Dr. Kennedy is a graduate of Palmer College and has been in both private and MD/DC practices in Berlin, PA, for over 23 years. He is a leading authority in North America on decompression and rehabilitation procedures and has successfully treated tens of thousands of patients. He has pioneered decompression therapy technique since 1993. Dr. Kennedy is also a renowned product designer and holds multiple patents. Dr. Kennedy is a frequent guest lecturer at leading chiropractic colleges and decompression therapy certification seminars throughout the US. For more information email [email protected].
Decompression, a.k.a. traction therapy, as a primary treatment modality for herniated lumbar and cervical discs is well known in physical therapy (PT) and chiropractic. Over 50% of PT’s report using traction therapy as a primary treatment for herniated discs, especially conditions showing nerve tension signs. I believe up to 15% of DC’s now utilize decompression with 70% using Flexion/Distraction, primarily to affect disc and nerve conditions. Cervical traction is far more prevalent than lumbar traction, in both PT & DC practice, according to a recent survey by Hartte et al. However, both cervical and lumbar traction therapy tend, at least in the PT world, to be directed toward nerve encroachment syndrome (A condition with few other safe and utilitarian options).
Interestingly, lumbar traction has been completely usurped by disc decompression, even though they are one and the same. It is not far fetched to suggest advertising and marketing slogans are the primary differences. Decompression is the potential disc related outcome achieved during axial traction. The prime contingency being that the disc must be intact and hydrostatic (pressurized fluid). When axial tension is applied, a centripetal effect can enhance osmotic renewal. Movement of fluid and nutrients can expedite healing in many cases. This is typically referred to as molecular solute transport and the hydrophilic property of the proteoglycan molecules affords the nucleus its pressure deformation and resiliency characteristics. Keep in mind, decompression isn’t ‘table dependent’, it is an inherent action of axial elongation applied to an intact (hydrostatic) disc.
The primary clinical question is; why Decompression does not always work and why, if so theoretically valuable does it so rarely demonstrate dramatic efficacy in controlled trials? (see Cochrane collaboration; traction review 2006) That remains one of the most puzzling questions for those of us regularly using traction and convinced of its efficacy.
Traction (axial tension) apparently affords 3 potential outcomes:
1. Decompression…if the above mentioned criteria of disc patency hold true.
2. Stretch…creating pain modulation via mechanoreceptor/nociceptor pain gate mechanisms.
3. Directional preference…a range-of-motion that tends to centralize referral pain based on a potential migration or stress-shielding effect of the disc.
These actions-of-traction allow a theoretical answer to why a clinical outcome is attained from treatment. However, we don’t as of yet have the ability to know with certainty what is actually causing the pain and how traction is affecting it specifically. It remains largely theoretical and its benefits largely empirical. My experience through 15 years of clinical use and study of traction tells me it does offer improvement, often dramatically, in disc herniation conditions, with or without nerve involvement. I believe, it will become a primary treatment modality in chiropractic and is fast approaching a tipping-point acceptance.
Dr. Michael Schneider has been a practicing chiropractor for 27 years. He has a PhD in rehabilitation science from the University of Pittsburgh where he presently is an Assistant Professor in the School of Health and Rehabilitation Sciences. Dr. Schneider has obtained a five-year Federal grant from the National Institutes of Health to conduct chiropractic research on low back pain
Rehabilitation involves the use of therapeutic exercises and activities to stabilize the spine. The evidence based approach to rehabilitation of herniated discs has two basic components:
1. Directional preference exercises to directly affect the disc
2. Stabilization exercises to improve function in the muscles around the disc
Direct treatment of the disc requires that the chiropractor pay careful attention to how various movements affect the patient’s lumbar and leg symptoms. McKenzie was the first to describe the centralization phenomenon, in which repeated movements cause a receding of leg symptoms proximally toward the spine. Old time chiropractors used the term “retracing” to describe the same observation of pain leaving the foot and slowly retracing back to the spine. When a particular movement causes centralization of symptoms, this is called a directional preference, and is thought to be mechanically causing movement of the herniated nucleus pulposis back toward the center of the disc. When the disc has herniated posteriorly, often repeated extension movements will drive the nuclear material anteriorly and reduce the sciatic symptoms. In patients with a lateral shift or antalgia, repeated lateral bending movements into the same side of pain will cause centralization. This concept was called “closing the open wedge” by some old time chiropractors.
Once directional preference exercises have helped to reduce the disc herniation and symptoms are centralizing, the next step is to stabilize the spine with rehabilitative exercises. Patients should first be taught the postural cat-horse exercise in order to be able to sense their “neutral position”, which is the normal lumbar lordosis. Next, patients should learn how to tighten their abdominal muscles as if someone were to punch them in the stomach. This reflexive tightening of the abdominals is known as an abdominal brace, and immediately stiffens all of the muscles surrounding the spine. Finally, McGill talks about the “big three” exercises for spinal stabilization which consists of training these key muscle groups:
a) Partial crunches: Activates the rectus abdominis without flexion of the spine
b) Side bridge: Activates the oblique abdominals without rotation of the trunk
c) “Dog Pointer”: Activates the erector spinae muscles without hyperextension
Most patients with herniated discs need to be careful not to aggravate their condition with exercises that are beyond their ability. This mistake is made in many physical therapy clinics who take a “no pain – no gain” attitude. McGill has shown that most disc patients do not require intensive strength training to stabilize their spines, with his research showing that only a 5-10% improvement in muscular strength is needed to greatly improve spine stability. Chiropractors can easily incorporate these directional preference and stabilization exercises into their practices without expensive equipment, and help many disc patients to improve.
Dr. Seaman is an Adjunct Associate Professor at Palmer College of Chiropractic Florida, has a part-time practice in Ormond Beach, and is the Clinical Education Director for Anabolic Laboratories. He has written numerous articles on the treatment options for chronic pain patients, with a focus on nutritional management. He can be reached at [email protected].
For many years, we have known that the presence of disc herniation does not equate with the presence or severity of back/leg pain.1 It is also known that, substantial disc degeneration associated with a grade II spondylolisthesis can be pain-free.2 Thus, the first treatment technique should be to reassure the patient that disc degeneration, internal disruption, and herniation are common and often remain painless throughout one’s life. Reassurance, as a treatment, is important because we know that there can be a negative effect on outcomes when patients view images of their degenerated spine.3 The second treatment technique involves the realization that no treatment technique fits all patients and so there is no specific technique that is responsible for reducing herniations. Interestingly, if a patient does not have progressive neurologic changes and they can withstand the pain of discopathy, most herniated discs will resorb on their own within two to twelve months.4
In terms of managing patients with herniated discs, the goal should be to reduce the pain to a tolerable level, while the natural resorption process occurs. In addition to traction, manual procedures, and rehabilitative exercises, both dietary and nutritional supplementation may be helpful. While there is no specific “nutrition” technique for discs, it is important to realize that the pain process with herniated discs is no different than any other pain. Foods known to reduce inflammation in general include omega-3 fish, vegetables, fruit, and nuts. Lean meats and skinless chicken are also acceptable. Tubers such as potatoes are also anti-inflammatory, so long as they are consumed with the aforementioned low glycemic index/load foods. Foods that are less anti-inflammatory are whole grains, legumes and dairy. And foods that are overtly pro-inflammatory are refined grains, grain/flour products, sugar-rich foods, deep fried foods, trans fat-containing foods, and dressings/foods that contain omega-6 fatty acids from oils derived from corn, safflower, sunflower, cottonseed, peanuts, and soybeans. Ensuring adequate digestive function is also an important consideration. Bearing down during a bowel movement increases intrathecal pressure and can dramatically increase back and leg pain in those with disc herniations. In addition to eating anti-inflammatory foods, supplemental fiber such as psyllium husks can dramatically improve bowel habits. Meals should be spiced with ginger, turmeric, oregano, and other spices, and/or these can be taken as supplements. Not well known is that these spices have anti-inflammatory actions that are similar to NSAIDs. Three key supplements that can influence inflammatory and nociceptive processes include magnesium, vitamin D, and EPA/DHA, which are omega-3 fatty acids from fish oil.
These nutritional recommendations are known to reduce levels of inflammatory mediators in humans, and so should be considered in all of our pain patients.