Patient engagement is at the core of a patient-centered approach to spine care. Spine professionals engage with their patients with different tools. We all use language but to enhance it, very often a physical model can support the words chosen to educate.

In the past, models have been static, so it made it very difficult to connect patient’s back and neck pain to the specific movements that cause the pain. At Dynamic Disc Designs, we have developed models to help the practitioner engage in a mechanical way through a better rendering of a motion segment. We have created a dynamic disc with the ability of the models to bulge or herniate. We have integrated a dynamic nucleus pulposus and a stiffer annulus fibrosus as well as added features of the ligamentum flavum to show how the facets are inter-related to one another.

Explore how a dynamic model can enhance the language one uses in a clinical setting of a musculoskeletal practice.

Goal of the study?

In this study, 1 the objective was to assess the effectiveness of a patient education booklet to overcome barriers to the delivery of recommended care for patients with low back pain. 

 

Why are they doing this study?

Low back pain is the leading cause of disability and a major health cost worldwide. One of the reasons for this is that low back pain tends to be managed without following clinical guidelines. For example, almost half of patients undergo inappropriate imaging, which drives up healthcare costs associated with increased disability. To address the barriers to implementing clinical guidelines, Australian researchers developed a patient education booklet that educates patients and their healthcare providers, reminding practitioners of guidelines and facilitating communication. 

 

What did they do?

The researchers used a cluster-randomized trial design to assess the booklet’s effectiveness with low back pain patients in primary care compared to usual care. They recruited 8 clusters, 4 for the intervention (212 participants) and 4 for the control group (203 participants), with 408 participants in the sample. The practitioners in the intervention group were provided with the booklet and a 30-minute training session. The booklet was then also provided to their patients in the intervention group. The professionals only received a short training session on the study and recruitment procedure in the control group. All consenting patients received usual care but did not get the booklet.

There were two outcomes: 1) The proportion of patients presenting with low back pain who underwent imaging examinations due to low back pain during the first three months of follow-up, and 2) Change in Patient-Reported Outcomes Measurement Information System (20 items physical functioning short form) from baseline to three-month follow-up. 

They used statistical software to analyze between-group differences. 

 

What did they find?

The patient education booklet substantially reduced the proportion of patients with low back pain who underwent imaging at 3 months, but the result was not statistically significant. It was only statistically significant when a physician was the first contacted professional. This was compared to the findings at 12 months, which resulted in an effect that was slightly larger and statistically significant. 

The researchers did not find any differences in the Patient-Reported Outcomes Measurement Information System between baseline and 3 months or 12 months. They did find a change in the number of sick days in the intervention group was less than in the control group at 3 months and 12 months. There were no statistically significant differences between the intervention and control groups in the number of healthcare appointments or patient-reported secondary outcomes.

The use of the booklet had no impact on the patient’s pain, physical functioning, disability, or quality of life compared to usual care.

 

Why do these findings matter?

Patient education often matters, and how and when it is delivered should be optimized for each patient. A custom-tailored approach to each patient should be at the forefront of each clinical encounter. This study using a booklet did not show any changes in a patient’s pain score. Something needs to change in how patient education is delivered.

 

At Dynamic Disc Designs we believe a ‘booklet’ is a dated format and practitioners can improve their patient education through the use of accurate modelling to help patients truly understand and see the causes of their specific symptoms. Fostering the right motivational movement within patients is at the hallmark of what we do. To help in the construct of tackling biomechanical causes while addressing the fears of the unknown.

 

Goal of the study?

In this study,1 the purpose is to investigate if the physical therapy (PT) evaluation process of history taking and physical exam results in a meaningful change for patients with low back pain (LBP), even before implementing treatment interventions. 

 

Why are they doing this study?

Low back pain (LBP) is the most widely reported musculoskeletal disorder globally and has significant healthcare expenditures. In the US, LBP accounts for 25% of outpatient physical therapy (PT) visits, with an estimated 170,000 people daily seeing a PT for this issue. 

With a shift toward a biopsychosocial model, more focus has been put on the therapeutic alliance (TA) and its impact on patient outcomes. TA is essentially the working social connection between a patient and clinician, blending clinical skills, verbal and non-verbal communication, a sense of warmth, collaboration, and trust. There is increasing evidence that TA and trust play a significant role in patients’ pain outcomes before any formal treatment is started.

 

Evaluation

 

What did they do?

This observational study included 34 patients with LBP with/without leg pain who went to four different outpatient PT clinics over a 3-month period. They had one PT at each site do the history taking and physical exam, and a different PT does the outcome measurements. Before the examination, all participants completed a demographic survey, disability index, and outcome measurements, including pain (low back and leg; numeric pain rating scale – NPRS), fear-avoidance beliefs (FABQ), Pain catastrophization (PCS), lumbar flexion, nerve sensitivity – pressure pain thresholds (PPT). After completing this pre-assessment, history taking and physical exams were done on each patient. 

All data were analyzed using statistical software.

 

What did they find?

This study found that for patients with LBP, the process of history taking and a physical exam had a significant therapeutic effect regarding fear-avoidance, pain catastrophization, movement and sensitivity of the nervous system. However, while some changes met or exceeded clinically significant differences, these were not correlated to physical exam duration and perceived connection by the PT.

Following history taking, the authors also found that NPRS for leg pain, PCS, trunk flexion, and PPT measurements showed a significant change from the initial intake. While adding a physical exam generated some improvement, only active trunk flexion and PPT for the low back were significantly improved compared to the measurements after history taking alone. Overall, they found that history taking resulted in the most significant changes seen in the evaluation process. The authors suggest that in line with existing research, this finding may result from the fact that history-taking happens at first contact and therefore provides an opportunity for a connection to alleviate patient fears and establish a TA. 

They did not find that the PT’s connection with the patient altered changes in pain or function.

 

Limitations?

The main limitation of this study is the study design. Being observational, the findings cannot speak to any causal relationships between the changes and outcome measures. Additionally, as there were no strict controls on the history taking and physical exam, with each PT doing them their own way may have affected the findings.

 

Why do these findings matter?

Understanding what factors provide the most significant treatment outcomes for patients with LBP can help address patient pain and function and reduce overall healthcare costs.

facet osteoarthritis, facet joint pain

Goal of the Study?

The objective of this study 1 evaluates the feasibility of sensory mapping of lumbar facet joint pain in patients scheduled to undergo radiofrequency (RF) denervation. 

 

Why are they doing this study?

Lower back pain (LBP) is a widespread condition that can result in chronic pain.  While there are many treatment approaches, one of the most established interventions uses diagnostic blocks to identify the source of nociception. Though many parts of the back can be involved in LBP, facet joints are among the most common sources contributing to back pain. Most often, for treatment in clinical practice, the medial branches are anesthetized to establish the diagnosis of facet joint pain. RF denervation of these nerves, which is a process to stop nerves from transmitting pain, is used as pain management. 

The authors argue that while this approach has been well established, the use in a clinical setting has been questioned due to the high rates of false-positive (30%), cost-effectiveness and lack of standardization and anatomical variation. For this reason, the authors hope to develop a strategy for a more precise identification of the nerves involved in LBP.

facet capsule nerves, facet joint pain

 

What was done?

In total, they had 15 participants for this study. After written consent, participants completed a pre-procedure pain diagram and rated their pain on a scale of 1-10. The researchers used a standard procedure for RF denervation, including a single diagnostic block and imaging in determining cannula placement. To reproduce the pain in patients with chronic back pain, medial branches were stimulated using 50Hz electrical stimulation to determine the threshold. This was then increased threefold to achieve the suprathreshold stimulation, after which participants were asked to map their pain and compare this against the initial pre-procedure pain diagram.

 

What did they find?

A total of 71 nerves were scheduled for RF denervation. Sensory stimulation was successful in 68 out of 71 nerves using 50Hz electrical stimuli. All 15 participants reported either pain or paraesthesia (tingling or prickling) during suprathreshold stimulation, and 14 (93%) reported complete coverage of their usual painful area. In one participant, the upper lumbar pain was not covered by suprathreshold stimulation. For 60% of the participants, they reported pain/paraesthesia outside of their normal pain area during suprathreshold. Overall, in their population, 7.5% of the denervated nerves did not contribute to pain transmission. The average sensory detection threshold was 0.3V, with the suprathreshold was 0.6V.

 

Why do these findings matter?

Using suprathreshold stimulation, lumbar facet joint pain can be mapped and offers objectivity by reproducing patients’ back pain. This approach can also improve patient safety and experience by limiting RF denervation to nerves involved in pain transmission. This can improve patient safety and experience. 

exercise

Goal of the article?

 

Back pain is very common in people who practice sport at the elite and non-elite levels. In this article 1, the authors look at the existing research to understand how physical exercise can impact biologic and structural changes to the intervertebral disc (IVD) and spine. 

 

What is the IVD?

 

The IVD is the hydraulic cushion between vertebrae, making up almost one quarter of the spinal column. IVD provides stability by absorbing and distributing the stress and shock of the body during movement and preventing the vertebrae from approximating one another. Each IVD is made up of two parts: 

 

  1. Annulus fibrosis – this is the outside of the disc, made up of water and elastic collagen fibers
  2. Nucleus pulpous – this is the inside of the disc, made up of a gel like elastic substance

 

What did they find?

 

Research shows that different types of exercises have different outcomes for the IVD and spine. Low-impact and moderate physical exercise are beneficial to IVD as they can promote regeneration and muscle function. For example, regular walking or low demand running can help to improve IVD structure and support by providing nutrition to the IVD in the form of oxygen and lactate. 

 

In contrast, high impact activities that over rotate the spine or force it to overly compress can break down the IVD early and result in back pain. This pain can result in a reduction in muscle strength and muscle activation. It can also result in a worsening of coordination and proprioception (the sense of self-movement and body position). This means that individuals with lower back pain can have a reduced ability to sense how the body is moving and its’ actions. 

 

However, not only does pain have an impact on how a person can move, but it can also result in changes to the brain or what is called cortical neuroplasticity. These brain changes can alter the body’s motor and behaviour control. They can also limit the effectiveness of learning a new skill by reducing the ability of an individual to make necessary adaptions to movements that further deteriorate the spinal tissues. 

 

Why does this review matter?

 

Back pain is a very common finding in exercise and sport. Therefore, it is important to understand what types of exercise are beneficial to IVD and what types can deteriorate the spine and spinal tissues. Understanding how prolonged back pain can change the way human bodies experience and adapt to pain, and the long-term impacts that can have on learning a new skill, are important to addressing treatments for patients living with back pain. 

 

At Dynamic Disc Designs, we work to model the biology of the spine in a flexible and interactive way so professionals can make the best clinical decisions for their patients.

podcast

In a recent podcast hosted by Shireesh Bhalerao of Tulip Seminars, Jerome Fryer reveals the backstory behind the origins of Dynamic Disc Designs among many other topics.

Spotify click here to listen

Apple click here to listen

Topics include:

  1. Practice (down time between patient visits)
  2. Pain is dynamic should be modeled for patient education
  3. Connecting patients and their anatomy with self awareness
  4. The connection between Dynamic Disc Designs and Degenerative Disc Disease
  5. Explaining and revealing the progressive changes of the disc
  6. The patient encounter and optimizing outcomes
  7. Jerome’s research in joint cavitation
  8. Jerome’s inspiring background
  9. How do you find a receptive audience to partner with?
  10. Cavitation research from the observations of research and development of a Dynamic Disc Model
  11. Collapsing Bubble vs. Bubble Formation does that make any sense?
  12. Early discoveries of sound origin of joint cracking, it may not be either — formation nor collapse
  13. Vacuum phenomenon – vacuum sign. (unpacking of joint cracking research)
  14. Tulip seminars and teaching moments from dynamic disc models. Students are blown away.
  15. How one should connect with patients.
  16. Pathoanatomic diagnosis vs. movement based diagnosis – Jerome does not think they should be separated.
  17. Empowering patients with their understanding
  18. Chiropractic and Physiotherapists tension – why? There is no need.
  19. Surgical world – NASS meetings
  20. Making Jerome work with advancing modeling of different pathoanatomical models
  21. Bridging medical and chiropractic
  22. Optimize patients with Dynamic Disc Designs
  23. The Pain Meter – new venture.
lordosis. degenrative joint disease

Flat Back (Lack of Lumbar Lordosis) and Disc Herniation

Lordosis, or the lack of it, has been thought to be a biomechanical precursor to disc herniation in the lumbar spine. To investigate this possible correlation, a group of researchers from Gothenburg University looked at sixteen young active young patients with a median age of 18yrs old who experienced a disc herniation and underwent discectomy surgery. 1

Lordosis is the curve in the lower back—which they measured before and after the surgery.

Lordosis

Researchers used the Roussouly 4-type classification system to measure the degree of lordosis in the lumbar spine.

The researchers found less lordosis in the subjects that had surgery for their disc herniation. In other words, disc herniation was twice as likely to be present in the group with a flatter back. All the disc herniations were found to be in the lowest two levels of the lumbar spine (L4-5 and L5-S1), consistent with other epidemiological studies. 2

Dynamic Disc Designs Models

At Dynamic Disc Designs Corp. we have worked to represent the anatomy accurately. Our Professional LxH  Dynamic Disc Model is created with 12mm of disc height anteriorly and 10mm posteriorly providing a slight lordotic curve. Further, the model has been created with a higher percentage of nucleus pulposus which is often found in younger lumbar spines. To demonstrate that disc herniation occurs more likely with less lordosis all one has to do is dynamically move the single-level model into a less lordosis position and manually create compression. With more lordosis, the nucleus has a more difficult time penetrating through the outer annulus fissure. This can be an important posture teaching point in the prevention of disc herniation.

If you want to take your patient education to a dynamic level, explore what Dynamic Disc Designs models can do for you, your practice and ultimately, your patients.

facet osteoarthritis, facet joint pain

Facet osteoarthritis pain is common and thought to be a significant contributor to back pain in the US. Within the United States, it costs 100 Billion dollars annually to combat this endemic problem. However, back pain can originate from many anatomical structures, and the facet joint is only one of them but thought by many as significant. Other common pain structures are the intervertebral discs in the case of disc bulges, disc extrusions, disc protrusions and frank nuclear sequestration. There are also more severe causes of back pain like aneurysm and other organ pathology, so it is crucial to have a professional look carefully at the diagnostics of each case.

In the case of mechanical lower back pain (others use the term non-specific lower back pain), the facet joint garners good attention. The word ‘facet’ comes from the French facette (12c., Old French facete), diminutive of face “face, appearance” and are two anatomical structures that reside behind the intervertebral disc.

Facet osteoarthritis

Modeling facet osteoarthritis is tricky because of the complexity of motion at the spinal level. The intervertebral disc height plays a role with respective facet compression because it resides on the front of the spinal motion segment. It is this compression thought to be contributing to back pain.

Clincally, facet osteoarthritis pain is often unilateral in nature

In a study conducted recently 1, researchers worked to induce facet joint arthritis by creating compression with a spring. Over time the researchers found the increased expression of interleukin‑1β and tumour necrosis factor‑α expression. In other words, with more compression elapsing over time, the more the expression of the molecules related to many low back pain patients.

This is an important study linking the mechanics of compression and the associated physiology of molecules, which are thought to be markers of back pain patients.

At Dynamic Disc Designs, we have developed models to help explain the associated compression of facet joints as it relates to disc height loss and gains. We are committed to bringing the best in modelling. Explore our website for more.