Archive for year: 2016

Sari et al in Physiotherapy Theory Practice (2005) assessed (via CT-scan) 32 patients with HLD during and post-traction treatment and made detailed quantitative measures. The authors discuss that this was the first study to offer detailed analysis and quantitatively evaluate the effects on spinal structures. Their findings include a decrease in size of herniated disc material, widening of foramina, increased disc height and decreased psoas thickness. The spinal canal and foraminal increases were 22% & 27% respectively. The effects of traction were also assessed in different locations (median & posterolateral) as well as different spinal levels.

Ozturk et al in the journal Rheumatology Int (2005) also investigated traction in a randomized cohort of 46 patients 24 who received traction along with a standard PT regiment. Size of the herniation decreased only in the traction group and pain relief appeared concomitant. They noted patients with the largest herniations tended to respond better to traction. (A phenomena we have noted for years as well).

Kamanli et al in 2010 evaluated the addition of traction to a standard PT program and noted conventional PT with traction is effective in treatment of sub-acute LDH. Most interesting was the finding of a “significant decrease in hernia size in 5 patients but an increase in 3, however clinical improvement was equal in both groups. Their conclusion: “patients with Lumbar disc herniation should be monitored clinically” (as opposed to making direct clinical judgments based predominantly on MR findings).

Eur Spine J. Apr;22(4). 2013.

As has been reported for the last few years, infectionary-processes may account for a substantial percent of cLBP. For instances Stirling et al found 53% of patients were infected with P. Acnes in nuclear tissue removed under sterile conditions. In a cross comparison of patients with herniation vs. scoliosis, fractures and tumors over 37% of herniation patients were infected with P. Acnes.

The authors conclude IF skin contamination accounted for the bacterial presence the percentage of patients would be similar.

It is thought that these anaerobic mouth and skin commensal organisms gain access to the disc during normal bacteremias as a result of neo-vascularisation associated with disc degeneration or herniation. Local inflammation in the adjacent bone may be a secondary effect due to cytokine and propionic acid production i.e. the infection is in the disc and the Modic change is a “side effect” manifest in the bone. P. Acnes cannot live in the highly vascularized/aerobic bone and is not present.

Much discussion centers on the importance of the traction force (tension). Our experience after more than 2 decades of use perhaps seems counterintuitive however we’ve found the amount-of-force is only marginally connected to improved outcome but substantially connected to increased pain or iatrogenic (negative) outcomes. Not that there is a direct analogy to the SAID principle however like overtraining, over-stretching or burdening the spinal structures with tensions they cannot easily adapt to is not clinically sound.

When we lie down and eliminate Y-axis compression disc-osmosis begins (in those discs still hydrostatic). Adding a modest axial-tension enhances that effect. In perfectly healthy structures its likely very large forces can be quickly adapted to and no injury results, however virtually every “patient” will have desiccation and degenerative changes, especially in the posterior annulus. This compromised tissue has a poorer adaptation to rotation and axial stretch. A 1/3^rd bodyweight (or less in some cases) is still the best starting point. We add 5-10 pounds only after the first 2-3 sessions where full tolerance has been proven but subjective indicators are not changing. You can add the force after the 2^nd pull (on most traction units you can do this on-the-fly). The rest force (20-25 pounds needs not be altered…and this remains true irrespective of the pull-force).    

Very few of us need a tutorial on using a drop-piece for pelvic-rotation adjusting. The Neural-flex incorporated a crisp, effective drop-piece into its normal articulating segments last year. The premise was to afford the doctor the ability to adjust relevant PI/AS pelvic rotations (pre or post NOT during the pull) decompression to reduce time and improve office flow. Adjusting is what most patients anticipate Chiropractors will do…though many sessions of course may not include it for a number of reasons. However addressing the pelvis (leg asymmetries/bony landmarks & palpatory findings) via a drop-adjustment affords one more plug-in to captivating and “controlling” the patient. IF an adjustment Pre-or-post decompression (based on chronicity of condition) is given importance in the ROF and continues through the treatment the patient is more likely to recognize your intervention as unique and well-directed to their condition. Creating a compelling clinical sequence regarding the decompression, modalities and drop-pelvic adjustment is one more way of improving retention and addressing the patient’s condition more accurately.

That most orthopedic tests haven’t been proven definitive in diagnosing some or most musculoskeletal conditions is a given. In fact even those tests with good inter-reliability suffer with short comings in validity. Laslett, Bogduk et al did a systematic review in 2010 to determine whether tests could accurately determine a disc vs. facet vs. an SI joint and found the answer to be “generally NO”. However most experts suggest a barrage of tests (with the majority negative (or positive)) give an acceptable odds-ratio as to the likelihood of involvement. This is more so the case with the SI joint vs. facet or disc.

The above picture from SI-Bone suggests a clinical testing procedure with the (5) most diagnostically-relevant SI tests. IF (4) of the (5) are positive there is a 75% likelihood the SI may be involved. The opposite is true as well ((4) of (5) negative). However other studies suggest the MOST relevant tests are the THIGH TRUST and distraction/compression. These (2) tests tended to give the strongest indications.