Rehabilitation of the patient with a herniated disc consists of improving their strength and flexibility while, at the same time, addressing their posture and habits. You must reorient yourself to think about low back problems in a functional way rather than a pathoanatomical way.1 The focus should be on restoring correct posture and normal productivity, achieved by teaching your patients the proper way to engage in their normal activities, while acknowledging the origins of herniations. McGill, in Low Back Disorders, makes four general conclusions from his research that most herniations come from extreme deviated posture, repeated loading of the spine over thousands of times, and the sitting posture in sedentary occupations.2
In order to prevent further herniation and low back dysfunction, the patient must relearn how to sit and stand properly, strengthen weak muscles and lengthen restrictive muscles and fascia. Specifically with disc herniations, you do not want to increase the compression forces on the discs with unnecessary loading, so it’s preferable not to prescribe sit-ups or exercises which put the spine in extreme flexion, or with extreme extension, like "reverse sit-ups" and the "Superman." Instead, you want to teach your patients to do the "Bird Dog" (Fig. 1) and Side Bridges (Fig. 2). Both exercises are two of the safest and most effective core stabilization exercises anyone can do.
Functionally, it is strongly recommended not to do any flexing of the spine immediately upon rising in the morning or after long periods of driving. A patient of mine complained that he was getting back pain every morning after he got up, lasting about 45 minutes. We figured out that he bent over the sink and brushed his teeth every morning, then took a shower. I had him change his habit and shower first, then brush the teeth. Within the week, his low back pain disappeared. One reason you feel stiffer in the morning is because, while lying horizontal for 6 to 8 hours, the extracellular fluid in the body pools in the joints, and movement redistributes it.
There is also the variable of "internal friction" within the joints caused by prolonged static posture, seen in truck drivers and athletes who sit on the bench for long periods.3 Because a high percentage of chronic low back pain is due to a sedentary lifestyle, it is imperative that you teach your patients to sit properly and to take frequent breaks. I have always taught my patients to establish a "neutral posture" while sitting (and standing); but there is also the philosophy that there is no ideal sitting posture and it is better to employ a "variable" posture which reduces the risk of tissue overload.4 It is repetitive immobility, replicated on a daily basis that leads to chronic postural overload and adaptive shortening of the muscles and fascia. Kendall, in Posture and Pain, notes that "normal joint range for adults should provide an effective balance between motion and stability. A joint which is either too limited in range or not sufficiently limited is vulnerable to strain."5
This promotes the need for both a trunk stabilization program and a daily stretching program. Stretching should become a habit, like brushing your teeth. Without any stretching, you and your patients continue to promote a pattern of restricted movement and muscle fatigue. Guyton points out in Medical Physiology that muscle fatigue comes from prolonged and strong contraction of a muscle. This causes the interruption of blood flow, which leads to muscle fatigue due to a loss of the nutrient supply and lack of oxygen.6
I recommend four basic back stretches that should be done daily. They are the Cat/Camel (Fig.3), lateral side bends, and back rotation. These stretches minimize the compressive load on the spine and move the spine through all ranges of motion. The fourth stretch is The Lunge, which stretches the psoas muscle, a major hip flexor and postural muscle. It has a tendency to tighten and shorten with prolonged sitting, leading to weakness, and the Lunge stretch helps to keep it lengthened and balanced. Consider, then, that a key element of your care is the education of your patients. This means that you must address their posture, habits, strength and flexibility, and to make sure they do not engage in any activity which will increase the compressive forces on the spine, be it active or passive.
Benjamin Griffes, M.A., D.C., shares his time between Tarzana and Thousand Oaks, CA, offices when he’s not lecturing or writing on health, fitness, stretching and proper posture. A 1990 graduate of Cleveland Chiropractic College, he also has a Master's Degree in Physical Education/Sportsmedicine from California State University Northridge. He is the author and producer of Stretching for Life products ( www.Stretching4Life.com ) and recently joined Your Best Form ( www.YourBestForm.com ) as Chief Health Advisor.