Goal of the Review?
In this article, 1, the authors ask the question of whether current manual intervention practice reflects the scientifically proven biomechanical aspects of degenerative disc disease (DDD) or if the field is ignoring the science in an effort to discard the diagnostic label?
Why are they doing this study?
The American Academy of Orthopedic Manual Physical Therapists (AAOMPT), released a position paper that opposes the use of the term degenerative disc disease (DDD), saying that the diagnostic label can result in overuse of diagnostic imaging and treatment. They assert that DDD is a common age-related issue, not a disease.
While the authors agree that diagnostic labels must be well thought out, they argue there are significant physiologic and biomechanical changes that occur as a result of disc degeneration. Therefore, scientific evidence such as imaging findings that illustrate these changes should serve to guide treatment decisions as one aspect of larger clinical reasoning.
What was done?
The authors perform a narrative review to examine the literature on DDD. This includes a look at the historical research on disc instability, the role of the disc as a pain generator, a review of the science on the cycle of disc degeneration, as well as the impact of rotation on the degenerated disc. In addition to the biomedical research, they provide an overview on the implications of this research for manual therapy and recommendations for evidence-based treatments.
What did they find?
In response to the literature review, the authors make a few evidence-based recommendations for manual therapy treatment. First, they suggest that traction-based manual interventions should be done in mid-position without side bending or axial rotation. This recommendation is in response to evidence suggesting that forceful rotatory treatments may cause further damage and potentially lead to loss of structural integrity of the disc.
Next, they argue that current clinical practice of spinal manual therapy may not be paying enough attention to the frequency of early disc degeneration, and resulting instability, in the asymptomatic population. Therefore, they recommend that oscillatory traction-based manual interventions be applied in combination with stabilization exercises and neuromuscular re-education thereby serving to enhance disc rehydration and nutrition, as well as facilitate neuromodulation and reduce muscular reticence.
Why do these findings matter?
Many patients use manual spinal therapy for pain and mobility. Understanding how to implement evidence-based treatments that will benefit, and not harm, patients is critically important for providers and patients.