Patient engagement is at the core of a patient-centered approach to spine care. Spine professionals engage with their patients with different tools. We all use language but to enhance it, very often a physical model can support the words chosen to educate.

In the past, models have been static, so it made it very difficult to connect patient’s back and neck pain to the specific movements that cause the pain. At Dynamic Disc Designs, we have developed models to help the practitioner engage in a mechanical way through a better rendering of a motion segment. We have created a dynamic disc with the ability of the models to bulge or herniate. We have integrated a dynamic nucleus pulposus and a stiffer annulus fibrosus as well as added features of the ligamentum flavum to show how the facets are inter-related to one another.

Explore how a dynamic model can enhance the language one uses in a clinical setting of a musculoskeletal practice.

 

Dr. Jerome Fryer (CEO of Dynamic Disc Designs Corp):

“Hello everyone. Dr. Jerome Fryer here of Dynamic Disc Designs. I just want to reach out to those customers that have one of my models. There’s been a lot of talk lately on social media regarding how models can be scary. I don’t know how they’re scary. Models are not scary. It really depends on the user and these models are not intended to scare anybody. It’s to teach them their own anatomy, so they can improve their posture and biomechanics to relieve their symptoms. It’s a team player. It’s like a car. You can go out there ram into people or you can drive defensively and respectfully. Anyway, so one thing that’s important when you’re using the model is to relay realistic biomechanics  and use the model in a way that simulates real-time and load.

You want to use it in a way that actually represents the actual tissue. You can talk about all sorts of things, but you can talk about disc height changes as the disc over the course of the day loses a percentage of its height. You can talk about normal loading patterns of the disc as it relates the associated nerves. But, what I would encourage is just to use real-time forces. For example if someone goes to sit down, they change their lumbar angle and they compress their disc. When they sit for a period of time, the disc actually loses further height. You want to show the subtle endplate angle changes as it relates to the facet joint for example, or in the suspected case of disc herniation, you can actually create a disc herniation.

Single-Level Disc Herniation

Model of Single-Level Disc Herniation.

One example is the changing fluid expression over the course of the day. This is an important little graph to help patients understand how first thing in the morning you’ll actually lose their height very quickly in the disc height, so the facets will actually approximate with the changing intradiscal pressure, and then over the course of the day the disc height will slowly reduce. Some people talk about around 4:00 or 5:00 in the evening as the day progresses, my symptoms become pronounced. Then also with first lie down too. You can see there’s a quick change in disc height. Anyways, I just wanted to share with you that it’s how you use the model and you want to use it in ways that are realistic with regards to movement.”

 

 

 

A new study 1 sought to create an etiology-based system of classification by identifying and characterizing typical endplate irregularities and found that tidemark avulsions were a predominant pathology in the cadaveric spine sample images. This represents a previously unidentified observation and, along with the histologic classification system developed in the study, should assist practitioners in organizing their patients into categories that will help to diagnose, research, and treat their spine symptoms.

 

The Study

Researchers used magnetic resonance imaging (MRI) to analyze and categorize 15 donated human cadaveric spines from 11 males and four females between the ages of 49 to 67 years old. Each of the spine samples showed evidence of moderate to severe disc degeneration. Motion segments were excluded if they appeared with imaging to have experienced pre-mortem surgery, deformity, or fracture. No medical history about the donors was obtained.

Histological Observation

Spinal segments were extracted using a band saw, and their various features were stained with different colors for observation. Each of the sections were imaged with polarized lights under a microscope, and two raters developed a classification system to identify and record various focal tissue-scale endplate irregularities and their anatomical location.

Researchers noticed a novel histological phenomenon wherein there appeared to be a separation of the annulus from the vertebra at the tidemark (the insertion point of outer annular fibers into the calcified layer of cartilage). They immune-stained the “tidemark avulsions” to search for the 9.5 neuronal marker protein gene using a polymer detection system. Each of the slides was then analyzed to identify the presence or absence of nerves in the bone nearest the endplate irregularity.

endplate irregulariities, models

Models to help explain back pain as it relates to endplate irregularities.

MRI Analysis

Each spine was studied via MRI to identify the presence of absence of tidemark avulsions, and their location was noted. Two orthopedic specialist clinicians were used to assess the findings. These researchers—neither of whom was previously used as a rater— were blinded to the histologic findings.

Findings

The endplate irregularities were grouped into three categories based upon their features and location. They were then subcategorized to further classify their pathologies.

The categories and subcategories identified were:

  • Avulsions: There was a separation of the tissue at the place where the disc joined the vertebra. Two types of avulsions were observed—tidemark (separation occurring at the tidemark location, where outer annulus fibers join the layer of calcified cartilage, and CEP-bone avulsion—occurring where the bone meets the cartilage endplate (CEP).
  • Nodes: Traumatic nodes occurred when there was a herniation of the nuclear materials reaching through the endplate. When abnormal fibrocartilage ingrowth or bony erosions were found, the were classified as Erosive.
  • Rim degeneration: This classification was reserved for samples that showed loss of organization in the annular fiber, bone marrow alterations, or degradation of the bone-marrow interface.

Endplate Irregularity Observations

The most common irregularities noted were rim degeneration (50 %) and avulsions (35%). Nodes were less common (15%) and found mostly in the thoracic spine, where the avulsions and rim degenerations were found in the lumbar spine samples. Eighty-seven percent of the noted avulsions were found in the anterior discs.

Though linear regression showed little association between endplate irregularities and age, the largest number of tidemark avulsions (90%) were found in the oldest spine samples. Interestingly, the annular fibers in the tidemark avulsions appeared to change their direction after crossing the tidemark. Of the 35 discs that showed tidemark avulsions, 14 of them contained multiple avulsions. Marrow changes and increased innervation was noted along vertebral bones beside endplate irregularities. An increase of nerve density was observed even in bones adjacent to very small tidemark avulsions.

Conclusion

The ability to identify tidemark avulsions on MRI may help practitioners identify and treat disc-vertebra injuries in a targeted way. High density images in the study showed that fluid can collect around avulsion irregularities, potentially creating gas in the extra-cellular spaces surrounding thee separation. High-intensity regions in MRI may indicate disc delamination or potentially painful lesions.  It is possible that tidemark avulsions may create anterior widening and create a scenario wherein the disc may detach from the vertebra. Overall, the findings of this study should contribute to a beneficial system of classification, allowing clinicians to more effectively diagnose and treat their lower back pain patients.

KEYWORDS: endplate irregularities, tidemark avulsions, endplate pathologies, histologic classification system, separation of the annulus from the vertebra at the tidemark, CEP-bone avulsion, traumatic nodes, rim degeneration

 

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

A cross-sectional study 1of the multifidus muscles (MM) and erector spinae muscles of 68 women and 42 men found significantly higher levels of muscles in subjects without disc herniation than in the disc herniation group, indicating that chronic pressure on the root of the spinal nerve may cause degeneration and atrophy of the MM and erector spinae muscles groups.

 

Single-Level Disc Herniation

Model of Single-Level Disc Herniation.

 

The Study

110 LBP patients with an average age of 40 were analyzed and divided into two groups—those with single-level disc degeneration, and those without disc degeneration. Subjects with multilevel degeneration were excluded, as were those with deformities of the spine or a history of spinal surgeries. Both groups were radiographed via MRI at the lumbar levels, and the imaging results were compared to examine the paravertebral muscles, disc heights, and perpendicular distances between the laminae and MM. Statistical analysis using software compared the variables using the Kolmogorov-Smirnov test to investigate data distribution.

Results

The LBP patients without lumbar disc herniation had clinically-significant greater MM and erector spinae muscles than those with radiographically-confirmed disc degeneration. No significant differences existed, however, in the disc heights, perpendicular distances between the MM and the laminae, or the psoas major cross-sectional areas of the two study groups.

Discussion

The MM stabilizes the lumbar spine and, when negatively impacted, contributes to LBP. The muscle group create more force over a smaller range than the longer spine muscle groups, which helps to stabilize movement. The dorsal rami of the spinal nerves stimulates the MM and erector spinae, but the psoas major is stimulated by ventral rami lumbar spinal branches, prior to their joining the lumbar plexus. The medial paraspinal muscles are stimulated from one nerve root, but the iliocostalis and longissimus muscles receives stimulation from many roots. Indications of muscle degeneration include decreased muscle size and increased fat deposits in the area.

Because the MM and erector spinae are stimulated by the dorsal root stemming from a singular level, the chronic and long-lasting pressure on the root due to disc herniation contributes to the degeneration and atrophy of these muscles. This atrophy is not evident in the psoas muscle because it is stimulated by the nerves of many different levels, rather than a singular source. In order for muscle atrophy to occur, there must be at least six weeks of compression, according to this study’s authors.

Conclusion

Evidence of increased fatty deposits and decreased muscle in a cross-sectional lumbar image indicates the existence of muscle degeneration in LBP patients, assuming there has been at least six weeks of compression on the MM or erector spinae muscle groups, which are stimulated by a single nerve root.

 

KEYWORDS: Muscle Degeneration in LBP Patients with Single-Level Disc Herniation, single-level disc degeneration, paravertebral muscles, disc heights, and perpendicular distances between the laminae and MM, pressure on the root due to disc herniation contributes to the degeneration and atrophy of these muscles

  1. Volumetric Muscle Measurements Indicate Significant Muscle Degeneration in Single-Level Disc Herniation Patients
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

Physician-Patient Communication

A qualitative phenomenological study of 15 musculoskeletal patients and their physiotherapists found that patients were better able to express their concerns and outcome expectations when their practitioners utilized a patient-centric, communicative approach during their initial healthcare consultation. When practitioners were well-versed in contemporary pain and pathology theories, they were better able to anticipate and elicit feedback about their patients’ concerns, leading to a more positive dialogue and better patient satisfaction. Practitioners who have developed systems and approaches to encourage proactive communication from their patients about their health concerns were more likely to have positive patient outcomes than those who relied only upon their prior medical expertise in diagnosing and treating their patients.

Purpose of the Study

Recent healthcare approaches have trended away from the strictly traditional biomedical paradigm to include the biopsychosocial approach to patient consultation and treatment. The newer model recognizes the importance of communication in empowering patients to take an active role in their own treatment and encourages them to consider and express their own health agendas, allowing their clinicians to more fully understand and attend to their specific healthcare needs. To develop a true partnership with their patients, healthcare practitioners must be willing to abandon the “doctor knows best” attitude and develop better communication skills that will allow for a patient-clinician treatment collaboration. This study proposed to investigate the relationship between a clinician’s communication technique and skills and how well the patient was able to express healthcare concerns during an initial consultation.

Methods

15 musculoskeletal patients and their physiotherapists were interviewed after an initial consultation encounter of between 15 and 20 minutes, which was recorded and later analyzed, utilizing predetermined topic guides, including: presenting problems and symptoms; understanding diagnosis theories, how the patients reacted to referrals, the behavior of the clinician during the consultation, desirable and undesirable treatment activities, fears, concerns, and emotional or social issues related to the patient’s treatment or diagnosis.

Findings

Each of the patients involved in the study presented with a range of two to five topics they wanted to discuss with their clinician. The data determined three main themes when it came to important topics of patient-clinician communication during consultations:

Clarity of the patient’s agenda

The first theme identified was how clear or unstructured a patient’s agenda was during their consultation. Some patients had very clear health agendas and were able to communicate their expectations and needs effectively to their clinician. Others were more passive and had more difficulty in communicating their expectations. These patients would have likely benefitted from a practitioner who was better able to create an atmosphere of trust and confidence, which would encourage the patient to discuss their needs.

The need for information and understanding

Patients who had more information about and better understood their health concerns were better at identifying and expressing their expectations and needs during their consultation. The subjects reported being more satisfied with and reassured by their consultation when their clinician took the time to explain and discuss the healthcare issue with them, rather than simply offering a diagnosis and treatment plan. When the clinicians offered evidence-based information regarding their diagnosis and reassurance that their health problem was not due to a serious underlying condition or likely to create too much disruption in their lives, they felt more satisfied with their experience. They were also happier about their consultation when their clinician was able to illicit further information regarding their symptoms and concerns, especially when the patients had neglected to mention these concerns, either through forgetfulness or reluctance to communicate their fears.

Developing Collaboration

Patients in the study reported feeling more supported and engaged when their healthcare provider used a person-centered approach during the interview at their initial consultation. They were better able to trust and have confidence in providers that projected a sense of partnership and were concerned with the social, emotional and physical condition of their patients, rather than treating their dysfunction as a stand-alone concern.

The results of this study emphasize the need for clinicians to create an atmosphere of trust, collaboration, and communication in their patient consultations, rather than relying exclusively on their medical expertise during diagnosis and treatment. By encouraging their patients to more effectively communicate their healthcare concerns, and by creating an atmosphere of collaboration between themselves and their patients, healthcare providers can empower and reassure their patients, which may improve diagnosis, treatment, and healthcare outcomes.

 

KEYWORDS: Importance of Physician-to-Patient Communication, patient-centric, communicative approach, clinician’s communication technique and skills, desirable and undesirable treatment activities, fears, concerns, emotional or social issues related to the patient’s treatment or diagnosis

intervertebral disc degeneration, model

Mechanobiology Research

Low back pain is a huge burden on our limited resources with limited knowledge of its pathophysiology. It is widely known that intervertebral disc degeneration (IDD) is intimately related, with the degree of degeneration associated with the severity of low back pain. The characteristics of intervertebral disc degeneration include disc height loss, proteoglycan loss, loss of water, annular fissures, and end plate calcification.

The degenerative process of the intervertebral disc has been seen as a phenotype change within the cells. This anabolic to catabolic shift seems to occur to the cells deep within the disc. One branch of research that studies the influence of mechanical forces on the biology is called Mechanobiology. In other words, can physical stressors on discs influence the process of degeneration? Can moving the disc is a certain way change the outcome of degeneration?



The Study

In this open access study, researchers were the first to investigate this kind of cyclical mechanical tension on the nucleus pulposus cell’s changing behaviour.  They extracted disc cells from caudal spines of (3-month-old) male Sprague-Dawley rats and conducted the mechanical testing using a device after the cells were cultured and prepared. They used this device to apply mechanical force on the cells of the nucleus pulposus (the centre of the disc) to see how the cells behaved under specific loading conditions.

Disc cell senescence involves telomere shortening,  free radical stress, DNA breakdown and cytokine proliferation. Mechanical loading conditions in the upright posture have been found to promote disc cell changes towards intervertebral disc degeneration in rats.  Studying the role of mechanical stress and the influence on disc health will benefit our understanding of disc pathogenesis. 

The results of this study showed a direct relationship of prolonged mechanical cyclic stress towards the catabolic shift of the cells in the nucleus pulposus. They concluded that unphysiological mechanical stress could push a disc into the degenerative cascade. They believe that eventually, too much mechanical stress can influence a cell’s behaviour and suggested that research continue searching the optimal mechanical environment for intervertebral disc cells.

At Dynamic Disc Designs, we work to bring dynamic models to the practitioner to help in the discussions related to motion and the spine.