Back Pain, Chiropractic, and Disc Degeneration | Podcast Ep. 40

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Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. Today we have an absolutely great episode of the Evidence Based Chiropractor, video podcast and audio podcast, depending upon what your medium is. And we are going to talk about a research paper that came out in 2015. So a brand new piece of research that is titled Disc Degeneration Implies Low Back Pain. This is exquisitely important from a chiropractic perspective to make sure you know this research for your patients, number one, and also for building those channels of communication, number two. So as I said at the top, it's important that we pay attention, or hopefully that you pay attention to today's episode because we are talking about a piece of research that was released in 2015 from the Journal Theoretical Biology and Medical Modeling, kind of a journal that probably you're not particularly familiar with. So I'd be surprised if you're familiar with this piece of research which makes it even more important. Again, the title of this piece is Disc Degeneration Implies Low Back Pain. We know as chiropractors that nearly everybody throughout time is going to experience low back pain or some form of spine complaint, 90 plus percent of the population. We also know that nearly everyone will experience some level of disc degeneration as time goes on. Degenerative changes are a normal part of the aging process. However, it doesn't necessarily have to correlate with pain. The degenerative process of a disc. On an MRI image, as we know, you look at your T2 weighted MRI images and you will find that that disc is darker and as opposed to lighter, it is hypointense rather than hyperintense. And that's because on a T2 weighted MRI image, water shows up as white. So as the disc becomes degenerative, the disc inherently becomes darker on that image. As that disc becomes darker, the instantaneous axis of rotation migrates posteriorly loading the facet joints. We touched on this actually on a previous podcast because the instantaneous axis of rotation is, is that pinpoint where the motion of a disc takes place. And when we're young, that's in the middle of a disc. But as we age and the degenerative process takes hold, that pinpoint migrates or pushes posterior back towards the facet joints, which in turn loads the facet joints more than they are designed to handle. And the degenerative cascade continues down from there. So the other challenge that we experience during this degenerative process is that nociceptive fibers, or truly vessels, infiltrate the annular tissue of a disc. We know the inside of course is the nucleus pulposus. The outside are those annular fibers, the jelly donut analogy. And as time goes on, our body develops or grow vessels or vasculature into the annular fibers of the disc. And that vasculature contains of course nociceptive fibers along with blood vessels. So that sensitizes the disc. So not only does the disc lose water content, the facets get loaded, but then we can also, lo and behold, feel them as we get older, which can lead to pain. This study specifically provides valuable insight into the relationship between disc degeneration and low back pain. Their analysis indicated that the pain associated with long term degenerative changes may be episodic. And that's why many asymptomatic patients may have degenerative changes on film. We also know looking at those MRIs, that many patients who are asymptomatic might have degenerative changes. So this research study starts to correlate perhaps an episodic nature of pain with while the degenerative process continues on. So we know and what we promote of course throughout the evidence based chiropractor is degenerative disc disease. Any sort of degenerative changes of the spine can often be treated non surgically with conservative care. So this is about improving function, it's about decreasing pain. You're not going to reverse a degenerative change, gravity going to take its toll. But as time goes on, you certainly can help improve the function of individuals that come into your office and reduce the pain level, thus increasing their quality of life. Nutrient transfer to that disc is facilitated through motion. So when you're going through and providing a chiropractic adjustment and stimulating that area, stimulating the central nervous system, gapping the facet joints and facilitating motion in that segment, that is a very good way to decrease pain because it's going to gate those nociceptive fibers. Also emerging research of course has shown that chiropractic directly facilitates that nutrient transfer. So we'll talk about a few quotes that the researchers found in this study which are of importance to every chiropractor listening today. The researchers in this study found lumbar intervertebral disc degeneration is nearly ubiquitous among patients with symptomatic low back pain. No kidding. We know now that the pain might be episodic, but the degenerative changes continue on. So when a Patient becomes symptomatic, of course the degenerative changes are there. And even when they're asymptomatic, those degenerative changes might still hold true. The researchers also found the natural history of low back pain shows not only age dependence but also a pattern of remission and recurrence, which is different from other irreversible clinical outcomes such as cancer, stroke or heart attack. So again, we look towards remission and recurrence. Pain might come and go, but the degenerative cascade and gravity, the still take hold. That's important from a referral standpoint as well, because often a pain management physician, perhaps a surgeon, they might, an overzealous one, might look at that degenerative cascade and imply that the patient should have a more aggressive treatment plan, when in all reality the episodic nature of that pain might warrant continued conservative care. The researchers also found disc degeneration is, is well underway and most discernible among the young and continuously rises among an older adult population. As I talk to patients every day in practice, I say, hey, disc degeneration, if you're over about 25 years old, we expect to see some of it. This research re emphasizes that point. And finally, the researchers found, quote, in summary, the complexity of low back pain epidemiology results from the coexistence of two different timescales, the slow dynamics of disc degeneration and the fast dynamics of pain recurrence. So this is another very interesting point in this research because they're harping on what we've spoke of earlier, but putting it into a clinical context, and that is the fact that episodic pain might become very acute, subacute and chronic and it can certainly flare up to that 10 out of 10 on a visual analog scale. But the disc degeneration process is a slow burn that takes place over decades. As we lose that hydration, as we lose mobility and as the facets become loaded and the disc loses water content, our body continually goes through that degenerative cascade with ebbs and flows of potential periodic pain. This is why in my opinion, the research has shown chiropractic care to be so effective in the long term treatment of these patients. Now we're going to do short term care. It certainly is what we recommend at the evidence based chiropractor for individual bouts as far as the frequency and duration of those visits. But as time goes on, I think all signs of the research point to the fact that conservative chiropractic care stimulating the central nervous system, mobilizing the facet joints, working on the disc, providing motion, providing stability, and is exquisitely important in at least slowing down that degenerative process. On top of that, as chiropractors we're able to offer nutritional advice. Many chiropractors get into active care, so all of those things can truly make a seismic shift in what our patients experience as months become quarters, become years, become decades down the road. So I think it's important from a clinical perspective as we touched on on the top, that you should be aware of this information and aware of research such as this not only to be able to communicate that with your patients, but we highlighted this not too terribly long ago in November of 2015 for all of our members. Again, this research came out in 2015 and we highlighted it as a monthly piece of research for our members in November 15th. And that is in order to bridge the gap and in order to make sure that our members with the evidence based chiropractor are able to accurately bring value to other providers in their community. So when you can position your practice as a leader in musculoskeletal care, a leader in the conservative care space, and provide value to other practitioners through research, through highlighting pertinent research, and through highlighting research which is going to impact their clinical decision making and your clinical decision making, you really start to create a nice situation to be able to co manage and refer patients back and forth, which is something that has been sorely lacking in chiropractic throughout time. So that is really the heavy hitters for this week's episode of the Evanist Space Chiropractor podcast, audio or video component. 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