LBP During Upright Standing May Be Related to Lumbar Intervertebral Angle Distribution, Study Finds

A study of how intervertebral angles were distributed in two asymptomatic control groups—those who would develop lower back pain (LBP) after prolonged standing, and those who did not develop pain—found that there was a correlation between the distribution of intervertebral angles in pain developers (PD) throughout lumbar spines during upright standing poses, while there was little difference in the amount of lumbar lordosis, range of motion, lumbar spine recurve, or lumbar vertebral wedging between the two groups.

The Study

Eight subjects from a previous study were recruited for the purposes of characterizing lumbar postures in PDs and non-pain-developers (NPD). Researchers wished to find out how the distribution of intervertebral angles differed in both groups during standing x-rays. The study also looked at the range of motion (ROM) and various lumbar vertebral characteristics in members of each group. Eight male and female PDs were compared with eight male and female NPDs. PDs had reported developing LBP after two hours of standing in the previous study. An x-ray technician used a diagnostic high voltage x-ray generator to create radiographs of each participant during three static poses: upright standing, full extension, and full flexion. Measurements were made to determine each subject’s intervertebral angles as they related to each other and to the superior endplate and inferior vertebrae. The person responsible for analyzing the measurements was blinded to the pain groups until all the variables had been computed, and statistical models were created using SAS, with dependent variables grouped by Pose. The data was later analyzed, where statistically significant.


Overall, those in the NPD study group had L5/S1 angles that were significantly more extended than their L1/L2, L2/L3, or L3/L4 angles. In addition, their L4/L5 angles were more extended than their L1/L2 angles. Those in the PD group were less varied and only showed differences between L1/L2 and L5/S1 with extension. For the most part, the two pain groups showed little variation in ROM, lumbar lordosis, vertebral wedging, or recurve, though subjects in the PD group did have a more equitable distribution of intervertebral angles throughout their lumbar spines in standing and full extension poses. PDs did not exhibit more lumbar lordosis while standing, but they were more likely to be recognized by their rate of extension during upright standing poses. This indicates that the overall lumbar spine characteristics of PDs and NPDs are similar, though they vary regionally when in extended poses. Therefore, it may be useful to use fully extended postures when identifying PDs versus NPDs in radiographic studies.

How Microgravity Affects the Biomechanical Properties of Caudal and Lumbar Mouse Discs

A lumbopelvis spine model with elastomeric sacroiliac joints (simulated hyaline and fibrocartilage thickness) adhered to a matching ilium and sacral bony specimen

A study of how microgravity affects the biomechanical properties of caudal and lumbar mouse discs showed that caudal discs that had been exposed to microgravity for 15 days experienced biomechanical diminishment, while their lumbar discs were relatively unaffected. The caudal discs lost height, were more likely to creep, and demonstrated less nuclear swelling strain dependence than the discs used in the control group.

The Study

The mice involved in the study were part of NASA’s Biospeciman Sharing Program and were exposed to 15 days of flight on the space shuttle prior to being sacrificed for analysis. Each mouse was radiographed prior to being dissected and having the soft tissues removed. The mice were mounted onto custom mechanical instruments that measured the rate of compressive creep and tissue deformation under a constant load. After five cycles of compressive creep loading and measuring, a displacement controlled stress relaxation test was used to measure the amount of nuclear swelling pressure, then the researchers calculated the change displacement and load response to determine the swelling pressure. All results were then analyzed using the Levonberg-Marquardt algorithm, and creep parameters were analyzed with a non-parametric test. The results of the control (non-flight) and space-flight group were compared for all parameters to determine any statistical differences or similarities.


There was a statistically-significant difference in the caudal discs of the control and spaceflight specimen groups, but there was little difference in the lumbar discs of the two groups. The caudal discs of the spaceflight group were 32 percent shorter and crept 2.5 times more than those in the non-flight subjects. Strain-dependence of the spaceflight group’s swelling pressure was 70 percent lower than that of the non-flight group. This could help to explain the back-pain complaints of astronauts returning to Earth after long spaceflights.


The results of this study indicate that the effects of microgravity on the biomechanical properties of intervertebral caudal discs is significant in murine samples. Specifically, there is a diminishing effect in that microgravity appears to lessen disc height, increase the rate of creep, and lower strain-dependence swelling pressure in caudal discs. Though there were no statistically-significant differences between the spaceflight and non-flight study groups at the lumbar disc levels, it is possible that this is because mice are quadrupedal and thus may not have the excess swelling capacity that humans require to counter the daily loading of an upright posture. It is also possible that mice counter loading demands by transferring loads to their tails or adapting their movements during usual and zero-gravity conditions. In any event, the study findings indicate that constraining spinal movements to reduce nucleus swelling during the return to normal gravity conditions could help to lessen the negative effects of microgravity on astronauts on their return to Earth after a lengthy space flight.


Lower Back Pain a Possible Indicator of Future Osteoarthritis of the Knee or Hip, Study Finds

Future Osteoarthritis of the Knee or Hip

A study examining the purported link between lower back pain (LBP) and lumbar disc degeneration (LDD) determined evidence of an association between LBP and hip or knee osteoarthritis. A review of several published observational studies was unable to establish an association between LBP and osteophytes, though a moderate association between LBP (particularly neuropathic pain) and disc space narrowing was noted.

The Study

Researchers used logistic regression models to analyze associations between radiographic features of LDD and neuropathic pain in a total of 699 study participants who completed a questionnaire and lumbar radiograph. The radiographs were analyzed by two independent observers, who found that the presence of osteophytes in 98 percent of the population was not associated in any significant way with LBP.

Disc space narrowing, however, which occurred in 67 percent of the study participants, was significantly associated with neuropathic and LBP.  

The results of the 8-year follow-up, cross-sectional study in the Cohort Hip and Knee (CHECK) cohort in the Netherlands found that radiographs of the lumbar spine in patients with hip and knee osteoarthritis demonstrated a strong association between LDD and disc space narrowing, with LBP (particularly neuropathic) but little association between osteophytes and LBP. However, LBP was frequently reported in patients with osteoarthritis of the hip and knee.


Though there appears to be no overt association between the presence of osteophytes in radiographs and LBP, a link is evident between disc narrowing/ degeneration and LBP. Furthermore, the presence of LBP in a great percentage of hip and knee osteoarthritis patients in cross-sectional study indicates a possible link between the conditions. The results of this study indicate the need for further research into the possible link between osteoarthritis of the hip and knee and LBP/LDD.

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Few Studies Examine the Effect of Health Literacy on LBP Treatment Outcomes

Spine Patient Education, Patient Centered, Education

A review of published research on the implications of patient Healthcare Literacy (HL) in patients with lower back pain (LBP) found that evidence-based studies were minimal and that further research could be beneficial in determining future treatment costs and outcomes. The ability of chronic pain sufferers to access, understand, and apply health information defines HL and can be helpful to practitioners treating LBP patients. The reviewers sought to understand how HL affects LBP patient treatment outcomes.


The Review

Researchers performed a data search using lower back pain terms in PubMed, Web of Science, PsychInfo, and CINAHL but found only three studies that directly addressed the issue of HL in patients with LBP. The search parameters were limited to studies conducted between the years of 2000-2017, published in English, and formatted as an article or review. Of the initial 1037 articles that met the initial criteria, only three were empirical research studies related to HL in patients with LBP.

Due to the lack of adequate data, a full, systematic review of the subject in question was not possible. Still, the authors of the review noted that, based on the limited data, patients with chronic LBP may have a more negative attitude towards their health and a more difficult time managing their health than patients without chronic back pain. Since self-health management is a central tenet of HL, this finding could indicate that better HL could assist in determining a better, more satisfying attitude and outcome for LBP patients.

One reviewed study looked at the effect of HL on patient empowerment and found that patients who had lower levels of HL were the most dependent on practitioners and least self-empowered when it came to managing their LBP. This was true of patients who used medication for chronic conditions and those who were treated without medication. This suggests that better HL in LBP patients can empower patients and lead to a more satisfying treatment outcome.



Though there are limited published studies about how HL affects LBP patient treatment outcomes, the available data suggests that patients who are better informed about their health are more likely to feel empowered and have a more satisfying treatment outcome. Patients who were being treated with or without medication were more likely to report better self-sufficiency and a sense of empowerment when they were more familiar with their condition and understood the health treatment options available to them. Further evidence-based research should be conducted to fully understand the relationship between improved HL and patient treatment experience and outcomes.


KEYWORDS: the effect of health literacy on LBP treatment outcomes. the implications of patient healthcare literacy (HL) in patients with lower back pain (LBP), how HL affects LBP patient treatment outcomes, self-health management, satisfying treatment outcome.


Follow-Up Study Finds Lumbar Transforaminal Epidural Steroid Injections Offer Only Temporary Pain Relief

Lumbar Transforaminal Epidural Steroid Injections

A post-five-year physician follow-up of a predetermined study group of patients who had received lumbar transforaminal epidural steroid injections (TFESI’s) to treat acute unilateral lumbar pain from their single level herniated nucleus found that, although the procedure offered temporary relief, most patients reported needed some type of additional pain intervention (medicinal, another TFESI, or back surgery) when interviewed 5 to 9 years after their procedure.

The Study

The 39 patients interviewed in this study were part of an original 78 subjects who had enrolled in a randomized controlled trial, in which the remaining patients were unreachable after multiple attempts five years after their TFESI’s.



During a phone follow-up, 30 of the 39 patients reported having experienced recurring pain since their initial procedure, though only nine reported experiencing pain at the time of the phone call. Three patients were taking opioid medication to relieve their pain. Nine patients reported having had subsequent TFESI procedures since the first, and 19 of the subjects reported having had back surgery since their TFESI. Three patients reported unemployment due to their recurring back pain.

A comparison of the subjects who reported having had surgery to those who had not showed no difference in the rate of recurring or current pain, additional injections, unemployment, or opioid use.



While TFESI ‘s can be an effective means of short-term pain relief for patients with lumbar intervertebral disc herniation radicular pain, most patients interviewed in this study reported the recurrence of symptoms and need subsequent relief treatments—surgical, opioid, or another TFESI—five to nine years after their initial injection. Because there was little difference in the percentage of patients who chose surgery and those who had at least one subsequent TRESI in relation to the rate of pain recurrence, the authors of the study suggest that physicians should discuss and decide upon appropriate pain treatment measures with their patients based upon the frequency and severity of their acute pain, as well as their response history of previous treatments. Radicular pain caused by a herniated disc is a condition that should be treated effectively in its acute stage, though it is likely to remain a recurring health issue that may require multiple treatments over long periods of time. This fact should be considered by the practitioner and patient when deciding on appropriate treatment measures.

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Study of Primate and Human Skeletons Demonstrates Low Rate of Spinal Disease in Apes

vertebral osteoarthritis

An investigation of degenerative joint disease (DJD) studied data from chimpanzees, lowland gorillas, bonobos, and human samples to ascertain the relative rate of osteoarthritis and peripheral joint osteoarthritis in each species and found that all types of apes were significantly less prone to DJD than humans.


The Study

Museum skeletal samples of adult chimpanzees, lowland gorillas, and bonobos were examined and analyzed for vertebral osteoarthritis (VOP) and osteoarthritis (OE). The resulting data was compared to data sets from a series of adult human skeleton sets wherein comparable analytic methods had been used to determine the rate of VOP and OE. All samples were evaluated for DJD and the presence of VOP. The relative severity of the conditions was scored using ordinal scaling criteria, categorizing the groups into: none, slight, moderate, or severe DJD. The researchers discarded the “slight” sample data and focused instead on the “moderate” to “severe” data sets for the study.


There was a low prevalence of VOP in the ape samples (0-3.8 %) across all vertebral segments, while the human prevalence was between 11 and 85 times that of the apes, with more uniform involvement throughout the vertebral column.

OA of the spinal joints was also rare in African apes, with chimpanzees being least affected, followed by gorillas, and bonobos. Though OA is less prevalent than VOP in humans, it is still three to four times more common in humans than in apes. Broken down into spinal segments, gorillas were more susceptible to cervical and thoracic segments than chimpanzees. Where chimps showed no lumar involvement, gorillas were variably affected at the level. Humans were uniformly more prone to OA at all levels than any of the apes sampled.


Ape samples were much less likely to show signs of spinal degeneration at all levels than comparable human samples. Although it makes sense to assume that the divergence is due to the greater compressive stress on the bipedal human form, the patterning of VOP data in apes and humans suggests that other forces—such as torsional loads related to axial spinal rotation— are likely contributing to the higher incidence of DJD in humans.

KEYWORDS: thoracic segments, degenerative joint disease, spinal degeneration, spinal disease, compressive stress, vertebral osteoarthritis, peripheral joint osteoarthritis


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Radiographic Study Indicates Optimal Standing Lordosis Angles Could Help Reduce DJD

lordosis. degenrative joint disease

A radiographic study of the effect of hypo- and hyper-lordosis in the lumbar spine concluded that a lordosis angle of between 65-68 degrees can be considered ‘optimal’ in the reduction of degenerative joint disease (DJD) of the lumbar spine. The results of the study should be helpful in the treatment of spinal pain and rehabilitation.

The Study

Archival standing radiograph images from a single clinic of 301 adult female and male chiropractic patients aged 4 to 79 were analyzed in a blind study using RadiAnt DICOM viewer software. All the images were scored for the severity of DJD by one experienced clinical investigator to ensure consistency using the Kellgren-Lawrence (K-L) criteria—categorizing the results into three groups: 1 and below (no DJD); 2 (mild DJD); 3 (moderate DJD); and 4 (severe DJD). The Cobb angle (CA) was used to measure lumbar lordosis.


In examination of the data, researchers found significant quadratic correlations between the Azari-LeGrande Degenerative Index (ALDI) and the CA values in nearly all study subjects. (No correlation was found in younger men). The correlations were more pronounced in all five spinal motion segments in women under and over the age of 40 than in their male age-counterparts. The findings indicate that too little or too great lordosis can contribute to lumbar spinal degeneration, particularly in women.



Though the effects of lumbar lordosis angles on lower DJD was modest—between 17 and 18 percent in women, and roughly 13 percent in older men—the information is significant because, unlike other contributing factors to DJD, such as genetics, lumbar lordosis can be modified to the optimal degree of between 65 and 68 degrees to reduce the risk of DJD (73 degrees in older men). An increased incidence of DJD was found whenever subjects deviated outside of these optimal weight-bearing parameters, either through hypo— or hyper-lordosis. This information may help prevent, treat, or rehabilitate patients with lower back pain.


KEYWORDS: the effects of lumbar lordosis angles on lower DJD, hyper-lordosis, optimal standing lordosis angles, degenerative joint disease, lumbar spine