Archive for category: KDT Blog

Spine J. 2008; 8(6): 982–990.

A Cadaveric Study

Ralph E. Gay, M.D., D.C et al

RESULTS

All distraction conditions markedly reduced nucleus pressure compared to either simulated standing or lying. There was no difference between distraction with flexion and distraction with extension in regard to posterior annulus compressive stress. Discs with little or no degeneration appeared to distributed compressive stress differently than those with moderate or severe degeneration.

Dr. Kennedy comment: I point to this study to iterate that the effects of distraction are not dependent on “flexion” (or extension). Proponents of F/D seem to believe that there are necessary benefits to the flexion-phase, however it’s benefits are that of distraction: flexion achieved just 65% the ‘decompression’ achieved via ‘distraction’. IF your goal is to create decompression axial distraction-traction is the biomechanical choice…flexing just adds a less-effective transmission of distraction and often untenable stress/strain on spinal structures that prefer NOT being flexed.

We have found 3 primary areas of focus to improve the Decompression ROF:

1. Making the patient aware there is a disc “lesion” likely creating the pain.
2. The lesion will benefit from the treatment modalities we offer because: “decompression (and Laser etc) enhances blood contact, reduces inflammation and can often reduce the size of the herniated or protruding portion. This reduction-phase of treatment will be followed by a stabilization and rehab phase necessary to reduce the likelihood of recurrence”.
3. Correlate the exam findings e.g. directional preference, pressure pain threshold, form closure/”stability”, location, intensity and disability profile with the disc lesion (and if an MRI report is available further validate it to those findings).

We always need to create a compelling story as to why accepting the recommended care is an imperative if the fullest relief is to be achieved.  However, don’t shy away from a “fall back” position (triage or a reduced number of treatments) when the full complement of care is simply not going to be accepted.

BJ Palmer first developed the idea that “pain” was the patients’ calling card, but “subluxation” must be the Chiropractors’ calling card. IF we take the focus off the spine “lesion” and place it squarely on the patient’s “pain” we dedicate ourselves to a false paradigm.

If you think about surgeons, their focus is on the structural stuff they are working on…IF the patient comes out pain-free so much the better…but the patients’ pain is in effect “peripheral” to the surgeons skill and focus.

 

 

Conclusions: “The treatment group was given instructions in reduction of morning flexion; the control group was given six exercises shown to be ineffective for LBP. Significant reductions in pain intensity were found in treatment group vs, control. After similar instructions to the control group the response was similar reductions in pain”.

 

Dr. Kennedy comment: this is a consistently cited study and we’ve discussed the implications at the seminars for years…the natural disc swelling after sleeping imposes ligament tension changes which reduce the neutral-zone in flexion (and rotation). With instruction and specific efforts to dramatically reduce flexion (as well as rotation) soon after arising (and my experience suggests this “control of flexion is always a prudent idea throughout the day) most patients with cNSLBP (the majority of us) can be well served and have days & weeks of disability reduced or eliminated. Interestingly the sham-exercises served no apparent benefit even though they are the most often prescribed for LBP. McGill has referred to such exercises: knee-to-chest, hip side-to-side rolls, toe touches, side bends and the like as “silly and pointless”.

There appears to be less efficient “disc-fluid-reduction” in some patients with cLBP and reduction of flexion for several hours (not just the first hour after arising) serves them even better.

MD’s and engineers have worked for many years to try to unlock the mystery and treatment of discogenic pain. Annular tears and compromises of the outer annulus of degenerated discs arguably disable untold millions of 40-60 year olds. IDAP/Intradiscal annuloplasty (Smith & Nephew name brand: IDET/intradiscal endothermic therapy) is a 20 year old procedure which initially appeared to show tremendous promise but failed to really materialize. The premise is similar to cauterizing a wound; a super-heated needle attempts to both ‘hypercollagenate’ torn tissue and obliterate pain nerves. Freeman and colleagues (2005 Anesthesia) conducted a study on individuals with discogenic back pain and annular tears who failed to improve with conservative treatment. No participant met the criteria for a successful outcome. The findings of this study suggest there is no significant benefit of IDAP over placebo. A Cochrane review suggested the same. Discogenic pain (of which annular “tears” constitute a substantial affect) remains an oft recalcitrant problem. Thus far no one else has come up with a significant and validated treatment. Laser, core control, ergonomics, meds and judicious decompression (when pre-tolerance-classified) are still the most sensible treatments.

This magazine article in July’s The Horse continues a trend toward good press for the profession. Dr. Taryn Yates DVM begins: “equine Chiropractic care is a rapidly emerging field among veterinarians due to increasing demand from horse owners for alternative therapies”. “It is an art of healing that focuses on restoring the spinal column’s normal movement and function to promote healthy neurologic activity”. “Chiropractic can be very useful for alleviating pain in horses with chronic issues…its benefits are greatest when used in conjunction with traditional veterinary care to help keep a horse balanced and performing at his best”. “There are many circumstances where adding chiropractic to your horses’ health care routine would be appropriate, the most significant being signs of pain…behavior changes, abnormal posture, reduced performance sensitivity to touch or difficulty turning”.

 

Dr. Kennedy comment: I have attempted (using an Arthristim, not manipulation) to adjust my and others horses over the year. Never were there any adverse consequences and often very good results. More recently with our older horse we’ve been relying on Diowave 15 watt Laser treatments for a stifle issue. The medical director of Diowave is in fact a DVM and is always enthusiastic to recommend a series of Laser sessions.