, , , , , ,

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.


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 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.


, , , , ,

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.


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

, , , ,

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.


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

, , , ,

Study Finds Strong Correlation Between LBP, Age-related Degeneration, and Spinal Instability


A study examined the relationship between lumbar disc degeneration and instability in spinal segments of three groups of volunteers and found that factors of spinal instability were closely related to disc height and the age of the study subjects and that disc height was intimately associated with age and spinal instability and was the most consistently affiliated parameter of those examined.

Patients with lower back pain (LBP) and/or sciatica often have evident disc degeneration in MRI their images, especially elderly patients. Because these patients may demonstrate no other neurological symptoms, it is commonly assumed specific evidence of LBP –aside from degeneration and the age of the patient—may not exist. Excessive motion surrounding the affected disc segment can cause LBP and spinal instability, and previous studies on the relationship between instability and LBP have been inconsistent in their findings—in part, because imaging of the subjects was performed while the patients were in the static supine position.

Study Design Utilized Flexion-Extension Standing Postured Imaging Reviews

The authors of the current study were building upon their previous research utilizing images that had been performed on patients during flexion-extension standing postures to examine the relationship between spinal instability and disc degeneration of the L4/L5 motion segment. Because disc degeneration may not be associated with LBP at all stages, the authors of the study devised a method of measurement to examine different types of segmental degeneration and any relationship it may have with spinal instability.

The subjects of the study were LBP or leg pain outpatients who had received radiologic and MRI imaging within a two-month interval during the past three years. Of the 447 patients included in the study, 268 were men, and 179 were women. Their ages ranged from 10 to 86 years, with an average age of roughly 54 years-old.

Instability was measured at the L4/L5 spinal segments during neutral, extension, and flexion postured images and was then analyzed and categorized into three variable types: Anterior slip at L4 onto L5 while in neutral position (SN), sagittal translation (ST), and segmental angulation (SA). Measurements were taken of each slip, and the results were evaluated and noted to determine the degree of apparent instability.

The disc segments were evaluated radiologically for degeneration by looking at and comparing disc height, spur formation of the anterior vertebral edges, endplate sclerosis, and evidence of vacuum phenomenon in the films taken during flexion-extension. Sixty-eight of the subjects had high disc height (HDH), 212 patients were considered to have medium disc height (MDH), and 67 patients were categorized as having low disc height (LDH). Bony spur measurements were taken, and the presence of endplate sclerosis and vacuum phenomenon were noted as either being present or not. The level of disc degeneration was evaluated by MRI and graded from 1 to 5, as “normal,” to “severe” degeneration. The patients were divided into eight groups based upon the severity of their spinal instability, and the relationship between disc height, spur size, endplate sclerosis, vacuum phenomenon, and degeneration in the MRI’s was noted in relation to the types of instability present.

The compared data indicated a link between instability, age, and a reduction in disc height. Though increased age and a loss of disc height have long been suspected to be linked to degeneration and instability of the spine, this study uses MRI to evaluate that relationship more closely, demonstrating that a lower disc height was associated at least a 3mm slippage and a higher disc height was associated with subjects who were younger in age, with larger angulation in the spinal segments. Instability was prevalent in older patients with prominent anterior spur formation and/or vacuum phenomenon.

Age and relative spinal stability were intimately related to disc height, and this instability was progressive in nature and occurred over decades.


KEYWORDS: Correlation Between LBP, Age-related Degeneration, and Spinal Instability, relationship between lumbar disc degeneration and instability, comparing disc height, spur formation of the anterior vertebral edges, endplate sclerosis, and evidence of vacuum phenomenon, link between instability, age, and a reduction in disc height, degeneration and instability of the spine

, , ,

Post-Treatment Interviews Offer Insight into How Conceptions about Care Affect Outcomes in LBP Patients

Post-Treatment Interviews, LBP patients

A phenomonenographic study of post-treatment interviews of lower back pain (LBP) patients’ conceptions regarding their clinical experience revealed common themes that correlated to negative or positive treatment efficacy and suggests practitioner approaches that may empower and create a therapeutic alliance between patients and their health care providers (HCP).

Effective Treatment Involves Holistic Approach

LBP is a worldwide phenomenon that affects adults of all ages. It is a leading cause of lost work and wages and may require long-term treatment with a variety of practitioners. Managing LBP can be challenging, especially when one’s HCP limits treatment or discourse to strictly biomedical or physiological causations. To more effectively address patients’ needs, a holistic, psychosocial approach to understanding LBP and creating effective treatments may be more conducive to patient empowerment and satisfaction with treatment outcomes. The study of post-treatment interviews sought to determine common themes in patients’ conception of their treatment and suggests models that might encourage better, more satisfying care.

Study Design and Data Collection and Analysis

To better understand and describe the full contextual nature of patient experiences with their HCP and treatments, researchers utilized the phenomenographic study design method and created a hierarchical structure of categorized themes derived from the data sets. The study authors were concerned with patients’ conceptions of their practitioner visits, rather than mere opinions. The 17 volunteers (five men and 12 women with a mean age of 46 years) were chosen from LBP patients who were undergoing treatment for episodic or chronic conditions and were categorized as “high risk” on the Keele STarT Back Screening Tool, indicating high levels of psychological risk factors in their daily lives. All of the volunteers agreed to participation in the study and were asked to view videos of their HCP encounters and respond to interview questions regarding their physiotherapy consultation and treatment experience. The experience of viewing and discussing the video prompted many of the subjects to reflect upon their overall healthcare journey. The researchers asked the subjects to talk about who they were and how they ended up in LBP treatment. Further questions queried the patients about the experience of being treated, examined, and the explanations they received from their HCP about their LBP, as well as how aligned they felt with the process of therapy and their HCP.

Categorizing Data

The conceptions of LBP patients were categorized into themes that included: convincing care, lifestyle change, participation, reciprocity, and the ethicality of their encounters. Each of the themes was then broken down into four categories: “non-encounters,” seeking support, empowering cooperation, and autonomic agency.

Invalid “Non-Encounters” Left Patients Frustrated

Patients that described their encounters as “non-encounters” felt that their HCP experience was invalidated by not being listened to or receiving the level of care they had expected during treatment. They complained that their treatment was inconsistent or that the explanations they received during their encounter was inadequate, which left them frustrated, afraid, or filled with anxiety. Some of these patients abandoned therapy altogether and resigned themselves to a life filled with pain. Others opted for more treatments or sought a clearer diagnosis—requesting imaging or surgery to explain or alleviate their symptoms. When their condition was not clearly explained or cured, they felt that treatment was ineffective or that they had been patronized. Those living with long-term pain discussed how their condition had inhibited them in social and work life when they did not get the support they needed. They felt helpless when it came to their own care and were disheartened as they moved from provider to provider seeking out appropriate care. They reported having to wait for long periods of time to receive care and said they felt tired from work and lacked the energy or resources to enjoy leisure activities. They complained that their HCP seemed not to hear them or were dismissive about their own thoughts when it came to their LBP. They were given information that replicated what they already knew or were talked down to with medical jargon that was unhelpful because they did not understand its meaning. They felt their practitioners were disinterested in them and rushed them through an impersonal therapy routine. Some patients felt blamed by their HCP for their pain or received unnecessary treatments that “robbed” them of their time and money, without benefit.

Seeking Support from Care Providers

Patients that sought support in understanding their LBP and treatment options were sometimes frustrated in their efforts to receive a confident examination and interview with a qualified professional who treated them with respect. These patients reported wanting clear explanations of their LBP, delivered in language that was understandable to them. They were most satisfied when their HCP took the time to give a thorough examination and helped them to find reasons for their symptoms. By interviewing patients thoroughly, HCP’s were better able to discern their patients’ life circumstances and give them the type of support needed, including teaching them to recognize and deal with stress in their bodies. Attentive practitioners were best able to be empathetic and supportive to their patients’ needs.

Cooperation and Support Empowered Patients

Patients reported feeling empowered when their HCP gave them the opportunity to take an active part in their own treatment plan. They were best able to do this when the provider gave them understandable explanations about their condition and how treatment techniques and lifestyle changes would benefit their recovery. Having sensible, written treatment plans—rather than merely verbal explanations, which they might forget—made the patients feel more secure and involved in their care. Physiotherapists who were able to demonstrate how the patients’ everyday activities affected their spinal health gave the patients a renewed sense of familiarity with their bodies and helped them to make better choices during normal activities that would reduce strain and injury to their spines. This newfound mind/body connection created a sense of confidence and balance that was beneficial to the patients’ overall well-being and treatment outcome. By learning to associate their LBP with their own physical and psychosocial health, patients gained insight and were likely to make lifestyle changes—including getting adequate rest and relaxation—that benefited them overall. Building a therapeutic, cooperative relationship with their HCP involved reciprocal understanding, good listening skills, and an attitude of respect. When a provider was able to repeat in their own words what their patient had said to them, the patients knew they were truly being heard.

The Development of Autonomic Agency

The group of patients who were best able to transform from patients to active participants in their own care felt the most empowered and reported that their treatment therapy extended beyond office visits and into their lives, work, and homes. Having a clear plan for their future—even when regular physiotherapy was needed—and knowing they could contact their providers with questions or concerns about their health empowered the patients to utilize the instructions and information they had received from their HCP’s and see steady, lasting improvement in their symptoms.

These patients had learned from their care providers about the importance of a family and friend support system and that it was necessary to relax and find a centered calm in life. They learned that strenuous exercise was not necessary to physical well-being and that less taxing types of exercise were sufficient to improve fitness and reduce daily stresses. Overall, they reported better moods due to their lifestyle changes and improved relationships with their loved ones and peers. They accredited many of these changes to the ability of their HCP’s to listen to them and introduce the idea of how psychosocial issues in their lives affected their overall health. They felt confident with their providers because their concerns and goals were discussed and considered when developing a plan of long-term treatment.


Post-treatment interviews in this study indicate the need for HCP’s to develop a patient-centric approach in to therapy that involves listening, cooperation, clear, written instructions, and an overall respect for the patient. When practitioners involve their patients in the process of healing and wellness, and when they see the patient as a whole person whose psychosocial involvements are integral to their physiological health, they are able to inspire confidence and empower their patients to effectively participate in their own acute and long-term LBP management.


KEYWORDS: how conceptions about care affect outcomes in LBP patients, empower and create a therapeutic alliance between patients and their health care providers, a holistic, psychosocial approach to understanding LBP, patients’ conceptions of their practitioner visits, understanding their LBP and treatment options, the importance of a family and friend support system

, ,

Patients Value Collaborative Care, Information, Validation, and Good Communication Skills During Treatment

Patients Value Collaborative Care

A systematic review of data regarding lower back pain (LBP) patients’ perceived healthcare provider needs found four areas were prominent factors in overall patient satisfaction. These included good communication and shared decision-making, the legitimization of symptoms and information about their cause and treatment, individualized, holistic care with continuity, and greater access to treatment, with lower waiting times and costs.

LBP affects 8 to 10 adults during their lifetime and accounts for approximately $88 billion in U.S. healthcare costs each year. To effectively treat chronic back pain, patients may require a combination of approaches, including psychological, medical, chiropractic, and physical therapists, but they are less likely to seek out or maintain their treatment when they are dissatisfied with their care. The authors of the review study sought to identify how practitioners might best adopt a patient-centric model of care that would align with the perceived needs of most LBP patients.

The systematic scoping review was based on the Arksey and O’Malley framework and mapped key concepts to identify specific evidence types in the available literature. An electronic search of medical data bases included studies published between January 1990 and June 2016. A multidisciplinary team involving a senior academic librarian, clinician researchers, and input from patients was utilized to design the search strategy that identified data from LBP patients with, or without leg pain, but excluding injuries, cancers, inflammatory spinal disorders, and pain caused by infections. The articles chosen were then reviewed by trained epidemiologists, Rheumatologists, Physiotherapists, or PhD Candidates.  Another set of articles was then reviewed independently and in correlation with the first set as to their relevance. Studies included in the review were those of LBP patients 18 years or older that reported on the patients’ perceived practitioner needs, and were conducted in English. The data was then categorized and grouped into similar themes.

Four Areas of Perceived Needs

The data sets indicated four main areas of perceived need when it comes to patient satisfaction with their care giver. These include healthcare providers that exhibit desirable characteristics when it comes to treatment and care; a need for information about the cause and treatment of LBP; aspects of care needs; and potential barriers to satisfactory care.

Type of Care Patients Desire

One of the most important characteristics in a good practitioner to most LBP patients interviewed in the literature was good communication skills. Being able to discuss their discomfort and feel their ideas have been heard is very important to patients, as is clear instructions that do not involve medical ‘jargon.’ Patients want their provider to treat them with encouragement and to individually personalize their communications. (Interestingly, older patients were not as concerned about the communication style.)

Sharing Decisions

Patients in two studies reported their wish to be actively involved in the decision-making and having the medical instructions be more consultative and less prescriptive. They preferred to be listened to and felt frustrated when their condition appeared to be more of a priority than their self.

Empathy, Confidence, Understanding

Patients in several studied reported their desire that care providers be empathetic and non-judgmental, especially when it came to understanding their unique work environments and other potential stressors that might contribute to or exacerbate their LBP.

Skills and Qualifications

Patients in four studies were concerned with their healthcare providers’ technical skills, reputation, and qualifications and reported feeling more comfortable with confident, highly-trained practitioners.

The Need for Information

Repeatedly, patients reported the need for a clear diagnosis that would identify the cause of their LBP.  Patients who were unable to get a clear understanding of why they were experiencing LBP from their healthcare provider reported anger and frustration when their expectations went unfulfilled.

Better Understanding of Treatment Techniques

Patients in 15 studies were concerned that their practitioners had not adequately explained how to care for their back and wished they had received more reassurance and direction about activities to avoid that might make their pain worse. These patients reported the need for information they could clearly understand and suggested that the use of diagrams or visual aids might help them to better visualize their condition and remedies. In fact, being unable to understand their practitioner’s explanation of their LBP was one of the most frequent complaints in these reviews.

Aspects of Better Overall Care

When it comes to practitioner approaches to care, five studies indicated that patients prefer holistic, supportive, personal, and encouraging approaches to care. Rather than focusing only on the source of discomfort, patients reported feeling more empowered when their practitioners would place less emphasis on the disease and more on their person, as a whole. They placed tremendous value on encouraging words and emotional support.

Assessment, Continuity of Care, Time, and Effort

Patients in six studies wished to have a more thorough physical assessment from their care provider. A physical exam, oral history, and clear discussion of the problem were important to them, as was a continuity in their care.


Many patients expressed feeling stigmatized by family, friends, employers, and the community due to their pain. They sought answers and legitimacy from their healthcare providers. They also wished for better collaboration and understanding between their primary care provider and their LBP specialist.

Care Complaints

The rising cost of healthcare was reported as a common barrier to receiving effective treatment for LBP in many patients. The expense of exercise programs was also prohibitive when it came to being proactive about their condition. Finding quality care in a timely way, and having to wait for treatment were other difficulties reported by patients, as were weather concerns, a lack of social support, commitments to the job and family, and not enough personal time to address LBP treatment needs.


Patients with LBP believe they would benefit from providers that have good communication skills and listen well. They wish to be treated with empathy, respect and understanding, and they want their condition to be legitimized by their practitioner and explained in a way that makes sense to them. The use of diagrams or other visual aids are preferred over lengthy verbal explanations alone. They want to be treated promptly and in a collaborative way that involves them in the decision-making process about therapeutic methods. They are frustrated when no diagnosis is offered or when practitioners do not offer an understandable explanation of their condition. They want their practitioners to be qualified and confident and to work in a collaborative manner with their other healthcare providers to address their LBP. They wish to be treated in a holistic, personal way and to not feel stigmatized or judged because of their pain. Studies have demonstrated that patients who are satisfied with their healthcare providers have better overall treatment outcomes, and this review defines key ways that practitioners may become more effective in treating their LBP patients successfully.

KEYWORDS: Patients Value Collaborative Care, Information, Validation, and Good Communication Skills, patient-centric model of care, important characteristics in a good practitioner, key ways that practitioners may become more effective in treating their LBP patients