151. The Difference Between a Disc Bulge & a Disc Herniation

Welcome back to the Evidence Based Pilates Podcast with your host, Dr. Adam McAtee, physical therapist and passionate Pilates instructor. And we have a very informative episode in store for you today because we are going to get nerdy with a little bit of anatomy and injuries, special populations, etc. Because we are discussing the difference between a disc bulge and a disc herniation. And this is one of those episodes that I wish I was exposed to during my Pilates training shortly after the training, even years after my Pilates training. Because I didn't really understand the difference between these two conditions, as well as how to manage them as a Pilates instructor. So whenever we're talking about a condition, it's an injury, right? However, we want to refer to this. We always need to understand the anatomy and the biomechanics of the tissue of interest. And what we are discussing is the intervertipral disc. By the way, in the anatomy and biomechanics club, if you enjoyed this episode, we take a deep dive in both the intervertiple disc as well as dis bulges, as well as disc herniations, and so much more in the anatomy and biomechanics club. There's a couple hours of content just on this with videos and animations and all the things. But let's go ahead and dive into it here on the podcast. So the anatomy of the intervertipral disc, what intervertipral means, by the way, is intervertipral means between the vertebrae, vertebrae, by the way, means more than one vertebrae. Right? Words, I don't know if you've done this, I've certainly done this, where we kind of make up anatomical words, like vertebras and vertebrae. Those are both words that I've made up in my Pilates career. They're not actual words. Vertbrae means one, and then vertebrae means more than one. So intervertipral means in between the vertebrae. And then a disc is just like a flat round object. So it's the flat round object in between the vertebrae and you have them all the way down the spine. If they were to get injured, it's typically in like the cervical spine, usually lower cervical spine, and then also lower lumbar. Most like disc bulges and herniations happen at L5S1, and then L4L5, which mean that the lowest two segments. But when we talk about the intervertipral disc, someone looking to get your attention on Instagram, TikTok, or a similar social media platform, they'll go up to the screen, right? And they'll look really enthusiastic and they'll have this thing. It's called a jelly donut, and they're going to go ahead and they're going to squeeze it and say, that's your disc. It's classic marketing. Marketing is like you create a problem, and then you exacerbate the problem. And then you tell people how painful it is, you know, if they don't solve it, and then you provide a solution at the end. So at the end of that thing, they're going to tell you how fragile you are and like, why you need to buy their course. However, if you read an academic paper on that structure, they will never refer to the intervertipral disc as a jelly donut. They tend to use the words robust when it comes to the spine in general, particularly the disc, because you have an outer, like the outer ring in which in that jelly donut idea is just like soft, yummy bread. I love done it. Right? So like soft bread, right? That's like the opposite of what your intervertipral disc actually is. It's more like a car tire. If you go up to a car tire and you like poke it, right? Like it's, it's not doing anything to it, right? You have to like, you got to write it for hundreds and hundreds of miles, thousands and thousands of miles to wear it out. Or you need to like puncture it. So you need, you need like a significant injury. Okay? So they can like similar to a car tire. Yes, they can get injured and they get injured all the time. However, it's not fragile. Okay? A car accident could do anything to any body part. Okay? Your pelvis is the most stable structure in your body, aside from the sutures of your skull. But a car accident could have a beyond stable. And car accident can do anything. So trauma can do anything. But the spine is robust. And part of that is on the outer ring of your intervertipal disc, you have what's called your annulus fibrosis or you could also just call it the annulus. What it is is it is about like 20 collagenous rings that are organized obliquely. And that's like a lot of terms, right? Collageness, what's clasian is what's obliquely. So it's like 20 rings of collagen. Okay? And collagen is more than just the stuff that you put in like your coffee. It is the most abundant protein in your body. And this particular type of collagen resists tensile forces. So it resists tension. Okay? Like if you were to pull on it, okay? If you're to pull on like a piece of fabric, it'll eventually get tight. Right? So that's it's tensile strength. Other tissues that have a ton of collagen would be like ligaments tendons, right? These strong robust tissues that can get irritated, they can get injured. Right? Absolutely. But they're definitely not fragile. They see you have about 20 or so. Everyone's a little different collagenous rings that are organized obliquely to create your annulus. Okay? Now the organization of the manial bleakly, it's not like they're side by side obliquely. They're organized at different directions. Okay? So what that does is it allows your your disc to be robust at different angles. So you know what you can do? Stuff like Pilates where you side bend and then you twist, you can flex forward, you can bend back and the disc is robust. Okay? It can handle that at all directions. So we have the outside, which is called the annulus. Then you have almost like a like a like you can think of it as like the top of the jar. Okay? They're called end plates on the top and the bottom. Okay? They cover most of the disc, but they're just they connect the disc to the bone. So your disc is not just like wedged in between the bone. It is connected to it via the end plates. And on the inside is like the precious jewel. That is the nucleus pulposis, which is like a gel like material. So it is viscous. Okay? Viscous meaning I think there's a water in it. It's about 70 to 80% water. And then we have like other substances in there that make it different than water. So what it does is it acts like a fluid. Okay? Because it's a gel. It acts like a very viscous fluid. And it helps create what's called hydrostatic pressure in the spine. Because if you're stand, if you're vertical right now, right? Then you're compressing your spine. And that's a good thing, right? Your spine needs compression. But compression, just like anything else. Okay? The medicine and the poison is in the dose. So like if you fall from a 10-10 story building, like that's too much compression. You're gonna get injured if you're lucky, right? If you're you might die. Because it's compression, right? That's blunt force. Whereas if you are in outer space or if you're on bedrass, you're on earth, then you're having a lack of compression. Yeah? Among other things. So that's also not good. You need a good amount of compression. That's why like running and stuff like that is really healthy, for weight bearing joints. Now in regards to the disc, okay? The introverti-bro disc, if it is considered like healthy, which change that term changes the outline. It acts like a fluid. Okay? It's going to distribute forces throughout the spinal column. Because it creates what's called hydrostatic pressure. Now within the disc, okay? It's really, this next part is a lot easier when I have like drawings that I can draw on a board or I have a 3D model in the anatomy and biomechanics club. And I'm like, "Hey, look at this." And then look at that. And we look at it at different angles. So it's super useful. I'll do my best here. If you were thinking of the disc, behind the disc is going to be your central canal, which is where the spinal cord lives. The spinal cord is like the reason why you can move. Okay? It's important stuff. We have to protect it. So the annulus on the back side is actually thicker than on the front side. I'm sorry, I said that backwards. The annulus on the back side, okay? It is actually thinner. Okay? It's thinner, which is weird, right? Wouldn't we want to protect the spinal cord? The thinner on the back side is thicker on the front. You also have two ligaments, okay? That further reinforces. This is how robust your spinus, okay? You not only have the annulus, it's a little bit thinner on the back, okay? Between the nucleus of poses and the spinal cord, okay? But we also have a ligament on the back side. It's called your posterior longitudinal ligament, okay? So we have this extra reinforcement. However, the posterior longitudinal ligament doesn't, it's not very wide. So it's pretty narrow. It covers the spinal cord. What ends up happening is that of a discord or herniate, which we're about to talk about, that means the nucleus of poses has not only started to bulge outward, but it's starting to, think of it like escaping part of the annulus is tearing. It tends to go to, it tends to go what's called posterior lateral. Posteerial lateral is just a big word. That means to the back and a little bit to the side. And where that is, is where nerve roots are. Nerve roots come from the spinal cord. So in your lower back, good, let's say this were like a lumbar discarniation, if you were to have a symptomatic herniation, which we'll talk about symptomatic and asymptomatic in a moment, if you were to have a symptomatic discarniation in the lumbar spine, in a were post-zero lateral, and it was causing symptoms, it's likely going to irritate the nerve, the local nerve that is in that area, and it's the nerve root. What ends up happening is you could have a condition that is academically referred to as lumbar ridiculous apathy. In the clinic, it's probably going to be called sciatica, in the Plotty Studio, your client's probably going to come in and say, "I got sciatica." They're probably not going to say, "I have L4L5 lumbar ridiculous apathy." And let's start like a medical practitioner, right? So the havoc sciatica, when sciatica actually presents as more caffeine, than low back pain. Now, you may be like, "No, but my client has knee pain with our hip pain with sciatica." It's possible, absolutely possible. However, people will call anything, like any kind of leg pain, they'll be like, "That's sciatica." So it's a really abused term. I had a patient in the not-to-distant past, they were walking and they started to have lateral knee pain. It sounded like illegitimate, a band syndrome, and they were like, "It's sciatica." And I was like, "How's it hurt?" It's like, "Well, when I go down hills, it hurts on the side of my knee." That's classic ITV syndrome. It doesn't mean that's what they had. But they had no signs of sciatica. It was just the belief in the culture of the individual, or in their belief system, that leg pain, it's gotta be sciatica, right? There's nothing else around. So just because your client says they have sciatica, always check in with that, by the way. Check in with that. Just checking in with that could be something like, "Oh, tell me about your diagnosis." Or they might tell you about symptoms, and it's like, "Okay, well, how do you get the diagnosis of sciatica?" And they might be like, "Well, I googled it." Or I was having wine with my neighbor on the porch, and they told me they had sciatica, and that sounded like what I had. So I got a sciatica. That's very different than if someone went in, like, "I had an MRI, I've had this pain, I went through the healthcare system, yeah, yeah, "I got it," and it was a healthcare practitioner that confirmed it. Very different. But as we get back to dysbulge and discreneation, we're gonna continue to intertwine that with sciatica, 'cause one can lead to the next. Now, a dysbulge is not the same thing as a discreneation, and it's important to recognize, okay? It's important to recognize, because sometimes words are used synonymously that are not synonymous, and sometimes words that are different, they do mean the same thing. Like pelvis and pelvic girdle still refer to the same structure. They still refer to the same structure. A dysbulge is not a discreneation. It is not a discreneation, okay? This is, I'll put this paper in the show notes, 'cause at evidence-based Pilates, we use evidence to go ahead and support our claims. And so this is directly from a paper. It's called Lumbar disc nomenclature, version 2.0. Otherwise known as, this is the paper strictly on defining what Lumbar disc conditions are. So they state that a disc bulge, a dysbulge is tissue, okay? Disc tissue extending beyond its normal range throughout the circumference of the disc, okay? So it's basically, it's a wider, okay? And it has to be covering, it has to be wider for more than 25% of its circumference. So if it's just a little bit, that's gonna be more like a herniation, okay? You could think of a disc bulge is more like a swelling of the disc, okay, swelling as in it's just going wider. That may or may not be the right description, but it's not just like poking out a little bit, okay? It's like half of it is wider than the other half. Okay, that would be a disc bulge. But nothing is torn, okay? When I say torn, sometimes they'll use, like they'll use a turn anular fissure. It just means the tear of the amulet. And so it's not that things are like that, we have a fissure or a tear, however you wanna refer to it, it's just bigger. That's all that refers to, right? So this isn't really much of a concern. Okay, a lot of times they're not as symptomatic as other herniations. Okay, and you can have it, like plenty of people have this, especially as time goes on with like absolutely zero symptoms. Okay, but sometimes what happens is that we look at the data for a disc bulge, which I'll share with you in just a moment. And we're like, oh my gosh, like, you know, more than half of 50 year olds have a disc bulge. Therefore disc injuries are not painful, right? But in that, but a disc bulge is not a disc herniation. And with disc herniations, we have three different types of disc herniations. So you have to get more specific with this to have a sophisticated conversation. And it's also important to validate a client who may really be having a significant pain experience and it could be likely from a disc herniation. Now, within that, what is a herniation? A herniation, same paper, defined a herniation as localized or focal displacement. So now we have a displacement again, of disc material beyond the limits of the introvertible space. And it takes up less than 25% of these circumference. These tend to be post-euro lateral. They go to the back and they go to the side. Okay, and that is where a nerve root is. That doesn't mean that they can't go straight to the back. And that's more of a problem. If they go straight to the back, they could just press into the post-eurologist in the ligament, but you could also have an injury there. And then it or not an injury. And all of that is pressing back onto the spinal cord. That's where I'll talk about that in a moment, but that's gonna be more problematic. Now, I wanna get through the three types of disc herniations. First, they're called a protrusion, an extrusion and a sequestration. No, by no means what I ever expect you to memorize that. That's your first time ever hearing it, especially on an audio podcast, but we do have images, models and everything in the anatomy and biomechanics club. And one thing just a side note, I share this all the time with my members, is that anatomy and biomechanics is the long-term game. You gotta play a long-term game with this. I didn't learn this overnight. You're seeing me 16 years into studying. Okay? You're just seeing me after the marathon. (laughs) Okay, it's like you learn it. And then you, I don't know, tell me if this is if you've ever had this. You study anatomy, it's confusing. And then it gets a little bit less confusing and you got it for like a second. Then you try to recall that information, let's say a week later. It doesn't have to be a week, but you do. Let's say a week later and you don't have it anymore. You have to like, you have to like go through that process again. Because learning anatomy and biomechanics is a product of time and repetition. Okay, so these courses that tell you like for like two grand, come in for a week or it's like just a weekend, you know, in-depth anatomy, they're just throwing information at you. I can do that too. Like it's not that hard to just like tell you, it's shit ton of information. But learning takes time and repetition. Okay, you gotta put the time in, okay? And then you gotta repeat it over time. Okay, it's not about learning anatomy. So you're, you know, 20 times smarter in three weeks. How confident do you want to be in your anatomy in a year? Okay, play the long term game when it comes to anatomy and biomechanics. So as we talk about discerniations, there's protrusion, extrusion and sequestration. What this means is there's different grades, right? You can think of it as grade one, grade two, grade three. That's another way, because if those big words confuse you, forget it, grade one, grade two, grade three. Just know they're not actually called grade one, two and three. It's protrusion, sequest, extrude, how's that again? Pro-Trujian, extrusion, sequestration. I hope you're enjoying my imperfections, okay? With that, grade, like the lowest grade is the protrusion, and sometimes protrusions get mixed into the asymptomatic data, which is awesome, right? People can have protrusions and have absolutely no symptoms. However, that's just one type of discernation. There's three others. The other two are not, they're typically not in the asymptomatic data. Now, within that, a protrusion is when the material is starting to go outward, however, it's poking out just a little bit, okay? So the disc material is starting to press out. There may be some annular fizzers, it's pressing out a little bit. By type of an account, the base of the nucleus proposis, that's like, quote, unquote, escaping is thicker than the material. Hit in the material that is going a little further out. Now, an extrusion is where it's basically pushing out more, okay? It's like pushing out more. definitely outside of the intivertipral disk space, but it's still attached. Hey, think of it as like it's hanging on by just a little bit, okay? Whereas a disk sequestration is you have a nucleus proposes that is detached from the intivertipral disk itself and it is a free body floating. Hey, that is like red alert, red alert for your immune system. Your immune system doesn't like like just random things floating around in your body. Okay, but what's important to recognize that it just like a the term disc bulge or discarnation tells you nothing about how it happened. It tells you unless there's like a trauma or something you can try and put like two and two together. It tells you nothing about how long it's gonna take for someone to get better. And it doesn't even tell you if someone has symptoms or if they even need treatment with or without symptoms. Okay, it just it just tells you about structure. Okay, so one of the things that you get better at at over time with the science-based approach is you you make less assumptions. You make less assumptions, okay? That's one of those things where you just gotta put the time in and you gotta go through all of the headaches. Okay, like learning hurts, learning hurts your brain. Just like if you were to do bicep curls, bicep if you loaded enough, not on a reformer, like a actual weights, right? And you're lifting heavy things, okay? Like it hurts. Like could I get another one? (imitates a horn) Right? It hurts your biceps. And then learning hurts your brain. Okay, you're generating new connections. And so sometimes what happens is we learn this data of like, how many people have discarnations. And then a lot of people don't have pain with that. So it's like they don't cause, like we just assume that they don't cause any pain. Or we see an MRI and it's like, well, that disc is pressing on the nerve in this person as back pain. It must be from that. Well, we're assuming that. 'Cause plenty, plenty of people get a dysectomy and then they still have the pain. A dysectomy means that they go through surgery and the disc is removed. So you remove the pressure. But there's symptoms come back. I'm not here to give you like the one answer of solving discarnations. Like that's for the tick tockers. Okay, I'm here to talk about trying to make sense. Make sense of this condition and ultimately help your clients make sense of their experience as well. Now, what is useful to know is that individuals with a disc bulge or a discarnation are much more likely to have back pain. They are much more likely to have back pain than someone who doesn't. So if you take MRIs of individuals and you see some with them, we see some with discarnation, some with disc bulges in some with nothing, right? Like a clean MRI or they don't have those, you know, things, maybe they have other things going on. The individuals that don't have the herniations or the bulges are less likely to report having back pain. However, there's plenty of people with like a massive discarnation and they're great. Like they're your favorite client who did teaser today, okay? 'Cause when we look at asymptomatic scan findings, I'll put this in the show notes too. It's a systematic review, which means that they reviewed all of the literature at the time of the review. And the literature looked at, if we took scans of people, what do we find? Where are I, I'm sorry, if we took scans of people without low back pain, what do we find? So all these people had no low back pain. Okay, this is a chart that you see. I'll see all over social media. So glad it's getting out there. As it relates to dis bulges and discarnations, okay, they looked at this from like individuals from 20, in their 20s, 30s, 40s, 50s, 60s, 70s and 80s, okay? If you have an 80 year old client, they have an 84% chance of having a discarnation. If you have a 50 year old client, they have a 60% chance of having a discarnation. Oh yeah, by the way, your client, they don't have any back pain. No, nothing going down the leg, okay, nothing like that. Okay, now, so a 50 year old has a 60% chance. Even a 20 year old has a 30% chance of a disc bulge. It's not wild, it's freaking wild. Now, here's where it gets different. Okay, that's a disc bulge. That's not a discarnation and discarnations, right? You have protrusion, extrusion, sequestration. Third, not all the same. Sequestration, that, Nucleus proposes is flying around. It's not flying around, it's floating around, as if rebody. Okay, that's not the same thing. It's like the disc is just a little wider. Okay, but everything's on the inside, completely different. Now, for a disc protrusion, okay, rather than having a 50 year old, having a 60% chance, like they do for disc bulge, it's actually only down to 36% chance that you find this on a scan in an individual with no pain. Now, that is what, 24% difference. So that's actually pretty massive. And that's a big difference. And you can look at it this in different ways to say it's less likely, right? So you're more likely, like, it's more likely to be symptomatic than a bulge. However, in 36% of 50 year olds, you find this with no pain. This is where I play in the gray. And in the beginning of my career, I would have thought that that's like a big time pain, no flexion, definitely no flexion with rotation. We're gonna talk about that by the way. Then years later, I would look at this and be like, "Planning people have this with no pain." We don't know if that's causing your pain. So therefore, like I really just didn't, they didn't really, I didn't care very much. I don't know if they didn't care about the person, but that didn't influence any of my decision making. However, even as a physical therapist now, years later, like this, if someone's disc bulge does influence my decision making, but if you came in and you brought me an MRI, I'm gonna set the MRI on the desk and I'm gonna talk to you first. And I would, 'cause you wanna have the presentation of the person, we'll always tell you more than the MRI. 'Cause we see this asymptomatic data all the time. However, what in the asymptomatic data, the start that I'm looking at right now from a systematic review of Rikindu 2015, was they have disc bulge and disc protrusion on there, but they don't have disc extrusion or disc sequestration. So they don't have the more severe herniations on this chart. And I would hypothesize that they're gonna be less likely to find a sequestration in an asymptomatic individual. When that just tells you that there's nuance to this. A client's unlikely to know if they have a sequestration, extrusion or a protrusion. What I would kind of take from this thus far is that it's possible that it could be a contributing factor to their pain, if they have pain. But if they don't have pain, then the presentation is everything. They don't have any pain. And then this is then the asymptomatic data is really powerful to share with them. Now what's also cool is that you can, like, disc can spontaneously regress, which means that we didn't do anything to, to, like, we didn't remove the disc surgically or, like, anything of that nature, non-surgical treatment or no treatment at all. And for disc sequestrations, and that's the worst type, they have a 96.3, sorry, 96.3% chance of, of spontaneous, that you're regressing. That doesn't mean it's healed. That doesn't tell you anything about pain. It just means that if a year from now, let's say there's a disc sequestration, a year from now, we take a scam, okay? We are almost certain that the disc is going to be, regressing. Regressing could be that it was eight millimeters, and now it's five millimeters. But you still have five millimeters, right? It's still not healed. It's just healed, okay? It could be, you know, you could do the same thing with extrusion, protrusion and disc bulge, but without making it dizzy with numbers, the worst, the herniation, the more likely they are to heal. And part of this, I would hypothesize, is that you gotta have like a significant injury to get your immune system's attention when it's that deep, or at least at least at the level of the disc. Yeah, I think of the immune system like a busy manager at a business or a store. You don't tell them about every little problem you're having 'cause they're busy. You gotta solve some stuff on your own. But if there's a big problem, like I don't know, there's a fire at the front door. You should let everybody in power know, including the fire department. So when there's a disc sequestration, that's like there's a fire at the door. The immune system is going to take action. It's gonna take action. But with that, and this is an important part when we talk about symptomatic disc injuries and things of that nature, is that it isn't necessarily the pressure from the disc onto the nerve root, right? That's what TikTok will tell you. Okay, no data is gonna tell you that. It's a, that can be a contributing factor to it. But when the disc, let's say the anionus, there's visitors which just means tears, that's an injury. Okay, when you have a tear on your skin, like a paper cut, you go. through inflammation. It's a natural healing process. Okay? Now, you also go through inflammation at the level of the disc. Okay? That means it's gonna be redness, warmth, swelling. Okay? In all of that, it can be painful. Okay? Papercut painful. Like if you read a paper cut, like a new hand and then someone shakes your hand, oh my goodness. Yeah, don't do that. Right? It hurts my hand. Okay? It could be a similar thing here. And then in addition to that, we could have a, the immune system's response to the nucleus proposes being in the environment. You gotta remember the nucleus proposes, it is encapsulated inside of the anulus. It's encapsulated inside of the anulus or your life. It's not supposed to escape, but if it escapes, that is a new substance to your immune system. Okay? Just like if you were to go, how you feel about vaccinations and stuff, but part of the things with the vaccination, they put in an inactive ingredient to stimulate the immune system, right? So it's something new for the immune system and the immune system responds. That's why it feels like you can have the flu if you get a flu shot. Okay? And so here, right? We're putting something new into the environment, the immune system responds. But sometimes this can hang out for a long time. Okay? And what this really means is that, like symptomatic discreneations can be the combination of like actual mechanical pressure on the disc, but also chemical irritation, which could be the inflammatory response, as well as our immunosystem. The response of the immune system. And so this can absolutely heal on their own. Okay? They can, the worse they are, the better the chances that they can heal. But something important for us is Pilates instructors is like, okay, this is all cool, but my clients still have a back pain that's going down their leg. We call it sciatica and they have discreneations. So what do I do on Wednesday? There are no contraindications to a discreneation. Now, what's important with this is that you're really unlikely that like a movement is going to create more like damage and things of that nature. This is much more about symptomatology. Meaning the symptom that someone is presenting where. You can piss off their disc, or piss off their nerve, right? We'll just call that. Absolutely. You can have them go do elephant. Oh my goodness, they hate it. That doesn't mean elephant's contraindicated. It means elephant is symptomatic. Okay, forward flexion with the leg extended is symptomatic. And this is where anatomy and biomechanics is useful. So I was taught both in physical therapy school and in Pilates school that if someone has a discreneation is probably posterior lateral, meaning it's probably pressing towards the back to the side. So if you flex the spine, you're pushing the nucleus further back. Okay. Which there's some truth, there's some truth to that, right? Like that's kind of how it works. And then you're gonna make it worse. Right, you're gonna make it worse. So it's just gonna push out further. However, when you flex forward, the anulus also gets taught. It also gets tight, it gets tougher. Okay, so if you bend forward, if you bend forward, right, you're gonna stretch everything on your backside. You're gonna stretch your muscles on your backside. Think about it if your back feels tight, right? You bend forward, oh my gosh, that's a stretch. You also stretch all of the ligaments, but you also stretch the posterior aspect of the anulus. Okay, it gets taught. But actually at the front side, the anulus is on slack. Okay, just like if you curl forward, like if you're standing, right? You're passively curling forward. Your abdominals are gonna be on slack. Hey, you're actually subdominus on slack. You gotta contracting it. You're just letting it chill. Okay, it's gonna be on slack. It's a reduction of its normal resting length. Same thing with the anulus. And so where this is actually helpful to recognize is that they've done functional MRIs, which means that they can see what's going on in your body as you're moving. That when individuals extend, it's an acute response, but when they extend the disc, actually, that the disc herniates more on certain people. Some people it's flexion. Some people it's extension. And so we're not MRIs. Like we don't know. How do we know if my client is their disc is bulging more in extension or flexion? Well, which one hurts them? Okay, just meaning that nothing's off the table. Nothing's off the table. And this is where it's useful to do like a spine assessment with a client. And there's some important nuance to this. If someone has a symptomatic disc herniation, it's likely irritating a nerve. And it's likely going to go down the leg, down the path of the sciatic nerve, which is going to go all the way down to the calf and to the bottom of the foot. It could be like hamstrings, right? It could be irritating something else. It could refer to the hip. There's absolutely different things that could be going on. Now, if you have it, let's just assume it's a sciatic nerve and we're dealing with sciatic or more formally, lumbaric lumbaric lumbaric thing. The nerve goes from your lower back. There are, here's the way to think of it. If you want to stretch your sciatic nerve, do a hamstring stretch. However, Dorsey flex your ankle as well. Like you would if you were a biasing your calf. That's how you stretch a ham. That's how you stretch a sciatic nerve. You flex the hip. You fully extend the knee. You Dorsey flex the ankle and then you flex the spine. And just like if you were stretching your hamstrings to start running. Now, like if you had like your foot on a ledge, right? And then you bent forward to reach your toes. That's a sciatic nerve stretch too. So those things tend to irritate the sciatic nerve. If it truly is sciatic, those are tests that we would do in a clinic, again, a physical therapy clinic to assess the possibility of sciatic. Now, within that, that doesn't necessarily mean that bending forward is pushing the nucleus back. It means stretching the nerve irritates the nerve. So sometimes what you can do is you can have someone try and, if they're, if you're suspecting sciatica, they come and they say sciatica, whatever. Like you have them stand and then you can bend down, have them touch, try and touch their toes. Sometimes that just like pisses it off and you got all the information you need, right there. You don't have to have them like continue to do that. You can do the same thing with back bending. Sometimes it's back bending. That does it. I had a patient not too long ago. It was back bending. Like that was not what they, like they need it to build up to that. Okay, flexion was actually okay for them. And then you can also try it with the legs bent and that's a big thing. That's where understanding, that's where like sometimes people be like, oh, you don't need to know anatomy or biomechanics or really anatomy to teach Pilates. And like there's like some truth to that. But you're going to be better at it if you do know an anatomy, you're going to be more confident as well. And also with stuff like this, you can figure something out. So someone comes in and they have a discrepaniation and it's irritating the, on the long the path of the sciatic nerves, they have pain below the knee and the leg pain is worse than the back pain. That's classic sciatica. Like, so if you have them do like elephant it's going to piss off their sciatica. So it would be common to think, huh? I should not flex the spine. Not necessarily, not necessarily. Okay. What if you bend the knee? What if you put the sciatic nerve on slack and then you flex the spine now? How does a cat stretch feel? Huh? What if cat stretch felt great? Well, maybe it's not so much the disc, right? Pushing back and forth. We don't know. We're not a functional MRIs. We don't know. But if we put the sciatic nerve on slack, then it's okay. Because if they're sitting and slouching, right? They're flexing their spine all the time. Okay? And so that's just, that those are just things that are really useful to know. So what I would do is just like have someone flex the next time they're spine with the leg straight and with the legs bent. If they're fully functional, like there's no limitations in terms of I can't gum my knees, I can't, whatever it is, then having them do it upright and standing is great. And then quadruped will also be nice. However, you could do it, see it instead of quadruped as well. But sometimes sitting, you're compressing the nerve just by sitting. So sometimes that gets bothersome. One more thing here that is useful for you. There's a concept called centralization in which we're looking to you to which we want to achieve over time. And that means that the symptoms are either gone or that the symptoms that were once in the calf, they start to go up closer to the spine. So if it starts with like calf pain and then like two months later, someone has to say, "Adeca," but it's like on their bite more, then that's a really good sign. That's a really good sign. We want to bring the symptoms back up towards the spine. There's a concept called directional preference, which isn't a treatment to like cure somebody or speed up the healing, but it can improve quality of life because it's a short term symptom modification strategy. What all of that means is that you can make someone feel a little bit better or move a little bit better by trying something. And it's not dangerous. And it takes like a minute. Do it. Right? Low cost high reward. It's called directional preference. You can do this. It's the same thing that I mentioned where you would just be standing or seated. I-- when we do the literature, I interpret it that you could bend the spine. in any direction and try it. I have found no value in doing rotation or side bending. I clinically have just learned like just deflection or extension. But you can try it in any direction. I've just wanted to share that where I have found flexion and extension to be the most useful. So what you do is you just have someone bend down and then go up and you repeat it. Okay. So it's like you bend down touch your toes come up. Okay. If someone's like someone's like that didn't really piss off their symptoms. Try it again. Try it again. For some people it's underwhelming like you don't find anything. Right. But for other people I did this not just long ago. Someone came in coming in with like some it was actually anterior thigh pain and then low back pain. Right. And I was like kind of wonder if directional preference would work to this person. When they bent down the first and they bent down there were like right around their knees. And as we kept doing it, they were down to their feet. Okay. It was massive and they were like, wow, I didn't. Wow, I just had to go like a couple times and then I just feels better and better. Right. So for them back bending was not that case. Not like back bending. Right. But forward bending was great. So what that did was like one, I give him a strategy. Right. And I also gave him some education to say like bending is safe. Even though the internet, you know, what does not like for them, they read stuff on the internet didn't agree. So it was a helpful thing to go ahead and just give a little bit of education. But then also a guidance treatment. In this case it was a physical therapy clinic. So I was doing like table stuff. But in Pilates, right. It's like, huh. Knees stretches would probably be fine for this person. Or maybe you're your inflection of the spine. You're kicking back and in. Okay. Cat stretches are cool. Right. Other other flexion based exercises where the legs are bent. Right. Could be good. Maybe you don't do short spine with like the legs straight up towards the ceiling. But you could do like frog where you press out. Right. It's a straight legs. And then you bend the legs in and let the spine flex a little bit. So what it just does is it gives you a framework to be like flexion equals good. Right. That doesn't mean avoid all extension. But extension is like save for a rainy day. Right. Like we're going to not necessarily do that today. Or if we do, we're just going to proceed with caution. Right. But flexion is like cool. And then of course you can try lateral flexion in rotation as well. But with that said, there is no, there's no superior exercise for sciatica. That's why I'm not here talking about you need to do this and this and this with your sciatica client. There's also no contra indications. And at first, that can be like underwhelming to be like, I listen to this whole thing and I don't even know what to do. But then another way to look at this is like one, I hope this provided a helpful framework and was educational for you. If you really value video, there's the anatomy and biomechanus club. And also it like nothing's off the table. Okay. But the 68 year old sedentary individual who comes in with some like with like maybe a discarnation and sciatica and it seems like that could be contributing. They're probably going to need a different dose of exercise. I think cat stretch. Then like the triathlete who's like, I'm going to conquer this. Right. And they're just like, they're just going to like exercise their way out of this. They're going to need like a different strategy. Yeah. So there isn't a cookie cutter way to work with sciatica. You are going to be, you are going to be really guided by the symptoms of the individual. And that's not only the symptoms then, but also the symptoms the next day. Right. Like how did you feel tomorrow? How did you feel the next day? Because you want to figure out the dosage. And like, what's where's their Goldilocks on? And we want to go ahead and help them manage their symptoms as nature takes care of the healing at the end of the day. But with that said, if you enjoyed this podcast, you would absolutely love the anatomy and bio mechanis cub. And you can go ahead and hang out with me and the entire evidence based Pilates community, which is over 450 like-minded Pilates in structures. And you can go ahead and get a two week free trial with the link in the show notes. And for a limited time, the anatomy and bio mechanis club also comes with a full Pilates club membership and unlimited mentorship from mean directly. So if you would like to go ahead and have a sense of mentorship, a sense of community, and have full access to the anatomy and bio mechanis club and the Pilates club, it would just be too much content to tell you all about it. You just do just try it for free. See if it's for you. And you can reach out to me when you're in there, I'll walk you through it, get to know you, say hi, and all the things. With that, thank you for being an incredible member of this community, checking in with the podcast, and I'll see you in the next one.