- Okay, Brad and I have seen well over 1,000 patients
with sciatica in our careers;
stick around to see what we have learned.
- It's gonna be interesting. - Right.
(R&B synth music) ♪ Bob and Brad ♪
♪ The two most famous physical therapists on the internet ♪
- Number one, Brad. - Yes?
- We gotta stop making it worse.
- Right.
- So we're gonna demonstrate how you make it worse.
You go ahead and put the cups in place.
- Right, so this represents the lumbar vertebrae, L4 and L5,
and the red ball represents the disc,
and the disc is what bulges into the nerve
creating the pain and symptoms down the leg.
- [Bob] And what does that, Brad? This.
- [Brad] Flexion forward - Right, bending forward.
- in the majority of the cases, right.
- In the majority.
- So when you bend forward,
- [Bob] Repeatedly or at length.
- Ooh.
And the longer I let this go on, the bigger the bulge gets-
- And what does the bulge hit?
- The bulge, well, it could hit a couple things,
but typically the peripheral nerve right into the sciatica.
- The spinal nerve, right.
- It could go into the main canal...
- Right, hit the spinal cord.
- Yeah, that's bigger problems.
- Number two, we want you to start walking
as soon as possible, and generally it's gonna feel better
with short strides and also flat surfaces.
- Right, avoid the hills downhills, uneven surfaces,
and don't walk too far too soon;
build up gradually as tolerated.
- Very good.
Number three, as much as possible we want you to avoid
sitting, because what happens is your spine tends to flex.
So if you're gonna sit, use a lumbar roll.
- Right, particularly if you sit rounded
and not aware of it, so if you have to sit,
sit with good posture and use a lumbar roll,
like we have here; depends on what size you are,
and your chair, will depend on what size lumbar roll to get.
- You might start with a rolled towel.
- Yep.
- And they come in a plethora of sizes, right?
- Right, like this one's pretty narrow,
this one's bigger around,
depending on the size of the individual
or your chair that you're sitting in;
usually the bigger the person uses a bigger roll.
Okay, with sciatica, the symptoms are very common;
pain or numbness or tingling going from the back
down the leg- - Burning.
- Yep.
All the way down into the foot and sometimes into the toe.
- Right.
- The red marks represent where the symptoms are with Bob.
Now when you do the exercises, we're going to demonstrate,
the idea is if you can get the symptoms to centralize;
in other words, the farther away from the back
they need to disappear first and work their way up.
So example, if Bob does one of the exercises
and he has initially symptoms to the ankle like this,
he does the exercises 10 times, he gets done
and that symptoms, those pain is gone.
- [Bob] That's good.
- That is really good, we're happy.
On the other hand, if they stay down here
and the pain gets better up here, that's not good.
We wanna start distal,
that's why it's called centralization.
Keep doing the exercises, modify 'em a little bit
and if the pain-
Yep, the more the pain centralizes to the low back,
this is considered the center.
Oh, there we are over there.
And then, we've had this many times where,
"Oh, my leg pain is gone, but now I feel it in my butt."
Continue exercising. - And it's real subtle.
- Yeah, it is.
Sometimes people forget about it
'cause it's not hurting anymore.
- Right.
- Then I have to ask him, or Bob does, and then they say,
"Oh yeah, nothing there anymore."
- Right.
- And when you get the pain to the center,
like this spot right here, boy, you know you're gold,
things are looking really good.
- [Bob] And eventually that'll go away too.
- Exactly right.
So, that's the whole concept of the McKenzie theory.
- [Bob] Right.
- Is it a theory?
- No. - No, it's-
- Prove it. - What?
- Theorem? I don't...
- No, I'll think of it.
Okay, this is one exercise that we commonly start with
and see how it responds in regards to centralization;
we get in the all-fours position like this.
Quadruped, we call it in the therapy world,
and then we do the cat camel.
So, Bob, I don't know which is a cat and which is a camel,
but he is arching this way and then he rounds that way.
And you do see how your back and leg respond;
if you get some centralization,
this may be one you're continued.
- Or if it makes it worse, stop.
- Then you stop, go on to the next one.
To be honest with you, I have not used this as much,
I will use it some, but usually it doesn't help
early on in the symptoms.
- Right.
- But it's worth a try.
Okay, someone comes into the office, they got sciatica,
I'll ask 'em if they can lie down on their stomach.
They say, "No, that hurts when I lay on my stomach,"
so I'll put two, sometimes three pillows
under their waistline or stomach
and then it becomes tolerable and actually comfortable.
And at that point we can see if the pain
or the numbness, tingling, centralizes.
And sometimes just doing this for 30 seconds,
it'll start to centralize.
Then, as it does centralize,
you remove one pillow...
and drop down.
And it's amazing how this works, because then it's like,
"Oh, some of that pain came back in the leg,"
but you give it about 30 seconds, maybe a minute,
and it starts to centralize again.
If that's the case, you take another pillow away
and then we'll continue on;
we got exercises that will progress the progress.
Progress the progress.
- (laughing) Yeah, there we go.
- (laughing) All right.
Okay, moving on it's very simple,
you're lying flat without any pillows.
And this is typically not on a bed,
unless it's a real firm bed, but then it's simple
as put your fists like this, Bob demonstrate, there you go.
And what that does is elevates the head and the shoulders,
which puts a little arch in the back,
can help centralize that pain more, see how it responds.
- It's from (indistinct). - Yeah.
Okay, we're going to the next step
after the fist under the chin, things are improving
or tolerate the position more.
We continue to rise up, prone on elbows,
and you can see the arch coming in the back,
continued centralization.
- I just prop up.
- Right, now if you have success with any of these,
you're not gonna just do 'em once a day,
you're gonna do 'em up to as many as once every two hours
but at least three times a day.
- Yeah, very critical. - Yep.
As long as you continue to do it
and you have good response with centralization,
you can really go up to eight times a day.
- Yep, great.
- Once the prone on elbows is tolerated well,
then you go to the micro press-ups.
A lot of times in the clinic, I call 'em baby press-ups.
- There we go.
- [Brad] Whatever trips your trigger.
- Hands underneath the shoulders.
- Yes.
But look at this; Bob has his waistline glued, so to speak,
to the table, not this;
we want range-of-motion, the arch in the back.
And when I have a patient, I'll actually put my hands here
to make sure they understand that clearly,
and oftentimes they'll say,
"Oh, that feels like good pressure."
Once the baby press-ups are tolerated well,
it's time to move on to the full press-up;
Bob will demonstrate.
He locks his arms out, he relaxes when he's up there
and we get that nice arch of the back.
- Not doing this.
- Not that, absolutely.
Yep, there you go.
Boom, all the way up.
- All right.
- Moving on, once the full press-up is tolerated well,
doing 10 of those, it's time to add some over-pressure.
In the clinic, the therapist will actually manually
put pressure on here; at home, we teach our patients
to put a belt that goes around the waistline
and trapped under the hands so that it stops there
and a little over-pressure is experienced.
Either a belt that is not shiny works better,
like a canvas belt, or you can use a sheet like this
and that works well; you can improvise
as depending what you have available.
And once that's tolerated well,
you'll do five to 10 of those,
and we're really moving on well
'cause by this time the pain is centralized
and actually going to the point where it's gone
for part of the day.
Again, do these repetitively throughout the day,
as long as they have positive response.
- Very good.
- Now you might find yourself coming along
on the exercises we just did and then you get stuck
and all of a sudden things aren't going,
they're not progressing.
Maybe some pain comes back down the leg a little bit
and you get stuck; and that's not uncommon, it happens.
We do have tricks for that and our first trick,
we call this "The Banana."
So when you're lined on-
- This is the leg pain.
- Okay, go ahead.
So if this pain has the- this leg has the pain, pardon me,
we're gonna take the hips and shift them that way.
Pain's in the left leg, shift the hips to the left.
Are we on that-
- [Bob] To the right.
- To the, yeah, thank you Bob.
We're over there?
So you can see his body is skewed, kinda like a banana,
that's why we call it "The Banana."
And with that, you may have to wait 30 seconds or more,
and if that takes the pain away from the leg,
which we've seen that many times,
you know you're on the right track.
You're gonna do this and then you can start doing
baby press-ups while you're in "The Banana."
You won't go near as high, it's gonna feel different,
but again, we're looking for centralization
from that leg to the central back.
Now you've tried "The Banana," it's not working,
you still have pain in the leg, pain in the back,
it's not improving.
So, again, pain is down this leg,
we're gonna do a technique, this is kind of a weird name,
but it's been called "Roadkill."
(both chuckling)
So it looks like this; you take the painful leg and shift it
up to the side and looks just like this.
And I've had a number of patients,
as soon as they do this, they say-
- [Bob] "Oh, that feels good."
- "It feels a little bit better."
And then you give it another minute or so, or 30 seconds,
and it continues to feel better.
Oh, we're over here, good.
You can add baby press-ups with this;
again, you won't get near as high, but you continue
and I've had people feel good with "Roadkill"
and do press-ups with the "Roadkill"
and it's doing very well.
So that's another option, let's go on.
All right, and if the "Roadkill's" giving you problems,
you can try this; you take a rolled up towel,
so it's about four inches in diameter,
and then you put it under the side that has
the pain or the symptoms.
- Under the pelvis.
- Yep.
So it lifts up here, and you may shift it around
'cause he's kinda got it under his thigh.
- [Bob] Oh, sorry about that.
- That's all right.
And then he's got a, you know, a little twist in here
and actually while you're doing this,
you can shift your hips right to the left a little bit,
looking for the location that makes the leg feel better;
it's amazing how a little shift
can really make a big difference at times.
- Okay, once things have gotten better
and you're able to progress to this,
you could do some standing press-backs.
- And actually, you'll be walking by this time
for part of your therapy distances.
Bob is gonna do it with his hands for support.
- Right on my pelvis, bend back.
- Yep.
And how many repetitions, Bob?
- 10? - Yep.
Usually, you know, sometimes I'll say start out
three to five, but work yourself up to 10;
not more than 10.
- Again, should feel fine.
- Yes, it should feel like a good stretch.
You can take a belt, and I've had a lot of people do a belt
or a towel roll, put it around.
And I like this because you can get real specific;
sometimes if it's low, it doesn't feel so good
and you adjust it to a certain level
and then you hit the sweet spot and then you say,
"Oh, that's the spot," so you do adjust a little bit
and you can do that with your hands as well.
- Again, this will probably be later.
- Yes, yep.
Later on, you're doing fairly well at this time,
and this is where the point you gotta not overdo things.
- Right.
- Like don't go back to lifting and forgetting.
- Right. (laughing)
All right there you go, Brad, 15 pearls of wisdom.
- Right, you know, these are things
that we've done over the years...
- Right, over a hundred years, right?
- A hundred years, yeah,
so take your time with these things.
You're gonna have success,
we know sciatica can be real pain.
- What can we fix?
- Well, Bob, we can fix everything except...
- A broken heart.
- (murmuring) Yeah, whatever.
When we're working on it, we continue to,
and it's an effort.
- We're running out of excuses. (chuckling)
- Yeah, but we won't stop.
Just carry on with your back problem.
(Bob laughing)
(brief synth tones)