Degenerative
Disc Disease
Definition:
Degenerative disc disease is a consequence of aging or "wear and
tear" of the back. It refers to the changes that take place in the
discs separating the bones of the back. Disc disease is very common and
in the majority of cases, the outlook is good. Several factors are
involved in disc degeneration including genetic make-up and repetitive
overload or stress to the discs. As a result, other structures of the
spine also suffer wear and tear. Commonly, this occurs at the joints
that link the bones of the spine together called facet joints. This
increases the risk of additional problems such as disc herniation and
secondary problems such as spinal stenosis (spinal canal narrowing).
Symptoms:
The symptoms present in degenerative disc disease depend upon what
structures are being affected. In the early stages, back pain may be the
main symptom. However, if the disc disease is advanced and facet joint
degeneration has occurred, the space where the nerves exit the spine may
be narrowed. In such a case, often both back and leg pain occur.
Treatment Options:
This condition is generally manageable with appropriate treatment.
Physical therapy is often used to help with stretching and exercise in
order to correct mechanical problems present in the region of the low
back and pelvis. Degenerative disc disease may result from imbalances in
the muscles and ligaments around the spine, but patients can be taught
how to stretch tight muscles and strengthen weakened ones. Correction of
such imbalances will alleviate stress on facet joints and discs.
The
pain which results from degenerative discs can often be attributed to
inflammation. Patients are often started on a trial of anti-inflammatory
medications such as ibuprofen, naproxen and others. For more severe and
persistent pain, an injection of steroid (a very strong
anti-inflammatory pain medication) may be indicated. These procedures
use x-ray guidance to place medications directly at the source of the
pain. Surgery is rarely a consideration unless a patient experiences
substantial problems with nerve compression or experiences significant
changes in lifestyle that have not responded to non-surgical treatment.
Sometimes,
in spite of our very best treatment efforts, pain may still be present.
It is not uncommon and it is not usually dangerous. Exercise and
modifying one's activities can sometimes be the best way to achieve the
highest degree of function and minimize symptoms.
Reducing the Risk of
Degenerative Disc Disease:
People who have degenerative disc disease must alter particular
activities that cause or worsen their symptoms. Certain lifestyle
changes are recommended. For example, smoking can lead directly to
diminished blood flow in the back and can decrease the flow of vital
nutrients necessary for a healthy spine. Consequently, smoking cessation
is important. Maintaining ideal body weight is also important. The spine
supports the body from the hips up and extra weight puts extra,
unnecessary stress on it.
It
is helpful to follow a regular exercise program specifically designed
for the back and pelvic region. Regular aerobic walking is also helpful.
There are no specific guidelines regarding what activities should be
avoided. Each patient must be evaluated and advised on an individual
basis.
Disc
Herniation
Definition:
The intervertebral disc is a cushion or shock absorber between the bones
of the back and neck. A disc consists of two separate components. A
jelly-like center is surrounded by rings of cartilage. With wear and
tear or injury, some of the rings of collagen are weakened. Disc
herniation occurs when some of the jelly-like central disc material
pushes through a defect in the outer portion of the disc.
Symptoms:
The symptoms present from a disc herniation can be quite varied. A
person may not experience any significant pain. However, most people
with a disc herniation experience some degree of neck or back pain. The
location and severity of the symptoms are dependent upon what structures
are irritated. For example, if the disc presses against a nerve root,
one can develop "referred pain" (pain down the arms with a
neck herniation and down the legs with a back herniation).This pain may
worsen or improve with certain actions or changes in body position.
Treatment Options:
Initial treatment of a disc herniation focuses on pain control. Patients
are usually given anti-inflammatory medications such as ibuprofen or
naproxen and non-narcotic pain medications. The second step is
modification of certain activities which are likely to increase pain.
Prolonged bed rest is not recommended. Specific exercises can decrease
symptoms dramatically, so physical therapy with a therapist specializing
in spine-care is initiated. For more severe and persistent pain,
epidural steroid injections are often used to provide pain relief and
decrease inflammation.
This
condition is generally manageable with appropriate treatment. In 80 to
90 percent of cases the above measures combined with approximately 4 to
6 weeks of time to heal are enough to manage symptoms. Only when
symptoms remain unmanageable are more invasive procedures considered.
These may include minimally invasive procedures to decompress the disc
or surgery.
Unfortunately,
there is no "guaranteed or permanent cure". Surgery is a last
resort and considered only when all other options have been exhausted.
Indications for
Surgery:
- Progressive weakness
in the arm or leg affected by the disc herniation.
- Progressive loss of
sensation
- An inability to
control urination or bowel movements. This may mean an inability to
pass urine or wetting or soiling clothing.
- Severe, intractable
pain present for greater than 3 months which significantly
diminishes quality of life.
Prognosis:
Although aggressive conservative treatment plans are very effective, a
patient with a disc herniation is always at a higher risk for recurrent
episodes of back or neck pain. Exercise and modifying one's activities
can sometimes be the best way to achieve the highest degree of function,
minimize symptoms and reduce the risk of future problems. Patients
should use common sense and ease into more strenuous activities. Most
people are able to return to their former jobs and recreational
activities without restriction. It is helpful to follow a regular
exercise program specifically designed by a physical therapist and your
spine physician.
Myofascial
Pain Syndrome
Definition:
Myofascial pain syndrome is thought to be a form of muscle or soft
tissue pain. It may result from a single significant trauma such as a
motor vehicle accident. It may also result from repetitive minor trauma.
Patients develop "tight", "sore" or irritated
muscles. There is a tendency for the development of poorly functioning
areas of muscle called trigger or tender points. These areas may be felt
as "knots" of tissue under the skin. An experienced clinician
can determine whether painful regions are indicative of myofascial pain
syndrome. When trigger points are present and active, they can lead to
localized discomfort as well as pain in nearby muscles.
Myofascial Pain
versus Fibromyalgia:
Although often used interchangeably by patients and physicians, these
are different conditions. Fibromyalgia is considered part systemic
disease and part syndrome. It has more clearly defined criteria for
diagnosis, including pain present for more than three months, sleep
disturbance, and a minimum number of specific tender points. It is more
generalized with pain above and below the waist and on both sides of the
body. Fibromyalgia may also be associated with irritable bowel syndrome,
chronic fatigue syndrome, depression and mitral valve prolapse. There
may also be a family association.
Myofascial
pain syndrome is typically more localized and less likely to be
associated with systemic conditions. There are no laboratory,
radiographic or other diagnostic tests for myofascial pain syndrome or
fibromyalgia. The diagnosis is made when other conditions are not
present or "ruled out".
Symptoms:
Symptoms are usually confined to the muscle itself or muscle located
near a painful joint. The pain can be aggravated by motion and relieved
with rest. Range of motion may be impaired. Trigger points are thought
to result in or result from prolonged muscle spasm. These areas are
stiff and painful to the touch. Stress, limited sleep, and
deconditioning make symptoms significantly worse.
Treatment Options:
Successful long-term treatment involves proper exercise. An
individualized program of stretching and cardiovascular exercise is the
mainstay of treatment. The key ingredients to preventing recurrence are
strengthening the involved muscles and restoring physical activity.
Non-impact activities such as brisk walking, swimming and bicycling are
often helpful in preventing deconditioning.
Anti-inflammatory
medications also called NSAIDS such as ibuprofen and naproxen can be
helpful. Muscle relaxants and low dose anti-depressants have a role in
relieving spasm and helping to restore sleep patterns. Intramuscular or
trigger point injections can be very helpful when trigger points are
present.
Specific
physical therapy techniques such as neuromuscular massage and myofascial
release can provide significant relief as can moist heat and TENS (a
form of electrical stimulation).
In
stubborn, persistent cases additional resources are used to teach
patients techniques to promote relaxation and enable functioning despite
discomfort. These include stress management, biofeedback and
psychotherapy.
Tobacco
use and caffeinated beverages need to be discontinued. Caffeine and
nicotine are stimulants. They have been found to irritate muscles and
perpetuate muscular or myofascial pain.
