Our patient education dynamic spine models help low back pain sufferers better understanding of their pain sources.

A dynamic spine model can empower a patient to help him or her get to know the motions postures and loads related to pain. Once the specific movements are identified, a patient can learn what exercises and movement strategies that will reduce their symptoms. A disc bulge is often an MRI finding but it can also tells a story about hypermobility. For lumbar spinal stenosis, it is also common for a person to have symptoms while their spine is in relative extension. The Lumbar Spinal Stenosis Model helps a practitioner deliver this important message to engage with accurate patient education.

intensive patient education, pathoanatomy

This study 1 published in JAMA (Neurology), randomly selected 202 acute low back pain patients to compare pain education to non-pain education. The results demonstrated not much difference between the groups.

The Methods

Participants engaged with their common physician and in addition to this familiar interaction, each participant was then randomly partitioned into two groups. Each of these groups experienced, in addition to the advice and interaction of their physician, an additional two x hour sessions of either:

Group 1: Normal engagement with doctor PLUS intensive one on one patient education (delivered by clinical psychologist in pain management (M.K.N.) trained) for an additional 2 (1hr) sessions. This patient education was delivered based on Butler’s and Moseley’s work. 2

Group 2: Normal engagement with doctor PLUS placebo patient education (delivered by the same clinical psychologist) for an additional 2 (1hr) sessions. Participants in the placebo patient education group received no information, advice, or education about low back pain from the trial clinician. Participants were encouraged to talk about any topic that they desired.

The Results

Retention rates remained high for both groups at ninety percent. Intensive patient education was not more effective than placebo patient education at reducing pain intensity at the three months. There was a small effect of utilizing intensive at one week and at three months but not at six or twelve months.

 

Discussion

In this study, patient education was used through a psychological framework model rather than a biomechanical model. It is important to understand that this study does not mean that patient education is ineffective or as effective as a placebo. This patient education angle does not attempt to help patients understand the cause of their pain. This approach is more of a top-down psychological strategy of patient education. Methods to subclassify these acute low back pain patients into specific biomechanical categories and then, offer those patients specific education and movement strategies would be helpful to study as groups within the acute low back pain group. These sub-groups could then be compared to placebo.

 


At Dynamic Disc Designs, we believe that empowering patients with a greater sense of self-awareness on the probable mechanical cause of the acute low back pain can be helpful in the management. Initially, pain-reducing strategies through movement awareness of painful structures should be prompt and focus on reducing nociceptive inflammation for the patient. Following the acute phase of low back pain, professionals using our dynamic disc models can further promote the physical awareness of specific postures to help prevent the recurrence and avoid a progression of the condition. Our models allow the practitioner to explain patho-anatomy in a patient-friendly way that does not induce fear avoidance behaviours for the long term.  They also enable the practitioner to provide a realistic forecast of the temporal biological adaptation process within the degenerative cascade framework of natural ageing with a dynamic 3d model. In other words, our dynamic disc models assist the patient engagement process with the opportunity to bring up anatomy is a non-scary way and empowering way. We look forward to more research on this topic.

 

 

3d modeling, endplate lesion

An October 2018 study compared MRI’s of 966 lower back pain (LBP) patients to introduce a simplified, reliable method of classification for common endplate lesions. The study also noted associations between endplate lesions and variables, including age, rate of disc degeneration, sex, and Modic changes. The researchers then demonstrated the new system’s reliability by repeated observational rating over a period of days, using outside raters evaluating a percentage of the total sample results. The demographic and physiological findings of the study were largely in agreement with previous IVD endplate lesion studies but also added novel findings that had not previously been published.

basivertebral nerve, bone marrow edema, modic changes

Modic vertebra model- midsagittal cut exposing the basivertebral nerve.

The Study

The subjects in the study were all LBP sufferers under the age of 70, excluding patients with a history of back surgery, spondylodiscitis, or vertebral fractures. Data including age and sex were collected on all patients, and images were scanned and evaluated by an experienced radiologist.

A scoring and classification system for the Lumbar IVD spaces was noted on the images, with the descriptions:

  • Normal—Physiological curvature of both endplates, without the detection of any visual lesions in any of the sagittal MRI IVD space slices.
  • Wavy/Irregular—Curvature in at least one of the endplates, without detectable IVD lesions.
  • Notched—The presence of at least one circular small or V-shaped lesion on an MRI saggital slice.
  • Schmort’s Node—Clearly evident vertebral endplate deep focal defect, where the endplate is rounded, with a smooth margin
  • Fracture—Thickened bone fragment at the edge of an endplate, or any evident fracture of the endplate with similarly-sized fragments

A sampling of the image data was also evaluated multiple times over a period of two days by independent raters to ensure observer reliability. To determine how often each type of endplate lesion appeared associated with disc degeneration and alterations of the MRI signals, subgroups of the study subjects were created, and comparisons were made based on age and sex. A scatter-plot chart was created to track Modic changes, and the relative percentages were calculated and identified against an established threshold.

 

Results

The findings indicated minimal association between patient age at the time of the scan and disc degeneration, as well as minimal Modic changes in older patients, as opposed to entire population studied. The most common types of endplate lesion observed were the “notched” and “Schmorl’s Node” type lesions, and both were more common in male patients than in females. Few of the patients studied had “Wavy/irregular” or “fracture” lesions, which occurred in nearly equal numbers of male and female subjects.

There was a strongly evident correlation between disc degeneration and endplate defects across all LBP subjects in the study. All lesion types increased in all IVD levels where disc degeneration was evident. There was a significant increase in “wavy/irregular” endplate types whenever severe disc degeneration was present. This can be considered a reliable marker for the process of extreme disc degeneration.

Signal alterations were found to be associated with endplate lesions, specifically in “notched,” “wavy/irregular,” and “Schmorl’s Node” endplates. There were nearly twice as many notches in Modic changes of types 1 or 2 corner signal alterations. Schmorl’s nodes showed even more evidence of association.

 

Discussion

Though this study was conducted with the intention of developing a reliable method of endplate defect classification in LBP patients and to find correlations in the distribution of LBP by analyzing a large population of subjects via MRI, previous studies have indicated a correlation between back pain and lesions—something this study did not specifically address.

The results of this study agreed with previous studies that indicated male LBP patients are more likely to have IVD lesions than female patients, though similar lesion-levels were observed in male and female patients who showed evidence of severe disc degeneration, as is found in Schmorl’s nodes and in those with disc fractures.

Most of the patients showed no evidence of endplate lesions on the lumbar MRIs. Of those who who did have lesions, most (18.7 %) experienced them only in a single IVD level, and males were more likely than females (20.7 % to 16.7 %) to show evidence of lesions. Progressively fewer subjects had lesions involving more IVD levels.

There was a very slight correlation between age and lesions in this and some previous studies. That correlation appears to be stronger in the female LBP population than in males—a new observation that has not been discussed in previous studies.

The association between endplate defects and disc degeneration was evident, especially where “wavy/irregular” endplates occurred, indicating severe degeneration of the discs. Signal alterations and endplate lesions also showed a positive correlation, specifically in “wavy/irregular,” “notched,” endplates. This association was significantly evident in Schmorl’s nodes.

 

arthritic changes, lumbar models, cervical models

Arthritic changes are very common. They are often related to a person’s pain with neck pain as one of the highest ranked common causes of disability. In this specific research article 1, the authors looked at the micro-details of neck synovial joints. With osteoarthritis known to be related to neck pain, they were looking to reveal higher anatomical detail and they were also curious about whether men or women have more of these problems.

With both neck and back pain being multifactorial (which may include both psychological and social aspects) degenerative changes within the synovial joints play a significant structural role with the development of spondylosis. This is a general term to describe a disorder of the musculoskeletal system with an emphasis on joint space narrowing, intervertebral disc height loss and frequent formation of bony spurs.

The architecture of the cervical facet joints is quite well known with most of the current knowledge around the smooth (or lack of smoothness) hyaline cartilage to allow the joint to receive and distribute loads in an efficient manner. However, there has not been much quantitative data revealing the anatomy under the hyaline cartilage designated as the subchondral bone. This bone under the cartilage (sub, meaning below and chondral, meaning cartilage) has been of recent interest as there exist nerves in this area that can cause pain. This is thought to be similar to the basivertebral nerve of the vertebral body. The innervation of the facet, however, has ascending fibres travelling through the posterior primary division which can be seen in this Medial Branch Dynamic Disc Model.

 

modeling hyaline cartilage, models

Hyaline Cartilage Modeling in our Professional and Academic LxH Dynamic Disc Models

basivertebral nerve lumbar model

Basivertebral nerve of a lumbar vertebra.

Previous research has shown that the thickness of the hyaline cartilage is .4mm in women and .5mm in men with the subchondral bone making up approximately 5% of the total cartilage thickness. It is also known that with increasing age the cartilage starts to flake off (called fibrillation) and researchers also coin the stripping of cartilage from the bone, denudation. This means being nude. A joint surface within a covering. Other terms used to describe the break down of the hyaline cartilage is erosion, fissuring and deformation. All in all, the terminology all mean that the hyaline is thinning.

arthritic changes, subchondral, joint, model

Subchondral thickening – arthritic changes

How did they do it?

These researchers looked at 72 recently deceased people and examined their joints. They used microscopes to look closely at the facet joints to help understand the pathogenesis of the arthritic changes.

When they observed the osteocartilaginous junction, the morphological changes included: flaking, splitting, eburnation, fissuring, blood vessel invasion and osteophytes. They looked at the length of the cartilage, the hyaline cartilage thickness, the calcified cartilage thickness and the subchondral bone thickness.

They found that males tended to have more severe degenerative changes described by flaking and severe fissures in the facet cartilage. Click To Tweet

Points of Key Interest

  • this was a study that looked at 1132 unique cervical spine facets from 72 humans
  • males were found to have more degenerative changes of the osteocartilaginous junction
  • the thickness of the calcified cartilage and subchondral bone increased with age whereas the hyaline cartilage decreased
  • the osteocartilaginous junction is particularly important in the pathogenesis of osteoarthritis in the cervical spine facet joints

 

At Dynamic Disc Designs, we work to bring research to the practitioner so when there is a teaching moment, Professionals are ready to explain pain triggers as they relate to a patients symptoms and movements. Empowering people about their own anatomy helps in the crafting of customized treatment plans for each unique pain patient. Explore our dynamic models and help a patient understand their arthritic changes and what that means to them.

spine pain, models

Ed Cambridge: “Our colleague Jerome Fryer created some models for us, and this is some of the work that has come out of our lab with you and Christian Balkovec about the dynamic changes we see after herniation. Where we have disc height loss at one level, creating hypermobility at the adjacent level. So here you can see, when you move the spine around there is a stiffening effect down in the lower joint and in the upper joint hypermobility. That’s what we see when an injury propagates from one joint to the next. The patient says, “Well, the pain used to be lower but now its starting to creep up my back a little bit.” “

Stuart McGill: “Fabulous. Another little take on that … By the way, these are all cast from real human specimens. So this is the real deal. Once again, Dynamic Disc Designs has been so clever in representing the biofidelity. We start to see how this disc has been damaged, and it’s quite lax as we move it around. So those micro-movements now are triggering pain just at that level. And this joint has normal stiffness, but then look what happens. Over time, the join changes because of the change in mechanics. The lax disc now cases a bit more arthritis in those facet joints, because they are now responsible for much more motion. So then, look what happens to the cascade. As the person now extends, look what happens. The joint that was hypermobile has now bound up, has no mobility because the facets have bound up and all the motion is now left at the previously stiffened joint. The polar opposite. And then you need some kind of mobility to pop those facet joints open again after they’ve been jammed.”

inflammatory mediators

The changing spine and the anatomy. Professional LxH Dynamic Disc Model

Stuart McGill:  “So, when you understand the cascade of change that happens at a joint, it might be kicked off with a little bit of a flattened disc, which puts more load in the facet joints, which causes a little bit of arthritic growth. In two years, the joint has changed and so have the pain patterns and the mechanics. So, it really does lend insight to allow us to understand the cascade of how the patient reports those changes and their pain changes over the years. And it better allows us to show them what to do to wind down the pain sensitivity. “

 

patient educational tools

Recent studies12 on the effects of patient education in reducing stress and promoting long-term positive patient outcomes indicate that providing literature and visual aids that clearly describe or demonstrate the patient’s condition can help relieve anxiety and encourage a positive psychological state that fosters better health outcomes. Examples of patient educational tools include illustrated pamphlets, photographs, radiograph images, charts, and finely detailed dynamic design models to provide an overall contextual effect in framing treatment and health expectations.

Reframe Treatment Expectations by Providing Context

Clinicians, chiropractors, and physical therapists who are prepared with effective aids to answer their patients’ questions about disc herniation, bulging discs, disc degeneration, annular fissure, osteoarthritis, stability, hypermobility, nerve pain, sheer instability, neutral loading, recumbency, facet or disc pain, disc height changes with static loads, diurnal changes, and other spinal conditions can look forward to a better patient-practitioner experience, more patient cooperation,  and a better long-term treatment outcome for their patients than those who rely on simple diagnosis and treatment procedures without effective patient education.

Empower Patients with Biopsychosocial Approach

By providing patients with a better understanding of their condition through the use of dynamic models or other visual devices, practitioners improve patient-clinician treatment collaboration and empower patients to take a more active role in their own healing agenda. This biopsychosocial approach to treatment has been shown in studies to generate more positive, long-lasting treatment outcomes and improve relationships between patients and practitioners, fostering trust, communication, and respect.

When practitioners take the time to help patients understand their condition, the patient feels more supported and engaged in the healing process and report being generally happier with their treatment plan. Using a person-centered approach to healing, the practitioner is concerned not only with a patient’s diagnosis and treatment, but is also concerned about the patient’s perception of his diagnosis and treatment experience. This perception, according to studies, is more positive and empowering when the practitioner takes the time to fully address the patient’s concerns and questions and uses visual aids, images, charts, literature, dynamic designs, and other tools to demonstrate what the patient is experiencing and how the treatment will work.

Keywords: dynamic models and other tools in patient education, use of dynamic models or other visual devices, finely detailed dynamic design models, patient educational tools, biopsychosocial approach to treatment, disc herniation, bulging discs, disc degeneration, annular fissure, osteoarthritis, stability, hypermobility, nerve pain, sheer instability, neutral loading, recumbency, facet or disc pain, disc height changes with static loads, diurnal changes

lower back pain

A data review of how education of patients suffering from lower back pain (LBP) in a primary care setting affects their psychological state found moderate-to-high evidence that when primary care physicians provided information on the condition, their patients were reassured and experienced long-term healthy and psychological benefits.

patient education

Although it has been long-established that reassurance from a medical practitioner improves patient outcomes, it is also true that reassuring non-specific illness patients without educating them about their condition can contribute to stress, which can precipitate chronic pain and expensive, recurring health care costs.

Because LBP patients are often discouraged from receiving costly diagnostic imaging tests, they may not experience the reassurance that comes from understanding the source of their pain. Though only 25 percent of physicians in the UK currently order imaging as a matter of course, the number is increasing as the benefits of patient reassurance become more evident.

Another means of patient reassurance involves preplanned educational materials that explain the condition in understandable language. Booklets, diagrams, and dynamic devices that clearly demonstrate the health problem and how it can be treated may have beneficial health and psychological effects on LBP in a clinical setting, but there have been few studies to validate the effectiveness of these intervention methods. The purpose of this systematic review was to examine how patient education would increase reassurance in LBP patients and to determine which method of intervention was most effective.

Methods

A literature review of identified, eligible studies was conducted in November of 2013 and repeated in June of 2014. The studies reviewed involved LBP patient education, advice, reassurance, information, counselling, and consultation in clinical trial settings. Eligibility included LBP adult patients with acute or subacute conditions in clinical trials where more than 70 percent of the patients reported symptoms and where the interventions were conducted in a primary care setting, with at least one patient education element, either written or verbal, that provided reassurance.

Results

The data analysis of the review suggested, with moderate-to-high quality evidence, that patients with LBP are reassured when they receive education about their condition from their primary care provider and that the positive effects of the intervention are still evident at a one-year follow-up consultation. The evidence also showed that receiving education about their LBP during their initial primary care visit reduced the amount of LBP health-care visits over a one-year period. A sub-group review also determined that patients were more reassured when they received education about their condition directly from their physician, rather than from a nurse of a physiotherapist.

Discussion

The results of this review indicate that physicians who can provide their LBP patients with structured, understandable educational materials about their condition are more successful in reassuring their patients, who continue to have lasting health and psychological benefits for up to a year after their initial consultation. Because patients with LBP typically endure numerous costly treatments and may suffer from chronic pain and stress, it would be beneficial for primary care physicians to prepare educational materials that could lead to a more successful treatment outcome and reduced financial burden for their patients.

spine models, patient education, anatomy models

Dynamic spine models – Patient Education for Spine

KEYWORDS: educating lower back pain patients, patients suffering from lower back pain, patient reassurance, patient education, diagnostic imaging tests, psychological effects of LBP

somatosensory changes, LBP

A four-month study 1 of acute lower back pain (LBP) patients and a pain-free control group found a correlation between persistent LBP and somatosensory changes over time that appeared to increase pain and other types of neurological sensitivity in chronic LBP patients. Because even baseline pain awareness was elevated in the subjects that later developed chronic LBP, the authors of the study suggest further studies that would examine the evident link between heightened pain sensitivity and its possible role in the development of chronic LBP.

initial LBP diagnosis also be evaluated for potential psychological issues. Click To Tweet

They also suggest patients undergoing initial LBP diagnosis also be evaluated for potential psychological issues that might be contributing factors to their pain.

The Study

Quantitative sensory responses (QSR) were collected and analyzed at less than three weeks prior to the onset of an acute LBP episode (baseline), a two-month follow-up, and at four months for 25 LBP patients and a pain-free control group of 48 subjects.  LBP patients were recruited from a variety of treatment facilities, physicians, and practitioners. Excluding criteria included any history of serious spinal injury or back surgery, pregnancy, or any painful condition requiring at least a month of treatment in the past year or one that affected the subject’s ability to function in any way on a regular basis or required the use of long-term pain medications. Demographics including sex, age, race, work status, and body mass index (BMI) were collected from the LBP and pain-free control participants at the beginning of the study.

Collecting Initial and Follow-Up Data

Patients with LBP answered questions about their pain’s onset, duration, intensity, and how well they were able to function while in pain. The participants then answered questions about their levels of depression, anxiety, and scale of stress. Back pain patients also answered questions that would indicate how much they catastrophized their pain and how self-sufficient they were at dealing with their pain, as well as questions designed to measure the sensory and emotional or affective connection to their pain. They were screened by questionnaires to determine possible neuropathic features of their LBP. All participants involved in the study were given the questionnaires to complete at each of their three assessments, and they were then classified into blind groups according to their answers.

Sensory Testing

All patients were tested for their cold-pain threshold (CPT), followed by a test for their heat-pain threshold (HPT), mechanical wind-up ratio (WUR), pressure-pain threshold (PPT), two-point discrimination (TPD), and conditioned pain modulation (CPM). The testing was conducted at the same three body sites on the backs and hands of all patients. The LBP patients’ back testing was conducted at the location of their greatest pain. Thermal pain thresholds were measured using three consecutive measurements. Pain from the stimulus of a single pin-prick, followed by that of a 10-pin prick, was used to measure the WUR of all subjects and then compared using analysis of a numerical calculation. Three measurements of pressure-pain were used to calculate the PPT. A ruler was used to calculate the TPD of all subjects.

A series of 30-second contacts with a thermally-heated device was used to measure heat pain, and a cold foot bath was used to determine the subjects’ sensitivity to cold, as they were asked to withdraw their foot when they were no longer capable of tolerating the cold water. They were then asked to rate their discomfort at 30, 60, and 90 seconds on a pain scale, and their score was given a negative or positive inhibitory response value. Data and statistics were computed and analyzed by the researchers using statistical software.

Results

The data collected in this study showed that the chronic LBP group had a significantly increased pain sensitivity during early and later pressure and mechanical tests and were more cognizant of pain responses at baseline than their pain-free and recovered acute LPB study counterparts. The psychological effects of their pain were also measured higher at the two and four-month follow-up than their recovered LBP counterparts. This could mean that those patients were neurologically and/or psychologically more prone to pain, even prior to the development of their LBP symptoms. The study authors suggest better standardization of a CPM protocol in future studies to take psychological factors of the patients into account and improve the reliability of future test results.

 

KEYWORDS: correlation between persistent LBP and somatosensory changes, link between heightened pain sensitivity and its possible role in the development of chronic LBP. patients undergoing initial LBP diagnosis also be evaluated for potential psychological issues, cold-pain threshold, heat-pain threshold, conditioned pain modulation