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.

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.

Sacroiliac Joint

According to research, at least 10 to 30% of LBP or low back pain is linked to the sacroiliac joints. A review 1 in the journal of Best Practice & Research Clinical Rheumatology decided to give the said link a more in-depth look.

The Context
As mentioned, studies have shown an approximate 10-30% of all LBP being attributed to sacroiliac joints SIJ. While almost 44% of SIJ pain is associated with trauma onset, the etiology is still unclear. So, even today, there are numerous challenges when it comes to diagnosing as well as treating sacroiliac joints. One of the biggest challenges is determining whether or not pain or dysfunction in the human body is primarily due to the sacroiliac joint. SIJ being a causative factor, while theorized, doesn’t have a lot of evidence for support.

The Purpose of This Review

The current content aimed to cover the available data regarding the anatomy of SIJ along with its examination, etiology, and treatment to assist clinical approaches. One of the major questions dealt with: when pain is experienced at the SIJ, is it better to direct treatment at local tissues, or should it focus on factors that are remote to the joint?

Furthermore, the review also wanted to analyze if the pain in a region was primarily due to SIJ or were other factors in place (on and around the said joint)?

The review went over the anatomy and function of the Sacroiliac joints, the etiology of Sacroiliac joint dysfunction, the clinical assessment of the SIJ, and managing SIJ pain.

The review tried its best to consider all of the complexities associated with SIJ’s diagnosis and management (including sport and exercise-related SIJ pain). It took a bio-psycho-social perspective.

What did the Review Find?

The review summarized that clinicians and researchers shouldn’t conflate sacroiliac pain, stability, and dysfunction (as all three are separate). Furthermore, trauma and repeated training might be associated with SIJ pain in athletes.

Clinical evaluations should administer clustered pain provocation testing. Such a suggestion was made after determining that palpation and mobility test didn’t offer any proven value. When addressing persistent pain, taking a bio-psycho-social approach is crucial. Treatments (backed by evidence) included pelvic compression belts, surgery, manipulation, exercise, and corticosteroid injections.

Also, further research is required for understanding SIJ pain better.

 

A review article 1 in Spine Surgery and Related Research presented an interesting overview of the molecular mechanisms involved in the degeneration of intervertebral discs. The review also described certain molecular targets and therapies that may help with intervertebral regeneration and repair.

Why do such a Review?

Even though life expectancy has increased over the past century, it isn’t without a share of medical issues. According to research, neck pain and low back pain (LBP) tends to increase with age. They’re also the 1st and 4th leading causes of disability in humans, respectively. Furthermore, intervertebral disc degeneration (IDD) plays a significant role in generating back pain. That’s why it’s important to understand the degeneration of healthy joints (especially intervertebral discs or IVDs) with age to improve quality of life.

One of the first tissues that experience degeneration in adults is the IVD. While there’s still a lot to learn, the current review was conducted to share some of the molecular pathways and cellular changes that tend to lead to IDD.

molecular mechanisms

What Did the Review Cover?

The objective of the current review was to offer an overview of the known molecular mechanisms leading to IDD. The review was sure to address the complex interactions of endogenous and exogenous stressors. It focused on the degeneration of the extracellular matrix (of the nucleus pulposus and the annulus fibrosus).

Furthermore, the review also went over the supporting role played by the DNA and intracellular damage, oxidative stress, cellular senescence’s catabolic effects, as well as the inappropriate response by the cells to damage. All of the data can prove to be beneficial in understanding how physical and chemical changes can increase the spine’s degeneration. The review also shared certain therapies for spinal regeneration and repair.

What was Concluded?

The review shared that there’s potential to discover novel disc degeneration mechanisms by focusing on disc functions that help maintain stability as well as motion of a mechanically loaded structure in a nutrient-poor, acidic, and hypoxic environment.

It was important to note that disc degeneration is influenced by the degeneration of adjacent spinal structures and systemic factors. That’s why researching the entire spine is essential for the progress in the spine’s degeneration and regeneration therapies. Also, early intervention (before the functional failure of the spinal disc) is crucial.

lumbar disc herniation

A study investigating kinematic changes in subjects with lumbar disc herniation (LDH) performing five activities of active daily living (ADL) found that LDH patients were more apt than healthy subjects to restrict the lower lumbar (LLx) and upper lumbar (ULx) spinal motions when performing ADLs. The LDH patients used pelvic rotation to compensate for their reduced lumbar flexibility and increased pelvic tilt and lower extremity flexion during problematic ADLs. 

What’s at Stake?

Lower back pain affects up to 85 percent of the worldwide population—especially those over 40—and can contribute to musculoskeletal problems when the lower spine and its surrounding structure is overloaded. Because LBP patients often restrict musculoskeletal motions during ADLs to avoid pain, understanding the kinematic idiosyncrasies of LBP patients during their ADLs is essential when treating spinal issues through physical therapy that involves gait and functional training. 

Past research has indicated LBP patients had less transverse plane movement than healthy subjects during level walking exercises. One study found that LBP subjects were more likely to exhibit spinal or pelvic rotation, while another study came to the opposite conclusion but found that LBP patients had less range of motion (ROM) in the lumbar spine than the control group. Conflicting studies have concluded that LBP patients had significant reductions in the range of hip flexion and spinal movement across all three planes during trunk flexion or better ROM in the lumbar spine, with more restriction in the pelvic or thorax ROM. The divergent conclusions are likely due to the trunk and whole lumbar being considered a single, rigid segment, rather than interconnected segments that operate independently. The prior studies may also have neglected to consider the kinematic differences among LBP patient subgroups. Analyzing the variability of joints and segments is vital when studying LBP patients and their unique kinematics. 

This study focused on how lumbar disc herniation (LDH) specifically contributes to LBP, including the lower trunk, thorax, hip, and pelvis. The goal of the study was to use a computing model to study LBP patients with LDH and understand their pain-related modulation of their lower extremities and multi-segmental trunk kinematics during level walking, stair climbing, trunk flexion, ipsilateral pickup, and contralateral pickup. 

The Study

Twenty-six healthy males with a mean age of approximately 24 years and seven LHD diagnosed male patients who were, on average, approximately 28 years old participated in the study. The disc herniations occurred at L4/5 in three of the LDH patients, L5/S1 in three cases, and at both locations in one patient. 

The motion of thorax, ULx, LLx, pelvis, hip, and knee were tracked via 3D active markers placed in various locations on the subjects’ spines, pelvises, thighs, and shanks. All the markers were placed by a single surgeon, who had previously demonstrated the five ADLs the subjects were to perform. After practicing the motions a few times, the subjects repeated them while data was collected through the active markers. 

The kinematics of the thoracic segment, ULx, LLx, pelvis, hip, and knee were calculated using a modified Gait-full-body computing model that would analyze the motion of each lumbar vertebra using at least three markers. The kinematic spine and hip angles were analyzed with the computing model using a Euler rotation sequence of spinal segments or thigh/pelvis movement, and the thoracic segment as it related to the L1 vertebra. The ROM for all segmental or joint angles during flexion-extension or gait cycles across all three planes in three planes was calculated, and data analysis was performed using a custom program. 

Results

The LDH subjects had much more pelvic rotation and LLx rotation than the healthy subjects during level walking. The LDH group had much less ROM for thoracic flexion, pelvic tilt, and hip abduction during stair climbing, but they showed more ROM for LLx rotation. No clinically significant variance was noted between the two groups for thoracic flexion, trunk flexion or ipsilateral and contralateral pickups. Lumbar flexion ROM was significantly decreased in the LDH group—especially for ULx with nearly no sagittal angular displacement.  

The findings suggest that people with LDH modulate their movement patterns and motor regulation in response to, or avoidance of pain. There were evident kinematic differences between the healthy subjects and LDH patients in this study. LDH patients had more pelvic rotation and increased LLx rotation during level walking, contradicting earlier studies where patients had less than or similar pelvic rotation when compared with healthy subjects. The use of different marker sets, study methods, computer models, and speed of motion might account for the varying test results, but it appears that pelvis and LLx motions in the transverse plane may have a more pronounced effect than that of the other two planes during LDH abnormal motion level walking analysis. 

Conclusion

In regard to the direction or range of motion, there were contrasting kinematic characteristics and different adaptations to LDH between the ULx and LLx in this study. The thoracic motion did not appear to be affected by the LDH when subjects were performing the ADLs, with the exception of stair climbing. During all five ADLs the LDH patients maintained limited lumbar flexion, and their pelvises, knees, and hips compensated for the lost lumbar motion capacity in the sagittal plane during contralateral pickups. In four of the five ADLs (the exception being stair climbing), the LDH patients increased their pelvic rotation significantly. They also had higher rates of antiphase movement between thorax and pelvis in the two pickups and in level walking and stair climbing in the transverse plane between ULx and LLx.

The findings of this study should help provide a more comprehensive understanding of how LDH influences kinematics and lead to more specific treatments and better therapeutic outcomes for LDH patients. 

disc height

In this Spine Education video, Dynamic Disc Designs’ Dr. Jerome Fryer demonstrates the benefits of helping lower back pain patients better understand their condition by using dynamic models and visual aids.

“How often do you encounter a patient that explains that their symptoms are worse as the day progresses?” he asks.

Though clinicians understand the key to a graduating pain syndrome involves a complex biomechanical and biochemical matrix in the spine, back pain patients don’t need extensive medical knowledge to appreciate the dynamics of what is happening in their bodies. A simple visual aid can help clarify and simplify their predicament and potential solutions.

 

Hands-On Demo of Diurnal Expression of Fluid from the Disc

Using a dynamic disc model, Fryer demonstrates the diurnal expression of fluid from the disc as the disc height changes over the course of the day.

“We know that the disc height is tallest in the morning,” he says, holding a fully expanded disc model to the camera and then slowly squeezing the dynamic model to demonstrate the loss of height that occurs throughout the day.

“As the day progresses, the disc height will slowly lose its height [causing the facets] to imbricate or shingle. If a patient [complains] their symptoms are more present as the day progresses, you [use] this graph 1 to demonstrate what’s happening in their spine.

“As the person gets up in the morning, there is a quick change in the disc height in the first 10 minutes,” he says, pointing out a steep curve on the graph.

“As the day progresses, the disc height is lost.”

Annular Disruption in Degenerated Discs Reduce Capacity to Maintain Height

Fryer says the situation can be even more extreme when a patient is suffering from degeneration in the disc because the disc can no longer hold its full height, due to disruption in the annulus.

“Helping patients understand symptoms as the day progresses will help them understand why it hurts,” he says. “That gives you more empowered strategies to help patients get motivated, if its posture, or even recumbency, or exercise, or getting out of a chair to help with the disc height changes. These dynamic disc models are very powerful in helping patients with self-awareness.”

For more information on dynamic disc models and patient teaching aids, visit Dynamic Disc Designs.