The Aging Spine

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The Aging Spine

• Killinger

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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
• gt 60 Disc is dry, no nucleus, ligament-like,
  less volume, decreased ROM, more rigidity

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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

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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?

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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.

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The literature in review...

• A Chiropractic Clinical Approach to Aging,
  Degeneration, and the Subluxation. McCarthy,
  KA. TICC 20018(1)61-70
• Template for Developing a Clinical Impression of
  the Aging Spinal Pain Patient. McCarthy
  KA.TICC 20029(2)60-67.

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More in the literature...

• Waddell, Allen, and Nachemsons writings on back
  pain and disability
• Lintons and Turks 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..

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True or False? Degenerative changes, as seen
on x-ray, are a fairly good indicator of the
patients pain and/or functional status.
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No, pain and disability are NOT predicted by
radiographic findings. Disc herniation (visible
on MRI/CT) does not usually predict problems with
spinal function.
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Is it scientifically appropriate to use the
Radiographic Stages Of Generation images to
explain to patients why they are experiencing
pain?
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Pointing out a radiographic finding and tying it
to the patients 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).
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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.
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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
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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!

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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

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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?

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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?

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The tale of 3 patients.

• If you care for everyone the same, (ignoring the
  overall patients 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!)

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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.

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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 (?)

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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

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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, dont 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.

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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?

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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?

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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 doesnt seem
  to hold her adjustments well
• What adjusting strategies may offer the best
  results?
• How will you prevent this from becoming a chronic
  problem?

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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