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Degenerative Disc Disease -DDD

 

Did you know that up to 85% of the population will experience low back pain throughout their lifetime (1). In fact, back pain is the second-leading reason that patients seek out the help of their medical practitioner. 

 

Much of this type of pain is thought to be associated with the degenerative changes that take place in the spinal discs. It is estimated that the majority of the population has some degree of disc degeneration. Degenerative Disc Disease – DDD is a type of osteoarthritis of the spine.

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Degenerative Disc Disease can occur at any location in the spine but is most common in the neck (cervical region) and the low back (lumbar region).

 

This decreased level of shock absorption by the DDD discs will also result in increased stress upon the facet joints (a gliding joint between each vertebra) of the spine. 

 

Eventually this increased stress on the joints can cause facet joint degeneration (facet arthritis) – which in turn causes considerable pain, stiffness, and dysfunction.

 

Several other physiological changes can also occur due to the flattening of the discs.  This includes the formation of bone spurs and the degeneration of the vertebral body (end plates).  These degenerative changes may eventually cause increased pressure on the spinal nerve roots (nerves that exit from the spinal cord) and may be the reason for pain that radiates down the arm or leg (sciatica type pain).

More About Your Intervertebral Discs

 

It’s worth taking a minute to understand the important role that your intervertebral discs play in your daily motions and activities.

 

The intervertebral discs (fibro-cartilaginous cushions) make up to one-quarter of the spinal column's length, and function as the spine's shock absorption system. Intervertebral discs are designed to:

 

  • Absorb a huge amount of stress.
     

  • Act as a hinge, permitting increased range of motion and mobility in the spine.
     

  • Protect the spinal cord and its nerve roots.

 

The discs lie between, and are attached to, the vertebrae of the backbone. They form part of the front wall of the spinal canal.

 

The discs are made up of two primary layers:

 

  • Annulus Fibrosus – forms the outer edge of the disc and is a strong spherical structure made up of sheets of collagen fibres that are connected to the vertebral end plates (end of the vertebral bodies).
     

  • Nucleus Pulposus – forms the centre of the disc and is a gel- like material that is able to resist great compressive forces.
     

Since these intervertebral discs do NOT have a direct blood supply, they are dependent on the end-plates of the vertebral bodies to circulate essential nutrients. Any problems that cause a decrease in the normal exchange of fluids within this area can lead to a host of degenerative conditions.

 

What is Degenerative Disc Disease

 

Disc degeneration It is very interesting to note that what occurs during the normal aging to spinal discs is not that same as degenerative disc disease (DDD).  Normal aging and DDD are different biological events!

 

Let's review some of the major differences between normal aging and DDD in relationship the intervertebral discs of the lumbar spine.  Updated Material!

 

This recent information comes from RRS education (Dr. Shawn Thistle),  Dr. Thistle, the founder of RRS education,  teaches seminars covering the latest research on a wide variety of musculoskeletal topics. I highly recommend you attend one of his seminars if you are a practitioner. 

 

Hallmarks of the normal aging of the intervertebral discs include:

  • No decrease in the intervertebral disc height, 

  • A decrease in water content in the disc, considerable dehydration by age 40.

  • The fiber orientation of the disc (annular lamellae) becomes irregular, with formation of fissures. 

  • Aging occurs from the inside out. 

 

Hallmarks of the degenerative disc disease in the intervertebral discs includes:

  • Decreases in the intervertebral disc height, which decreased the disc's ability to absorb shock. 

  • Pathological changes in the vertebral endplates. When these endplate changes are observed it an indication that DDD is present. 

  • Changes from the outside in. 

  • The discs become very stiff/weakened, with a impaired load bearing capacity. 

  • Fissures and tears on the outside of the disc (Annulus Fibrous) moving inward, this enables ingrowth of nerves and blood vessels. This ingrowth creates generator of pain.

  • Degenerative Discs when loaded lose fluid quicker than aging discs, consequently lose disc height, and a decreased ability to bear loads. 

Note: Cervical Disc are common. In the 2015 study  (Nakashima et al 2015) 1211 healthy volunteers between the ages of 20 to 70 were examined by MRI for cervical disc degeneration. The results showed that 90% of those examined had bulging discs. What was interesting was that 75% of those in their 20's also had disc bulges.  

Management of Degenerative Disc Disease - DDD

 

Many of our patients do not realize that they have non-surgical options for treating Degenerative Disc Disease (DDD).

 

Though it is true that no one can turn back the clock and completely reverse the degeneration, there is still a considerable amount that can be done. 

 

A combination of manual therapy and exercise can - in the majority of cases improve the patient's quality of life while alleviating  the suffering they are experiencing.

 

There are three primary objectives that we try to address when treating DDD:

 

  1. First…Improvement of joint mobility.
     

  2. Second…Reduction of pain and stiffness.
     

  3. Third…Inhibition of the progression of further joint damage.

 

Time is required to achieve these objectives through therapy and exercise, and in most cases, we have achieved positive results.  Interestingly,  research is showing that (over the long term)  a combination of manual therapy and exercise  is just as effective as surgery (surgical spinal fusion)  at reducing pain and disability for patients who suffer from DDD (2). So if you are wondering if there is research to back up this perspective, the answer is YES!

Why You Need Help In Treating DDD?

 

 

 

Seeing a skilled  practitioner can do a number of things to help you address DDD.  For example :

 

  • The first thing that needs to be done is the completion of a comprehensive physical assessment that includes both standard orthopedic and neurological tests. This helps the  practitioner to ascertain whether or not DDD is the actual problem. 

     

  • Secondly, if required, your practitioner may order X-rays or other diagnostic procedures to aid in this evaluation. This is also a great way to rule out underlying pathologies, and if the problems is DDD it will give you a baseline to determine progression of the condition.

 

  • Finally, once your practitioner knows that he/she is actually dealing with a case of Degenerative Disc Disease (DDD), they can then  setup an appropriate course of manual therapy (such as Motion Specific Release)  in combination with a functional exercise program that is customized to your unique case.
     

Tip:  When you have both back pain and leg pain, and your leg is worse than your back pain you are probably dealing with a disc issue.

Manual Therapy Can be Very Powerful

 

There are two aspects of treating DDD that must be addressed.  These are joint mobility and the quality of surrounding soft tissue (myofascial release).

 

Joint Mobilization/Manipulation

 

Research has shown us that when joints become immobile, as in injury or osteoarthritis, they then become subject to several physiological changes. This includes a decrease in fluid content, which in turn can cause a decrease in the joint-fiber distance within the capsule surrounding the joint.

 

This in turn causes the development of increased cross-fiber linkages, which can then cause adhesion formation in the synovial folds of the joints.

 

These adhesions cause a decrease in the strength of collagenous tissue, which can then cascade into tissue failure, even with diminished tissue loading. (1, 2)

 

We have already mentioned that we cannot turn back the clock.  In addition current medical technology is not at the point where collagen degeneration can be reversed (although there are some promising studies) (5).

 

That being said, we do know that Mobilization/Manipulation can be used to promote several beneficial effects. The objective of joint mobilization is to reverse these negative physiological changes by promoting movement between capsular fibers.

 

  • Research has shown that joint mobilization can gradually cause rearrangement of collagen tissue to increase mobility.
     

  • In addition, joint manipulation can break adhesions within the joint capsule and help to increase the length of capsular fibers. (3)
     

  • Although the best evidence to support this has been focused upon measuring the short-term effects of joint mobilization, clinically,  we have found that it is possible to retain these changes over the long-term, by combining mobility exercises with appropriate strengthening routines.

Evidence for using Spinal Manipulation Therapy (SMT) in Lumbar Disc Herniations (LDH): There is good evidence for the use of SMT in the treatment of Lumbar Disc Herniations.  What we need to define is our objectives in using SMT. 

 

  • Reducing the time frame! We know that within about three years the material from a herniated disc will reabsorb back into the body. So whether type of treatment you use conservative care (SMT, Exercise) or surgery the results will often be similar. On the other hand who wants to be in pain and in a dysfunctional state for up to three years. SMT research supports it use of LDH to reduce pain

  • Increased mobility.

  • Increased disc hydration.