Emerging technologies

Peer Review Network, Inc.
MTG Newsletter
October 1998 / Vol. 5 No. 3
Low back pain can have many causes. It is exceedingly frequent sometimes are inappropriate or suboptimal. Surgery versus and is experienced at some time by up to 80% of the population.
conservative trail is the most obvious of such choices. However, The differential diagnosis of low back pain is broad and includes surgery is not the only treatment that can lead to increased systemic diseases (e.g. metastatic cancer), primary spine disease disability: Methods such as extended bedrest or extended use (e.g. disc herniation, degenerative arthritis) and regional diseases of high-dose opiods prolong symptoms and further debilitate (e.g. aortic dissection) that refer pain to the low back. Treatment patients. And although the existing literature has shortcomings, is often flawed, frequently painful and can be exceedingly there is sufficient evidence for a number of conclusions about the efficacy and safety of current assessment and treatmentmethods.
As demonstrated in the literature, the causes of mechanical lowback pain probably include degenerative disc disease, The manipulative techniques used for mechanical low-back pain degenerative spondylosis with limitation of range of motion, facet associated with facet syndrome or muscle strain have not been arthropathy, relative lateral recess stenosis; pressure changes found to be as useful in the management of herniated or affecting the thecal and epidural space from disc bulging, degenerated lumbar discs. Similarly, other modalities including subligamentous and/or extruded herniation and segmental ultrasound, electrical stimulation, short-wave therapy, instability. Any activity such as sitting, standing and/or lifting acupuncture, steroids, anti-inflammatory agents and muscle increases axial loading on the spine will exacerbate low back relaxants can fall short of treating underlying problems associated with intervertebral disc lesions. None of thesemethods relieve the pain from neurocompression or from the Anatomically, the spine consists of individual small bones called stimuli associated wit a prolapsed nucleus pulposus. We vertebrae that are stacked on top of one another to form a column.
reviewed studies on traditional traction that report less than 50% The cushion between each vertebra is called a disc. The problem with a disc is that it can pinch or irritate a nerve from the spinalcord resulting in pain that affects the legs (sciatica). Sciatica Although the uses of physical modalities in many forms are can be severe and disabling. If it persists longer than four weeks, useful as adjunct therapy, in the treatment of disc pathology worsens and there is no improvement, there is strong physiologic they are largely empirical. Nachemson et al have evidence of dysfunction of the spinal segment consisting of the comprehensively outlined changes in intradiscal pressures intervertebral disc and its adjoining vertebrae. This condition through various activities. They found that certain spinal motions needs to be confirmed at the corresponding level and side by and positions lower intradiscal pressures so that exercise findings on an imaging study (MRI) and warrants an appropriate programs and preventive ergonomic advice are fashioned after physician consultation. Primary disc pain can occur with these principles. Research implies that raised intradiscal mechanical strain of the annulus allowing nuclear herniations pressures play a role in producing disc lesions and now it is through radial fissures as well as from inflammation following shown that lowering intradiscal pressures in a controlled manner trauma. A healthy disc could become painful if diseases in other plays a role in treating low back pain. New advances centering portions of the spine cause it to bear greater mechanical load on the use of decompression, reduction and stabilization and secondarily subject it to excessive strain. It is critical to produced several important studies on the effect of realize that several mechanisms of causing pain may coexist decompression on intradiscal pressure.
and that similar disease processes give varying symptoms.
Effects on Intradiscal Pressures
But, what type of therapy would be best in order to return the The intervertebral disc and two zygapophysical joints above and patient to a function level of activity without pain? Diagnostic/ below form a spinal segment with limited range of movement treatment variations imply a lack of consensus about appropriate when isolated. Several spinal segments together, however, can assessment and treatment and suggest that these treatments produce large ranges of sagittal and coronal plane movement.
The disc provides the main strength and stiffness and consists results of this study indicated that it was possible to lower of a thick annular wall which attaches through cartilaginous pressure in the nucleus pulposus of herniated lumbar discs to plates to the vertebral bodies while the inner nucleus pulposus levels significantly below 0 mm Hg when distraction tension behaves hydrostically as a viscous fluid changing shape in was applied according to the protocol described for the response to body position – in effect, acting like a join.
The nucleus receives axial loads and redistributes the load In an outcome study of 778 patients, Gose et al (Vertebral axial centripetally to the surrounding annulus, but aging reduces the decompression therapy for pain associated with herniated or vascularity of the outer annulus and cartilaginous plates to a degenerated discs or facet syndrome: An outcome study, few small vessels. The nucleus pulposus is held under tension Neurological Research, April 1998) found that decompression within an envelope formed by the annulus and cartilage plates, therapy was a primary treatment modality for low back pain but this envelope is not extensible and maintains turgor by the associated with lumbar disc herniation at single or multiple attraction of water to the proteoglycan macromolecules. Thus, levels, degenerative disc disease, facet arthropathy, and nutrition to the inner nucleus is received by diffusion. Compared decreased spine mobility; that pain, activity, and mobility scores to the disc, the zygapophysical joints hold only 10-15% of the were all greatly improved after therapy. They demonstrated a load while standing by much larger when flexed or lifting. In success rate ranging from 68% for facet syndrome to 72% for other words, they are the guiding and restricting segment during multiple herniated discs and 73% for patients with a single spinal motion and protect the disc from rotational and transitional herniated disc. The average successful outcome for all diagnoses strains. Thus, back pain may result when these fibrous capsules was 71%. The authors have concluded that for patients with or synovial folds are irritated. The nucleus of the intervertebral low back pain decompression therapy should be considered a disc is contained under pressure and this is a useful index of front line treatment for degenerative spondylosis, facet syndrome, disc disease and nonsurgical lumbar radiculopathy.
Nachemson et al (“The lumbar spine: An orthopedic challenge, DRS System
Spine 1975; “Intravital dynamic pressure measurement of C. Norman Shealy, M.D., Ph.D., has developed a medical device lumbar discs,” and “Intervertebral disc pressure during traction,” that lowers intradiscal pressures, is non-invasive and has high Scand, Journal Rehab. Medicine Supplement, 1 and 9) and patient compliance – the DRS System. Dr. Shealy, a board- Ramous et al (“Effects of vertebral axial decompression and certified neurosurgeon who began his career at Harvard intradiscal pressure,” Journal of Neurosurgery, 1994) have University School of Medicine, is a nationally recognized author studies intradiscal pressures and have concluded that the ability and is the founder of the Shealy Institute in Springfield, Missouri.
of the disc to withstand compressive forces depends on both the Dr. Shealy has dedicated his life to the elimination of pain through integrity of the envelope and the turgor within; that movements non-invasive, cost effective treatments and the Shealy Institute such as felion and lateral bending increase intradiscal pressure is one of the most respected pain management facilities in the while resting pressures are lowest in supine and prone positions, world. Focusing on treatment of complex and often perplexing lower in standing than sitting and very low in activities of lumbar medical problems, the institute has been instrumental in the extension and rotation. Exercise programs and ergonomic successful rehabilitation of more than 70% of its patients, who techniques emphasize the maintenance of a lordosis to maintain are now once again leading productive lives. In a tribute to Dr.
decreased disc pressures. Since decreasing pressures helps Shealy and the American Academy of Pain Management, an prevent injury, then a controlled decrease in pressure can directly Institute affiliate, The Congressional Record state: “The American Academy of Pain Management is the largest societyof learned clinicians in the United States concerned with pain One of the best studies on intradiscal pressure was conducted management. Because of dedicated organizations such as the by the Department of Neurosurgery and Radiology, Rio Grande American Academy of Pain Management, our ability to reduce Regional Hospital and the Health Sciences center, University pain and suffering is improving.” The American Academy of of Texas. Intradiscal pressure measurement was performed by Pain Management operates an outcomes measurement system connecting a cannula inserted into the patients L4-5 disc space called the National Pain Data Bank which is designed to measure to a pressure transducer. The patient was placed in a prone the efficacy of pain treatments. The average cost of successful position on a vertebral axial decompression therapeutic table pain treatment at the Shealy Institute is cited less than half the and the tensionometer on the table was attached. Changes in pressure were recorded at resting state and while controlledtension was applied by the equipment. Intradiscal pressure Dr. Shealy is a firm believer in treating the disease, not just the deomonstrated an inverse relationship to the tension applied and symptoms. Phase One of the Shealy Pain program involves using tension in the upper range was observed to decompress the the DRS System to relieve pain quickly and effectively. This is nucleus pulposus significantly, to below –100 mm Hg. The followed by Phase Two – early mobilization and strengthening – and finishing with Phase Three dealing with education and evaluation on the first and third week. Patients with facet prevention of reoccurrence and further injury.
arthropathy may report a sudden pop sensation as facets unlockfollowed by relief symptoms. Treatments are tapered off Dr. Shealy’s has shown that nutrition in the avascular disc depends on diffusion of collagen precursors, nutrients andoxygen through direct channels in the annulus (30%) and the Motrin, Vitamin B complex, Vitamin C, mechanical massage hyaline end plate (70%) n the vertebrae above and below. It is or diathermy are given before sessions for cases of degenerated estimated that the cycle of praline uptake and renewal in the discs and facet arthropathy and therapeutic TENS for use during normal disc takes approximately 500 days. This inherently slow waking hours especially if the patient cannon tolerate anti- cycle is additionally compromised in herniated or degenerative discs. By lowering the intradiscal pressures, the DRS Systemgreatly facilitates this process and accelerates healing in the disc No additional benefit has been shown for treatment times over segment. Maximum clinical improvement occurs when 45 minutes; inconsistent results are shown with treatment less treatment is delivered directly to the affected disc. With the DRS than for 45 minutes. Patients have follow-up exams every week System, the treating physician can make adjustments in the angle to monitor progress and make adjustments to treatment. Joint of distraction, positioning of the spine and amounts of force mobilization occurs at the therapeutic force of one-half the necessary to unload through distraction and positioning to create patient’s weight plus ten to twenty five pounds. This window of the effect of decompression at the specific intervertebral lumbar treatment is altered by factors such as small body frame (less disc level. The FDA concluded that the DRS achieves its effects weight), large frame (more weight), acute injury (less weight), through decompression, that is, unloading die to distraction and positioning of the intervertebral discs and facet joints of thelumbar spine. Regular application of the DRS treatments results The DRS System is FDA approved and the outcomes of a in remodeling of shortened structures by applying end-range recently completed clinical study with orthopedists affiliated with movement to the spine in a controlled manner. Mobilization of Georgetown University and George Washington University on the hypomobile joint is used to restore motion. Limitations of a scientifically statistical number of patients (initially evaluated the patient’s motion depend on the irritability of the disorder.
by an orthopedic surgeons for diagnosis confirmed by MRI) Decompressing the disc space through positioning of the patient showed the subsiding of symptoms directly correlated with the promotes tissue healing as evidenced through MRI documented progression of treatment; all patients had final evaluation at which reductions in the size and extent of herniations.
time function range of motion was restored and activities ofdaily living were resumed; all patients had complete relief of Inclusion/Exclusion Criteria
pain. The patients were instructed in biomechanics and Inclusion criteria should include: Unrelenting or increasing pain modifications were made according to postural changes as over one week duration not responding to conservative care; outlined in the DRS System protocol. All patients who were pain over one month duration from causes other than herniation; surgical candidates also had MRI documented findings.
patient at least 18 years old or case by case consideration underage 18 as there still may be growth plate activity; and One of the most important notations is the studies and reviews documented herniated and degenerative disc disease or facet of the literature (also discussed in an earlier study by Shealy, LeRoy et al) was that conventional spinal traction was less
effective and biomechanically insufficient for optimal
Exclusion criteria includes pregnancy; lumbar fusion less than therapeutic outcome i.e. regular traction does not produce
6 months old; metastatic cancer; severe osteoarthritis or decompression, that is, unloading due to distraction and
osteoporosis with over 45% bone loss; compression fracture positioning of the intervertebral discs and facet joints of
within one year; aortic aneurysms recently diagnosed or greater the lumbar spine. The DRS System is not regular spinal
than 5cm; hemiplegia, paraplegia or cognitive dysfunction and traction and does not utilize the conventional traction table.
uncontrolled concurrent medical disorder.
It is also not physical therapy although the protocol does
contain elements of physical medicine. It is not to be
Smoking, previous surgery and chronic use of narcotic or steroid confused with standard traction that is often used by
medications, obesity and large amounts of daily caffeine can physical therapists and/or chiropractors.
have negative influences on the treatment.
Treatment frequency is based on diagnosis. For example, apatient with a herniated disc will on average be treated daily fortwo weeks, then 3x week for two weeks with re-evaluationweekly. For a degenerated disc, 3x/week for five weeks and re-

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