clinical question(s)

OK gang, here's the scenario:

I have a 62 year old cowboy/Realtor who first injured his back in a 1500 ft fall in a helicopter, outside of Aspen, CO, in 1974. He has suffered chronic LBP since this incidence. I have seen him as a private pay patient 2x (1x March, 1x in May): treatments (neck and low back) focused on mobilization/manip, instruction in self-mobilization and stretches and some core strengthening. He is considering a home, inversion (or not inverted) traction unit. His wife had a 'disc-ie' condition I helped greatly, so he trusts me.

Now, I was off on vacation last week and this gentleman had a severe episode of LBP (no leg pain). He tried to get in with a PT at our clinic, but the schedules conflicted, He went to a local 'VAX-D' clinic and had a consult (local chiropractor owns the local franchise), an MRI and advise that the program of 20-30 Rx would rehydrate (his words) the discs (MRI showed 3-4 levels of DDD) and reduce his chronic LBP dramatically. He then saw a PT at another clinic who told him his problems was caused by a torsion of his pelvis ('my hips and pelvis are twisted') and that this was what needed 'correcting'. He had some relief with the manual therapy, but showed up for treatment promptly this week.

He brought his MRI report and gave me the recent history. He has asked me in the past about a "back swing," or inversion traction unit, which I have had some clients find gives them a effective home management strategy for their chronic LBP. We discussed the Cochrane review on traction for acute and chronic LBP. We did a literature search for any evidence of re-hydration with traction: None that I found. We went to Google and found some interesting websites on traction (Aetna had a nice review of the evidence and some definitions), but sorting the commercial websites (with an agenda of sales or denying care (ie. 3 rd party payors)) from academically legitimate websites was difficult.

We discussed the osteopathic model of the pelvic obliquity and asymmetry. I have found little or no evidence that constitutes validation of the model. We also discussed what evidence is required to determine true cause-effect relationship (again, the Bradford-Hill criteria).

Chiefly, we commiserated about the difficulty in being a good consumer of health care in this marketplace. We wondered aloud why do we (medicine & society) create so much confusion.

Any thoughts or comments, again, on VAX-D? Any evidence of re-hydration?
Any thoughts on models of lumbopelvic problems? Making some one better with a technique does not constitute proof of a theoretical construct.
Any  definitions of what constitutes 'autotraction,' which is the form of traction the Cochrane Review on Traction found robust at all (not very) for effectiveness in treating LBP? I am familiar with the 1980's 'autotraction' machines (3-dimensional self-guided traction). Is a backswing autotraction?
Britt

Comments

[John Goodrich]

With regards to the Vax-D, refer to Dr. Barrett on Chiroweb,"Be Wary of Vax-D." To the best of my knowledge, and on reviewing the literature, there is virtually no support for manual treatment based solely on postural assymetry. I will be interested if anyone else out there knows something different.

[John Goodrich]

Excuse me, Barrett is on Chirobase not -web. As far as the practice variation is concerned, Rob in particular has addressed this issue very effectively. I for one don't know what else we can do and am convinced this ultimately needs to be addressed in our schools.

[britt]

John,
Nice, I had forgotten the Barrett article @ http://www.chirobase.org/06DD/vaxd/vaxd.html. Note that the web-page article, 'Be wary of VAX-D therapy' by Stephen Barrett MD was revised just 2 weeks ago (June 17, 2006). Great piece of information on the history of VAX-D.
Any definitions of autotraction for the record?

Thanks,
Britt

[Joe Rusinowski]

Considering the patient's age, I doubt if there is any ability to "re-hydrate" at this point. He most likely needs "space" but it will not come from rehydration at that age.

[Tim fearon]

Britt

Evidence on re-hydration????? Let's think about that for a moment. How is it that we impart a mechanical force on anything and create a chemical reaction that produces more Hydrogen and Oxygen in a supposedly targeted and impacted structure? This is such a foolish notion that it is impossible for me to believe that it is proposed at all. How is it that the pre-treatment and post treatment levels of hydration are measured? They are not. Never. If someone alleges that the pre-treatment and post treatment imaging studies measure hydration of the disc they need to go back to Physics 100. We cannot mix variables and measure fluid volume with a measure linear movement, much less fluid content. For the life of me I do not understand (yes I do $$$$) why Vax D, DRX and anything else that they want to call it is not categorized as what it is, passive traction, perpendicular separation between joint surfaces. How foolish can a supposedly scientific community be?

Lumbopelvic torsion fall into the same category. When we as a profession site that the problem is an anatomical abnormality (what is normal for that individual to begin with?) and then attempt to alter that abnormality all we are doing is changing a perceptible anatomic relationship. This is never more maddening than when the scoliotic patient is told that their problems stem from the pelvic obliquity that is a normal part of their anomaly, a rotary alteration in the spinal column, and that if we just change that lumbopelcic abnormality we will change their problem! Amazing. Few if any patients arrive complaining of abnormal anatomy. At a minimum we must acknowledge that the vast majority of our patients arrive with complaints of pain that affects their ability to function. What they really want is to change that relationship by minimizing pain and restoring function. If we do our best to prove a cause and effect relationship between their pain and the mechanical forces that we can either create or alter, we have a chance at changing this. We can come up with any theory that we would like to propose for why our chosen technique may have an impact but in the end we really do not know.

Auto traction. I suppose that it would be universally accepted that auto traction (if I am not selling the machine) is traction performed by the patient, not an external force generated by the therapist or a machine. Is inversion autotraction? My opinion is that many of the most salient points about traction are completely missed. Inversion in a "backswing" type device is a passive traction (generated by gravity only) in an extension position. The inverted position with arms overhead and ankle fixated amplifies the lumbar lordosis immediately. Conversely the "orthopod" type devices place the patient in a passive traction with a flexion pre-positioning. Those who cannot extend, nor tolerate the extension moments created will rapidly dismiss traction (in a backswing) as provocative while professionals such as PT, DC, MD or DO misses the point but not the paycheck.

We all too often cite the separation of end-plates as the major impact of traction. I would submit that if there is a perpendicular separation between endplates then there has also been a separation of each of the contributing facet joints, a capsular stretch at each joint effected, a stretch of every ligament crossing a longitudinal lengthening of the multifidi, paraspinals, quadratus, latisimus, and every other muscle that crosses that motion segment. The variables that we can utilize in traction are as broad as the variables available in any other technique, it is after all simply another mobilization technique. The most obvious ones should include positioning, direction of force, quantity of engagement of the patient (ie active muscular work through completely passive), duration, and effect on symptoms. These are all controllable on our part, hydration on the other hand is likely left to a higher power than joint mobilization.

Thanks for waking up my brain on a sweltering holiday weekend.

Tim

[Britt]

Tim,
Thanks for the comments. You're case for implausibility based on basic science is compelling. I believe that your comments get to the heart of the issue: the use of language, or abuse of language, to develop public buy-in for a treatment mode. Isn't it intriguing how these explanations of treatment effects(e.g. disc rehydration) attributed to a mode of care (e.g. traction)are used to explain an outcome (i.e. less pain) to the public. You give a very plausible alternative explanation for traction: Mobilization of the joints by traction.
All clincians flirt with the issue of language's limitations with the front line work of treatment. I know I've passed through phases of explaining the patient's problems with pathoanatomical explanations (e.g. facet syndrome), positional stuff (FRS R), or simple descriptive language (shift to right with loss of flexion, pain in extension)...all are given as explanations for manual therapy (which is equally effective or ineffective despite the explanation!).
I think the desire to explain, coerce or entice (or market)leads to similes, metaphors or analogies: rehydration of discs, torsion of the pelvis. The words are evocative. The public can more easily visualize or imagine the effects of rehydration on those oldie, moldie discs or reduction of the torsional positions with manual therapy: PLOP, PLOP, FIZZ, FIZZ...OH, What a relief it is!!!!
Aetna (www.aetna.com/cpb/data/CPDA0569.htm.) defines autotraction as "the use of one's own weight to create the traction force (i.e., the patient determines the traction force)." They list Spinalator, Spinalign Massage, Intersegmental traction table and Anatomotor. They cite 2 studies: Telso & Merlo (1993) and Ljunggren et al (1984) for quality evidence: one positive, one negative. Telso & Merlo compared autotraction with passive traction and had a 75% vs. 22% satisfaction of the former vs. the latter. Ljunggren et al found no difference between manual traction and autotraction. Interesting.
Erhard et al (2004)reported in JMMT a successful non-surgical management of patient with a far lateral disc using autotraction in an eclectic approach. [Erhard RE, Welch WC, Liu B, Vignovic M.Far-lateral disk herniation: case report, review of the literature, and a description of nonsurgical management.J Manipulative Physiol Ther. 2004 Feb;27(2):e3.]
I agree with your comments on the rehydration and assessment of motiviation from VAX-D. Isn't it a shame it is $o ea$y to $ee $$$$ $igns in the medical market place?
Thank you,
Britt

[Jason Silvernail]

Great discussion.

Given the sensitivity and demonstrated ability to change rapidly with stimuli, I think the only possible explanation for the effects of traction is that it reduces mechanical compression of the nervous tissue. Whether it's the root or any associated relevant nerve tissue, it seems to me that no other explanation makes sense. I mean, things like ligaments and muscles and joints being stretched or mobilized sounds completely plausible, but given what we know of neuroscience, I'm not sure those things make as much sense.

I promise I won't go on another manual therapy/ motion palpation rant, but John G's comment that it needs to be addressed in our schools is a great summary.

I think that what this gentleman (or any of our patients, for that matter) ultimately needs is movement that reduces the mechanical compression of his sensitive nervous tissue. It seems to me that active movement is the best choice for that, and I $econd other$ implication$ that we leave the VAX-D and related $tuff to tho$e intere$ted in money, rather than outcome$....
J

[Eric]

I have stumbled onto this great site through my brother in law. I have several questions for all of you. Please help, because I have seen patient subjectively respond to traction but this new decompression traction looks like a "flavor of the week" as well as glorified traction. My question is realated to the ODG-TWC and ACOEM guidelines that don't support any traction as being pallative and not recommended. I have many chiropractic physicians requesting my opinion on the matter. As a DC I also don't see the substaintial difference of decompression vs. traction and why this product has raised its head in the recent evidence base medicine which I practice. I have been asked by many insurance providers whether decompression therapy at 20 visits at approximately 250 dollars a pop is going to be reasonable, medically necessary and I just don't see the research supporting this type of therapy. what do you all say. I welcome any and all responses. Thanks Eric Tondera, D.C. Houston Texas.

[eric]

In addition, please don't misunderstand my plea for additional information on the decompression aspect of traction. There is a place for it in the management of cervical and lumbar radiculopathy and degenerative disc disease, but the problem I am having is with the clinicians prescribing this therapy to a already diseased disc, dissicated disc, dehydrated and or just plane bone on bone contact in the spine. We all can agree that a non-disease disc could show promising results but what about the diseased disc? Thanks Eric

[Britt Smith]

Eric,
Great questions and I don't know the answers to many. I don't know the effects on dessicated discs vs. healthy robust discs, but my suspicion is the group of responders may include both flavors.I don't see any compelling evidence supporting the claims on disc effectively by traction (I remember a CT study in the 1980s that demonstrated disc reduction in the lumbar spine...but how effective?). Stephen Barrett's website above is interesting about the history of VAX-D. He's a chiro-basher, but I imagine he is an EBP kinda-guy, so feel the collegiality.
I understand your position with advising others. The systematice reviews and evidence are generally negative on traction, but there are responders (SUBGROUP) out there taht need traction for relief. Thank you for the thoughtful response.
Britt

[kdkanz]

Try this:
(disc regeneration)

Can degenerative discs regenerate?
(they can in rabbits, but only after 28 days of tx)

http://www.spineuniverse.com/displayarticle.php/article3061.html

[kdkanz]

Can degenerative discs regenerate?
(they can in rabbits, but only after 28 days of tx)

http://www.spineuniverse.com/displayarticle.php/article3061.html

[Jason Silvernail]

Well, next time there's a rabbit in the office with a raging lumbar radiculopathy, I'll recommend 28 treatments.

Animal research has failed quite convincingly in many ways, so I've no reason to think this advances the debate.

And there's this: does disc degeneration cause pain? Does aiming treatments toward this degenerative process make sense in the context of the neurobiology of pain?

J

[kdkanz]

I think the question was posed... "Can a degenerative disc be regenerated?" Apparently it can, at least in this study. Animal research is not the gold standard, but it is the starting point for most surgical and pharmaceutical research. I'm not sure many humans would agree to be sacraficed in order to disect their spine following Vax-D treatment. As far as disc degeneration as a pain driver is concerned, I think there is a considerable amount published on spondylosis, canal stenosis and foraminal stenosis that leads to this conclusion. The same 'spineuniverse' link provided earlier will lead you to several.

I'm not an advocate for Vax-D, in fact, I think it is grossly over priced and over marketed (along with IDD, DRX, Spina and many others). I do have some experience with Saunders and the Triton DTS system and have found that are tremendously useful tools in my practice.
~K

[Britt]

Thanks, kd, I'll look up the study. Animal models are interesting, although the bipedal moment does give our spine a different twist.
Britt

[Jason Silvernail]

Well, while the issue of the disc being regenerated was the original question, I suppose my comment was meant to take us toward a construct or idea that was actually useful in managing pain.

The current state of degeneration of an individual disc just isn't important in that context.

Since discs cannot depolarize or transmit signals, they by definition cannot be a pain driver, contrary to what kdkanz suggests. Presence of pain and presence of such degenerative findings is correlation, not causation.

Many studies examining pain and prognosis have not shown imaging findings to be very helpful in indentifying responders vs nonresponders to therapy, and have not been able to identify those in pain vs those not in pain.
So, just to reiterate, the disc doesn't appear to have much to do with it. I did read a study (maybe in Spine?) about imaging showing that new disc contact with a nerve root was associated with pain. But again that has to with the nervous tissue, the tissue that can actually deploarize and send nociception, which is what I think we really need to be talking about. Not the disc. Just a thought.

J

[Dr. Palmer]

As a clinician who has used this therapy, I can say that it works very well if used right. Perhaps 'rehydration' is not a good word to use, but when you consider that it is neccessary for collagen formation, this really makes sense. In virtually evry case that I treated while I had a decompression machine, my patients were 50% relieved in 8 visits, and when I did post x-rays at visit 20, there was increased disc height, restored (at least partiallly) curves and I even saw reductions in sponlylosis and scoliosis. I have seen a lot of hype from the companies about this therapy and very little research, but some does exist. The salient points seem to include: angle of traction (90 degrees to the disc in question), amount of force (25-50% of body weight), time of tractioon (overall) and intermittency of the period (60sec on-30 sec off). Some other studies showed the table break to be important and SPINA has an oscillating feature that seems to overcome some of the discomfort in the proceedure.

Despite all of the hype and bullshit around this therapy, I believe that it is one of the most incredible to date. What I can't believe is that it takes a $100K machine to do it. I am not currently doing this, because I do not have access to a machine anymore, but would jump on it in a minute if I had the chance. If anyone would like to speak to me about my experience, I would be glad to. I tend to be a 'show me' kind of guy and hate taking things on faith. This, however, can be a great tool.

[Joe Gautier]

I don't mean to speak over my head...I am a civilian. But my neice is going in to have her "over 50% spinal curvature" addressed at Oschners. They told her the ONLY effective remedy for this 11-year-old is a steel rod. They have got to be joking, right?! I had radical curvature in my 3,4,5 and they chiro had me on glucosamine something and he hung me, stretched me, etc. I was 39 at the time...and the therapy made radical improvements. Please help me if you have any "alternative" course of action besides turning my young neice into WOLVERINE. Thanks, I'll take my seat in the back of the room now.

[Sean Hayes, PT]

I think we can all agree that any treatment for spinal pain reduction, when successful, leads to a relief of deformity on some neurological structure. However my next question/statement is in reference to disc rehydration which may spark more arguments.
I notice that in the morning, following 6 hours of gravity eliminated positioning, my spine is longer. I notice this because when I get into my truck and look out my mirrors, it seems like a much shorter person adjusted them before I got in. Can I conclude based on any research that >6 hours of gravity-eliminated positioning, in a healthy (non-degenerated) disc creates rehydration of said disc? What does the research say regarding this phenomenon?
If the scenario above is true, and leprachauns are not joy-riding in my vehicle during the wee hours of the night, what theory then might we extrapolate from this regarding traction? What would the ideal study design and measurement be to prove/disprove rehydration? And has this ever been done?
Shifting gears, in reference to pelvic asymetries, I have found my patients with asymetries have the majority of their pain complaints originating from the guarding/spasms in their muscles (hip rotators, ITB, etc.). 9/10 times these patients note significant relief following simple, selective stretching exercises. In addition, when gait abnormalities are present, these tend to resolve also.

[Carlos Estevez]

Sean,
Disc rehydration is a phenomenon well documented. This is how discs receive their nutrition via vertebral end plates.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=8064481&itool=iconabstr&query_hl=9&itool=pubmed_DocSum

Due to the human cruelty factor...any volunteers??Im not aware of any good studies demonstrating traction and disc rehydration, although plently of computerized, and animal studies done. Heres one in favor for traction.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16816759&itool=iconabstr&query_hl=6&itool=pubmed_docsum

[Sean]

Carlos,
Thanks for the references. So we agree disc rehydration takes place with prolonged gravity-eliminated positioning. So the theory of traction speeding this process up makes sense. All u have to do is MRI before say 15 Tx treatments and after. Measure the volume of the discs, have the pt's fill out some outcomes measurements tools, and the study's done. Then u do another study that has the same design with the sub-population that got the best results from the traction and voila' you have a rule for when traction is indicated.
I think we've all had a patient in our careers who ONLY responded to traction, and experienced long-term benfits. I mean isn't it simple to figure if traction is effective/useless, and who this subpopulation is, or am I missing something?

[Jason Silvernail]

Here's the thing with traction - the only possible way it could relieve pain is if it does one thing - relieves the mechanical deformation of the relevant nerve tissue.

Sometimes the relevant nerve tissue is positioned in such a way that the traction is very effective - especially if the nerve root itself is the primary sensitized tissue. Sometimes traction only unloads part of the sensitive tissue, sometimes not at all, and sometimes it worsens the mechanical deformation of the nerve tissue and worsens the patient.

Given the established level of sensitivity of nervous tissue and the established fractal nature of it's architecture, how do any of us suppose we could predict this response?

I do use traction sometimes, and I guess I have my own personal clinical prediction rule about it, involving more acute onset and reason to believe primarily nerve root involvement (from neuro signs). I'm not aware of my traction outcomes, but certainly I'd say it's a mixed bag, and I tell the patient that right away. Maybe I should take a page from Dr Palmer's book and tell them it's going to increase their disc height and reverse their curvature so I can get a stronger placebo response. On second thought, maybe not.

J

[OIF VET]

I am a victim of VAX-D. I was quickly assessed as "one of the "75%" who would benefit from Vax D therapy for my bulging L5-S1 that was causing spasms and pain. $4,000 later I ended up with a case of sciatica, $200 in useless vitamins and a $30 back support for $60. My V.A. doctor said their studies in the 70's indicated that when the back is pulled on (Vax D) the back muscles pull back. My piriformis pulled back, agitating my sciatic nerve, introducing me to a world of pain that had yet been a stranger to me. I actually was in the fetal position on the floor of the E.R crying one night...I never cry.

[lenejoseph32 lene]

I do use traction sometimes also but i want to apply also other methods to have more technique

[joselene41 lene]

Great info, I will bookmark your blog and follow your future content. Are you allowing us to post any medication for back pain to your blog? If so any referrals?

thanks