L5/S1 Disk Herniation

[Chris]

Kit,

I'm hoping you can shed some light on the following problem. I've been working on trying to get better but have reached a point where my progress has stopped.

Problem

I was diagnosed with a hernia at L5/S1 on the left side. The diagnosis was from a physiatrist looking at the results of a CT scan. At this point I purchased your book Stretching and Flexibility, had access to your book Overcoming Neck and Back Pain, watched videos on your YouTube channel and read some articles on your website all focused on an effort to heal from my hernia. I believe it was quite severe as I could not sit for more than five minutes, I had drop foot and entire numbness on the outer half of my left foot, nerve pain on the bottom of my left foot and a constant aching pain deep in my left buttock and hip among other issues.

I had an EMG and nerve conduction test where the specialist told me that there was nerve impingement on the left side but it was not fatal and the nerves should/would get better.

Treatment

I went to physiotherapy for a couple of months which helped to a point. But through your books and material I made incredible progress. Over several months I've gone from not being able to bend at the hip at all to being able to put the back of my hands on the floor. From doing the lying piriformis stretch with no range of motion to placing my chest easily on my foot. Everything has improved regarding my range of motion, my level of pain is very low but I'm still having issues with (what I believe) are getting signals through my nerves down my left leg. My left leg is still extremely weak. I have difficulty running, jumping rope and I cannot do a single leg calf raise with my left leg where it is no problem with my right leg. When I look up there is also pain in my left lower back.

I have concentrated my stretching on all the piriformis stretches, daily five, the stretch the resembles the front splits but you tuck the tail and extend the front foot out in front (found that one on your YouTube channel specifically dealing with disk herniation) and I rotate between all lower back and leg exercises trying to find the ones that feel the best. I have spent a considerable amount of time stretching from one to three hours a day but now I top off at about an hour.

I believe I have done some things wrong. I am currently on Coach Sommers Gymnastic Strength Training Program. I have found tremendous success with his program coupled with yours. But I believe my efforts on the Arch Body Hold (aka Superman) and Arch Body Rocks may be detrimental to my complete recovery. They were painful at first but subsided over time and I thought my body was adapting, recovering and getting stronger. The Arch Body Rocks eventually caused temporary numbness in my left foot again and some mild back pain. I have since stopped those exercises.

Questions - A Long Read Just to Get to This

1) Which stretches and exercises could you recommend to bring me the rest of the way to full recovery where I can run, jump rope, have the least amount of stiffness/weakness and generate the same amount of power between both legs?

2) What exercises/stretches will hinder my recovery and I should stay away from at all costs?

Thank you very, very much for your help.

Sincerely,

Chris

[Kit_L]

Thanks for posting this here, Chris. The short answer is: stay away from any exercises that trigger the numbness/weakness feeling: that is a sign of impingement, though that impingement can come from other structures in the body than a bulging/extruding disc. Do any exercises that increase movement/mobility in that same area (here I refer to the lower and middle back as well as the hips: the research suggests strongly that, even in a disc event (extrusion or herniation), if you can keep moving during the first six months to a year, the prognosis improves significantly.

The back story: what I will write here is a distillation of all my years of research into low back pain during my postgraduate years. Understand that this was on the back of now about 30 years experience of lower back pain myself (and occasionally, in the past, that low back pain was completely crippling where I was unable to leave the bed I was lying in). In a disk exclusion event, where the nucleus is actually squeezed out through the annulus, the freshly exiting internal disk material is a chemical irritant to any nerve sheaths it happens to press on. In addition, there is the mechanical effect of the material itself physically pressing on the nerves. It's not clear from looking at anatomy text books but there is no spare space in this part of the body.

It is this pressure that gives rise to the numbness and weakness because it disturbs the transmission of nervous impulses from the brain to the periphery. If you can keep moving during these are early periods of adaptation, the exiting this material itself will change in time (the first change is it becomes chemically neutral and the second is that it actually gets resorbed into the body.) I would avoid any exercises that put additional pressure on this part of the body during this period. The arch body hold probably creates a greater compression in the lumbar spine area when done poorly than any other exercise I can think of in the bodyweight realm.

Olivia has just finished recording a 16 minute program where we break down our approach to cueing this excellent exercise and our approach reduces any whole back strain to the absolute barest minimum. With the problems in my own body I can do a decent arch body hold without any strain in the lower back even with the problems in my own body following these cues. As well I strongly recommend you play around with my two programs on my Vimeo On Demand channel (How to sit for meditation, and the Rolling around on the floor class); the reason is that both of those programs explore many, many points and ranges in between the formal poses and you need to explore all of these. Only this kind of experimentation can reveal exactly what needs to be stretched.

On the research front there is a lot more. Research going back 20-odd years shows strongly that extruded discs behave mechanically almost identically to healthy discs. There is more. It wasn't until 1995 when the first research into people with healthy backs was done, believe it or not. What the researchers found was that in the sample of 98 people they examined (using the most sophisticated MRI technology available at the time) 67% of these had the sort of pathology that, they said, had any of these people come to them for an answer to the cause of their lower back pain, what they were identifying in this paper would be judged to be a sufficient cause* of it.

36% of the same sample had these problems at more than one vertebral level; one woman had four completely extruded number discs; but none of these people had ever had back pain. You'll find a reference to this first paper in the back of my book Overcome neck & back pain. These researches have been done a further 11 times and the range of extruded disks and significant pathology in the non back pain suffering population varies from 45% to 70% in all research. In other words (if I have not been clear) extruded disks are normal in the population. If you can get through the first year or so it is very likely that you will have no ongoing problems.

The one exception to this is where the patient demonstrate what are called neurological deficits: these are unrelenting pain in one leg or both, or when the involved is elevated (the straight leg raising test, or SLRT), the elevation causes strong pain to be experienced in the hip, leg or the foot. Another neurological deficit is the loss of dorsiflexion. If while lying on your back you can get the involved leg into the normal range (which we reckon to be 60° from the floor or better), then a wholly exercise-based approach is likely to be effective in time. What the literature does not say however is that all neurological deficits can actually be caused by piriformis syndrome and this is why we devote so much time to this muscle group.

There is a further dimension that the specialist you mentioned above has considered: nerves do regenerate but they do so very slowly and they need stimulation to drive the process. The best stimulation I can think of (now thinking of how you are going to get the strength back in the weaker leg) is to make sure that you exercise barefoot as much as possible and do everything you can to make sure all the information from the sole of the foot is getting back to the brain.

If I were in your position I would do some walking outside in bare feet on gravel or something that really stimulates the bottom of the fleet every day. Last I would caution you during this period to do less exercise rather than more. Following any gymnastics strength training protocol you will know that every exercise is a core exercise: this means that every exercise has the potential to really put pressure on the lower back. So until your back gets better (which will manifest as strength and feeling coming back in the weaker leg) I would recommend reducing the gymnastic strength training exercises until you have full mobility and normal feeling in the leg. In terms of your strength training make sure that all of the leg strength work is unilateral; do twice the work for the weaker leg; and only do as many repetitions of any exercise on the strong as you do on the weaker leg, even though you will feel that you want to do more. In this way the weaker one will get much stronger much more quickly.

My last advice concerns the hip flexors: you must loosen these off to the max. but without hurting your lower back. Those exercises are available on the YouTube channel free (Partner Hip Flexor). The best one by far needs a partner though and I suggest you find one and ask him or her to help you in a serious stretching session once a week.

I dictated this this morning so there might be a few typos; I will come back to this later.

[Craig]

On top of Kit's excellent advice, I would also recommend looking through Todd Hargraves archives, as he has dealt specifically with this topic on numerous occasions. You can start with this article here: http://www.bettermovement.org/2010/back-pain-myths-posture-core-strength-bulging-discs/

You'll notice at the bottom there are even more articles on the subject, I would highly recommend going through them all (and everything else todd has written if you have time!)....no better way to heal then to become properly educated about your own body, and this stuff will really help that!

[Chris]

Kit,

Thank you very much for the advice. When I posted this, I would never have expected such an indepth answer. I will implement what you wrote immediately and will let you know how's it going in a couple of months. Without your material I know I would still be far behind in my recovery where I am now. Thank you again.

Chris

[Chris]

Craig,

Thanks for the link too. I will be reading all of it.

Chris

[Chris]

Thanks for posting this here, Chris. The short answer is: stay away from any exercises that trigger the numbness/weakness feeling: that is a sign of impingement, though that impingement can come from other structures in the body than a bulging/extruding disc. Do any exercises that increase movement/mobility in that same area (here I refer to the lower and middle back as well as the hips: the research suggests strongly that, even in a disc event (extrusion or herniation), if you can keep moving during the first six months to a year, the prognosis improves significantly.

The back story: what I will write here is a distillation of all my years of research into low back pain during my postgraduate years. Understand that this was on the back of now about 30 years experience of lower back pain myself (and occasionally, in the past, that low back pain was completely crippling where I was unable to leave the bed I was lying in). In a disk exclusion event, where the nucleus is actually squeezed out through the annulus, the freshly exiting internal disk material is a chemical irritant to any nerve sheaths it happens to press on. In addition, there is the mechanical effect of the material itself physically pressing on the nerves. It's not clear from looking at anatomy text books but there is no spare space in this part of the body.

It is this pressure that gives rise to the numbness and weakness because it disturbs the transmission of nervous impulses from the brain to the periphery. If you can keep moving during these are early periods of adaptation, the exiting this material itself will change in time (the first change is it becomes chemically neutral and the second is that it actually gets resorbed into the body.) I would avoid any exercises that put additional pressure on this part of the body during this period. The arch body hold probably creates a greater compression in the lumbar spine area when done poorly than any other exercise I can think of in the bodyweight realm.

Olivia has just finished recording a 16 minute program where we break down our approach to cueing this excellent exercise and our approach reduces any whole back strain to the absolute barest minimum. With the problems in my own body I can do a decent arch body hold without any strain in the lower back even with the problems in my own body following these cues. As well I strongly recommend you play around with my two programs on my Vimeo On Demand channel (How to sit for meditation, and the Rolling around on the floor class); the reason is that both of those programs explore many, many points and ranges in between the formal poses and you need to explore all of these. Only this kind of experimentation can reveal exactly what needs to be stretched.

On the research front there is a lot more. Research going back 20-odd years shows strongly that extruded discs behave mechanically almost identically to healthy discs. There is more. It wasn't until 1995 when the first research into people with healthy backs was done, believe it or not. What the researchers found was that in the sample of 98 people they examined (using the most sophisticated MRI technology available at the time) 67% of these had the sort of pathology that, they said, had any of these people come to them for an answer to the cause of their lower back pain, what they were identifying in this paper would be judged to be a sufficient cause* of it.

36% of the same sample had these problems at more than one vertebral level; one woman had four completely extruded number discs; but none of these people had ever had back pain. You'll find a reference to this first paper in the back of my book Overcome neck & back pain. These researches have been done a further 11 times and the range of extruded disks and significant pathology in the non back pain suffering population varies from 45% to 70% in all research. In other words (if I have not been clear) extruded disks are normal in the population. If you can get through the first year or so it is very likely that you will have no ongoing problems.

The one exception to this is where the patient demonstrate what are called neurological deficits: these are unrelenting pain in one leg or both, or when the involved is elevated (the straight leg raising test, or SLRT), the elevation causes strong pain to be experienced in the hip, leg or the foot. Another neurological deficit is the loss of dorsiflexion. If while lying on your back you can get the involved leg into the normal range (which we reckon to be 60° from the floor or better), then a wholly exercise-based approach is likely to be effective in time. What the literature does not say however is that all neurological deficits can actually be caused by piriformis syndrome and this is why we devote so much time to this muscle group.

There is a further dimension that the specialist you mentioned above has considered: nerves do regenerate but they do so very slowly and they need stimulation to drive the process. The best stimulation I can think of (now thinking of how you are going to get the strength back in the weaker leg) is to make sure that you exercise barefoot as much as possible and do everything you can to make sure all the information from the sole of the foot is getting back to the brain.

If I were in your position I would do some walking outside in bare feet on gravel or something that really stimulates the bottom of the fleet every day. Last I would caution you during this period to do less exercise rather than more. Following any gymnastics strength training protocol you will know that every exercise is a core exercise: this means that every exercise has the potential to really put pressure on the lower back. So until your back gets better (which will manifest as strength and feeling coming back in the weaker leg) I would recommend reducing the gymnastic strength training exercises until you have full mobility and normal feeling in the leg. In terms of your strength training make sure that all of the leg strength work is unilateral; do twice the work for the weaker leg; and only do as many repetitions of any exercise on the strong as you do on the weaker leg, even though you will feel that you want to do more. In this way the weaker one will get much stronger much more quickly.

My last advice concerns the hip flexors: you must loosen these off to the max. but without hurting your lower back. Those exercises are available on the YouTube channel free (Partner Hip Flexor). The best one by far needs a partner though and I suggest you find one and ask him or her to help you in a serious stretching session once a week.

I dictated this this morning so there might be a few typos; I will come back to this later.

[Chris]

Hi Kit,

I've been following your advice and have cut out any exercises that causes the numbness and tingling sensation in my left foot. I gave myself about two weeks off from any GST training to give my body some time to heal. I've been incorporating your How To Sit for Meditation and Rolling Around on the Floor sessions alternating between them everyday or every other day. I'm finding some weak areas, especially the side cobra bend where my left side is extended (the same side where my L5/S1 hernia is/was). That was an uncomfortable surprise but I've adjusted the range of motion accordingly.

I'm back into my GST training (minus the exercises noted above). On the stretching and GST training I'm holding back from going to the point of any type of pain or moderate discomfort.

Now I find that something interesting is happening. I will stretch in a particular way (e.g., hip flexor stretch with the rotation and the included quad stretch in particular) or do a GST exercise (e.g., Jefferson curl/stiff leg deadlift with light weight for me at 45 lbs or the stiff leg windmill again with light weight of 20lbs) which will feel absolutely phenomenal but when I'm done I feel a deep moderate throbbing pain deep in my left buttock. A little ice, some ibuprofen and I'm ok. Next morning I'm stiff in that area but once I stretch it out I'm pretty good.

Question: Is this the normal path of recovery with my body slowly adapting or am I completely missing the cues my body is sending me saying this is not a good idea?

Thank you again,

Chris

[Kit_L]

Or that throbbing could be piriformis, too. If you feel sensational at the time, and there is no impingement being experienced, that's a very good indicator that what you are doing is being tolerated by the body. Why don't you try the strong floor piriformis pose to finish with next time and report back?

[Chris]

Hi Kit,

Just wanted to give a quick update saying I'm been spending a lot of time in the lying piriformis stretch and I've noticed a huge difference. My piriformis on the left side is extraordinarily subborn but as long as I keep on it I'm making progress. I'm getting more strength in my left leg and have started the odd light job coupled with my GST. Thank you again and I'll keep you updated.

Chris