Our lumbar models are identical in size and geometry to a real cadaveric specimen. With careful construction of the soft tissues including a flexible intervertebral disc including an annulus fibrosus and a nucleus puplosus,  each model is meticulously hand-crafted to provide the most accurate modeling to help the musculoskeletal practitioner to engage with patients in a convincing way.

Lumbar models have historically been static and immobile, but at Dynamic Disc Designs, we have developed flexible lumbar models to help relay essential movements to the patient related to their pain triggers. Having a patient genuinely understand their body mechanics empowers the patient and improves outcomes.

Patient-centered care must include translational strategies to help a pain sufferer understand their origins. A dynamic lumbar model helps execute efficient and accurate patient education.

Lumbar

NOTE: THIS PAPER IS STILL IN REVIEWS

 

Goal of the study?

 

To evaluate the frequency of lesions (injuries) in the lumbar region (lower back) of asymptomatic adolescent soccer players using MRI.

 

Why are they doing this study?

 

To date, there are very few studies that look at the frequency of spinal lesions in young athletes. Most of the research has focused on adult athletes and has shown that the lower back region is the most common site for problems. However, we know that the pediatric musculoskeletal system is particularly at risk to injury because adolescent bodies have not finished growing. Injuries at such a young age can result in an imbalance in bone tissue and muscles, which may cause an increased risk of injury, pain and limit young adolescents’ daily activities. These injuries can also get worse as we age. Therefore, it’s important to know if adolescent soccer players are getting lower back lesions that are not being identified and treated.

 

Lumbar

Modic Model

 

Who was involved?

 

The study 1 looked at two groups of asymptomatic male adolescents aged 13-18. 

 

  1. Soccer players who practiced the sport for at least two consecutive years, at least three times per week for 1-3 hours.
  2. Control group was made up of asymptomatic adolescents and was matched for age, gender, height and weight. They could not play soccer or any other sport more than once a week for more than 1 hour.

 

  • No one in the study could have any history of lesions, surgery, chronic disease or a high BMI score.
  • While they originally recruited 60 adolescents (30 in each group), because of exclusions the final sample size was 45.

 

What was done?

 

The researchers used MRI to evaluate the spine and look for the frequency of lesions in the lower back of adolescent soccer players. 

 

Two different radiologists examined the MRI images looking for the presence or absence of swelling, protrusions and disc extrusions (bulges). They also looked at stress reactions, cracks or stress fractures in the vertebras, vertebras slipped out of place, enlargements or growths, as well as swelling of the interspinal ligaments and muscles. 

 

What did they find?

 

Comparing the two groups, the researchers found that the proportion of spinal lesions was 76% in the soccer players compared to only 35% of the control group. In particular, they found that the percentage of lesions in the anterior and posterior of the spine was significantly higher in the soccer players than the control group. They did not find any significant differences between the age and BMI Z-scores between the two groups.

 

 

This study was able to show a high number of lesions in soccer players compared to other youth soccer studies that did not use MRI. However, research on young athletes playing other sports shows a similar frequency of spinal lesions.

 

What are the limitations?

 

This study had a very small number of participants. Also, all of the soccer players were studied during their championship season. This means it is likely that they are doing more intense training and playing than during regular season. As of Dec 28, 2020, the paper is still under review and going through the editorial process.

 

Why do these findings matter?

 

Lower back injuries in childhood and adolescence can lead to early degenerative changes. Therefore, the high number of lower back lesions in adolescent soccer players should be considered in the changing landscape of a person’s spinal health. Sport specific prevention efforts are important to reduce the occurrence and impact of lower back injuries on young adolescents. Better identification and management of spinal lesions may help to ensure that young people are able to continue playing sport and reduce the impact of these injuries in adulthood and into their senior years to avoid conditions like lumbar spinal stenosis. Learning recovery strategies show promise.

osteophyte

The patterns of vertebral osteophytosis (or the growth of bony projections from vertebrae) is a common study among researchers. The actual cause of these bony outgrowth projections has been questioned over the years, with some pointing to the abnormal movement patterns of motion segments. Others have questioned this and believe the cause to be related to age and genetics. In a 2014 paper, researchers sought to answer: Is vertebral body osteophytosis a reliable indicator of occupational stress1. A shallow dive into their findings will be shared here.

What we do know from the work of Kumareson et al. 2 and Adams & Roughley 3 is that osteophytosis looks to be linked to degeneration of the intervertebral disc which is defined by an aberrant, cell-mediated response to progressive structural failure. With this structural failure, inevitably, there must be physical stress and thought to influence the cells at the vertebral-disc interface margins to produce bony outgrowths.

Furthermore, others have looked at these bony outgrowths and tried to relate them to aberrant mechanical loading patterns along with physical age and genetics. 4 5 6. Archeologists that study biological remains have used this finding as a tool to measure historical population activity level and lifestyles 7 drawing speculative conclusions on the inter and intra-population differences. Two well documented skeletal population differences demonstrated that the women had more severe osteophytosis than the men and was thought to be caused by heavy lifting that the men did not do during this same time period.

However, other researchers believe that degeneration is not solely related to physical activity and more so related to genetic factors 8, ageing 9, and body mass 10. And with this, one can see the complexities underpinning the causative factors of these bony outgrowths that some call ‘bony spurs’ projecting from vertebrae.

The osteophytes’ anatomical margins are the entheses, which you can see in our Lumbar Spinal Stenosis Model. This is the region where a muscle, tendon or ligament attaches to the bone. It is the interface where force intersects with bony anatomy. This is often represented in the extremities but the same biological process is thought to be at the crux of these anatomical changes.

osteophyte

Osteophyte Projection in our Lumbar Spinal Stenosis Model

What did these researchers investigate?

A group of researchers 1 wanted to see if they could determine whether mechanical factors related to osteophyte formation. They looked at these entheseal margins in the lower and upper extremities and the spine to see if they were correlated. Their logic was to see if the bony osteophytes were similar in all anatomical regions and if so, they could speculate that there was a mechanical influence of the formation of them. They also wanted to see if age played a factor as they explored the relationship between vertebral osteophyte formation and entheseal changes in the extremities.

The samples that were used came from a burial site in Cedynia, Poland. 101 male skeletons were examined and divided into two age groups, 20-40 years old and 41-56 years old. To determine the vertebral osteophyte degree, they used a rating scale developed by Swedborg (1974) to measure the entheseal grade; they used Mysezka & Piontek (2012). The entheseal anatomical sites they measured included the humerus, radius, femur and the tibia.

What they found

Interestingly, the researchers found no significant age differences when comparing the presence and degree of both osteophytosis and enthesopathy in the spine and extremities, respectively. They did find a significant correlation between the lower extremity enthesopathy and the vertebral osteophytosis, however. In other words, if they saw bony spurs in the lower extremities of the specimens, there was a good chance they were going to find vertebral osteophytes of the spine.

 

Does this solve anything regarding whether mechanics plays a role in osteophyte presence?

No. But it does shed light on the possible mechanics. These researchers agreed that other factors, besides physical ones, could be at play and should be considered. In particular, like age, body mass and genetics.

 

Commentary by Jerome Fryer

From a clinical standpoint, we should be mindful of these anatomical changes. Do they cause pain and problems all the time? No. We have seen this time and time again with clinically abnormal imaging findings. However, in the case of vertebral osteophytosis, a projecting osteophyte into the foramen where an exiting nerve root needs room for its vascular geometry for nourishing itself, space is everything. Learning about how to prevent the progressive changes of these types of osteophytes that can encroach on the dorsal root ganglia is important. Ongoing facet arthropathy is an adaptable process, but if adaptation is too great and osteogenesis takes up space where the nerve needs it, pain and disability can present and often, there is no turning back. My hunch is if we can improve the spine’s mechanics and keep an eye on disc height changes over a lifetime, we can keep the spine healthier and avoid spinal conditions like lumbar spinal stenosis. However, this is purely speculative in nature, and much more research on the causes of osteophytosis must occur. JF

 

  1. Anthropol. Anz. 71/4 (2014), pp. 381–389 Notes J. Biol. Clinic. Anthropol. Stuttgart, November 2014
  2. Kumaresan, S., Yoganandan, N., Pintar, F.A., Maiman, D.J. & Goel, V.K. (2001): Contribution of disc degeneration to osteophyte formation in the cervical spine: a biomechanical investigation. – Journal of Orthopaedic Research 19, 977–984. DOI: 10.1016/S0736-0266(01)00 010-9.
  3. Adams, M.A. & Roughley, P.J. (2006): What is intervertebral disc degeneration, and what causes it? – Spine 31, 2151–2161. DOI: 10.1097/01.brs.0000231761.73859.2c.
  4. Sambrook, P.N., McGregor, A.J. & Spector,T.D. (1999): Genetic influences on cervical and lumbar disc degeneration: magnetic resonance imaging study in twins. – Arthritis and Rheumatism. 42, 366–372. DOI: 10.1002/1529-0131(199902)42:2<366::AIDANR20>3.0.CO;2-6.
  5. Spector, T.D. & McGregor, A.J. (2004): Risk factors for osteoarthritis: genetics. Osteoarthritis and Cartilage 12, 39–44. DOI:org/10.1016/j.joca.2003.09.005.
  6. Knüsel, C., Göggel, S. & Lucy, D. (1997): Comparative degenerative joint disease of the vertebral column in the medieval monastic cemetery of the Gilbertine Priory of St. Andrew, Fishergate, York, England. – American Journal of Physical Anthropology 103, 481–495. DOI: 10.1002/(SICI)1096-8644(199708)103:4<481::AID-AJPA6>3.0.CO;2-Q.
  7. Novak, M. & ˇ Slaus, M. (2011): Vertebral pathologies in two Early Modern Period (16th–19th) century) populations from Croatia. – American Journal of Physical Anthropology 145, 270–281. DOI: 10.1002/ajpa.21491.
  8. Sambrook, P.N., McGregor, A.J. & Spector,T.D. (1999): Genetic influences on cervical and lumbar disc degeneration: magnetic resonance imaging study in twins. – Arthritis and Rheumatism. 42, 366–372. DOI: 10.1002/1529-0131(199902)42:2<366::AIDANR20> 3.0.CO;2-6. , ageing and body mass index.
  9. Snodgrass, J.J. (2004): Sex differences and ageing of the vertebral column. – Journal of Forensic Science 49 (3), 458–463.
  10. Oishi, Y., Shimizu, K., Katoh, T., Nakao, H., Yamaura, M., Furuko, T., Narusawa, K. & Nakamura, T. (2003): Lack of association between lumbar disk degeneration and osteophyte formation in elderly Japanese women with back pain. – Bone 32, 405–411. DOI:10.1016/S8756-3282(03)00031-0.
  11. Anthropol. Anz. 71/4 (2014), pp. 381–389 Notes J. Biol. Clinic. Anthropol. Stuttgart, November 2014
Static Flexion

A study 1 in the journal of Clinical Biomechanics shared results pointing toward the relationship between the muscular flexion-relaxation response in humans and period of static flexion. The aim was to further understand the phenomenon and its link to muscular modification (including low back pain).

Understanding Static Lumbar Flexion

Research has shown that workers are at risk of static lumbar flexion. However, not a lot of data is present that experimentally addresses the physiological biochemical and histological processes that are active in the evolutionary progression of the resulting low back disorder. Studies, involving animals, have shared that static lumbar flexion is responsible for the development of creep in associated viscoelastic tissues. This leads to elicit spasms and even modifies muscle function.

The current study set out to investigate neuromuscular changes while assessing normal (health-wise) human participates through the flexion-relaxation phenomenon.

The Study

The current research included male and female participants. There were 24 males and 25 female participants. The males ranged from 22 to 40 in age (the mean being 23.7 years old). The females were 19 to 30 in age (with the mean being 23.3 years). None of the participants reported issues in their spinal functions. Take note, six additional participants served as a control group.

They were asked to perform three bouts of lumbar flexion-extension before as well as after a 10 minutes long period of static flexion. The researchers recorded the surface electromyographic from the erector spinae muscles along with the flexion angle.

ANOVA was utilized on the angle in which electromyographic was reduced during flexion and initiated during the extension stage.

The Results

The study saw that the human erector spinae were active through a significantly larger angle during the flexion stage and were able to initiate activity significantly earlier during the extension stage (after static flexion). More pronounced changes were seen in the female participants (compared to the male participants). Furthermore, spasms were recorded by the researchers in more than 50% of the participants during the static flexion period.

What does it all mean?

According to the study, it was concluded that creep which was developed during a short static lumbar flexion was able to elicit a significant change in the flexion-relaxation phenomenon’s muscular activity pattern (in humans). It was observed that due to the loss of tension in the lumbar viscoelastic tissues, the muscles offered some compensation. The recorded spasms suggested minor micro-damage due to the viscoelastic tissues. The data was helpful in understanding why static lumbar flexion was an activity that was a risk factor for the development of the low back disorder in humans.

What are the Risk Factors Associated with Recurrent Lumbar Disc Herniation After Discectomy

Not many reports address whether LSTV (Lumbosacral transitional vertebrae) has a link with LDH (Lumbar disc herniation). A study 1, in the journal International Orthopedics, was conducted to rectify that. The results showed that LSTV and a hypermobile disc in flexion-extension radiography were risk factors for recurrent LDH.

What was the Context?

Reports show that LDH is a common complication following discectomy. The reported frequency has been observed to be up to 21%. The previous operation site was where the recurrence was the most frequent. Patients were likely to experience pain in the legs and back. They might even require revision surgery.

There’s still controversy present with regards to the risk factors associated with recurrent LDH. There are a lot of conflicting results. While gender, age, obesity, and smoking status are considered risks, radiological factors might be risk factors, too. These factors include disc degeneration, larger sagittal range of motion (SROM) in flexion-extension radiography, and larger disc height.

The Study

The current study investigated numerous risk factors for LDH following discectomy. The study involved a total of 119 participants. All of them had undergone a discectomy for L4-5 disc herniation. The minimum follow-up was of two years.

The study evaluated a range of risk factors. The clinical parameters involved body mass index, smoking status, and gender. The radiological parameters were LSTV, degree of disc degeneration, SROM, and type of herniated disc.

Disc Herniation

What were the Results?

The results showed that 21 of the participants had recurrent disc herniation at L4-5. From the 21 patients, 11 had LSTV. Seven patients had LSTV in the 98 patients from the non-recurrent group. The study shared that it had confirmed LSTV and a larger SROM being significant risk factors at L4-5 (for recurrent disc herniation).

What does it Mean?

The current study, deemed to be the first of its kind, concluded that LSTV and a hypermobile disc in flexion-extension radiography were indeed risk factors for recurrent LDH. The current data can offer beneficial knowledge for future research.

 

A study 1 in the Frontiers in Bioengineering and Biotechnology investigated the in vitro glucose consumption as well as gene expression by NP cells (over time) while under varying oxygen tensions. The study’s objective was to gain data for understanding disc pathophysiology and to determine the therapeutic potential of notochordal NP cells.

Why such a Focus?

Low back pain or LBP is a common condition affecting millions of people around the globe. According to research, LBP has a relationship with the degeneration of the spine’s intervertebral discs. Furthermore, an imbalance in the catabolic and anabolic activity by disc cells is known to result in such degeneration. Due to intervertebral discs being avascular (in their nature), there may be an oxygen deficiency in the central NP or nucleus pulposus. While the mechanisms require further understanding, the matrix regulation and energy metabolism of the disc cells can be affected by the resulting hypoxia. Monitoring such affects might help with better LBP treatments down the line (including treatment and preventive strategies for degenerative intervertebral discs).

The Study

The current study cultured notochordal procine NP cells in agarose discs. The cultures were at 21, 5, or 1% oxygen tension for 1, 5, or 10 days. An RT-PCR was used to analyze the expression of 10 key matric genes, as well as Brachyury (T), by the said NP cells. A two-point method was used to measure the consumption of glucose.

Spinal bone

What were the significant Results?

The study’s results revealed that glucose consumption rates (by NP cells) were significantly affected by oxygen tension and culture time. Furthermore, significant changes were seen in T expression based on the culture time and oxygen level. Take note, better maintenance of the notochordal phenotype may be indicated due to how the T expression was significantly higher in the 1% oxygen tension on day 10 (compared to the other two groups).

What does it mean?

The study shared that (when it comes to agarose disc culture) a vital role is played by oxygen tensions level in maintaining the proper expression levels of matrix regulation genes of notochordal NP cells. The study offered data regarding the role of nutritional environment to support healthy NP cell expression. Better treatment strategies for disc regeneration might be helped by using the quantitative information gathered by this study. The data can also prove helpful to understand disc pathophysiology.

Can Verbal Suggestions Manage Musculoskeletal Pain A Review

How much of an impact do verbal suggestions have on managing pain? We can’t be entirely sure. There has been a lot of controversy surrounding the power of suggestion and pain management. A review 1, in the journal of Physical Therapy Reviews, was conducted to find some answers. While there is potential in such a field, more research is required to see any clinical significance associated with pain management and verbal suggestions.

What’s the Context?

Numerous studies prove that pain has socioeconomic and health implications. This includes disability and functional limitation. Chronic lumbar pain has been observed to have the greatest prevalence. Low Back Pain or LBP is an economically draining ailment for individuals around the globe. Furthermore, reduction in pain due to surgeries and other LBP treatments isn’t always accompanied by improvement. Due to LBP being multi-faceted (including psychological factors), a person’s psyche has been suggested to help with recovery. So, verbal suggestions might have a role to play in the treatment of LBP.

Musculoskeletal lower back pain

The Purpose of This Review

The aim of the current review was to describe as well as explore the neurobiological mechanisms associated with verbal suggestions when it came to managing musculoskeletal pain in patients.

The literature search was conducted by two independent reviewers. The databases included were PEDro databases, Medline, Cochrane Library, Lilacs. Systematic reviews, randomized clinical trials, and literature reviews were included in this review.

After the study’s exclusion criteria, a total of 13 studies were involved in the current review. The total included four randomized controlled trials and nine reviews. The current review covered the neurobiology of verbal suggestion, and the effects of verbal suggestion in pain sufferers.

What did the Review Conclude?

The review concluded that there’s potential in positive verbal suggestion to improve the effectiveness of LBP management in patients. The review pointed out that such suggestions could generate hypoalgesia via the placebo effect. However, more research is required to fully determine the clinical significance of verbal suggestions for pain management in patients.

Can Hypersensitivity Be Decreased in Patients of Chronic Whiplash after a Medial Branch Block Procedure

A study 1, in the BMC Musculoskeletal Disorders, was conducted to determine if there was any change in sensory hypersensitivity in patients of chronic whiplash disorders after a medial branch block procedure in the cervical spine. The results showed a decrease in the patient’s pain.

What’s the Context?

It’s common for motor vehicle collision (MVC) to result in cervical spine pain and dysfunction. While many are able to recover (significantly) from neck pain and disability in about six months or even a year, reports show that 32% to 56% of patients continue to suffer.

According to studies, the cervical zygapophyseal joints are known to be a primary source of pain in as many as 60% of people who experience WAD or whiplash associated disorders. Such joints may also be playing a role in peripheral and centrally mediated pain (sensory hypersensitivity).

The Study

The current study was conducted to determine any change in sensory hypersensitivity in WAD grade II patients after a medial brank block (or MBB) procedure in their cervical spine.

This exploratory study utilized a pretest-posttest design. Eighteen participants (3 males, and 15 females) with whiplash associated disorders grade II, and 18 healthy (matches gender breakdown) participants were involved in this study. Take note, patients with chronic WAD and aged 18 to 60 years, who reported neck pain for more than 6 months, and who experienced a minimum of 80% decrease in the said neck pain after an intra-articular zygapophyseal joint block procedure were included.

zygapophyseal joints

The study used a single item Numeric Pain Rating Scale (0-10) for measuring the cervical spine pain intensity of patients before as well as after the MBB procedure.

Quantitative sensory testing (QST), which considered pressure pain thresholds (PPTs’) and cold pain thresholds (CPT’s), was used to measure sensory hypersensitivity. In patients dealing with WAD, the measures were taken at three sites bilaterally, pre and post-MBB. The study used an independent and dependent t-test to determine differences between thresholds.

The Results

The study revealed that, at baseline, the PPT’s were decreased at all three sites in the WAD group. The cervical spine had an increase of cold pain thresholds in the WAD group. Significant increases in PPT’s at all sites was observed in the WAD group (post-MBB), along with a substantial decrease in CPT’s at the cervical spine.

What was Concluded?

The study concluded that chronic WAD patients showed evidence of widespread sensory hypersensitivity in the presence of thermal or mechanical stimuli. Decreased levels of sensory hypersensitivity were observed in the WAD group after the decrease in the primary source of pain caused by the cervical zygapophyseal joints.

However, the study did note that large clinical trials, addressing long-term follow-up interventions targeted at eliminating or reducing the source of cervical pain in WAD patients, were required.