As we age, we think that it inevietable that the body deteriorates and that pain should be part of our future. Then you hear that you have degenerative disc disease (DDD) and all our assumptions are proved correct. Wrong!!!  Yes, our bodies do undergo changes as we age and that brings us to challenges and adaptions, but we need not give in to a future of pain and stiffness. With the correct treatment and management there is so much more to look forward to and experince

The body’s shock absorbers

Our spinal discs do a wonderful job in absorbing the shock that we place on the spine with our daily activities, be it walking, running or simply sitting at work. Wihout them, our bones, mucles and nerves would be under continuous stress and we would not have the mobility or flexibilty to move with the freedom that we do.

In total there are 23 discs in our spine, reaching from our necks and all along the spine into our lower back. It has a strong outer structure with a middle that is made up of a gel like substance, mostly made up of water. This gel can be compressed when we put weight on the spine, thus absorbing some of the force at each level. As we age, the fluid content of the disc can slowly decrease, thus taking away some of this function. At the same time, with wear and tear, the outer layers of the disc also undergo changes and do not supply as much support to the inner gel. These factors, as well as changes to the spinal bones (vertebrae) give rise to degenerative disc disease.

Physiotherapy can help to ease the forces acting on the discs and correct the underlying mechanics putting too much pressure on the discs.

There are a total of 23 discs in the human spine

6 Cervical (Neck)

12 Thoracic (Midback or ribcage)

5 Lumbar (Lower Back)

The structure of the intervertebral disc (IVD) is similar over all levels of the spine and is made up of 3 distinct parts:

1. Nucleus Pulposus

This is the soft, gel-like inner layer of the disc that does most of the shock absorption. The nucleus is made up of between 60-80% water with the remainder being various types of collagen and proteoglycans. The disc continuously reabsorbs water into the nucleus pulposus, usually at night when the disc is unloaded. During the day as we load the disc, some of this is lost and we can loose some of our disc height. It is true that we are that slight bit taller in the morning as our discs have recovered, so if you want to measure your true height, mornings would be best.

2. Annulus Fibrosis

The annulus fibrosis is the structure made up of concentric rings of collagen that surrounds the gel-like inner nucleus. Being more sturdy than the nucleus pulposus, it gives stability to the disc and allows the forces to spread throughout the disc. As we age, these rings may not be as strong and can become over-stretched. If this occurs, the annulus cannot contain the gel within the nucleus and we can start to develop small bubbles extruding past the normal disc space which produces what is colloquially referred to as a slipped disc.

3.Vertebral end plates

These 2 structures make up the roof and floor of the intervertebral disc and attaches the disc directly to the vertebrae (spinal bone)above and below. The fibres of the annulus fibrosus merge with the end plates above and below to form a tight container to hold the nucleus pulposus. It also allows diffusion so that the disc can receive nutrition and hydration, thus keeping it healthy.

The disc is a wonderful structure that is designed to ease the loading  forces that are placed on the spine as well as assist the vertebra (spinal bones) in normal movement. As such, the spinal disc can act as joint from which movement occurs. When the spinal disc is healthy and well hydrated, it positions the facet joints of the vertebrae in the optimal position to allow movement. At the same time, the vertebral body can move on the gel-like disc and add extra movement to the spine. This movement is controlled by the muscles around the spine and given stability the ligaments around the disc and vertebrae, especially the anterior and posterior longitudinal ligaments.

Another important function of the disc is to maintain the opening between the vertebrae through which the peripheral nerves move from the spinal chord and out towards the limbs. This opening can be narrowed due to many factors, such as arthritic changes in the vertebrae; disc bulging; scar tissue formation or swelling and inflammation around the nerve itself. So, by maintaining good disc health and hydration we can help keep the pressure off our peripheral nerves and prevent painful nerve conditions such as sciatica

There are numerous factors that contribute to disc degeneration, of which ageing is only one component. Other factors include, disc nutrition, mechanical forces (including compression, torsion and vibration), toxic factors, metabolic and genetic factors. As can be seen, degeneration is not only an ageing process but can have many underlying factors which we can try and influence or reduce.

In a healthy disc there is a continuous process of disc hydration, which means that the water that makes up the majority of the gel like nucleus pulposus is pushed out and reabsorbed as stresses are placed on the disc. If anything effects this balancing process, it leads to a dehydration of the disc and, as such, the disc will loose some of its core characteristics like shock absorption and joint function. However, it is not only the gel like inner substance that can be effected, but also the outer fibres of the annulus as well as the 2 vertebral end plates.

• Disc Nutrition

An adult intervertebral discs is the largest avascular tissue in the human body, with the cells at the centre of the disc being up to 8mm away from the nearest blood supply. As such, the disc is vulnerable to any changes to the blood supply that provides oxygen and nutrition to the disc and helps in recovery. Most of this blood supply comes from the vertebral end plates above and below the disc.

• Ageing

Father time moves slowly forward and we all undergo the ageing process. Time, therefore, also effects what is happening to all our processes on a cellular level. The rate at which the body produces the vital proteins (proteoglycans) starts to slow down, especially in the outer annulus fibres. These proteoglycans are also smaller and less aggregated. This leads to a decrease in the cells ability to reabsorb water and thus loosing some of its hydration and function.

• Mecahnical forces

Three main forces have a direct impact on the disc: compression, torsion and vibration.

Compression is the most obvious force influencing the disc as this is its main function. In fact, loading of the disc is healthy and helps stimulate normal disc metabolism – a reason physiotherapists love to give weight bearing exercises! The problem comes in when we start to overload the discs, especially the lumbar discs. Prolonged or repeated excess compression can damage the vertebral end plates, causing inflammation and scar tissue or callus formation. We have seen that the disc gets most of its blood supply from here and this leads, unfortunately, to impaired nutrition and healing.

Torsion is when we apply a rotation force to the discs. When we rotate our spine, half of the circular fibres of the annulus are put under tension as the other half are slackened. If we get excessive rotation, especially when we twisted and bend at the same time, the fibres can tear. This leads to a weakend outer layer that can predisose the disc to further damages.

Vibration is the one mechanical force we tend to forget has a role to play in degenerative disc disease. This is often seen in pilots and long distance drivers and occurs at frequencies of 4-6 Hz. This can have an effect on the compression of the end plates as well as influencing normal cell nutrition and metabolism.

• Toxic factors

Nicotine is the biggest toxic factor involved in degenerative disc disease. Smoking can decrease the amount of oxygen carried in the blood, supplying less to the tissues of the disc and slowing normal recovery. It can slow down the production of the vital protein and collagen production needed to keep the annulus fibres strong, thus leading to increased oppertunities for a disc bulge or herniation

• Metabolic and genetic factors

Metabolic conditions, such as diabetes, can also contribute to degeneration of the disc and can occur via many different pathways. Firstly, the blood supply can be compromised due to changes in the circulation process. Secondly, the effect the sugars can have on the formation of the proteoglycans and collagen fibres changes the normal metabolism of the disc and can slow the healing and recovery process required after we load our spine normally throughout the day.

When it comes to genetic factors, twin studies have shown us that there may be a hereditary component to degenerative disc disease. Mostly, the proposed way that genes may encode how the make up of the cellular substance is set up. This predisposition is worth to keep in mind during the assessment.

All these factors may sound daunting, but it also allows us to change and prevent so much. A well hydrated and healthy disc allows the compression and rotation we need to work and play, even to the extremes of running, jumping and picking up weights. Any changes that occur due to the factors described above can cause a loss of disc height and also mobilty. These changes can lead to irritation of the nerves around the disc and cause inflammation and pain. Loss of mobility can also be seen as we cannot touch our toes or reach up to the roof to change a light bulb. All this can lead to irritation of the surrounding muscles causing spasm and pain.

Any repetitive movement or prolonged position that causes compression or twisting of the spine.

• Prolonged sitting -computer work
• Heavy lifting with bending
• Running
• Long distance driving
• Obesity
• Poor posture and muscle weakness
• Age >40 years

Pain can occur in either the neck or lower back region. The midback region rarely gives pain as the ribs give support to the spine and thus helps keep the disc space stable.

Symptoms of degenerative disc disease in the neck or back can include:

Neck

• Pain in Neck
• Spasm of neck or shoulder
• Shoulder pain.
• Stabbing ache or pain between the shoulder blades
• Pain or ache down the arm
• Head feels too heavy
• Headaches coming from the back of the skull
• Weak or heavy feeling in the arm
• Numbness or tingling in the arm or hands
• Difficulty with opening jars, lids

Lower Back

• Pain in the back
• Tightness or spasm of the back muscles
• Pain into buttocks and down the leg
• Difficulty with bending and twisting
• Weakness of the leg or foot with walking
• Back cannot carry the weight
• Leg giving in with walking
• Numbness or tingling down leg

Self- test your disc  at home with these modified home tests to determine your general disc health

Initially, you will not notice any symptoms if you have been diagnosed with degenerative disc disease. As a matter of fact, most people above the age of 35 – yes, you read that correctly – have radiological evidence of disc degeneration in the lumbar or cervical spine. This can be aggrevated by previous trauma, body weight, type of exercises done and our daily sitting and standing postures.

The first symptoms that may appear can include an ache in the spine, especially after more intense activity or prolonged positions. Aching will occur very localised with no radiation into the limbs.Rest and heat will usually settle this ache and no futher action then needs to be taken.

However, as the disc starts loosing more of its hydration and we loose some of the disc height, more severe symptoms can be noticed as the shock absorption and mobility aspects of the disc start to decrease. Movement starts to be less easy and you can’t move as far as you might have thought. The aching feeling in the spine after strenuous activity may start to progress into pain and cover a larger area. Due to the limited and abnormal movement, the surrounding soft tissue may become irritated and result in compensatory movements and adaptions. This can also lead to protective muscle spasms and localised inflammation which increases the severity of pain. The time to recover from over-use and activity takes longer and may require more than just heat. Depending on the state of the disc, this is where we may see the start of Lumbar Disc Bulge or Hernia.

Bulging or herniation of the disc brings with it their own patterns of pain and radiation into the limbs that can be much more specific. So, it can be difficult to differentiate if your spinal pain is coming from disc degenertion only, or if there is the start of a hernia. In degenerative disc disease we the pain increasing as we load the spine more, be it either with prolonged positions, repetitive movents, impacts or heavy lifting. This can be in any direction or position, depending on which disc is involved. When it comes to herniation, it will follow a very specific referral pattern of the nerve that is being piched, whereas the pain of degeneration can be more diffuse.

In severe cases, where the disc has lost all its fluid and height, you may be in constant pain. movements can be even more restricted and there can be pain even at rest. Activities such as walking, which usually gave relief, can be causing pain. Back muscle spasm are constantly present as the body tries to stabilise the spine and try and decrease the pressure placed on the disc. The exiting spinal nerves may also now be irritated constantly as their opening is now much smaller, again mimicking the symptoms of a hernia.

This is one of the things we see a lot of in clinical practice and as such we are the ideal medical practioners to correctly diagnose and help you through this process.

This experience that we have, combined with our expert and in-depth knowledge of spinal anatomy, physiology and mechanics stands us in good stead to get you moving to the best of your ability. Movement and function are what we are trained for and we can adjust your treatment programme to move you from stiffness and pain to your self.

As with with any of the other conditions we treat, the thing to get right from the beginning is to get an accurate diagnosis. If you don’t know what is wrong, how can we proceed to fix it. Our therapists will do a complete assessment of the spine to determine which structures are involved in causing your specific problem. Structures included in the assessment of degenerative disc disease would be:

• Spinal disc
• Exiting nerves in the area
• Spinal joints (facet joints)
• Other joints that can refer pain (shoulder or hip)
• Protective muscle spasms
• Muscle lengths and strengths

Once we have identified the specific structures involved, as well as how this affects your pain and mobility, we can start with getting you right again. Patients should have a great understanding of what exactly is wrong with them and then be involved with setting up the rehab plan. Degenerative disc disease can be well managed with the correct treatment and exercise, but it is always a team approach between therapist and patient.

Degenerative discs cannot be seen on an X-ray, so diagnosing a degenerative disc will not be adequate. X-rays will, however, show the integrity and alignment of joints in your spine. This will enable us to see if something is wrong with the structure of the bones in your spine or if there is a loss of disc space.

Your physiotherapist can refer you to get x-rays taken if necessary.

Diagnostic ultrasound cannot visualize a degenerate disc and will be useless.

If you need an ultrasound, your physio will refer you.

An MRI scan can image all of the structures in your lower back, including soft tissue, discs, nerves and bones. It is the diagnostic tool that works best to see all aspects of a disc and its surrounding tissue.

You will be referred to the right specialist if your physiotherapist suspects disc involvement.

The name says it all. It is a degenerative process that occurs in the spinal discs and if we do not intervene, the pain will remain the same or even worsen over time. As physiotherapists, this kind of condition is what we see very often in our practice and can readily help with alleviating the symptoms associated with DDD and get you onto the road to recovery.

All the stresses and strains that we put onto the disc add to, over time, the degeneration process. The body is constantly trying to heal the damage that is occuring, but if we do not help in taking off some off the underlying causes, this healing process cannot work properly. Our bodies are wonderful in trying to repair themselves, but if the enviroment is not right, the quality of tissue repair is less than optimal, leading to a weaker tissue structure that is prone to easier and more damage. This then can become a viscious cycle and we spiral down the degenerative process.

Incorrect movement patterns, muscle weaknesses and imbalances, poor posture and incorrect sitting and standing positions all contribute to the process. In fact, it is not only a single factor that is involved in this degenerative process, but rather a combination of all the small factors that we do on a daily basis that leads us down the path of pain and loss of movement.

Low back pain is one of the most common orthopaedic problems in our society today with up to 70% incidence in industrialised countries. This leads to the assumption that we need to live with low back pain and restrictions as it is the normal part of ageing. Leaving the problem to grow results in more tissue damage and deterioration and makes the rehabilitation and healing process so much longer. This is the most common factor we see in our practice.

We all want to be without pain and also dont always go seek the medical help we need when a problem starts. Trying to self treat and self medicate at home can give short term relief, but an accurate diagnosis is always essential in treating any type of low back or neck pain. Continous use of anti-inflammatories, pain medications and muscle relaxants often masks the problem and in some cases even impede the essential tissue repair needed to help heal the body. There is definitely a place for medication in the management of disc pain, but should be used sparingly and at the correct times.

Movement, as we have discussed, is also essential for good disc health. However, when we are in pain, we tend to want to move less due to fear of making things worse. This leads to abnormal movement patterns and stiffness in the joints which in most cases will make things worse in the long run. Also, the wearing of a neck or back brace can feel comforting and soothing when the pain is present, but is also not a long term solution. The muscles that are needed for the normal control of the spine need to work normally and by prolonged wearing of a brace, these muscles then become weaker and we are left with an even more uncontrolled spine. Your physio will absolutely incorporate muscle strengthening exercise in any rehab of the spine and we need these muscles to work for us.

When we get to the point of the pain being too much, surgery is often the thought that comes up, with all the fears and connotations that it conjours . Physiotherapy would still be the place to start, as we need to get you moving correctly and unloading the disc as much as possible. Correcting muscle imbalances, postures and normalising any irritations on the nerve can often be done with rehab and can prevent a surgical option. That is not to say that surgery is never an option, but should not be the first option when talking about disc disease. Just like medications, it has its uses, but used sparringly and at the correct time, it can become an option in the treatment process. Rehabilitation, however is never wasted. If surgery does become a necessity, having had good physiotherapy makes the recovery process post surgery so much easier.

Degenerative disc disease is manageable with the correct conservative treatment, but getting the correct diagnosis and early intervention is essential for the optimum outcome. If you are unsure of what is causing your back pain, rather come and get it evaluated by us early so that we start getting back normal movement in your life.

This is a condition we treat often and we do it well. We will guide you through the whole rehabilitation process and discuss all your questions and concerns. The most important thing to start with is to get an accurate diagnosis.

Is coming to see a physiotherapist the best way forward?

Yes, most definitively. This is a very common problem which we see often and can treat and manage very well.  The approach we take is to look at the patient as a whole and determine the stage of the degeneration, as well as your lifestyle and movement requirements. After the thorough assessment we can then guide you through the rehabilitation process, give you a prognosis and answer any questions you may have about your condition. Together, we can then plan and implement a structured programme that is effective, atainable and with long term benefits.

The whole goal of therapy is to get a spine that is mobile, stable and painfree. You should have confidence in all your movements that your discs are up to the tasks you need them to perform. That is why we take a global look at all the structures involved to achieve this level of confidence and control. Some of the aspects that will be covered will include:

1. Muscle Strength
2. Joint mobility
3. Nerve Control
4. Flexibilty
5. Disc Hydration
6. Ligamentous control
7. Gradual conditioning and loading

Your therapist will be your guide during this process by changing and increasing exercises as required, but also giving advice answering any concerns you may have along the way.

Healing time will all depend on the severity of degeneration of the disc and how long the condition has been present. That is why an accurate history and diagnosis is important to determine the correct prognosis. Spinal rehabilitation is the first step in the non-surgical approach to treating degenerative disc disease, with the goal of preventing or delaying any surgical options.

Physio treatment will initially be 2 or 3 times a week for the first 2 weeks. This time is needed to decrease strain on the disc, decrease inflammation and muscle spasm and start to incorporate correct spinal postures and movement.

As you progress, this may change to once a week session where we will work on the muscle imbalances, muscle and core weakness, stiffness and mobility as well as re-education of correct and normal movement patterns. You will also be given a home exercise programme as well as ergonomic adaption advice to maintain all the progress that has been achieved. Further progress will be added to load the spine with more functional exercise as well as sport specific rehabilitation. Getting the confidence to use your spine normally and without fear is the end goal we would like to achieve.

The entire process will be between 8 to 12 weeks depending on the area and initial severity. This treatment protocol is depends on both the therapist, as well as the patient to be completely involved in the process. Your recovery rate will greatly depend on how much you put into it during the sessions and at home.

Your doctor will be involved with the medical part of managing the degenerative disc and may include the prescription of pain or anti-inflammatory medication. In times of severe flare ups, injections of muscle relaxants and/or cortisone may be needed. However, this is purely symptomatic management and will not solve the underlying problem.

Manipulation of the spine, or getting it clicked into place, can give some short teerm relief. However, it will not do anything to change the muscle control or mechanical causes of the disc disease. In many cases it may even make the condition worse and trigger a bigger muscle spasm. We need to focus on both the symptoms and causes when treating your disc. Remember, the whole system must work together!

A good person to see, together with your physio, would be the biokineticist. They can become involved in the final stages of your rehabilitation and get you back to your sport and physical activity. Together, we can focus on muscle control, mobility and conditioning to help maintain the condition of the discs.

Home treatments may have their own benefits and risks. One of the first things we see patients do is putting on a brace to “protect” the spine. This may have short term benefits as it takes some of the strain of the structures, but in the long term it is most definitely harmful as the muscles that are already weaker become even weaker and so we get even less control of the spine. We should try and avoid bracing as much as possible due to this reason and focus more on regaining correct mobility and muscle control.

Other things such as hot/cold therapy and foam rolling may help get temporary relief. It may even be part of your physiotherapy rehabilitation programme. However, it is best to consult with a therapist of what to use when, as we need to focus on the correct structures that are involved.

So when should we consider surgery?

Sometimes, there comes a point when surgery may be considered, but it should never occur as a first option.

When the degeneration of the disc causes pressure on the central or peripheral nerves we may consider surgery. Symptoms may include:

• Loss of bladder or bowel control
• Mucle weakness down the arm or leg
• Constant and severe pain, with medication and conservative treatments not providing relief

The options that may be open for surgical intervention can vary, depending on age, degeneration and activity level of the patient.

1. Discectomy
2. Discectomy with laminectomy
3. Disc replacement
4. Spinal fusion

All the above procedures will require physiotherapy rehabilitation afterwards. In fact, this is as important as the surgery itself. The physio will train the correct muscle control to return to normal activity. Also, getting full mobility  and nerve gliding is important so that the spine can return to full function again.

Another aspect to consider before we opt for the surgical option is the idea of pre-habilitation. This will work on all aspects of the spine and get you ready for the surgical procedure by improving mobility, flexibility and control. Recovery after surgery should then be faster and easier as the tissues and structures are already prepared for the work they need to do post-operatively. As an added benefit, pre-habilitation can help decrease pain and improve symptoms to such an extent the the surgical option can be delayed or even cancelled!

• Disc protrusion – This usually presses on the exiting nerves and can give a specific referral pain pattern down the arm or leg
• Muscle spasm – Can be occuring together with degenerative disc disease
• Kidney stones – Change of position or specific movements don’t elicit the pain response
• Facet joint – can be more one sided and feel like a locking or stuck feeling at the end of the movement
• Spinal stenosis – can give pain  both down legs and is usually eased by a forward leaning posture

• Disc degeneration
• Intervertebral disc degeneration
• Collapsed disc
• Compressed intervertebral disc
• Non specific low back pain