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Fostering Postural Interoceptive Exercises to Help Reduce Neck Pain

posture, awareness, pain, spine model

In a recently accepted Level 1 evidence publication (Jan 31, 2017), a study looked at how postural awareness can make an impact on non-specific neck pain. Non-specific neck pain usually indicates that there isn’t  any pathological problems. Moreover, this usually indicates a degenerative problem associated with the intervertebral discs and/or facet joints.

In their study (Does Postural Awareness Contribute to Exercise-induced Improvements in Neck Pain Intensity? A Secondary Analysis of a Randomized Controlled Trial Evaluating Tai Chi and Neck Exercises) seventy-five subjects were randomly allocated to two groups: a Tai Chi group and conventional neck exercise group. After a period of 12 weeks, neck pain VAS measures decreased significantly in both groups.

The authors speculated that postural awareness played an important role in the positive outcomes.

Postural awareness can be a challenging concept to encourage especially when patients do not know the reason to do so. Dynamic Disc Designs models allow the practitioner to explain why posture is important. This fosters postural awareness through education rather than a dictatorship approach.

Interoceptive consciousness often begins with an understanding of how changing posture can change the stresses on the internal spinal structures.

Whether you are trying to motivate postural interoceptive awareness or explain why certain neck exercises are important to the patient, our models help connect the reasons at to why.

“ Your models have re-established the vital importance of the doctor / client communication relationship, dramatically bridging the gap for both to have a common understanding of the condition, the process ahead, and the targeted outcomes towards health and wellness for life. Simply perfect.” Barry Kluner DC

Postural awareness begins with an understanding of how the spine works. Our viscoelastic models show patients the effect of load and time dependent compression. Changing the angles of the endplates can significantly improve ones posture and the reduction of pressure on sensitive tissues. Teaching a patient as to WHY to improve their posture is a key to helping them reduce their pain.

 

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Migration of Nucleus Pulposus

Treatment strategies related to intervertebral disc displacement often involves extension. Robin McKenzie’s work on centralization of symptoms in the case of disc herniation has been used by many.  Most of the research on migration nucleus pulposus has been previously investigated in the lumbar spine. In a recent study published in PM&R 1 , researchers looked at the cervical spine and wondered if this was a similar case. They hypothesized that cervical extension would centralize and shift the nucleus anterior–away from the associated disc herniation.

They looked at 10 healthy young males with mean age of 22 yrs old and compared neutral to extension position of the cervical discs using MRI. They carefully mapped out the nucleus pulposus and found that in extension the migration nucleus pulposus was anterior and away from the posterior disc margin.

They concluded that moving the cervical spine into extension could be clinically valuable in the case of cervical disc problems.

At Dynamic Disc Designs, we have seen what these researchers have seen! When our handcrafted models (with an annulus and nucleus) are moved into extension, the nucleus can been seen to move anterior. In our lumbar models, the clear L4 vertebra of our Professional LxH Model allows full migration visibility of the nucleus pulposus. This is helpful in the clinical explanation of treatment targets for patients with intervertebral disc problems.

migration nucleus pulposus, lumbar model

Posterior nucleus migration in flexion.

  1.  Kim YH, Kim SI, Park S, Hong SH, Chung SG Effects of Cervical Extension on Deformation of Intervertebral Disk and Migration of Nucleus Pulposus. PM R. 2016 Sep 6. pii: S1934-1482(16)30905-4. doi: 10.1016/j.pmrj.2016.08.027. [Epub ahead of print

Posterior Annulus and the High Intensity Zone – Research looks to sub-classify this MRI finding

posterior annulus

Discogenic pain is quite common. A finding on MRI that has been hotly debated is a hyperintensity zone, often seen within the posterior annulus of the intervertebral discs.

In a recent study published in PLOS One 1 researchers conducted the first large scale study to identify subclassifications of high intensity zones (HIZ). They looked at a cross sectional study of 814 participants both using T1 and T2 weighted imaging and created a morphological and topographical classification system. Findings included HIZs on the posterior annulus and anterior annulus.

High Intensity Zone, HIZ, Lumbar Disc, posterior annulus

They believe the results could help in the standardization of MRI findings in clinical and research settings.

MRI has been thought to be not very helpful in the early management of back pain. However, more research (like this) to extract MRI findings should help localize pain generators and direct patient care and treatments. Even if imaging is thought to be less than optimal in the early management of back pain 2 it is still important to look carefully at MRI and correlate a patient’s symptoms to help direct patient care. Otherwise, it is a bit of guessing game which structures are inflamed.

Dynamic Disc Designs Corp. develops models that can help the clinician in the explanation of MRI findings. Visit us.

This is the best model lumbar spine I have seen. I am proud to possess one. It will be of great value when explaining to my patients as well as in my research using Upright MRI

Francis W. Smith MD Clinical Professor of Radiology Positional MRI Centre Woodend Hospital Aberdeen, Scotland

 

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Nuclear tracking spine model – helping explain research findings.

3D discogenic pain model

Nuclear tracking as a result of vibration for spine has been revealed in an ISSLS price winning study in Spine. In a microanatomical investigation titled : ” Vibration Really Does Disrupt the Disc ” 1 researchers looked at motion segments and the influence of vibration as it relates to intervertebral disc damage.

There has been background knowledge stating that whole body vibration can lead to back pain but no-one had studied the micro structure of the disc. Looking carefully how nuclear tracking disrupts the annulus and endplate, this study looked at sheep discs, with controls, and vibrated motion segments under 7 degrees of flexion. The forces used were 1300 plus or minus 500N and the frequency applied was 5hz. This equates to 5 vibration movements per second. They conducted the movement for 20,00 to 120,000 cycles to mimic lose does and high dose variation.

Nuclear Tracking in a Spine Model

nuclear tracking, flexion, motion segment, model, modeling

Flexion load causes posterior nuclear tracking.

They found there was no sharp significant drop in displacement revealing there was not one moment of catastophic failure. What they found was nuclear tracking and internal disruption of the inner and mid layers of the annulus fibrosus. They also saw delamination of the annular fibres where they attach to the endplate (aka, Sharpey’s Fibres)

In conclusion, these researchers revealed that vibration in a flexed spinal motion segment leads to inner and mid layer annular disruption rather than outer annular disruption that is seen with disc herniation. They believe this mechanism could lead to a better understanding of the initiation of the degenerative cascade of spine.

Dynamic Disc Designs tries to highlight important research and model the respective findings for spine professionals working with patients of back problems. Educating patients about the mechanisms  of back pain can be an empowering tool for both doctors and patients.

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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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Osteoarthritis model – subchondral bone

osteoarthritis model, spine, facet, disc height loss

Osteoarthritis is a burden on the people of this world and a major cause of disability. It is considered a degenerative disorder, affecting the aging population as it erodes cartilage, disrupting subchondral bone, leading to osteophytosis, muscle weakening and inflammation to the structures within the joint. 1 An accurate osteoarthritis model would be very helpful for spine.

Historically, osteoarthritis has been looked at from the perspective of cartilage wear with newer insights and interest at the subchondral level. (sub = below + chondro = cartilage) In a paper published in Arthritis and Research Therapy, researchers gave special attention to the subchondral bone. 2

In the perspective of the spine, disc height loss has an influence on the facet joints which are synovial joints. 3 It is disc height loss (a measure of vertebra approximation or closeness) that has shown to have the greatest impact on the biomechanics of a spinal motion segment. In particular, it narrows the intervertebral foramen, causes disc bulging as well as annular stress, and the narrowing can have an effect on the vascular flow in and around the nerves that exit the spine directly influencing nerve roots. There are few other degenerative conditions that can have such a large impact effect on the musculoskeletal system. 4

In Figure 1. of Subchondral bone in osteoarthritis: insight into risk factors and microstructural changes 2 a beautiful histological image showcases the microanatomy of the: calcified cartilage, uncalcified cartialge, the subchondral bone along with the tide mark and cement line of a normal synovial joint. This is an important area of the facet joint.

osteoarthritis model

As mechanical stress is placed onto the uncalcified cartilage, stress will translate through this avascular structure and into the subchondral bone. Chondrocytes secrete glycosaminoglycans (GAGs) and collagen type II-rich extracellular matrix (ECM) that are essential for the maintenance and regeneration of the cartilage which acts to protect subchondral bone. 6 Articular cartilage is mainly water, contributing to 80% of its weight. 7 Interestingly, we have seen that there is a diurnal variation of the cartilage in cartilage 8 similar to what we see in the discs. 9

The bottom line is our tissues that marry our bones together are dynamic and are in constant change to mechanical forces. Disc height loss of the spine will cause the facet joints in the spine to compress and lead to arthritis if not carefully managed.

Dynamic Disc Designs develops models to help in the greater understanding of how a compressed disc can have a multitude of mechanical effects on a spinal motion segment. Understanding the load distribution as it occurs naturally with diurnal variation, lying down, or with injury lifting, or prolonged sitting can be of great assistance in managing the treatment of spinal osteoarthritis as a result of disc height loss and facet arthrosis. Patient education proves to improve outcomes of osteoarthritis when patients understand what not to do first and secondly, why it is important to continue to do safe exercise. 6

The Professional LxH Model demonstrates hyaline cartilage and perichondrial vascularization, while the Lumbar Spinal Stenosis Model demonstrates subchondral sclerosis helping in the education of facet osteoarthritis. A dynamic osteoarthritis model for spine is important to have if educating is a part of a physician’s clinical life.

“Helping doctors be better teachers”

 

  1. Grynpas MD, Alpert B, Katz I, Lieberman I, Pritzker KP: Subchondral bone in
    osteoarthritis. Calcif Tissue Int 1991, 49:20–26.
  2.  Li et al. Arthritis Research & Therapy 2013 2013, 15:223 http://arthritis-research.com/content/15/6/223
  3.  Arbit, E., Pannullo, S., 2001. Lumbar stenosis: a clinical review. Clin. Orthop. Relat. Res.(Mar), 137–143.
  4.  Disc height loss and restoration via injectable hydrogel influences
    adjacent segment mechanics in-vitro Christian Balkovec , Andrea J. Vernengo, Stuart M. McGill Clinical Biomechanics 36 (2016) 1–7
  5.  Li et al. Arthritis Research & Therapy 2013 2013, 15:223 http://arthritis-research.com/content/15/6/223
  6.  Blazek AD, Nam J, Gupta R, Pradhan M, Perera P, Weisleder NL, Hewett TE, Chaudhari AM, Lee BS, Leblebicioglu B1, Butterfield TA, Agarwal S. Exercise-driven metabolic pathways in healthy cartilage. Osteoarthritis Cartilage. 2016 Feb 27. pii: S1063-4584(16)01025-6. doi: 10.1016/j.joca.2016.02.004. [Epub ahead of print
  7.  The basic science of articular cartilage: structure, composition, and function. Sophia Fox AJ, Bedi A, Rodeo SA. Sports Health. 2009 Nov;1(6):461-8.
  8.  J Biomech. 2013 Feb 1;46(3):541-7. doi: 10.1016/j.jbiomech.2012.09.013. Epub 2012 Oct 24. Diurnal variations in articular cartilage thickness and strain in the human knee.Coleman JL, Widmyer MR, Leddy HA, Utturkar GM, Spritzer CE, Moorman CT 3rd, Guilak F, DeFrate LE.
  9.  Botsford, D. J. MD; Esses, S. I. MD, FRCS(C); Ogilvie-Harris, D. J. MB, FRCS(C)  In Vivo Diurnal Variation in Intervertebral Disc Volume and Morphology. Spine: April 15, 1994
  10.  Blazek AD, Nam J, Gupta R, Pradhan M, Perera P, Weisleder NL, Hewett TE, Chaudhari AM, Lee BS, Leblebicioglu B1, Butterfield TA, Agarwal S. Exercise-driven metabolic pathways in healthy cartilage. Osteoarthritis Cartilage. 2016 Feb 27. pii: S1063-4584(16)01025-6. doi: 10.1016/j.joca.2016.02.004. [Epub ahead of print