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1st Jan


Manual Physical Therapy for Disc Degeneration

Up to 80% of the population will at some point in their lives experience acute low
back pain.  A significant percentage of these people will experience at least occasional
recurrent episodes of acute low back pain.  In the lower back, the intervertebral disc
between each vertebra is believed to often be involved in the development of low back
pain, although available medical tests today are often either inconclusive, or not
performed, and therefore the medical literature today states that the exact cause of low
back pain is “unknown” in the majority of cases of pain.

However, a thorough clinical examination performed by
a skilled manual medicine/manual physical therapy professional may provide more
valuable information, which can help us determine the main tissues involved,
with a reasonably high level of accuracy, and therefore also enable us to
develop the most appropriate treatment plan.  It must be pointed out that
the types of manual procedures and exercise performed, as well as exercise
dosage, must vary from person to person depending on their history and clinical

The intervertebral disc essentially consists ofcartilage cells and fiber
strands that run in diagonal patterns, but are also oriented in other directions. 
The cartilage cells, or chondrocytes,resist compression and act as shock absorbers. 
The fibers, made up mostlyof collagen, resist tension, in particular in torsion
or rotation, but also inmovements such as bending forward.  A healthy disc can withstand
considerable compression and tension, whereas a weakened, or degenerated disc
(DDD) has reduced capacity to tolerate such forces.  Disc herniations often
occur as a result of failure of the discal end plate where the disc blends in
with the vertebral bone, or due to breakdown of the outer layer of the disc,
the annulus.  Progressive degeneration of the disc also shifts compression
forces from the more central nucleus pulposus in the disc, to the outer annulus
fibrosis,  which is not designed very well to tolerate compression.
Therefore, it may lead to disruption of the annulus over time, and disc bulges
or herniations.

Some degree of disc degeneration is unavoidable with
aging which does not necessarily cause pain, very much like arthritic joints,
depending on the forces that we put on them.  Therefore, if a disc is
symptomatic, the first thing a person needs to do is to modify activities that
provoke the pain.  For the disc, this may be activities that cause too
prolonged or intense compression on the spine (cartilage cells), or excessive
strain on discal fibers-most commonly in bending with twisting.  Sitting
produces more discal compression than standing, and therefore many people with
disc problems do not tolerate prolonged sitting well.  Frequently
interrupted sitting is usually helpful to lessen the deformation of the disc
cells, until the tolerance to compression has improved.  High impact such
as running or jumping, or heavy lifting, may cause excessive impulse
compression loading on the disc, and must also be modified at first, e.g. by
switching to walking or other low impact conditioning exercise, and by
lessening resistance used with weight training, and modifying exercises to e.g.
only standing or lying exercises, with lighter weights/higher repetitions.

If the discal fibers cause pain with movements, these
at first should be modified, by avoiding excessive movements, in particular in
forward bending with or without twisting.  Backward bending may hurt as
well, as the annular disc gets compressed.  Therefore, sustained stretches
often aggravate disc problems, since the discal fibers cannot tolerate such
tension well, even though the stretch may at first feel good on the tight back
or hip muscles.  However, such muscle tightness is a symptom, or guarding
response to the underlying spinal disc problem.

For treatment to be effective, we must always combine
tissue protection early on, gradually progressed rehabilitation to regenerate
tissues, and gradual return to activities.  This requires patience, since
both collagen and cartilage cells have very low metabolism, and may require
over a year to regenerate (the spinal disc also naturally has reduced capacity
to regenerate).  However, symptoms often decrease much sooner after
starting rehabilitation, as mobility and muscular function improves.

Most human tissues can regenerate, if we apply the
specific forces that promote this.  For the spinal disc, this includes a
combination of on and off modified compression as well as modified pain free
tension  in the direction of the discal fibers.  Since many of these
fibers are oriented in a diagonal fashion, rotation motions create such
tension.  If we add resistance, initially light and with many repetitions,
we also create on and off compression on the disc, caused by contraction of
muscles that cross the spinal discs.  Self treatment early on may include
hundreds to thousands of small spinal movements performed every day lying down
to affect the discal fibers, and gradually progressed daily walking, for on and
off compression on the disc.

It is very important that the pain does not increase
during or after sessions, which may indicate that the tissue tolerance has been
exceeded.  The intensity of the exercises will be increased over time, to
both stimulate further disc regeneration, and to build up muscle support and
stability during movements and tasks.  Such muscular stability can help
protect the spinal disc and surrounding ligaments, until continued specific
rehabilitation exercise on your own for at least a year has had the desired
effect on the disc itself.  This does not mean that you have recreated a
normal disc-it may continue to have limitations in its tolerance to certain
forces-or that it will look much different on an MRI or x-rays, however the
available disc tissues often become stronger and tolerate activities better.

We do not only perform rotational exercise.  We
often include motions in other directions such as bending and in functional
diagonal patterns, which stimulate discal fibers in various directions, and
also train muscles to control such complex movements which are part of normal
life, and certainly sports.  Manual treatment is usually helpful as well,
to reduce muscle guarding and soft tissue restrictions, and to improve joint
mobility in the spine, if reduced.  This can significantly reduce the
pain, and make the rehabilitation exercises more effective.

Since many people have back problems, you may know of
someone who you could forward this letter to.  As always, please feel free
to comment and send us your thoughts.

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