♪ Bob and Brad ♪
♪ The two most famous ♪
♪ Physical therapists ♪
♪ On the Internet ♪
- Hi folks, I'm Bob Schrupp, physical therapist.
- Brad Heineck, physical therapist.
- And we are the most famous
physical therapists on the Internet.
- In our opinion of course, Bob.
- Hey, Brad.
We're gonna talk about the best exercise
for L4-L5 disk bulge
and L4-L5 herniation.
We're gonna include a couple self-tests,
try to determine whether or not you have it.
Of course, we prefer that you go to a professional
and get it diagnosed properly,
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Brad, take it away.
- All right, Bob.
I'm excited to do this video.
I've had a lot of patients with herniations or symptoms
at this level for all five, including myself.
So, don't get too excited.
It is treatable, often times, not 100% of the times
through therapy.
So--
- You certainly wanna give it a go
because you don't wanna look at surgery right away
unless you have severe weakness.
- Now, if you're watching this video
and you've already had an MRI
and the MRI says you have a herniated
or a bulging disk at L4-L5 disk.
Let's say you've got that,
but you don't have any symptoms down the leg.
Or in other words, there's no pain,
no numbness, no sciatica,
but you may have some back pain with it,
that's pretty good news.
It means it's not too serious.
- We should say right here, Brad,
that actually, they do MRI's on people
that are having no pain whatsoever sometimes
and they'll find disk bulge and disk herniations in them,
especially as you get older.
It's kind of like gray hair, wrinkles,
it's part of the aging process.
The things start to break down.
So, don't panic when you get these diagnoses
because it's very common.
- Right, that it may not be a problem.
Your body's adapted to it.
However, if you are having symptoms down the leg,
then it all makes sense
and we're gonna show you a couple simple tests.
Now, if you do have a diagnosis of this
and you don't have pain down the leg
or any symptoms at all down the leg
and just minor back pain,
at the end of this video, we're gonna show some exercises,
some posturing stuff, that you're gonna want to do as well
even though you don't have the symptoms.
But before we go to that,
let's talk about where is this?
Cause if you understand the anatomy
in some of the tests,
you're gonna do better.
You're gonna have a much better chance of--
- When you have increased knowledge,
it always is a positive thing.
It's gonna make you more likely to have positive results.
- Exactly.
So if you look here at Sam,
L4-L5, here's the lumbar vertebrae.
Here's L5, here's L4, L3 and so on and upwards.
And if you look, here's L5, L4,
so it's your lowest two lumbar vertebrae.
And this yellow...
And this is pretty realistic,
it's about this diameter and the nerves are kinda yellowish,
more whitish actually,
but it comes out here,
then it goes through the pelvis and at this point,
it is part of this sciatic nerve.
There's a nerve bundle, it's just not L4, L5 nerve,
or L4 is actually what we're looking at.
It goes through the bundle and as it comes down,
it starts to separate
and L4 nerve root is what we're looking at
at the L4-L5 disk,
and it comes in through the front of the leg,
the front of the knee, and down and into the foot.
So that just gives you a general mapping of that nerve.
Now if you look here, this red bulge is Sam's model
of a bulging or herniated disk.
This would have to be right here
and you can see where that would push into the nerve,
irritating the nerve and creating those symptoms.
So, the whole goal is to get that bulge out of there
without surgery, which is, not always,
but it can be possible through therapy.
- The body wants to heal and we'll allow it
and you want to show this now, Brad?
- Yeah, so what I wanna show you the dermatome.
In other words, the location you're gonna feel the...
Typically, it's numbness, burning, cold feeling,
all these symptoms are related to a nerve pinch.
And so, we put some green tape on the location
and the mapping of where you're gonna feel it
on the L4 nerve.
So it's in the middle of back...
Now sometimes I have people,
that don't feel anything here,
but It'll come down on the leg, can you turn, Bob?
It goes to the front of the thigh,
over the kneecap, down the front of the shin,
and actually down to the top of the foot.
And that's L4.
L5 actually is part of the big toe
as they kind of get mished and mashed there a little bit.
So, that's where a typical--
- Pattern is.
And so, that gives you a clue where the problem is at.
If we see somebody and they come in and they got pain here,
the first thing we're thinking is L4-L5.
- Right, exactly.
And the next thing that you can...
And this is a real simple test you can do
is a muscle test.
Now, one of the muscle groups
that L4 innervates is your dorsiflexion, the anterior tib.
So, if this is my involved side
and if you can do this, that means the nerve
is not pinched so bad that it turned off that muscle group.
One of the typical tests that doctors and therapists do
is they say, can you walk in your heels like this.
And that's a good indication if L4 is intact.
Now if you do this and your left leg is your good leg,
you can do it easy there, and you try it here
and it just plops down like that,
that means you better go see the doctor.
- Yeah, we a lot of times call it foot slap
if it's not working quite well
like you're walking and you're hearing a slap going on
in the right side.
- Or foot drop.
- Foot drop.
- If that's the case, you need to be seeing a therapist
or the doctor.
- And now remember,
safety first when you're doing this test.
So hang on to something, I don't want anybody falling
while we're testing it.
- You can just go like this,
you don't have to walk and hold onto this.
If you do this and that one foot always drops like that
cause you cannot hold it up,
that's more a serious stage of a nerve impingement.
And so, what I wanna go onto next
is let's say you have the nerve impingement,
but you can pass the manual muscle test
but you have the symptoms--
- Some pain going down the leg.
- Now, we gotta get to the exercise.
Now, we're gonna go to the McKenzie routine.
Robin McKenzie, he started a whole system
treating symptoms just like this
and it's been going on since the 1960's,
it's a whole worldwide system--
- 30 some countries.
- We're going right to the best.
So Bob, why don't you show
one of the most common exercises that works for this?
- So what we're looking for here, by the way,
is we're looking for the symptoms to get better
on the distal, which is the furthest part away
from your body.
So what I'm looking on,
let's say I got pain all the way down my leg here.
What do we wanna see first, Brad?
We wanna see that foot pain go away.
Or symptoms.
- We're gonna do the exercise
that we're gonna show in a second and if all of a sudden,
and I've had this happen with patients.
- Oh, many times.
- They do 10 press-ups and oh,
my foot doesn't feel numb or tingly now.
- I ask them cause they'll go any change?
And no, no and I go, well how's the foot feel?
Well, I don't feel it now,
I don't feel the pain, I don't feel the tingling,
I don't feel the numbness.
- There you go.
- So, that's what you wanna feel.
And if it gets better and better,
it starts going up further and further.
This goes away.
So that's all a really good sign
if you're doing the exercises
and that's what you're going for.
- That's called centralization of the pain
or the symptoms.
And the way you get that,
one of our real common exercises is prone press-ups,
which Bob is gonna do.
- Right so, you usually start off,
you might lay like this for a bit.
Sometimes, we even have your lay-in pillows
to start off with.
But eventually, you get up onto your elbow
and maybe lay there for a little bit
but then eventually, you're gonna do
what we call micro press-ups.
So you're not pushing all the way up yet
because you're just starting these
and you're not sure what your range of motion
of your spine is.
What you don't wanna see is this.
You're so stiff, you're not able to keep your pelvis down.
If you can't keep your pelvis down,
just keep it down as far as you can
and just start some micro press-ups.
- Now, if you do 10 micro press-ups
and all of a sudden the foot starts to feel better,
boy, you are gold.
There's a really good chance
that if you continue this progression,
you're gonna get rid of that leg symptom.
- That's a very good sign
and then eventually you can get up to this point.
You're gonna start seeing some real gains
if you can keep the pelvis down.
Now if you do these and it's not getting better
or if it's even getting worse,
then you need to try some of these advanced things.
- Right.
Should we go to the banana?
- Sure, let's go to the banana.
Let's say I know just for their sake,
let's say the pain is on this leg, Brad.
I would actually shift my hip away from the painful side
and I would shift my shoulders over to the painful side.
So if you're looking at me, I'm making a banana.
- If you look from the top-down,
his body curves so that the painful side
is on the concave side, if you will.
- The concave side.
- There you go.
So, it looks like a banana looking from the ceilIng.
And then in that position,
you actually do some mini press-ups.
- Yep, and I would even,
lot of times, but I maybe lay like this first
and then maybe even get up on your elbows again
just to see how they're doing.
Sometimes you just wiggle back and forth a little bit here.
And then yeah, we try some press-ups again.
Just some micro press-ups, you don't do full ones
in this position.
- Right, exactly.
- And again, you're looking for the same thing.
Is that taking the pain out of the foot, out of the leg?
Is it going up the leg
or is the numbness or tingling getting better?
It doesn't always just have to be the pain.
If anything, it's improving.
Oh, you wanna do roadkill time?
- Yeah, we can throw one more advanced one in there.
- So roadkill, I would actually take the leg
and go like this.
I'm putting my foot against my opposite knee.
- It's kind of hard to see black on black,
but his foot is against his knee here.
- And this is the same thing.
I'm gonna start this way
and maybe just lay here for a bit.
I might lay on my elbows for a little bit.
I might wiggle a little bit,
and then I might try some press-ups like this.
- Bob is saying might do this, might do that,
and that's the way it is, we have to kind of work.
- It's an experiment.
- The whole idea is that these positions
are gonna get that bulge to centralize,
go back in, take pressure off the nerve.
So, be patient with it.
We do have other videos
if you do Bob and Brad sciatic--
- Well actually, we have a whole series on this.
So if you go to bobandbrad.com,
go to the program section, and look for sciatica.
We have 40 videos on sciatica.
And so, we go into great detail on all of this.
- And you can go pick out the video.
Leg pain, difficulty reducing leg pain,
pick that video out and isolate it.
- You wanna go over a few more things though
that you wanna do, Brad?
- Now the other thing, particularly,
regardless of whether you have symptoms,
you have a bulging disk or you have the pain down the leg
is posture.
Seated posture, in particular.
- A lot of this was probably caused by bad posture
in the first place.
The slumped bad posture may have contributed
to your bulging disk.
- Or it could have been the whole start of it, possibly.
For sure, if you have a throw pillow,
that can be helpful, but they're not always the best,
but it's still a step in the right direction.
- Especially in a couch or a soft chair,
like a recliner.
- You're gonna know it's the right thing
cause as soon as you put it in there,
it's gonna feel like oh,
that feels like really good support,
everything feels better.
This is a little bit broad.
If you have an L4-L5, you probably are gonna need
something more specific.
You can start out with a towel roll.
You just roll it up like this,
we put tape on it.
And about this size may be good for you.
And you're gonna put it right about at the area,
at the belt line area.
The position is gonna be critical,
but you'll know.
It's like...
You go back there, it's like
boy, it feels like it's too high,
then just shift it down
and it's like oh, that feels better.
It's that--
- I would highly recommend it for your car
that if your car doesn't have lumbar support
that you can adjust, I would try a towel.
Eventually if that towel feels fine,
pick out a lumbar support off the Internet and...
That's actually a McKenzie roll.
M-C-K-E-N-Z-I-E.
And it's actually...
You wanna get one that fits you.
Like if you're a thin guy,
you probably want a thinner support.
If you're a big person with a large buttock
and a large gap here,
then you want a larger support.
It's as simple as that.
- And they make, there's so many varieties of these.
You have to look at them carefully on the Internet.
There's a little bit of a chance that it's the wrong size,
but they're squishy, they're soft,
and they're more comfortable than a towel roll, typically,
then you'll use that.
Now, the other thing I wanna address is postures
when you're standing or if you're gonna bend over
to pick something up.
- Yeah, cause a lot of...
Again, you can trace the start of a lot of disk bulging
and herniations to poor bending or poor lifting.
Rounding out your back like that.
- So, if you take a stick about five-foot long or so.
We use a Booyah Stik, you could use a broom stick
or anything that's straight,
you'll see what I'm gonna do here.
I'm going to put it...
And I use this with my patients to train them
how to do proper body mechanics for lifting.
- You used to have three points of contact.
He's got a contact on his head,
mid-back, and low back.
- And look how straight I am.
That takes pressure off that bulge.
And I'm just gonna practice squats.
Now the reason I'm doing this,
I'll say do 10 of these three times a day.
And then use that same body mechanics
when you squat to pick something up.
You can go down on one knee,
if you're gonna pick up even a pencil,
because we don't wanna do this
and get that bulge to come back out.
- Yeah, you wanna picture like that stick is in place
even when it's not.
- Right, exactly.
- Visualize it saw.
- So that's actually a bonus
cause we only said one exercise.
But primary exercise is the press-ups,
but the posture and mechanics of bending and lifting
are very important.
- You know Brad and I can fix just about anything?
- Except for--
- A broken heart.
- There you go, Bob, but we'll continue to work on that.
- We'll stick to it, we'll stick to it.