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The Aging Spine

The Aging Spine. Killinger. Aging Spine Changes. Age 0-4-nucleus pulposis present 9-14: less nucleus, bilateral clefts form in anulus, at jts of Lushka 20-35: Clefts enlarge and dissect disc towards midline

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The Aging Spine

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  1. The Aging Spine Killinger

  2. Aging Spine Changes • Age 0-4-nucleus pulposis present • 9-14: less nucleus, bilateral clefts form in anulus, at jts of Lushka • 20-35: Clefts enlarge and dissect disc towards midline • > 60: Disc is dry, no nucleus, ligament-like, less volume, decreased ROM, more rigidity

  3. Other age-related spinal changes • Nucleus dries & becomes rigid (blends w/annulus) • Hyaline endplates calcify • Nutrients to disc decrease • Decreased ligament elasticity (ROM) • Flattened jts of Lushka • Thicker ligamentum flavum • Decreased muscle mass, bone density • Increase thoracic kyphosis • Anterior head carriage

  4. So, how can we assess age-related changes in spinal health and biomechanics of the spine? • Bone density: How? • Poor biomechanics:? • Health of discs? • Ligament elasticity? • General spinal function?

  5. Introducing Kirkaldy-Willis… (KW) • Dysfunction-Subluxation or poor biomechanics may produce a focal swelling, pain, muscle splinting. • Instability- Trauma or prolonged dysfx. Leads to aberrant motion, inability to “hold” the adjustment, chronic pain, ms. fatigue, etc. • Stabilization-The body tries to fuse or immobilize areas prone to disuse or trauma.

  6. The literature in review... • A Chiropractic Clinical Approach to Aging, Degeneration, and the Subluxation. McCarthy, KA. TICC 2001;8(1);61-70 • Template for Developing a Clinical Impression of the Aging Spinal Pain Patient. McCarthy KA.TICC 2002;9(2):60-67.

  7. More in the literature... • Waddell, Allen, and Nachemson’s writings on back pain and disability • Linton’s and Turk’s articles on psychosocial influences on pain (Spine 2000, Pain 1987, and text on back and neck pain; 2000) Waddell (x5!), Main, Kendall, Suarez, Bland, etc…..

  8. True or False?“ Degenerative changes, as seen on x-ray, are a fairly good indicator of the patient’s pain and/or functional status.”

  9. No, pain and disability are NOT predicted by radiographic findings. Disc herniation (visible on MRI/CT) does not usually predict problems with spinal function.

  10. “Is it scientifically appropriate to use the ‘Radiographic Stages Of Generation’ images to explain to patients why they are experiencing pain?”

  11. Pointing out a radiographic finding and tying it to the patient’s pain or function is not only disingenuous, it may cause patient harm (chronic pain)*. However, there IS value in educating patients about improving biomechanics (related to posture, function, ergonomics, physical stressors and activities).

  12. Is this an scientifically accurate and appropriate statement for chiropractors to say to patients?“The scientific research has shown that chiropractic can prevent or slow degenerative processes in the spine.”

  13. There is little scientific evidence that chiropractic changes the rate or level of spinal degeneration. But this may be changing due to the research being done at Palmer!Thanks to Dr. Henderson

  14. So, what should we do? • Educate patients about the things they CAN do (supported by science) that ↓↓ pain and ↑ function related to the spine and joints. • Chiropractic care: ↓↓ pain and may ↑ jt mobility • Physical activities (best evidence) • Moderation in activities, diet, etc. (avoiding repetetive stress injuries) • Proper biomechanics, posture, lifting techniques, work habits, etc. • QUIT smoking!

  15. Should our recommendations be the same for everyone? • NO! The entire clinical picture must be viewed before clinical management plans are developed. (For chiropractic technique choices, and other recommendations!!) • All subluxations are not created equal • Kirkaldy-Willis revisited…

  16. Initial Technique Thoughts… • Consider the technique tools you now possess • Consider the patients you hope to serve • Consider the clinical goals of these patients (in the framework of Kirkaldy-Willis) • Are you prepared?

  17. More specifically… • What will I do (what tools will I use) for a patient who has acute joint dysfunction? • What will I do for a patient who has become unstable? • What will I do for the patient in the “stabilization” phase to reach the goal of HEALTHY AGING? • How will I prevent patients from progressing to the “instability” and “stabilization” phases?

  18. The tale of 3 patients…. • If you care for everyone the same, (ignoring the overall patient’s clinical picture, phase of degeneration, etc.) chances are you will get • excellent results with some, • mediocre results with others, and • poor outcomes with a few. (We can do better than a toss of the dice!)

  19. Dysfunction • Goals: To prevent progression to chronic pain, or long-standing aberrant motion (instability) in the affected joints • Recommendations: • Specific chiropractic adjustments, • Prevention/health promo recommendations • Proper nutrition, rest, posture, phys. activity, etc.

  20. Instability • Goals: Prevent long-standing aberrant motion, and chronic pain: stabilize joints • Recommendations: • Strengthen Postural Muscles (the great stabilizers) • Conservative spinal adjustments • Improve proprioception, small muscle coord. • Stress reduction • Proper diet, rest, physical activ., support (?)

  21. Stabilization (most often older pt.) • Goals: To retain strength, flexibility and ROM • Recommendations: • Yoga or flexibility training • Spinal adjustments/motion focused intervention • Gait/proprioceptive training • Regular physical activity to maintain muscle strength around joints, and overall

  22. So, how does this relate to chiropractic technique choices? • Dysfunction: A broad palate; choices galore! • Instability: Care needs to be exercised to not aggravate ligament laxity and joint instability (And, don’t ignore the postural muscles!). • Stabilization: Need to balance the need for safety in adjusting (these may be older or more frail patients) with the need for MOTION; Either use techniques that incorporate movement into joints, or address movement in the form of other physical activities/recommendations/therapies.

  23. Case #1: Justin • A 25 year old student and rugby player • Presents with a localized area of taut and tender muscles around T11-T-12 • No other spine or health problems • What are your/his clinical goals? • What adjusting strategies may offer the best results? • What can you do to prevent this from becoming a chronic problem?

  24. Case #2: George • 75 year old African American male with a chief complaint of stiffness and pain in the low back • Long history of acute and chronic low back episodes • What do you need to ask/rule out? • What are yours/his clinical goals? • What adjusting strategies may offer the best results? • What else might you talk to patient about?

  25. Case #3: Lydia • 30 year old Hispanic single mother of 2 • Works 2 jobs; no college education • Chief complaint: Pain in neck and mid back • Radiation into right arm; + occas. left arm • Long history of chiropractic care; doesn’t seem to hold her adjustments well • What adjusting strategies may offer the best results? • How will you prevent this from becoming a chronic problem?

  26. Coming up in class… • Meet some people who are aging well. • Small group activity on chiropractic techniques and aging • Continue discussion of chiropractic techniques and aging patients: Demo Day

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