Adding Value to the Conservative Management of Degenerative Disc

31st Annual Meeting of the North American Spine Society Highlight

Physicians who incorporate the biopsychosocial model can add value to the management and treatment of patients who have degenerative disc disease according to Dr. Don Murphy.

Donald R. Murphy, DC, FRCC is the Director of Primary Spine Care Services in the Care New England Health System and Assistant Professor at Alpert Medical School of Brown University. His presentation at the 2016 North American Spine Society meeting began by discussing the case of a man with back pain that was worsening over the past 5 years. The radiology and MRI reports revealed degenerative disc, facet arthrosis, spondylosis, and disc bulging. “The fact is these findings do not tell me a lot about what is causing his suffering. The literature tells us that degeneration occurs naturally as we age.”

Dr. Murphy cautioned physicians that labeling the patient with degenerative disease may lead to iatrogenic imaging disability. “To the layperson, they feel they will only keep getting worse leading to hopelessness.”
Man holding his low back, in painThe meeting began by discussing the case of a man with back pain that was worsening over the past 5 years.A Better Way
The biopsychosocial model was discussed as an emerging paradigm that when implemented could lead to a better understanding of the patient's problems and therefore, a more appropriated treatment. “The patient is seeing us not for pain, but because they have pain, disability, and a suffering experience. As a result, they are not able to do what they want in life.”

Factors Contributing to the Pain, Disability and Suffering Experience
“There are somatic factors, neurophysiological factors, and psychological factors all occurring in the social context in which the patient lives. To understand what is causing the patient's pain, disability and suffering experience, we need to know the factors contributing to the problem.”

Making the Diagnosis

Question 1: Do the presenting symptoms reflect a visceral disorder, or a serious or potentially life-threatening illness?

Question 2: Where is the pain coming from? “Pain comes from the disc, joint, nerve root or muscle, and patients may have more than one, but usually, there is one that is predominant.”

Question 3: What is happening with this person as a whole that would cause the pain experience to develop and persist? What are the perpetuating factors? “There are neurophysiological factors, including dynamic instability (impaired motor control) or passive instability like an unstable spondylolisthesis or ligamentous injury. Another neurophysiological factor is nociceptive system sensitization. There are also psychological factors, including fear, catastrophizing, passive coping, low self-efficacy, and depression.”

Chiropractic and Physical Therapy Treatment

Disc Pain
According to Dr. Murphy, patients with disc-related pain can be treated with exercise and a distraction manipulation. The exercise involves finding a directional movement that when done repetitively centralizes or reduces the pain. If this is found, “repeated exercise at home is the treatment of choice to resolve the disc derangement.” Distraction manipulation is a type of decompression in which the patient lays face down, and the clinician gently tractions the lower back.

Joint Pain
Patients who have joint pain have dysfunction of the joints which respond well to spinal manipulation.

Pain from Radiculopathy
Acute:
“For patients in the acute stage, either oral or injectable anti-inflammatory measures are the first-line treatment. However, another option is to wait for the inflammation to resolve on its own, but utilizing medications will resolve it quickly.”

Subacute or Chronic: “The treatment of choice is neural mobilization, which is a series of manual maneuvers as well as exercises designed to mobilize and desensitize the nerve root.”

Myofascial Pain
“If the patient has myofascial pain, there are a number of treatments that can be effective.”

Instability
“Stabilization exercise is the treatment of choice for patients with dynamic or passive instability. If conservative management fails to help those with passive instability, surgical correction may be considered.”

Psychological
Dr. Murphy recommended cognitive and behavioral therapy and acceptance and commitment therapy because of their demonstrated effectiveness in treating patients with spinal disorders. “All practitioners can apply the principles of these two psychotherapeutic schools of thought into the management of the patient during each encounter. There are no neutral practitioner-patient encounters, only those that promote recovery or interfere with recovery.” Referral may be indicated for those patients with significant psychological factors.

Nociceptive System Sensitization
For patients with nociceptive system sensitization, the first step is reducing the peripheral source. “If that does not resolve the problem, then a graded exposure is done to attempt to desensitize the nociceptive system through a process of habituation. We introduce movements, positions, and activities that provoke the patient’s pain to a level they can handle. We maintain that stimulus until the nociceptive system habituates, adapts, or stops responding to that stimulus. We then step up the intensity of the stimulus to the point it bothers the patient again, but to a level they can handle, until habituation occurs again.”

Conclusions
Dr. Murphy stressed the importance of finding the cause of the patient’s pain, suffering, and disability experience as well as finding the different factors contributing to the patient’s problems.

He concluded by saying, ““Value is outcomes divided by costs, and as physicians, we need to determine whether imaging is going to provide additional diagnostic information.”

Donald R. Murphy, DC’s disclosures:
Stock Ownership: Primary Spine Provider Network, Spine Care Partners
Consulting: Allstate, CRISP Education and Research
Speaking and/or Teaching Arrangements: CRISP Education and Research
Trips/Travel: New York Chiropractic College
Scientific Advisory Board: MedRisk

To view additional meeting highlights from the 31st Annual Meeting of NASS, click here.

Updated on: 02/27/18
Continue Reading
Do Spinal Injections in the Treatment of Degenerative Disc Disease offer Value?
SHOW MAIN MENU
SHOW SUB MENU
Cancel
Delete

Get new patient cases delivered to your inbox

Sign up for our healthcare professional eNewsletter, SpineMonitor.
Sign Up!