Advertisement

Can specific loading through exercise impart healing or regeneration of the intervertebral disc?

      Abstract

      Background context

      Low back pain (LBP) is highly prevalent and presents an enormous cost both through direct health care and indirectly through significant work and production loss. Low back pain is acknowledged widely to be a multifactorial pathology with a variety of symptoms, dysfunctions, and a number of possible sources of pain. One source that has been suspected and evidenced for some time is the intervertebral disc. Some degree of disc degeneration is a physiologic process associated with aging, however, more severe degeneration and/or structural abnormality may be indicative of a pathologic process or injury and is more commonly present in those suffering from LBP. Much like other tissues (ie, muscle, bone, etc.), it has been suspected that there exists an optimal loading strategy to promote the health of the disc. Exercise is often prescribed for LBP and effectively reduces pain and disability. However, whether specific loading through exercise might plausibly heal or regenerate the intervertebral discs is unknown.

      Purpose

      To examine the effects of loading on regenerative processes in the intervertebral disc and consider the potential for specific exercise to apply loading to the lumbar spine to produce these effects.

      Study design

      A brief narrative literature review.

      Methods

      Studies examining the effects of loading on the intervertebral discs were reviewed to examine the plausibility of using loading through exercise to induce regeneration or healing of the intervertebral disc.

      Results

      Research from animal model studies suggests the existence of a dose-response relationship between loading and regenerative processes. Although high loading at high volumes and frequencies might accelerate degeneration or produce disc injury, high loading, yet of low volume and at low frequency appears to induce potentially regenerative mechanisms, including improvements in disc proteoglycan content, matrix gene expression, rate of cell apoptosis, and improved fluid flow and solute transport.

      Conclusions

      Research suggests a dose-response relationship between loading and disc regenerative processes and that the loading pattern typically used in the lumbar extension resistance exercise interventions (high load, low volume, and low frequency) might impart healing or regeneration of the intervertebral discs. Future research should examine an exercise intervention with in vivo measurement of changes in disc condition. This may provide further evidence for the “black box” of treatment mechanisms associated with exercise interventions.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Spine Journal
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • World Health Organisation (WHO)
        The World Health Report 1998: life in the 21st century: a vision for all.
        Office of Publications, World Health Organisation, Geneva, Switzerland1998
        • Waddell G.
        • Burton A.K.
        Occupational health guidelines for the management of low back pain at work: evidence review.
        Occup Med. 2001; 51: 126-135
        • Walker B.F.
        The prevalence of low back pain: a systematic review of the literature from 1966 to 1998.
        J Spinal Disord. 2000; 13: 205-217
        • National Institute for Health and Clinical Excellence (NICE)
        Low back pain: early management of persistent non-specific low back pain.
        Royal College of General Practitioners, London, UK2009
        • Maniadakis N.
        • Gray A.
        The economic burden of back pain in the UK.
        Pain. 2000; 84: 95-103
        • Katz J.N.
        Lumbar disc disorders and low back pain: socioeconomic factors and consequences.
        J Bone Joint Surg Am. 2006; 88: 21-24
        • Van Tulder M.W.
        • Koes B.W.
        • Bouter L.M.
        A cost-of-illness study of back pain in The Netherlands.
        Pain. 1995; 62: 233-240
        • Guo H.R.
        • Tanaka S.
        • Halperin W.E.
        • Cameron L.L.
        Back pain prevalence in US industry and estimates of lost workdays.
        Am J Public Health. 1999; 89: 1029-1035
        • Waddell G.
        • Aylward M.
        • Sawney P.
        Back pain, incapacity for work and social security benefits: an international literature review and analysis.
        The Royal Society of Medicine Press Ltd, Glasgow, Scotland2002
        • National Research Council (NRC)
        Work-related musculoskeletal disorders: a review of the evidence.
        National Academy Press, Washington, DC1998
        • National Research Council (NRC) and The Institute of Medicine (IOM)
        Musculoskeletal disorders and the workplace: low back and upper extremities.
        National Academy Press, Washington, DC2001
        • Mixter W.J.
        • Barr J.S.
        Rupture of the intervertebral disc with involvement of the spinal canal.
        N Engl J Med. 1934; 211: 210-215
        • Adams M.A.
        • Roughley P.J.
        What is intervertebral disc degeneration, and what causes it?.
        Spine. 2006; 31: 2151-2161
        • Adams M.A.
        • Stefanakis M.
        • Dolan P.
        Healing of a painful intervertebral disc should not be confused with reversing disc degeneration: implications for physical therapies for discogenic back pain.
        Clin Biomech. 2010; 25: 961-971
        • Boden S.D.
        • Davis D.O.
        • Dina T.S.
        • Patronas N.J.
        • Wiesel S.W.
        Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation.
        J Bone Joint Surg Am. 1990; 72: 403-408
        • Jensen M.C.
        • Brant-Zawadzki M.N.
        • Obuchowski N.
        • Modic M.T.
        • Malkasian D.
        • Ross J.S.
        Magnetic resonance imaging of the lumbar spine in people without back pain.
        N Engl J Med. 1994; 331: 69-73
        • Weishaupt D.
        • Zanetti M.
        • Hodler J.
        • Boos N.
        MR imaging of the lumbar spine: prevalence of intervertebral disk extrusion and sequestration, nerve root compression, end plate abnormalities and osteoarthritis of the facet joints in asymptomatic volunteers.
        Radiology. 1998; 209: 661-669
        • Borenstein D.G.
        • O'Mara J.
        • Boden S.D.
        • Lauerman W.C.
        • Jacobson A.
        • Platenberg C.
        • et al.
        The value of magnetic resonance imaging of the lumbar spine to predict low back pain in asymptomatic subjects.
        J Bone Joint Surg Am. 2001; 83: 1306-1311
        • Baranto A.
        • Hellström M.
        • Cederlund C.G.
        • Nyman R.
        • Sward L.
        Back pain and MRI changes in the thoraco-lumbar spine of top athletes in four different sports: a 15 year follow-up study.
        Knee Surg Sports Traumatol Arthrosc. 2009; 17: 1125-1134
        • Maurer M.
        • Soder R.B.
        • Baldisserotto M.
        Spine abnormalities depicted by magnetic resonance imaging in adolescent rowers.
        Am J Sports Med. 2011; 39: 392-397
        • Iwamoto J.
        • Abe H.
        • Tsukimura Y.
        • Wakano K.
        Relationship between radiographic abnormalities of lumbar spine and incidence of low back pain in high school rugby players: a prospective study.
        Scand J Med Sci Sports. 2005; 15: 163-168
        • Holt E.P.
        The question of lumbar discography.
        J Bone Joint Surg Am. 1968; 50: 720-726
        • Walsh T.R.
        • Weinstein J.N.
        • Spratt K.F.
        • Lehmann T.R.
        • Aprill C.
        • Sayre H.
        Lumbar discography in normal subjects. A controlled, prospective study.
        J Bone Joint Surg Am. 1990; 72: 1081-1088
        • Endean A.
        • Palmer K.T.
        • Coggon D.
        Potential of magnetic resonance imaging findings to refine case definition for mechanical low back pain in epidemiological studies.
        Spine. 2011; 36: 160-169
        • McNee P.
        • Shambrook J.
        • Harris E.C.
        • Sampson M.
        • Palmer K.T.
        • Coggon D.
        Predictors of long-term pain and disability in patients with low back pain investigated by magnetic resonance imaging: a longitudinal study.
        BMC Musculoskelet Disord. 2011; 12: 234
        • Shambrook J.
        • McNee P.
        • Harris E.C.
        • Kim M.
        • Sampson M.
        • Palmer K.T.
        • et al.
        Clinical presentation of low back pain and association with risk factors according to findings on magnetic resonance imaging.
        Pain. 2011; 152: 1659-1665
        • DeLeo J.A.
        • Winkelstein B.A.
        Physiology of chronic spinal pain syndromes: from animal models to biomechanics.
        Spine. 2002; 27: 2526-2537
        • Kjaer P.
        • Leboeuf-Yde C.
        • Kowsholm L.
        • Sorenson J.S.
        • Bendix T.
        Magnetic resonance imaging and low back pain in adults: a diagnostic study of 40 year old men and women.
        Spine. 2005; 30: 1173-1180
        • Cheung K.M.C.
        • Karppinen J.
        • Chan D.
        • Ho D.W.H.
        • Song Y.
        • Sham P.
        • et al.
        Prevalence and pattern of lumbar magnetic resonance imaging changes in a population study of one thousand forty-three individuals.
        Spine. 2009; 34: 934-940
        • de Schepper E.I.T.
        • Damen J.
        • van Meurs J.B.J.
        • Ginai A.Z.
        • Popham M.
        • Hofman A.
        • et al.
        The association between lumbar disc degeneration and low back pain.
        Spine. 2010; 35: 531-536
        • Kitano T.
        • Zerwekh J.E.
        • Usui Y.
        • Edwards M.L.
        • Flicker P.L.
        • Mooney V.
        Biochemical changes associated with the symptomatic human intervertebral disk.
        Clin Orthop Relat Res. 1993; 293: 372-377
        • Mooney V.
        • Verna J.
        • Morris C.
        Clinical management of chronic, disabling low back syndromes.
        in: Morris C. Rehabilitation of the spine: a Practitioners manual. McGraw-Hill, New York, NY2006
        • Mayer J.
        • Mooney V.
        • Dagenais S.
        Evidence informed management of chronic low back pain with lumbar extensor strengthening exercises.
        Spine J. 2008; 8: 96-113
      1. Steele J, Bruce-Low S, Smith D. A review of the specificity of exercises designed for conditioning the lumbar extensors. Br J Sports Med 2013 Oct 3. http://dx.doi.org/10.1136/bjsports-2013-092197. [Epub ahead of print].

        • Highland T.R.
        • Dreisinger T.E.
        Degenerative disc disease in a collegiate volleyball player.
        Med Sci Sports Exerc. 1992; 24: S163
        • Nelson B.W.
        • O'Reilly E.
        • Miller M.
        The clinical effects of intensive, specific exercise on low back pain: a controlled study of 895 consecutive patients with a one year follow up.
        Orthopedics. 1995; 18: 971-981
        • Choi G.
        • Raiturker P.P.
        • Kim M.J.
        • Jin C.D.
        • Chae Y.S.
        The effect of early isolated lumbar extension exercise program for patients with herniated disc and undergoing lumbar discectomy.
        Neurosurgery. 2005; 57: 764-772
        • Kleinstuck F.
        • Dvorak J.
        • Mannion A.F.
        Are “structural abnormalities” on magnetic resonance imaging a contraindication to the successful conservative treatment of chronic nonspecific low back pain?.
        Spine. 2006; 31: 2250-2257
        • McGill S.M.
        Low back disorders: evidence-based rehabilitation and prevention.
        2nd ed. Human Kinetics, Champaign, IL2007
        • Callaghan J.P.
        • McGill S.M.
        Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force.
        Clin Biomech. 2001; 16: 28-37
        • Smith D.
        • Bruce-Low S.
        • Bissell G.
        Twenty years of specific, isolated lumbar extension research: a review.
        J Orthop. 2011; 5: e14
        • Lotz J.C.
        • Chin J.R.
        Intervertebral disc cell death is dependent on the magnitude and duration of spinal loading.
        Spine. 2000; 25: 1477-1483
        • Stokes I.A.F.
        • Iatridis J.C.
        Mechanical conditions that accelerate intervertebral disc degeneration: overload versus immobilization.
        Spine. 2004; 29: 2724-2732
        • Chan A.C.W.
        • Ferguson S.J.
        • Gantenbein-Ritter B.
        The effects of dynamic loading on the intervertebral disc.
        Eur Spine J. 2011; 20: 1796-1812
        • Lotz J.C.
        • Colliou O.K.
        • Chin J.R.
        • Duncan N.A.
        • Lienbenberg E.
        Compression-induced degeneration of the intervertebral disc: and in vivo mouse model and finite-element study.
        Spine. 1998; 23: 2493-2506
        • Kroeber M.W.
        • Unglaub F.
        • Wang H.
        • Schmid C.
        • Thomsen M.
        • Nerlich A.
        • et al.
        New in vivo animal model to create intervertebral disc degeneration and to investigate the effects of therapeutic strategies to stimulate disc regeneration.
        Spine. 2002; 27: 2684-2690
        • Fisher J.
        • Steele J.
        • Bruce-Low S.
        • Smith D.
        Evidence based resistance training recommendations.
        Med Sport. 2011; 15: 147-162
        • Fisher J.
        • Steele J.
        • Smith D.
        Evidence based resistance training recommendations for muscular hypertrophy.
        Med Sport. 2013; 17: 217-235
        • Graves J.E.
        • Pollock M.L.
        • Foster D.
        • Leggett S.H.
        • Carpenter D.M.
        • Vuoso R.
        • et al.
        Effect of training frequency and specificity on isometric lumbar extension strength.
        Spine. 1990; 15: 504-509
        • Bruce-Low S.
        • Smith D.
        • Burnett S.
        • Fisher J.
        • Bissell G.
        • Webster L.
        One lumbar extension training session per week is sufficient for strength gains and reductions in pain in patients with chronic low back pain ergonomics.
        Ergonomics. 2012; 55: 500-507
        • Walsh A.J.
        • Lotz J.C.
        Biological response of the intervertebral disc to dynamic loading.
        J Biomech. 2004; 37: 329-337
        • Maclean J.J.
        • Lee C.R.
        • Alini M.
        • Iatridis J.C.
        Anabolic and catabolic mRNA levels of the intervertebral disc vary with the magnitude and frequency of in vivo dynamic compression.
        J Orthop Res. 2004; 22: 1193-1200
        • Maclean J.J.
        • Lee C.R.
        • Alini M.
        • Iatridis J.C.
        The effects of short-term load duration on anabolic and catabolic gene expression in the rat tail intervertebral disc.
        J Orthop Res. 2005; 23: 1120-1127
        • Ferguson S.J.
        • Ito K.
        • Nolte L.P.
        Fluid flow and convective transport of solutes within the intervertebral disc.
        J Biomech. 2004; 37: 213-221
        • Wang D.L.
        • Jiang S.D.
        • Dai L.Y.
        Biologic response of the intervertebral disc to static and dynamic compression in vitro.
        Spine. 2007; 32: 2521-2528
        • Khan K.M.
        • Scott A.
        Mechanotherapy: how physical therapists' prescription of exercise promotes tissue repair.
        Br J Sports Med. 2009; 43: 247-251
        • Mooney V.
        • Gulick J.
        • Perlman M.
        • Levy D.
        • Pozos R.
        • Leggett S.
        • et al.
        Relationships between myoelectric activity, strength and MRI of lumbar extensor muscles in back pain patients and normal subjects.
        J Spinal Disord. 1997; 10: 348-356
        • Pollock M.L.
        • Gazarella L.
        • Graves J.E.
        • Carpenter D.M.
        • Leggett S.H.
        • Lowenthal D.
        • et al.
        Effects of isolated lumbar extension resistance training on bone mineral density of the elderly.
        Med Sci Sports Exerc. 1992; 24: S66
        • Braith R.W.
        • Mills R.M.
        • Welsch M.A.
        • Keller J.W.
        • Pollock M.L.
        Resistance exercise training restores bone mineral density in heart transplant recipients.
        J Am Coll Cardiol. 1996; 28: 1471-1477
        • Braith R.W.
        • Magyari P.M.
        • Fulton M.N.
        • Aranda J.
        • Walker T.
        • Hill J.A.
        Resistance exercise training and alendronate reverse glucocorticoid-induced osteoporosis in heart transplant recipients.
        J Heart Lung Transplant. 2003; 22: 1082-1090
        • Mitchell M.J.
        • Baz M.A.
        • Fulton M.N.
        • Lisor C.F.
        • Braith R.W.
        Resistance training prevents vertebral osteoporosis in lung transplant recipients.
        Transplantation. 2003; 76: 557-562
        • Braith R.W.
        • Magyari P.M.
        • Fulton M.N.
        • Lisor C.F.
        • Vogel S.E.
        • Hill J.A.
        • et al.
        Comparison of calcitonin versus calcitonin + resistance exercise as prophylaxis for osteoporosis in heart transplant recipients.
        Transplantation. 2006; 81: 1191-1195
        • Braith R.W.
        • Conner J.A.
        • Fulton M.N.
        • Lisor C.F.
        • Casey D.P.
        • Howe K.S.
        • et al.
        Comparison of alendronate vs alendronate plus mechanical loading as prophylaxis for osteoporosis in lung transplant recipients: a pilot study.
        J Heart Lung Transplant. 2007; 26: 132-137
        • Schumann B.
        • Bolm-Audorff U.
        • Bergmann A.
        • Ellegast R.
        • Elsner G.
        • Grifka J.
        • et al.
        Lifestyle factors and lumbar disc disease: results of a German multi-center case-control study (EPILIFT).
        Arthritis Res Ther. 2010; 12: R193
        • Ireland D.
        Molecular mechanisms involved in intervertebral disc degeneration and potential new treatment strategies.
        Bioscience Horizons. 2009; 2: 83-89
        • Smith L.J.
        • Nerurkar N.L.
        • Choi K.
        • Harfe B.D.
        • Elliot D.M.
        Degeneration and regeneration of the intervertebral disc: lessons from development.
        Dis Model Mech. 2011; 4: 31-41
        • Smith D.
        • Bissell G.
        • Bruce-Low S.
        • Wakefield C.
        The effect of lumbar extension training with and without pelvic stabilization on lumbar strength and low back pain.
        J Back Musculoskelet Rehabil. 2011; 24: 1-9
        • Steele J.
        • Bruce-Low S.
        • Smith S.
        • Jessop D.
        • Osborne N.
        A randomised controlled trial of limited range of motion lumbar extension exercise in chronic low back pain.
        Spine. 2013; 38: 1245-1252
        • Helmhout P.H.
        • Staal J.B.
        • Maher C.G.
        • Petersen T.
        • Rainville J.
        • Shaw W.S.
        Exercise therapy and low back pain: insights and proposals to improve the design, conduct, and reporting of clinical trials.
        Spine. 2008; 33: 1782-1788
        • Helmhout P.H.
        • Harts C.
        • Staal J.B.
        • de Bie R.A.
        Rationale and design of a multicentre randomized controlled trial on a ‘minimal intervention’ in Dutch army personnel with nonspecific low back pain.
        BMC Musculoskelet Disord. 2004; 5: 40