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Treating Acute Disc Injuries of the Lower Back

back painWhat are the Intervertebral Discs in the Spine?

They are fibrocartilaginous cushions between each vertebral body and play a major role in shock absorption and mobility of the spine. They are composed of the annulus fibrosus (outer layer) and nucleus pulposus (inner layer). They are a common cause of low back pain.

How are they injured?

Excessive twisting of the lower back and forward bending can cause a ‘torsional’ stress on the disc, resulting in a tear in the annulus fibrosus. A tear will stimulate an inflammatory response and can predispose to an outward bulge of the the inner nucleus pulposus.

Compression injuries result from excessive weight bearing forces and may be initiated by fractures of the vertebrae. This can lead to degradation of the nucleus and increase load on the annulus fibrosus, which produces pain.

What does a disc injury feel like?

  • Acute sudden onset of pain
  • Can be triggered by a relatively minor movement e.g. bending over
  • Pain may be central, on one side or across the lower back
  • Pain radiate to buttocks as a ‘deep seated ache’, hamstrings, or lower leg
  • May get sharp pains down the leg indicative of nerve root irritation
  • Often aggravated by bending forwards and may be eased by leaning backwards

Physiotherapy treatment may include:

Manual Therapy
Spinal mobilisations can help reduce pain and restore movement to the hypomobile intervertebral segments. The choice of technique will vary depending on the location of the pain and on the irritability, amount of tenderness and stiffness in the joints. With an acute disc injury, there is often associated muscle spasm and tightness in the erector spinae, gluteal muscles and quadratus lumborum. Soft tissue techniques aim to ease spasm tension, eliminate taut bands in the muscles and restore normal length and function.

Acupuncture
In the acute stage of disc injuries, gentle needling can be beneficial in reducing pain and muscle spasm but will vary hugely depending on the clients presentation. It may not be indicated if the client is very tense or sensitive. Acupuncture works by reducing pain locally and ‘segmentally’ by inhibiting pain signals travelling to the brain, and by deactivating taut bands or trigger points that are causing muscle tension and tenderness.

Exercise
Exercise is important in the management of acute low back pain as the earlier movement begins, the better the clinical outcomes. In the acute stage, gentle exercise in the direction away from aggravating movements should be commenced as early as possible and should not be painful. It is important to try gently activate the pelvic floor and transversus abdominis muscles as these muscles support the spine. If bending forwards aggravates the pain, extension or leaning backwards exercises should be performed such as lying on your stomach, progressing to lumbar extension by pushing up onto the elbows if pain allows. If leaning back aggravates the pain, flexion exercises or rotations should be performed such as knee to chest, knee rolls, seated knee flexion (knee hugs).

Medications
Non-steroidal anti-inflammatory drugs (NSAIDS) are effective for relieving pain in the short-term and reducing inflammation in acute disc injuries e.g ibuprofen. Long-term NSAIDs are ineffective and may have adverse effects.

Self-Management Advice
Be reassured that movement and activity will not cause harm!
Rest is recommended in the first 24-48 hours, any longer and it can be detrimental.
Avoid movements or positions which aggravate the pain.
Try not to sit for too long, get up for 5-10 mins every hour.
Avoid prolonged poor posture that places excessive strain on your low back e.g slouched sitting.
Use a heat pack over your low back for 10-15 mins.
Avoid heavy lifting and activities that involve bending over and if unavoidable, maintain back as vertical as possible and lower self to level required.
If you have leg pain, try to move in ways which do not aggravate the pain, this may mean avoiding excessive bending, twisting, standing on one leg while dressing (better to sit) or stretching which can further irritate the nerves.
Avoid repeatedly ‘testing’ the back to see if it is still painful.

Progressions
Once the acute phase (up to 48 hours) has passed, with reduction in pain and muscle spasm, we can together plan how to get you back to full function. More intensive treatment can begin, as required, which may include more intensive acupuncture, electro-acupuncture, higher dosage of joint mobilisations, deeper soft tissue techniques and movement and exercise advice. We will guide you through the exercises you should be doing which will focus on stretching, range of motion, strengthening and stability. As you recover, you will be encouraged to stay as active as possible and return to all usual activities as soon as possible.

When are you ready for discharge?
Pain and other symptoms fully resolved.
Full range of movement.
Trigger points deactivated with resolution of taut bands, full muscle length and function restored.
Adequate strength and functional stability.
Return to functional tasks and sporting activities.
Independent with self-management strategies and home exercise programme.

Commonly asked questions:

Do I need to see a GP before beginning physiotherapy?
No, you do not need to see a GP before attending physiotherapy. We will carry out a detailed examination and if we deem your condition requires a GP’s medical attention, we will refer you.

Do I need a scan before I see a physiotherapist?
No, you do not need a scan before attending physiotherapy. If your symptoms are not settling or you develop bladder/bowel function changes, progressive muscle weakness, clumsiness in gait or sensation loss suggesting nerve root compression we would then refer you for an MRI scan.

What happens if I am not recovering with physiotherapy?
If you are not improving as expected within a certain timeframe, we would discuss referring you to your GP and a specialist consultant for further investigations. This would be unusual as most disc injuries recover with high quality physiotherapy.

If you feel you may be suffering from a disc type injury, please call our reception on 01 2834303 and book an appointment with me so I can assess you, make a diagnosis and if indicated, develop a physiotherapy treatment plan with you.

By Hannah Moran BSc Physio, MISCP
Chartered Physiotherapist

References
1.Brukner & Khan’s Clinical Sports Medicine Fourth Edition
2. NICE Guidelines 2016, ‘Low back pain and sciatica in over 16s: assessment and management’.
3. New Zealand Guidelines Group 2004, ‘New Zealand Acute Low Back Pain Guide’

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