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Explaining back pain with a spine model – Patient-centered Education

connecting the patient to the anatomy of back pain

Connecting with patients is the future of healthcare.  With low back pain and neck pain as the leading cause of disability and lost work days on this planet, getting to the roots of helping people with these conditions is imperative. These origins are mostly biomechanical in nature. But how a practitioner connects the curious patient with a better understanding of their anatomy can be a challenge.

Much research has talked about how important education is important for better outcomes of low back and neck pain. But how does one execute and teach a patient about their biomechanics? The spine is a complex structure and to help patients understand which movements are good and bad for their condition can be tough.

Patient-centred care is leading the way in healthcare. Engaging with patients in a way they can understand their back condition is helpful. MRI, CT and X-ray findings can be quite intimidating and confusing for the patient, but here at Dynamic Disc Designs Corp., we have made it a lot easier for the professional.

Explaining the intricacies of the annular fibres, for example, and what discogenic back pain means is a lot easier with our dynamic disc model that includes a clear see-through lens. The Professional LxH spine model includes many of the anatomical features that have never been shown in a lumbar model before. Created with the physician in mind who want to communicate effectively the biomechanical origins of back pain, now, with a two-part intervertebral disc that includes an elastomeric annulus fibrosus and nucleus pulposus certain postural changes can be taught to the patient in a dynamic and interactive way.

Below are a few videos that other professionals have created using these detailed spine models.

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Degenerative disc and impact on flexibility

Degenerative disc, flexibility, model

Aging and Degenerative Disc Changes of the IVD’s Impact on Spinal Flexibility

A publication reviewed several studies involving the biomechanics of the intervertebral discs (IVD) with macroscopic changes associated with degenerative disc disease with the aim of finding out how spinal flexibility was affected by dehydration, tears, fissures, osteophytes, and the inevitable collapse of the intervertebral space. The studies under review used cadavers and did not contribute to information about how degenerative disc disease may cause symptomatic back pain. However, the review can contribute to the understanding of disc degeneration disease and its progression, as well as offer insight into what surgical treatments could be beneficial in improving flexibility and spinal functionality in patients.

 

About Disc Degeneration

Degeneration of the IVD causes mechanical and biochemical changes in the disc and its surrounding structures. The space between the discs can collapse, and proteoglycan and water content can be greatly reduced, contributing to the damage of endplates and osteophytosis. The entire motion segment of the IVD is affected macroscopically and biomechanically by the degenerative process, and this can cause a loss of functionality and mobility that contributes to further progression of disc disease in the spine.

 

How the IVD Works

A properly functioning IVD evenly distributes weight-bearing loads across the spinal segments and allows the spine to suffer intense compressive loads without collapsing or losing its range of motion. Inside each IVD is a nucleus pulposus (NP)—a gelatinous substance with proteoglycans, elastin fibers, and Type II collagen. The NP is enclosed by the annulus fibrosis (AP)—a lamellar structure made up of Type I collagen fibers. The angle of the collagen fibers in the AP (30 degrees), alternates with that of the adjacent lamellae, which contain gel rich in proteoglycan and may be surrounded by connective bundles of collagen. Endplates connect the IVD to the surrounding vertebrae. The NP transitions to the AF in a transitional zone that is indicated by diverse types of tissue, rather than a distinct border. Negatively charged proteoglycans are balanced by positive cations within interstitial fluids, contributing to osmotic pressurization in response to its environment. Because of this, the IVD absorbs copious amounts of water, which helps the nucleus to adjust in reaction to high compressive forces.

The NP is bookended by the endplates and the AF, which allows the resulting hydrostatic pressure to balance any swelling pressure during active loading and at rest so that the disc will not bulge or collapse under compression. The structure of the lamellae in the AF is tension-loaded and assists with bending and shear. Vicious fluids flow through the permeable endplates, which help evenly distribute pressure within the nucleus or annular tension. The AF’s collagen bundles create an elasticity that absorbs compressive loads. The exchange of fluids within the IVD creates a balance between tension and flexibility that is integral to the function of the spinal unit.

Degenerative disc, flexibility, model

Degenerative disc model

 

Effects of Degenerative Disease and Aging on the IVD

 

  • Cellular/matrix alterations—Aging and degenerating IVD exhibit early changes in the endplates which in turn cause changes to the nucleus and annulus. A progressive reduction of cells begins in childhood and continues throughout a lifetime, decreasing and fragmenting the proteoglycan content in the nucleus and surrounding areas. In time, this leads to a reduction of the disc’s ability to repair itself. As the cells lose their ability to synthesize, there is further loss of proteoglycan content. Changes at the cellular level create biochemical alterations throughout the entire matrix. In time, the NP loses the ability to attract and retain adequate water and an increase in fibrous tissue takes place. A similar –though lesser—loss of water and collagen in the AF leads to reduced swelling pressure and contributes to the degenerative state.

 

  • Structural changes—Structural failures including tears and clefts follow (or are perhaps caused by) alterations in the NP and AF. Considered a symptom of degenerative disc disease, these changes are related to, but distinct from, the simple aging process. Endplate separations, radial tears, and rim lesions increase in the aging population, and approximately 50 percent of the cadaver specimens in one study showed evidence of IVD degeneration in subjects over 30. Calcification of the cartilaginous endplates cause biomechanical changes that reduce the flexibility of the endplates and make the IVD vulnerable to fracture, reduced water intake, and a lower solute exchange rate between the disc and vertebrae. Collapse of the intervertebral space occurs often in a degenerated IVD, though disc height reduction is not a common result of simple aging. In addition to a reduction in disc height, osteophytes may form around the affected vertebrae. Studies have suggested that these osteophytes may be the body’s attempt at providing supplemental stabilization in the degenerated spine segment.

 

  • Pain—A common cause of back pain, degenerative disc disease undermines the spine’s structural integrity and creates tension and spasms in the surrounding muscular structure. In severe cases of disc degeneration, disc prolapse, and collapse, radial tears that cause a leakage of collagen and fluids can increase the frequency and amount of back pain. Another common source of back pain is lesions or uneven loading in the endplates. When there is a reduction in disc height, nerve roots located in between the vertebrae may be squeezed or pinched into the space near the capsule joint, causing radicular pain. This type of pain can intensify with activity or prolonged sitting or standing. Facet join arthritis can cause a decrease in cartilage between the apophyseal or zygapophysial joints and may contribute to back pain.

 

  • Changes in Flexibility—When the IVD are in a degenerative state, the entire motion segment(s) can become more rigid and less flexible. Researchers have theorized that the spine loses its flexibility over time, triggered by an initial dysfunction and followed by instability, which leads to an attempt at stabilization. Thus, disc degeneration is a progressive event which is the result of the spine’s attempt to handle physiological loads. However, there is no evidence that shows a definitive connection between reduced range-of-motion therapies (such as surgical implants that inhibit the range-of-motion) and an improvement of disc degeneration.

 

 

Conclusions

Research into the biomechanics of the IVD systems clarifies some aspects of degenerative disc disease but offers little insight into the specific causes of lower back pain. Degenerative changes of the IVD systems cause changes to the functionality of the spine, with some inconclusive evidence of a loss of flexibility and increasing stiffening over time.  Further studies of the effects of disc degeneration and a possible link to spinal instability are recommended.

 

 

 

 

 

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Spine Patient Education to Improve Compliance

spine patient education, patient education, spine, models, lumbar, cervical

Improving compliance through spine patient education.

Communication is very important. We all know that. In any relationship, communication seems to be the key element in making sure a common goal is delivered. This is especially important when doctors connect with patients about spinal problems. Spine patient education is imperative in a patient centered model. It also seems helpful in reducing fear avoidance behaviours. 1

Spine Patient Education, Patient Centered, Education

Patient Centered

Doctor-patient communication is critical when relaying information about what the spinal diagnosis is.  Effective communication is also important when relaying the best options for treatment. Doctors and therapists will use their skills to connect with patients. Making reference to the experience they have had with the condition with some offering of favourable outcomes.

What is important is that the patient feels ‘listened to’ and that the doctor can relate their symptoms with the spinal movements that seem to aggravate or miminize the problem.

For example, if a patient exhibits pain bending forward, it can be very helpful to have a dynamic spine model that bulges under flexion load. If a patient can physically see and understand that bending forward can compress the discs (or squeeze on the nerves), this can be very effective in communicating the disc is the likely culprit in the case of sciatica.

spine, education, patient, doctor

Bending forward can cause pain.

Conversely, if a patient demonstrates pain while bending backwards, a dynamic model can show how the facets rub together into extension.

A doctor unequipped for spine patient education is like a mechanic without its tools. Patients are usually very curious about the internal workings of their own bodies. When a doctor or therapist can clearly demonstrate where and why it hurts, often they will be a patient for life.

Spinal pain frequently relates to the spacing of the vertebrae, or lack thereof. Dynamic disc height loss, for example, can now be shown with a model both a doctor and patient can hold and manipulate.

 

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Disc hydration – Unloading / Loading during the act of sitting.

posture, disc hydration

Disc hydration fluctuates naturally and diurnally. That is, over the course of the day/night cycle we (as humans) lose up to 20% of the water out of our spinal discs. 1 The intervertebral discs are sensitive to load and because of their visceo-elastic make-up they will deform under load. Most notable changes seem to occur under sustained or static loads. 2 3 4 5 6 Therefore, it is important to offload the spine, especially when one sits for an extended period of time.

Recently, a study published in the Lancet 7 looked at the 188 countries and followed them between 1990-2013 and revealed that the number one reason for disability was back pain. Yes, back pain! Not heart disease. Could we extract from this that it is perhaps the introduction of computers and more time sitting? There could be other factors but there little doubt that the human population is moving less and fixated in front of a computer….just like myself at the moment.

Lumbar Disc Changes Associated with Prolonged Sitting

Take a Break and Off-load

This 8 off-loading strategy is thought to relieve the compressive forces of the spine to allow it to refill slightly….interupting sustained compressive loads, which we know is harmful.

Interestingly, a paper published in the Journal of Human Evolution in 2000 9 looked at knuckle walkers and ‘compared to humans, all ape samples show dramatically less spinal disease, especially when considerng vertebral body involvement’ . The authors concluded that this significant difference was likely due to the gait mechanism. And obviously, they use their upper extremities to off-load their spines during the course of their gait cycle.

Therefore, it looks like if you behave more like an ape and use your upper extremities, your spine will benefit. Teach your patients to minimize compressive loads by integrating off-loading strategies in their day to decrease the creep and compressive responses in the spine…..keeping the discs hydrated to prevent disc height loss.

 

 

  1.  Urban,J.P., McMullin,J.F., 1988. Swelling pressure of the lumbar intervertebral discs: influence of age,spinal level, composition,and degeneration. Spine 13, 179–187.
  2.  Adams, M.A., Hutton,W.C., 1983. The effect of posture ont he fluid content of lumbar intervertebral discs. Spine (Philadelphia1976) 8, 665–671.
  3.  Kazarian, L.E., 1975. Creep characteristics of the human spinal column. Orthop. Clin. N. Am. 6, 3–18.
  4.  Keller,T.S., Spengler,D.M., Hansson,T.H. ,1987. Mechanical behavior of the human lumbar spine. Creep analysis during static compressive loading. J.Orthop.Res. 5, 467–478.
  5.  Koeller,W., Funke,F., Hartmann,F., 1984a. Biomechanical behavior of human intervertebral discs subjected to long lasting axial loading. Biorheology 21, 675–686.
  6.  Markolf, K.L.,1972. Deformation of the thoracolumbar intervertebral joints in response to external loads: a biomechanical study using autopsy material.J.Bone Jt. Surg.Am. 54,511–533.
  7. Lancet. 2015 Aug 22; 386(9995): 743–800. 
  8.  Fryer JC1, Quon JA, Smith FW. Magnetic resonance imaging and stadiometric assessment of the lumbar discs after sitting and chair-care decompression exercise: a pilot study. Spine J. 2010 Apr;10(4):297-305.
  9. Jurmain, R Degenerative joint disease in African great apes: an evolutionary perspective. Journal of Human Evolution (2000) 39, 185–203
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Herniated Lumbar Disk – Review and Modeling

Published May 5th, 2o16 in the New England Journal of Medicine 1 is a review paper on herniated lumbar disk. Dr. Deyo opens the manuscript with a case presentation of  41-yr-old man. He develops progressive increasing lower back and leg pain from doing yard work. This involved pulling out large bushes. With a positive straight leg raise at 40 degrees, the most probable diagnosis is herniated lumbar disk.

About two-thirds of adults experience back pain some time in their life. Sciatica is often used to describe the result of a disk herniation as the sciatic nerve is the downstream nerve effected. A more appropriate term is lumbar radiculopathy. This is due to the proximal origin of the issue and the sensory and motor findings that presents along the sciatic nerve distribution.

Herniated Lumbar Disk

To help with patient education of a herniated lumbar disk, accurate modeling of the nucleus pulposus and annulus fibrosus is developed by Dynamic Disc Designs Corp. Now, a patient can understand the geometry and forces involved to create a disk herniation and may think twice about repeating the activity that causes the problem initially. Accurate patient education of herniated lumbar disk to reveal the mechanism of the injury is very helpful in the management of the condition. This is both in onset and rehabilitation as load with flexion causes the nucleus to push posteriorly.

herniated lumbar disk. lumbar, disk

Herniated lumbar intervertebral disk – important for patients to see how this happened

It is important for patients to understand what caused their symptoms as to change future behaviours. It is known that a herniated lumbar disk is caused by hydraulic compression of overloading the spine into a flexion moment as the posterior annulus is compromised causing radial fissures 2. And now, this never before seen event can be shown with a knowledge transfer to the patient in an easily understandable dynamic model to help improve outcomes.

 

  1. Richard A. Deyo, M.D., M.P.H., and Sohail K. Mirza, M.D., M.P.H. Herniated Lumbar Intervertebral Disk. The New England Journal of Medicine. May 5, 2016 1763-72
  2.  Samuel P. Veres, BEng, Peter A. Robertson, MD, Neil D. Broom, PhD The Morphology of Acute Disc Herniation. A Clinically Relevant Model Defining the Role of Flexion. SPINE 2009 Volume 34, Number 21, pp 2288–2296
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Intervertebral Disc – Stress Shielded by Facets – Dynamic Education

intervertebral disc, model, facets, stress shielded, dynamic, spine, patient education

The intervertebral disc annulus can be shielded by the facets. This is important for the patient to understand to help motivate exercise strategies to relieve their back pain.

Researchers have seen in studies that bending the spine backwards (extension) helps resist compression of the spine discs 1 especially when the disc has already lost some height. 2 3 When crafting exercises, and if the facets are not considered a pain generator, bending backwards, especially in the unloaded position, can be an effective strategy to help heal discogenic pain.

Several mechanisms have been proposed on why extension-based exercises aid in the reduction of back pain. One likely path is the direction the nucleus moves as the spine is bent backwards. It has been shown in several studies that the nucleus moves away from the posterior annulus in spinal extension 4 5 6 7 8 9

Dynamic Disc Designs Corp. is the only spine modeling company that demonstrates these findings in a dynamic spine education platform. The Professional and Academic LxH models allows clear visualization of the nucleus as the model moves through 6 degrees of freedom. Patient education that motivates and drives compliance through knowledge to improve clinic outcomes for spine.

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Cervical Disc Anatomy Model Helps Learn About Injuries

cervical model, anatomy

Cervical Disc Anatomy Model Helps One Learn About Neck Injuries

If you’ve ever been a student of anatomy, there’s a huge chance that you spent many a night staring blankly at the pages of your text book and the photographs and drawings inside. The human body is a complicated system as millions of mechanisms are occurring at once and to understand it – even if you’re really into the science surrounding it – can be quite difficult. There are so many bones, tissues, tendons, organs, nerves, etc. and each one has its place and its purpose.
Anatomy students – as well as students of particular medical disciplines – spend a lot of time studying artists’ rendering of the parts underneath our skin. We try to picture how they’d really look if we could see them or how they’d feel if we could touch them. If you have been a student of the spine – be it a chiropractor, a spine surgeon, or perhaps a physiotherapist – you’ve certainly spent a good amount of time with those drawings, trying to understand how the parts of the spine move and what happens when things go wrong.
But perhaps those who teach spinal anatomy, chiropractic, or any number of other anatomy-related courses, could use something that would enhance the teachings of it. Rather than offering high-quality drawings of the spine to students for study, they should be prepared to offer their students something much better – 3D dynamic models like the cervical disc anatomy model and others offered by Dynamic Disc Designs.

cervical, disc, anatomy, model
Good spinal health for patients starts with good educational tools for future doctors and other caretakers of the spine. A classroom equipped with a cervical disc anatomy model, or any of the more than two dozen models offered by Dr. Jerome Fryer of Dynamic Disc Designs (ddd), is a classroom where true hands-on and  takes place.
Designed and originally rafted by a highly-experienced chiropractor, these lumbar and cervical models take learning out of the text books and put it in the hands of students, where their fingers can manipulate the discs in a dynamic way. With these models, future spine surgeons, for example, understand what they need to do to make their patients better in a patient education platform they can trust. Up-and-coming chiropractors better understand the specifics of manipulation therapy and the value of an adjustment to the spine. And physiotherapists can picture how their stretches and exercises will help their clients achieve better spine health.
“Dynamic Disc Designs spinal segmental models are unique in many ways and represent a new standard in quality and anatomical detail far superior to any of their predecessors. Their value far exceeds their cost,” explains Ara Deukmedjian MD CEO of the Deuk Spine Institute.
“The ddd models have helped me as an instructor in a DPT program show a more realistic anatomical representation of the human spine,” adds physical therapy instructor Stephen Elam. “This helps the students have a more accurate image of the spine in their head and allows them to have a stronger anatomy foundation.”

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Dynamic Disc Design cervical disc anatomy models and other carefully-crafted spine models are available individually or as a package. Choose one or several to improve how you educate the spine care professionals of tomorrow.