Our patient education dynamic spine models helps a low back pain sufferer a better understanding of their sources of pain. Very often, an  accurate diagnosis can be found and the mechanics around the pain triggers can be learned and avoided for a period of time to wind down pain generators.

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 also tells a story about hypermobility very often. For lumbar spinal stenosis, it is also very 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.

Patients Value Collaborative Care

A systematic review of data regarding lower back pain (LBP) patients’ perceived healthcare provider needs found four areas were prominent factors in overall patient satisfaction. These included good communication and shared decision-making, the legitimization of symptoms and information about their cause and treatment, individualized, holistic care with continuity, and greater access to treatment, with lower waiting times and costs.

LBP affects 8 of 10 adults during their lifetime and accounts for approximately $88 billion in U.S. healthcare costs each year. To effectively treat chronic back pain, patients may require a combination of approaches, including psychological, medical, chiropractic, and physical therapists, but they are less likely to seek out or maintain their treatment when they are dissatisfied with their care. The authors of the review study sought to identify how practitioners might best adopt a patient-centric model of care that would align with the perceived needs of most LBP patients.

The systematic scoping review was based on the Arksey and O’Malley framework and mapped key concepts to identify specific evidence types in the available literature. An electronic search of medical data bases included studies published between January 1990 and June 2016. A multidisciplinary team involving a senior academic librarian, clinician researchers, and input from patients was utilized to design the search strategy that identified data from LBP patients with, or without leg pain, but excluding injuries, cancers, inflammatory spinal disorders, and pain caused by infections. The articles chosen were then reviewed by trained epidemiologists, Rheumatologists, Physiotherapists, or PhD Candidates.  Another set of articles was then reviewed independently and in correlation with the first set as to their relevance. Studies included in the review were those of LBP patients 18 years or older that reported on the patients’ perceived practitioner needs, and were conducted in English. The data was then categorized and grouped into similar themes.

Four Areas of Perceived Needs

The data sets indicated four main areas of perceived need when it comes to patient satisfaction with their care giver. These include healthcare providers that exhibit desirable characteristics when it comes to treatment and care; a need for information about the cause and treatment of LBP; aspects of care needs; and potential barriers to satisfactory care.

Type of Care Patients Desire

One of the most important characteristics in a good practitioner to most LBP patients interviewed in the literature was good communication skills. Being able to discuss their discomfort and feel their ideas have been heard is very important to patients, as is clear instructions that do not involve medical ‘jargon.’ Patients want their provider to treat them with encouragement and to individually personalize their communications. (Interestingly, older patients were not as concerned about the communication style.)

Sharing Decisions

Patients in two studies reported their wish to be actively involved in the decision-making and having the medical instructions be more consultative and less prescriptive. They preferred to be listened to and felt frustrated when their condition appeared to be more of a priority than their self.

Empathy, Confidence, Understanding

Patients in several studied reported their desire that care providers be empathetic and non-judgmental, especially when it came to understanding their unique work environments and other potential stressors that might contribute to or exacerbate their LBP.

Skills and Qualifications

Patients in four studies were concerned with their healthcare providers’ technical skills, reputation, and qualifications and reported feeling more comfortable with confident, highly-trained practitioners.

The Need for Information

Repeatedly, patients reported the need for a clear diagnosis that would identify the cause of their LBP.  Patients who were unable to get a clear understanding of why they were experiencing LBP from their healthcare provider reported anger and frustration when their expectations went unfulfilled.

Better Understanding of Treatment Techniques

Patients in 15 studies were concerned that their practitioners had not adequately explained how to care for their back and wished they had received more reassurance and direction about activities to avoid that might make their pain worse. These patients reported the need for information they could clearly understand and suggested that the use of diagrams or visual aids might help them to better visualize their condition and remedies. In fact, being unable to understand their practitioner’s explanation of their LBP was one of the most frequent complaints in these reviews.

Aspects of Better Overall Care

When it comes to practitioner approaches to care, five studies indicated that patients prefer holistic, supportive, personal, and encouraging approaches to care. Rather than focusing only on the source of discomfort, patients reported feeling more empowered when their practitioners would place less emphasis on the disease and more on their person, as a whole. They placed tremendous value on encouraging words and emotional support.

Assessment, Continuity of Care, Time, and Effort

Patients in six studies wished to have a more thorough physical assessment from their care provider. A physical exam, oral history, and clear discussion of the problem were important to them, as was a continuity in their care.

Legitimization

Many patients expressed feeling stigmatized by family, friends, employers, and the community due to their pain. They sought answers and legitimacy from their healthcare providers. They also wished for better collaboration and understanding between their primary care provider and their LBP specialist.

Care Complaints

The rising cost of healthcare was reported as a common barrier to receiving effective treatment for LBP in many patients. The expense of exercise programs was also prohibitive when it came to being proactive about their condition. Finding quality care in a timely way, and having to wait for treatment were other difficulties reported by patients, as were weather concerns, a lack of social support, commitments to the job and family, and not enough personal time to address LBP treatment needs.

Conclusion

Patients with LBP believe they would benefit from providers that have good communication skills and listen well. They wish to be treated with empathy, respect and understanding, and they want their condition to be legitimized by their practitioner and explained in a way that makes sense to them. The use of diagrams or other visual aids are preferred over lengthy verbal explanations alone. They want to be treated promptly and in a collaborative way that involves them in the decision-making process about therapeutic methods. They are frustrated when no diagnosis is offered or when practitioners do not offer an understandable explanation of their condition. They want their practitioners to be qualified and confident and to work in a collaborative manner with their other healthcare providers to address their LBP. They wish to be treated in a holistic, personal way and to not feel stigmatized or judged because of their pain. Studies have demonstrated that patients who are satisfied with their healthcare providers have better overall treatment outcomes, and this review defines key ways that practitioners may become more effective in treating their LBP patients successfully.

KEYWORDS: Patients Value Collaborative Care, Information, Validation, and Good Communication Skills, patient-centric model of care, important characteristics in a good practitioner, key ways that practitioners may become more effective in treating their LBP patients

fissures in the annulus fibrosis, model

A recent study found that fissures in the annulus fibrosis can create a biomechanical and chemical environment that is conducive to the ingrowth and formation of blood vessels and nerves, which may contribute to back pain in patients with disc degeneration—particularly of the lumbar segments. An examination and analysis of cadaveric discs used safranin staining to examine the proteoglycan loss and measure the water concentration in the 25 surgically-removed discs and compared the data from intact and disrupted annular region to quantify the extent to which a reduction in compressive stress might allow blood vessels to grow and thrive within annular fissures. Results indicated 54 percent less proteoglycan content in the fissured annulus than in the intact samples, with only a slight reduction in water content.

 

Examining the Link between Fissures and Nerve Growth

Persistent lower back pain—particularly of the lumbar intervertebral discs—often presents with severe symptoms that can lead to long-term disability and loss of earnings. Chronic pain may be the result of posterior annulus fibrosis and the stimulation of the sinuvertebral nerve. Previous studies have demonstrated that the injection of neurotoxins into the compromised discs can curtail this nerve pain for up to two years. While studies have shown that disc degeneration increases the risk of lower back pain, much of the focus of previous research has been on the association between structural defects, such as endplate defects and a loss of annular height, rather than biochemical changes.

Radial fissures in the annulus, with, or without disc herniation, are considered a strong indicator of LBP. The subsequent in-growth of blood vessels and nerves into these fissures can sensitize the disc area and cause inflammation, which may cause pain in some—but not all—with disc degeneration. Researchers involved in this study supposed a possible causal link between annulus fissures and nerve ingrowth.

lumbar models

A professional lumbar spine model with a demonstration of in-growth of nerves and blood vessels from fissures in the annulus fibrosis.

Three Comparative Studies of Thoracolumbar Spine Segments

Three consecutive studies of surgically-removed cadaveric thoracolumbar spine segments from subjects who had experienced no spinal injury or extensive bed rest prior to death were compared with 25 samples taken from 18 cadavers of patients who had suffered from LBP, disc herniation, scoliosis, or spondylolisthesis prior to being deceased. The first study used die to identify annular fissures in 35 discs and radiographs to assess disc degeneration and height. Stress profiles were then performed on the segments in flexion and extension postures and then repeated following two hours of “creep” loading to simulate the rate of disc dehydration that might occur after a day’s activity. The discs were then dissected and photographed, then graded to determine the scale of degeneration.

The second study measured focal loss of proteoglycans from annular fissures in 25 samples using a custom-made software program, and a third study measured the loss of sulphated glycosamineoglycans in the fissured annulus.

 

Results—Higher Levels of Stress Reduction and Proteoglycan Loss in DD Samples

The analysis of the three studies indicated a compressive stress reduction of between 36 and 46 percent within the annulus fissures. The level was higher in degenerated discs. The fissured annulus regions had between 36 and 54 percent less proteoglycans than intact areas of the same discs, though the water content was only slightly reduced.

Pressure Reduction Contributes to Loss of Proteoglycans and Nerve Growth

The reduction of pressure inside the annulus fissures creates a biochemical environment that is conducive to the loss of focal proteoglycans. This allows for the in-growth of blood vessels and nerves within the fissured areas. These findings suggest that the injections of therapeutic neurotoxic dyes into the affected fissures could disable the in-grown nerves and help alleviate LBP in some patients.

KEYWORDS: Link Between Annular Fissures and In-growth of Blood Vessels and Nerves; fissures in the annulus fibrosis can create a biomechanical and chemical environment that is conducive to the ingrowth and formation of blood vessels and nerves; reduction in compressive stress might allow blood vessels to grow and thrive within annular fissures; possible causal link between annulus fissures and nerve ingrowth; reduction of pressure inside the annulus fissures creates a biochemical environment that is conducive to the loss of focal proteoglycans; posterior annulus fibrosis; persistent lower back pain

MDT, mechanical diagnosis, spine, low back pain

A study of 45 musculoskeletal disorder patients in Japan sought to determine the extent to which mechanical diagnosis and therapy (MDT) could help patients in the self-management and self-monitoring of their pain symptoms. The results of the study indicate that MDT is effective in helping patients to understand, monitor, and manage their own pain and symptoms of musculoskeletal disorders.

 

The Study Subjects Received MDT Twice a Week for One Month

The subjects involved in the study included 45 outpatients from an orthopedic clinic in Japan. Each subject suffered from a musculoskeletal disorder that had been previously diagnosed by an orthopedic surgeon. Only patients without medical contraindications to MDT techniques could participate. Those with fractures, infections, or severe osteoporosis were excluded from the study, as were patients with diagnosed cognitive or neurological disorders or who were undergoing other forms of medical intervention. Each participant was involved in outpatient physiotherapy at a local orthopedic clinic and was over the age of 20 years-old.

Establishing a Baseline and Follow-Up to Track Progress

Each subject in the study received MDT from a qualified MDT physical therapist for 20 to 40 minutes, up to twice a week. The intervention included physical evaluations, a discussion of the patient’s medical history, and MDT-classified managements. Follow-up visits addressed any problems with the therapy, and appropriate adjustments of the techniques were made. The MDT visits were conducted for approximately one month, and a baseline questionnaire was completed by the subjects at the beginning of treatment and in a follow-up consultation, one month after the end of their treatment period. The Health Education Impact Questionnaire and the Self-monitoring and Insight and Skill and Technique Acquisition scores rated the subjects’ answers to compare the proportion of subjects who demonstrated a positive “reliable change” in self-monitoring, insight about their conditions, and the ability to self-manage their symptoms after having undergone MDT.

 

Improvement in Self-Monitoring and Self-Management Skills Post-MDT

The results of the study indicated a significant improvement in the subjects’ abilities to self-monitor, have insight into, and manage their own musculoskeletal disorders after a series of MDT treatments over the course of one month. In addition to gaining valuable insight into and ways to manage their own conditions, more than 71 percent of the study’s participants experienced meaningful improvement in their physical condition after an average of 3.8 MDT sessions. The results of the study compare favorably to previous studies of passive therapeutic forms, where patients receive therapeutic manipulations by their practitioners, without being educated or counseled about the condition being treated. The results of this study indicate that MDT is not only an effective means of treatment for patients with musculoskeletal disorders, but it empowers patients in learning to self-manage and monitor their own symptoms and dysfunction.

 

KEYWORDS: Mechanical Diagnosis and Therapy Helps Patients Self-Manage, mechanical diagnosis and therapy (MDT) could help patients in the self-management and self-monitoring of their pain symptoms, significant improvement in the subjects’ abilities to self-monitor, have insight into, and manage their own musculoskeletal disorders after a series of MDT treatments, effective means of treatment for patients with musculoskeletal disorders, pain and symptoms of musculoskeletal disorders

 

 

 

Spine Patient Education, Patient Centered, Education

A review of published research on the implications of patient Healthcare Literacy (HL) in patients with lower back pain (LBP) found that evidence-based studies were minimal and that further research could be beneficial in determining future treatment costs and outcomes. The ability of chronic pain sufferers to access, understand, and apply health information defines HL and can be helpful to practitioners treating LBP patients. The reviewers sought to understand how HL affects LBP patient treatment outcomes.

The Review

Researchers performed a data search using lower back pain terms in PubMed, Web of Science, PsychInfo, and CINAHL but found only three studies that directly addressed the issue of HL in patients with LBP. The search parameters were limited to studies conducted between the years of 2000-2017, published in English, and formatted as an article or review. Of the initial 1037 articles that met the initial criteria, only three were empirical research studies related to HL in patients with LBP.

Due to the lack of adequate data, a full, systematic review of the subject in question was not possible. Still, the authors of the review noted that, based on the limited data, patients with chronic LBP may have a more negative attitude towards their health and a more difficult time managing their health than patients without chronic back pain. Since self-health management is a central tenet of HL, this finding could indicate that better HL could assist in determining a better, more satisfying attitude and outcome for LBP patients.

One reviewed study looked at the effect of HL on patient empowerment and found that patients who had lower levels of HL were the most dependent on practitioners and least self-empowered when it came to managing their LBP. This was true of patients who used medication for chronic conditions and those who were treated without medication. This suggests that better HL in LBP patients can empower patients and lead to a more satisfying treatment outcome.

Conclusion

Though there are limited published studies about how HL affects LBP patient treatment outcomes, the available data suggests that patients who are better informed about their health are more likely to feel empowered and have a more satisfying treatment outcome. Patients who were being treated with or without medication were more likely to report better self-sufficiency and a sense of empowerment when they were more familiar with their condition and understood the health treatment options available to them. Further evidence-based research should be conducted to fully understand the relationship between improved HL and patient treatment experience and outcomes.

KEYWORDS: the effect of health literacy on LBP treatment outcomes. the implications of patient healthcare literacy (HL) in patients with lower back pain (LBP), how HL affects LBP patient treatment outcomes, self-health management, satisfying treatment outcome.

 

lordosis. degenrative joint disease

A radiographic study of the effect of hypo- and hyper-lordosis in the lumbar spine concluded that a lordosis angle of between 65-68 degrees can be considered ‘optimal’ in the reduction of degenerative joint disease (DJD) of the lumbar spine. The results of the study should be helpful in the treatment of spinal pain and rehabilitation.

The Study

Archival standing radiograph images from a single clinic of 301 adult female and male chiropractic patients aged 4 to 79 were analyzed in a blind study using RadiAnt DICOM viewer software. All the images were scored for the severity of DJD by one experienced clinical investigator to ensure consistency using the Kellgren-Lawrence (K-L) criteria—categorizing the results into three groups: 1 and below (no DJD); 2 (mild DJD); 3 (moderate DJD); and 4 (severe DJD). The Cobb angle (CA) was used to measure lumbar lordosis.

Results

In examination of the data, researchers found significant quadratic correlations between the Azari-LeGrande Degenerative Index (ALDI) and the CA values in nearly all study subjects. (No correlation was found in younger men). The correlations were more pronounced in all five spinal motion segments in women under and over the age of 40 than in their male age-counterparts. The findings indicate that too little or too great lordosis can contribute to lumbar spinal degeneration, particularly in women.

Conclusion

Though the effects of lumbar lordosis angles on lower DJD was modest—between 17 and 18 percent in women, and roughly 13 percent in older men—the information is significant because, unlike other contributing factors to DJD, such as genetics, lumbar lordosis can be modified to the optimal degree of between 65 and 68 degrees to reduce the risk of DJD (73 degrees in older men). An increased incidence of DJD was found whenever subjects deviated outside of these optimal weight-bearing parameters, either through hypo— or hyper-lordosis. This information may help prevent, treat, or rehabilitate patients with lower back pain.

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.

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.