Degenerative Disc Disease
Disc Degeneration, Disc bulge, Slipped Disc, Disc Prolapse or Sciatica are conditions that present with back pain and/or trapped nerves. Disc desiccation is quite a prevalent condition and is often cited as one of the main causes of lower back pain complaints.
The Intervertebral disc or more commonly called spinal disc is located between two adjacent vertebral bodies. There are five discs in the lumbar spine, the first being located between L1/L2 (lumbar vertebra 1&2) and the last one is located between L5/S1 (Lumbar vertebra 5 and Sacrum)
The disc consists of two separate parts. The outer part consists of a series of bands or rings called annulus fibrosus. These bands resemble sliced onion and their behavior can be described as a telephone directory rolled into a tube shape (very strong under compression). The central portion of a disc is called the nucleus pulposus and acts like a jelly substance that has a lot of fluid. Its behavior resembles a spongy ball. Because every vertebra has a distinct shape in the thoracic, lumbar, and cervical spine, the function and structure of the disc also vary.
In the lumbar spine region, the main purpose of the intervertebral disc is to absorb shock and control compressive loads. It is important to mention here that the disc in any other part of the spine is not subjected to the same degree of compression because of the vertebral shape. What this means is that a disc issue in the lumbar spine is very different from a disc issue in the neck.
When the intervertebral disc is subjected to compressive load the central portion (nucleus pulposus) tries to expand sideways but is restrained by the rings of the annulus fibrosus.
The annulus is an elastic structure but more rigid than the nucleus and it resists the pressure to deform – much like the metal rings on a wooden beer keg.
The pressure in the disc varies according to the position of the spine and how long the position is maintained.
Many people find it surprising that the disc is placed under significant pressure when sitting – a daily occurrence for many. This can be a little surprising because sitting doesn’t feel like a lot of effort to sit but it does place continuous compression upon the disc. That’s also why it’s a good idea to get up, move around & change positions regularly even if your job does not require it.
Forward Bending (Spinal Flexion)
Bending forwards causes the front section of the disc to be compressed while the back portion gets stretched.
If this motion is conducted in a repetitive manner such as in jobs that involve bending or hobbies like gardening, this can cause damages to the annulus fibrosus fibers and can lead to degenerative disc disease.
Forward Bending / Twist (Spinal Flexion)
Forward bending or twisting is a very common motion that many of us throughout our lives. However, anyone with back pain issues will attest that this position is the culprit behind acute and sharp lower back pain and chronic back pain sufferers try their best to avoid this position. Workspace safety training advice avoiding bending the spine and instead of using legs to compensate.
Unfortunately, despite several years and decades of rigorous training, the prevalence of pain injuries in the workplace has not been reduced. Under normal conditions, our pelvis, hips, and spine are designed in such a way that they can withstand the pressure of twisting and bending.
If the back gives out suddenly, it usually means there has been an underlying joint change (which is often ignored) and usually stays under the radar. This change alters muscle control and joint mechanics, hence predisposing the pain to injury. The most common underlying factors include poor muscle control i-e spine stiffness, hips and pelvis, trunk and/or hip joints muscle control.
The diagram below illustrates all the stages of change that occur within the disc.
Something important to note here is the fact that the first two stages are considered, for the most part, to be non-painful and rarely generate any symptoms.
Mostly the result from repeated low-grade trauma which, in most cases, doesn’t generate any conscious awareness or inflammation. The inner part of the disc doesn’t have any nerve supply therefore it can’t generate any pain sensation. It is when the condition worsens over time, symptoms are usually felt.
Symptoms of Disc Degeneration
Sciatica (nerve pain in the legs) is the most widely reported and recognized symptom of disc-related issues.
Some sciatica patients might also have back pain but most of the cases are centered around leg pain. If the disc bulges but doesn’t compress any nerves, it might cause pain in the back region (primarily around the hip and buttocks section) and not down the leg.
If the disc itself is painful, it can produce a sensation of pain described as “deep” pain and it is not very easy to locate through the surface.
This pain can either be very sharp (might be referred to as nerve pain) or it can be a more generalized aching sensation that produces discomfort. A disc that is just irritated but hasn’t prolapsed through the annulus fibrosus region might feel very vulnerable similar to any other sprained structure like ankle or knee ligament.
“Too much pressure” in the back region is another sensation often reported and patients often need to lie down to ease the sensation.
Other Common Disc Degeneration Symptoms Include:
- pain when sitting
- pain when sneezing or coughing
- pain during bending
- pain while lifting
- morning stiffness
- pain when turning in bed
- shoulders or hips shifted to one side (lateral shift)
Degenerative Disc Disease Treatment
Physiotherapy treatment options depend on the severity and stage of the condition. The first and foremost priority should be unloading the disc using support strapping, muscle activation, corrective exercises, or in some cases Lumbar corset. One thing important to note here is that every effort should be made to avoid disc bulges progressing to a full hernia which requires surgical intervention. This is one of the main issues faced using different techniques to “put the disc back”
If the disc has shown some signs of recovery (which might take some days to several weeks), the next step in the rehabilitation process should be increasing movement, ensuring food postural muscular function, and increasing load tolerance with very carefully crafted and executed exercise sequences.
This is the most crucial part of the rehabilitation process and if it is not executed properly, it can easily cause a relapse.
Your Physiotherapist will prescribe exercise, this will be precisely selected, executed, and monitored.
In the final phase of the Physiotherapy rehabilitation process, all the normal daily living tasks need to be comfortable, the more advanced and challenging tasks related to your lifestyle should be incorporated into the physiotherapy rehabilitation program gradually.
If your hobby is gardening, the physiotherapy rehabilitation program should focus on ensuring that your spine is fully capable of bending and tolerating that sustained position
In some cases, this type of advanced flexibility might be problematic. For such cases, alternative ergonomic adaptations are required to facilitate the activity.
If the motive behind physiotherapist rehabilitation is to return to sporting activities such as tennis or golf, the advanced stages of rehab need to analyze the components that are involved in these activities, testing each one of these components in a controlled setting under proper supervision and then increasing the load to replicate the particular sport-specific activity.
Doing so requires your sports physiotherapy rehab process to involve a combination of specific manual therapies directed at the joints, coordinating the muscles, specific corrective exercise with some forms of simulated activity in a rehabilitation gym to prepare for activities of daily life.
To sum it up, physiotherapy involves identifying and treating the painful structure and then addressing and treating the causative factors. Causative factors might be a combination of extrinsic factors (such as tools, workstation, time, position, breaks, etc) and intrinsic factors (mechanics of the body). All these elements need to be carefully assessed and treated by a qualified physiotherapist.