Back pain is a common ailment that many of us have experienced at some point in our lives. One specific type of back pain, known as discogenic low back pain (LBP), is characterized by pain originating from the intervertebral discs (IVDs) in the spine. Despite extensive research, the exact causes of discogenic LBP have remained elusive. However, a recent study conducted by Seiji Ohtori and his colleagues sheds new light on the underlying mechanisms of this condition.

Animal Models and Discogenic LBP:

Through the use of animal models, researchers have made significant discoveries regarding discogenic LBP. They have found that sensory nerves grow into the inner layer of the lumbar IVDs, and this nerve ingrowth is induced by certain inflammatory substances called cytokines. 

These cytokines, such as tumor necrosis factor-α and interleukins, stimulate the ingrowth of sensory nerves into the discs. Moreover, nerve growth factor has been identified as a key player in inducing this nerve ingrowth. Animal models have also revealed that disc degeneration triggers the production of collagenases, enzymes that break down collagen, leading to hypermobility and pain.

 

Sinuvertebral Nerves

Unveiling Human Discogenic LBP

Further insights into the mechanisms of discogenic LBP have been gleaned from the examination of degenerated human IVD specimens. These specimens have revealed sensory innervation and nerve ingrowth, similar to what has been observed in animal models. The presence of cytokines in human discs suggests a shared mechanism with animal models. 

This indicates that the findings from animal studies can be applied to human patients as well. In addition to sensory innervation and cytokine involvement, sensitization of sensory nerve fibers innervating the IVDs is a crucial factor in discogenic LBP. When these nerve fibers become sensitized, they become more responsive to pain stimuli, leading to heightened pain perception.

Psychosocial factors also play a role in the perception and experience of pain associated with discogenic LBP. Factors such as stress, anxiety, depression, and social support can influence an individual’s pain experience. Understanding the interplay between these psychosocial factors and the physiological aspects of discogenic LBP is important in developing comprehensive treatment approaches.

Tackling Discogenic LBP: Treatment Approaches

Understanding the underlying pathomechanisms of discogenic LBP opens up avenues for potential treatment strategies. To effectively manage this condition, it is crucial to prevent sensitization of sensory nerve fibers within the IVDs. This can be achieved through targeted interventions that aim to suppress the pathogenic increases of cytokines. By reducing the levels of pro-inflammatory cytokines, such as tumor necrosis factor-α and interleukins, the ingrowth of sensory nerves into the discs can be controlled, thereby reducing pain.

In addition to cytokine regulation, addressing disc hypermobility is an essential aspect of treating discogenic LBP. Hypermobile discs can magnify pain and further damage the disc structure. Treatment options such as physical therapy and specific exercises can help stabilize the spine, reduce hypermobility, and alleviate pain. Other interventions, such as spinal manipulative therapy and epidural steroid injections, may also be considered in certain cases to manage pain and promote healing.

Conclusion:

Discogenic low back pain is a complex condition with multiple underlying mechanisms. The research conducted by Seiji Ohtori and his colleagues has provided valuable insights into the pathomechanisms of this condition, highlighting the role of sensory nerve ingrowth, cytokines, and disc hypermobility. By understanding these mechanisms, health professionals can develop more targeted treatment approaches to help patients suffering from discogenic LBP.

One innovative product that aids in the understanding and communication of discogenic LBP is the Professional LxH Dynamic Disc Model by Dynamic Disc Designs. This model accurately represents the structure and function of the intervertebral discs, allowing health professionals to visually demonstrate the impact of disc degeneration, nerve ingrowth, and hypermobility to their patients. By using this model during patient consultations, health professionals can help individuals better comprehend the nature of their condition and the rationale behind the recommended treatment approaches.

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In a recent article in The Lancet Rheumatology, researchers show how lower back pain is a rapidly escalating global issue, affecting an estimated 619 million people in 2020 – nearly 10% of the world’s population. Experts predict that this number will reach 843 million by 2050.

Compounding problems in the lower back epidemic

Asia and Africa are expected to experience the most significant rise in lower back pain cases. These regions often already face challenges due to limited and overburdened social support systems and healthcare resources.

The COVID-19 pandemic has further exacerbated the problem. Increased inactivity due to lockdowns and poor ergonomics from remote work setups have contributed to the intensity and prevalence of lower back pain. Additionally, limited access to healthcare services during the pandemic has added to the suffering of individuals already affected by this condition.

It’s important to consider that the provided figures may underestimate the true burden, as they do not fully account for the impact of the pandemic.

The Societal Burden of Lower Back Pain

Lower back pain imposes a substantial burden on society and the economy. In the United Kingdom, the National Health Service spends nearly £5 billion annually on general practitioner appointments alone for this condition.

Similarly, the cost of lower back and neck pain in the United States reached a staggering $134 billion in 2016. Of course, the consequences extend beyond the financial costs.

Lower back pain leads to increased absenteeism, reduced productivity, and early retirement, particularly among the working-age population. There is also a strong association between lower back pain and higher rates of depression, leading to prolonged disability and hindering recovery.

The researchers warn it is crucial to address the societal impact of lower back pain and develop comprehensive strategies to mitigate its effects.

Addressing the Issue of Back Pain Globally

Addressing the global issue of lower back pain will require immediate attention and collaborative efforts. Solutions should prioritize strategies aimed at alleviating lower back pain in the workplace, where many people spend a significant part of their time.

Implementing ergonomic practices and promoting physical activity can help prevent and reduce the problem of lower back pain. Moreover, improving access to rehabilitation services is essential for effective management and recovery.

Specialized training for healthcare practitioners in the treatment of lower back pain can lead to better outcomes and patient care. Additionally, reducing reliance on ineffective and potentially harmful treatments, such as opioids, is crucial.

Finally, the researchers stress that governments, healthcare systems, and policymakers must work together to prioritize lower back pain and allocate resources effectively. By taking proactive measures, we can alleviate the burden of lower back pain and improve the quality of life for millions of individuals worldwide.

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Introduction Summary

Low back pain (LBP) is a prevalent and costly health problem that affects a significant portion of the global population. Pain developers (PDs) are individuals who are considered a pre-clinical LBP population at risk of developing clinical LBP, which can exact great social and economic costs. Prolonged standing has been identified as a risk factor for LBP, and it is necessary to investigate the risk factors of standing-induced LBP in PDs comprehensively. By identifying these risk factors, appropriate preventive measures can be planned, which may reduce the incidence of standing-induced LBP and its associated costs.
This study1 used a systematic review and meta-analysis approach to investigate the distinctive characteristics and risk factors of standing-induced LBP in PDs. The study aimed to identify statistically significant differences between PDs and non-pain developers (NPDs) in demographics, biomechanical, and psychological outcomes and to determine the pooled effect sizes of these differences. The study’s findings have important implications for preventing and managing standing-induced LBP in PDs and for future research investigating the association of these distinctive characteristics to standing-induced LBP and interventions that may modify them.

Characteristics of Pain Developers and Non-Pain Developers

The systematic review and meta-analysis identified 52 papers and theses involving 1070 participants (528 PDs and 542 NPDs) that were eligible for inclusion. The studies used a prolonged standing duration greater than 42 minutes to classify adult PDs and NPDs without a history of LBP.

Significant differences were found between PDs and NPDs in terms of movement patterns, muscular, postural, psychological, structural, and anthropometric variables. PDs exhibited altered motor control in the anterior hip abduction (AHAbd) test and displayed higher lumbar lordosis in individuals over 25 years old. These factors were found to have a statistically significant association with standing-induced LBP.

Muscular differences were also identified between PDs and NPDs. PDs had a higher level of co-activation between gluteus medius and the erector spinae muscles, which can lead to increased lumbar loading and potentially contribute to the development of LBP.

In terms of postural characteristics, PDs had less trunk control and increased trunk sway during standing compared to NPDs, which may suggest a lack of postural stability.

Psychological characteristics were also found to differ between PDs and NPDs. PDs had higher levels of pain catastrophizing, which is the tendency to magnify the threat value of pain and to feel helpless in the face of it, and is associated with increased pain intensity and disability.

Finally, anthropometric and structural differences were found between PDs and NPDs. PDs tended to have higher body mass index (BMI) and shorter stature compared to NPDs, which may result in altered spinal loading during standing.

These findings suggest that PDs have distinct biomechanical and psychological characteristics that may predispose them to standing-induced LBP. Altered motor control displayed in AHAbd test and higher lumbar lordosis in individuals over 25 years seem to be probable risk factors for standing-induced LBP. The study’s findings have important implications for preventing and managing standing-induced LBP in PDs and for future research investigating the association of these distinctive characteristics to standing-induced LBP and interventions that may modify them.

Risk Factors for Standing-Induced Low Back Pain

The systematic review and meta-analysis identified several factors that were found to have a statistically significant association with standing-induced LBP:Lumbar fidgets – Participants with PDs displayed more lumbar fidgets, defined as small voluntary or involuntary movements of the lumbar spine, which are indicative of discomfort or pain. This factor was found to have a significant negative effect size (Hedge’s g − 0.72).

Lumbar lordosis in participants over 25 years – Participants with PDs had higher lumbar lordosis, defined as the natural curvature of the lumbar spine, in individuals over 25 years old. This factor was found to have a significant positive effect size (Hedge’s g 2.75).

• AHAbd test – Participants with PDs displayed altered motor control in the AHAbd test, which measures the ability to control the hip and pelvis while lifting one leg. This factor was found to have a significant positive effect size (WMD 0.7).
• Gluteus medius co-activation – Participants with PDs had higher levels of co-activation between the gluteus medius and erector spinae muscles. This factor was found to have a significant positive effect size (Hedge’s g 4.24).
• Pain catastrophizing – Participants with PDs had higher levels of pain catastrophizing, which is associated with increased pain intensity and disability. This factor was found to have a significant positive effect size (WMD 2.85).

These risk factors suggest that altered motor control, higher lumbar lordosis, increased gluteus medius co-activation, and pain catastrophizing may predispose individuals to standing-induced LBP. The findings may help identify individuals at risk of developing standing-induced LBP and plan appropriate preventive measures.

Future research should investigate the association of the reported distinctive characteristics to standing-induced LBP and whether they are manipulable through various interventions. Such interventions may include physical therapy, posture correction, and mindfulness-based stress reduction, among others. Identifying modifiable risk factors may lead to the development of effective interventions for preventing and managing standing-induced LBP in individuals with pre-clinical LBP.

Implications for Future Research

The systematic review and meta-analysis identified several distinct characteristics and risk factors for standing-induced LBP in PDs compared to NPDs. However, the study authors note that the identified risk factors do not necessarily prove causality or provide a complete understanding of the mechanisms underlying standing-induced LBP. As such, future research should investigate these factors in greater detail, and identify modifiable risk factors that can be targeted for preventive interventions.

The study authors recommend that future research should investigate the following areas:Association with standing-induced LBP – Further research should investigate the association of the identified distinctive characteristics and risk factors to standing-induced LBP. Studies should investigate whether these factors are predictive of standing-induced LBP and whether they are specific to standing-induced LBP or generalizable to other types of LBP.

Mechanisms underlying standing-induced LBP – Future research should also investigate the underlying mechanisms of standing-induced LBP, such as the interplay between motor control, muscle activation, and posture. Understanding the mechanisms underlying standing-induced LBP can help identify modifiable risk factors and develop effective interventions.

Intervention strategies – Future research should investigate the efficacy of various interventions for preventing and managing standing-induced LBP in individuals with pre-clinical LBP. Such interventions may include physical therapy, posture correction, mindfulness-based stress reduction, and other strategies aimed at reducing risk factors identified in this study.

Generalizability of findings – Finally, future research should investigate the generalizability of the study findings to other populations, such as individuals with clinical LBP or those with different occupational or lifestyle factors. This will help to determine the applicability of the findings to a broader population and inform the development of preventive measures for standing-induced LBP.

Conclusion

In summary, this systematic review and meta-analysis found that pain developers (PDs) – individuals with a history of low back pain (LBP) – have distinct characteristics compared to non-pain developers (NPDs) when exposed to prolonged standing. These characteristics include altered movement patterns, muscular, postural, psychological, structural, and anthropometric variables. The study also identified several risk factors associated with standing-induced LBP, including lumbar fidgets, higher lumbar lordosis in participants over 25 years, AHAbd test, GMed co-activation, and higher scores on the Pain Catastrophizing Scale.

These findings have important implications for preventing and managing standing-induced LBP, particularly in individuals with a history of LBP. The study suggests that altered motor control displayed in the AHAbd test and higher lumbar lordosis in individuals over 25 years old are probable risk factors for standing-induced LBP. Therefore, future interventions may focus on improving motor control and reducing excessive lumbar lordosis. Additionally, the study highlights the importance of addressing psychological factors, such as pain catastrophizing, as a potential risk factor for standing-induced LBP.

Overall, the study emphasizes the need for a comprehensive approach to preventing and managing standing-induced LBP, including a focus on biomechanical, psychological, and other factors. Future research should investigate the association of these distinctive characteristics to standing-induced LBP and whether they are manipulable through various interventions. By identifying and addressing these risk factors, it may be possible to reduce the prevalence of LBP and improve the quality of life for individuals with a history of LBP.

This study emphasizes the importance of developing appropriate preventive measures for standing-induced low back pain (LBP) in pain developers (PDs). PDs are individuals with a history of LBP and are considered a pre-clinical population at risk of developing clinical LBP, which can lead to significant social and economic costs. The study found that PDs have distinct characteristics compared to non-pain developers (NPDs) when exposed to prolonged standing, which suggests that targeted interventions may be necessary to prevent standing-induced LBP in this population.

The development of appropriate preventive measures requires a thorough understanding of the risk factors associated with standing-induced LBP in PDs. This study identified several risk factors, including lumbar fidgets, higher lumbar lordosis in participants over 25 years, AHAbd test, GMed co-activation, and higher scores on the Pain Catastrophizing Scale. These risk factors suggest that interventions targeting motor control, lumbar lordosis, and psychological factors may be effective in preventing standing-induced LBP in PDs.

In addition to identifying risk factors, the study highlights the importance of comprehensive interventions that address biomechanical, psychological, and other factors associated with standing-induced LBP. These interventions may include postural education, physical therapy, and cognitive-behavioural therapy. By addressing these factors, it may be possible to reduce the prevalence of LBP and improve the quality of life for individuals with a history of LBP.

Overall, the study underscores the importance of developing appropriate preventive measures for standing-induced LBP in PDs. Identifying risk factors and developing targeted interventions may help reduce the burden of LBP in this population and improve their overall health and well-being.

Dynamic Disc Designs

Dynamic Disc Designs offers dynamic anatomical models that musculoskeletal healthcare workers (chiropractors, medical doctors, physiotherapists, osteopaths) can use to help explain how the spine is impacted when one stands, for example. The models are designed to simulate the spinal movement dynamically, allowing various spinal specialists to better illustrate to patients the impact that standing can have on the spine.

Using the dynamic disc model, a healthcare worker can demonstrate how the intervertebral discs are compressed when standing due to the force of gravity on the spine. They can show how the discs lose water content and height throughout the day, resulting in reduced shock absorption and increased pressure on the spinal nerves. This can lead to various symptoms, including low back pain, stiffness, and numbness or tingling in the legs. In this particular research highlighted in this post, a practitioner can explain dynamically what excessive lordosis means and how the facets are approximated in this case. Explore.

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Discs are always either filling or emptying with water. Intervertebral discs are the large hydraulic structures between vertebrae that separate them in the spine. They undergo significant compression forces while we are upright, walking and sitting, and decompress when lying down. And this change is also known as the diurnal change.

Contexual factors and their influence in low back pain care

Contextual factors play a part in the care of low back pain sufferers. These factors are things like: what the doctor is wearing, how he smells, what the office looks like, where the clinic is located, how the front-end customer service is, and what kind of tools the professional uses to convey the clinical findings and proposed treatment could be.

When treating acute nonspecific low back pain (LBP), bed rest is often not recommended. 

It is nothing new to learn that low back pain is a worldwide problem, having a leading role in disability days lost.¹ MRI plays an important role in identifying underlying problems within the spine, however, there is a debate on its utility as often the symptoms do not match up to the findings.

The Spinal Forecast

Lumbar disc herniation(LDH) is an event, which could be progressive or instantaneous, whereby the nucleus pulposus of an intervertebral disc slips out of place. 

Goal of the Study?

The goal of this study is to learn more about a patient’s perception and expected outcome when a diagnosis is shared with them regarding their low back pain. In a recent paper published in the European Spine Journal¹ the authors wanted to know how diagnostic labels influenced the participants. Did labelling a patient with a common diagnosis create poorer expectations and outcomes?

Goal of the Study?

This study aims to assess whether someone is generally fearful of painful movement or is it related to a specific task. It is common for those with chronic low back pain to experience an avoidance and fear of movement, likely because the movement has triggered a pain episode in the past. In this research paper published in Pain Reports¹, the authors sought to see if kinesiophobia ( fear of movement ) is related to a specific movement or is it related to a general fear a person has developed.

Why are they doing this study?

One of the problems regarding questionnaires that are often used to evaluate fear avoidance is they do not replace an astute clinician who carefully assesses the presenting patient’s movement. Establishing an assessment strategy for the fear of specific movements would be more helpful.²

“The self-reported questionnaires administered before performing a particular
movement may not reflect the “actual” fear during the movement
because the questionnaires evaluate fear of general movement, not
the target movement.”

 

What was done in this study?

To better understand which movements may contribute to kinesiophobia, the researchers looked at 51 people and monitored lumbar flexion (bending forward). They used two accelerometers attached to the top and bottom of the lumbar spine and evaluated task-specific fear.

Evaluation of lumbar flexion and task-specific kinesiophobia

What did they find?

Task-specific fear was significantly more related to the kinematics of lumbar flexion, particularly in the speed of return to the starting position. In their 2 measures,task-specific fear and general kinesiophobia, they found task-specific fear was more closely related to peak angular velocity of the return from bending forward rather than fear avoidance general questionnaires.

 

Why do these findings matter?

The researchers of this paper concluded that specific tasks should be considered when fear of movement is part of the clinical picture for chronic low back pain patients.

At Dynamic Disc Designs, we believe the pain onset from flexion likely relates to instability, and if a patient with chronic low back pain can be shown the mechanical cause and the solutions to reduce pain, then a reduction in fear of the specific task can empower patients about their movements. Consider our L2-5 Hypermobility Dynamic Disc Model as a teaching tool.

1. Task-specific fear rather than general kinesiophobia assessment is associated with kinematic differences in chronic low back pain during lumbar flexion: a preliminary investigation ↩
2. The fear avoidance model disentangled: improving the clinical utility of the fear avoidance model. Clin J Pain 2010;26:739–46. ↩

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