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Adjusting Deranged Discs - Just What Are We Doing?
June 20, 2010 by Dr Matthew D. Long
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Adjusting Deranged Discs - Just What Are We Doing?
June 20, 2010 by Dr Matthew D. Long
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Adjusting Deranged Discs - Just What Are We Doing?
June 20, 2010 by Dr Matthew D. Long
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In our last Clinical Clarity Blog post (found here) we examined the prospect of hypermobility being a common feature of many spinal pain patients. What’s more, we also suggested that it is these hypermobile segments that can benefit from the proprioceptive burst that accompanies a spinal adjustment.
But what is going on at a tissue level? And can our adjustments influence the connective tissue features of common spinal derangements?
It seems plausible that spinal dysfunction may initially be due to poor sensory feedback from the segment - a ‘proprioceptive lesion’, if you like. And we have looked earlier at why this might be the case (lack of environmental stimuli, multifidus wasting etc). However, over time such instability appears to lead to degenerative changes in both the facet joints and the intervertebral discs. According to Kong et al (1), “The main cause of spinal segmental instability has been thought to be the reduced mechanical function of the intervertebral discs... Many studies have shown that abnormal increased movement of a spinal segment may occur in severe disc degeneration accompanied by capsular laxity in the apophyseal joints and posterior ligamentous structures and lack of effective muscular control.”
Kong also states, “The results of the present study showed that disc degenerates before facet. Initial degenerative changes in the lumbar spine most commonly occur within the intervertebral disc (nucleus pulposus). The exact cause of degenerative changes within discs is not clearly understood, but one important mechanism in this process is a decrease in nutrition to the disc.”
So the question then arises, can we do anything to directly influence disc nutrition and fluid regulation?
Perhaps so...
A recent paper by Beattie and colleagues in JOSPT (2) looked at the question of why some patients with lumbar pain respond well to manipulative treatment, while others who seem clinically identical do not. They suggest that, “One potential reason for variation in outcome following treatment may be linked to differences in the physiological responses of lumbar tissues to the stimuli generated by intervention.”
In this study they cleverly investigated what was going on inside the lumbar discs using a specific type of MRI examination called diffusion-weighted imaging. This technique allows examiners to track the diffusion of water into the discs, which we know to be critical for the load tolerance of the disc tissue. By measuring the apparent diffusion coefficient (ADC) Beattie could reliably measure how much water had entered the L5-S1 disc in patients who had responded to treatment, and in those who hadn’t. Treatment, by the way, consisted of both prone mobilisation of the L5 segment, followed by prone press-up exercises as described by McKenzie.
Interestingly this study found that patients who did respond symptomatically to the treatment protocol showed a rapid increase in diffusion of water into the nucleus of the intervertebral disc (a small, but significant 4.2% increase). Non-responders did not seem to enjoy the same fluid migration.
At this stage Beattie and his collaborators are quick to point out that we must be careful in extrapolating too much from these findings. However, if we remember that disc integrity and longevity are intrinsically intertwined with fluid diffusion and retention characteristics we could theorise that any treatment that aids this has some potential to be helpful.
Food for thought...
Matthew D. Long
BSc (Syd) M.Chiro (Macq)
But what is going on at a tissue level? And can our adjustments influence the connective tissue features of common spinal derangements?
It seems plausible that spinal dysfunction may initially be due to poor sensory feedback from the segment - a ‘proprioceptive lesion’, if you like. And we have looked earlier at why this might be the case (lack of environmental stimuli, multifidus wasting etc). However, over time such instability appears to lead to degenerative changes in both the facet joints and the intervertebral discs. According to Kong et al (1), “The main cause of spinal segmental instability has been thought to be the reduced mechanical function of the intervertebral discs... Many studies have shown that abnormal increased movement of a spinal segment may occur in severe disc degeneration accompanied by capsular laxity in the apophyseal joints and posterior ligamentous structures and lack of effective muscular control.”
Kong also states, “The results of the present study showed that disc degenerates before facet. Initial degenerative changes in the lumbar spine most commonly occur within the intervertebral disc (nucleus pulposus). The exact cause of degenerative changes within discs is not clearly understood, but one important mechanism in this process is a decrease in nutrition to the disc.”
So the question then arises, can we do anything to directly influence disc nutrition and fluid regulation?
Perhaps so...
A recent paper by Beattie and colleagues in JOSPT (2) looked at the question of why some patients with lumbar pain respond well to manipulative treatment, while others who seem clinically identical do not. They suggest that, “One potential reason for variation in outcome following treatment may be linked to differences in the physiological responses of lumbar tissues to the stimuli generated by intervention.”
In this study they cleverly investigated what was going on inside the lumbar discs using a specific type of MRI examination called diffusion-weighted imaging. This technique allows examiners to track the diffusion of water into the discs, which we know to be critical for the load tolerance of the disc tissue. By measuring the apparent diffusion coefficient (ADC) Beattie could reliably measure how much water had entered the L5-S1 disc in patients who had responded to treatment, and in those who hadn’t. Treatment, by the way, consisted of both prone mobilisation of the L5 segment, followed by prone press-up exercises as described by McKenzie.
Interestingly this study found that patients who did respond symptomatically to the treatment protocol showed a rapid increase in diffusion of water into the nucleus of the intervertebral disc (a small, but significant 4.2% increase). Non-responders did not seem to enjoy the same fluid migration.
At this stage Beattie and his collaborators are quick to point out that we must be careful in extrapolating too much from these findings. However, if we remember that disc integrity and longevity are intrinsically intertwined with fluid diffusion and retention characteristics we could theorise that any treatment that aids this has some potential to be helpful.
Food for thought...
Matthew D. Long
BSc (Syd) M.Chiro (Macq)
References:
1. Kong MH, Morishita Y, He W, Miyazaki M, Zhang H, Wu G, Hymanson HJ, Wang JC. Lumbar Segmental Mobility According to the Grade of the Disc, the Facet Joint, the Muscle, and the Ligament Pathology by Using Kinetic Magnetic Resonance Imaging. Spine 2009; 34 (23) pp 2537-2544
2. Beattie PF, Arnot CF, Donley JW, Noda H, Bailey L. The Immediate Reduction in Low Back Pain Intensity Following Lumbar Joint Mobilization and Prone Press-ups Is Associated With Increased Diffusion of Water in the L5-S1 Intervertebral Disc. JOSPT 2010; 40 (5) pp 256-264
1. Kong MH, Morishita Y, He W, Miyazaki M, Zhang H, Wu G, Hymanson HJ, Wang JC. Lumbar Segmental Mobility According to the Grade of the Disc, the Facet Joint, the Muscle, and the Ligament Pathology by Using Kinetic Magnetic Resonance Imaging. Spine 2009; 34 (23) pp 2537-2544
2. Beattie PF, Arnot CF, Donley JW, Noda H, Bailey L. The Immediate Reduction in Low Back Pain Intensity Following Lumbar Joint Mobilization and Prone Press-ups Is Associated With Increased Diffusion of Water in the L5-S1 Intervertebral Disc. JOSPT 2010; 40 (5) pp 256-264