Degenerative Disc Disease (DDD),Pinched Nerves and Proper PostureHow are they Related?The Five System Approach to Treatment
- Mark
- Mar 15
- 13 min read
BY: MIKE DIXON, RMT
Through my 38 years of practicing massage therapy, I have had the opportunity to meet and treat many people with conditions, such as “Degenerative Disc Disease” (DDD).
Patients, who receive this diagnosis from their physicians, often are left with the feeling of despair and hopelessness. I wanted to author an article that can be useful to the reader in understanding DDD. Frequently, this condition is misunderstood or better yet not understood. When a patient receives the diagnosis of DDD, this does not mean that he/she is disabled and does not mean that they are headed for a downward spiral of health and further spinal degeneration. DDD tends to be part of the natural aging process that we all go through, to one extent or another. In this article, I hope to explain degenerative disc disease, the resulting signs, and symptoms, and what can be done about managing this condition.
Firstly, we need to know a few facts about the body as it ages. Secondly, we need to have a general understanding of what the condition is, and thirdly, we need to know what can be accomplished to mediate the effects of this condition. I will try to explain this in terms so that the general population can comprehend it, as many articles are written for the medical practitioner, and as so, not comprehensible to the general public.
What happens to our bodies as we age?
As we age, the body’s mobility starts to decrease. We start to feel stiff in the mornings, and it’s generally harder to get out of bed. The first 30 minutes in the morning are the worst and then the body starts to loosen or warm up. It also may be harder to find a comfortable position to lie in when going to bed. Turning over in bed might start to become a challenge, whereas before, you may have never given it a second thought. Yes, even sex might be difficult at times. I am sure this hits home with the reader who is now past forty-five years of age. It is also common, for the younger population, not to relate to these signs of aging, as they have not yet experienced it.1 By the age of 35, approximately 30% of people will show evidence of disc degeneration at one or more levels.
These are all normal incremental symptoms people feel, usually starting at around 35-40 years of age. So why does this happen?
One of a plethora of reasons is when we are younger, our intervertebral discs, which are situated or positioned between each vertebra in our spine, are full of a viscous fluid (jelly-like material). This fluid is called the nucleus pulposus. The nucleus pulposus is in the center of each disc; whereas the outside of the disc is a tough fibrous tissue called the annulus fibrosis. To give an analogy to this, discs are akin to a rubber tire on a car that is full of jelly, instead of air. The rubber tire is like the annulus fibrosis, and the air inside the tire is where the jelly-like substance is.
As we age, the fluid in the disc becomes thicker and the annulus fibrosis degrades or weakens. The fluid becomes more like tar than jelly. Being a proud Canadian, I call this the “hockey puck syndrome”, as the disc becomes more like hockey pucks rather than tires full of jelly. 2
By the age of 60, 90% of people will have some degree of degeneration as the disc dehydrates. Most of the fluid has transformed into this much thicker tar-like fluid, than soft hydrated jelly. The outside of the disc, the annulus fibrosis, may become bulging, develop cracks, or may herniate. (leaking the nucleus pulposus).
This scenario primarily plays out (pun intended) in the lower back, between the fourth and fifth vertebrae and the fifth vertebrae and the sacrum. These are the aptly named the L4 and L5 intervertebral discs.
Discogenic pain (pain arising from discs or surrounding tissues) can be felt in the lower back when these discs are dehydrated and deformed. It is not necessarily the disc causing any pain but the pressure from the disc on the surrounding tissues especially the nerves exiting the spine. The secondary area that is affected is the cervical spine (neck) usually between C4-C5, C5-C6, and C6-C7. Or the mid to lower part of the neck.
This degrading process of the discs is known as degenerative disc disease.
In some people, as the discs degrade, the space for the nerves where they exit out of the spine, called the intervertebral foramina, or IVFs, becomes narrow. This narrowing, or stenosis, can put pressure on the nerves that exit the spine where they travel to the arms or legs.
When this stenosis (narrowing) occurs in the neck, it can cause pressure on the cervical nerves. This is sometimes called a pinched nerve. When pressure is applied to the nerves in the lower back or lumbar spine, it can cause a condition called Sciatica, which is when pain radiates down the back side of the leg to the heel. When the pressure is applied to the nerve roots at the neck, or cervical spine, the pain travels down the arm and sometimes into the hand depending on which nerve is compressed.
The most common area of compression in the neck is the C5 nerve root, which causes pain radiating over the deltoid (shoulder) and outside of the upper arm or lateral brachial region. The most common area of compression in the lower back is the L5 nerve root, which causes pain radiating down the leg to the heel.
These areas of pain or sometimes numbness, are aptly called the dermatomes, which are the areas of skin that are supplied by that particular nerve root. If the muscle is affected corresponding to the nerve root, this is called the myotome. Muscular weakness without any pain is possible when the myotome is affected and not the dermatome. If the dermatome is affected without the myotome, then pain or numbness is felt according to the nerve root being compressed. So, the symptoms are dependent on which nerve that is being compressed.
These conditions are known as peripheral nerve stenosis, which means a decrease in the opening of the nerves exiting the spine (Intervertebral Foramina). These conditions can be very painful and limiting to functional activities such as walking, running, hiking, and daily grooming activities, like brushing the hair and getting dressed. These activities can pose a real problem for some people who have this affliction.
Ok, now that we understand some of what may be happening with this condition (DDD), what can we do to help mediate the effects of this condition?
Here is my “five-system approach” to conservative treatment and management of DDD.
Here is the “five system approach”:
1. Education
2. Postural correction or mechanical extension of the spine
3. Nerve mobilization and mechanical drainage
4. Exercise therapy for core stability and cardiovascular health
5. Therapist-assisted maintenance for general spinal and musculoskeletal health.
1. Education
The client/patient must understand the condition and the musculoskeletal effects of poor posture including sitting and standing postures. A healthy spine is a spine that has gentle curves from front to back (anterior to posterior). The lower back or lumbar spine should have a small curve forward called a lordosis. The middle back or thoracic curve should gently curve backward, called a kyphosis. The neck or cervical spine should have a gentle curve forward, called a cervical lordosis. When these curves are increased or decreased, the result is an enormous amount of stress on the discs (IVD) and the facet joints in the spine.
Let’s talk about the 3 joint complex for a moment.
The three joints that support each vertebrae, allow us to move freely and in multiple directions. They are the two facet joints on either side of the vertebrae (see Figure #2 and the disc (IVD) in between each vertebra). These three structures are known as the three-joint complex. Each of these structures is designed to control and attenuate specific loads onto the spine. When one of these structures is affected, the other two are also affected. One of these structures can’t be affected without the other being affected.
When the disc is disrupted, so are the facet joints, and when the facet joints are disrupted so are the discs. This tri-complex is notably so connected that mechanical disruption of any of the components of the “three joint complex” can lead to DDD and osteoarthritis of the spine. Compare this, if you will, to a car; if the tire is flat and you continue to drive on it, the wheel and bearings will break down. If the bearings and rim are not right, then the tire will break down. One of these 3 complexes can’t work without the proper function of the other.
Results that are seen on imaging (MRIs, x-rays, CAT scans, etc.) are that DDD and osteoarthritis of the facet joints go hand in hand with each other. The term that is used is Spondylosis.
2. Postural Correction
Again, and to reiterate, poor posture puts an enormous amount of pressure on the skeleton, especially the discs between the vertebrae. The truth is that gravity pulls us forward into a slumped posture. When you have a slumped or forward posture, there is a lot of pressure on the discs (IVDs), which causes discs to slowly degrade. Simply put, the fluid within the disc creates bulges in the annulus fibrosis and causes disc degeneration. This degeneration can cause spinal, and back pain and sometimes leg and arm pain.
The following is what I commonly see and observe every day in my practice. I will outline the following three dysfunctional postures:
1. Head forward carriage or posture.
2. Slumped posture with rounded shoulders (Hyperkyphosis).
3. Flattening of the lower back (hypolordosis) and or exaggerated curve in the lower back (hyperlordosis)
a. Head forward carriage or head forward posture.
Most people have 1–3 inches of head forward carriage or posture. This is viewed and measured from the center of the ear to the center of the shoulder joint while looking at the side view of the person.
A general guide is that for every inch of head forward posture the neck (cervical spine) compression is equal to the weight of the head. So, for example, if the head weighs 8 pounds, and a head forward posture of 3 inches is noted, then this position adds 24 pounds of stress on the discs (IVDs), and facet joints. This prolonged stress can lead to DDD. So, correcting head forward carriage can unload the compressed discs and joints significantly. This procedure can reduce neck and arm pains and even reduce headaches. The solution is to do a mechanical correction of the head forward posture supported or followed up by specific exercise therapy.
b. Hyperkyphosis or slumped forward posture of the upper thoracic spine and rib cage.
This is when the shoulders are rounded forward, and the spine is rounded too far backward. The muscles in the back are too weak and the chest muscles are too short and tight. The back muscles have what is known as stretch weakness.
The rib cage starts to compress in the front of the body. This posture generates pain in between the shoulder blades, upper back tension, and stress in the trapezius and related muscles. Myofascial pain can result from weakened back muscles which are over-stretched. Some of these muscles develop active trigger points which can generate severe muscle-skeletal pain.
In this typical posture, the muscles in the back are constantly contracting to try, unsuccessfully, to right or correct the person’s posture (fighting against gravity).
This muscle-skeletal condition is an extremely common complaint of slumped posture or hyperkyphosis. Along with muscle-skeletal pain, the cardiovascular (heart-lung) system is compromised as the heart and lungs get compressed between the spine and the rib cage/sternum (chest bone). The abdominal organs can also be negatively affected due to compression and lack of proper nerve flow from the spine to the organs and visceral tissue. For example, with the condition of hyperkyphosis, I have found a correlation to a condition called Gastroesophageal Reflux Disease or GERD (see Published Article in Massage Therapy Canada Magazine, Fall 2011). It is my experience that long-standing cases of GERD have had remarkable positive changes, with a reduction of the symptoms of this disease, after performing a mechanical reduction of the hyperkyphosis. Muscle-skeletal pain often resolves with this correction and specific exercise therapy.
c. Flattening of the low back (hypolordosis) and or exaggerated curve in low back (hyperlordosis)
This is when the lower back flattens out and the gluteals (bum muscles) start to shrink or flatten (muscular atrophy). This flattening is most notably found in the aging population, with males being affected more than females. This posture puts undue stress on the discs (IVF) in the lower back (Lumbar spine).
To understand the mechanics of this, normally the discs support about 75% of the weight of the trunk, and the corresponding facet joints are about 25% of the weight of the trunk. When this ratio is disrupted or changed, the degenerative changes can occur. With a flat back posture, the discs (IVDs) attenuate or support 100% of the load. This added stress compresses the discs into a flat arrangement creating possible herniations or disc derangements (bulging tires). This derangement can lead to DDD. A wrong lift or twist can spell disaster with the herniation of a disc resulting in severe spinal pain and likely sciatica.
Hyperlordosis or an exaggerated lumbar curve
On the other hand, if the low back curve is exaggerated, then the facet joints are over-compressed, which can lead to degeneration of the facet joints. The condition where the facet joints degenerate is called a degenerative joint disease DJD or Spondylosis. These two conditions often occur simultaneously. Severe back pain can be the result of either of these two conditions or the two conditions coexisting.
So, I come back to what can be done about treating spinal pain and conditions associated with it, like degenerative disc disease, and degenerative joint disease. I have clinically found that mechanically correcting the posture and reshaping the intervertebral disc goes a long way to reducing or eliminating back and nerve pain. Especially conditions like Sciatica and radiating limb pain caused by peripheral stenosis (pressure on the nerve roots). How is this procedure performed, and what are the effects of this procedure?
2. Postural extension or mechanical extension of the spine.
The process is quite passive and done only to the patient's comfort level. The patient will lie face down on a specially designed treatment table, after receiving a massage to the back muscles to soften the muscle tissue and reduce tension. The patient is covered with a blanket or towel. A broad strap is placed over the lower back or mid back (the area to be treated). Slowly, the patient is extended (bent backward) with the use of the moving parts of the table. This is done only to the patient’s comfort level. Traction is then applied to the spine to decompress the facet joints.
The position of extension allows the viscous fluid within the discs to shift towards the front side of the disc (anteriorly) shifting away from the back side of the disc. The shifting of the fluid takes the pressure off of the backward side of the disc (posterior wall) ligaments and supporting structures allowing the body to regain the proper spinal curves and alignment.
3. Nerve Mobilization and Mechanical Drainage of Nerves
Pain that travels down a limb, whether it is an arm or a leg, usually means the nerve associated with that body part is likely being compressed at the nerve root level. The nerve root compression can lead to radiating pain, loss of motor control (muscular weakness), and or loss of autonomic function (blood vessel control) which affects the blood flow, which in turn can cause swelling in the limb. People who suffer from Sciatica or a pinched nerve in the neck can well relate to these symptoms.
Nerve mobilization and mechanical drainage of the nerves help to decrease the swelling within the nerve to allow for better functioning of the neurovascular bundles. These techniques help to restore proper functioning to the nerves and therefore the quicker return to normal functional activities of daily living. These techniques are not within the scope of this article but have been well described by the works of Dr. David Decamillis and Dr. David S. Butler.
4. Exercise Therapy for Core Stability and Crdiovascular Health
To support the postural corrections, proper strengthening and stretching exercises are indicated, as spinal alignment needs a proper strength-length balance of supporting muscular tissue. Core stability exercises have been well documented to help the body recover from spinal conditions and muscular skeletal injuries. These types of exercises should be incorporated into an exercise program to maintain the proper health and function of our bodies.
Cardiovascular health benefits should not go without mention, as a strong cardiovascular system has a plethora of positive benefits for the human body including muscular-skeletal and systemic health.
The above three elements: stretching and strengthening, core stability exercises, and cardiovascular training are needed for proper alignment, musculoskeletal health, and overall healthy body conditioning.
5. Therapist-Assisted Maintenance for General Spinal and Musculoskeletal Health
In today’s living and world, due to the ergonomics of the workplace, i.e. sitting and working on the computer and many other factors of activities of daily living, everyone needs some help, guidance, and reminders for health. This should include mechanical correction of posture for the majority of the population. I call this the “spinal tune-up”. Many of my patients will book appointments for spinal tune-ups which include the postural correction techniques and exercise recommendations. Patients will often say something like: “Wow I feel straighter”, or, “My body feels like it is taller”. One athlete reported feeling like she had an extra lung. One patient reported that his GERD had completely gone away after having it for 19 years. (see gastroesophageal reflux disease massage therapy Canada Fall 2011 by Mike Dixon).
Regular spinal maintenance is much better than treating acute injuries, such as a herniated disc or unrelenting back pain. I recommend monthly or even bimonthly corrective extension procedures to maintain spinal health and proper posture.
In Summary, I have tried to give the reader an understanding of how conditions like degenerative disc disease, back pain, and faulty posture are treatable conditions with positive outcomes. I would hope that the reader will gain some insight into maintaining spinal health and will seek out regular therapy for these conditions. This could mean seeing registered massage therapists, chiropractors.
Footnotes:
References:
1.http://www.laserspineinstitute.com/back_problems/spinal_anatomy/lumbar_pain/ 2.Joint Play the Right Way for the Axial Skeleton 3rd edition 2006, Arthrokinetic Publishing 3.www.arthrokinetic.com 4.http://en.wikipedia.org/wiki/Degenerative_disc_disease” 5.www.spine-health.com
6.www.laserspineinstitute.com/back_problems/foraminal_narrowing/def/ 7.http://drdavedecamillis.com/ 8.http://drdavedecamillis.com/articles/scans/MechanicalDrain_DeCamillis.pdf 9.http://drdavedecamillis.com/articles/pubmed/DifferentiallyDiagnosingMechanicalLo BackPain_DDeCamillis.pdf 10.http://en.wikipedia.org/wiki/Spondylosis 11.www.spine-health.com/glossary/annulus-fibrosis 12.http://prohealthsys.com/ 13.Orthopedic Physical Assessment, 4th edition, David J. Magee 2002 14.http://www.massagetherapycanada.com/ 15.http://en.wikipedia.org/wiki/Myotome 16.http://en.wikipedia.org/wiki/Dermatome_(anatomy) 17.http://en.wikipedia.org/wiki/Degenerative_disc_disease 18.www.noigroup.com/en/product/nsbe 19.Carolyn Kisner, M.S., PT, & Lynn Allen Colby, M.S., P.T.: Therapeutic Exercise, Fourth Edition, 2002 20.Cynthia C. Norkin, EdD, PT & D. Joyce White, DSc, P.T.: Measurement of Joint Motion A Guide to Goniometry, Third Edition, 2003 21.Darlene Hertling, B.S., R.P.T., Randolph M. Kessler, M.D.: Management of Common Musculoskeletal 22.Disorders, Physical Therapy, Principles and Methods, Second and Third Editions, 1996 23.David J. Magee, PhD., B.P.T.: Orthopedic Physical Assessment, Second and Third Editions, 1996 24.Philip E. Greenman, Principles of Manual Medicine, second edition 25.Frank H. Netter, M.D., Atlas of Human Anatomy 1993, The CIBA Collection of Medical Illustrations, 1991 26.Janet G. Travell, M..D., David G. Simons, M.D.: Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1 & 2, 1992 27.Joseph E. Muscolino, The Muscular System Manual- The Skeletal Muscles of the Human Body, 2005 28.Joseph E. Muscolino, Kinesiology: The Skeletal System and Muscle Function 29.Laura K. Smith, Elizabeth L. Weiss, L. Don Lehmkuh. : Brunnstrom’s Clinical Kinesiology. 5th edition 30.Nikita A. Vizniak, D.C. Clinical Consultant Physical Assessment, Second Edition, 2005. 32.Pamela K. Levangie, Cynthia C. Norkin: Joint Structure and Function a comprehensive analysis, third edition 33.Robert B. Salter, MD, Textbook of disorders and injuries of the musculoskeletal System 34.Robert E. McAtee, Facilitated Stretching 1993 35.Stanley Hoppenfeld, M.D.: Physical Examination of the Spine & Extremities, 1976 36.Steve Anderson, RMT, BSc.: Anatomy and Kinesiology lecture notes, 1992 37.Susan L. Edmond, M.P.H., P.T.: Manipulation Mobilization and Spinal Techniques, 1993 38.Taber’s Cyclopedic Medical Dictionary, 1983 39.Carolyn Kisner, Lynn Allen Colby: Therapeutic Exercise Foundations and Techniques