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.


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Cyclic Mechanical Tension and Intervertebral Disc Degeneration

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 cells 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 the cell’s behaviour and suggested that research continue on finding the optimal mechanical environment for the cells of the disc.

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


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Study of Human Lumbar Foramen Dimensions During Activity Show Changes are Segment-Dependent

Lumbar Foramen

 An in vivo study of cross-sectional lumbar foramen dimensions during a weight-lifting activity showed that all levels of the lumbar intervertebral foramen (LIVF) area decreased, except for the L5-S1 segment during lumbar extension, which had consistent measurements of the foramen, height, and width throughout the activity. The results of the study could provide insight into ways to improve the diagnosis or treatment of lumbar foramen stenosis.

Purpose of the Study

Radiculopathy caused by nerve root compression is a common symptom of LIVF stenosis and is often treated surgically, through the implantation of an interspinous device or decompression. Because the LIVF is surrounded by mobile facet joints, its shape undergoes changes during typical daily movement. As it changes shape, it may put pressure on nerve roots or other structures that may cause pain. Complications arising from the changing dynamic anatomy of the LIVF during activity can lead to failed back surgery syndrome, so understanding how movement and weight-bearing affects the LIVF is important to effective treatment and maintenance of back pain.

The Study

An MRI study of 10 healthy subjects (five male, five female) in supine, relaxed positions was conducted, and 3D spine models were constructed based upon the results of the scans. The lumbar spines of the subjects were then imaged during lumbar extension postures of 45 degrees to a maximally-extended position, while the subjects were holding an 8-pound dumbbell in both hands. These scans were also used to create 3D vertebral models of the in-vivo dimensions during activity, and a data analytic design was created to determine the area, height, and width of the L2-S1 vertebral levels during the activity for 45-degree flexion, upright position, and maximal extension.


Researchers found that the LIVF area in L2-L3, L3-L4, and L4-L5 decreased during weight-lifting activity. The LIVF widths also showed a similar decrease, but the heights remained throughout the extension activity. However, the foramen area, height, and width at L5-S1 did not change during the weight-lifting. Overall, the data for all other areas demonstrated a change of approximately 10 percent from 45 degrees flexion to an upright standing posture, and again from upright standing to maximal extension. This information underscores how patients with LIVF stenosis may experience nerve root impingement pain during extension postures and feel relief from that pain during flexion. Understanding the in vivo dynamics of the functioning lumbar spine may help practitioners in the treatment and diagnosis of lumbar foramen stenosis.


lumbar spinal stenosis, spinal canal narrowing

A superior view of our Lumbar spinal stenosis model with a dynamic disc bulge and dynamic ligamentum flavum.

KEYWORDS: Lumbar Foramen Dimensions During Activity, in vivo study of cross-sectional lumbar foramen dimensions during a weight-lifting activity, insight into ways to improve the diagnosis or treatment of lumbar foramen stenosis, Radiculopathy caused by nerve root compression, Complications arising from the changing dynamic anatomy of the LIVF during activity, nerve root impingement pain during extension postures

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Post-Treatment Interviews Offer Insight into How Conceptions about Care Affect Outcomes in LBP Patients

Post-Treatment Interviews, LBP patients

A phenomonenographic study of post-treatment interviews of lower back pain (LBP) patients’ conceptions regarding their clinical experience revealed common themes that correlated to negative or positive treatment efficacy and suggests practitioner approaches that may empower and create a therapeutic alliance between patients and their health care providers (HCP).

Effective Treatment Involves Holistic Approach

LBP is a worldwide phenomenon that affects adults of all ages. It is a leading cause of lost work and wages and may require long-term treatment with a variety of practitioners. Managing LBP can be challenging, especially when one’s HCP limits treatment or discourse to strictly biomedical or physiological causations. To more effectively address patients’ needs, a holistic, psychosocial approach to understanding LBP and creating effective treatments may be more conducive to patient empowerment and satisfaction with treatment outcomes. The study of post-treatment interviews sought to determine common themes in patients’ conception of their treatment and suggests models that might encourage better, more satisfying care.

Study Design and Data Collection and Analysis

To better understand and describe the full contextual nature of patient experiences with their HCP and treatments, researchers utilized the phenomenographic study design method and created a hierarchical structure of categorized themes derived from the data sets. The study authors were concerned with patients’ conceptions of their practitioner visits, rather than mere opinions. The 17 volunteers (five men and 12 women with a mean age of 46 years) were chosen from LBP patients who were undergoing treatment for episodic or chronic conditions and were categorized as “high risk” on the Keele STarT Back Screening Tool, indicating high levels of psychological risk factors in their daily lives. All of the volunteers agreed to participation in the study and were asked to view videos of their HCP encounters and respond to interview questions regarding their physiotherapy consultation and treatment experience. The experience of viewing and discussing the video prompted many of the subjects to reflect upon their overall healthcare journey. The researchers asked the subjects to talk about who they were and how they ended up in LBP treatment. Further questions queried the patients about the experience of being treated, examined, and the explanations they received from their HCP about their LBP, as well as how aligned they felt with the process of therapy and their HCP.

Categorizing Data

The conceptions of LBP patients were categorized into themes that included: convincing care, lifestyle change, participation, reciprocity, and the ethicality of their encounters. Each of the themes was then broken down into four categories: “non-encounters,” seeking support, empowering cooperation, and autonomic agency.

Invalid “Non-Encounters” Left Patients Frustrated

Patients that described their encounters as “non-encounters” felt that their HCP experience was invalidated by not being listened to or receiving the level of care they had expected during treatment. They complained that their treatment was inconsistent or that the explanations they received during their encounter was inadequate, which left them frustrated, afraid, or filled with anxiety. Some of these patients abandoned therapy altogether and resigned themselves to a life filled with pain. Others opted for more treatments or sought a clearer diagnosis—requesting imaging or surgery to explain or alleviate their symptoms. When their condition was not clearly explained or cured, they felt that treatment was ineffective or that they had been patronized. Those living with long-term pain discussed how their condition had inhibited them in social and work life when they did not get the support they needed. They felt helpless when it came to their own care and were disheartened as they moved from provider to provider seeking out appropriate care. They reported having to wait for long periods of time to receive care and said they felt tired from work and lacked the energy or resources to enjoy leisure activities. They complained that their HCP seemed not to hear them or were dismissive about their own thoughts when it came to their LBP. They were given information that replicated what they already knew or were talked down to with medical jargon that was unhelpful because they did not understand its meaning. They felt their practitioners were disinterested in them and rushed them through an impersonal therapy routine. Some patients felt blamed by their HCP for their pain or received unnecessary treatments that “robbed” them of their time and money, without benefit.

Seeking Support from Care Providers

Patients that sought support in understanding their LBP and treatment options were sometimes frustrated in their efforts to receive a confident examination and interview with a qualified professional who treated them with respect. These patients reported wanting clear explanations of their LBP, delivered in language that was understandable to them. They were most satisfied when their HCP took the time to give a thorough examination and helped them to find reasons for their symptoms. By interviewing patients thoroughly, HCP’s were better able to discern their patients’ life circumstances and give them the type of support needed, including teaching them to recognize and deal with stress in their bodies. Attentive practitioners were best able to be empathetic and supportive to their patients’ needs.

Cooperation and Support Empowered Patients

Patients reported feeling empowered when their HCP gave them the opportunity to take an active part in their own treatment plan. They were best able to do this when the provider gave them understandable explanations about their condition and how treatment techniques and lifestyle changes would benefit their recovery. Having sensible, written treatment plans—rather than merely verbal explanations, which they might forget—made the patients feel more secure and involved in their care. Physiotherapists who were able to demonstrate how the patients’ everyday activities affected their spinal health gave the patients a renewed sense of familiarity with their bodies and helped them to make better choices during normal activities that would reduce strain and injury to their spines. This newfound mind/body connection created a sense of confidence and balance that was beneficial to the patients’ overall well-being and treatment outcome. By learning to associate their LBP with their own physical and psychosocial health, patients gained insight and were likely to make lifestyle changes—including getting adequate rest and relaxation—that benefited them overall. Building a therapeutic, cooperative relationship with their HCP involved reciprocal understanding, good listening skills, and an attitude of respect. When a provider was able to repeat in their own words what their patient had said to them, the patients knew they were truly being heard.

The Development of Autonomic Agency

The group of patients who were best able to transform from patients to active participants in their own care felt the most empowered and reported that their treatment therapy extended beyond office visits and into their lives, work, and homes. Having a clear plan for their future—even when regular physiotherapy was needed—and knowing they could contact their providers with questions or concerns about their health empowered the patients to utilize the instructions and information they had received from their HCP’s and see steady, lasting improvement in their symptoms.

These patients had learned from their care providers about the importance of a family and friend support system and that it was necessary to relax and find a centered calm in life. They learned that strenuous exercise was not necessary to physical well-being and that less taxing types of exercise were sufficient to improve fitness and reduce daily stresses. Overall, they reported better moods due to their lifestyle changes and improved relationships with their loved ones and peers. They accredited many of these changes to the ability of their HCP’s to listen to them and introduce the idea of how psychosocial issues in their lives affected their overall health. They felt confident with their providers because their concerns and goals were discussed and considered when developing a plan of long-term treatment.


Post-treatment interviews in this study indicate the need for HCP’s to develop a patient-centric approach in to therapy that involves listening, cooperation, clear, written instructions, and an overall respect for the patient. When practitioners involve their patients in the process of healing and wellness, and when they see the patient as a whole person whose psychosocial involvements are integral to their physiological health, they are able to inspire confidence and empower their patients to effectively participate in their own acute and long-term LBP management.


KEYWORDS: how conceptions about care affect outcomes in LBP patients, empower and create a therapeutic alliance between patients and their health care providers, a holistic, psychosocial approach to understanding LBP, patients’ conceptions of their practitioner visits, understanding their LBP and treatment options, the importance of a family and friend support system

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Patients Value Collaborative Care, Information, Validation, and Good Communication Skills During Treatment

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 to 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.


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.


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

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Study Finds Mechanical Diagnosis and Therapy Helps Patients Self-Manage Symptom

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




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Dynamic Disk Research – Disk Height and Fluid Flow

dynamic disk

The dynamic disk plays a significant role in the resistance to compression. It is known to physically compress over the course of the day by as much as 20 percent with recovery achieved during sleep or recumbency. Its implications intertwined with back pain. 1 One of the focused investigations into its essential function has been its intrinsic ability to maintain and absorb water. Negatively charged proteoglycans contain properties that attract water, and it is this hydraulic characteristic believed to be at the core.

However much still is to be discovered; especially in the higher understanding how best to draw in fluid and recover the expulsion of this water under axial compression. In a manuscript published in the Journal of Biomechanics 2, researchers worked to answer the questions regarding loading and unloading of the dynamic disk.

The researchers revealed a new personality of the annulus fibrosis as playing a significant in the ability to absorb water. The annulus demonstrated both properties of viscoelasticity as well as the binding capacity to retain water. This information is new in the better understanding of how disks maintain vertebral spacing with regards to recovery. Load and unloading cycles are natural, but it is the intrinsic ability of the dynamic disk to maintain spacing over time that is important to continue to study. Congratulations to the authors for choosing a worthy investigation.

At Dynamic Disk Designs, we work to model the dynamic nature of the spinal structures to improve communication of spine science. Our work facilitates patient education and student teaching of spine. Having a model dynamic disk allows the better understanding of disk height loss over time to explain back pain mechanics and the respective hydraulic solutions.

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Few Studies Examine the Effect of Health Literacy on LBP Treatment Outcomes

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.


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.