indicate specific areas of pain, numbness, and tingling
    • Perform tests of muscle strength and sensation to determine the severity of the pressure on your nerves
    • Examine your posture and observe how you walk and perform other activities
    • Measure the range of motion of your spine and your arms and legs
    • Perform special tests, such as the straight leg raise test or the crossover straight leg raise test, that help diagnose a herniated disk
    • Use manual therapy to evaluate the mobility of the joints and muscles in your spine
    • Test the strength of important muscle groups

    If you have muscle weakness and loss of sensation or very severe pain, special diagnostic tests, such as magnetic resonance imaging (MRI), electromyography, or nerve conduction studies may be needed. Physical therapists work closely with physicians and other health care providers to make certain that you receive an accurate diagnosis and appropriate treatment.

    Research shows that in all but the most extreme cases (usually involving muscle weakness or high levels of pain), conservative care, such as physical therapy, has better results than surgery.

    If your physical therapist’s evaluation indicates that there are no signs of nerve compression and you don't have any signs of muscle weakness or numbness, treatment can begin right away. If the evaluation indicates that the herniated disk might be compressing the nerves, your therapist will consult with a physician specialist.

     

    How Can a Physical Therapist Help?

    Your physical therapist's overall purpose is to help you continue to participate in your daily activities and life roles. The therapist will design a treatment program based on both the findings of the evaluation and your personal goals. Your treatment program most likely will include a combination of exercises.

    Your therapist will design:

    • Exercises that involve specific movements to relieve nerve pressure and decrease pain and other symptoms, especially during the early stages of treatment
    • Stretching and flexibility exercises to improve mobility in the joints and the muscles of your spine, arms, and legs—improving motion in a joint can be key to pain relief
    • Strengthening exercises—strong trunk muscles provide support for your spinal joints, and strong arm and leg muscles help take some of the workload off those joints
    • Aerobic exercise, which has been proven to be helpful in relieving pain, promoting a healthy body weight, and improving overall strength and mobility—all important factors in managing a herniated disk

    This might sound like a lot of exercise, but don't worry: research shows that the more exercise you can handle, the quicker you'll get rid of your pain and other symptoms.

    Your physical therapist also might decide to use a combination of other treatments:

    • Manual therapy to improve the mobility of stiff joints and tight muscles that may be contributing to your symptoms
    • Posture and movement education to show you how to make small changes in how you sit, stand, bend, and lift—even in how you sleep—to help relieve your pain and help you manage your condition on your own
    • Special pain treatments—such as ice, traction, and electrical stimulation—to reduce pain that is severe and not relieved by exercise or manual therapy

    Once your pain is gone, it will be important for you to continue your new posture and movement habits to keep your back healthy.

     

    Can this Injury or Condition be Prevented?

    Herniated disks can occur as a result of aging, but there are lifestyle changes you can make to reduce your overall risk:

    • Maintain a healthy weight may reduce the overall stress on your spine
    • Use proper posture—improving your alignment may contribute to the health of your spine
    • Use proper body mechanics—changing how you perform activities, especially those that you do frequently, may help reduce your risk of a herniated disk. Not sure what changes to make? Discuss your occupation with your therapist, who will provide an analysis of your job tasks and make suggestions on how you can reduce your risk of injury.

    Many physical therapy clinics conduct regular educational seminars to help people in the community learn to take care of their backs and necks. These seminars often are free and provide demonstrations along with written information about exercises for the back and neck, instruction on proper lifting and sitting postures, and other tips to keep your back healthy.

    If you already have a herniated disk, your physical therapist can help you develop a fitness program that takes into account your herniated disk. There are some exercises that are better than others for people with a herniated disk, and your therapist will educate you about them. For instance:

    • Exercising in water can be a great way to stay physically active when other forms of exercise are painful
    • Exercises involving lots of twisting and bending are not good for everyone
    • Weight-training exercises, though very important, need to be done with proper form to avoid stress to the back and neck
     

    Real Life Experiences

    Jeff is a 42-year-old maintenance supervisor with a recent onset of low back pain after lifting heavy bags of sand to build a playground for his daughter. This is not the first time he has had pain, but this time the pain seems different. In the past, his pain was only in his back and didn’t last for more than a week. This time, his pain lingers, gets increasingly worse, and is now going down his leg into his foot. There is a physical therapist with a practice close to his home who has treated some of his neighbors, all with positive results. Jim schedules a visit with the therapist, who specializes in the treatment of people with back pain.

    At the time of the physical therapist’s evaluation, Jeff's pain is traveling down the back of his leg into the calf and into the foot as well. He has some numbness and tingling but no weakness. His pain is worse with sitting and bending. He is unable to sit for more than 10 minutes without having both back and leg pain. Except for the physical work he does on the job, Jeff gets no regular exercise.

    As part of her evaluation, Jim's physical therapist asks him many questions about his health, his pain, and his lifestyle. She uses tests to determine the severity of his condition and assesses the strength of his muscles and the movement of the joints of his back.

    During Jim's first treatment session, the physical therapist:

    • Explains some of the reasons for his problem and discusses the importance of specific exercises to relieve his pain
    • Shows him how to manage his pain by making simple changes in how he performs his daily activities, such the best muscles to use for lifting on the job
    • Performs a manual therapy technique to his low back, which relieves both his back and leg pain
    • Gives Jim special exercises to do at home and encourages him to begin a walking program

    Jim follows the advice of his physical therapist, and, after only 4 weeks, he is free of symptoms. He is committed to a program of regular exercise and activity and makes an appointment to return to his physical therapist in 6 weeks to review his exercise program and make sure that he is staying on track.

     

    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 disk. 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 Orthopaedic 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 disk.
    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
     

    Further Reading

    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.

    Raney NH, Petersen EJ, Smith TA, et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. European Spine Journal. 2009;18:382–391.  Free Article.

    Chou R, Qaseem A, Snow V, Casey D, et al. Clinical Guidelines: Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society.Ann Intern Med. 2007;147:478-491. Article Summary on PubMed.

    Fritz JM, Cleland JA, Childs JD. Subgrouping Patients With Low Back Pain: Evolution of a Classification Approach to Physical Therapy. J Orthop Sports Phys Ther. 2007; 37;290-302. Article Summary on PubMed.

    Roh JS, Teng AL, Yoo JU, Davis J, et al. Degenerative disorders of the lumbar and cervical spine.Orthop Clin North Am. 2005: 36:255-262. Article Summary on PubMed.

     *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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