Does minor trauma cause serious low back illness?

Spine (Phila Pa 1976). 2006 Dec 1;31(25):2942-9.

Carragee E1Alamin TCheng IFranklin THurwitz E



Prospective, 5-year, cohort study of working subjects.

CONCLUSIONS: Age and sex-adjusted prediction models, including abnormal psychometric testing, smoking, and compensation issues, accurately identified 80% of serious LBP events and 93% of LBP disability events.

In this study cohort, minor trauma does not appear to increase the risk of serious LBP episodes or disability. The vast majority of incident-adverse LBP events may be predicted not by structural findings or minor trauma but by a small set of demographic and behavioral variables.

Dr. Kennedy Comment: This study is yet another (and nearly10 years old) indicating psychometric, financial/compensation and likely lifestyle issues (e.g. smoking) are huge drivers of long-term LBP & disability. But we can’t lose sight of the connection our counsel, enthusiasm, kindness & confidence have in establishing a positive and substantial healing environment. High-power Laser and decompression and ‘movement therapy’ play a major role in those aspects.

From: HealthDay Reporter/WebMD

TUESDAY, May 19, 2015 (HealthDay News) — Doctors often prescribe oral steroids (Medrol) to treat sciatic symptoms – often caused by a herniated lumbar disk.
But a new study finds steroids are no more effective than a placebo for the pain and provide only modest improvement in function.
Sciatica affects about one in 10 people in their lifetime, the researchers said. For this study, 269 people with sciatica were randomly assigned to take an oral steroid (prednisone) or a placebo for 15 days. The participants were followed for up to a year.
“When we compared the prednisone to placebo, there was a modest improvement in function,” said study researcher Dr. Harley Goldberg, director of spine care services at Kaiser Permanente San Jose Medical Center in California. People reported they could go about their daily activities somewhat better than before.
However, “when we compared the pain [between the two groups], there was actually no difference,” he said.


Dr. Kennedy Comment: Many nutritional proponents suggest a “high inflammatory/metabolic syndrome” diet directly influences the pain (and thus level of disability) from HNP. In fact Dr. Seamen reports that MMR and other pain/inflammatory mediators are only “turned on” via inflammatory dietary influences….without them HNP remains “benign”. Perhaps those showing non-response are already too systemically inflamed and even steroids can only provide modest benefit.

A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain Eur Spine J. 2011 Jan; 20(1): 19–39

Marienke van Middelkoop, 1 Sidney M. Rubinstein,2 Ton Kuijpers,3 Arianne P. Verhagen,1Raymond Ostelo,4 Bart W. Koes,1 and Maurits W. van Tulder5

The most promising interventions for a physical and rehabilitation treatment in chronic LBP patients are a multidisciplinary and behavioral treatment approach. All types of behavioral therapy were more effective in reducing pain intensity than controls. Multidisciplinary treatment was found to be more effective in reducing pain intensity compared to controls and active treatments (e.g. exercise therapy, physiotherapy, and usual care) sick leave is also reduced at short-term follow-up. Added exercise therapy reduced pain intensity and disability significantly compared to usual care.

Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial BMC Med. 2011; 9: 128.

Steven Z George, 1,7 John D Childs,2,3 Deydre S Teyhen,3,4 Samuel S Wu,5 Alison C Wright,3Jessica L Dugan,3 and Michael E Robinson6,7

Dr. Kennedy comment: and multidisciplinary practices make significantly more revenue as well. (Chiro Eco June 2015. Practice income profiles), Laser, decompression and adjusting are powerful but the evidence on long term chronic LBP seems more and more to point towards a multidiscipline and behavioral approach.

Double-thumb, segmental specific contact using the Versa-open belt

A cLBP patient with point tenderness at L3/L4 (very common with LB pain without leg referral) had been decompressed/prone over (4) sessions with only short-term relief (Laser was avoided due to a tattoo and previous Ultrasound was ineffective). The response to decompression was good but very short-term so we opted to add ‘manual-contact’ at the most painful segment. The tricky nature of painful segments is that ‘hypermobility’ may be the issue (McGill shear instability test) and thus a mobilization is unlikely the best treatment if long term relief is the goal (cavitation and mechanoreceptor affects likely giving the temporary relief…and if L5 is hypermobile but you want to move L4…the cavitation is still more likely to occur at L5). The advantage of an axial pull with a harness is that it frees up both of the clinicians hands (in this case thumbs) for direct, segmental specific manual treatment. The contact is I-S and the amount of pressure in other planes of motion is to the doctors’ discretion. I found more right-sided pressure gave immediate benefit and after 2 (8) second pulls there was a loud cavitation ‘apparently’ at the L3 level, after (4) manual-contact sessions the patient improved markedly and began low-tech rehab.

Spine (Phila Pa 1976). 2007 Mar 15;32(6):681-4. Disc degeneration in low back pain: a 17-year follow-up study using magnetic resonance imaging. Waris E1, Eskelin M, Hermunen H, Kiviluoto O, Paajanen H.


Early DD in adolescent patients with low back pain predicted the evolution of enhanced DD and herniation in adulthood, but it was not associated with severe low back pain or increased disability or frequency of spinal surgery.

Dr. Kennedy comment:  Many population studies (some as early as 1990) conclude MRI findings rarely dispose a patient to an accurate diagnostic or future outcome profile. Twin-separation studies also conclude DD is likely highly familial. Focusing on impaired motions, ergonomics, psychological risk factors and attending to the patients’ pain (and not on MRI findings) is still the most reasonable approach.  JACA 13 years ago (spring 2002) recommended DC’s use caution in relying on and being too quick to recommend MRI for typical back presentations. That remains even truer today given the many studies like this.

Vibration during supine decompression: Med Eng Phys Nov. 2014

The combination of 12 Hz vibration along with traction (angles greater than 10° for Lumbar erectus) could provide a better treatment for reduction of lower muscle fatigue for back pain compared with either vibration or traction alone.
This is one of the conclusions of a 2014 study from China investigating the effect of axial traction with vibration along the X-axis. They were looking to see if vibration had an adverse effect on blood pressure or pulse pressure…which it didn’t. They determined muscle activity was reduced and such decreases could significantly improve the benefit of traction and muscle discomforts. In some cases vibration isn’t tolerated by the patient but there is no known mechanism by which it could ever really worsen any condition. If the patient complains, don’t force them to use it. However vibration does give a more potential unique selling proposition to a percent of your patients and its’ worth exploiting when possible.

Are minimal, superficial or sham acupuncture procedures acceptable as inert placebo controls? Lund I1, Lundeberg T. Author information

Dr. Kennedy comment: Here is one of the most intriguing and interesting discussions on acupuncture I’ve seen. Not only does it present an important challenge to the procedure but presents a great potential neurologic explanation. It’s important to note that recent studies utilizing electro-acupuncture during traction demonstrate subjective benefits vs. either alone.


Most controlled trials of acupuncture have used minimal, superficial, sham, or ‘placebo’ acupuncture. It has recently been demonstrated that light touch of the skin stimulates mechanoreceptors coupled to slow conducting unmyelinated (C) afferents resulting in activity in the insular region, but not in the somatosensory cortex. Activity in these C tactile afferents has been suggested to induce a ‘limbic touch’ response resulting in emotional and hormonal reactions. It is likely that, in many acupuncture studies, control procedures that are meant to be inert are in fact activating these C tactile afferents and consequently result in the alleviation of the affective component of pain. This could explain why control interventions are equally effective as acupuncture in alleviating pain conditions that are predominantly associated with affective components such as migraine or low back pain, but not those with a more pronounced sensory component, such as osteoarthritis of the knee or lateral epicondylalgia.

Don’t forget the “hook” under your table top…!

Don’t forget the “hook” under your table top…!

In case you haven’t watched the various videos on the Kdt table operations its worth reiterating that below the ‘U’ cut-out in the leg support section there is a ”hook” in the shape of a (7). It’s worth repeating that the hook serves a very important function, both for patient comfort (and safety) as well as for mechanical efficacy. When we “break the plane” of parallel of the lower body section (Prone treatment accommodating neural stress signs) or drop the table from its’ fullest height the lower belt strap can pull up into the pubis. Additionally the ideal axial pull on the pelvis is reduced and an upward tension is created. So if the prone patient is placed in the “neural-flex” position (caudle section flexed downward) the tail strap needs to be placed under the hook which will keep it from lifting upward.

Also If you intend to do any “hands-on” procedures i.e. “distraction without-flexion”, trigger-points etc. or require the patient to be lower than the full table elevation height (such as when doing Laser or Ultrasound with the “open” Versa belt) the hook should be used as well to restrain the belt from lifting and to maintain the “axial” pull.

Disc degeneration in low back pain: a 17-year follow-up study using magnetic resonance imaging.

Spine (Phila Pa 1976). 2007 Mar 15;32(6):681-4.

Disc degeneration in low back pain: a 17-year follow-up study using magnetic resonance imaging.

Waris E1Eskelin MHermunen HKiviluoto OPaajanen H.


This study, which began in 1987 is yet another indicator of the difficulty of using MRI (unarguably the most sophisticated imaging process available) to predict future pain or LBP disability. As has been noted in at least a dozen “follow-up” studies over the last 25 years very few findings are associated with actual patient outcome i.e. disability, future medical costs, future pain or severity of future pain. What is interesting is that early findings of degenerative disc  “disease” is generally indicative of progression of degeneration (in this case over the next 17 years) however those changes were not able to predict future pain and in fact were not directly associated with pain, severity of pain or disability. It is immensely tempting to want to MRI everyone and, as patients tend to believe; “find out what’s really going on”. The trouble is knowing what’s going on hardly ever tells us what’s actually going on…and that’s doubly frustrating due to the fact 80% of the population with the same findings are not in pain.

J Orthop Sports Phys Ther. 2004 Nov;34(11):701-12. Intermittent cervical traction and thoracic manipulation for management of mild cervical compressive myelopathy attributed to cervical herniated disc: a case series. Browder DA1, Erhard RE, Piva SR.


For those of you who have some reservations doing spinal adjustments on the cervical spine in the face of radiculopathy this study offers a viable alternate regime. The patients all had various duration of cervical compression syndrome and received (9) sessions of intermittent cervical traction along with thoracic adjustments. Treatment duration averaged 50 days.  The majority of patients showed good reduction in all subjective indicators. It’s interesting to note several studies have proposed adjusting/manipulation of the thoracic spine appears to have distinct benefits to both cervical pain and especially headaches (though my experience with cervical pain without impingement issues certainly indicates cervical adjusting along with thoracic works better than either alone). Since the spine is a continuous column and the network of muscles act as guide-wires etc this shouldn’t be too surprising.

If you are hesitant to do a cervical rotary (or P-A) manipulation due to myelopathy symptoms the combination of thoracic adjustment (generally done in the “anterior” position which can better maintain the neutral skull) and Kdt cervical procedures of 30 sec hold/15 sec rest  10-15% total bodyweight initially) are a proven option.