Firstly, there is NO such thing as a decompression table, system, device or motor. There are traction units, machines and motors (this according to the ONLY viable authority to which to appeal such questions, the FDA) all of which have the ability to create an osmotic/centripetal-effect (decompression) in a hydrostatically active and able nucleus. ALL devices have 510K clearance as traction machines.  Click here to view the searchable FDA Cleared database for traction.  They all use predicate devices and deny any “new” status requiring extensive research or product repositioning (or FDA “new device” classification. And it is worth noting patents do NOT prove efficacy or technological “advance” per se). Decompression is an outcome, traction the mechanism utilized. We can rationally interchange these words but have to always keep in mind the science behind it: (dis)traction via recumbent position & distraction creates decompression. Decompression is spinal (disc) unloading to create an osmotic fluid in-flow. Traction is literal, decompression somewhat metaphorical, that is when and IF a significant pain relief results we assume decompression and its’ phasic, physiological attributes were the likely source (but even this mechanism is just one of several plausible reasons for relief).
The public has become enamored with the term decompression. It is by no stretch a dishonest market strategy that both manufacturers and clinicians position traction therapy as decompression…it isn’t lost on most clinicians that decompression just sounds more substantial, scientific, effective….and sexy! And in fact is likely the inherent operative “value” traction offers.
In addition this book represents a concise compilation of ideas & clinical research relating to classification analysis, Form/Force closure tests (FmCl/FcCl), the ATM2 device and some discussion on pertinent modalities & exercise that make traction clinically efficacious. The illustrations demonstrate many of the concepts and set-ups discussed including the simplified testing, evaluation procedures, belting and exercises. (There are many video-tutorials already posted online through Mir-Com Products demonstrating all the pertinent aspects of the table and its’ procedures so multiple resources are available if you feel certain information herein is lacking or seems incomplete).
Though by no stretch can this technique be considered original research (or are the basic assessments of my invention) I did combine several of the more utilitarian concepts which could be sensibly related to axial traction and then gathered extensive input from clinicians. Together I believe they make the classification & therapy more directed, practical and clinically effective.
The in-office Kdt/Comfortrac cervical traction-therapy unit affords a simple, clinically effective means of delivering axial-traction to the cervical spine. It is the first new in-office unit introduced in over 20 years. It has all the attributes necessary to comfortably position a patient in cervical traction and yet is designed as an ultimately simple and esthetically pleasing device. It is meant to afford beneficial treatment at the lowest forces possible. As will be discussed we strongly suggest a calculus for the cervical spine of ~10% (sometimes less) total body weight, at least as a staring force. This correlates well with new research regarding both patient safety as well as comfort.
In a 2014 study on cervical traction (Fritz et al JOSPT 44(2)) the initial force utilized was just 12 pounds. The author’s conclusions:
“Adding mechanical cervical traction for patients with cervical radiculopathy resulted in less disability at long-term follow up”. The final section of this text offers a cervical decompression discussion including further details of the above noted study.

Continue reading What is a decompression traction technique?

Chiropractic & techniques have had a long history and have tended to be good bedfellows. Of course the word technique can be applied to virtually any activity as it is defined as: a practical method applied to a particular task. In creating a means to disseminate new methods and clinical insights in Chiropractic it appears to make sense to term the exploit a technique. However many techniques are based more on the cult of personality than facts. Our information is based on many personal clinical insights for sure, however many pertinent and well researched physical medicine concepts & protocols are appealed to including form closure tests, directional preference & centralization of pain.
Many of the standard protocols and procedures are up to 40 years old. This may lend credence to the therapy (that it has changed so little) or it may mean no new insights have really been introduced. Even the newest, revolutionary decompression systems from major manufacturers are either borrowed from previous technology (axilla posts for instance appear in a 1961 study by Crisp and friction-free pelvic sections were standard-fare by 1970) or fabricated from manual therapy methods….And most simply to create product differentiation for their sales force.
Our decision to create a decompression technique is based on several important points not the least of which is to create a reason-centered approach and to counter the hyperbole of the magic machine. Again, though 20 years have elapsed since decompression (contrasted from traction…) was introduced to Chiropractic, as of 2014 advertisers continue the unsupportable: Traction is NOT Decompression. Why the differentiation regarding traction and decompression remains almost sacrosanct in some clinician’s eyes is enigmatic.

Continue reading Let’s be realistic

Decompression/traction is one therapy among many and like most has more opinions than facts. It certainly has both strident critics and dedicated supporters. I will put myself in the latter camp however I temper my support with an ample dose of realism. What can’t be misunderstood is that decompression/traction is optimally beneficial when used as a part of a multi-focused treatment regimen…not as the sole intervention.
In regards any therapeutic intervention we need to recognize the shortcomings of diagnosing ‘back troubles’. Bogduk and others point out: “discogenic pain cannot be diagnosed clinically with any degree of certainty” and “although many contentions abound (as to the source of back pain) few have been validated”. Additionally they point out: “it is quite striking that no single form of treatment is able to improve on the natural history of the phenomena”. This is very much the turmoil of decompression (and Chiropractic in general). It can be described as a parsimonious approach to a chimerical problem (seeking a single, silver bullet answer to a problem which is unequivocally multi-factorial, multi-dimensional). What isn’t lost on most insightful Chiropractors is the realization that there are over 50 techniques, each boasting hundreds or thousands of adherents…all quick to point out their “remarkable” and consistent success rates. In fact it is stunning how financially successful practices which utilize only ONE technique can be (such as Activator or upper cervical). And likewise how many successful practices combine multiple approaches with great success. All seem to describe the inevitable “+80%” success rate (though many decompression shills routinely say their particular system garners 90-95% success). Every technique has both shared and disparate diagnostic criteria and treatment classification(s). Many of these methods of classification are most accurately described as opinions and not technically validated. I believe however traction as part of a multi-focal treatment is a valid aspect of an “evidenced based” treatment approach for low back pain with referral (whether somatic or radicular).
The latest research is reinforcing that concept as well.

Continue reading What is the difference between traction and decompression?

This inevitable question still causes me to stutter…because if decompression is exposed as nothing but “pelvic traction” doesn’t it discount the very premise that got us here in the first place i.e. decompression isn’t traction because “traction doesn’t work and decompression does (?)”. Firstly, No one has determined traction (lumbar or cervical) doesn’t “work”, simply that there is a dearth of high-quality research capable of convincing insurance adjudicators definitively either way (but of course there are innumerable clinicians and patients who believe otherwise and new positive research is beginning to appear). And secondly new research (just as with manipulation) continues to be burdened by the inevitability of heterogenic populations and the ineffable “self-limitation” of pain, placebo effect(s) and the effect(s) of synergy of treatments. So on the one hand we don’t want to curtail clinicians from getting involved in “decompression” therapy by so diminishing it as to make it pointlessly similar to old-time hospital traction (which never really worked too well) yet we don’t want to cultivate the same lies and hyperbole of the hyper-expensive decompression manufacturers. The reality of the differentiation from a scientific viewpoint is this: it is made up…it is junk science. Decompression differs from traction in doctor skill, table versatility & comfort and the synergy other therapies add… and not solely in the attributes of the machine doing the “pulling”.
Decompression is a codified, patient-classification based application of axial traction with the intention of decompressing a compressed structure i.e. a disc. The inherent reasons are to enhance metabolic processes via osmosis, reduce neural pressure, alter pain perception via stretch and reduce muscle hyper-activity. All of these outcomes are intended to reduce the pain of disc disruption/herniation, nerve irritation and the compression associated with the involved tissues …often temporarily but also very often long term especially when sensible spine-sparring (McGill) rehab, modalities and ergonomic education are added.

Continue reading Muscle guarding

It (decompression “technology”) stems from the misguided, ignorant or nefarious perpetuation of the concept that muscles (either paraspinal global muscles or more implausibly, local muscles) “guard” the spine from elongation when a traction force (tension) is applied. This “guarding” or axonal spasm “locks down” (as one decompression “educator” puts it) the spinal segments from separating. Without segmental separation you cannot achieve disc decompression (centripetal effect). The difficulty for the honest and scientific educator and investigator is that this premise is simply (and demonstrably) untrue. Additionally it can’t be overemphasized that the entire concept of “guarding” is based on the accidental or purposeful misinterpretation of a 30 year old Nachemson study comparing passive traction to active-traction/Auto-Trac (where active pulling by the patient contracts muscles and decidedly increases disc compression). And regrettably it stands as the ONLY proposed mechanism separating traction from decompression (machines). The decompression machines house magic “logarithms”, “servo-motors” or “oscillatory actuators” that defeat this anatomical chimera (spasm). These magic-machine attributes are of course inherently hidden from scrutiny and comparison and remain unique-selling-propositions for the salespeople to exploit and use to denigrate the competition.
We can’t put too fine a point on the reality discs imbibe fluid when compressive stress is eliminated (even when recumbent). This occurs consistently and demonstrably but ONLY in the discs capable of fluid (osmosis) inflow i.e. hydrostatic. That eliminates the likelihood of decompressing a severely degenerated disc or an uncontained disc (two types of lesions routinely targeted for the therapy and the types of lesions decompression systems like to tell you can be “fixed”). Relief is obviously different from “fix”.

Now we have this specious differentiation of decompression on the one hand but we have viable repositioning of traction…in effect the reduction of the misapplication on the other. Decompression is in effect expertly delivered traction with the intention of creating decompression (where the body can). Decompression traction is codified, consistent and utilizes clinically reasonable protocols. I mentioned earlier that one reason the Kdt systems are more aesthetic and sophisticated looking (and with several more utilitarian features as well, including inversion, vibration and caudle flexion) is to attract positive attention and enhance the salability of the therapy to the public. Instead of making the modern “decompression” system LOOK like an age old “traction table”…and thus possibly be dismissed as a worthless intervention, we chose to also reinvent not only its’ utilitarian attributes but also its external appeal.

Continue reading A brief disc primer

Where tractions effect as decompression can be viewed as valid, at least in theory is in stimulating disc metabolism. The discs constitute the largest avascular structures in the body (as well as approx. 6” of our height). They have such low cell density as to be incapable of remodeling the collagen fiber bundles of the annulus within the working lifetime of an adult. Nucleus cells respond to cyclical stretching by proliferating and producing more collagen. These cells may be capable of behaving like fibroblasts or chondrocytes dependent on the mechanical environment. This diffusion model of improved healing from cycles of pull/release has been promulgated more than any other aspect of decompression. It is perhaps the most viable explanation as well. Lacking a direct blood supply discs rely on diffusion with approximately 50% from the peripheral margins and 50% through the endplate from within the vertebral body. Glucose and oxygen pass in based on osmotic gradients and waste products such as lactic acid and carbon are expelled out. Motion facilitates this flow. Flexion, which reduces the diffusion path length into the posterior annulus can enhance metabolite diffusion into the inner posterior annulus; the area with “the most precarious nutrient supply” (thus traction is best delivered recumbent). It is suggested as well that flexion increases the surface area of the posterior longitudinal ligament perhaps helping to funnel metabolites. Cyriax proposed traction as expedited bed rest, without the disuse side-effects. He also speculated hernias could be pulled in and off nerve roots. This has actually been shown to occur in in vivo and in vitro studies (in CT scans and motion radiographs) though the effect is while the traction is occurring. Perhaps adding mechanical traction in some patients profoundly expedites this diffusion and thus triggers a healing effect including phagocytosis. We do know from clinical experience it simply doesn’t occur in everyone. Gay et al; Spine (2007) suggest distraction appears to predictably reduce nucleus pressure though the effect is probably dependant on the heath of the disc. A severely degenerated disc has a fibrous nucleus which no longer acts like a hydrostatic mechanism (a pressurized fluid). This would obviate tractions effect in moderately severe desiccated discs. Degeneration has also been shown to allow in-growth of blood vessels and nerves generating pain in regions typically painless. (Disc degeneration doesn’t necessarily occur uniformly and can account for atypical bending patterns [atypical directional preference/migration effects] and the potential of traction having a decompression effect on an apparently degenerated disc). A lot of damage to the disc occurs with repetitive flexion with compression and these injuries will often result in endplate damage/fracture. This leads to a matrix degradation at the disc attachment to the endplate and assures a thin disc within a few decades. Bogduk refers to this as isolated disc resorption and accounts for the somewhat counterintuitive finding of just one bad disc out of the five.

Continue reading IASP

The criteria prescribed for diagnosis by the International Association for the Study of Pain (IASP) require reliable and valid tests specific to the tissue(s) allegedly involved. In contemporary practice these criteria cannot be satisfied (Bogduk, Adams). This includes ligament and muscle sprain, muscle spasm, trigger points & segmental dysfunction. Yikes! Check out Wikipedia and the thoughtful (and accurate) discussion of muscle spasm and ask yourself, though 728.85 is used ubiquitously as a diagnosis it hardly qualifies as a viable, valid or reliable finding. Back sprain/strains fall under the same burden. Interestingly WebMD and the Mayo newsletter, among others still suggest muscles are the leading cause of most acute and sub-acute back pain. This suggestion however gets little support when the science is scrutinized. To diagnose even a simple strain/sprain requires us to define the exact tissue, extent of injury and internal architecture of the injury. This isn’t really possible with any available testing methods readily available to a Chiropractor. Interexaminer reliability studies on our most favored methods rarely suggest agreement beyond coincidence.
Where we do agree; leg length inequality, pressure pain threshold (PPT) and global posture alterations we tend not to understand or agree as to what they actually mean. We can identify them but we’re left with a gap in the actual understanding of how they might be affecting us e.g. a decreased PTT is deduced by some as vertebral hypo-mobility and other hyper-mobility. The roots of most musculoskeletal conditions are so deeply embedded in both our complex anatomy & neurology as to overextend the reach of our understanding. Like the genesis of a forest fire the evidence is often consumed by the time we can investigate it. Thus the myriad of methods and experts and testimonials of satisfied patients convinced they had whatever the clinician was looking for…and the clinician convinced they cured whatever the patient had. One of my favorite saying regarding what works for back pain: “everything in general, nothing in particular”.
However we, as practicing clinicians have to do and say something when patients come to us in pain. To try to codify what we do know (or think we know…) is far more reasonable than to continue suggesting we know what we simply can’t (like which exact bone is out-of-place), or to believe in untenable, parsimonious propositions with little hope of scientific validation (like “my ‘magic’ decompression system has a 95% cure rate and can make a degenerative disc like new”).

Many of the tests available fail to show distinct validity OR reliability. Thus they tend to fail to actually create “diagnostic prevalence”. And perhaps more sobering is the suggestion that even IF we were to accurately classify the exact tissue source of pain, such knowledge may be of little inherent value unless you’re planning on doing surgery. Other tests, which include directional preference (typically 75% extension) and antalgic or translational shifts of the torso suggest perhaps a ~60% ‘prevalence’).

Continue reading Interest in traction as “axial decompression therapy”

Interest & enthusiasm in mechanical traction as decompression therapy has continued to grow in the Chiropractic profession (and to a lesser degree the medical profession) over the last dozen years. I believe I have been part of the fuel for this interest with consistent (and I’d like to believe honest) lecturing, inventing and writing on the topic…and the introduction of clinically effective low cost units. We have seen a big upsurge in just the last few years as discussion of its clinical effectiveness and profitability have become more widely circulated (and insurance reimbursements on other things further decline).We are also seeing unprecedented acceptance and referral from MD’s as they further recognize the weaknesses of their approach and the sensible nature of traction in many cases. We’re likely seeing an approaching tipping point in the Chiropractic profession. Just as flexion/distraction (F/D) and functional foot orthotics have all gone from fringe interests to ubiquitous interventions we’re likely to see traction in a majority of clinics sooner than later. The DTS & the Kdt traction systems have opened the market to thousands of DC’s many who have become vocal proponents. The introduction of these low cost ($10-12,000.00) decompression traction platforms and the alignment with reputable clinicians has fostered the sale of well over 4000 units. Since the 2002 launch several other low cost systems have entered the market continuing to undermine the high price, magic-machine hyperbole that had initially created the interest. Most however offer little real innovation and are just trying to capitalize on the growing market.

Continue reading Decompression re-invents traction

Decompression has been able to resurrect & reinvent traction therapy to a more desirable, interesting and profitable package…especially to the Chiropractic profession. The VAX-D entered the Chiropractic arena in 1993, heavily marketed at $125,000.00 by the David Singer Enterprises. The medical profession (who operated close to 60% of the VAX-D & DRS systems) had scant little interest in traction therapy but has been captivated by magic scientific decompression machines. VAX-D had initially sought medical exclusivity but learned early on that Chiropractors were much more amenable to the concept. The vast majority of clinics had both an MD and DC on staff.
The downside of this (besides the $125,000.00 price tag) was the misinformation, hyperbole and less than honest characterizations of what was actually occurring and possible. As suggested by most authorities decompression is an outcome of traction…they can’t be seen as exclusive or independent.
By some estimates only ~20% of the profession is actively utilizing decompression/traction therapy (2013)…this ostensibly after one of the biggest advertising blitzes ever presented to our profession.
On the positive side the more doctors who become involved with traction/decompression the more likely pertinent questions and demands for viable scientific answers will occur. Additionally the more clinically adept proponents of decompression NOT using $30-100,000.00 systems become the greater the likelihood the hyperbole and mischaracterizations of magic machines will disappear completely.

Continue reading VAX-D, DRS

Without much argument most would agree Decompression as a defined therapy began with the expertly marketed VAX-D (vertebral axial decompression/VAT-Tech Inc.) in 1992-93. The era of decompression of the disc via a quasi-magic, pseudo-scientific and very expensive table mechanism was launched. The initial price of a VAX-D in 1994 was $125,000.00. The marketing differentiation between traction and decompression was often analogized as that of an MRI vs. an X-ray. Though no such differentiation technically existed the marketers were able to finely weave pseudo-science, a compelling lexicon and the lure of high clinic profits into a white hot enthusiasm. This enthusiasm was brought to fruition by leasing companies granting a generous $2250.00 per month, closed-end 60 month term lease.
VAT-Tech coined the term time/force logarithm (and was also granted a utility patent for it) to explain the supposed mechanism of action and the differentiation between traction and decompression (the ability to overcome muscle “guarding”)…and not surprisingly only available in their system. Their marketing focused on this mechanism and thus created a table-dependant therapy. (I like to point out that a utility patent does NOT prove efficacy, the patent office doesn’t test stuff…but only that the device or product is not available in the prior art). Other devices followed, none all the time. They state: decompression is an “event”…to be honored as exclusive apparently intending to truly develop the science of traction or to mainstream it for the masses.
The interesting genesis of decompression therapy actually includes a very short list of characters. Allan Dyer MD developed the VAX and the DRS (credited to Norman Shealy MD though their actual mechanical development included others including the Accu-Spina’s oscillatory actuator patented by Bacerra et al in 2004). This competitor to the VAX-D, the DRS (Decompression, Reduction & Stabilization) was introduced in 1996 by the same marketers which had sold over 75 VAX-D systems. A pending lawsuit between the parties is what apparently fueled the development of the DRS. The VAX-D’s prone-only, arm extended restraint afforded the supine-only DRS an area to exploit, namely perceived comfort and shoulder safety. Though it is hard to say what real scientific investigation entered into either parties’ designs they both had obvious utilitarian features. Interestingly the more basic design of the DRS (which was a standard traction motor installed in an elaborate tower and a split traction table) opened the eyes of other marketers (Lordex, Axiom, DiscForce, Spina/North American Medical LLC) to produce elaborate looking traction machines and branding them “Decompression”. Often running ads with the wholly unsupportable (and likely illegal): Traction is NOT Decompression.

Continue reading Mega structures and exaggerations

The marketing direction of the most egregious of the manufacturers was (is) to build imposing mega structures, full of lights and beguiling contrivances. They up the clinical rhetoric to suggest almost miraculous outcomes virtually to those utilizing high-priced “advanced” technology. They overstate the potential of their machine, create elongated treatment regimes that easily coincide with the natural resolution of many disc herniation(s) and never create an honest cross-comparison to less expensive systems operated by PT’s or DC’s with traction expertise. (Further they often unflinchingly force the recumbent patient to endure a video on how they should refer more patients for what is often a prohibitively expensive and poorly administered treatment regime).
That they can still captivate a buyer into shelling out $30-100,000.00 (or getting a +$2000.00 per month lease) is testament to the potency of these strategies…and to the dearth of a substantial clearinghouse of counter (truthful) information. Though it may also point to an inherent desire to want to believe in a miraculous therapy, one which obviates extensive clinical reasoning and does the job for us! (Of course one needs only visit EBay to recognize how long the ‘magic’ honeymoon lasts). I have also encountered clinicians convinced that there must be a $90,000.00 difference in outcomes with these systems…”If not how could the government (FDA) allow the sale of them?” That one is easy…the FDA is understaffed and has bigger fish to fry (most of the time).

It is readily apparent to me that the prolix non-sense required to differentiate “traction” from “decompression” by these folks tends to prove the absurdity of their claims. There is simply NO substance to their discussion. IF there was a real reason “traction machines” were NOT “decompression machines” they wouldn’t need to hide it behind vague, confusing and wholly unsatisfying jargon (and the VAX-D would be on every street corner solving the worldwide back pain epidemic). And there wouldn’t be thousands of clinicians NOT utilizing these supposed “decompression units” getting equivalent results. Nor would the FDA have chastised the VAX-D and afforded ANY cleared traction device the use of the term “decompression”…and “traction achieves results via decompression”.
It is also interesting that one particular manufacturer suggests it is inappropriate to borrow research done on a device and vicariously apply it to another device. This however is impossible to logically apply to traction therapy as all published, peer-reviewed research ALWAYS refers to the treatment as traction (If this suggestion is taken to its most deleterious conclusions we would be unable to suggest manipulative therapy in clinical trials is applicable to our practice…since it wasn’t our manipulative therapy). When it comes to traction therapy be assured virtually ALL research on ANY machine is applicable to your tractioning-machine as well. Where discrepancies erupt is in patient positioning and force. I believe it is a persuasive argument (based both on biomechanics and my own experiences) that prone traction outcomes…and at lower force, are NOT directly equivalent to supine treatments (or higher force). These positions constitute a major disparate form of the traction application and thus could have a decided effect on outcome(s). The same holds true with force and patient restraint(s).

Continue reading More of the story

Though the magic-table has apparently been very lucrative for many manufacturers regrettably it has had devastating effects on untold clinicians not to mention their patients. We have heard stories of DC’s charging elderly patients in excess of $8500.00 for 20+ treatments, suggesting they can “rebuild” their degenerated discs.
Many doctors were often compelled into their purchase with the suggestion of medically verified 86% success rates (or better). Their patients then being charged thousands of dollars for an often inappropriate (and most often inappropriately applied) therapy…most doctors getting their training from a sales rep or marketing “wizard” sorely unfamiliar with any pertinent traction research. This still remains perhaps the most common method of decompression training in the US. Patients were (and are) very often sold an elongated series of treatments using questionable tactics of fear and intimidation. The treatment length often well within the typical self-healing time frame of many disc lesions (something well known by many of the manufacturers I suspect). The study No effect from IDD therapy for cLBP a RCT Spine 2009 exemplifies this point. Of course many other clinicians, unable to muster the confrontational sales tactics necessary to thrive were buried under the weight of the lease payment. (EBay has become one of the most potent means to prove this point with over 100 decompression systems available at any time). Besides the damage this can have to Chiropractic’s public reputation I believe it has severely derailed any hope of a truce with the insurance industry regarding traction. In fact we have seen sweeping judgments across the country from carriers now denying many types of traction described as “decompression”. CPT ascribes an RUV of 4.2 for mechanical traction and that typically translates to $8-9.00 payment. Though not as lucrative as we’d like it is an unattended therapy (on relatively low cost equipment) done for about 10 minutes. Having the ability to be reimbursed by insurance is not something all clinicians are enthusiastic to eliminate.

Continue reading Traction as an intuitive intervention

Traction, more than any other passive therapy is intuitive…if compression hurts, decompression should be relieving. A recent study in JOSPT 2012: Clinical test to determine who may benefit from axial decompression demonstrated that patients with cLBP who didn’t show improvement to “realignment/repositioning” or form/force closure invariably showed relief with modest “decompression maneuvers” (modestly lifting the torso or suspending the pelvis while seated etc). Most patients don’t complain to their doctor that their searing low back and sciatic pain would go away if someone would just give it a good “crack”. However many patients perceive a good “stretch” could be of great benefit. Most inherently recognize they are hurting with compression.
The major problem is that generally speaking compression hurts as long as the activity is occurring and decompression is often relieving as long as it is occurring. The hope of improved classification and treatment is that there will be a long-term improvement…over time. Good long-term results seem to suggest all factors were right…again pointing to patient selection classification and homogeneity of patient condition.
IF “unweighting or unloading due to position & distraction” (the FDA’s definition of non-surgical ‘decompression’) can actually trigger a healing reaction the patient should continue to get better each treatment. This is the promise of decompression but it has not, as of yet been verified in structured and repeated research…it remains theoretic and empirical. It certainly is a consistent finding of most clinicians however. (Many skeptical investigators assume either care-giver/placebo results, recall bias or perhaps simply forced rest may be the reason for results). It has also been speculated that in much of physical therapeutic procedures there is a perceptual misinterpretation i.e. intervention is mistakenly credited for natural self-limitation & healing. As was pointed out previously most back problems tend to wax and wane, exacerbate and reduce over our lifetime with only ~15% of people having chronic, unremitting pain. Degenerating discs create hypermobility then hypo-mobility to their associated vertebral segments. So over time patients go through brief or elongated periods of pain and less (or no) pain. What care you are receiving when yours subsides often gets the credit. And frustratingly studies suggest the ubiquitous spinal “instability” may have its origins in disc degeneration. And frustratingly mono-zygomatic twin studies (separation at birth) indicate disc degeneration is highly familial irrespective of job or leisure activities.

It is a viable and proven assumption that discs imbibe fluid through motion and recumbent positions and though portions of the disc have a nutrient exchange “barely adequate to fulfill its’ requirements” (Bogduk) most discs do tend to revive and repair without disabling breakdown…or if they do breakdown they don’t necessarily create disabling pain. True extrusion or prolapse (the most dramatic of disc herniation) occurs in less than 10% of presentations (and like a severely degenerated disc tend to have negative intradiscal pressure and thus tend to be resistant to tractions effect). Also important to mention when discussing these most ominous of lesions is a phenomena referred to as shrinkage. Studies suggest as many as 80% of extrusions will undergo at least a 50% reduction in size over a 4-6 month period. This seems to be a natural phenomena occurring with or without therapeutic intervention.

Continue reading Traction as adjudication

Decompression/traction in my clinical experience has clear benefits when applied to specific patient groups. It works as both a healing modality as well as a treatment adjudication giving us both insight into the patient condition and a direction for future treatment. Suffice to say it isn’t for everyone… but nor should we suggest based on some current (negative) research that it isn’t for anyone either. As has been pointed out by others; lack of evidence isn’t (necessarily) evidence of lack. Reduction of compression, albeit temporarily can still give us valuable insight into movement disorders and corruption of contraction patterns etc. attendant with the disc and the extent traction/decompression may benefit or affect the symptoms. Traction can sweep compression out of the way temporarily and gain us insight into prognosis…and reveal underlying motion dysfunctions & disorders hidden behind the compression. We use traction clinically because it can’t be self-induced. And once activated the CNS often gives us new insight. We also rely on so-called form & force closure tests as adjudicators. The reasonable assumption that muscle contraction creates the largest compression burden on the disc can be used clinically to provoke it. The simple assumption being; IF overt muscle contraction imposing large compressive stress fails to cause pain the disc is probably NOT a prime site of pain….thus de-compression procedures NOT the most sensible treatment approach. This allows us to improve our prediction/diagnosis and gain insight as to the benefit of further intervention.

Continue reading Real traction innovations

Tru Wilhelm, a pharmacist, introduced the first popular electro-mechanical system in the late 1950’s called the Tru-Trac (Tru-eaze Inc). He and Claude McCormick (Armedica manufacturing) created what has become the standard approach equipment-wise for over 40 years. The motor was mated to an all purpose 4 section articulating therapy table with a split-section under the pelvis (X-axis). This section effectively reduced Z-axis frictional resistance by allowing an out & back sliding motion. This feature (or a powered caudle section) has remained a staple on all traction tables ever since. Most patients and clinicians do recognize the benefit and comfort afforded via the friction-free section. No specific research has sought to prove if a pulling system (motor mounted at the table end) works better than a powered table-section however, and I might speculate there would be little difference. Both require a stationary pull point/harness at the pelvis and a fixation-harness (or axilla pressure restraint) for the torso. The Spine-Med system (2003) created an iliac grappler which eliminates the pelvic harness. However its’ ability to effectively traction the spine any better than typical systems is unproven….and as of this printing I’m not sure they are still actively selling these units. With the new, quick-belting systems, adaptable axilla posts as well as handlebars and bent-arm thoracic restraint the speed and efficiency of traction belting/restraint is really no longer a problem.

Continue reading Spring-retraction of the sliding pelvic section

Tension Spring

During my tenure as a design consultant I suggested an extension spring be installed to limit the speed & distance at which the split-table-section would separate (an idea proposed by Grieves PT in the 1980’s). This feature was met with great delight from most PT’s familiar with the annoyance of over-separation. It is of course unneeded on ‘pusher tables’ i.e. a powered pelvic section (though I believe most adept clinicians prefer the accuracy, treatment variability and mechanical advantages of ‘pulling motors’ vs. powered sections). On the Kdt Neural-flex a variability of the sliding section via a reactive compression spring on a worm-gear (with handle) is standard. This allows a clinician to finely control the section opening (and thus the perception of applied tension). We suggest it allows the lower body segment to participate at variable rates with the applied traction force, something not available previously on any device. This may become a standard feature on most tables in the future since it gives an extra control to traction force onset. Michelle Cameron MD on this point in her book Physical agents in rehabilitation states: “Initially the table should remain locked…the sections should then be slowly unlocked…to control the speed at which the traction force is applied”. Except this variable control design there is no other means of slow onset of the traction force via the sliding section now available.
The early traction equipment developments afforded clinicians the ability to easily create traction to the spine with reproducibility of force (static or intermittent) and session duration, aspects whose reproducibility was untenable with manual methods. This also afforded the ability to begin structured investigations into the most effective force and time/pull ratios. Regrettably, as I mentioned before, some 60 years later neither the ideal application nor ideal patient has been completely agreed upon.

Continue reading The clinical classification starting point

We need to properly position the therapy in relationship with an understanding of mechanical movement disorders, static & dynamic instability, disc provocative classification analysis and realistic, empirically proven examination-to-treatment algorithms…this in addition to a relatively in depth knowledge of disc anatomy and pathology are imperative. We reference Biomechanics of back pain by Bogduk, Adams, Burton & Dolan and highly recommend their newest edition to all clinicians.
Mechanical traction as a therapy for the spine and spine related pain has a long history with mankind in general but a relatively short history with physical medicine and Chiropractic. Mixter & Barr in their 1930’s research first proposed the dynasty of the disc opening physical medicine to the idea of disc related pain and specific disc therapies. There are some illustrations of Hippocrates with a rack type traction device for back pain some 2800 years ago. Manual traction was the obvious starting point until pulley and lever systems and eventually electric motors developed in the later part of the 1950’s. Earliest examples of 20th century traction included hand cranks with in-line scales attached to leather belts. James Cyriax MD is credited with many of the early methods and the hypothesis of axial tractions’ benefits. In 1968 JA Mathews used radiographs and dye-contrast during prone traction to demonstrate how the centripetal effect reduces a HNP. The benefit of ‘sucking-in’ extruded disc hernias can’t be overestimated. The reality (or consistency) of this outcome however was brought into question by Alf Nachemsons’ cannula-insertion research in the 1980’s and later by an in-vitro study by Twomey (as discussed in Physical Therapy of Low back pain 1996). At least 4 studies published since 1989 have demonstrated that traction indeed can reduce outer-wall distention and open foramina. Of course numerous studies showing the self-limiting/self-healing nature of large hernias makes it difficult to directly associate treatment to physical disc changes e.g. the so-called shrinkage phenomena, as well as the numerous studies showing MRI changes often do not correlate directly to pain relief or long term outcome. After various therapies, which efficiently reduce pain, MRI studies reveal some disc lesions actually increase in size. Marshall and McGill 2010 published a porcine disc study revealing that twisting torque, flexion and combinations can create delamination of the annular layers. Repeated motions (such as extension facilitated exercise) may be detrimental in certain cases creating more lamina damage.

Continue reading Examination protocols: compression vs motion disorder

Our empirical evidence indicates there are several aspects to a physical exam necessary to create the most robust traction outcomes. We recognize that “adverse mechanical loading” creates the potential for damage/deformation & subsequent pain/disability. And compression (like distraction) is an accessory biomechanical action. When we deduce compression we intuitively imagine (de)compression as a treatment. We’ve put these into our examination protocols (borrowed liberally from McKenzie, Mulligan, Lee & Mcgill and others).
Like much of physical medicine & Chiropractic, patient classification remains a decided missing link. There is an underlying assumption from traditional medicine that differential diagnosis is both necessary and possible. However as discussed before whether a diagnosis is even possible concerning (non-pathological) back pain (90-98% considered idiopathic) is at best debatable. The inability to fully understand & identify homogeneity of patient conditions is apparent in most studies on back pain and considered a methodological flaw in many studies on traction. Grieves suggests the word prediction is far more reasonable than the term diagnosis. As discussed previously to diagnose even our most common conditions requires us to be able to use valid and reliable tests (tests which don’t exist).
However that being said we have gathered together a group of signs, symptoms and tests that get us as close to a traction/decompression classification as we believe is possible.
These can also give us guidance as to patient position and other treatment factors as well. These “compression-burden tests” include:
>Relief posturing (reducing compression with regular postural shifts)
>Relief with simple ‘decompression maneuvers ‘such as the seated triceps lift-up, crooked-knee laying and upward pressure under the ribcage.
>IDP provocation tests such as Millgrams, SLR and seated/pressure Slump.
>Antalgic shifts.
>Form/force closure tests increasing pain and limiting ROM.
>Typically pain in the first 1/3rd ROM in flexion.
>Typically pain in first 1/3rd (initiation) ROM of extension.
>Centralization of pain (typically in extension or lateral flexion) i.e. a directional preference.
>Peripheralization of pain
>Referral/projection of pain into the limb(s).
>Numbness/neurological signs/symptoms.
>Pain below the knee/elbow.
>Pain still standing.
>Typically relief in lordotic sitting (vs. slump sitting).
>Pain/increasing pain with elongated sitting or standing (static postures allowing detrimental disc “migration”)

We contrast these compression-burden findings with motion disorders i.e. an inappropriate muscle activation pattern (creating stress/strain on an innervated structure).
>Pain with repetitive motion.
>Limited pain referral into limb(s).
>Highly mechanical i.e. form/force closure tests give substantial relief.
>Shear instability tests reduce PA pressure-pain thresholds.
>Pain in the last 1/3rd ROM.
>Compression tests are negative.

Of course these are in effect “opposites” and thus can be seen as a caricature and thus a starting point, NOT a definitive analysis of anatomy per se. Most patients demonstrate a combination of the two. We assume behind every disc lesion there are inappropriate muscle-activation patterns and postural permutation(s). Functional exams are in fact potentially more important than MRI findings. It’s always important to note, though incredibly sophisticated and revealing MRI’s suffer from “too much information”…most of us have read enough reports to realize the ubiquitous: “clinical correlation is necessary”. There is simply a dearth of information now available to directly indicate what MR finding’s actually mean to the patients’ functionality. So we utilize these tests to deduce the inter-mix of compression to disordered-motion. We focus on ATM2 as our go-to treatment when primary motion disorders are uncovered but other methods are available as well.
Form/force closure tests in effect re-order the inappropriate motion(s) reducing hypermobility and shear instability apparent in most back troubles.
As McGill and others have discovered hypermobility resulting in shear stress creates many of the chronic back conditions we see. Recent motion MRI studies show those patients with cLBP invariably have a hypermobility at L5 vs. control subjects. These studies cast doubt on the accuracy of deciding subluxation (segmental “fixation”) from PA palpable pain…we are probably finding excessive segmental motion not limited motion. Force closure testing can be a key to this end (see McGill shear instability test).

Continue reading The back pain epidemic

As mentioned previously it’s important to recognize the “big picture” of back pain and related disability in the western world. Enough research has explored these topics to at least conclude passive centered approaches to back problems rarely offer more than short-term pain relief (not that short-term relief isn’t appreciated by everyone). But self initiated programs of exercise, including aerobic, strength/endurance as well as a good diet virtually always give better long-term results than repetitive passive interventions. However many of us have discovered that passive treatments seem to trigger a healing that simply wouldn’t have been possible without them (again, at least in the short term). My concern with Chiropractic in general and Decompression in particular is the firm, almost dogmatic assertion many hold that something is actually being “fixed”. We simply can’t make that claim with the knowledge we now possess and given the number of techniques, devices and proposed mechanisms, it would seem nearly impossible to imagine them all having actual curative merit. More likely neurological and psychological mechanisms (which we are now only vaguely beginning to understand) are the reason for relief…albeit temporary. Many patients (and back-pain suffering doctors) recognize ergonomics and “first do no more harm…” are the real keys to long-term success. Of course many can never appreciably alter their ADL’s and thus become our palliative, maintenance patients….or SSI combatants. The relief they get being commensurate with their ability to avoid hurting themselves further (vs. our ability to fix them appreciably).

I think we need to focus our attention where our passive treatments like decompression (and adjustments) can offer robust relief (and or rapid return to work…both of which we Chiropractors recognize spinal adjustment can create) and to then know how to implement active, patient controlled rehab/exercise strategies as quickly and effectively as possible. Of course these commentaries have been voiced by many others including Robin McKenzie PT who suggests that up to 75% of physical therapy encounters are of questionable value (to the patient, not the therapist). Recent long term studies have shown a back booklet can have equal benefit at follow-up when compared to a dozen PT sessions. When travel and lost work time are factored in PT for LBP/leg pain is actually a drain on the society, not a benefit according to a UK study. Additionally when studies compare manipulation, heat patches, McKenzie, massage or medical care (medication) there is typically only marginal differences between them. Logically this simply couldn’t be the case if something absolutely profound and anatomical was occurring from the applied therapy (such as when a broken bone is set or a cavity is filled). It is consistent however with modest physiological changes (triggers) and the nebulous constructs of the central nervous system and relation to our subjective experience of pain. A parsimonious or silver bullet approach is not really consistent with science or compromise. Thus this is why illustrious researchers, those who have devoted a majority of their lives to the topic state: “no single treatment has been able to improve on the natural history of the phenomena”.
There have been recent publications of several CPR’s (clinical prediction rules) for manipulation and traction. To find the right patient and apply the right therapy with anticipation of a robust result is genuinely valuable. If we are to continue to engage patients with hyperbole and impossible-to-validate mechanisms of action we’re going to slowly be eliminated from most insurance reimbursement and may lose credibility with the public (though the public’s standard for credibility is fairly low…). Though I am always quick to point out DD Palmer had no misgivings in branding Chiropractic “of religious intention”. Given that the body (and life itself) is beyond our comprehension, keeping religion (perhaps better described as spirituality) alive in our profession is not a bad or incongruous idea. Keeping it, like a weed, from choking off the host remains tricky business.

Continue reading Going back to 1985…

In 1985 a book from the New York Times Press appeared entitled: Backache Relief.
This was given to me one year before I graduated and at the time I simply dismissed it (as it clearly could have had a deleterious effect on my enthusiasm for Chiropractic’s’ results). What the authors did was simply find several hundred readers and track their results with numerous interventions for back pain. Everything from yoga to manipulation to the Alexander technique were included. What is fascinating is that some 30 years later the essence of their research remains consistent with new population-based research on these interventions. As an example they found long-term success for ‘manipulation’ was 14% with short-term relief at 30% (those being made worse; 10%). As disheartening as this appears it isn’t inconsistent with recent studies (or the fact we tend to treat about 15% of the population). When multi-focal Chiropractic treatments were reviewed the long-term results went to 25%. Exercise, yoga and Pilates all scored higher in both long term results as well as satisfaction. Exercise showed a 45% dramatic and 34% moderate long term benefit. In 1985 their research showed only 25% of clinicians recommended exercise.
Traction was about the least effective intervention with only 2% describing a dramatic/long-term relief and 23% reporting being made worse. Short term relief was found in 22%. Interestingly inversion therapy (which was just in it’s’ infancy in 1985) scored 30% long term results with 0% being “made worse”. These reviews are sobering (especially given the view many old-time Chiropractors hold that “new” Chiropractors just can’t adjust. Clearly in 1985 great adjusters were still having trouble curing more than 25% of their patients!). It also tends to reinforce the notion that “traction”…at least back then…”didn’t seem to work”. Whether it qualified as viable research aside what it does tend to validate is active, patient-motivated exercise and body-awareness is the real key to long-term success. Passively applied modalities, like manipulation and traction make their mark in short-term relief…they are rescue, triage procedures. Selling patients on their long-term, curative effects is difficult to support. We need to use them to gain robust, albeit potentially short-term benefits then progress patients to exercise/improved movement patterns. Of course having practiced for 27 years (and suffered back troubles for 20) I am never too quick to dismiss maintenance/palliative interventions which “only” provide short-term relief. Often there is nothing else available, especially without untoward side-effects. Once monthly treatment I’m sure has saved millions from losing their jobs

Continue reading Flexion vs. extension traction

Generally there are two directions with which we can apply sustained or intermittent traction to the spine; flexion or extension. Axial traction (+Y axis translation) as I’m describing is axial flexion i.e. the spinal curves and the vertebra are flexed (& separated) upon the application of tension/dis-traction. Extension traction is more often than not a remodeling procedure i.e. the patient does static (or modified static) extension to remodel the ligaments sustaining the decrease in lordosis. Extension however compresses the posterior regions and usually creates a modicum (or more) of discomfort. Axial traction decompresses the posterior regions (stretching the anterior) and typically creates comfort (at least during an episode of disc compression pain). Extension is a + rotation (not translation) around the X axis (though most patients with a diminished lordosis have an attendant anterior skull translation as well). Most stenosis & encroachment syndromes will not enjoy forced extension as it decreases the foramina size up to 20% possibly increasing nerve pressure. However, as extension is the directional preference in a vast majority of cervical & lumbar (contained) disc derangement syndromes, extension may be the best direction for some eventually…even if not initially. The McKenzie classification describes reducible and irreducible disc derangements. Reducible derangements accounting for nearly 75% of presenting cases (Man Ther 2008 Feb;13(1)). 70% demonstrate the classic extension directional preference which tends to suggest the neurological consequences of extension are NOT at issue in the vast majority of disc presentations. (And taking into account 8% lifetime prevalence for a true pinched nerve, most of our patients should likewise benefit from extension at some point in their care. Iyengar yoga also adds some interesting insights on this point for those interested. See www.Iyengar-yoga.com). A contained disc, with a hydrostatically patent mechanism will benefit, often dramatically with controlled and careful repetitive extension facilitated motions.
It is my experience after some 20 years of clinically using sustained extension traction that it requires diligence and excellent patient selection. Extension won’t be discussed past these points except to direct interested readers to CBP technique and Dr. Harrison’s lifetime contributions. Also a few newer studies such as: Extension traction treatment for patients with discogenic lumbosacral radiculopathy. Clin Rehabil 2012 June(8). Lumbar lordosis rehabilitation for pain and lumbar segmental motion in chronic mechanical LBP. JMPT 2012 May;35(4) both demonstrate that extension can mitigate either the pain of discogenic origin or mechanical alterations leading to it.

As flexion traction (+Y translation) is applied the lordosis is reduced (or it was reduced during set-up) and additional axial tension begins to overtly separate the posterior elements and tighten the posterior longitudinal ligament. If continued unloading occurs more vertebral separation will be the inevitable result…but how much is needed remains unknown.
Most clinical research suggests this separation is predominantly posterior (not anterior) and typically is not more than a few mm at L5-S1. Additionally a study by Twomey (PT of the Low Back. 1996 Churchill Livingstone) showed there was no residual ‘set’ or ‘creep’ in terms of spine lengthening after traction was released…this however was in cadaveric specimens. The assumption being traction/decompression is a ‘phasic’ phenomenon (though disc imbibition increases spine length for up to an hour post). Lee et al demonstrated that Fowler (knees up) positioning is an efficient way to enhance posterior element separation and speculated tensioning of the PLL contributed. Interestingly the vast majority of disc lesions are posterior or posterior-lateral. Intuitively, prone position should be the preferred position based on the assumption of gravitational bias…the disc protrusion wants to migrate back toward the center anteriorly. Supine positioning seems counterintuitive in those cases.
It isn’t surprising that those patients amenable to prone positioning can be comfortably and successfully treated prone and also tend to have contained/healable disc lesions. Simple posterior/contained discs tend to be “prone tolerant”. This is an important clinical concept and one recognized by the original VAX-D.
Again we recognize this as a clinical reality: prone traction seems to often work “faster” for relief and/or centralization of pain. However we also realize the position can be stressful for some (as in stenosis) and in those cases, whether due to another directional preference or unavoidable morphological considerations, supine (or side-lying) may be the only position tolerated. We can, and do exploit the extension directional preference in most (+75%) by treating them prone with a degree of extension/hyperextension and allowing the arms to be bent at 90º (a table design attribute). Often patients can be made comfortable prone via amending the table (into extension) or by adding a bolster under the abdomen and then flexing the lower body into 10-40º of flexion (a table design attribute most appropriate for stenosis or minor nerve tension signs). Our technique describes this exploiting of directional preference in both flexion & extension but various other observations e.g. nerve tension signs, severe degeneration, movement disorders etc. must also play a key role in assessment and treatment positioning and whether in fact the patient is a traction candidate. Somatic referral pain must be differentiated from radicular symptoms. Though the former can, and does refer pain into the leg and lower leg via 2nd order neuron “convergence” it is inherently different from a “pinched nerve”, which often require a supine/hyper-flexed treatment position.

Continue reading How much force?

This is an inevitable question and one which defies a direct, absolute answer. As stated the lordosis must be flattened in order for the posterior regions to be elongated (this can use-up 50% of the force if pre-positioning isn’t a focus) but how much force is needed is inherently unknown person to person. However what we can suggest and recommend is that less may be more…at least initially. Since absolute diagnosis is impossible…absolute knowledge of what force to use is also difficult. Overstretching is obviously far more detrimental than under-stretching…and starting low allows you to add more over the next several visits. Invariably only men insist that “more force would work better”. But its best to choose wisely before arbitrarily ramping up the tension more than 10 pounds. What we do know from the 1994 J Neurosurg VAX-D study by Ramos & Martin is that somewhere around 40 pounds of tension (while prone) the intradiscal pressure was recorded as (-) negative mmHg. Thus a fairly low force generated a decompression-result. The authors also suggested there was a trend toward an “inverse-relation” between force and negative pressure i.e. as the force increased the disc IDP increased. Maitland has suggested some cases of Sciatic respond to as little as (10) pounds of force (interestingly under 50 pounds is termed ‘sham’ since supposedly NO vertebral separation can occurs but this simply isn’t the case). We suggest if a calculus is needed 30-35% TBW be used for the initial session(s). And increase only judiciously if well tolerated but unresponsive.
As to cervical traction a study in Spine by Lui et al 2009 showed foraminal cross-sectional diameter did not increase substantially after (20) pounds of axial cervical traction. Other studies suggest 10% total body weight is sufficient to improve cervical conditions but reduce iatrogenic issues…issues very common with too much cervical tension. Over the door units are typically limited to 20 pounds as well.
However the rapid fluid in-flow (osmosis) occurring via recumbent pre-positioning (we initially try to reduce the lordosis prior to the traction force application) and added traction may foster a healing response in many patients within that supposed “sham” force. One thing is for certain…IF you overstretch you can’t take back any injury or insult…and you may lose the patient as a result. Some patients and conditions simply DO NOT tolerate the increased tension resulting from the fluid-diffusion. IF the condition doesn’t respond to low forces, higher force is just a knob-turn away.
The sit-and-reach test is often utilized to determine the turgor/fluid imbibition of the discs. If the disc has imbibed fluid the resultant swelling tightens the interspinal ligaments and diminishes flexion and rotation of the torso (thus flexion e.g. sit-and-reach is shortened). We get up taller than when we went to bed (diurnal height change) due to this. This also can give us insight into patient-condition classification. IF a patient experiences severe LBP and limitations to motion in the early AM but improves substantially thru the days end…we tend to see this patient as having an annular ‘compromise’ and not a ‘distention’…these conditions tend to be irritated by the use of traction….irrespective of the “magic” in your machine! The bottom line is not to fret over force…start low…IF relief, don’t (arbitrarily) increase. A progression of force is typically NOT the most effective method. Allow the body to use whatever force IT requires. Don’t superimpose your dogma where it may not be appreciated. Maitland points out that the force is simply for recording purposes.

Continue reading An initial mention of the ATM2 & motion disorder(s)

We have also aligned with a device called the ATM2 (Active Therapeutic Movement; Backproject.com) to dovetail treatment from the passive to the active in a very unique and functionally dramatic way. We recognize there is a distinct and valuable differentiation between a “compression/disc” problem and a motion disorder (inappropriate muscle activation patterns and NOT compressive in nature).Though many are completely unfamiliar with the ATM2 we cannot overstate its’ significance and its’ significant contribution to the outcomes of many decompression patient conditions. ATM2 is called an active relief modality based on the fact it generates rehabilitation and pain relief simultaneously. We recognize that discs don’t go bad based on the will of the wind. Though genetic factors, end plate damage etc. in our early years can’t be ruled out as contributory discs tend to break down based on a corruption of muscle contraction patterns, postural alterations and repetitive flexion. Over time discs may be subjected to unendurable repetitive stress/strain (especially in flexion) and eventually “sprain” or herniate during a (typically) mundane activity…a so-called critical factor. How often do we hear a patient say: “all I did was bend over”? (Of course serious trauma can certainly ‘blow out a disc’ as well but in a typical practice I believe it’s about 80% time & corruption vs. 20% extreme trauma). These alterations also foster disc degradation/degeneration leading to the downward cascade which defines many patients’ lifelong battle with back pain and the often poor results to standard interventions. As will be discussed in much greater detail later the ATM2 often affords a rectification of the embedded, chronic movement disorders/impairments which eventually foster further disc breakdown and pain syndromes…and frustrate clinicians. It also affords us access to dramatic functional pain relief with a minimal learning curve and virtually no side-effects. A proverbial clinical grand slam!
A very interesting side discussion regarding the ATM2 and its mechanism of action is in regards the Mackenzie classification; dysfunctional syndrome. The dysfunction is typically described as stress at end-range of motion on “shortened structures”. These shortened structures requiring vigorous end-range manipulation or repetitive, cyclical motions (such as the REPEX) to recover. What is fascinating is that (though end-range manipulation is a shibboleth to Chiropractors and others) those who both recognize this classification, AND have years of experience with the ATM2 notice the rectification of these dysfunctions routinely with ATM treatment …and not just momentary improvements but substantial benefits. When an end-range restriction is encountered (and simple form/force closure tests alter it) the ATM2 can often eliminate it without any manipulation or end-range motions whatever. To me this is both ultimately interesting, and confusing….demonstrating how dogma may infiltrate any treatment theory.

Continue reading Decompression, stretch & directional preference

It’s important to understand traction (Latin: tractico; to pull or draw toward) as the mechanical action (+Y axis translation to the body). Decompression an outcome (though obviously only assumed to occur in typical daily practice and certainly only assumed to be occurring at an exact disc level…regardless of what some bank of buttons on a $95,000.00 machine may seem to indicate). We have deduced three (3) responses or “operations” to traction therapy. These are mainly definitional and would be assumed to be overlapped (as each disc level affected via the stretch may manifest unique characteristics, thus variable responses). But they allow us a clinical insight or ‘direction-of-travel’ as to classification and outcome assessment.
1. Decompression (osmotic, centripetal/vacuum effect): an enhancement of the potential for healing via diffusion/imbibition of nutrients (molecular solute transport) and/or a theoretic possibility of ‘pulling’ extruded nuclear material centrally from peripheral fissures. The disc must be hydrostatic, intact and only minimally degenerated in order to have a real ‘decompression’ effect… and this is often dubious in older adults. Additionally though ‘global decompression’ (lessened Y-axis compression) occurs during traction and any recumbent position, an increase in intradiscal pressure (tension) from the osmotic in-flow of fluid can also be a distinct spinal stressor in some patients and at some points in their condition (e.g. diurnal height increase/morning pain syndrome). The extreme morning stiffness/pain many arthritic suffers experience may be from diffusion (in the hydrostatic discs) elongating, and thus creating stress in the axial plane on the sensitive spinal structures. (This imbibition may reduce the ‘neutral zone’ intersegmentally and increase resistance to torsion and bending. Within approx. an hour 75% of the fluid is ‘squeezed’ out and the neutral zone decreased & stiffness reduced). This same phenomenon of feeling very stiff, especially to flexion can occur post traction as IDP is increased via diffusion (so decompression may not always be a comfortable outcome. Interestingly many have found prone traction and reduced hold-times less likely to create this phenomenon). This further suggests a defined and definitive patient classification treatment algorithm is both reasonable & practical. IF post traction pain is marked I have not found a distinct classification for those who may be best served to “deal with it”. That is many of the patients forced to endure moderate post-traction pain are not actually being well served. If in fact they appear to recover over several weeks I contend it was in spite of the traction not as a direct result of it. As with manipulation and deep tissue work, IF the patient is feeling worse then they are NOT getting better…irrespective of the faith you have in your technique or equipment!
2. Stretch: stretch-of-structures in the axial plane may foster a temporary improvement not only in mobility but also pain perception via mechanoreceptor modulation of type IV nociceptors via type I, II & III (as manipulation). There has been the suggestion that it is the distracted joint surface which is operative in the relief garnered with manipulation (Wyke) (though as Panjabi has pointed out virtually all spinal ligament structures and discs have embedded receptors and could contribute to pain modulation) thus its not surprising traction can reduce/inhibit pain effectively as well. Mobilization of shortened structures, though temporary, can have a positive effect on pain perception and the feeling of enhanced mobility. Axial compression is endemic, thus axial stretch can be extremely comforting (at least in the short-term) irrespective of whether discal “decompression” occurs. Variable pull patterns (variation of time/force interplay) may theoretically have merit in manipulating the pain gate and affecting mechanoreceptors embedded in the annulus itself though no research proves this and practically speaking minor fluctuations in pull & hold are inherently imperceptible. Muscle spindles may also play a role in temporary relief as well.
3. Directional preference: as defined by McKenzie a derangement syndrome (disc) amenable to mechanical intervention will have a preferential motion (end-range loading) that will diminish pain (or centralize symptoms) and a direction that will incite pain (peripheralize symptoms through-range loading). Very often that direction is in extension/hyperextension, though can be flexion/lateral or combinations. These directional preferences (physiologic motions) are usually done by the patient…however the axial plane is an accessory motion and must be induced/created for the patient (most often by traction). Some patients’ directional preference may include both an axial component and either flexion or extension. Or there may be greater benefit to extension (or flexion) with traction. It is important to fully grasp this concept as well as having a traction system with sufficient adaptability (prone/supine/lateral) for the various patient presentations. Additionally a recent study clinically tested a proposed CPR (clinical prediction rule) for traction (in this study treatment was prone neutral or with extension) and suggested traction may have benefit when there is no definitive directional preference or extension creates peripheralization of pain. (Interestingly, and to the point of temporary relief, after 6 weeks both patient groups had similar outcomes i.e. improved).

Continue reading F.A.C.T.R. treatment

We have coined the acronym: F.A.C.T.R. This stands for Find the impairment (or problem), Assess it, Create an awareness in the patient of it, Treat it and Reassess it post the treatment. Obviously in a mechanically treatable condition a mechanical (improved) outcome should occur. This methodological approach is well known in physical medicine as Maitland, Mulligan and McKenzie systems are based on mechanical classification-to-treatment-to-reassessment analysis. We’re simply codifying it more directly to decompression/traction therapy. A mechanical problem should obviously render a mechanical improvement when given a mechanical treatment. Finding reproducible impairment of movement and function, assessing it with additional motions and form/force closure strategies, treating it with a viable intervention then reassessing it post the treatment only makes sense. So often in cases of motion disorders “re-ordering” of the inappropriate contraction pattern will substantially improve the global painful motion(s).

Continue reading Basic research overview

There has been no shortage of clinical research on traction in the last 30 years. Whether that research has been of sufficient quality to end the confusion is the issue. The majority of studies have been small sample size and poorly controlled. Most systematic reviews recognize these as methodological flaws so they either contribute nothing towards a positive review or contribute to a negative one. The conclusions of such reviews stating: inconclusive evidence exists due to methodological flaws…” or “the currant literature doesn’t support or refute the use or effectiveness of traction…” Several well-structured studies comparing 30-60% bodyweight traction vs. a well conceived control using an inflation belt failed to show a defined benefit to traction. However as many researchers point out; “lack of evidence does not prove evidence of lack”. Many positive case studies, tractions theoretic value as well as the limited alternative, conservative treatments available for disc/nerve conditions continue to fuel enthusiasm and use. A recent study by Harte et al suggests close to 50% of Physical Therapists continue to use traction. The majority (85%) uses it for disc/nerve involvement and uses it in conjunction with other therapies. There have been 2 recent studies showing positive value with both cervical and lumbar traction when certain condition-variables are recognized.
Also the McKenzie institute appears to embrace cervical traction in certain patient conditions as well (though lumbar traction remains discounted officially). Again, my experience in over 15 years of traction/decompression application has also led me to believe that it has genuine merit for a Chiropractic clinic especially where rotational manipulation and passive modalities may be the only other treatment(s) offered.

Continue reading Differentiating disc vs face vs SIJ

Research often tends to be contradictory. Back troubles affect 85% or more of us yet the why remains inherently mysterious excepting in a tiny percent of conditions. Nietzsche pointed out that man has a tremendous capacity to suffer if he can be given a why…and he also pointed out “it’s not the extent a proposition is true that matters it’s the extent to which it is believed to be true that matters”. Thus our striving to give pain a why…even if it less than satisfying from a strict scientific viewpoint. (When haven’t you had a bout of gastroenteritis and not immediately scanned your memory for your last encounter with mayonnaise?). Subluxation remains convincing to many Chiropractors and their patients though it certainly suffers from the charge of a parsimonious and difficult to codify hypothesis. Often any explanation is better than “I have no idea”. Placebo/care-giver responses appear to require a positive feed-back mechanism where the story, the treatment, and the receptivity of the patient (and their beliefs) all work in concert. The hope of scientific research should ideally be to lead us to actual, beneficial outcomes vs. the more nebulous and inconsistent placebo type. When it comes to back pain however science has yet to crack the code fully and care-giver type benefits shouldn’t be discounted as unimportant. They may turn out to be ultimately important.
A recent systematic review Eur Spine J (2007) by Hancock, Maher, Bogduk and others titled: Systematic review of tests to identify the disc, SIJ or facet as the source of low back pain attempted to answer the question of diagnostic acuity of “site” tests. This review also asked if the specific tissue/site of pain was known would it be of distinct value for treatment. They found: “the results of this review demonstrate that tests do exist that change the probability of the disc or SIJ (but not the facet joint) as the source of low back pain. However the changes are small, at best moderate. The usefulness of these tests in clinical practice, particularly for guiding treatment selection, remains unclear”. Further: “Currently there is no literature indicating that knowledge of the tissue source of low back pain leads to improved outcomes however this research has been very difficult to perform without easily available and valid methods of identifying the source of low back pain”. This review authored by some of the most eminent researchers in the world helps to put a fine point on the shifting sand of our foundations. To the point of classification however it is important to recognize there are tests which improve or increase our likelihood of tissue source (or disc vs. disorder…just not to the extent of being diagnostic per se). It is worth noting however that recent research by Mark Lasslett and others contends that in fact Kemp’s test is highly specific for ‘facet’ involvement. This means that if Kemp’s test is negative the facets are likely NOT the source of the pain (extension with rotation). Irrespective if facets are a source or a contributor to the patient’s pain they are probably subordinate to the disc and disc height loss. I am dubious as to whether traction per se has a direct positivistic effect on the facets or if pain relief isn’t still a result of the effects on disc healing.

Continue reading A basis of classification

The 3 categories

To create a viable but simple classification algorithm we have to begin with categories. We need to make clear that these are for clinical convenience and do not intend to create a defined anatomical truth. The 3 categories are:
1. Compression (disc)
2. Movement disorder (which can include “sprain/strain”)
3. (Combination)
By referring to these 3 main groups we can have an initial relatively homogeneous pool from which to assess and classify. It’s important to keep in mind that a compression (disc) problem may always need a movement disorder however a movement disorder doesn’t necessarily need a disc/compression component (though it certainly might…). What this means is that in our view compression and disorders are discernible as separate categories during patient examination. This affords those of us interested in decompression therapy to define our enemy early in the assessment process and properly implement traction when warranted. It also indicates many patient conditions will not necessitate traction/decompression. Initially we will take a patient history and L.I.P.I.D. profile gaining our initial prediction of “source”. Once a generalized assumption of compression is made the most important consideration is to deduce whether “disc swelling/imbibition” (and the resultant mechanical consequences) is a benefit or detriment. And this is the essence of a sprain/annular ‘tear’ vs. an annular ‘distension’. The former being irritated via stretch & fluid in-flow the latter typically helped.

Continue reading Site vs. Source

It’s important to make note again of the concept “site” vs. “source” in relation to pain conditions. We define a site-predominant problem as one whose treatment and/or rectification will probably require “site” directed interventions. A torn annulus, a disc sprain, a nuclear extrusion, a nerve encroachment and discitis conditions can be seen as site problems. We don’t anticipate specific exercise or manipulation etc. to offer immediate defined relief in the acute stage of these problems. Nursing modalities such as heat/ice, medication, LASER, ultrasound and certainly rest may be necessary to allow inflammatory mechanisms to settle and tissue “healing” to ensue. “Source” type conditions we will typically anticipate relief with mechanistic interventions i.e. the source of the problem is a short leg or a muscle imbalance etc. whose mechanical properties need to be fixed before real relief is realized. Thus the suggestion that classification using provocative assessment is so important. We need to Recognize that a movement disorder is less a site problem than is a disc/compression syndrome. McKenzie identifies 5 basic categories for clinical classification:
1. Inflammatory
2. Postural
3. Dysfunctional
4. Derangement (disc)…reducible and irreducible
5. Nerve adhesion.
It’s important to realize inflammatory conditions typically fail to show mechanistic tendencies & signs and thus fare poorly with mechanical interventions per se. Though I don’t quickly recommend cortisone/prednisone there are certainly conditions where pain and impairment fail to be relieved (and the patient is unable to tolerate) without a potent systemic anti-inflammatory dose pack. NSAIDS continue to be judged in systematic reviews as a clinically viable strategy for inflammation-based back pain. And without these anti-inflammatories millions of people would be unable to function through their pain. Often these conditions show nighttime and in-bed movement pain and especially lingering morning pain post arising. We’re very likely to find our nerve-tension signs (SLR, ULTT, Femoral stretch etc.) in this group as well, as chemical mediation & trauma are common incitements of nerve/radicular pain. MMR appears to be released from damaged nucleus pulpous and can cause morphological and functional changes in spinal nerve roots. Anti-TNFά biologic medicines such as Enbrel© and Humira© have potential benefit in reducing chronic sciatic problems. Inter-lamina injections consistently show better than placebo results. Again there are numerous texts and more valuable experts on these topics. My hope is to give a basis for channeling conditions to traction therapy (and in many cases the ATM2 as well) via a predictive and instructive classification algorithm.

Continue reading L.I.P.I.D. (history)

This is an acronym for Location, Initiation, Provocation, Intensity & Duration. These give us the what, why, when & how indicators gaining us clinical insight to recognize a compression vs. a movement disorder problem.
Compression impairments tend to have several common denominators not the least of which is relief while “decompressed”. This can include ‘lordotic/arched back’ seated relief and the avoidance of flexion in the morning etc. Other typical findings are a directional preference, postural re-positioning or relief posturing, antalgia (most often antalgia which is painful to correct), sit-to-stand pain with some improvement after arising & walking and often exacerbation upon standing still or slump sitting. Obviously some patients are relieved while seated and others relieved standing or walking…the general observations though hold true and several indicators should be appealed to. The location of pain in disc conditions tends to be referral in nature though that referral may simply be iliac crest (trapezium or lateral neck with cervical conditions) or a grapefruit sized circle of low back pain. More often than not as the disc’s outer annulus is disturbed the patient feels what Bogduk calls somatic referral symptoms, or more specifically discogenic pain. These symptoms tend to be diffuse and located into the limb and torso but typically not below the knee or elbow. As mentioned previously somatic pain from a lumbar disc can extend into the lower limb via convergence with 2nd order neurons. The more stress applied to the damaged area (soma) the more projection of pain into the leg. However these symptoms tend to retreat upon less-stressed postural positions. This contrasted from radicular/encroachment/stenosis syndromes which tend to be much more ‘diagnostic’. This one differentiation is often a telltale sign of the severity and complexity of the case and indicative of disc compression. These referral patterns actually resist demonstrated patterns in contrast to dermatomes which tend to show commonality and can give better diagnosis potential.

Continue reading Clinical prediction rules & 4 treatment types

Beginning in the 1990’s the scientific literature began seeing research centering on clinical prediction rules (CPR) for musculoskeletal interventions. The 4 treatment types are based on patient conditions and response to interventions. They include:
1. Manipulation responsive
2. Traction responsive
3. Directional preference responsive
4. Stabilization responsive.

These 4 types were proposed by eminent names in physical therapy research. By codifying conditions and their response to particular interventions a potential advancement in evidenced-based care may result. As is the cases with virtually all research, countervailing studies also appear…just to keep us on our proverbial toes.
A 2010 study: Critical appraisal of CPR’s that aim to optimize treatment selection for musculoskeletal conditions was published in Vol. 90 of J Physical Therapy. The conclusion puts a fine point on the difficulties of creating “rules” for treatment.
“There is, at present, little evidence that CPR’s can be used to predict effects of treatment for musculoskeletal conditions. The principal problem is that most studies use designs that cannot differentiate between predictors of response to treatment and general predictors of outcome”. The authors posit that sample size and spectrum bias weaken the generalizability of the CPR and creates doubt as to their inherent clinical relevance.

Continue reading A few published traction trials and clinical prediction rules

In Spine 2007 Fritz et al published: Is there a patient sub-group likely to benefit from traction a 5-point CPR was proposed and put to trial to see if a statistically significant benefit could be gained from the addition of traction to a typical (extension-oriented) physical therapy program. The CPR guidelines included these findings:
1. Sciatic/pain below the knee
2. Positive cross-leg SLR
3. Low FABQ
4. Extension peripheralizes symptoms
The study did show the traction group gained a quicker improvement. In fact the research was sufficiently compelling to generate a subsequent 4 year study with participants getting appreciably more traction sessions than the 6 given in the 2007 study.
The extension oriented treatment program is a standardized approach in PT low back therapy and is based, in part on the McKenzie method and the active pursuit to re-focus the lumbar spine to neutral and extension posture(s). As was discussed previously repeated extension can give insight to the inherent benefit facilitated motions (like extension) can have but also uncover the likelihood of a stenosis (from the ancient Greek: ‘narrowing’) or encroachment issues…which will create a peripheralization of symptom(s) upon repeated extension. This initial finding (peripheralization) often being a key sign decompression/traction may be warranted.
A 2010 study in JMPT offers a further verification of the benefit traction added to a PT regime for the pain from an acute HNP can achieve. The results show significant improvements in the group having the addition of traction therapy (as well as Ultrasound and LLLT).
In Eur Spine 2009 Congcong et al also published a CPR for the use of lumbar traction in LBP. In their opinion several factors increased the result achieved by traction from ~20% to over 70%, those included:
1. Not having neurological deficits
2. Low FABQ,
3. Non-involvement in manual labor
4. Over 30 years old.
It’s interesting to note that in this study only about 10% of the study base was traction responsive…but of those ~70% improved when the rules were factored in.
Development of a clinical prediction rule to identify patients with neck pain likely to benefit from home-based cervical traction (Eur Spine 2011) showed an improvement from ~45% to over 80% when 3 of 4 variables were found. These included positive distraction test and pain referral to the shoulder among others. A 2009 Eur Spine (Raney et al) sought: Development of a CPR to identify patients with neck pain likely to benefit from traction and exercise. This study also identified 4 variables which improved outcome 4-fold. They included shoulder abduction test, distraction relief and upper-limb-tension test (type 1) and pain referral into the arm. Cervical traction and mobilization exercise were the intervention(s).

Continue reading Cervical decompression

KDT Cervical Unit

Traction of the cervical spine is perhaps equally as common vs. the lumbar spine….though this is clinic dependent. It is certainly very popular in most PT clinics and its popularity (unlike that of lumbar mechanical traction) hasn’t tended to wane over the last thirty years. Studies conclude the lumbar disc(s) may contribute to pain in 75-80% of cases (certainly chronic conditions). In the cervical spine it is likely 50-50 with the facets. Though axial mobilization is helpful in many cervical conditions over-stretch can be an issue. The 10% total bodyweight rule makes sense clinically in cervical traction applications as a starting point. The set-up, pre-traction position flattens the lordosis sufficiently that minimal axial tension will separate the posterior elements.
Systematic reviews of cervical traction find the same conclusions as lumbar…quality studies are lacking to give a complete assessment. However one conclusion which has been drawn is that intermittent traction likely works whereas static does not. As noted above several studies suggesting effectiveness have been published and at least 3 CPR’s have been introduced.
The considerations in cervical testing involve deducing what symptoms improve or degrade when foraminal pressure or tension is applied. Since it is well recognized that cross-section size of the foramina change based on distraction or compression (Spurlings’ test vs. distraction) these are important clinically. We recognize the skull distraction test as a very important measure as to the effect of mechanical traction. IF pain or symptoms abate then traction is warranted. Bakodys’ sign likewise gives a strong indication that encroachment is likely and traction may be warranted (often a seated variety is better tolerated). The 2009 Eur Spine study suggesting a CPR for cervical traction found a 2-fold improved outcome when distraction was relieving and Spurlings’ or upper limb tension tests were positive. Since the cervical spine requires less tension to create vertebral separation it is somewhat easier to administer. It’s also important to note that extension traction and extension/retraction can be beneficial (Mackenzie reports extension and extension with retraction constitute the most common directional preference in the cervical region). These extension motions often must be administered by a doctor or therapist unlike the lumbar spine. Pain referral into the arm or hand is also a strong sign cervical traction is warranted. Fritz et al JOSPT 2014;18(2) CPR for cervical traction concluded that cervical traction should be seen as a viable co-intervention in cases of radiculopathy as well as other cervicogenic conditions.

Continue reading A few concluding comments

Many traction studies have been published over the last 20 years.

Traction continues to be a very popular treatment choice and shows little sign of waning. What is apparent is that the daily experience of a DC utilizing a codified method of traction (within a multi-focal approach) IS consistent with the positivistic outcomes demonstrated in many of these trials.

Most clinicians have recognized that patients are more savvy and inquisitive than ever before. IF they believe there is a treatment that is safe, and MAY hold an advantage they will seek it out. With the thousands of websites clamoring for disc patients to try decompression therapy to NOT have it available could spell trouble for the long term health of any practice. And an inevitable addendum to this is that a lower-cost treatment regime may well be the most practical approach in most areas. Since modestly priced equipment (leases for around $200-300.00 per mo.) do not tax the budget there is much more latitude toward per patient/per case price structure. Of course how much you charge for any intervention is ultimately up to you. How you choose to charge whether as a total case-fee or simply per treatment is also an individual decision and based on many variables. Decompression however has seemed to work well as a case-fee procedure where both the traction and several allied procedures may be grouped together, over a defined time frame and billed as a unit (and as a cash service). The CPT 97012 (traction) has a 4.2 RUV and pays little more than $12.00 under most plans. Many doctors simply see this as too insubstantial and opt to perform it as a cash service. That remains your personal prerogative.

What we may know…
• Intermittent traction is preferred over static.
• Intermittent is more effectuations than static.
• Low/moderate force is better than high force (typically).
• Consistent progression of force may be unnecessary or problematic.
• Stretch and fluid-diffusion (imbibition) are contraindicated in acute/inflammatory and disc-tear/strain/irritable conditions.
• Sessions need not exceed 15 minutes.
• If well tolerated, more sessions are better than fewer sessions.
• Traction tends to show poorer outcomes when done as a sole intervention.
• Prone lumbar traction may be more effective than supine for HNP.
• Supine may be more effective for stenosis.
• Traction may improve the efficacy of facilitated-extension-exercise.
• Pulling’ (motor) systems tend to work better than ‘pushing’ systems.
• A non-split (or locked pelvic-section) dissipates as much as 30% of applied tension.
• Being able to “Target” specific discs with traction is nonsense.
• There is no decompression “pull pattern”.
• A severely degenerative disc likely can’t be decompressed.

A full listing of the studies can be found in the KDT Certified Only website at www.kennedytechnique.com