Education

Goal of the Study?

These researchers sought out to answer the question of does reassurance helps patients with acute low back pain? In this study 1, the authors looked at two hundred and two people with acute low back pain with a high risk of developing chronic low back pain. They were curious as to whether helping someone with supportive psychological language could help reduce disability outcomes.

 

Why are they doing this study?

The current zeitgeist and research push has emphasized reducing nocebic iatrogenic influences and steering away from the biomedical model. This has naturally led to alternative strategies like the use of emphasized reassurance tools.  However, does this strategy alone make a difference?

 

Bulging Disc Model

 

What was done?

Using a  randomized sham-controlled clinical trial mediation analysis, these researchers compared patient education to sham patient education. Enrolled participants listened to either: 1. two 1-hour sessions explaining the benign aspects using a biopsychosocial framework. 2. two 1-hour sessions that included active listening only, as of the sham comparison.

 

What did they find?

Those that did receive patient education did express improved re-assurance(compared to the sham); however, this did not lead to improved disability scores or was associated with health care use frequency. All in all, the results demonstrated there was no association with participants feeling reassured and improved outcomes.

 

Limitations?

The main limitation was the length of patient education in this study. This is obviously much longer than what clinicians often employed in clinical practice. The authors also suggest that less time would unlikely result in a different outcome.

 

Why do these findings matter?

Clinicians have been encouraged to use reassurance in the case of many clinical conditions.  The authors suggest that although patient education can be effective, overemphasis does not lead to better outcomes. Clinicians with their clinical time restraints should be selective in the time allocated to specific topics. The authors suggested that perhaps more time listening and matching appropriate treatment strategies may be a better option with time management restrictions.

 

Pain Syndromes

Goal of the Study?

In this study, 1, the authors have developed a framework to differentiate Parkinson’s Disease (PD) pain from non-PD-related pain and classify PD-related pain into 3 groups based on already validated mechanistic pain descriptors – nociceptive, neuropathic and nociplastic. 

 

Why are they doing this study?

In Parkinson’s disease (PD), about 20% of patients experience chronic pain at diagnosis. This number climbs to 80% during the course of the disease. PD pain has been divided into three categories: de novo pain related to disease onset and symptoms (PD-related); previous chronic pain aggravated by the disease or treatment (PD-indirectly-related); pain that is neither caused nor aggravated by the disease (PD-unrelated). Moreover, pain is considered PD-related when one of the following applies: when occurring along with the first motor symptoms, when occurring/aggravated during the OFF stage of the disease, when occurring at the same time with choreatic dyskinesia or when improved by dopamine treatment. However, these categories have not been validated or tested, making diagnosing and treating pain in PD. In response to this need, the authors develop a classification system to define and distinguish PD-related pain from non-PD-related pain.

 

What was done?

The authors used an international, cross-sectional, multicenter study. They recruited 159 non-demented PD patients and 37 healthy controls across 4 centers. Using the mechanistic pain descriptors (nociceptive, neuropathic and nociplastic), the authors developed a PD pain classification system (PD-PCS) by including classic pain-related situations of PD into each category. The severity of PD-related pain syndromes was scored by ratings of intensity, frequency and interference with daily living activities. Finally, they did an analysis and validation of their scale.

 

What did they find?

This study provides a unifying system for pain in PD that differentiates between PD and non-PD pain and outlines a treatment-based and mechanistic classification system for PD-related pain. Using this system, the authors found that 77% of patients experienced PD-related pain, with 15% suffering more than one syndrome at the same time. PD-related pain with nociceptive, neuropathic or nociplastic components was diagnosed in 55%, 16% and 22% of participants, respectively. Mixed pain syndromes were mostly found in nociceptive pain combined with nociplastic (12.7%) or neuropathic (9.6%). Pain unrelated to PD was found in 22% of participants, versus only 5% of controls. 

Concerning the PD-PCS, the authors found that pain severity scores significantly correlated with commonly used questionnaires such as the pains’ Brief pain Inventory and McGill Pain questionnaire. They did not find that the PD-PCS scores correlated with a motor score.

Finally, they suggest that the three pain types identified by the PD-PCS are different pain syndromes and reflect different mechanistic backgrounds and, potentially, different treatment approaches.  For example, they found that patients with higher nociceptive pain scores had worse quality of life scores, but this was not found for patients with nociplastic pain. 

 

Why do these findings matter?

Better classification of pain in PD will ensure that PD patients’ pain is treated more effectively and timely, ultimately contributing to better outcomes.

 

Sagittal

Goal of the Study?

In this study 1, the authors investigated the flexion-extension range of motion (ROM) and centre of rotation (COR) of lumbar motion segments in a large population, as well as the relationship between lumbar movement and sex, age and intervertebral disc degeneration (IVD).

 

Why are they doing this study?

Research on the in vivo motion of the spine has a long history. However, many of these studies have used non-invasive technologies with inherent limitations impacting their accuracy and precision. Moreover, many studies have included a lower number of subjects, preventing the ability of the data to represent the general population.

The authors argue that radiographic techniques in this study help overcome these limitations as the images allow for better visualization of each vertebra and movement of the lumbar segments. Additionally, the use of a large sample size for this study addresses the issue of representation and is the largest study to date looking at in vivo lumbar motion. 

 

What was done?

The researchers did a retrospective study looking at the radiographs of the lumbar spine in full flexion and extension for 602 patients, with the age and sex documented for each one.  Additionally, they used MRI scans of 354 patients. 

All spinal levels between T12-L1 and L5 – S1 were analyzed, resulting in 3612 lumbar motion segments from the radiographic images. They also examined 2124 images from the MRI scans looking at disc degeneration. ROM and COR were calculated for all lumbosacral segments using the software. They then examined the associations between motion and age, sex, spinal level and disc degeneration.

 

What did they find?

The median ROM in this study was 6.6 °. The researchers found an association between age and ROM, with older individuals, have lower ROMS. They argue these findings clearly demonstrate a relationship between age and lumbar spine flexibility independent of any signs of spinal degeneration. They also found that lower ROMS were associated with disc degeneration. However, they did not find any association between sex and ROM.   

In this study, they did not find an association between the position of the COR and the spinal segment. The most common COR was at the centre of the lower endplate of the IVD or slightly lower. With degeneration, particularly severe degeneration, they found the location of the COR spread randomly around the centre of the intervertebral space.

 

Limitations?

One of the main limitations of this study was the sole focus on the flexion-extension motion of the lumbar spine rather than including information on movements of different areas of the back. 

 

Why do these findings matter?

This study comprises the largest examination of the in vivo lumbar spine in flexion-extension, paying attention to age and spinal degeneration issues. Understanding the relationship between age and spinal mobility provides patients and doctors with information to better treat back pain and instability.

Facet angle

Goal of the Study? 

In this study 1 the authors use MRI to measure changes in the facet angles of the lumbar spine and analyze the relationship between angle changes and the herniated lumbar intervertebral disc. 

 

Why are they doing this study?

The incidence of lower back pain (LBP) is prevalent in today’s society and can place an enormous burden on individuals and health systems. There are many causes of LBP, including lumbar facet joint (LFJ) degeneration, lumbar disc herniation (LDH), compression of nerve roots, and others. There is currently little understanding of the role of lumbar facet joint angle changes and lumbar disc herniation play in LBP. The authors comment that there is a lack of knowledge on whether the structural abnormality of the spine resulting from LFJ degeneration causes the abnormal force of the lumbar intervertebral disc herniation. Additionally, there is a need to understand whether lumbar facet joint angle changes are common in patients with lumbar disc herniation.

 

Professional LxH Model (L4-5) with asymmetric facet angles

 

What was done?

First, the authors review both direct and indirect signs of lumbar disc herniation as seen on MRI. They state that MRI provides an advantage to obtain horizontal and sagittal three-dimensional scanning of the spinal cord, subarachnoid space, vertebral body and intervertebral discs. They review the various signs of the nucleus pulposus, schmorl nodules, lumbar dural sac, lumbar spinal cord and nerve root compression.

The authors used cross-sectional images of the MRI to measure angles of the articular processes on both sides. They included 500 cases of patients with a clinical diagnosis of lumbar disc herniation and concurrent lumbar disc MRI examination. This included 227 males and 273 females with an average age of 41. This was broken down into 137 cases in the central LDH group, 140 cases in the left paralateral LDH group, 127 cases in the right-side LDH group and 75 cases in the control group. The cases were based on those who met the diagnostic criteria over 18 and relevant imaging and clinical data. Statistical software was used for statistical analysis.

 

What did they find?

The authors found no statistically significant relationship between age, gender, height and weight of the groups and LDH. They found no statistically significant relationship between MRI and CT measurements of the facet joint angle. They argue a correlation between the changes illustrated in MRI images of lumbar disc herniation and the TCM syndromes of lumbar intervertebral disc herniation. They found that the L4/5 and L5/S1 segments of the lesion in the central LDH group and the left paralateral LDH and right-side LDH were all significantly different from the control group.  Facet joint asymmetry is closely related to lateral lumbar disc herniation. However, the asymmetry of the facet joints is not related to the central lumbar disc herniation. They argue that MRI has a high sensitivity concerning measuring angles of the facet joint and changes to those angles and how they correlate with herniated discs. 

 

Why do these findings matter?

Understanding the relationship between lumbar facet joint angle changes and lumbar disc herniation is useful for preventing and treating LBP

spinal mobility

Goal of the Study?

The goal of this study [1.Spinal mobility in radiographic axial spondyloarthritis: criterion concurrent validity of classic and novel measurements] is to evaluate spine range of motion (ROM) measured by tri-axial accelerometers compared to both current clinical tests and radiography in radiographic Axial spondyloarthritis (AxSpA) patients. 

 

Why are they doing this study?

AxSpa is a chronic and progressive form of inflammatory arthritis. To measure progression and plan treatment, there is a need to measure indicators for spinal mobility in forward and lateral bending. Currently, this is often done using a clinical tape measure. However, research has illustrated that there is poor validity using a tape measure to assess spine mobility compared to the images and RoM from radiographs. However, with the risks associated with repeated exposure to radiation for radiographs, and the lack of validity in using clinical tape measures, there is a need for better alternatives. To that end, research has illustrated the value of devices that incorporate strain gauges and/or accelerometers to measure spinal curvature.

spinal mobility

A novel measuring approach to minimize radiation exposure.

 

What was done?

This study recruited fifteen radiographic Spondyloarthritis patients. First, each participant had lateral and posterior-anterior radiographs taken standing upright. Following this, each participant completed three RoM trials in forward flexion, right lateral and left lateral bending. In total, five lumbar radiographs were taken. For each participant, three measurements were collected: tape, synchronized radiograph and accelerometer measurements at the end range of forward and bilateral lateral flexion. The researchers then used statistical software to determine reliability.

 

What did they find?

The findings of this research support using accelerometers as a replacement for sagittal spine mobility, but not lateral. The accelerometer measure of the sagittal spine had a stronger correlation to the radiographic measure than all tape measures. They argue that this approach can overcome some of the inherent challenges with tape, such as skin stretching. In lateral bending, the Lateral Spinal Flexion tape (LSFT) correlated stronger than the accelerometer method. Furthermore, an accelerometer-derived measure of frontal plane spine mobility underestimated lateral bend angles from the radiographs. It demonstrated a moderate correlation to the radiographic gold standard lower than either the LSFT or DT.

 

Why do these findings matter?

The use of accelerometers can limit patients’ exposure to ionizing radiation through repeated radiographs in the AxSpA population. Improved ability to measure spinal changes is important to evaluating and managing disease progression and treatment. 

 

Cervical Herniated Disc

Goal of the Study?

In this review 1 the authors examine 76 cases of spontaneous herniated cervical discs and one direct patient experience to understand the phenomenon better.

 

Why are they doing this study?

Spontaneous regression of herniated lumbar discs has been well researched. However, spontaneous regression of herniated cervical discs has not been examined to the same extent. For this reason, the authors felt it essential to do a review of the existing literature, as well as one case study.

 

What was done?

Using PubMed and EMBASE databases, the authors found 75 cases that related to “spontaneous regression,” “herniated cervical disc,” and “MRI studies.” Patients averaged 41 years of age and were split equally male and female. In addition, they used a case study of one patient who had been experiencing neck pain for three weeks, right upper extremity radicular pain and right C7 distribution weakness and numbness. This patient’s cervical MRI showed a suitable paracentral disc extrusion at the C6-C7 and right C7 root compression. The patient did not want surgery and instead chose management with pharmaceuticals. At the same time, he reported improvement, three months after an MRI showed spontaneous regression of the C6-C7 disc extrusion.

 

What did they find?

The most predominant symptoms identified in the literature review were neck pain or radiculopathy (91%) and myelopathy (9%). The discs were paracentral or foraminal in 61 cases (84% of the total cases) and central in 12 cases. The literature illustrated a higher incidence of spontaneous disc regression in the paracentral/foraminal lesions. Discs mainly were located at the C5-C6 (31 cases) and C6-C7 (22 cases) and were most frequently extruded or sequestrated. The average period between the initial presentation and spontaneous regression of herniated cervical disc on MRI scans was 9.15 months. Using MRI, the studies illustrated that extruded/sequestrated discs were more likely to undergo spontaneous regression than protruding discs.  

 

Why do these findings matter?

Reviews such as this can better understand how and when to treat spontaneous regression of herniated cervical discs.


Do you have a model to show this regression?

At Dynamic Disc Designs, we have models to help show patients the retraction of the nucleus pulposus to assist in the management and education of patients with disc herniation.

loading

Goal of the Study?

In this preliminary study, 1 the authors compared the effects of loading compression and traction on lumbar disc measurements, particularly the magnitude and distribution pattern of fluid within lumbar discs, in relation to intervertebral disc degeneration.

 

Why are they doing this study?

Intervertebral disc degeneration (IVDD) is associated with many biochemical and morphological changes in the disc that contribute to degeneration and negatively impact normal function. With degeneration, there are changes to the amount of fluid and the distribution pattern of this fluid within the disc. The authors argue that this may provide unique biomarkers that can help with diagnosing and classifying degeneration. The authors hypothesize that using T2- weighted MR images will enable better insight into disc degeneration. It only changes in response to variations in fluid distribution and these potential degeneration biomarkers. 

 

What was done?

A total of 35 volunteers between the ages of 18-65 were recruited: 20 with and 15 without low back pain (LBP). Using a custom MRI compatible loading table, the participants spent 20 minutes in the supine, unloaded position; then they spent 20 minutes loaded in axial compression and then 20 minutes with axial traction. A compressive load equal to 50% of each subjects’ body weight was applied to simulate loading and traction. For lumbar discs, the height, angle, width, mean-T2 and T2 weighted centroid (T2WC) locations were calculated. Disc degeneration was measured using the 5-point scale by Pfirrmann et al.

 

What did they find?

Most of the effect size (ES) differences the authors found in response to loading were seen from compression to traction. They observed small but statistically significant changes with an inferior and posterior shift in L4-5 (ES: 0.4, 0.14) and L5-S1 (ES: 0.25, 0.33) T2 weighted centroid. More degeneration was associated with larger anterior displacement and more superior displacement of the disc T2WC. Moreover, degeneration was not associated with changes in disc width, but with greater degeneration, there were larger decreases in an extension of segmental angles.

From unloaded to compression, they found statistically significant small posterior shifts for the disc T2WC at the L1-2 level (ES: 0.39). They also saw an increase in L5-S1 width (ES: 0.22), an anterior shift in L1-2 T2WC (ES: 0.39), and L3-4 (mean 2.1˚) and L4-5 (1.8˚) extension angle. Additionally, with more degeneration, there were larger inferior movements of the disc T2WC, but not changes in disc width. 

Overall, their findings on compression to traction demonstrated the most significant findings in the lower lumbar levels. They also found a magnitude difference associated with the severity of disc degeneration. This supported their hypothesis that fluid distribution-related measurements illustrating the effects of degeneration and lumbar disc loading.

 

Why do these findings matter?

Biomarkers can help to illustrate how the lumbar spine responds to different loading conditions and can be used to monitor degenerative changes in the lumbar spine.

 


At Dynamic Disc Designs, we appreciate the dynamics of the discs and how professionals can communicate these small changes to patients as it relates to their dynamic symptoms and the solutions of back pain.