436- The Role of Genetics and Environmental Factors in Disc Pathology

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 back with another brand new study. It is an awesome one and it is all around intervertebral discs and it basically highlights what did we know in the past, what do we know today, what are the differences and what are some risk factors for pathology of the disc. Lot of great clinical pearls take home messages, action items you can use in conversations with your patients. Probably literally starting today. Before we get started on today's episode, I want to say a few words about neckcare.com Objective assessments of the cervical spine. You've heard me talk about it. I hope you have seen my video on YouTube. This is the most reliable assessment of the cervical spine I have ever seen. Neuromusculoskeletal control, proprioception, range of motion, sensory motor integration. If you are serious about cervical spine assessments, you have to check out neckcare neckcare.com again that is neckcare.com and I'll drop a link down in the show. Notes Technology is absolutely awesome and I'm looking at a unit of theirs about six feet away from where I'm at right now. Absolutely fantastic. Check it out neckcare.com but as I said at the top, we're talking discs and the title of this study. I'll drop a link down in the show. Notes. Risk factors for intervertebral disc A point of view Formerly and today a review. So discs are something we see and work with pretty much every single day as chiropractors and it is a critical component of what drives people into our practices, our challenges with the discs. But we also know that over time a lot of our knowledge has evolved. What causes disc pathology? How do people get into some of these pretty difficult situations regarding compressor compression, compressive pathology related to their discs, disc bulges, herniations, et cetera. We're going to dive into that. So let's start with the spine itself. As everybody knows, spine is has five primary parts or segments regions cervical spine, thoracic spine, lumbar, sacral and coccygeal region. This provides flexibility and mobility and also provides protection to the spinal cord. Primary items of the spine that we all know very well. Now the discs, of course they support the spinal column and and behave like shock absorbing cushions against axial load. Now, interestingly, I wanna point out, we also have come to learn that the vertebral bodies actually also act as more of a shock absorber than the discs themselves. That was totally mind blowing to me a few years ago, learning that because the discs have hydrostatic forces, they do have give and take, so to speak. But the shock absorption a lot of times comes from the vertebral body. Now, when there's a limitation of matter that can obviously result in a compression fracture, right? Either the bone is too brittle or the load is too heavy. And we know that the vertebra quite often will shatter with abject axial load prior to the disc exploding, so to speak. It's the. We're gonna get into this in this episode. But the annular fibers, when there's fissures, degenerative changes. Now we start to see disc herniations, little change. But the discs, typically, there's always exceptions, don't blow out. Most often the actual vertebral body will blow out, AKA compression fracture prior to the disc, which is really, really wild. So the discs have, of course, two primary components. Nucleus pulposus, inner part, annulus fibrosis, the outer part, nucleus pulposus. Remember type 2 collagen? I did not remember that. And this makes up about 20% of the dry weight of the disc. A lot of proteoglycans in there that also maintain that hydrostatic press. So a lot of stuff going on in the nucleus pulposus. The annulus fibrosis is type 1 collagen. I had forgotten that as well. So good reminder there. Which forms that fibrous tissue around the nucleus. And the annulus is attached to the vertebral body by those sharpie fibers. Had not heard that in a while. So intervertebral disc pathology is a common name for an array of different pathologies connected to the disc. This includes degenerative changes, disc associated pain, disc herniations, histological changes, changes, pretty much that all falls under the bucket of intervertebral disc pathology. Now, important to remember the histological findings. They can be associated with disc degeneration. This is an increase in cell density, chondrocyte proliferation, the occurrence of granular changes, structural alterations. This can be tears and clefts in addition to a severe increase in polysaccharides. So all of this can happen when we start. Those are some of the changes we can. Some we can see and some we can't see. But they are all associated with disc degeneration. Now, a herniated disc, disc pathology when part of the nucleus protrudes through the annulus. The most common, this is interesting to me. The most common type of. Is chronic herniation, which occurs due to reduced proteoglycan content. Therefore, the nucleus pulposus is weakened due to a loss of hydration. In contrast, acute herniation, as you can probably now piece this together, occurs because of trauma resulting in the nucleus pulposis extruding through a defect in the annulus. So those are two different brackets or buckets that I had not thought of in a while. Now, if we look at the studies and the research that have come over the last hundred years or so, there's a lot of environmental factors that are brought up with not really any mention of genetic factors. Lift and heavy stuff, you know, staying still all day, lifting heavy all day. Right. Those environmental factors that we're all super familiar with. But there's been very little research until recently. And this is where we're going to go today in terms of potential genetic factors that could predispose. Now, I want to be careful with this and I'm probably going to come back around to it later in the episode, but this is a fine line, especially conversationally with patients. When we talk about genetic factors, it does not mean throw your hands up in the air, nothing I can do about it. That is nothing farther from the truth. A genetic factor may have, may not absolute, may have a predisposition for something, but it's still the environmental factors, nature versus nurture, right. That ultimately can supersede that. They can accelerate that natural tendency or that predisposition, or your environmental factors can dramatically slow or sometimes reverse that factor. So it's a factor, not an absolute. And quite often for people that don't live and breathe in the healthcare space every day, and so many that do, as a matter of fact, you can hear genetic factors and believe that that's. Well, it's preordained. Right. That's just gonna do what it. That's not true. The. The genetic factor can nearly always be impacted by environmental factors, some dramatically impacted, some less impacted. But that is the truth we all need to keep in mind. So there have been these new molecular studies that have been coming out, pretty interesting, and they cast doubt that environmental factors are the only cause. Well, duh. Of course there's a potentially a genetic component, but that doesn't mean to go the other direction with this. So over the years, the classical theory of aging and wear and tear has evolved into a sophisticated model that has multiple causative events in multiple disease processes based on molecular and genetic alterations combined with environmental factors. Now, they highlight in this study that genetic factors appear to play a pretty big role in the pathology of diseases associated with disc generation. But they can be influenced by environmental factors such as injuries. Right. Predisposition. You had previous injuries. Now you have maybe biomechanically. How would you say biomechanically, you're not at your best occupation. Smoking, aging. All of these factors can play with environmental and that balance between environmental and genetic factors. Now, environmental factors may only serve to accelerate the process of disc generation or slow it down, depending upon the factors. So what are some of the genetic factors? We'll highlight some. This study goes into pretty good detail, but I'm gonna highlight them just at a high level here. Some of these important genetic factors, some of them are new to me. Vitamin D receptors. Interesting that vitamin D could play a critical role. A lot to be unpacked. This goes into some detail, but I got a feeling there's gonna be a lot of future studies, and that is something to think about as well. If you have individuals that have disc issues, are they getting enough vitamin D? Really interesting. Especially in the. Maybe the colder months for the wintertime, Right. When vitamin D really needs to be supplemented. People aren't getting outside, or if they are fully clothed, et cetera. Right. So really important to think about vitamin D as a genetic factor or the receptors. Collagen type 1, important. Collagen type 9, important. Collagen type 11, important. In addition to that, we look at interleukin 1, interleukin 6. How are these inflammatory cytokines, these mediators? How are your. Is your body genetically predisposed to either facilitating them getting out or limiting their ability to get out? We all have these just different kind of thresholds, and that's what they're referring to with these genetic factors. Now, there are some factors that have nothing to do with genetics whatsoever, and they are age old. One of them is age, and the other one is smoking status. So they also highlight the fact that disc degeneration may be associated with occupation. And there's some specific criteria around that. But there's no question that smoking is a risk factor for disc issues. Why? Well, because smoking causes the contraction of capillary vessels, leads to decreased diffusion of nutrition to the disc. That just puts it in a precarious situation. There's no other way around it. There's also a decreased amount of collagen, which can be a predisposing factor to traumatic injury. So Smoking can increase your likelihood of injury and it also just puts it in a bad state to begin with, thereby increasing your. So bottom line is, avoid smoking when you can. It'll leave you to better health overall, but it actually affects your spinal health pretty directly. Now, work as well, right? Occupation. There are previous studies that have showed physical workload had the most influence when we look at factoring. So physical workload was really, really important. Hard work, heavy work, work period, stress at work period, meaning more than eight hours of he stress at work. All of those items are really, really important. When we start to think and consider what are those environmental factors that might play the biggest role. Now, as you hear that and specifically from a patient point of view, it's like, okay, well, what do I do about all this? Right? That leads into prevention. So they highlighted some really, really important aspects of prevention at a high level and we will just touch upon them today. So one, and these are just very direct factors. How do you prevent disc issues or reduce the risk of a disc issue? You avoid an elevated body mass index. So bmi, absolutely something that needs to be looked at. And it's just the way it is. It's important. Load matters, stress matters. And when you're carrying a lot of extra load, at best, you're probably going to change your biomechanics. At worst, you're going to change your biomechanics and just have cascading issues relative to disc and spinal health, as well as other issues, of course, chronic, chronic disease. So avoiding elevated bmi, important in prevention, avoiding smoking. We just kind of touched on that. Really important in prevention. Stretching often when sitting for long periods of time. So this is a really interesting one because we've historically looked at this and said, well, if you're lifting heavy stuff improperly all day, you could suffer from a disc challenge. True. But what's more interesting, in my opinion, that could be up becomes pretty obvious, right? Lift, lift with your legs, have good technique, good ergonomics, but everybody that's sitting at an office chair might be at a higher risk. So really stressing the importance, we think about how seriously, when we hear about somebody who has a really physical job, a lot of us dive in, right? We're like, ah, let's talk about lifting technique, let's talk about ergonomics, let's talk about all this stuff. And we geek out on it. When often somebody that has a sedentary role, which is most of your patients sitting at a desk all day, we're like, oh, you should get up and exercise and stretch. We should take that just as, if not more seriously. So stretching often when sitting for long periods of time, Absolutely critical component. Again, I'll say it one more time for emphasis. Stretching often when sitting for long periods of time. This is a preventative mechanism and it needs to be talked about in a really, really proactive sense. Additional regular physical exercise, really important from a preventative standpoint. Obviously, nutrition comes into a disc through movement. Strength and flexibility are built through movement. So absolutely critical to have that. So as they kind of look back at the turn to the turn of the 21st century, they say many studies were performed regarding the origin of challenges to the discs. And while aging and wear and tear were really the thought process from before, that's expanded over time doesn't mean it's been eliminated. Aging is still a factor. Wear and tear, whether seated or sedentary, and inactivity by being seated too much or overdoing it. Long hours, heavy lifting, poor ergonomics, both are challenges, right? The sweet spots in the middle. You want to be able to move your body, but move it to the point of stress, not to the point of breakage. And that's really, really critical. So they highlight the fact that this has changed over time and now it's a really sophisticated multi causative disease. When they look at disc challenges based on environmental factors, molecular changes, genetic alterations, so all really, really important. Now, how much do we know about when somebody walks in, do they have genetic challenges that could lead to that? Probably not that much at this point in time. This research is brand new. Does everybody need to go run out and get genetic marker testing to know if they're at liberty for a disc issue? No, not yet. At this point in time for most people, most of the time just doing the right thing, drinking enough water, getting enough rest, moving their body to the point of building strength and flexibility, but not to the point of injury, and maintaining a good bmi, not smoking for most cases, most of the time, these are the items that are going to make a substantial impact. Much more than any predisposition. They're going to override, should I say any genetic predisposition based upon doing the right things with consistency over a long period of time. However, it's important to note that we continue to learn more about molecular and genetic changes. So I love this study. I thought it was a really, really great one. I hope you did too. If you have any feedback, of course you can leave it. Jeff, the evidence basedchiropractor.com if you have not left a rating or review for this podcast. Maybe you're a new listener, maybe you're a veteran listener. I would love to have your ratings or reviews whether on Spotify or on Apple Podcasts. It helps more and more docs Find out about this podcast and before we wrap up, I want to say a few words about Patient Pilot by the Smart Chiropractor if you have more than 500 people in your EHR of inactive patients and you're not actively communicating with them every single week, we want to work with you. Communicating with your patients is a great idea. We can send patient reactivation emails to your patients each and every week. We can show you the stats of who's opening, who's clicking, who is taking action and most likely to come back in. And what that results in is more patient reactivations. Some patients will click in those emails and hop right back onto your phone, hop right back onto your calendar schedule themselves. Others we will give you a super hot leads list, a patient recall list that's not just well since last time somebody came in blindly calling and wasting time. But being hyper specific, who's engaging with my practice? Because those are the people who are most likely to come back in. So if you want to set your team up for easier patient reactivations while driving the process in an automated fashion week in and week out, we want to have a conversation. We'd love to work with you. You can Visit us@thesmartchiropractor.com and again, I'll drop that below in the show notes thesmartchiropractor.com Other than that, thank you for being a chiropractor. Thank you for tuning in. I hope you have an awesome week in practice and I will talk to you soon.

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