(Recovery of intervertebral disc in case of osteochondrosis by means of yogatherapy methods)
Today the spine osteochondrosis comes as one of the most common diseases of civilization since according to statistics it affects 80 to 85 percent of the workforce. Back pains are ranked second among the diseases that result in disability. In this way this issue becomes actual not only for physicians, scientists and social workers, but also for lots of ordinary people.
Recently a brand new medicine trend called Vertebroneurology has been established aiming at researching and finding ways to treat and prevent this disease, and it has already gained a lot of interesting discoveries and promising beginnings.
Let us make use of the discoveries made by modern medicine and take a brief overview of the cornerstone of human skeletal system — the spine / vertebral column – in order to get a better understanding of specific features of osteochondrosis and to find eventual and promising ways of its treatment.
What is actually that low back pain?
Today osteochondrosis is interpreted as a polyetiologic * degenerative disease of the spinal motor segment (SMS) ** that primarily affects the intervertebral disc and derivatively damages other parts of the spine, musculoskeletal and nervous system (Ya.Yu. Popelyansky). In other words, the disease affects all the structures that make up the vertebral body, mainly:
— vertebra bone tissue; joints and ligaments that make part of vertebrae articulation; muscles that move the spine;
— neural structures;
— vascular formations.
Accordingly, in terms of clinical implications, osteochondrosis is manifested through the muscle-dystonic, neurodystrophic and neurovascular syndromes.
With such total involvement of all tissues within the pathological process the unchanged specific symptom that defines the disease is the affection of intervertebral disc that normally performs functions of a crash pad transmitting pressure from vertebra to vertebra. As it was aptly said by Ya. Yu. Popelyansky, «there is no osteochondrosis without destructive affection of the disc». Moreover, degenerative changes in the intervertebral discs occur much earlier than they do in bone or muscle structures [N. Boos, S. Weissbach et al., 2002] and they increase with one’s ageing [J. Miller, C. Schmatz, A. Schultz, 1988].
Hence we can assume that having found out the mechanisms of pathological changes of the intervertebral discs we will be able to define the method of the earliest and the most effective impact on the incipient osteochondrosis.
Yet before hypothesizing let us imagine what is inside the intervertebral disc.
The intervertebral disc is located between the bodies of two adjacent vertebrae. The space between the disc and the vertebra itself contains a thin chondral arch laminae (end plate) which plays a major role in the process of disc nutrition.
The disc itself is represented by connective tissue consisting of connective tissue fibers (they facilitate the transmission of stresses caused by motions and perform supportive function being, in fact, a kind of microscopic reinforced grid) and the ground substance (it performs a bridging role for fibers and it is the place where all
metabolic processes happen). The disc also contains a number of cells some of which are allegedly involved in the formation of the «reinforcement” due to their cell processes. Some part of the cells produce components of the intercellular substance thus being responsible for maintenance of the disc’ biochemical balance.
Thus, the disc itself is a non-homogenous formation and a biological system of unique complexity (A. Kadyrov, N. N. Sack, A.E. Sack). Without going into details we shall note that within the disc one can conventionally single out the central zone, or the pulpal complex, and the peripheral fibrous ring which after the age of 20 shall become firmly fused with the edges of the adjacent vertebrae. The fibrous ring contains more fiber, and it determines its supporting functions. The pulpal center contains more water which determines its function of shock absorption.
What is the process of disc nutrition?
The disc is the avascular area (this is understandable: a place that is subjected to constant and many-sided load cannot contain blood vessels, otherwise it would increase the risk of permanent clamping and vessels rupture bringing to nothing their function of transporting nutrients and oxygen). Nearby vessels are located in the vertebral bodies and on the periphery of the fibrous ring. Consequently, there should exist a mechanism for exchange of water and nutrients required by the disc despite the availability of vessels within the disc itself. And so it does. Water exchange occurs in scope of motions performed by spinal-motion segment. In this process the disc can be compared to a certain pump that attracts water.
What determines the effectiveness of the suction function of the disc?
First, the location of connective tissue fibers. And here it is important to remember the well-known medicine law: all fibrous structures of the body are arranged in accordance with the applied load. That is, the harmonious arrangement of fibers which facilitates maximum efficient exchange of water and nutrients is formed under appropriate load upon the spine and along the spinal muscles. With this type of load it is important to perform the most appropriate movement that stipulates redistribution of pressure occurring upon the fibers of connective tissue.
Second, the state of the endplates. As we have said, the endplates are made of cartilaginous tissue and they are of insufficient thickness — normally less than 1 mm. The efficiency of fluid carryover to disc structures is directly related to the endplate thickness and condition. The case of intervertebral disc’ overload or underload shall cause reorganization of capillaries of the vertebral bodies and induration of endplates thus impeding the diffusion of nutrients [S. Roberts et al., 1996].
When continuously under loads, the disc shall start to deform and it will eventually lead to osteochondrosis.
Therefore, for normal functioning of the endplates the required power load should be adequate.
Third, the state of the blood vessels themselves. In addition to already mentioned reasons, disk malnutrition can be linked to various anaemias and vascular scleroses [J.P. Jones, 1997].
Fourth, the biochemical composition of the disc itself.
The disc ability of water absorption depends upon the level of hyaluronic acid and proteoglycans within its composition, for due to large number of negative bonds in molecules they form and support the swelling pressure which determines the disc ability of water intake.
The research done has revealed an interesting pattern: the intradiscal content of proteoglycan increases upon proper execution of movements done in scope of physical exercise. It is not only the load intensity that plays the core role, as it has been previously thought, but the proper execution of movement that actually does.
Having analyzed the conditions of the most efficient mode of disk nutrition we can identify an interesting regularity — the health of the intervertebral disc to a large extent depends upon the load on the spine, while the parameters that are significant in this respect are the strength and direction of the load.
Let us try to get a detailed understanding of the loads that have a health-restoring effect upon the vertebral disc.
For the purpose of this we need to define the concept of the load, identify the factors that form the load and clarify load characteristics that are important for our search.
In this case the definition of load as of engagement, as of workload by means of physical movement shall be extremely inaccurate. However it is interesting from the point of illustrating the misbelief that is still circulating in public mind stating that osteochondrosis is caused by hypodynamia, by lack of overall physical activity. Hypodynamia may come as a factor contributing to disease, and not only to osteochondrosis but to some other ailments of the cardiovascular system, gastrointestinal tract and almost all organs and systems. Hypodynamia deprives the person of ability to act openly and by means of engaging integral resources of his body. But it would be the connivance and inaccuracy to assume such lack of exercise to be a decisive and primary cause of osteochondrosis.
This can be proved by the lack of stable positive dynamics shown by patients suffering from osteochondrosis in case of simple increase of physical activity.
Besides, there is another proof of the above-set point of view.
Studies have shown that the incidence rate of osteochondrosis among employees not engaged in physical labor is rather high and just like in case with workers engaged in performing physical exercises it leads to significant employment loss (T.E. Galantseva, 1970, et al. ). It means they have not found any direct correlation between the intensity of overall muscle activity and osteochondrosis morbidity.
The motor impairment may act as a decisive factor here, but perhaps in some rather limited aspect.
In scope of research some interesting information has been received: the rate of osteochondrosis with loss of one’s ability to work is increased by prolonged stay in an uncomfortable position regardless of the nature of the performed activity. For this purpose they have examined various professional groups and have revealed this pattern by steelworkers (Kuhlendahl K, 1954, 1956, V.Z. Koltun, 1971), agricultural workers (Yu.I. Batyasov, 1973 V.I.I Mishchenko , 1975), medical attendants (Magora A., 1970) and vehicle drivers (Kuhlendahl H., 1954,1956; Z.N. Gocharov, 1964, N.S. Lashchenko et al., 1973; Kelsey Y., 1980 ).
Basing upon research evidence we may suggest that it is the condition of paravertebral muscles, not the skeletal muscle in general, that is significant in the formation of degenerative disc disease.
So let us consider the load as a set of forces acting on the SMS and the spine as a whole at a given time. In this case the load will determine the weight of the human body and spatial position of the body parts. The load direction will be determined by working muscles.
And let us also study the way various parameters of the load act upon the intervertebral disc.
The parameter called load intensity has been investigated in details; it is determined indirectly – by means of measuring the pressure in the intervertebral disc. (The first study was performed in 1964 on 16 volunteers by the scientists A. Nahemson and Dzh.Morris).
According to studies, the weight, body posture and muscle activity play a key role in formation of intradiscal pressure.
Fig. Relative intradiscal pressure in different positions of the body compared to the pressure in the upright standing position (100%)
Depending upon the body position, the pressure on the discs in rest varies from 0.1 to 0.2 MPa, while when bending and weight lifting this pressure increases up to the level of 1.5-2.5 MPa. The pressure within the disc is normally created mainly by means of water contained in the core and inner part of the outer ring. By increasing the load upon the disc the pressure is evenly distributed along the disc and the cartilaginous plate.
When squeezed, the disc is deformed and flattened. Cartilaginous plate and the outer ring swell up, the tension in these structures increases and thus increases the pressure within the core. It is assumed that the rise of pressure within the disc up to some certain level invokes disc traumatization.
Therefore there were developed a set of recommendations for the correct execution of movements — for instance, the well-known recommendation to perform weight-lifting with keeping one’s back straight. This point is important. But it takes into account only those positions of body parts that facilitate correct and harmonious distribution of the load. And it overlooks the thing that in case of a more accurate and proper performance of the pose the microstructures that perform the load balance – the connective fiber of intervertebral bands and disc – shall be also arranged in a proper way. And in fact in such a case there is no load adequate for body resource that shall be able to injure the intervertebral disk.
So we can resume that the endurance of SMS elements directly depends upon correct body posture.
Direction of load distribution
It is determined by position and direction of the fibrous connective tissue elements of the muscles, tendons and the disc, which in their turn depend upon the «usual» direction of forces that affect upon the given elements, that in fact being the habitual state of muscles that support the spine. Simply – the body posture.
If the condition of the muscles running along the spine is harmonious, i.e. the muscles are perfectly in tone, the activity of their constituent motor units *** is aligned and coordinated, one can expect harmonious distribution of emerging workloads.
If the muscles are hypo — or hypertonic **** and their trigger points are strained, the even distribution of the load along the spinal column is not possible.
Not to mention the fact that the muscles with chronically modified tone at some certain moment will simply fail to make a compensatory movement.
The rate of load increase
A very important and interesting observation that is often left out of account is that the degree of disc deformation depends upon the rate (the speed) of load increase. In terms of backbone bending and unbending the disc can shrink or expand up to 30-60% of its thickness, and the distance between the processes of adjacent vertebrae may be increased by more than 4 times. Slow performance of intensive bending and unbending apparently leads to adaptation of the pressure inside the disc and a more accurate formation of muscle-tendon and connective tissue structures that provides optimum level of water saturation, and therefore, the optimum of its damping function. (The issue of the time of disc recurrence back to its original state has been studied by Hirsh).
A rather sufficient load applied rapidly onto the disk can make vibrations occurring inside the disc damage the fibers of the fibrous ring (Hirsh’ works).
Duration of load
If the load vanishes within a few seconds or minutes, the disc shall return to its original size rather quickly. However, if the load is maintained, the disc shall not restore its height (the phenomenon of disc aging). In fact, the existence of such chronic and inharmonious load is in process is case of deep-rooted postural disorders.
From all afore-said it becomes clear that the most important factors in harmonious redistribution of loads are the harmonious posture and harmoniously performed moves (static and dynamic movement patterns).
Thus we can conclude that the load that is most adequate in terms of maintaining the disc in its sound condition shall comprise movements that act upon the paravertebral muscles and form optimal movement patterns.
And it is yoga with its system of asanas (physical postures among which many are determined at arranging the muscles located along the vertebral column) and pranayamas (breathing exercises that have an effect on the musculoskeletal system) that holds a powerful arsenal of techniques for formation of movement patterns.
If to talk about health-improving aspects of currently existing systems, one can also mention osteopathy and applied kinesiology which also use a system of movements and breathing techniques, in particular, for normalization of the spine.
Their main distinction from yoga is stipulated by the fact that the main actions are performed by osteopath or kinesiologist. Neither osteopathy nor kinesiology give their patients the criteria for maintaining their muscles in the state of harmony. Due to this the patient is not able to adequately reproduce the harmonious position in the absence of an osteopath or a kinesiologist. And it subjects the system to significant limits despite all those numerous ideas, them being interesting and perspective, that are put forward by doctors of these directions.
Within yoga the is a health-improving system aimed at restoration of the injured vertebral column – the yogatherapy.
When one deals with restoration of the spinal column he should adhere to the following algorithm and sequence of actions.
1. One should first restore the normal tone of paravertebral muscles, work through and improve contractures and trigger points, abnormal muscle archs.
2. Afterwards, one needs to arrange the most harmonious links between the guiding connective tissue elements of muscles, tendons and the disc.
3. The last step is to keep the achieved balance and to work up some standby capacity for all components of the vertebral-motor segment.
This is the key to restoring the capacity of pulpal complex, and therefore, the key to long-term and lasting results in the treatment of osteochondrosis.
*The word “etiology” originates from the Greek αἰτία — ‘the reason, cause’, and, λόγος — ‘the study, science’. Thus etiology is a science about reasons and provisions of disease incidence.
** The spinal motor segment (SMS) consists of two adjacent vertebrae, including the intervertebral disc, articular-ligamentous apparatus and muscles that cause its motion. It is the functional unit of the vertebral body.
*** Motor unit is the functional unit of the skeletal muscle. It is a group of muscle cells controlled by one nerve cell of the spinal cord (the motor neuron).
****Hypo-/ hyper-tone (from Greek τόνος — ‘tension’) – is the state of the skeleton muscle’s insufficient / extensive strain.