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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.

 

Conclusion

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.

 

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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.

Results

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.

Conclusion

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.

Results

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.

 

Conclusion

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

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Research Finds Difference between Office Chair Angles on Postural Stress

postural stress, chair, design, seat pan

A study 1 on the impact of different office chair features on spinal posture while sitting found that seat pan tilt and some types of lumbar supports may offer negligible improvement in sitting postures, but overall, sitting for extended periods of time puts stress on the spine and may generate spinal injury. Perhaps something new needs to be invented to minimize end range postural stress and spinal compression over time.

What’s at Stake

Sitting involves flexing the hips and back and moves joints out of their neutral zones, which contributes to stress in the lower back. Even 20 minutes of spinal flexion can cause laxity in the ligaments and change the reflex action of spinal muscles. Over the years, office chair manufacturers have attempted improvements in their products that would lessen stress on the back and improve overall sitting postures, but standing postures that incorporate a neutral posture—where the lower back maintains its convex curvature and the pelvis keeps a slight forward tilt— remains the optimal stance for preventing back damage and pain.

Studies have found that chairs that help the sitter to extend their lumbar spine and anteriorly rotate their pelvis while sitting are the most helpful in reducing the likelihood of damage to the ligaments, muscles, and vertebrae. These types of chair features fall into three categories: thoracic supports, lumbar supports, and seat-pan tilting mechanisms. Of these three modifications, only one type of seat pan mechanism and lumbar supports have been radiographically studied. It is also unclear if men and women have similar lumbar lordosis and pelvic inclination.

This study examined lumbar spine and pelvic postures radiographically using three available seating features to determine which, if any of the three features caused an improvement in spinal or pelvic positioning during sitting. It also looked at posture responses in men and women to see if there were differences between them.

 

The Study

The study involved 28 participants (14 males and 14 females) with no recent history of lower back problems. The volunteers, whose mean age was 25 years, were not told about the conditions being tested or the relevant features of the products being tested. They were each radiographed in the standing and sitting postures using standardized postural and breathing instructions during their x-rays. Their radiographic measures were then compiled into the software program, and a statistical analysis was performed.

Results

Researchers found that the lumbar postures of all participants were significantly flexed and extended in the seating position compared to the standing position. There was trivial improvement between those using postural interventions and the control groups whose chairs did not employ those features.  There were slightly reduced levels of flexion with seat pan tilt features and lumbar support mechanisms, indicating potential value in these accommodations, but lumbar lordosis or intervertebral joint angles were not affected in any significant way across the improvement features.  At the pelvic level, researchers found statistically significant results: The seat pan tilt configuration produced more anterior rotation of the pelvis and less flexion. The male subjects showed greater flexion during sitting than females.

Conclusion

Sitting places strain on the lower back, particularly at the L4/L5 and S5/S1 disc levels. Lumbar supports and some seat pan tilt features may be slightly helpful in reducing the stress put upon the lower back while in the seated position, but overall, there was minimal difference between the various office chair features on reducing lumbar lordosis or IVJ joint strain. What improvement was evident was local to the spinal segment, rather than posture as a whole. Male and female subjects displayed angle differences in the effects of sitting at the L1/L2 and L2/L3 IVJ joints and pelvis.

KEYWORDS: postural stress, different office chair features, spinal posture, seat pan tilt, lumbar support, lumbar lordosis, flexion, joint strain, posture responses in men and women, back damage and pain, lower back, IVJ joint strain

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Study Finds Evidence Asymmetrical Postures During Loading Contribute to Disc Failure

disc failure

A microstructural analysis of how healthy discs respond to compression and complex loading postures—specifically those incorporating flexion and facet-constrained shear—found evidence that the required load contributing to disc failure was reduced when complex postures, rather than simple flexion, were utilized in load-bearing situations. In addition, when asymmetric postures were used during lifting, rather than simple compression or flexion, there occurred more infiltration of the nucleus material as it made its way to the annular periphery. The results of the study indicate that asymmetric postures during lifting are more likely to contribute to disc degeneration and lower back pain and should therefore be avoided.

The Study

The study 1 involved 30 motion segments from 10 sheep spines that had no previous signs of disc degeneration. The discs were frozen, thawed, and then rehydrated fully prior to the compression experiments to be in agreement with previous similar experiments and maximize the annular load. Researchers created a bending, twisting, lifting scenario that involved axial rotation, lateral, anterior, and posterior shear, and flexion, adapting the mechanical rig to compress and rotate the disc segments to failure using compressive force.

The typical failure was lower under complex loading conditions than in conditions of simple flexion. Microstructural damage included fractures of the vertebrae and three variations of annular damage, including mid-span direct tearing, non-continuous mid-span tearing, and annular-endplate tearing. Combinations of all three types of damage occurred, as well as circumferential failure, in all 30 discs.

The complex postures utilized in the study lessened the discs abilities to withstand compressive loading and contributed to failures. The complex loading conditions contributed to instances of dual modes of failure, including the circumferential (circuitous tracking of nuclear materials towards the annular periphery) evident in all study samples. This suggests that the lateral parts of the disc may be especially vulnerable during flexion because of shear loading in the area. Circumferential damage was evident in all 30 discs involved in this study, which suggests that it is likely an important type of damage involved in disc failure under complex loading conditions.

Conclusion

Complex postures during load-lifting may contribute to herniation and disc failure. Asymmetrical postures (in addition to flexion) should be avoided during lifting to reduce the likelihood of sustaining a lower back injury.

 

KEYWORDS: complex loading, disc failure, asymmetrical postures during loading, compression and complex loading postures, flexion and facet-constrained shear, disc degeneration, annular damage, disc herniation

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Increasing Gradients of Compressive Stress Can Lead to Annular Delamination, Collapse, and IVD Degeneration

delamination, annulus

A ISSLS Prize-winning study 1 examined how increasing gradients of compressive stress within the intervertebral disc (IVD) contributed to the progress of dis degeneration. The research findings suggest that an increased grade of disc degeneration created decreased nucleus pressure and compressive annulus stress, but anterior annular stress gradients increased by approximately 75 percent, and by 108 percent in the posterior annulus—findings that are clinically significant.

The neural arch may provide a stress-shield for the degenerating disc during mechanical loading, but delamination and collapse of the annulus are most likely caused not by loading, but by increasing gradients of compressive stress, leading to advanced disc degeneration, despite the stress-shield.

The Study

Using 191 motion segments from 42 cadavers of varied ages, researchers measured the intradiscal stresses under 1 kN of compression. A pressure transducer was pulled along the midsagittal diameter of the disc to measure the intradiscal stresses. Stress gradients in the annulus were quantified using a formula that averaged the rate of increase in compressive stress between the area of maximum stress in the anterior or posterior annuls, and the nucleus. Measurements were compared before and after applied creep-loading, as well as in flexed or erect postures. A scale of 1to 4 was used to describe the amount of macroscopic disc degeneration observed.

 

Results

An increase of disc degeneration from 2 to 4 decreased by 68 percent the amount of pressure in the nucleus, and compressive stress in the annulus was decreased by 48-64 percent, depending on the simulated posture of the segment and the location of the disc. However, anterior annular stress gradients showed an average 75 percent increase in the flexion position, and posterior annular stress gradients increased 108 percent in upright posture.

 

Conclusion

The neural-arch provides stress-shielding, but compressive stress gradients are significantly increased with an increasing grade of disc degeneration. Adjacent lamellae are sheared by the stress gradients, which may contribute to the delamination and collapse of the annulus.

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Lumbar Disc Herniation and Resorption – What does the literature say?

A professional lumbar spine model with a flexible and totally dynamic herniating (or prolapse) nucleus pulposus.

Lumbar disc herniation is a very common condition which often generates pain and disability. It is a physiological process that starts from the inside out as the nucleus pushes radially into the annulus fibrosus. But not all disc herniations cause pain, and many of them don’t cause long-term disability.

The literature has been quite varied in answering questions surrounding resorption rate. Yes, many disc herniations resorb, and it is believed to be due to the anaerobic and avascular nature of the nucleus pulposus. Once the material extends beyond the annular outskirts, the immune system identifies it as foreign and macrophages begin to chew it up.

But not all lumbar disc herniations are equal while some respond to manual therapy and some do not. Some cases require surgery to remove the offending material.

In a recent meta-analysis titled: ‘Incidence of spontaneous resorption of lumbar disc herniation’ 1 a group of authors looked at 11 cohort studies but found only a very limited number of high-quality papers on the subject. What they found was the phenomenon of lumbar disc herniation resorption to be 66.66% and suggested that conservative treatment may be a first line approach to reduce costs associated with unnecessary surgical bills.


Disc herniations are quite varied in nature, and this is likely why there is such variability in the outcomes reported regarding resorption and pain. As a spine modeling company which continuously invests in the property characteristics of materials, we have found that subtle changes to the nucleus pulposus make-up and annulus fibrosus tensile properties have a significant impact on the biomechanical behaviour of our lumbar disc herniation model.

Many mechanically anatomical variations exist which can cause a wide spread of varying symptoms. These symptoms are likely related to the type of herniations with some more central within the spinal canal and others are more lateral. Further to that, Depending on the severity, an astute clinician can be relatively accurate in the anatomical location to help in the mechanical management of lumbar disc herniation.

flexion, lumbar, model, pain, relief

Flexion lumbar loading

 

 

To see how a spine surgeon uses the model to explain a lumbar disc herniation while referencing an MRI, we present Iona Collins of fixmyspine below.