We're all competing for new patients. We're competing for new patients with physical therapists, massage therapists, medical specialists and hospital fitness centers. We're even competing with side-effect-ridden medications that quit working every four hours. However, one thing we're not competing against is a revolutionary new "cure" for back pain.
Though we're regularly introduced to such cures (and secrets of how the spine and nervous system "really work"), most of us have never seen anything actually live up to its press release. Rhetoric, marketing and testimonials have no real limits; science, however, is constrained by the laws of physics, the limitations of matter and (usually) the inherent boundaries of logical integrity.
Real scientists typically modify their findings behind phrases like: "No specific conclusions can be drawn at the present time" or "More research is required."1 Marketers, however, take these same findings and translate them to such phrases as: "Scientists unlock the secret to a pain-free back"; "The cure for arthritis is in this bottle" and "Weight loss without diet or exercise." We've seen similar headlines in our own profession.
Putting the cart before the horse is a staple of advertising; screaming from the rooftops regarding the newest product usually comes long before that product has really ever proven itself to be effective (such as a pharmaceutical prescribed prior to the realization it kills people).
Over the past two decades, decompression-traction has found a remarkable niche in many chiropractic practices. It has taken its place as both a co-treatment with manipulation and rehab, and as a substantive adjunct to manipulation and rehab. What is remarkable is how the public has embraced decompression as both an alternative to spinal adjustments (and surgery, in many cases), and as an alternative to "traction." This is a stunning testament to the initial decade of hyperbolic misdirection.
I have never purposefully suggested to a patient (at least in the past 12 years) that the decompression I provide is not traction (I consider what I do decompression-traction) or that I didn't inherently do axial traction. However, I have discussed the often-dramatic differences between the attributes, operation and misapplication typical in many traction sessions dispensed by hospitals and PT centers versus the codified application of decompression we strive to offer.
And in the basic understanding of what we coin "synergy-response decompression," the sum of the parts is greater than any one piece (such as when applying class IV laser or ultrasound during traction).
This is not to say these clinicians can't or don't deliver benefits to their patients with the use of traction therapy; however, their protocols and methodologies, I believe, are often: 1) poorly aligned with more recent advances; and 2) administered on relatively antiquated equipment.
Axial decompression is a codified, classification-based application of axial traction with the intention of decompressing a compressed structure. The well-worn (and relatively accepted) theory is that the decompression effect creates a positive, often profound change in the internal healing potential of the damaged discal / joint structure(s).
Though the effect is temporary in terms of the reduction of axial-compression (since gravity never loses the perpetual tug-of-war), the underlying metabolic and physiologic processes set in motion may continue for several minutes or several hours. Apparently, this is the trigger for the pain relief most often associated with traction treatment. Both internal disc alterations due to altered / improved blood / nutrient contact and mechanoreceptor pain gate modulations can account for pain relief, probably in synergy versus one or the other.2-3
So, should this effect be seen as exclusive to any particular piece of equipment or is it uniform to virtually any axial-traction treatment? These are the questions not fully answered by research projects to date, but enough empirical evidence exists to suggest it is in fact a result of spinal stretch and out-of-gravity positioning, and is equipment (pulling-motor) independent.
Where a comment on antiquated equipment can be seen as substantive and not just rhetoric is in an examination of patient-classification and positioning. If we examine HNP research over the past 40 years, two concepts have proven relatively valid and reliable: centralization of pain and directional preference.4 Given that extension is a preferential direction to centralize pain in more than 70 percent of HNP (typically those under age 50), it makes sense that prone decompression be at least attempted in many cases ... if for no other reason than to foster that concept in the patient's mind.
Additionally, extension repetitions immediately after the axial treatment may better facilitate the posterior disc migration effect.5 Attributes of the table should facilitate both effective and ultimately, comfortable positioning; a big part of that is the harness system.
A complete circumferential binding assures proper axial transmission of the tension (and clinical research is clear; a pulling application is superior to a pushing application).
Lateral preference is perhaps found in some 20 percent, so having an offset pull (combining motor and belt shift) is important, as is allowing quick and effective side-lying positioning. Often medial-disc / nerve displacement syndromes are best initially treated in the side position, allowing reduction of nerve tension and painless maintenance of the antalgia ... something less tenable when prone or supine. Side-lying position affords a more acute or persnickety patient an option for comfortable traction therapy when prone or supine is too uncomfortable.
I consider supine decompression-traction a default position, though in daily practice it certainly may constitute 50 percent or more of treatments due to degenerative conditions, elderly patients or those with morphologic considerations (or concomitant extension motion disorders) invalidating prone.
No well-versed proponent of traction over the past 60 years would suggest supine-only treatment is a clinically viable means of applying traction. In fact the prone position emerged from the stationed clinical viewpoint of Mathews, Cyriax, Saunders and many others who recognized prone traction as likely more beneficial for more people than supine; many of their insights decades before Mackenzie. Of course, prone-only has its own set of problems.
The frustration scientific-minded individuals are up against when discussing and practicing physical medicine and "alternative" treatment methods is that personal experience is often all we really have to go on. I count myself both scientific and skeptical. Like everyone in practice, I have had years of remarkable and perhaps ultimately inexplicable results with chiropractic and decompression. Conditions improve, people get better, get their lives back, and we get paid; the ultimate full-circle. However, the problem of proving it convincingly to the "outside" world persists.
We have fragments and theories at present, and I guess that will have to suffice until more definitive research is gathered – which could take another decade if the National Institutes of Health and other agencies that allot money believe research is still warranted. At present, it is difficult to get traction, manipulation and other modality research funded since so much of it in the past has been negative, inconclusive or equivocal.6
We should continue to offer decompression to patients who fit into a reliable classification analysis of a compressive-disc syndrome, since the other options – medication, surgery or injections – are themselves of limited long-term benefit.7 With active rehab procedures and manipulation, decompression-traction adds a passive mode of treatment that has sufficient validity, affordability, safety and effectiveness to be recognized as a substantial core treatment method in chiropractic's future.
References
- Cochrane Summaries. Cochrane Collaboration website, 2013.
- Bogduk N, Twomey L. Clinical Anatomy of the Lumbar Spine. Churchill Livingstone, 1992.
- Ozturk B, et al, Effect of continuous traction on the size of herniated disc material. Rheumatol Int, 2005 Oct;25(1).
- May S, Alessandro A. Centralization and directional preference: a systematic review. Manual Ther, 2012;17(6).
- Fritz JM, A randomized clinical trial of the effectiveness of mechanical traction for sub-groups of patients with LBP. BMC Musculo, 2010 Apr;30(11).
- Personal communication, NIH Office of Administration (2012).
- Slipman CW, et al, Etiologies of failed back surgery syndrome. Pain Med, 2002;3(3).
