We’ve been busy behind the scenes at MyRehab over the last several months. The primary thing that has changed is that we have moved our entire video library onto a new and improved video hosting platform. Subscribers will now see improved video quality, faster loading rates, and improved view-ability across browsers, operating systems devices. When we officially re-launch, we hope to have some new features available but need to keep those under wraps for the present time. However, we will maintain our base price for monthly subscription at $19.99 and we will continue to extend our student rate to a whopping 75% discount off of the normal rate, or $4.99 monthly. We will also keep that rate in place for the first 6 months of your clinical practice, to help keep those first year expenses managed…I’ve been there and remember how it feels. 🙂 IMPORTANT NOTE: IF YOU ARE A STUDENT OR GRADUATE WITHIN THE PAST 6 MONTHS, YOU MUST CONTACT ME DIRECTLY TO RECEIVE THE DISCOUNTED RATE. YOU CAN REACH ME AT DRPHILLIPSNELL@GMAIL.COM. PLEASE PLACE “STUDENT DISCOUNT” IN THE SUBJECT LINE. A recent request from one of our R2P chapter presidents (and fellow gastronome), Nav Sohi at Palmer West, prompted me to spend a moment to put up a few examples of the video content available on the site. These videos are meant to be shared with your patients via email link, so they are in “plain-English” form to make it easy for your patients to understand and perform well. While we continue to work behind the scenes, you can still sign up and enjoy the benefits of the site. Follow the links below to answer your questions or sign up and we look forward to working with you for years to come!
FYI, MyRehab grew out of my own clinical practice and I suspect you’ll like the way it is set up. We have searchable libraries comprising material from many of the courses you’ve attended…FMS, DNS, McKenzie (we have the entire spine and extremity exercise library!), McGill, Liebenson and many more. Here are a few samples:
Some time ago, a question came up in the member discussion forum at FixYourOwnBack.com as to whether extruded lumbar disc herniations “went away” or whether they remained in the epidural space. This coincided with an older paper (Haro, 2000) that was discussed on Facebook as the potential mechanism for resorption of extruded disc fragments. I thought that would be a good topic to flesh out a bit with a literature search. I’ll attempt to summarize my reading of the past 13 years of investigation into this topic. In direct response to the above question, “Yes, resorption of the extruded herniated disc fragments is part of the natural history of disc injury.” The amount of time that takes to happen varies from person to person but here are a few cullings from several studies:
- Follow up MRI 6-12 months after initial injury demonstrates about 50% of patients see about 70% decrease in size of extruded material. (Fagerlund, 1990, Maigne, 1992, Bush, 1992; Jensen, 1996; Autio, 2006; Monument 2011)
- In a retrospective cohort study, Saal and Saal demonstrated that lumbar disc herniation with radiculopathy can be successfully treated nonoperatively, with nonoperative treatment resulting in “good to excellent” outcomes for approximately 90% of patients. (Saal, 1996)
- MRI findings lag behind improvement of leg symptoms (Ito, 1996)
- Larger extrusions and sequestrations are more likely to resorb. (Maigne 1992, Bush 1992, Jensen 1996)
That last point is interesting as all too often patients report to me that their neurosurgeon suggested surgery because to the large size of the herniated disc fragment. This is somewhat understandable as often a large herniation can cause not only chemical irritation of the nerve root (due to inflammation) but also mechanical compression of the nerve root. Often intense pain in the leg accompanies this scenario and sometimes motor weakness as well. Years ago, more than 3 days of progressive motor weakness in these cases drove the clinical decision to decompress the nerve surgically. These days, this 2011 review article sums it up the current “gray” zone we are in… “In the absence of serious neurologic deficits or for persistent non-radicular low back pain, consensus whether surgery is useful or not has not yet been established. Furthermore, the timing of the intervention with respect to prolonged conservative care has not been evaluated properly.” (Jacobs, 2011) In their review of randomized controlled trials comparing various interventions for herniated lumbar disc injury with sciatica Jacobs, et al found that after 1 year, there was no difference between surgical vs. conservative interventions. The primary benefit in surgery was quicker relief of the leg pain, with average time before resolution of leg pain averaging 4 weeks in quick surgical interventions, vs. 12 weeks for conservative care. For those who opt for conservative care and want to know how they can help the process of resorption of the herniated disc material, we are still learning what those variables are. One clear thing to not do is smoke. Tsarouhas et al in 2011 showed that smoking resulted in more severe pain with disc injury, longer time for resorption of herniated disc material and smokers have a longer duration of symptoms. Many might wonder what the actual mechanism is for resorption of an extruded disc. That discussion gets a bit technical with histochemistry and biochemistry. For those that are interested, let’s “suit up” and get to it!
The Role of Macrophages and Matrix Metalloproteinases (MMPs) in Disc Resorption
Remember those Pac-Man-like things under the microscope in cell biology class that were called macrophages? As it turns out, these differentiated white blood cells (WBC) play a key role in the process. In a very amoeba-like fashion, they sidle up to the extruded annulus and get to work with a toolbox of cytokines and proteolytic enzymes. Some of these macrophages are residents in a normal disc; others arrive if blood vessels in the outer third of the annulus or in the vertebral endplate are disrupted. The more blood vessels that are disrupted, the more macrophages that are on the scene. While we’re still learning a lot about this process, it resembles a lot of other common inflammatory cascades. Among the enzymes that the macrophages bring that have been studied a bit more, are the matrix metalloproteinases (MMPs)
At present, about 24 of these proteolytic enzymes have been discovered and they come not only from macrophages but also from chondrocytes in the disc. I like to think of the different MMPs as different types of cleaners you might use around the house. Maybe you use 409 to clean your kitchen counters, Windex to clean your windows, Clorox to brighten your white clothes and Tide to clean the color garments. Some of those cleaners in certain combinations might not be a good idea for health (ammonia in the Windex + bleach=chlorine gas) and we’ll discuss that analogy a bit more in a minute. Also, you might be able to get a really dirty window cleaner with 409, but Windex will be superior to get the job done. You get the drift? So those 24 MMPs have been divided up into groups depending on their function. 1. Collagenases (MMPs-1, -8, -13 and -18)– the only enzymes that can cleave intact interstitial collagen molecules. 2.Gelatinases (MMPs-2 and -9)–degrade denatured collagen molecules and basement membrane collagens. 3. Stromelysins (MMPs-3, -10 and -11)– cleaves cartilage matrix components, including aggrecan, proteoglycans, and fibronectin. 4. Membrane-type MMPs (MMPs-14, -16, -17 and -18)–responsible for the activation of other MMPs, but only play a secondary role in direct matrix degradation. One interesting finding is that a few of these MMPs are present in low quantities in even normal and young discs. As the disc shows signs of increased degeneration, the amount of MMPs and the variety of MMPs increases. So, if MMPs are needed to clean up a herniated disc, then more must be better…right? Well hold on sparky. These are catabolic proteins, they break stuff down. We have known since the late ‘90s that they are present in greater quantities in degenerated discs, and some suspect that their very presence is the CAUSE of the disc degeneration. As in most bodily reactions, a catabolic agent has an anabolic partner and homeostasis is maintained when we balance those reactions. It seems that when the scale tilts toward the catabolic agents, that’s when we see increased disc degeneration. At least that’s what the correlational studies suggest. Of course you can’t extrapolate causation from a correlation. It could be that the upregulation of MMPs is reflective of a response to injury (essentially a normal inflammatory response) rather than being the cause of the observed degeneration.
Current investigations into MMPs are attempting to manipulate the ratio of catabolic MMPs vs. anabolic agents. Some are also investigating the lifestyle issues that are correlated with low back pain, disc degeneration and with upregulation of certain MMPs. Among those lifestyle items that have been associated with higher levels of degeneration and with higher levels of MMP in the disc is hard physical labor, especially when it involves frequent lifting. The researchers often infer that that lifting equates only compressive load without regard to other vectors of load like torsion and shear. Adams demonstrated to us in 1982 that even in vivo discs are remarkably resistant to pure compressive force but they prolapse with additional flexion + compression. I personally think that an area worthy of investigation is in HOW the disc is compressed. Most of the studies I’m aware of infer compressive load by lifestyle questionnaires looking for employment that involves heavy physical loading of the discs. Some of that sample likely lifts with maintenance of the lumbar lordosis and some likely don’t. I suspect that those that don’t with the inherent flexion + compression moment on the disc, will experience more LBP and more disc degeneration. Indeed, I have noted for years the presence of habitual lumbar hinging (flexion + compression) with naïve and loaded movements toward the floor. Correction of this lumbar hinge by training a hip hinge stereotype has proven to be a remarkably simple intervention to help these painful backs improve.
In regards to disc resorption, what are we left with? The natural history after disc herniation is for resorption to occur at varying speeds and degrees dependent on a variety of other lifestyle factors. If you want to improve the resorption process, don’t smoke, exercise moderately but limit heavy physical labor. We still have more investigation to do on the specifics of dose and type of “physical labor” and “lifting”. As that comes up in the literature, I’ll try to keep you posted. Be well, and if you want my personal advice based on clinical experience…hip hinge when you bend towards the floor. If you need help figuring out how to do that hip hinge thingy, go here…
References:Haro H, Crawford HC, Fingleton B, MacDougall JR, Shinomiya K, Spengler DM, Matrisian LM. Matrix metalloproteinase-3-dependent generation of a macrophage chemoattractant in a model of herniated disc resorption. J Clin Invest. 2000 Jan;105(2):133-41. Jacobs WC, van Tulder M, Arts M, Rubinstein SM, van Middelkoop M, Ostelo R, Verhagen A, Koes B, Peul WC. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. Eur Spine J. 2011 Apr;20(4):513-22. Henmi T, Sairyo K, Nakano S, Kanematsu Y, Kajikawa T, Katoh S, Goel VK. Natural history of extruded lumbar intervertebral disc herniation. J Med Invest. 2002 Feb;49(1-2):40-3. Saal JA, Saal JS, Herzog RJ : The natural history of lumbar intervertebral disc extrusions treated nonoperatively. Spine 15 : 683 – 686, 1991. Bozzao A, Gallucci M, Masciocchi C, Aprile I, Barile A, Passariello R : Lumbar disc herniation. MR imaging assessment of natural history in patients treated without surgery. Radiology 185 : 135 – 141, 1992. Delauche – Cavaillier MC, Budet C, Laredo JD, Debie B, Wybier M, Dorfmann H, Ballner I : Lumbar disc herniation. Computed tomography scan changes after conservative treatment of nerve root compression. Spine 17 : 927-933, 1992. Komori H, Shinomiya K, Nakai O, Yamaura I, Takeda S, Furuya K : The natural history of herniated nucleus pulposus with radiculopathy. Spine 21 : 225 – 229, 1996. Teplic JG, Haskin ME : Spontaneous regression of herniated nucleus pulposus. AJNR 6 : 331- 335, 1985. Yukawa Y, Kato F, Matsubara Y, Kajino G, Nakamura S, Nitta H : Serial magnetic resonance imaging follow-up study of lumbar disc herniation conservatively treated for average 30 months. Relation between reduction of herniation and degeneration of disc. J Spinal Disord 9 : 251- 256, 1996. Orief T, Orz Y, Attia W, Almusrea K. Spontaneous resorption of sequestrated intervertebral disc herniation. World Neurosurg. 2012 Jan;77(1):146-52. Iwabuchi M, Murakami K, Ara F, Otani K, Kikuchi S. The predictive factors for the resorption of a lumbar disc herniation on plain MRI. Fukushima J Med Sci. 2010 Dec;56(2):91-7. Reyentovich A, Abdu WA. Multiple independent, sequential, and spontaneously resolving lumbar intervertebral disc herniations: a case report. Spine (Phila Pa 1976). 2002 Mar 1;27(5):549-53. Cribb GL, Jaffray DC, Cassar-Pullicino VN. Observations on the natural history of massive lumbar disc herniation. J Bone Joint Surg Br. 2007 Jun;89(6):782-4. Zhou G, Dai L, Jiang X, Ma Z, Ping J, Li J, Li X. Effects of human midkine on spontaneous resorption of herniated intervertebral discs. Int Orthop. 2010 Feb;34(1):103-8. doi: 10.1007/s00264-009-0740-2. Epub 2009 Mar 11. Doita M, Kanatani T, Ozaki T, Matsui N, Kurosaka M, Yoshiya S. Influence of macrophage infiltration of herniated disc tissue on the production of matrix metalloproteinases leading to disc resorption. Spine (Phila Pa 1976). 2001 Jul 15;26(14):1522-7. ItoT,YamadaM,IkutaF,etal.Histologic evidence of absorption of sequestration-type herniated disc. Spine 1996;21:230–4. Fagerlund MK, Thelander U, Friberg S. Size of lumbar disc hernias measured using computed tomography and related to sciatic symptoms. Acta Radiol 1990;31(6):555–8. Maigne JY, Rime B, Deligne B. Computed tomographic follow-up study of forty-eight cases of nonoperatively treated lumbar intervertebral disc herniation. Spine (Phila Pa 1976) 1992;17(9):1071–4. Bush K, Cowan N, Katz DE, et al. The natural history of sciatica associated with disc pathology. A prospective study with clinical and independent radiologic follow-up. Spine (Phila Pa 1976) 1992; 17(10):1205–12. Jensen TS, Albert HB, Soerensen JS, et al. Natural course of disc morphology in patients with sciatica: an MRI study using a standardized qualitative classification system. Spine (Phila Pa 1976) 2006;31(14): 1605–12 [discussion: 1613]. Autio RA, Karppinen J, Niinimaki J, et al. Determinants of spontaneous resorption of intervertebral disc herniations. Spine (Phila Pa 1976) 2006; 31(11):1247–52. Monument MJ, Salo PT. Spontaneous regression of a lumbar disk herniation. CMAJ 2011;183(7):823. David G, Ciurea AV, Mitrica M, Mohan A. Impact of changes in extracellular matrix in the lumbar degenerative disc. J Med Life. 2011 Aug 15;4(3):269-74. Tsarouhas A, Soufla G, Katonis P, Pasku D, Vakis A, Spandidos DA. Transcript levels of major MMPs and ADAMTS-4 in relation to the clinicopathological profile of patients with lumbar disc herniation. Eur Spine J. 2011 May;20(5):781-90 Adams MA, Hutton WC. Prolapsed intervertebral disc. A hyperflexion injury 1981 Volvo Award in Basic Science. Spine (Phila Pa 1976). 1982 May-Jun;7(3):184-91. Vo NV, Hartman RA, Yurube T, Jacobs LJ, Sowa GA, Kang JD. Expression and regulation of metalloproteinases and their inhibitors in intervertebral disc aging and degeneration. Spine J. 2013 Mar;13(3):331-41. Zigouris A, Batistatou A, Alexiou GA, Pachatouridis D, Mihos E, Drosos D, Fotakopoulos G, Doukas M, Voulgaris S, Kyritsis AP. Correlation of matrix metalloproteinases-1 and -3 with patient age and grade of lumbar disc herniation. J Neurosurg Spine. 2011 Feb;14(2):268-72. Weiler C, Nerlich AG, Zipperer J, Bachmeier BE, Boos N. 2002 SSE Award Competition in Basic Science: expression of major matrix metalloproteinases is associated with intervertebral disc degradation and resorption. Eur Spine J. 2002 Aug;11(4):308-20. Bachmeier BE, Nerlich A, Mittermaier N, Weiler C, Lumenta C, Wuertz K, Boos N. Matrix metalloproteinase expression levels suggest distinct enzyme roles during lumbar disc herniation and degeneration. Eur Spine J. 2009 Nov;18(11):1573-86. Guterl CC, See EY, Blanquer SB, Pandit A, Ferguson SJ, Benneker LM, Grijpma DW, Sakai D, Eglin D, Alini M, Iatridis JC, Grad S. Challenges and strategies in the repair of ruptured annulus fibrosus. Eur Cell Mater. 2013 Jan 2;25:1-21. Review. Peng BG. Pathophysiology, diagnosis, and treatment of discogenic low back pain. World J Orthop. 2013 Apr 18;4(2):42-52.
Here are 3 new exercises that subscribers have requested at MyRehab. Full versions of the exercises are available for subscribers to send to their patients to help with patient education. As always, this process is easy to perform and allows you to send these videos directly to your patient’s email in-box. If you’re not yet a subscriber, you can trial MyRehab for 30 days for $1 by signing up here. Monthly membership after that is only $19.99 without contract or obligation. More info is on the video to the right of the page here
- YTWL-Standing: Based on Blackburn’s rotator cuff research, this standing version requires fewer props at home using a piece Theraband. The prone version is already in the library at MyRehab.
- Quadruped Rock Back-Gym Ball: This is a nice correction for loss of lumbar lordosis at the bottom of squatting exercises. Sometimes referred to as “butt winking”, this rounding of the lumbar spine under load produces the injury vector for lumbar disc herniation.
- Pallof Presses: Named after John Pallof, PT, these core stabilization exercises are a great intervention for rotary instability. Standing versions on 2 legs are shown as well as single leg versions. I’ve had a lot of success using the single leg version in runners prone to overpronation and patellofemoral syndrome.