Picture this - a staggering 85% of our global family will at some point feel the gnawing discomfort of lower back pain, the relentless visitor that often invites itself into our lives unannounced (1). It's a painful truth, and it's one that secures lower back pain's position as the second-highest contender for reasons we knock on our doctor's door.
Now, take a journey with me to the very heart of this common affliction - our spinal discs. These intricate structures hold the dubious honour of contributing to our collective discomfort. You see, much like an old family heirloom passed down through generations, most of us have inherited some degree of disc degeneration. In the medical world, this shadowy figure is known by its formal name - Degenerative Disc Disease (DDD).
Article Index
Anatomy & Biomechanics
Examination & Diagnosis
Treatment
Exercise
Conclusion & References
Intro to Degenerative Disc Disease (DDD)
Degenerative Disc Disease (DDD) can materialize in any segment of the vertebral column, albeit it predominantly exhibits in the cervical (neck) and lumbar (lower back) regions of the spine.
Intervertebral discs serve as shock attenuators between adjacent vertebrae in an optimal physiological condition. Yet, with the onset of DDD, these discs undergo pathological alterations, resulting in an immediate diminution of their shock-absorbing capacity.
This degenerative process may precipitate a cascade of serious medical implications. For instance, there could be an accelerated deterioration of the facet joints, a clinical scenario synonymous with osteoarthritis. Additionally, individuals may experience a constellation of symptoms encompassing spinal discomfort, inflexibility, and functional impairment due to compromised spinal biomechanics.
The condition can also stimulate the formation of osteophytes, or bone spurs, an adaptive response to increased biomechanical stresses on the spinal column. Furthermore, there could be a progressive degradation of the vertebral body, particularly the end plates, leading to amplified mechanical pressure on the spinal nerve roots.
Intervertebral Disc Anatomy and Physiology
Let's momentarily divert our attention to understanding the pivotal role that your intervertebral discs play in orchestrating routine biomechanics and locomotion.
Intervertebral discs, anatomically characterized as fibro-cartilaginous structures, account for nearly a quarter of the spinal column's overall length and function as the primary system for mechanical shock absorption within the spinal architecture.
These biomechanical entities are designed to:
Withstand extreme magnitudes of biomechanical stress and load.
Operate functionally akin to a synovial joint, thereby facilitating an augmented range of spinal motion and flexibility.
Provide a protective envelope to the spinal cord and the emerging nerve roots. These discs are anatomically located interposing the vertebrae and are securely tethered to them, thus contributing to the formation of the anterior wall of the spinal canal.
From a structural standpoint, these discs predominantly comprise two components:
Annulus Fibrosus: This component forms the external boundary of the disc, characterized by a sturdy annular assembly of multi-directional concentric collagenous lamellae, which are intrinsically interwoven with the end plates of the vertebrae (the terminal aspects of the vertebral bodies).
Nucleus Pulposus: This component represents the central core of the disc, primarily comprised of a mucoprotein gel substance with high water content, specifically engineered to resist substantial compressive loads. Considering the avascular nature of these intervertebral discs, they rely primarily on the diffusion process across the cartilaginous end plates of the vertebral bodies for their metabolic requirements and nutrient exchange. Any pathophysiological alterations that inhibit the standard osmotic fluid exchange within this region can instigate a spectrum of degenerative pathologies.
Understanding the Complexities of Degenerative Disc Disease
When considering disc degeneration, it's fascinating to note that the alterations occurring in spinal discs during the ordinary aging process differ considerably from those witnessed in Degenerative Disc Disease (DDD). Astonishingly, physiological aging and DDD represent two distinct biological processes!
To illuminate this further, let's explore some of the differences between the physiological aging process and DDD, particularly in relation to the intervertebral discs in the lumbar region of the spine.
We owe this enlightened perspective to the educational endeavours of RRS (Dr. Shawn Thistle), the organization's founder. Dr. Thistle organizes and leads seminars that encompass recent research across a wide range of musculoskeletal topics. For healthcare practitioners, I strongly advocate for attending one of his enlightening seminars.
Hallmarks of normal intervertebral disc aging:
There is NO diminution in the height of the intervertebral disc. A decrease in the vertebral disc's water content occurs, culminating in significant dehydration by the fourth decade of life.
The fiber orientation within the disc becomes irregular, and fissures begin to develop. The aging process progresses from the center outwards, implying that the disc's nucleus begins to age prior to the external layers.
In contrast, Degenerative Disc Disease involves a unique set of changes and impacts that can result in pain, discomfort, and restricted mobility. Recognizing these differences is vital for healthcare providers in the accurate diagnosis and treatment of spinal disorders.
Critical signs of Degenerative Disc Disease (DDD) within the intervertebral discs include:
A significant decrease in intervertebral disc height, which undermines the disc's shock-absorbing capability.
Pathological modifications occuring in the vertebral endplates. The existence of these changes serves as a definitive indicator of DDD. In opposition to normal aging, DDD instigates changes that originate from the periphery and progress inward.
Discs become substantially rigid and weak, with a diminished capacity to accommodate loads.
Fissures and tears initiate at the disc's outer region (Annulus Fibrosus) and advance inward, promoting the ingrowth of nerves and blood vessels.
The inward proliferation resulting in the establishment of pain generators.
Under loading conditions, discs affected by DDD loosing fluid more rapidly than aging discs, resulting in disc height reduction and a decreased capacity to bear loads.
In essence, DDD represents a more advanced and rapid variant of disc degeneration compared to normal aging, yielding prominent structural alterations and often leading to substantial pain and functional constraints.
A Word of Caution:
The incidence of Cervical Disc Degeneration is high. A 2015 study by Nakashima and colleagues evaluated 1211 healthy volunteers aged 20 to 70 for cervical disc degeneration using MRI. The results revealed that an astonishing 90% of participants exhibited disc bulging. Remarkably, even among those in their 20s, 75% demonstrated disc bulges. The potential for vertebral disc damage in individuals as young as their 20s is frequently underestimated, despite this study's clear demonstration of its possibility. (Thank you Dr. Thistle)
Diagnosis
The following video demonstrations cover typical orthopedic, neurological and vascular examination tests that we administer to our patients suspected of having Degenerative Disc Disease. These tests are crucial for assessing the physical and neurological aspects of the patient's condition. They provide insights into the structure and function of the spine, the nervous system's health, and potential vascular issues that could be contributing to the patient's symptoms. Please note that these tests are performed in conjunction with diagnostic imaging as needed, which further aids in a comprehensive and accurate diagnosis.
Orthopedic Testing
This video delves into some of the typical causes of lower back pain and illustrates how to diagnose them employing orthopedic examination techniques. Orthopedic testing is pivotal in the diagnostic process as it helps rule out other potential conditions that might present similar symptoms. By accurately identifying the source of the pain, we can ensure that the patient receives the most suitable treatment for their specific condition.
Lower Limb Neurological Examination
The examination of lower limb neurology plays a significant role in the comprehensive neurological assessment, evaluating the motor and sensory neurons responsible for lower limb function. This assessment is critical for detecting nervous system deficiencies. In the context of Degenerative Disc Disease (DDD), neurological testing becomes even more crucial due to potential nerve compression, resulting in pain, numbness, or weakness in the lower limbs. By employing this examination as a screening and investigative tool, we can identify nerve-related problems early, gain insights into nerve involvement, and customize treatment plans accordingly.
Peripheral Vascular Examination: Key Considerations
A peripheral vascular examination is a crucial diagnostic tool used to identify signs of vascular-related conditions. In the case of Degenerative Disc Disease (DDD), this examination takes on added significance. Although DDD primarily affects the spine, it can indirectly affect the vascular system through inflammation or structural changes that may impede blood vessels, potentially causing circulatory problems. Early detection and treatment of Peripheral Vascular Disease (PVD) are vital in preventing cardiovascular and cerebrovascular complications. This video provides an overview of common procedures performed in clinical practice to assess vascular health.
Addressing Degenerative Disc Disease Non-Surgically
A large portion of our patients aren't typically aware that there exist non-surgical approaches to managing Degenerative Disc Disease (DDD).
Certainly, it's essential to realize that although we can't rewind time and completely repair the disc degeneration, there's a significant scope in managing the condition to enhance the patient's overall life quality.
By combining manual therapy and exercise, we can cause a noticeable improvement in most instances. This strategy can increase the life quality of patients and significantly diminish the discomfort they undergo due to DDD.
Our treatment blueprint for DDD primarily concentrates on three objectives:
Boosting joint mobility: By augmenting the movement range in the affected areas, patients can observe a reduction in discomfort and a boost in overall functionality.
Mitigating pain and rigidity: Through specialized therapies and exercises, we strive to alleviate the enduring pain and stiffness frequently linked to DDD, contributing to an improved life quality.
Decelerating additional joint damage: While we cannot halt the degenerative process completely, our techniques can aid in slowing down the disease's progression, helping maintain joint health for an extended period.
Equally as Effective as Surgery!
Interestingly enough, ongoing research suggests that a blend of manual therapy and exercise can be equally as effective as surgery (specifically, surgical spinal fusion) over time. This strategy can decrease pain and disability for patients afflicted with DDD, providing a non-invasive alternative with similar outcomes (2). Hence, patients possess more options in managing their condition, which can be customized to their unique needs and preferences.
Manual Therapy
In addressing Degenerative Disc Disease (DDD) using manual therapy, two essential elements must be taken into account to ensure optimal results: joint flexibility and tissue health.
Joint Flexibility: With DDD, the joints involved frequently lose their usual range of motion, which results in stiffness and discomfort. Manual therapy, employing a variety of hands-on techniques, can aid in regaining this lost mobility. By delicately manipulating the affected regions, we can augment joint suppleness and mobility, thus diminishing pain and increasing functionality.
Tissue Health: DDD can adversely affect the health of nearby tissues, including muscles, ligaments, and tendons. Manual therapy, utilizing focused massage and manipulation, can aid in enhancing the health and resilience of these tissues. It can stimulate improved blood flow, alleviate muscle tension, and expedite the healing process.
Manipulation & Mobilization
Chiropractic Care: A Gentle Approach
Patients with chronic back pain from DDD often improve significantly with Chiropractic Maintenance Care - regular, scheduled chiropractic treatments. This strategy is notably beneficial compared to seeking help only during acute pain instances.
The goal of chiropractic care, marked by gentle manipulations even in cases of osteoporosis and severe osteoarthritis, is to restore spine functionality and mobility, often compromised by DDD. Beyond the affected discs, this holistic approach considers how the condition affects overall spinal function and musculoskeletal balance.
Cervical Adjustments vs. Mobilization - Your Choice!
For Degenerative Disc Disease (DDD) in the neck, patients have options: cervical adjustments or neck mobilization techniques.
Cervical adjustments manually restore neck mobility and alleviate pain. Conversely, neck mobilization is a gentler approach, improving flexibility with controlled movements. Both methods can mitigate DDD symptoms and enhance neck function, depending on patient comfort and preference.
Dr. Abelson's video demonstrates Cervical Joint Mobilization, clarifying the procedure and potential benefits for treating cervical DDD. Our goal is to offer personalized care, promoting your overall spinal health.
The Role of Soft Tissue Mobilization in Managing DDD
The myofascial system, when balanced, distributes force efficiently across the body, aiding in normal motion. In the case of Degenerative Disc Disease (DDD), this system acts as a secondary shock absorber for the spine, reducing damage and maintaining stability.
However, DDD can disrupt this system, leading to issues like muscle imbalances. The tissues near the spinal column may thicken, compromising stability and intensifying DDD-related discomfort and functional restrictions.
Techniques like soft tissue mobilization can address these problems. By using precise pressure and motion on muscles, ligaments, and tendons, this method can reestablish balance, enhance tissue health, and improve spinal stability.
Low Back Release Protocol - Motion Specific Release
Dr. Abelson, demonstrates an effective low back release protocol in the video that is being presented.
Treatment Frequency for DDD
The logic behind these recommendations is grounded in the principles of rehabilitation, which emphasize a gradual transition from a more intensive, therapist-directed approach during the acute phase towards a more patient-independent, self-management approach in the chronic phase. The goal is to promote healing, restore function, and equip the patient with the skills and knowledge to manage their condition independently over the long term. As the condition transitions from acute to chronic, the role of manual therapy may shift from a primary intervention to a supportive or maintenance role, complemented by exercise, education, and other self-management strategies.
Acute LBP (less than 4 weeks):
During the acute phase, the primary goals are to alleviate pain, reduce inflammation, and prevent further damage.
Manual therapy can be applied 2-3 times per week to promote mobility, manage symptoms, and facilitate the early stages of healing.
The frequent sessions allow for continuous assessment and adjustment of the treatment plan as the body responds to therapy.
Sub-Acute LBP (4 to 12 weeks):
In the sub-acute phase, the body is typically in the process of healing and adapting.
The frequency of manual therapy might be reduced to once a week to continue to support mobility, address any remaining or reoccurring inflammation, and encourage adaptive changes while allowing more time for the body to heal between sessions.
This stage aims at transitioning from a symptom-focused approach to a more function-focused approach, emphasizing the restoration of normal movement patterns and functional abilities.
Chronic LBP (12 weeks or longer):
Chronic LBP represents a stage where the condition has stabilized but may still present with ongoing pain and movement restrictions.
The frequency of manual therapy might be further reduced to once every 2-4 weeks or as needed.
This stage aims at maintaining the achieved levels of mobility and comfort, managing chronic symptoms, and promoting self-management and independent function.
The less frequent sessions could help in promoting self-efficacy and adherence to self-care routines like exercises and posture corrections which are crucial for managing chronic conditions.
Exercise: A Key Element in DDD Management
Integrating exercise into your daily regimen is crucial for effectively managing back pain from Degenerative Disc Disease (DDD). It's important to tailor exercise routines to the individual's unique needs and capabilities for optimal outcomes.
Exercise significantly contributes to DDD management by enhancing mobility, strength, and balance. This helps in pain reduction, promoting spinal stability, and decelerating disease progression. Here are a few examples of exercises often recommended for DDD patients. These should be customized to each person's specific condition and fitness level, ensuring a safe and efficient journey towards improved spinal health.
Two Minute Cat-Cow Exercise
We recommend patients perform the Cat Cow exercise immediately when they wake up, even before they get out of bed every morning. Most patients never adequately perform enough repetitions of this exercise to receive all its benefits. That is why we have designed this incredibly effective two-minute Cat-Cow Protocol.
5 Minute Low Back Pain Relief
Have a sore low back from sitting too long in front of your computer? Try our "5-Minute Low Back Pain Relief" routine. Doing this routine several times per day can make a huge difference in your back pain.
6 Minute Plank Routine
Intermediate Having a weak core makes you susceptible to poor posture, lower back pain, hip and knee injuries and more. If you want to improve your athletic performance working on your core strength is a great place to start.
Conclusion
Degenerative Disc Disease (DDD) is a common condition that can notably impact individuals' quality of life. While reversing the degenerative process entirely isn't feasible, various non-surgical treatments can effectively control the condition, relieve pain, and enhance everyday functions.
Key strategies for managing DDD encompass manual therapy for improved joint mobility and tissue health, chiropractic manipulations, and soft tissue mobilization to reinstate myofascial system balance. Implementing a personalized exercise regime that boosts mobility, strength, and balance is also vital.
Furthermore, comprehensive diagnostic methods, such as orthopedic, neurological, and vascular evaluations, play a crucial role in DDD diagnosis and excluding other potential conditions. Comprehending these assessments and DDD's nature enables patients to navigate their treatment options and make knowledgeable healthcare decisions.
Contrary to popular belief, a DDD diagnosis doesn't equate to a life of inactivity and discomfort. With the right approach and mindset, DDD individuals can lead an active lifestyle and enjoy high life quality. Navigating this condition in a way that allows for continued participation in beloved activities is indeed achievable. Your DDD journey may be demanding, but it doesn't define you or your potential for a fulfilling life.
DR. BRIAN ABELSON DC. - The Author
Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.
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References
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Fascia: The Tensional Network of the Human Body - E-Book: The science and clinical applications in manual and movement therapy., Schleip R, Findley TW, Leon Chaitow L, and Huijing PA. (2012). Canada: Elsevier
An improved Collagen Scaffold for Skeletal Regeneration, Serafim M. Oliveira, MS, PhD, Rushali A. Ringshia, MS, Racquel Z. LeGeros, PhD, Elizabeth Clark, MS, Michael J. Yost, PhD, Louis Terracio, PhD, and Cristina C. Teixeira, DMD, MS, PhD, J Biomed Mater Res A. 2010 Aug; 94(2): 371–379.
Sakai, D., & Andersson, G. B. (2020). Stem cell therapy for intervertebral disc regeneration: obstacles and solutions. Nature Reviews Rheumatology, 16(4), 213-228.
Nakashima, H., Yukawa, Y., Suda, K., Yamagata, M., Ueta, T., & Kato, F. (2015). Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine, 40(6), 392-398.
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Jacobs, W., Van der Gaag, N. A., Tuschel, A., de Kleuver, M., Peul, W., Verbout, A. J., & Oner, F. C. (2013). Total disc replacement for chronic back pain in the presence of disc degeneration. Cochrane Database of Systematic Reviews, (9).
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