cervical hydraulic recovery with recumbancy

A retrospective study 1. [Clinical Relationship of Degenerative Changes between the Cervical and Lumbar Spine] reviewing MRIs of 152 back patients showed a positive correlation between cervical and lumbar intervertebral disc degeneration (IDD) in patients presenting with lumbar spondylosis. The results suggest the necessity of screening LBP patients for evidence of cervical IDD.

Introduction

The diagnosis of IDD may be complicated by the patient’s pain patterns and the tendency of practitioners to focus only on the area of discomfort. Studies have demonstrated the interrelatedness of spinal kinematics, reflexes, and complex neurogenic responses in IVD degeneration, but few studies have examined the connection between degenerative changes in the lumbar and cervical spine, as it relates to diagnosis. This study’s aim was to quantify the possible correlation, which could lead to better diagnostic and treatment outcomes for future IDD patients.

 

Method

Positional MRIs of 152 patients presenting with cervical or lumbar spondylosis were reviewed and assessed and graded on a scale of 1 to 5 for every spinal segment. A degenerative disc score (DDS) was achieved by summing the grades across all segments, after which, the subjects were divided into two groups based upon their IDD for each spinal segment. The “normal” group received a grade of 1 to 2; the “degenerative” group had grades of between 3 and 5. The groups were then compared for evidence of a positive correlation.

Results

A review of the two groups showed a positive correlation between DDS of the cervical and lumbar spine, with higher cervical DDSs at the upper lumber segments than at the lower degenerative segments. This indicates that patients demonstrating degenerations in the upper lumbar spinal segments are likely to suffer from some cervical spondylosis on further examination, regardless of whether they are currently symptomatic.

Conclusion

Patients with lumbar degeneration should also be screened for cervical spondylosis, particularly if their lumbar degeneration is present in the L1 to L3, to reduce the likelihood of a missed cervical degeneration diagnosis. Click To Tweet

KEYWORDS: positive correlation between cervical and lumbar intervertebral disc degeneration, better diagnostic and treatment outcomes for future IDD patients, the interrelatedness of spinal kinematics, reflexes, and complex neurogenic responses, patients demonstrating degenerations in the upper lumbar spinal segments are likely to suffer from some cervical spondylosis

somatosensory changes, LBP

A four-month study 1 of acute lower back pain (LBP) patients and a pain-free control group found a correlation between persistent LBP and somatosensory changes over time that appeared to increase pain and other types of neurological sensitivity in chronic LBP patients. Because even baseline pain awareness was elevated in the subjects that later developed chronic LBP, the authors of the study suggest further studies that would examine the evident link between heightened pain sensitivity and its possible role in the development of chronic LBP.

initial LBP diagnosis also be evaluated for potential psychological issues. Click To Tweet

They also suggest patients undergoing initial LBP diagnosis also be evaluated for potential psychological issues that might be contributing factors to their pain.

The Study

Quantitative sensory responses (QSR) were collected and analyzed at less than three weeks prior to the onset of an acute LBP episode (baseline), a two-month follow-up, and at four months for 25 LBP patients and a pain-free control group of 48 subjects.  LBP patients were recruited from a variety of treatment facilities, physicians, and practitioners. Excluding criteria included any history of serious spinal injury or back surgery, pregnancy, or any painful condition requiring at least a month of treatment in the past year or one that affected the subject’s ability to function in any way on a regular basis or required the use of long-term pain medications. Demographics including sex, age, race, work status, and body mass index (BMI) were collected from the LBP and pain-free control participants at the beginning of the study.

Collecting Initial and Follow-Up Data

Patients with LBP answered questions about their pain’s onset, duration, intensity, and how well they were able to function while in pain. The participants then answered questions about their levels of depression, anxiety, and scale of stress. Back pain patients also answered questions that would indicate how much they catastrophized their pain and how self-sufficient they were at dealing with their pain, as well as questions designed to measure the sensory and emotional or affective connection to their pain. They were screened by questionnaires to determine possible neuropathic features of their LBP. All participants involved in the study were given the questionnaires to complete at each of their three assessments, and they were then classified into blind groups according to their answers.

Sensory Testing

All patients were tested for their cold-pain threshold (CPT), followed by a test for their heat-pain threshold (HPT), mechanical wind-up ratio (WUR), pressure-pain threshold (PPT), two-point discrimination (TPD), and conditioned pain modulation (CPM). The testing was conducted at the same three body sites on the backs and hands of all patients. The LBP patients’ back testing was conducted at the location of their greatest pain. Thermal pain thresholds were measured using three consecutive measurements. Pain from the stimulus of a single pin-prick, followed by that of a 10-pin prick, was used to measure the WUR of all subjects and then compared using analysis of a numerical calculation. Three measurements of pressure-pain were used to calculate the PPT. A ruler was used to calculate the TPD of all subjects.

A series of 30-second contacts with a thermally-heated device was used to measure heat pain, and a cold foot bath was used to determine the subjects’ sensitivity to cold, as they were asked to withdraw their foot when they were no longer capable of tolerating the cold water. They were then asked to rate their discomfort at 30, 60, and 90 seconds on a pain scale, and their score was given a negative or positive inhibitory response value. Data and statistics were computed and analyzed by the researchers using statistical software.

Results

The data collected in this study showed that the chronic LBP group had a significantly increased pain sensitivity during early and later pressure and mechanical tests and were more cognizant of pain responses at baseline than their pain-free and recovered acute LPB study counterparts. The psychological effects of their pain were also measured higher at the two and four-month follow-up than their recovered LBP counterparts. This could mean that those patients were neurologically and/or psychologically more prone to pain, even prior to the development of their LBP symptoms. The study authors suggest better standardization of a CPM protocol in future studies to take psychological factors of the patients into account and improve the reliability of future test results.

 

KEYWORDS: correlation between persistent LBP and somatosensory changes, link between heightened pain sensitivity and its possible role in the development of chronic LBP. patients undergoing initial LBP diagnosis also be evaluated for potential psychological issues, cold-pain threshold, heat-pain threshold, conditioned pain modulation

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

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

 

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.

 



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

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.