Degenerative Disc Disease
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Clinically Relevant Anatomy
Dengenerative Disc Disease (DDD) is thought to begin with changes to the annulus fibrosis, intervertebral disc, and subchondral bone. The process of degeneration is divided into three classifications including: early dysfunction, intermediate instability, and final stabilization.
Early dysfunction is the classifed as the beginning of degenerative changes which can occur as early as 20 years. Intermediate instability is classified by a loosening of the annulus fibrosis, which can cause back pain. Fibrosis to the posterior structure and formation of osteophytes denotes the final stabilization classification. Pain decreases, but there is less motion. 
Degenerative disc disease refers to a condition in which the involved disc causes LBP. Lumbar degenerative disc disease is usually the result of a twisting injury to the lower back, such as when a person swings a golf club or rotates to put an object on a surface to the side of or behind them.
The pain is also frequently caused by simple wear and tear on the spine and comes with the general aging process.
Degenerative disc disease is fairly common, and it is estimated that at least 30% of people aged 30-50 years old will have some degree of disc space degeneration, although not all will have pain or ever receive a formal diagnosis.
The process that leads to DDD begins with structural changes. The annulus fibrosis (outer portion of the disc) loses water content over time which will make it increasingly unyielding toward everyday stress and strain on the spine. The loss of compliance in the discs contributes to forces being redirected from the anterior and middle portions of the facets to the posterior aspect, thus causing facet arthritis. Another result is hypertrophy of the vertebral bodies adjacent to the degenerating disc. The overgrowths are known as bony spurs (or osteophytes.)
People with DDD will have low back pain; however there are varying levels of severity. Pain is often chronic, but one with DDD can experience varying episodes of exacerbation where pain levels are elevated.
DDD commonly occurs with other diagnoses such as:
- idiopathic low-back pain
- lumbar radiculopathy
- lumbar stenosis
- zygapophydeal joint degeneration 
Activities that typically increase pain include:
- Sitting for extended periods of time
- Rotating, bending, or lifting
- Activities that typically decrease pain include:
Changing positions often
Staying active 
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Xray findings are used to diagnose DDD. Anterior-Posterior and lateral views are taken; presence of osteophytes, narrowing of the disc joint space, or a “vacuum sign” is noted. 
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Patients may present with a history of Chronic LBP, and can experience symptoms into the buttock. They may also state a history of spine stiffness that gets worse with activity and tenderness with palpation over involved area. 
Management / Interventions
The preferential treatment for patients with chronic low back pain, caused by disc degeneration, is a conservative method consisting of physical therapy and medications (O'Halloran, 2007 (D)). 
Medications such as non-steroidal anti-inflammatories (e.g., ibuprofen, naproxen, COX-2 inhibitors) and pain relievers like acetaminophen (such as Tylenol) help many patients feel good enough to engage in regular activities. Stronger prescription medications such as oral steroids, muscle relaxants or narcotic pain medications may also be used to manage intense pain episodes on a short-term basis, and some patients may benefit from an epidural steroid injection. Not all medications are right for all patients, and patients will need to discuss side effects and possible factors that would preclude taking them with their physician. Epidural steroid injections can provide low back pain relief by delivering medication directly to the painful area to decrease inflammation.
A part of the physical therapy treatment is aimed at reducing pain. For this purpose, different physical modalities are used, including heat and cold application, electrical stimulation (TENS), traction, spinal manipulations (Beattie P, 2008 (D); Zhang Y (C), 2008; Mirza SK, 2007 (A1))    and exercise programs. Other objectives are to enhance the core stability by strengthening and improving the coordination between the abdominal and back muscles through a spinal stabilization program (Brox JI, 2003 (A2)) . These stabilization exercises can increase the patient’s capacity to resist higher loads in the degenerative discs(Beattie P, 2008 (D)). 
In patients with degenerative disc disease it is also advised to add behavioral therapy to the usual treatment since it has been shown that the addition of behavioral therapy gives better results (Brox JI, 2003 (A2)) . This is related to the fact that the diagnosis of degenerative disc disease also entails many psychological effects. Many patients assume that degeneration means that their spine is becoming weaker, associated with constant pain. These erroneous thoughts often cause fear of movement (kinesiophobia) and lead to the avoidance of movements of the spine (Beattie P, 2008 (D)). 
The task of the physical therapists includes giving information and advice (Mirza SK, 2007 (A1)) . Good communication with patients is of great importance, they have to realize that degeneration of the intervertebral disc is a normal aging process. The physiotherapist must help the patients to identify and overcome their fears and to adapt their coping strategies (Mirza SK, 2007 (A1)) . It is important that patients understand that they must stay active and that activities of daily life and other moderate physical activity will not cause additional damage or have adverse effects (Brox JI, 2003 (A2)) . Patients must be encouraged to perform low impact aerobic exercises, such as walking and water aerobics. Low impact aerobic conditioning ensures adequate flow of nutrients and blood to spine structures, and decreases pressure on the discs. They should avoid prolonged static postures as much as possible (Beattie P, 2008 (D); Brox JI, 2003 (A2)).  
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Clinical Bottom Line
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Recent Related Research (from Pubmed)
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- ↑ 1.0 1.1 Dutton M. Orthopaedic Examination, Evaluation, and Intervention. 2nd ed. New York, NY: McGraw-Hll; 2008.
- ↑ 2.0 2.1 Ullrich, P. F. (2006 11 6). Lumbar Degenerative Disc Disease. Retrieved 06 02, 2009, from Degenerative Disc Disease: http://www.spine-health.com/conditions/degenerative-disc-disease/lumbar-degenerative-disc-disease
- ↑ 7SecretsMedical. Degenerative Disc Disease. Available from: http://www.youtube.com/watch?v=UTBrVj7F6kI [last accessed 03/05/13]
- ↑ 4.0 4.1 Ulrich, P. F. (2005, 11 29). Common Symptoms of Degenerative Disc Disease. Retrieved 06 02, 2009, from Degenerative Disc Disease: http://www.spine-health.com/conditions/degenerative-disc-disease/common-symptoms-degenerative-disc-disease
- ↑ 5.0 5.1 Thompson, J.C. MD. Netter's Concise Atlas of Orthopaedic Anatomy. (2002) Saunders Elsevier. p.36-7
- ↑ O'Halloran DM, Pandit AS. Tissue-engineering approach to regenerating the intervertebral disc. Tissue Eng 2007; 13(8):1927-1954.
- ↑ uwaterloo. Waterloo's Dr. Spine, Stuart McGill. Available from: http://www.youtube.com/watch?v=033ogPH6NNE [last accessed 03/05/13]
- ↑ 8.0 8.1 8.2 8.3 Beattie P. Current understanding of lumbar intervertebral disc degeneration: a review with emphasis upon etiology, pathophysiology, and lumbar magnetic resonance imaging findings. fckLRJOSPT 2008; 38(6):329-340
- ↑ Zhang Y. Biological treatment for degenerative disc disease: Implications for the field of Physical Medicine and Rehabilitation. Am J Phys Med Rehabil 2008, fckLR87(9): p.694-702
- ↑ 10.0 10.1 10.2 Mirza SK, Deyo RA. Systematic Review of Randomized Trials Comparing Lumbar Fusion Surgery to Nonoperative Care for Treatment of Chronic Back Pain. Spine 2007; 32(7): 816-823
- ↑ 11.0 11.1 11.2 11.3 Brox JI, Sorensen R, Friis A. Randomized Clinical Trial of Lumbar Instrumented Fusion and Cognitive Intervention and Exercises in Patients with Chronic Low Back Pain and Disc Degeneration. Spine 2003; 28(17):1913-1921