Archive for year: 2016

In a general sense there can be no absolutely accurate ‘traction-force calculation’ since most mechanical attributes patient to patient are unknown. However we have to make assumptions and these are based on both morphology, function, patient condition and duration of pain. It makes sense to “limit the liability” in ALL cases, however limiting the pull force (tension) in ALL cases could let patients needing robust, high-force procedures to slip through “underserved”. The more ‘Acute’ the condition the lighter the pull. Acute both in temporal-terms and level/intensity of pain. Since most moderate or severe LBP (or neck pain) is indubitably a SPRAIN or annular compromise overstretching it early on is utterly counterproductive. The VAX-D protocol called for a 3-4 week “cooling off” period where “real/traction-able/traction-responsive” conditions were allowed to simmer…becoming more apparent after several weeks of natural de-inflammation/healing. After which, persistent symptoms gave a green light to decompression. The more chronic the symptom the more relavant higher force MAY be…but as discussed before; degenerative disc fibers are not infinetly adaptable to stretch, and can sustain injury if overloaded. And that could mean prolapse in the worse scenario.

We seem to agree 30-35% TBW is a good starting point for sub-acute/chronic conditions whose symptoms are LB with or without some pelvic/thigh referral. Sub-acute is typically likely at least 2-3 weeks since onset. Acute presentations (you feel compeled to decompress) its best to stick to 20-30% TBW with a TRAC-short pull (10-15 secs pull/rest, 5-8 min). IF it’s a compromised condition you probably will not have crippled them too badly.

I routinely say: “don’t be dogmatic about high force OR low force”, our rules are guide posts. There are many patients (yes typically big men) who do require (or demand) serious force (90-120 pounds) however more patients require less force and are better served at 30-35%.

In regard the previous blog on “classic herniations” this pre-post MRI series certainly reveals an excellent reduction in hernia size and impact. The frustrating component of what we do, and all of physical medicine is the inability to absolutely know what part of pain relief, healing and improved function are directly attributable to our interventions…vs. time. Voltaire pointed out some 200 years age: “nature heals, doctors take credit”. However in the above series the pain and disability (and the pre film) had persisted with little remission for several months during PT treatments. After 3 months he switched to our decompression treatments and in 5 weeks had a VAS drop from 7.5-2. A post film revealed the extreme reduction in size and impact. His pain eventually went to zero and in the subsequent year  saw no exacerbation. 42 y/o male, treatment was prone with 10 degrees of extension to comfort, 10 minutes at ~70 pounds, 3Xs a week. Laser and extension-facilitated exercises were also utilized.

We designed the articulations of the Neural-flex so a modest ‘Inversion’ position could be achieved by simply pressing two buttons simultaneously on the controller. The inversion posture allows approx. 35° of declination either prone or supine. The Prone-declined position creates a robust ‘unique selling proposition’ especially with the addition of various instrument adjusting procedure (such as Arthro-Stim or similar units). Utilizing the overt muscular-relaxation from the declination adds the selling-proposition that a better adjustment results due to lessened postural muscular ‘activity’. Additionally massage and manipulation are both clinically enhanced with inversion for similar reasons. We suggest 3-4 total minutes of massage (manual or mechanical) then a return to neutral for 10-30 seconds, then repeat. We’ve found good results and excellent patient receptivity to this procedure. Manual distraction (thumbs or thenar) is also easily added as the proximal table section remains unlocked allowing it to slide forward increasing the sense of lumbar and thoracic ‘stretch’. In this position it’s also interesting to try reflexology/foot massage or foot/ankle manipulation.    

Over the past several decades ‘good’ and ‘bad’ posture has been to a large degree based on experimental data concerning the hydrostatic pressure of the nucleus. These studies found that lordotic postures reduce the pressure in the nucleus compared to flexed postures and they concluded that lordotic postures reduced spinal loading. We now know that lordotic postures reduce nucleus pressure only because they transfer load-bearing to the posterior annulus and zygapophysial joints. These structures are frequently sources of back pain themselves, whereas the nucleus is not…so the concept of ‘good’ posture needs to be re-evaluated.

There are advantages to BOTH lordotic and moderately flexed postures dependent on numerous variables including whether one is moving, static standing or sitting or lifting. Recommendations should also incorporate the need for consistent postural ‘adjustments’. Additionally internal disc disruption (IDD) degenerative changes and pain alter load-transfer and increase ‘peak-stress-concentrations’ on the disc further complicating the concept of ideal posture.

In regards the occupational incidence of LBP Nechemson, in 1980 stated that: LBP occurs with about the same frequency in sedentary occupations as those involved in heavy labor. Sitting, especially prolonged sitting is frequently referred to as a potential hazard for development of LBP, a risk that is increased when driving. In general sitting for any length of time results in slouched sitting…in examination it will be found most sit with spine in full flexion. The few who sit upright do so to mitigate pain.

McKenzie (1979) concludes that poor sitting posture is the main predisposing factor to mechanical back pain…this constitutes an inherent fault in our lifestyle. (It is generally accepted now…and it was also accepted in the 1970’s) that LBP can be aggravated and perpetuated by poor and excessive sitting. McKenzie: “it is the responsibility of the therapist to advise and instruct the patient in ergonomic and other methods to reduce and modify postural stress and eliminate predisposing factors” (1979).