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Importance of Physician-to-Patient Communication in Musculoskeletal Physiotherapy Consultations

Physician-to-Patient Communication, Patient Education, Communication, Musculoskeletal

A qualitative phenomenological study of 15 musculoskeletal patients and their physiotherapists found that patients were better able to express their concerns and outcome expectations when their practitioners utilized a patient-centric, communicative approach during their initial healthcare consultation. When practitioners were well-versed in contemporary pain and pathology theories, they were better able to anticipate and elicit feedback about their patients’ concerns, leading to a more positive dialogue and better patient satisfaction. Practitioners who have developed systems and approaches to encourage proactive communication from their patients about their health concerns were more likely to have positive patient outcomes than those who relied only upon their prior medical expertise in diagnosing and treating their patients.

Purpose of the Study

Recent healthcare approaches have trended away from the strictly traditional biomedical paradigm to include the biopsychosocial approach to patient consultation and treatment. The newer model recognizes the importance of communication in empowering patients to take an active role in their own treatment and encourages them to consider and express their own health agendas, allowing their clinicians to more fully understand and attend to their specific healthcare needs. To develop a true partnership with their patients, healthcare practitioners must be willing to abandon the “doctor knows best” attitude and develop better communication skills that will allow for a patient-clinician treatment collaboration. This study proposed to investigate the relationship between a clinician’s communication technique and skills and how well the patient was able to express healthcare concerns during an initial consultation.

Methods

15 musculoskeletal patients and their physiotherapists were interviewed after an initial consultation encounter of between 15 and 20 minutes, which was recorded and later analyzed, utilizing predetermined topic guides, including: presenting problems and symptoms; understanding diagnosis theories, how the patients reacted to referrals, the behavior of the clinician during the consultation, desirable and undesirable treatment activities, fears, concerns, and emotional or social issues related to the patient’s treatment or diagnosis.

Findings

Each of the patients involved in the study presented with a range of two to five topics they wanted to discuss with their clinician. The data determined three main themes when it came to important topics of patient-clinician communication during consultations:

Clarity of the patient’s agenda

The first theme identified was how clear or unstructured a patient’s agenda was during their consultation. Some patients had very clear health agendas and were able to communicate their expectations and needs effectively to their clinician. Others were more passive and had more difficulty in communicating their expectations. These patients would have likely benefitted from a practitioner who was better able to create an atmosphere of trust and confidence, which would encourage the patient to discuss their needs.

The need for information and understanding

Patients who had more information about and better understood their health concerns were better at identifying and expressing their expectations and needs during their consultation. The subjects reported being more satisfied with and reassured by their consultation when their clinician took the time to explain and discuss the healthcare issue with them, rather than simply offering a diagnosis and treatment plan. When the clinicians offered evidence-based information regarding their diagnosis and reassurance that their health problem was not due to a serious underlying condition or likely to create too much disruption in their lives, they felt more satisfied with their experience. They were also happier about their consultation when their clinician was able to illicit further information regarding their symptoms and concerns, especially when the patients had neglected to mention these concerns, either through forgetfulness or reluctance to communicate their fears.

Developing Collaboration

Patients in the study reported feeling more supported and engaged when their healthcare provider used a person-centered approach during the interview at their initial consultation. They were better able to trust and have confidence in providers that projected a sense of partnership and were concerned with the social, emotional and physical condition of their patients, rather than treating their dysfunction as a stand-alone concern.

The results of this study emphasize the need for clinicians to create an atmosphere of trust, collaboration, and communication in their patient consultations, rather than relying exclusively on their medical expertise during diagnosis and treatment. By encouraging their patients to more effectively communicate their healthcare concerns, and by creating an atmosphere of collaboration between themselves and their patients, healthcare providers can empower and reassure their patients, which may improve diagnosis, treatment, and healthcare outcomes.

 

KEYWORDS: Importance of Physician-to-Patient Communication, patient-centric, communicative approach, clinician’s communication technique and skills, desirable and undesirable treatment activities, fears, concerns, emotional or social issues related to the patient’s treatment or diagnosis

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Dynamic Imaging Study Suggests Some Degenerative Spondylolisthesis Patients May Not Require Fusion

Degenerative, Spondylolisthesis model, vertebra model, spondylolisthesis

An in vivo dynamic radiographic imaging study of two sets of subjects (symptomatic and asymptomatic) revealed that some degenerative spondylolisthesis (DS) patients showed a greater range of aberrant motion, creating occult instability, in their mid-range kinematic images than previously exhibited on static imaging studies. The new data could have important clinical and diagnostic implications, as practitioners learn to distinguish between DS patients who might benefit from non-surgical interventions and those who require fusion to treat their condition.

Degenerative Spondylolisthesis model

A degenerated lumbar disc model with a grade 1 spondylolisthesis.

Background

Surgical spinal fusion and decompression with laminectomy are the remedies most often prescribed to patients suffering from lumbar DS, but some patients may be treated with decompression alone and avoid costly and potentially risky surgical procedures. Understanding how lumbar spinal instability contributes to DS can help predict which patients may be at risk of destabilization after laminectomy and thus require surgical fusion. The authors of this study sought to compare static and dynamic clinical radiographs to see if the full spectrum of rotational and translational kinematics were evident in MRI’s of subjects utilizing flexion/extension poses.

The Study

Seven Degenerative Spondylolisthesis patients and seven asymptomatic control subjects were imaged during torso flexion as a tracking system measured and calculated the movement of each vertebra and AP slip. Static, and dynamic radiograph images were obtained and compared. The results showed that the static radiographs did not detect the full spectrum of aberrant motion and underestimated AP slip. In contrast, the continuous dynamic imaging showed that DS patients demonstrated a wide range of aberrant motion with high kinematic heterogeneity that was not visible on the static radiographs.





Implications

The results of this ISSLS bioengineering prize-winning study suggest that the presence or absence of lumbar instability in DS patients should be considered and evaluated prior to prescribing treatment. Mid-range kinematics and AP translation may play an important role in determining the relative effectiveness of decompression and laminectomy with—or without—surgical fusion and might spare a subgroup of lumbar DS patients unnecessary expense, risk, and recovery from procedures that are potentially superfluous (or harmful) to their recovery.

KEYWORDS: Some DS Patients May Not Require Fusion Surgery to Improve, some degenerative spondylolisthesis (DS) patients showed a greater range of aberrant motion, creating occult instability, in their mid-range kinematic images, from non-surgical interventions and those who require fusion, static radiographs did not detect the full spectrum of aberrant motion and underestimated AP slip, kinematics and AP translation may play an important role in determining the relative effectiveness of decompression and laminectomy

 

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Cyclic Mechanical Tension and Intervertebral Disc Degeneration

intervertebral disc degeneration, model

Mechanobiology Research

Low back pain is a huge burden on our limited resources with limited knowledge of its pathophysiology. It is widely known that intervertebral disc degeneration (IDD) is intimately related, with the degree of degeneration associated with the severity of low back pain. The characteristics of intervertebral disc degeneration include disc height loss, proteoglycan loss, loss of water, annular fissures, and end plate calcification.

The degenerative process of the intervertebral disc has been seen as a phenotype change within the cells. This anabolic to catabolic shift seems to occur to the cells deep within the disc. One branch of research that studies the influence of mechanical forces on the biology is called Mechanobiology. In other words, can physical stressors on discs influence the process of degeneration? Can moving the disc is a certain way change the outcome of degeneration?



The Study

In this open access study, researchers were the first to investigate this kind of cyclical mechanical tension on the nucleus pulposus cell’s changing behaviour.  They extracted disc cells from caudal spines of (3-month-old) male Sprague-Dawley rats and conducted the mechanical testing using a device after the cells were cultured and prepared. They used this device to apply mechanical force on the cells of the nucleus pulposus (the centre of the disc) to see how the cells behaved under specific loading conditions.

Disc cell senescence involves telomere shortening,  free radical stress, DNA breakdown and cytokine proliferation. Mechanical loading conditions in the upright posture have been found to promote disc cell changes towards intervertebral disc degeneration in rats.  Studying the role of mechanical stress and the influence on disc health will benefit our understanding of disc pathogenesis. 

The results of this study showed a direct relationship of prolonged mechanical cyclic stress towards the catabolic shift of the cells in the nucleus pulposus. They concluded that unphysiological mechanical stress could push a disc into the degenerative cascade. They believe that eventually, too much mechanical stress can influence a cell’s behaviour and suggested that research continue searching the optimal mechanical environment for intervertebral disc cells.

At Dynamic Disc Designs, we work to bring dynamic models to the practitioner to help in the discussions related to motion and the spine.

 



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Study of Human Lumbar Foramen Dimensions During Activity Show Changes are Segment-Dependent

Lumbar Foramen

 An in vivo study of cross-sectional lumbar foramen dimensions during a weight-lifting activity showed that all levels of the lumbar intervertebral foramen (LIVF) area decreased, except for the L5-S1 segment during lumbar extension, which had consistent measurements of the foramen, height, and width throughout the activity. The results of the study could provide insight into ways to improve the diagnosis or treatment of lumbar foramen stenosis.

Purpose of the Study

Radiculopathy caused by nerve root compression is a common symptom of LIVF stenosis and is often treated surgically, through the implantation of an interspinous device or decompression. Because the LIVF is surrounded by mobile facet joints, its shape undergoes changes during typical daily movement. As it changes shape, it may put pressure on nerve roots or other structures that may cause pain. Complications arising from the changing dynamic anatomy of the LIVF during activity can lead to failed back surgery syndrome, so understanding how movement and weight-bearing affects the LIVF is important to effective treatment and maintenance of back pain.

The Study

An MRI study of 10 healthy subjects (five male, five female) in supine, relaxed positions was conducted, and 3D spine models were constructed based upon the results of the scans. The lumbar spines of the subjects were then imaged during lumbar extension postures of 45 degrees to a maximally-extended position, while the subjects were holding an 8-pound dumbbell in both hands. These scans were also used to create 3D vertebral models of the in-vivo dimensions during activity, and a data analytic design was created to determine the area, height, and width of the L2-S1 vertebral levels during the activity for 45-degree flexion, upright position, and maximal extension.

Results

Researchers found that the LIVF area in L2-L3, L3-L4, and L4-L5 decreased during weight-lifting activity. The LIVF widths also showed a similar decrease, but the heights remained throughout the extension activity. However, the foramen area, height, and width at L5-S1 did not change during the weight-lifting. Overall, the data for all other areas demonstrated a change of approximately 10 percent from 45 degrees flexion to an upright standing posture, and again from upright standing to maximal extension. This information underscores how patients with LIVF stenosis may experience nerve root impingement pain during extension postures and feel relief from that pain during flexion. Understanding the in vivo dynamics of the functioning lumbar spine may help practitioners in the treatment and diagnosis of lumbar foramen stenosis.

 

lumbar spinal stenosis, spinal canal narrowing

A superior view of our Lumbar spinal stenosis model with a dynamic disc bulge and dynamic ligamentum flavum.

KEYWORDS: Lumbar Foramen Dimensions During Activity, in vivo study of cross-sectional lumbar foramen dimensions during a weight-lifting activity, insight into ways to improve the diagnosis or treatment of lumbar foramen stenosis, Radiculopathy caused by nerve root compression, Complications arising from the changing dynamic anatomy of the LIVF during activity, nerve root impingement pain during extension postures

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Diurnal Disc Shape and Height Changes – Basic Science and Natural Variations to Understand Back Pain

Diurnal Disc Shape

The spine undergoes natural shape and fluid changes over the course of 24 hours. Often, back pain symptoms vary as well over the day and night cycle.  But the small changes and the links to pain have not been researched thoroughly. Here, a group of researchers from Duke University looked at the reliability of measuring intervertebral disc shape with recumbent MRI. This large avascular structure is linked to back pain and has significant diurnal variation in the human body. It would seem wise to further understand its diurnal disc shape changes.

Some people feel pain in the mornings and others feel things more so at the end of the day. Yet others feel pain more so when they lie down.

The intervertebral disc hydraulically keeps vertebrae separated. Water is squeezed out throughout the day as the human frame is vertical, and this water gets resorbed when an individual lays down. During the process, the disc changes shape and height. And when pain is involved, these shape and height changes can bear increased ( or decreased ) physical stress on structures that may be inflammatory. These can include annular fissures, disc bulges, disc herniations, disc protrusions, encroaching nerve or rootlets of nerves and the shingling of facet joints, just to name a few.

The purpose of this study was to determine intra and inter-rater reliability using MRI to measure diurnal changes of the intervertebral discs.

They did find excellent reliability, and interestingly they saw the most significant change in the posterior annulus region of L5-1. The diurnal variations were in line with what others had seen in previous work. Boos at al. in 1996 saw a 1-2mm change over the course of an 8h workday while Hutton et al. in 2003 saw a volume change of 1-2 cm3.

This research is essential if we are to fully understand back pain origins. Often pain syndromes related to the lower back present with symptoms that are diurnal. At Dynamic Disc Designs, we have models to help explain these subtle but significant changes to the discs, assisting patients to understand the onset of their pains and the diurnal disc shape and the natural variations.

 

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Exploring the Link Between Lower Back Pain, Disc Degeneration and Intradiscal Pressure

intradiscal pressure, model

A study of in vivo intradiscal pressure in subjects with and without lower back pain (LBP) sought to find out how disc degeneration affects intradiscal pressure, measure the loading capacity of the L4/L5 IVD segment, and determine any relationship between movement in that disc segment and the spinal loading capacity. The researchers found that there was a significant relationship between spinal loading and the angle of the motion segment in healthy discs in vivo. In degenerated discs, the intradiscal pressure was much lower than that measured in healthy discs. Further study with wider parameters is suggested to fully understand the phenomenon and the problems associated with it.

Study Motivation and Design

The only way to directly measure spinal loading in humans is via the measurement of intradiscal pressure—a complex in vivo task. Most current knowledge about loading capacities were derived from pioneering studies in the 1960’s and 1970’s by Nachemson, but little corroborating evidence has been published on the topic since. These early studies utilized an inefficient means of evaluating intradiscal pressure—the polyethylene coated disc pressure needle until 1965, and after that, another needle designed specifically for intradiscal pressure measurements. This new needle was not without its deficits and required special handling and was prone to destroying structural defects on insertion. The current study’s authors utilized a newly designed silicone-based needle to measure the pressure and spinal load in 28 patients suffering from LBP, sciatica, or both at the L4/L5 segment, and in eight healthy volunteers with an average age of 25 years-old.

Magnetic resonance imaging (MRI) was performed on the healthy subjects prior to the beginning of the study to ensure no disc degeneration in the volunteers. The 28 LBP patients (10 women and 18 men with a mean age 45 years) were also imaged prior to pressure measurements being taken to visualize the amount of water content in their discs. These patients were diagnosed with disc herniation (16 patients) or spondylosis (12 patients).

The subjects were measured while in the prone position, without sedation but with a “local” dose of anesthesia. A guiding needle was used to position the pressure sensor needle into the nucleus pulposus of the L4/L5 IVD discs. Fluoroscopy was used to confirm correct placement of the needle had been achieved. The subjects were measured in eight positions: prone, upright standing, lateral decubitus, flexion and extension standing, and upright, flexion, and extension sitting positions. Radiograms of the lateral view were also taken of each of the subjects during their testing.

Observations

Pressure measurements in this study indicate that respiration creates a fluctuation in intradiscal pressure even when subjects are in the prone position and utilizing no other muscle activities. An IVD that is healthy is also elastic, with an intradiscal pressure that fluctuates in correspondence to muscle activities and respiration. It is possible that the normal pressure changes involved with respiration could be associated with the maintenance of the nutritional content inside the nucleus pulposus. There was a slight difference between horizontal and vertical pressures in healthy and degenerated discs and in the silicon gel, which may indicate that the nucleus pulposus has a similar pressure tropism to silicon gel. Normal discs had high water content, which explains the small difference between the horizontal and vertical pressure measurements. There was, however, a significant difference between the pressures of the total value (horizontal and vertical and whole posture) of healthy and degenerated discs. These values may not have been significant enough to measure in previous studies utilizing the less efficient needle-types. The information obtained in this study through the use of the sensitive silicone pressure needle will help in developing a better understanding of degenerative disc disease.

 

KEYWORDS: Link Between Lower Back Pain, Disc Degeneration and Intradiscal Pressure, relationship between spinal loading and the angle of the motion segment in healthy discs, respiration creates a fluctuation in intradiscal pressure, degenerative disc disease

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Study Finds Annulus Fibrosus GAG Content Alters the Mechanics of Disc Torsion

Facet Joints, GAG, Annulus Fibrosus, Torsion

A recent study evaluated the role of facet joints in torsion using four different compressive preload conditions in healthy and degenerated lumbar discs—with, and without facet joints. The study also sought to develop a quantitative relationship between structure and function in tissue and torsion mechanics. The study found that annulus fibrosis GAG content substantially affects the mechanics of disc torsion.

Purpose of the Study

Because there is a large population of lower back pain (LBP) sufferers whose jobs involve excessive loading and rotating the lumbar spine, the authors of this study sought to quantify and understand how the facet joints in healthy and degenerated discs would behave under axial rotation scenarios. They did this by observing in vivo changes in spinal segments during torsional behavior. The intervertebral disc (IVD) is capable of stability and flexibility during most movement, receiving stresses and sharing them with the nearby facet joints and other surrounding structures. The facet joints should protect the disc from overload and degeneration by restricting motions that would cause damage to the spine, but some complex motions that involve axial rotation and bending during heavy loading can increase the chance of micro-damage and disc failure. How well the IVD and facet joints share loads is determined by the mode of loading and posture. Previous studies have demonstrated that up to 25 percent of axial compressive forces may be supported by the facet joints. Between 40 to 65 percent of healthy disc joint rotational and shear forces are also supported by the facet joints. Therefore, it is important to understand how the facet joints in healthy and degenerated discs react during torsion.

Study Design

Researchers obtained and imaged seven human cadaveric lumbar spine segments aged 43 to 80 years-old. The musculature and ligaments were then removed, and the intact facet joints near the discs were subdivided mid-vertebrae prior to the samples being potted in bone cement. The segments were then wrapped in gauze and stored in a phosphate solution until brought to room temperature just before testing. They were then mounted onto a testing machine and secured with screws.

The segments underwent a moderate-to-low preloaded axial compression, followed by axial rotation through the center of the disc. The cycles of compression and rotation were performed for two hours to allow the formation of creep. Ten cycles of cyclic rotation, and the samples were tested under four axial compressive preloads and allowed to recover between each test. The facet joints were then removed, and the samples were tested again, using the same loading configuration. For each round of testing, the researchers recorded the levels of force, rotation angle, displacement, and torque.

Isolating and Imaging Each Disc

Each disc was isolated and imaged after mechanical testing. Researchers measured the disc area, anterior-posterior and lateral width using a custom algorithm. Disc height was measured from the posterior, anterior, left, and right lateral sides, as well as the center. A mathematic formula determined the applied axial stress, and the images were graded and compared with radiographic-based grades.

Conclusion

The results of the tests indicated a strong correlation between creep and axial compressive preload and the loss of disc height. Removing the facet joint had no effect on this phenomenon. The presence of facet joints and an axial compressive preload did have a strong effect on torsional mechanical properties, with torsional stiffness and range decreased 50 to 60 percent for compressive loads after removing the facet joints. Energy absorption decreased about 70 percent during rotation after facetectomy, and disc-joint strain increased 74 percent, compared to only 62 percent in disc strain energy using the same axial compression.

Annulus Fibrosis GAG content in degenerated discs greatly reduced torsion mechanics, while the facet joints are integral in keeping the spine from rotating too far and helping to reduce shear stress and damage to the disc. The relationship between the biochemical-mechanical and compression-torsion levels noted in this study may help to provide for more effective and targeted biological repair methods for degenerating discs of various levels.

 

KEYWORDS: AF GAG Content Alters the Mechanics of Disc Torsion, role of facet joints in torsion, axial rotation scenarios, correlation between creep and axial compressive preload and the loss of disc height, targeted biological repair methods for degenerating discs