The therapy always depends on the degree of disc herniation. For example, after an operation must be treated with very simple exercises / methods. From week to week there is then a steady increase in stress.
However, if there is no indication for surgery, the patient does not start therapy at “O”. The patient can start more quickly with more complex exercises under load.
- In the further course of this article you will find the individual stages of healing after a disc surgery, with the respective allowed movements!
- Pelvis and lumbar spine mobilization
- Strengthening of the abdominal muscles
- Strengthening of the back muscles
- Strengthening of the front trunk muscles
- Strengthening of the rear muscle loop
- Mobilization of the spine
- Eagle Swings
- Rowing
- Lat Train
- Cervical spine rotation
- Cervical spine retraction/protraction
- Lifting the head from the double chin
Physiotherapeutic intervention
Inflammation phase: The healing phase is decisive for the treatment of a herniated disc. In the first phase, the inflammatory phase (day 0-5), inflammation and pain mediators are released in the affected area. This results in pain and a restriction of movement due to a protective tension of the musculature.
Measures in this phase are therefore relief through traction (possibly also in the sling table). This results in an enlargement of the intervertebral foramina, which reduces compression. The change between traction and normal position of the vertebrae, i.e. pressure and traction, stimulates the metabolism, which allows the edema in the area to be reduced.
Pain-inducing substances can also be removed. The position of the patient is determined according to his pain-free position and can be prone, lateral or supine. In the case of a lumbar disc herniation, the physiotherapist hooks onto the pelvic shovel and pulls, or depending on the position, pushes it towards the foot, while the other hand fixes the upper spine area (cross grip).
A stroke-free mobilization of the BWS in lateral position in combination with a mobilizing massage provides for a damping of the sympathetic nervous system and thus for an improvement of the trophic (nutrition through improved metabolism) and pain in the area. In general, it is attempted to activate the metabolism by careful massage in the affected area in order to reduce reflective hypertension. In addition to massage, lymphatic drainage, heat applications and gentle mobilization of the spine also help to remove pain and inflammation mediators.
The mobilization takes place without strokes and can cause pain at the beginning, as the patient is brought out of his or her comfortable, gentle position. In the further course of the healing phase, however, it is important to achieve a normal range of motion. The patient is also instructed to support his herniated disc with certain positioning and to slide back into the original position.
In case of a dorsal-medial herniated disc, an underlay of the abdomen should be done and in case of a dorsal-lateral herniated disc, a half-side position on the unaffected side should be chosen and a carpet pad on the abdomen should be done. In which direction, the herniated disc has occurred, the doctor can see on the appropriate imaging procedures. The pain can also be reduced by the return of the disc material.
The patient should also be instructed to help himself. This can be done by using relief positioning (step positioning), which the patient should take at home, as a prevention but also in case of acute pain. The patient can draw in warmth as a support.
In addition, the patient is practiced in physiotherapy to stand up and sit down correctly and generally the transfer from supine to standing position. This is important so that no further damage occurs and the patient can protect himself or herself in the long term. Healing phase: In the 2nd healing phase for a herniated disc, the proliferation phase (5th – 21st day), the new formation of tissue continues to increase and scar tissue is formed.
Slowly the load capacity of the intervertebral disc increases again. In this phase, physiotherapy shows itself through increased mobilization of the spine. The movements continue to take place in the pain-free area and the areas of the spine that have become stiff are mobilized in a targeted manner.At the beginning, a stroke-free position should also be selected, whereby the goal in the further course of physiotherapy is improved mobility of the head and pelvic joints even in loaded positions.
The treatment of the neural structures will also be started. A longer relieving posture can lead to small adhesions around the nerves, which are carefully released by nerve stretching. The lower extremity is treated according to Lasegue, the patient lies in a supine position, the physiotherapist lifts the leg up to the pain threshold, gets out of the pain easily (if the patient has a pain below 70° the test can be evaluated as positive) and holds the leg in position.
To achieve the extension, the physiotherapist either lets the head bend or presses the foot into the dorsal extension. This extension is for the sciatic nerve, the nerve that innervates the entire posterior leg chain. For the anterior femoral nerve, the patient lies in the prone position, the physiotherapist bends the knee as far as possible without moving the hip away, this position is maintained and can also be mobilized by extending the head backwards or the foot in plantaflexion.
Furthermore, the therapist appeals to a good behavioral pattern of the disc patient in everyday life. The rules of behaviour when getting up and changing position in bed are repeated and consolidated and a correct bending is worked out. Furthermore the patient is instructed to feel and correct his posture.
He should pay attention to how the head, thoracic and pelvic muscles are positioned above each other, which can be supported by a mirror. A good perception of the own body is essential in the post-treatment of a herniated disc and also as a prevention. In the proliferation phase, light strengthening exercises can now be added, whereby exercises with long levers and heavy load should be avoided.
The deep stabilizing muscles, such as the Multifidus or Transversus abdominis muscle, are particularly important in this phase. In this phase, exercises in water are often built in to minimize gravity. 2nd exercise For the abdominal muscles the starting position remains the same, one leg is lifted closer to the abdomen and the hand on the same side grabs the knee and pressure is built up equally from the hand and the knee.
Then change sides. Each side should be held for 20-30 seconds and repeated 10 times. The oblique abdominal muscles can also be activated by pressing crosswise.
During both exercises, however, it is particularly important to pay attention to any sensation of pain and to discuss this with the physiotherapist, as the exercise can be modified. No pain should be caused by the strengthening exercise. In addition to the isometric exercises, exercises from the PNF treatment scheme are also available.
3rd exercise The patient can lie in a stepped position and the patient works with his arms. The direction of movement of both arms is upwards and outwards and the physiotherapist only gives a guiding resistance to avoid too high a load on the lower spine. The patient tries to keep the tension in abdomen and back and moves the arms.
If pain and hypertonus of the musculature are still present, soft tissue techniques can be used to support the patient. 2nd exercise For the abdominal muscles, the starting position remains the same, one leg is lifted closer to the abdomen and the hand on the same side grabs the knee and pressure is built up equally from the hand and the knee. Then change sides.
Each side should be held for 20-30 seconds and repeated 10 times. The oblique abdominal muscles can also be activated by pressing crosswise. During both exercises, however, it is particularly important to pay attention to any sensation of pain and to discuss this with the physiotherapist, as the exercise can be modified.
No pain should be caused by the strengthening exercise. In addition to the isometric exercises, exercises from the PNF treatment scheme are also available. 3rd exercise The patient can lie in a stepped position and the patient works with his arms.
The direction of movement of both arms is upwards and outwards and the physiotherapist only gives a guiding resistance to avoid too high a load on the lower spine. The patient tries to keep the tension in abdomen and back and moves the arms. If pain and hypertonus of the musculature are still present, soft tissue techniques can be used to support the patient.Consolidation and remodelling phase In the 3rd and 4th phase of wound healing (consolidation and remodelling phase 21st day- 360th day) the existing scar tissue is transformed into more stable connective tissue.
From this phase on, it is important that the stress stimuli are consistently increased to regain the physiological resilience of the intervertebral discs. The previously learned patterns of behavior in an acute herniated disc are slowly replaced by normal movements to strengthen the newly formed tissue. Circulation-enhancing measures can still be applied as needed.
The main focus in this phase of wound healing is to increase training. All directions of movement should be trained again and especially the former trigger for a herniated disc should be trained to avoid a recurrence. Besides the training, improvement of neural structures and improvement of mobility, which are still part of physiotherapy/therapy, especially the strength training is increased.
The coordinative demand can be increased and dynamic aspects can be included. However, the prerequisite for this is freedom from pain and the achievement of complete freedom. Thereupon all exercises can be performed on machines, but care must be taken that a moderate weight is used and still no extreme movements.
Cervical spine The healing phases mentioned above are generally related to the intervertebral discs, but certain examples are related to the lumbar region (lumbar spine). For the cervical and thoracic spine, however, the measures remain similar but the execution and positions change. For the cervical spine, the supine position is particularly suitable.
This allows the patient to place his head in the hands of the physiotherapist and to release the muscle tension. The physiotherapist can thus carry out a careful traction or stimulate the metabolism with light movements in the pain-free area. The physiotherapist will also notice increased muscle tension in the neck and shoulder muscles and also in the area of BWS.
On closer examination, trigger points (points at which the myosin and actin filaments of the muscles become too tightly interlocked) can also be found, which can be released by the special trigger point therapy. The physiotherapist keeps the point pressed until a pain point of 7 is reached (pain scale 0 is no pain and 10 is a pain that is no longer bearable). This point is held down until the pain subsides.
Fascia therapy The global muscle tensions in a herniated disc are improved by simple massage grips, the main aim being to stimulate the blood circulation in the area. Due to the long bad posture or one-sided strain before the herniated disc, the fasciae in the area of the back can stick together. The fasciae are loosened by deep fascial therapy, whereby the physiotherapist works either with aids or with his own thumb for a better feeling.
In doing so, he pulls the fascia along with light pressure in the area of the muscle transitions or muscle tendon transitions. This results in a ripping pain and an immediate reddening, but this proves the good effect of the method. Nerve stretching The nerve stretching takes place in the supine position.
Decisive are the nerves N. Medianus, N. Radialis, N. Ulnaris, which can be stretched by adjusting the shoulder, elbow, hand and head accordingly. The patient can also be instructed to stretch himself. A herniated disc of the BWS is rather rare, since these are well supported by the ribs and thus increased stress can be absorbed.
More often in this area, blockages of the ribs occur. However, if a herniated disc is still present, the healing process can be supported by measures to promote blood circulation (massages). Nerve stretching The nerve stretching takes place in the supine position.
Decisive are the nerves N. Medianus, N. Radialis, N. Ulnaris, which can be stretched by adjusting the shoulder, elbow, hand and head accordingly. Here, too, the patient can be instructed to stretch himself. A herniated disc of the BWS is rather rare, since these are well supported by the ribs and thus increased stress can be absorbed.
More often in this area, blockages of the ribs occur. However, if a herniated disc is still present, the healing process can be supported by measures to promote blood circulation (massages). In the early phase, only stabilizing, isometric exercises for the spine should be performed.1st exercise Lumbar spine Patient lies on his back with his legs turned up, toes are pulled towards the body, the patient breathes deeply into the abdomen, when breathing out he tilts the pelvis so far that the lower back is completely on the floor, thereby shortening the lower back.
This exercise can be intensified by alternately stretching the leg, whereby it is important that the patient can hold the tension in the abdomen and back well. 2nd Exercise Lumbar Straight Abdominal Muscles: Supine position, one leg is lifted closer to the abdomen and the hand on the same side grabs the knee and a pressure is built up equally from hand and knee. Then change sides.
3rd Exercise Lumbar spine Inclined abdominal muscles: bring hands and knees of opposite side together, build up pressure As the healing process continues, the exercises can be increased. It is important that the exercises do not cause pain. 4th exercise lumbar spine patient lies in supine position and builds up the tension as above, instead of releasing the tension he now lifts the pelvis completely and builds a bridge.
He also pulls the shoulder blades to increase the tension in the entire back. He holds this position for about 30 seconds. (In an even later phase of healing the exercise can be intensified by alternately pulling the leg or by standing with legs on a Pezzi ball) 5th exercise Lumbar spine Patient lies on the stomach, elbows are adjusted under the shoulder joints, knees remain in the upright position at the beginning.
The patient pulls the navel inwards so that the pelvis automatically tilts a little and then lifts the pelvis. He now forms a straight line (forearm support) and tries to hold it for 20 seconds. In the further course of time the duration can be increased and later the knees can also be released from the floor.
6th exercise Lumbar spine Patient lies in prone position, feet are upright, arms are stretched and then the shoulder blades are contracted. Increase the exercise: Arms are held stretched and one leg and one arm are raised crosswise 7. Exercise Lumbar spine quadruped: Patient stretches leg backwards.
He makes sure that the navel remains pulled inwards and that no hollow back is created. The exercise can be increased by bringing opposite arm and leg together under the abdomen and stretching them both away. 8th exercise lumbar spine supine position, patient bends one leg 90° and stretches the other leg so far that he does not yet feel any pull in his back and then changes sides (cycling) In the further course of the training phase / physiotherapy exercises in the lateral position (lateral support), exercises on the Pezzi ball and more complex holding exercises can be added, but these should be done under close observation of the trainer or physiotherapist.
More exercises can be found in the articles
- Physiotherapy for a LWS syndrome
- Exercises for a herniated disc
- Physiotherapy exercises back.
As mentioned above, a herniated disc of the thoracic spine (BWS) is rather rare, which is mainly due to the good support of the ribs, but also to the little movement that occurs in the segment. In the following, general mobility exercises and strengthening exercises are shown. 1. exercise BWS four-footed stand: patient emphasizes a hunched back by simulating a cat’s hump and then lets himself fall completely into overextension 2. exercise BWS forearm support (see above) 3. exercise BWS turtle: patient stands leaning on the table, hands on table, shoulder blades are pulled together and the head is pushed upwards 4. exercise BWS turtle: patient stands on the table, hands on the table, shoulder blades are pulled together and the head is pushed upwards 4. exercise BWS turtle: patient stands on the table, hands on the table, shoulder blades are pulled together and the head is pushed upwards Exercise BWS prone position: Feet are up, arms are stretched and then the shoulder blades are contracted 5.
Exercise BWS rowing: Seat, elbows are moved close to the upper body and shoulder blades are contracted 6. Exercise BWS lat pull: Seat, rod in hands, arms are stretched upwards and the rod is pulled down behind the head Further exercises can be found in the articles:
- Exercises for a herniated disc
- Physiotherapy for a slipped disc in BWS
The short neck muscles can be trained mainly by isometric exercises.1 Exercise Cervical Spine Patient rotates head as far as possible, hand to cheek rotated away, tension with hand and head against each other 2 Exercise Cervical Spine Double Chin Movement (Retraction) and push out (Protraction) of head forward: The retraction can be done with the hand. (The same movement can be performed in supine position with a sand cushion under the head, holding the final position for a few seconds) 3 Cervical Spine Turtle Exercise (see above) 4 Cervical Spine Supine Position Exercise: Head is lifted straight and held for a few seconds (can be increased with time) Further exercises can be found in the articles:
- Herniated disc in the cervical spine
- Exercises for a herniated disc
- Cervical spine mobilization exercises
- Physiotherapy for nerve root compression of the cervical spine
