News for Dynamic Disc Designs which includes updated research and a synthesis of the most updated studies to help efficiently engage with patients and their back and neck pain.

We take an approach that an evidence-based practitioner would take. Carefully dissecting the history of a patients complaints, weaving the mechanical and psychosocial factors and then deliver a rational and tangible approach to relieving the back pain to the patient. Our news helps keep the practitioner abreast of the latest publications related to musculoskeletal health.

At our headquarters, we dedicate weekly hours to comb through the research for those who treat back pain and neck pain and deliver it.

Disc Herniation Spondylolisthesis

Spondylolisthesis is the slippage of one vertebra on another—frequently found with disc herniation. However, in this recent paper titled: “Over-reporting of the disc herniation in lumbar spine MRI scans performed for patients with spondylolisthesis” 1 they sought to find if disc herniation is over-reported and in turn, possibly over-treated.

Spondylolisthesis is best diagnosed when the spine is under load. Many MRI scans, because done in the lie-down position, miss these small (or large) slippages. To accurately assess one for a spondylolisthesis, the spine is best visualized by x-ray in the forward bending and backward bending position. Upright MRI is also another great way to assess; however, the access to these expensive machines may not be available.

The authors of the above paper discuss how it is imperative to find an accurate diagnosis for both the conservative and surgical management of back pain.

Disc herniation is often found with spondylolisthesis. However, what they found was disc herniation reporting was often over-reported and believed that the disc herniation was more of a pseudo disc herniation rather than an actual disc herniation.

 

What do the authors mean by pseudo-herniation?

 

The authors point to a nomenclature issue. In Fardon’s 2014 paper 2 he helps clarify the language professionals use when discussing disc herniation, extrusion, protrusion and bulge. However, the authors of this paper explain that Fardon’s article does not address this nomenclature in light of spondylolisthesis.

 

They point out in this retrospective study of 258 patients that disc herniation was over-reported because the disc herniation was read with the superior vertebra in mind rather than referencing the lower vertebra. In other words, if the radiological reporting used the lower vertebra as a reference point, the reporting of a disc herniation would be much less because the outer disc border remained anterior to the posterior vertebral ring apophysis. Therefore, it is essential to deferentially diagnose whether symptoms are related to a real disc herniation or due to the mechanics of a spondylolisthesis. A spondylolisthesis can throw off the reporting in this case.

 

 

Dynamic Disc Designs creates 3d models to help reveal the dynamics of disc herniation, including the up-roofing of the disc material. This mechanism is shown in our Professional LxH Model, with the added features of spondylolisthesis.

 

Ergonomic Seating

Lower back pain is a global problem. Its rate has increased steadily over the last several decades, with now more than 637 million individuals suffering around the world. 1

What has also been steadily increasing is the act of sitting. People are working from home more than ever, especially with the recent coronavirus outbreak, forcing people to self-isolate to reduce the spread of the disease. Even before COVID-19, businesses and individuals have increasingly adopted computer-based platforms that increase screen time. Engaging with screens are a large part of life for many and presents a new reality of work life.

What do we know about the origins of lower back pain?

Lower back pain is considered multifaceted with intervertebral disc degeneration (IDD) being the most probable leading cause. IDD is a precursor to many commonly known conditions, with only some of them being disc herniation, spondylosis and lumbar spinal stenosis. 2 A common radiological finding within IDD and the other related spinal conditions are the reduction of spacing between the vertebra. Or, in other words, disc height loss. So how does disc height loss occur?

 

Disc height loss is normal through the day/night cycle. As humans, we lose approximately 20% of the fluid from our discs over the day to regain it at night, when we lie down to sleep. 3 The regaining or recovery of the fluid and respective height is imperative for the health of the disc. If we do not recover the height, this leads to a state of compression and resulting pain. On the flip side, if discs regain too much fluid, this also results in over expansion as we see with astronauts. Problems also incur if one lies in bed for too long.

 

So we need a balance—a balance of compression and decompression to our spines. If there is an excess in either direction, problems can arise. To minimize over-compression, we have to look at our postural behaviours. And one act that we just do too much of is sitting. We know that sitting causes disc compression and height loss as the spine undergoes the movement of flexion. 4. And why does the spine round into that posture? Well, the main reason is because of traditional seat pans 5 which cause the lumbar spine to round and causing increased pressure on the disc. 6

So what is it about sitting that is so different?

If you look carefully at a single motion segment (vertebra-disc-vertebra complex), each vertebra is separated by three joints. The largest and most important anatomical structure in the fight to resist compression is the intervertebral disc, which supports about 80 percent of the load in the standing posture. The remaining 20% load is distributed through the facet joints. Lumbar Model - Intervertebral Disc and FacetsProfessional LxH Dynamic Disc Model

I often describe this using a tricycle as a metaphor. The big tire on the front is like the disc, and the two facet joints are similarly like the two little tires. Sitting will place all the pressure over the big tire on the front of the tricycle, which increases the pressure on it. And over time, because the disc is a hydraulic structure, water will squeeze water out of it, reducing its height.

Neutral Loading

Office Chairs and Lumbar Alignment

To optimize sitting alignment during sitting, researchers have looked at lumbar supports to balance the motion segments of the spine. 7 These groups of researchers asked one question: Which office chair feature is better at improving spine posture in sitting? What they did was evaluate 28 participants, measuring by x-ray postures in four different chair conditions: control, lumbar support, seat pan tilt and backrest with scapular relief. They concluded that not one of the four stood out with regards to improving lumbar flexion, but the angled seat pan did improve pelvic posture significantly. They also discussed how the tilting seat pan did reduce flexion in the lumbar spine and suggesting that this may still be of practical significance. 8

 

Ergonomic Seating from Dynamic Disc Designs Corp.

At Dynamic Disc Designs, we are introducing ergonomic seating. Some may know the CEO, Jerome Fryer BSc DC, who has, from an early start in his career, observed the increasing trend of global sitting. In 1998, he made a simple observation during his training years as a chiropractor. And this simple observation of self-decompression led to two publications in The Journal of Bodywork and Movement Therapies and also The Spine Journal.

With the knowledge gained, he thought it was time to bring it to others.

With an adjustable seat pan and a saddle orientation to keep your hips in a more neutral position, the Ergonomic Saddle – Task Chair will optimize lumbopelvic posture. A 12-degree seat pan tilt is adjustable to each user’s unique lower back.

Seat Pan Angle Adjustability

Adjustable Tilt

 

 

 

 

 

Telehealth in light of COVID19

The current focus of health systems on hospital preparedness and public health measures to reduce spread of the COVID-19 virus, and flatten critical illness curves, has led to the reduction, or temporary closure, of many in-person clinical services around the world.  Despite the importance of readiness for spikes in critical illness related to COVID-19, as well as for maintaining physical distance to curb spread of disease, it is also crucial to keep in mind that many patients are currently at risk for experiencing gaps in care, as services deemed non-urgent have been put on hold.  Health care providers are finding that telemedicine may present a possible solution to the issue of continuity of care while maintaining physical distance during the COVID-19 pandemic restrictions.

What is Telemedicine?

The World Health Organization defines telemedicine as “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.”1  As this definition suggests, there are many potential contexts for leveraging telemedicine technologies and approaches – as well, there is a growing body of literature to support and inform the use of telemedicine in practice.

Telemedicine is currently demonstrating utility in an environment where it is necessary to maintain distance while providing optimal patient care.2,3  Lock downs or quarantines due to COVID-19 have pressed the need to move the delivery of certain health care services onto a telemedicine platform for a number of patient scenarios.  One of these is to facilitate ongoing dialogue between patients and their health care providers regarding existing and/or chronic health conditions.4 A crucial part of this dialogue is clear, sound and effective patient education.

Patient education on a telemedicine platform – to support the initiation of treatment regimens, follow-up and/or self-care at home – can be carried out in accordance to evidence-based findings for effective in-person patient education practice. One such finding is the utility of demonstrations and visual aids in order to elucidate to patients their pathology and reasons for their symptoms, and in order to explain why and how certain treatment or self-care regimens/behaviours will be effective.5,6  In the case of patient care related to spinal and musculoskeletal conditions, this could include the use of spine and intravertebral disc models.

How Spine Models by Dynamic Disc Designs could help

Spine models by Dynamic Disc Designs are anatomically accurate with features that can easily and clearly be pointed out to patients during their education sessions with their health care provider.  This is especially useful when utilizing a telemedicine platform, where the patient may need extra support to feel connected to the health care provider’s message.

Jordan van der Westhuizen is a Managing Partner and an Occupational Therapist (Hons) at Enhanced Occupational Therapy in Perth Australia.  He utilizes Dynamic Disc Designs spine models in his patient education sessions, both in-person and via telemedicine.  He notes,  “…Not only for in-person consultations but now for telehealth, our spine model allows the patient to understand their back issues and mechanisms causing pain which is a key component in the patient’s health journey.”

Telehealth - Spine Education

Dr. Robert Peace is a chiropractor in Tulsa Oklahoma who also currently utilizes Dynamic Disc Designs models for patient education sessions via telemedicine.

“The ddd spine models are an invaluable resource for the relating of findings and communicating the many causes of spine pain. The patients always seem to get a better understanding of their condition when viewing the detailed anatomy on this model.  I’m looking forward to receiving my next model – the Medial Branch Dynamic Disc Model – to even better demonstrate and educate the patients in regards to facet joint inflammation and medial branch involvement.”

We are currently experiencing a global health environment that calls for innovation in patient care on many levels. Health care provided through telemedicine offers opportunities for health care providers to safely and quickly triage patients with symptoms that may be related to COVID-19, but also provides a platform for continuity of care for patients with other illnesses, particularly those that are chronic and thus require ongoing, long-term follow-up.   The use of visual aids such as spine and disc models for patients with spinal issues can enhance the patient education that is an integral component of optimal care for patients with chronic conditions

 

References

  • World Health Organization. (1998, December 11-16). A health telematics policy in support of WHO’s health-for-all strategy for global health development: report of the WHO group consultation on health telematics. Geneva. Geneva. https://apps.who.int/iris/handle/10665/63857
  • Xiaoyun Zhou, Xiaoyun Zhou, Centaine L. Snoswell, Louise E. Harding, Matthew Bambling, Sisira Edirippulige, Xuejun Bai, and Anthony C. Smith. (2020, March 23). The Role of Telehealth in Reducing the Mental Health Burden from COVID-19. Telemedicine and e-health, 26(4). https://doi.org/10.1089/tmj.2020.0068
  • Judd E. Hollander, M.D., and Brendan G. Carr, M.D. (2020, March 11). Virtually Perfect? Telemedicine for Covid-19. New England Journal of Medicine[online]. DOI: 10.1056/NEJMp2003539 https://www.nejm.org/doi/full/10.1056/NEJMp2003539
  • Vivek Chauhan, Sagar Galwankar, Bonnie Arquilla, Manish Garg, Salvatore Di Somma, Ayman El-Menyar, Vimal Krishnan, Joel Gerber, Reuben Holland, Stanislaw P Stawicki.(2020) Novel coronavirus (COVID-19): Leveraging telemedicine to optimize care while minimizing exposures and viral transmission. Emerg Trauma Shock[serial online], 13(1), pp.20-24. http://www.onlinejets.org/article.asp?issn=0974-2700;year=2020;volume=13;issue=1;spage=20;epage=24;aulast=Chauhan
  • Audrey Jusko Friedman, Roxanne Cosby, Susan Boyko, Jane Hatton-Bauer & Gale Turnbull. (2010, December 16). Effective Teaching Strategies and Methods of Delivery for Patient Education: A Systematic Review and Practice Guideline Recommendations. Journal of Cancer Education volume 26, pp12-21. https://link.springer.com/article/10.1007/s13187-010-0183-x
  • Robert P. Riemsma Erik Taal  John R. Kirwan  Johannes J. Rasker. (2004, December 8). Systematic review of rheumatoid Arthritis patient education. Arthritis care & Research, 51(6), 1045-1059. https://doi.org/10.1002/art.20823

 

A well-received study 1, in the journal ‘Spine,’ decided to observe the relationship between cellular nutrition and disc degeneration. The results shared that a fall in disc nutrient supply can lead to disc degeneration.

Why Was such Research Conducted?

According to previous studies, the disc tends to degenerate earlier when compared to other tissues. The consequences of such degeneration include sciatica, back pain, and other spinal disorders. The treatment of such ailments can be quite expensive. They also harm a person’s psychological wellbeing.

While genetics is involved in such an occurrence, there have been suggestions about disc nutrition playing a role, too. The disc happens to be the body’s largest avascular tissue. That is why certain theories exist about degeneration happening due to a decrease in the nutrients being transported into the disc.

The current research was conducted to further understand this existing relationship.

LxH Model

Use a dynamic disc model to help in the patient education of nutrition and discs.

What Methods Were Used?

The study design was about analyzing the disc cell viability in relation to the supply of nutrients as well as cellular demand in vitro (while using a diffusion chamber). The objective was to gather data about the possible relationship present between nutrient supply, concentrations, and viability of a cell.

The research team cultured isolated bovine nucleus cells in agarose gels. The cultures were grown (up to 13 days) in a diffusion chamber. The nutrients were supplied by copying the configuration found in the disc in vivo. The concentration of glycosaminoglycans and profiles of cell viability were measured with relation to the medium composition and cell density.

Data was analyzed, statistically, using the Student’s t-test or analysis of variance (ANOVA).

What was Concluded?

The results from this degeneration-centric study showed that the analyzed cells were able to remain viable (across the diffusion chamber) at low cell densities. However, cell death was seen (inside the chamber) at higher densities. Also, the increase in cell density led to a decrease in the viable distance from the disc nutrient supply. Glucose was observed to be a critical nutrient. Also, at an acidic pH (6.0), cell survival was poor.

Take note; disc cells were found to be capable of surviving up to 13 days with 0% oxygen. No loss in cell viability was observed during that period. However, these cells did produce very low levels of proteoglycan.

The conclusion of these results helped support the theory about disc nutrient supply playing a role in regulating disc degeneration. According to this study, a decrease in the disc nutrient supply leads to a reduction in the number of viable cells present in the disc and opens the door to degeneration.

Hopefully, further research can be done to help promote better nutritional supply to the disc to address disc degeneration and related ailments.

Facet joint degeneration

A very recent study from 2019, 1 in the Journal of Biomechanics offered some interesting results. It set out to analyze the relationship between IVD intervertebral disc (IVD) and facet joint (FJ) degeneration with regards to chronic low back pain. The results suggested that FJ loading is significantly impacted by the early mechanical changes linked to IVD degeneration. However, the said impact decreased as the degeneration progressed.

What Was the Context?

LBP or low back pain has been researched to be the most common condition (musculoskeletal), negatively affecting humans around the world. The impact of LBP is psychological, physical, economic, and sociological. While a majority of LBP cases are non-specific or generalized (which at our company does not exist), individual research studies have identified several specific causes behind LBP. The most common of these causes are IVD degeneration as well as FJ degeneration. Even though genetics is considered to be a contributor to degeneration, an important role is played by the mechanical environment with regards to pathogenesis. Furthermore, as degenerative changes occur, so can the load transfer from the disc to facets and vice-versa. The present study decided to look deeper into this relationship.

The Study

The current research effort developed a parametric finite element (FE) model using ANSYS APDL of an L4-L5 human motion segment. A total of five loading scenarios were considered for this experiment. The degree of disc degeneration was analyzed for each model based on the ratio of the intact disc height to the actual disc height. A similar method was used for FJ degeneration. Four groups were made to cover grades 0 to 3; Grade 0 = non-degenerated disc, Grade 1 = mild degeneration, Grade 2 = moderately degenerated, and Grade 3 = severely degenerated.

The analysis was conducted using a custom Python code. Volumetric operations and imaging were done using the vtk module v6.3. The statistical module of the SciPy library was used for data analysis. (To understand more we advise getting a hold of the full text)

What Were the Results?

Of the total of 1000 models, 14 of them were excluded from further evaluation. This was because they didn’t converge in a single loading scenario. The remaining models showed some interesting results. In the four groups made for disc degeneration (from grade 0 to 3), the said groups, respectively, had 248, 245, 246, and 247 models. In the FJ group, it was 178, 427, 330, and 51.

In Grade 0, 141 showed non-degenerated FJ. Grade 1 had 106 mild degeneration of FJ. The FJ was moderately degenerated in only one sample in Grade 2. Coming to the mildly degenerated disc group, there was an affinity toward higher FJ degeneration grades. The moderately degenerated disc group showed four instances of non-degenerated faces, with 111 being Grade 1, 126 being Grade 2, and 5 being Grade 3. In the severely degenerated disc group, the results showed FJ degeneration in 27 instances in Grade 1, 174 in Grade 2, and 64 models in Grade 3. A strong association between intervertebral disc and facet joint degeneration was observed. A strong positive correlation was analyzed between the FJ gap as well as both the strain in the anterior annulus and the force acting on the IVD.

What was Concluded?

The results of the current study put forth a strong association between IVD degeneration and FJ. The results were backed by previous literature. The gap width of the FJ showed the strongest correlation with disc load (the load which comes through the IVD). The research team of this study agreed that FJ degeneration causes loading and abnormal motion of the IVD, leading to the latter’s degeneration.

Furthermore, the team observed a strong negative correlation existing between FJ capsule tension and disc degeneration. The results of the study suggested that early mechanical changes linked to IVD degeneration had a significant effect on FJ loading. Also, as the degeneration progressed, the said impact is decreased. FJ degeneration also continued to affect disc loading, pointing toward a possible increase in support of disc degeneration.

The results of the current research study tend to suggest that early mechanical changes linked to IVD degeneration have the highest effect on the FJ loading. And as the degeneration continues, the said effect is lowered, whereas FJ degeneration seems to increasingly influence the disc loading, which might indicate increasing support of the disc degeneration.

The research team hopes their efforts help others in further understanding the existing link between FJ and IVD degeneration.

 

 

 

 

LBP and Disability

A cross-section study 1, in Spine, was conducted to investigate the link low back pain (LBP) and disability had with the structural features of the thoracolumbar fascia. The results shared that a relationship existed between these factors.

The Context

While the Global Burden of Disease Study has researched LBP to be the leading cause of disability in humans, a lot of work needs to be done to fully understand the etiology associated with LBP. More research needs to be done to address all of the factors linked to LBP. Such understanding is crucial because it will help with creating targeted prevention strategies to help millions around the globe.

Previous research has analyzed LBP and disability to be associated with structural abnormalities of the lumbar spine. Furthermore, MRI has shown LBP to be linked to disc protrusion, disc degeneration, nerve root displacement or compression, and high-intensity zone. While more research is still needed, the present results do suggest that the issues of LBP and disability can be addressed by targeting structural factors. Take note, there’s evidence that suggests the thoracolumbar fascia may be linked to LBP. However, few MRI studies have examined such a link.

hypermobility-spine

The Study

The current study had an aim to examine the link present between the lumbar fascia’s length and LBP as well as disability. The study used MRI.

A total of 72 participants (49 females and 23 males) were recruited. They weren’t required to have any history of LBP or current LBP to participate. The MRI was performed, in this study, using a 3.0-T magnetic resonance unit (with the participants in supine position). The study administered the Chronic Pain Grade Questionnaire (CPG) at the time of the MRI.

The study used the Logistic regression analyses for examining any likely associations between fascial length and high pain intensity (or disability).

What did the Results Conclude?

The results of the study concluded that there was a significant association between a shorter length of fascia and high-intensity LBP and/or disability. Such association was after adjusting gender, age, and the body mass index. The association was strengthened after adjustment for the cross-section area (in the paraspinal compartment).

While more studies are required, the current results do suggest that fascia’s structural features likely play a role in disability and LBP.