187- The Degenerative Cascade and How You Can Stop It

Welcome to the Evidence Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies, all in the time it takes to get to your office. Now, here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week we are talking about the degenerative cascade and how it can impact your patients. We're talking disc, we're talking facet, we're talking nerve compression. And then we're gonna talk about the steps that people can take and you can take as their healthcare provider to help them either slow down that process or hopefully never get there in the first place. But before we get started, I'll say a few words about Rock Tape. Rock Stock is coming up. It's happening September 13th and 14th out in beautiful Huntington Beach, California. I'm gonna be out there hanging out, talking with docs and having a good time. I'd invite you to do the same. The educational courses that they put together during Rock Stock are absolutely awesome and it's just a really, really good time. So if you are in Southern California, you want to make sure that you are there, or if you are not, you want to make sure you book your plane tickets and get out there. It's happening September 13th and 14th in Huntington Beach, California. You can learn more. Grab your tickets now@rock tape.com rockstock but as I said at the top, today, we are talking all about the degenerative cascade. So this is something that affects, well, pretty much everybody if you live long enough, right? There is no question that we've seen a change in the degenerative cascade over the last 20 years. And when I say a change, I don't mean in how our bodies are degenerating, but I mean more in terms of our understanding as healthcare providers regarding it. So up until about 20 years ago, people would see degenerative changes on an MRI, and quite frankly, that was a blank check for surgery. Now, we know that that is not only a good idea, but quite often it's counterproductive. A vast, vast majority of time. We have the New England Journal of Medicine to thank for that with their landmark MRI study. But we also know that as people age, if we take X rays, if we see advanced imaging such as an MRI or ct, the older somebody is, it is drastically more likely that we're going to see changes, degenerative changes, and then the associated things with that disc challenges, nerve compression, et cetera. So I wanna break down the degenerative process according to the three major structures, and then talk about some action steps where you can engage and educate the people in your practice and in your community regarding steps they can take to slow down that process as we understand it today. And this will be an evolving conversation as the podcast continues on. So, really, three primary structures, right? We look at disc, facet, and then nerve compression. I'm kind of putting in there as a structure, even though it's more of a result. But when we look at the disc and the degenerative changes associated with the disc, what we know is that the instantaneous axis of rotation migrates posteriorly as we age. So what the heck does that mean? That means if you were to take literally a pinpoint and put it in the disc where motion begins, the centerpiece of motion, when we're young, practically in the center of the disc, which you'd expect. But as we age, interestingly, the instantaneous axis of rotation, that pinpoint where all motion begins in the disc, starts to fall posterior. It migrates posteriorly. So that translates into increased load on the facet joints, which is structure number two. Right. So we see increased load on the facet joints. Well, guess what? The facet joints are meant to do their job and no more. So that increased load quite often results in the advancement of degenerative changes of the facets. Now, if you read an X ray report by a radiologist or MRIs, you could see a variety of different things. Facet degeneration, facet arthrosis, facet disease. To me, these basically all mean the same things. It means that while the facet surface is supposed to be a nice oval joint with a capsule on the outside, the bottom line is when people list facet degeneration or facet disease, it typically means they just nasty. So there's some osteophytic formation. The margins of the joint just look a little crooked instead of being nice and smooth. In other words, they've undergone some load and, or some injury. And ultimately you can see the result of that on the image. Now, tying back to the disc. One interesting thing about the disc is as we age, that instantaneous axis of rotation migrates posteriorly. But what we also know is, is that nerve fibers, a neurovascular bundle, essentially, I'm talking very, very small millimeters, if not tens of millimeters, start to infiltrate the outside of the disc. So here's the gist of that. When we're young, we basically can't feel our discs, meaning the blood supply is not so hot, which there's good things about that. In other words, we can't feel pain in the disc. But there's also some challenges associated with that. But as we age, ultimately, neurovascular bundles, anytime that there's a little nerve, there's going to be some vasculature that go with it and vice versa. So neurovascular bundles start to infiltrate the exterior, the annular fibers of the disc. So what that does is, number one, it does provide the ability for better fluid transfer and better vascularization. But the challenge is it often comes at the expense of us being able to start feeling issues in the discs. So anytime there might be an annular tear or an annular fissure, hey, if it's breaking through and irritating a bunch of nociceptive nerve fibers which have infiltrated that area, which is why we see this typically happening between 40 and 60 years old, that's when we start to see the pain that comes with those challenges. Incidentally, one other really interesting thing regarding motic changes on the end plates, you know, where the bone meets the disc, is that what the latest research shows is the disc does not actually act as a shock absorber. The bone actually does. So the bone in your back is more willing to get, give, so to speak, or have a little bit of oomph rather than the disc. And the disc is a closed hydrostatic unit. So actually there really is no shock absorption whatsoever. It does not particularly compress down the bone, does it? That was why it was eye opening to me. I actually did a presentation a couple years back for some of our leadership team and some of the surgeons in the multidisciplinary clinic I was at. And it was regarding modic changes. And that was absolutely mind blowing to me because I'd always heard of the disc as a shock absorption absorber. But the bottom line is, over time, we've talked about a little bit of disc, we've talked a little facet. So nerve compression typically is the third thing that comes with that. When we see the facet degenerate, when we see that there start to be osteophytic formation or bone spurs on the end play of the, of where the, the disc meets the vertebral body or on the facet itself, that takes up space, right? Anytime that there's increased load, osteophytic formation typically associated with that, you're going to see some of the ligamentous structure hypertrophic, it's going to become bigger. Not a big deal, except for the fact that you're in a really limited Amount of space. Right. So when we look at the foraminal canals, average foraminal canal might be something like, you know, 8 millimeters tall and 7 millimeters wide, something to that effect. And the spinal canal, as you know, the A to P dimension of that should be 10 millimeters is perfectly normal. So we start to get a millimeter or even 2 millimeters of ligament challenge, hypertrophic ligament, or a millimeter or two of a bone spur. So this starts to decrease every millimeter, about 10% or more of the overall dimension of the space where the nerve's traveling through. So you start to add on a millimeter anteriorly, a millimeter posteriorly, and you start to look at 20, 25% reduction in the overall space where a nerve's traveling through. Now, you can know where that leads to, obviously, whether it's the spinal canal or spinal cord traveling up and down the canal, or whether it's a nerve root traveling out the foraminal canal. That can lead to either mechanical compression, physical mechanical compression, or chemical irritation due to the inflammatory processes. This is what drives ultimately a ton of people into our practices and quite frankly, into other practices as well. If they start to have those ridicular symptoms. Many people deal with a little bit of ache and pain in their back, you know, axial pain. And that's degenerative by nature, mechanical, so to speak. But the bottom line is when people start to have pain that travels down their arm or their leg, numbness and tingling, you know, that's often when it impacts their life to the point where they say, I have to get this checked out. And that is where the process begins as far as a healthcare process. So that's really the degenerative changes in nutshell. Now, what advances those or slows those down? Well, we've seen a few different things. Number one, there is a genetic component. Sometimes you just pull two people, you know, that have a relatively similar job, live in a relatively same area, and they just have dramatically different spines at 40, 50, and 60 years old. So there is a genetic component in terms of how we age and how we age on the inside and the outside, and that includes the degenerative process. Now, injuries along the way also play a huge role. So injuries early on in life or right after skeletal maturity can set things up for advanced change later on. If there's not balance and symmetry, if there's an injury that didn't heal to the best of its ability, so to speak, now you start to end up with compensation patterns that compound over weeks of months, years and Decades. And that starts to result later on in life in pretty significant challenges for many people. And finally, we look at workload and daily habits. So what are those repetitive items that individuals are doing each and every day? It could be a long commute in a car, it could be poor ergonomics at a workstation. It could be just the nature of their job that causes degenerative change due to overuse and repetitive use. So what are some of the things that you and I can guide people on in terms of staying active and staying well and slowing down that process? Well, it comes back to a lot of the same things. Right. We also saw diet as a component of that. So when we can reduce the inflammatory nature of somebody's diet, that's a huge win because it makes the body much less apt to want to cause pain, so to speak. The sensitization goes lower, the thresholds go up, and you have the ability to do more without feeling the pain. So lowering inflammation based upon diet, Absolutely huge. Then we get down to really chiropractic care. When I talk about that, I mean guiding people on exercise, whole body motion, I mean talking about stretching, yoga, things like that, that is regional motion. And I talk all the way down to segmental motion. So we look at segmental motion, which typically falls in line with chiropractic adjustment. We look at regional motion, which could be exercise stretching, and then we look at whole body motion. When you can stay in motion, reduce the inflammatory nature and have better ergonomics within your workpl, you start to create a pretty compelling value proposition for somebody to stay well throughout time. This is why it's so important that when somebody gets out of pain as an evidence form doc, as an evidence based doc, when somebody gets out of pain, a lot of times I see evidence based docs, quote, unquote, ready to push them out the door immediately. The bottom line is if you haven't addressed nutritional issues with them, if you have not addressed proper ergonomics with them, if you have not addressed and been able to help facilitate consistent exercise in motion regionally, segmentally and whol realistically, then the person has a very high likelihood that they're going to be back in your office because they're going to go back to doing the exact same things that got them there in the first place. So being able, tying this all together with a bow, being able to read MRIs, being able to understand the imaging and reduce fears, super, super important. Being able to address the biomechanics with what you physically do in your practice, with the Chiropractic adjustment, absolutely imperative. And being able to be the guide for individuals to better whole body mot in whole body wellness, so to speak, is also super, super important. What drives many people into your practice is the pain and quality of life issue. But be sure to address the next steps you could. Some people take care of that in their office. Some people are just guiding individuals outside of their office. That's for you to choose. But when the pain goes away, that is the first thing to go. Keep in mind for the fact that you know, taking care of somebody doesn't mean three times a week for the next 40 years automatically. There is a middle ground. Don't swing the pendulum so that the first sign of pain decrease. You're getting people out of your practice just because you've been so disillusioned. Let's say with three times a week for the rest of your life. There's a great middle ground there and there is a great, great position. If you listen to last week's interview with Dr. Shawn Drake, it's about performance. It's about human performance and pain is the foundation of that. But it certainly is not the end of the story. So understanding the degenerative cascade, being able to explain that to individuals in your practice and help guiding them towards a better quality of life, will you build and grow your practice? And that's really what we had for today. So if you have any questions about that, shoot me an email. Jeffevidencebasedchiropractor.com Additionally, if you have not left a rating or feedback for us on itunes, I'd encourage you to do so. That's how a ton of docs can find out about the show. Itunes really, really, really loves it when there are a bunch of ratings or reviews. I think we are one of the most rated and reviewed podcasts in the chiropractic industry, but if you have not left one, I'd encourage you to do so. If you're listening iPhone, you can do it right from the iPhone. That helps more docs find out about what we're doing. I hope you guys have a great week in practice and I will talk to you soon.

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