Archive for year: 2015

Mulholland R Eur Spine May 17(5) 2008

The cause and hence the treatment of “mechanical” LBP remains unsolved, despite a century of endeavor. It is generally accepted that some form of failure of the disc is central to causation. In the latter 20th century failure of the disc leading to abnormal movement i.e. “instability” legitimized fusion as a treatment. However the result of fusion remain unpredictable. Despite progressively more rigid fusions results failed to improve, casting doubt on the concept that back pain was movement related…and stopping movement was central to success.
Is it more likely back pain is “load related” and not movement related?
Is instability as a cause of back pain a myth?
At the beginning of the 1950’s abnormal movement was not mentioned as a cause of pain.
Then how did the term “instability” become used as a diagnostic term?
Barr in 1950 appears to be the first reference to the term stating: “it is becoming evident that backache is often associated with mechanical instability of a degenerate disc lesion”. Harris and Macnab in 1954
further the concept that the disc plays a central role in Sciatica & LBP however it was not suggested that excessive movement is present, and translational movement is deemed to be unusual.
Conclusion: Abnormal movement of a degenerated segment may be associated with LBP but it is not causative….the concept of instability as a cause of back pain is a myth.

Several reviews have been published regarding the typical findings using a movement classification analysis. This 2006 study presents these findings in a useful way i.e. IF you find that 75% of your patients have a “flexion” directional preference you have probably misinterpreted the examination (or have the most unusual patients in America!). Their findings show an average (from a cohort of 187 patients) 140/187 were “reducible derangements” (a disc that can likely reduce or be positively affected with sequential movements); 11/187 were “irreducible”. In a general sense this suggests that less than 10% of back patients have conditions which can’t improve with treatment, 75% will. 24/187 were classified as “other”…suggesting inflammation, postural or adherence etc.

98/140 (70%) were EXTENSION, (5%) FLEXION and (25%) LATERAL (or rotation or side-glide). Other studies also suggest a 3% or less prevalence of nerve adherence syndromes. These studies support the premise that mechanical evaluation of spinal patients using some sort of directional-preference is warranted. In our decompression classification we utilize these tests; however in the 10% of patients NOT demonstrating a DP axial traction therapy is usually the most sensible treatment. By fostering directional-preference findings we have found that traction-therapy works better and quicker.

The Slump test, first described by Geoff Maitland PT some 40 years ago is used to elicit “sciatic” symptoms or pain radiating from the sciatic nerve or lumbar nerve roots. There are several forms or variations all meant to tense and thereby ‘irritate’ the lumbar nerve roots. The patient sits on a bench that allows there feet to hang without touching the floor. As with other neuro-mechanical tension tests a progressive application of movements and tensioning are added to elicit pain.

The patient slumps forward and the painful leg is raised (the foot can be dorsi-flexed preliminarily or after the addition of further leg extension) then further neck flexion is added to fully ‘tense’ the nerves. A positive finding is reproduction of pain. The positive test may suggest the patient is a candidate for flossing procedures…either seated or lying. If neck flexion doesn’t create pain then the sciatic nerve is not the structure of interest. If extension of the skull (while maintaining the various provoking positions) dramatically improves the pain it is assumed nerve tension may indeed be a source of pain.

Med Eng Phys. 2014 Nov;36(11):

Wang L¹, Zhao M¹, Ma J¹, Tian S¹, Xiang P¹, Yao W², Fan Y³.

Traction and vibration are commonly used to relieve LBP.

The effect of combining traction and vibration on back muscles, heart rate (HR) and blood pressure (BP) was investigated. Supine traction of varying angles with vibration were combined (0°, 10°, 20° and 30°) (0 Hz, 2 Hz and 12 Hz). The combination of traction and vibration (from 2 Hz vibration along Z-axis and up to 12 Hz vibration along Y-axis) had no significant effect on the cardio-vascular system. The activity of lumbar erector spinae (LES) and upper trapezius (UT) decreased significantly when the angle reached 20° under the condition of 2 Hz vibration along Z-axis compared with it of 0°. Furthermore, the MPF also decreased significantly compared to static mode at 20° for LES and at 30° for UT. However at 12 Hz vibration along Y-axis, we recorded significant increase at 20° and 30° compared to 0°. For LES, the MPF also had significant difference when the angle was increased from 10° to 20°.

Comment: This study gives us some insight into a few aspects of traction we promote. It validates traction with vibration is not a problem to the cardiovascular system. Additionally muscle activity is diminished generally however at steeper angles (inversion devices) and high-Hz vibration, muscle activity may actually increase. Vibration-plate users recognize this…high levels create increased muscle activity. Additionally the steeper the “inversion” angles the more muscle activity. This suggests moderate inversion and lighter vibration are preferred for pain relief.

Kyungsoo K et al J Phys Ther Dec(6) 2014                                                                                                                                           

Discussion

The biomechanical effects of two-step traction on the lumbar spine were investigated. During global axial traction, the intradiscal pressures at all MSUs (motion units) decreased and this resulted in increased stress on the fibers of the annulus fibrosus in the posterior region. The stress on the fibers of the annulus fibrosus in the posterior region was higher for the L4–L5 and L5–S1 MSUs than for the other MSUs. The results of the current study may explain why protrusion during excessive traction can occur. When the annulus fibrosus is weakened by degeneration and/or herniation, it could be damaged more easily by stress concentration, especially at the L5–S1 MSU. Axial traction therapy should be used with caution in patients with intervertebral disc damage at the L4–L5 and/or L5–S1 MSUs. Thus, 1/3 BW was assumed ideal for global axial traction in this study. Previously published experimental studies have shown that extension motion increases intradiscal pressure at the intervertebral discs (Sato et al., 1999, Rohlmann et al., 2001). Thus, proper local decompression helps decrease the risk of intervertebral disc damage and increases the beneficial effects of reduced intradiscal pressure. Typically, up to half of a patient’s body weight has been used for axial traction force however, No studies have documented the force transmitted through the vertebrae, intervertebral discs, and ligaments, and the translation of the vertebrae during traction and local decompression is also unknown.

Comment: part 2 will discuss what the researchers did and its clinical relevance.