Physical Therapy for Herniated Discs: How To Get Back On Your Feet Without Surgery

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).

A number of factors can place you at increased risk for developing herniated discs.‍

Lifestyle Factors

• 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

• Disc herniations are more common in people who are 45 years old or younger (12). 
• If you have a family history of lumbar disc herniation, you’re at increased risk of developing them yourself (1).
  

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.

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.

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).
  

As discussed, most cases of disc herniation resolve on their own without additional treatment, anywhere from 2 to 12 weeks after pain onset (11).

In cases when the pain doesn’t go away on its own, conservative treatment including physical therapy can often resolve the condition within 3-6 months of pain onset, without surgery (11, 12, 13).

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).

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).

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.‍

Prone Press-Up

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.‍

Piriformis Stretch

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.

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!