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The Back Doctors Podcast with Dr. Michael Johnson

The Back Doctors podcast is weekly conversations with doctors from around the world sharing patient stories as they inform, educate, and offer hope for the millions of people who have back pain.
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Now displaying: December, 2020

For more information go to http://thebackdoctorspodcast.com/

Dec 7, 2020

Listen as chiropractor and founder of the Cox Technic, Dr. James Cox explains what Cox Technic is and why it is so effective for treating back pain.

James M. Cox, DC, DACBR, FICC, Hon.D.Litt., FACO(H)

Dr. Cox is the developer of Cox® Technic Flexion Distraction Manipulation and the proud participant in the on-going federal research projects involving the Keiser University, National University of Health Sciences, Palmer College of Chiropractic Research Center, Loyola Stritch School of Medicine, University of Illinois, University of Iowa, Auburn University, etc. He is a member of the postgraduate faculty of the National University of Health Sciences and has been privileged to speak throughout the world.

Resources:

About Dr. Cox

curriculum vitae 

More about Cox Technic

Find a Back Doctor

The Cox 8 Table by Haven Medical

References:

Chesterton P, Evans W, Wright M, Lolli L, Richardson M, Atkinson G. Influence of Lumbar Mobilizations During the Nordic Hamstring Exercise on Hamstring Measures of Knee Flexor Strength, Failure Point, and Muscle Activity: A Randomized Crossover Trial. J Manipulative Physiol Ther. 2020 Nov 25:S0161-4754(20)30201-3. doi: 10.1016/j.jmpt.2020.09.005. Epub ahead of print. PMID: 33248746.

INFLUENCE OF LUMBAR MOBILIZATIONS DURING THE NORDIC HAMSTRING EXERCISE ON HAMSTRING MEASURES OF KNEE FLEXOR STRENGTH, FAILURE POINT, AND MUSCLE ACTIVITY: A RANDOMIZED CROSSOVER TRIAL. AFTER SPINAL MOBILIZATION, IMMEDIATE CHANGES IN BILATERAL HAMSTRING FORCE PRODUCTION AND PEAK TORQUE OCCURRED DURING THE NHE. THE EFFECT ON THE NHE FAILURE POINT WAS UNCLEAR. ELECTROMYOGRAPHIC ACTIVITY INCREASED ON THE IPSILATERAL SIDE.

Meet the Nordic hamstring exercise, also known as the Nordic hamstring curl—your potential new favorite go-to that can help keep you healthy while boosting your performance.  me 19

Lead researcher Nicol van Dyk, Ph.D., of Aspetar Orthopaedic and Sports Medicine Hospital in Qatar, told Runner’s World the move is simple: Begin in a kneeling position with both ankles secured—tucking your feet under a bar, for example, or having a running buddy hold them down—and then progressively lean forward as slowly as possible while keeping your back straight. When you can’t resist anymore, just fall forward, catching yourself with your hands against the floor. Check out the video below for how to do it properly.

 

Ekşi MŞ, Özcan-Ekşi EE, Özmen BB, Turgut VU, Huet SE, Dinç T, Kara M, Özgen S, Özek MM, Pamir MN. Lumbar intervertebral disc degeneration, end-plates and paraspinal muscle changes in children and adolescents with low-back pain. J Pediatr Orthop B. 2020 Nov 27. doi: 10.1097/BPB.0000000000000833. Epub ahead of print. PMID: 33252539.

FATTY INFILTRATION IN THE PARASPINAL MUSCLES AND IVDD WERE CLOSELY ASSOCIATED WITH MODIC CHANGES IN CHILDREN AND ADOLESCENTS WITH LBP. LUMBAR IVDD IN CHILDREN AND ADOLESCENTS COULD BE THE RESULT OF A MECHANICAL PATHOLOGY

 

Karartı C, Özüdoğru A, Basat HÇ, Özsoy İ, Özsoy G, Kodak Mİ, Sezgin H, Uçar İ. Determination of Biodex Balance System Cutoff Scores in Older People With Nonspecific Back Pain: A Cross-sectional Study. J Manipulative Physiol Ther. 2020 Nov 25:S0161-4754(20)30153-6. doi: 10.1016/j.jmpt.2020.07.006. Epub ahead of print. PMID: 33248744.

DETERMINATION OF BIODEX BALANCE SYSTEM CUTOFF SCORES IN OLDER PEOPLE WITH NONSPECIFIC BACK PAIN: A CROSS-SECTIONAL STUDY

BBS CUTOFF SCORES ARE SENSITIVE AND SPECIFIC IN DISTINGUISHING BETWEEN POOR AND GOOD POSTURAL PERFORMANCE IN OLDER PEOPLE WITH NSLBP.

 

TRACTION EFFECTS:

TRACTION AND DISTRACTION STUDIES ON WHICH OUR WORK IS BASED.

Luigi Albano, DC introduced the first paper on which I built the remaining studies.

This gives us foundational understanding as to the benefits of placing a spine into distraction prior to producing ranges of motion – IT FIRST REDUCES STENOTIC EFFECTS THAT COULD CAUSE GREATER NERVE AND DRG COMPRESSION AND CHEMICAL INFLAMMATORY IRRITATION. - JMC

 

Gaowgzeh RAM, Chevidikunnan MF, BinMulayh EA, Khan F. Effect of spinal decompression therapy and core stabilization exercises in management of lumbar disc prolapse: A single blind randomized controlled trial. J Back Musculoskelet Rehabil. 2020;33(2):225-231. doi: 10.3233/BMR-171099. PMID: 31282394.

A COMBINATION OF SPINAL DECOMPRESSION THERAPY WITH CORE STABILIZATION EXERCISE HAS PROVEN TO BE MORE SIGNIFICANT WHEN COMPARED WITH CSE ALONE TO REDUCE PAIN AND DISABILITY IN SUBJECTS WITH CHRONIC LDP.

 

Demirel A, Yorubulut M, Ergun N. Regression of lumbar disc herniation by physiotherapy. Does non-surgical spinal decompression therapy make a difference? Double-blind randomized controlled trial. J Back Musculoskelet Rehabil. 2017 Sep 22;30(5):1015-1022. doi: 10.3233/BMR-169581. PMID: 28505956.

THIS STUDY SHOWED THAT PATIENTS WITH LHNP RECEIVED PHYSIOTHERAPY HAD IMPROVEMENT BASED ON CLINICAL AND RADIOLOGIC EVIDENCE. NON-INVASIVE SPINAL DECOMPRESSION THERAPY (NSDT) CAN BE USED AS ASSISTIVE AGENT FOR OTHER PHYSIOTHERAPY METHODS IN TREATMENT OF LUMBAR DISC HERNIATION.

 

Karimi N, Akbarov P, Rahnama L. Effects of segmental traction therapy on lumbar disc herniation in patients with acute low back pain measured by magnetic resonance imaging: A single arm clinical trial. J Back Musculoskelet Rehabil. 2017;30(2):247-253. doi: 10.3233/BMR-160741. PMID: 27636836.

SEGMENTAL TRACTION THERAPY MIGHT PLAY AN IMPORTANT ROLE IN THE TREATMENT OF ACUTE LBP STIMULATED BY LDH.

 

Kamanli A1, Karaca-Acet G, Kaya A, Koc M, Yildirim H Conventional physical therapy with lumbar traction; clinical evaluation and magnetic resonance imaging for lumbar disc herniation. Journal of Back and Musculoskeletal Rehabilitation, vol. 30, no. 2, pp. 247-253, 2017

CONVENTIONAL PHYSICAL THERAPIES WITH LUMBAR TRACTION WERE EFFECTIVE IN THE TREATMENT OF PATIENT WITH SUBACUTE LDH. THESE RESULTS SUGGEST THAT CLINICAL IMPROVEMENT IS NOT CORRELATED WITH THE FINDING OF MRI. PATIENTS WITH LDH SHOULD BE MONITORED CLINICALLY

 

Choi J, Lee S, Hwangbo G. Influences of spinal decompression therapy and general traction therapy on the pain, disability, and straight leg raising of patients with intervertebral disc herniation. J Phys Ther Sci. 2015 Feb;27(2):481-3. doi: 10.1589/jpts.27.481. Epub 2015 Feb 17. PMID: 25729196; PMCID: PMC4339166.

SPINAL DECOMPRESSION THERAPY AND GENERAL TRACTION THERAPY ARE EFFECTIVE AT IMPROVING THE PAIN, DISABILITY, AND SLR OF PATIENTS WITH INTERVERTEBRAL DISC HERNIATION. THUS, SELECTIVE TREATMENT MAY BE REQUIRED

 

JUDOVICH BD. Herniated cervical disc; a new form of traction therapy. Am J Surg. 1952 Dec;84(6):646-56. doi: 10.1016/0002-9610(52)90127-x. PMID: 12986095.

CLINICAL STUDIES INDICATE THAT IN THE AVERAGE INTRACTABLE CASE THE CERVICAL SPINE SHOULD BE STRETCHED BY FORCE RANGING FROM 25 TO 45 POUNDS. ALMOST HALF THE PATIENTS IN A SERIES OF SIXTY CASES EXPERIENCED PARTIAL OR COMPLETE MOMENTARY RELIEF WHEN THIS FORCE WAS APPLIED.

ROENTGEN STUDIES REVEAL THAT IN THE AVERAGE PATIENT THE INTERVERTEBRAL SPACES OF THE CERVICAL SPINE BEGIN TO SHOW MEASURABLE WIDENING WITH TRACTION FORCE RANGING FROM 25 TO 50 POUNDS.

THE NECESSARY FORCE TO RELIEVE PAIN CANNOT BE TOLERATED BY THE AVERAGE PATIENT WHEN IT IS ADMINISTERED AS A CONSTANT PULL. IF ADMINISTERED INTERMITTENTLY, ADEQUATE AND MUCH GREATER TRACTION LOAD CAN BE TOLERATED WITHOUT THE DISCOMFORT WHICH WOULD NORMALLY ACCOMPANY SUCH FORCE.

A NEW METHOD OF MOTORIZED INTERMITTENT TRACTION IS PRESENTED. THE CLINICAL RESULTS OF INTERMITTENT TRACTION, BECAUSE OF ADEQUATE FORCE, HAVE BEEN EXCELLENT AS COMPARED TO CONVENTIONAL TRACTION METHODS.

 

Burton AK, Tillotson KM, Cleary J. Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation. Eur Spine J. 2000 Jun;9(3):202-7. doi: 10.1007/s005869900113. PMID: 10905437; PMCID: PMC3611397.

BECAUSE OSTEOPATHIC MANIPULATION PRODUCED A 12-MONTH OUTCOME THAT WAS EQUIVALENT TO CHEMONUCLEOLYSIS, IT CAN BE CONSIDERED AS AN OPTION FOR THE TREATMENT OF SYMPTOMATIC LUMBAR DISC HERNIATION, AT LEAST IN THE ABSENCE OF CLEAR INDICATIONS FOR SURGERY. Further study into the value of manipulation at a more acute stage is warranted.

 

Kirkaldy-Willis WH, Cassidy JD. Spinal manipulation in the treatment of low-back pain. Can Fam Physician. 1985 Mar;31:535-40. PMID: 21274223; PMCID: PMC2327983.

RESULTS OF SPINAL MANIPULATION IN 283 PATIENTS WITH LOW BACK PAIN ARE PRESENTED. THE PHYSICIAN WHO MAKES USE OF THIS RESOURCE WILL PROVIDE RELIEF FOR MANY PATIENTS.

 

Oliphant D. Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment. J Manipulative Physiol Ther. 2004 Mar-Apr;27(3):197-210. doi: 10.1016/j.jmpt.2003.12.023. PMID: 15129202.

THE APPARENT SAFETY OF SPINAL MANIPULATION, ESPECIALLY WHEN COMPARED WITH OTHER “MEDICALLY ACCEPTED” TREATMENTS FOR LDH, SHOULD STIMULATE ITS USE IN THE CONSERVATIVE TREATMENT PLAN OF LDH.

 

Kane MD, Karl RD, Swain JH. Effects of Gravity-Facilitated Traction on lntervertebral Dimensions of the Lumbar Spine*. J Orthop Sports Phys Ther. 1985;6(5):281-8. doi: 10.2519/jospt.1985.6.5.281. PMID: 18802302.

MEAN POSTERIOR SEPARATION WAS SIGNIFICANT AT ALL LEVELS EXCEPT L1-L2 AND L5-S1. MEAN INTERVERTEBRAL FORAMINAL SEPARATION WAS SIGNIFICANT AT ALL LEVELS BUT L5-S1. IF INCREASES IN INTERVERTEBRAL DIMENSIONS PLAY A ROLE IN THE RELIEF OF LOW BACK SYNDROME, THEN GRAVITY-FACILITATED TRACTION MAY BE AN EFFECTIVE MODALITY IN THE TREATMENT OF THIS CONDITION.

 

Unlu Z, Tasci S, Tarhan S, Pabuscu Y, Islak S. Comparison of 3 physical therapy modalities for acute pain in lumbar disc herniation measured by clinical evaluation and magnetic resonance imaging. J Manipulative Physiol Ther. 2008 Mar;31(3):191-8. doi: 10.1016/j.jmpt.2008.02.001. PMID: 18394495.

TRACTION, ULTRASOUND, AND LOW POWER LASER THERAPIES WERE ALL EFFECTIVE IN THE TREATMENT OF THIS GROUP OF PATIENTS WITH ACUTE LDH. THESE RESULTS SUGGEST THAT CONSERVATIVE MEASURES SUCH AS TRACTION, LASER, AND ULTRASOUND TREATMENTS MIGHT HAVE AN IMPORTANT ROLE IN THE TREATMENT OF ACUTE LDH

 

Chung TS, Yang HE, Ahn SJ, Park JH. Herniated Lumbar Disks: Real-time MR Imaging Evaluation during Continuous Traction. Radiology. 2015 Jun;275(3):755-62. doi: 10.1148/radiol.14141400. Epub 2015 Jan 22. Erratum in: Radiology. 2015 Jun;275(3):934-5. PMID: 25611735.

HERNIATED LUMBAR DISKS: REAL-TIME MR IMAGING EVALUATION DURING CONTINUOUS TRACTION

CONTINUOUS TRACTION ON HERNIATED LUMBAR DISKS AND SURROUNDING STRUCTURES RESULTED IN CHANGE IN DISK SHAPE, DISK REDUCTION WITH OPENING IN THE INTERVERTEBRAL DISK, REDUCTION OF HERNIATED DISK VOLUME, SEPARATION OF THE DISK AND ADJOINING NERVE ROOT, AND WIDENING OF THE FACET JOINT.

 

Isner-Horobeti ME, Dufour SP, Schaeffer M, Sauleau E, Vautravers P, Lecocq J, Dupeyron A. High-Force Versus Low-Force Lumbar Traction in Acute Lumbar Sciatica Due to Disc Herniation: A Preliminary Randomized Trial. J Manipulative Physiol Ther. 2016 Nov-Dec;39(9):645-654. doi: 10.1016/j.jmpt.2016.09.006. Epub 2016 Nov 9. PMID: 27838140.

HIGH-FORCE VERSUS LOW-FORCE LUMBAR TRACTION IN ACUTE LUMBAR SCIATICA DUE TO DISC HERNIATION: A PRELIMINARY RANDOMIZED TRIAL

PATIENTS WITH ACUTE LUMBAR SCIATICA SECONDARY TO DISC HERNIATION WHO RECEIVED 2 WEEKS OF LUMBAR TRACTION REPORTED REDUCED RADICULAR PAIN AND FUNCTIONAL IMPAIRMENT AND IMPROVED WELL-BEING REGARDLESS OF THE TRACTION FORCE GROUP TO WHICH THEY WERE ASSIGNED. THE EFFECTS OF THE TRACTION TREATMENT WERE INDEPENDENT OF THE INITIAL LEVEL OF MEDICATION AND APPEARED TO BE MAINTAINED AT THE 2-WEEK FOLLOW-UP.

DURING THE 2-WEEK FOLLOW-UP AT DAY 28, ONLY THE LT10 GROUP IMPROVED (P < .05) IN VAS (–52%) AND EIFEL SCORES (–46%).

 

Onel D, Tuzlaci M, Sari H, Demir K. Computed tomographic investigation of the effect of traction on lumbar disc herniations. Spine (Phila Pa 1976). 1989 Jan;14(1):82-90. doi: 10.1097/00007632-198901000-00017. PMID: 2913674.

COMPUTED TOMOGRAPHIC INVESTIGATION OF THE EFFECT OF TRACTION ON LUMBAR DISC HERNIATIONS. CHANGES OCCURRING UNDER THE EFFECT OF A TRACTION LOAD OF 45 KG HAVE BEEN EVALUATED IN 30 PATIENTS WITH LUMBAR DISC HERNIATION WITH CT INVESTIGATION. THE HERNIATED NUCLEAR MATERIAL (HNM) HAS RETRACTED IN 11 (78.5%) OF MEDIAN, SIX (66.6%) OF POSTEROLATERAL, AND FOUR (57.1%) OF LATERAL HERNIATIONS.

 

Clarke J, van Tulder M, Blomberg S, de Vet H, van der Heijden G, Bronfort G. Traction for low back pain with or without sciatica: an updated systematic review within the framework of the Cochrane collaboration. Spine (Phila Pa 1976). 2006 Jun 15;31(14):1591-9. doi: 10.1097/01.brs.0000222043.09835.72. PMID: 16778694.

INTERMITTENT OR CONTINUOUS TRACTION AS A SINGLE TREATMENT FOR LBP CANNOT BE RECOMMENDED FOR MIXED GROUPS OF PATIENTS WITH LBP WITH AND WITHOUT SCIATICA. NEITHER CAN TRACTION BE RECOMMENDED FOR PATIENTS WITH SCIATICA BECAUSE OF INCONSISTENT RESULTS AND METHODOLOGICAL PROBLEMS IN MOST OF THE STUDIES INVOLVED. HOWEVER, BECAUSE HIGH-QUALITY STUDIES WITHIN THE FIELD ARE SCARCE, BECAUSE MANY ARE UNDERPOWERED, AND BECAUSE TRACTION OFTEN IS SUPPLIED IN COMBINATION WITH OTHER TREATMENT MODALITIES, THE LITERATURE ALLOWS NO FIRM NEGATIVE CONCLUSION THAT TRACTION, IN A GENERALIZED SENSE, IS NOT AN EFFECTIVE TREATMENT FOR PATIENTS WITH LBP

 

Beattie PF, Nelson RM, Michener LA, Cammarata J, Donley J. Outcomes after a prone lumbar traction protocol for patients with activity-limiting low back pain: a prospective case series study. Arch Phys Med Rehabil. 2008 Feb;89(2):269-74. doi: 10.1016/j.apmr.2007.06.778. PMID: 18226650.

TRACTION APPLIED IN THE PRONE POSITION USING THE VAX-D FOR 8 WEEKS WAS ASSOCIATED WITH IMPROVEMENTS IN PAIN INTENSITY AND RMDQ SCORES AT DISCHARGE, AND AT 30 AND 180 DAYS AFTER DISCHARGE IN A SAMPLE OF PATIENTS WITH ACTIVITY-LIMITING LBP. CAUSAL RELATIONSHIPS BETWEEN THESE OUTCOMES AND THE INTERVENTION SHOULD NOT BE MADE UNTIL FURTHER STUDY IS PERFORMED USING RANDOMIZED COMPARISON GROUPS.

 

REAL-TIME MR IMAGING WHILE PERFORMING TRACTION IS POSSIBLE.

Mitchell UH, Beattie PF, Bowden J, Larson R, Wang H. Age-related differences in the response of the L5-S1 intervertebral disc to spinal traction. Musculoskelet Sci Pract. 2017 Oct;31:1-8. doi: 10.1016/j.msksp.2017.06.004. Epub 2017 Jun 9. PMID: 28624722.

TO DETERMINE DIFFERENCES IN THE APPARENT DIFFUSION COEFFICIENT (ADC) OBTAINED WITH LUMBAR DIFFUSION-WEIGHTED IMAGING (DWI) OF THE L5-S1 IVD BEFORE, AND DURING, THE APPLICATION OF LUMBAR TRACTION

STATIC TRACTION WAS ASSOCIATED WITH AN INCREASE IN DIFFUSION OF WATER WITHIN THE L5-S1 IVDS OF MIDDLE-AGE INDIVIDUALS, BUT NOT IN YOUNG ADULTS, SUGGESTING AGE-RELATED DIFFERENCES IN THE DIFFUSION RESPONSE. FURTHER STUDY IS NEEDED TO ASSESS THE RELATIONSHIP BETWEEN THESE FINDINGS AND THE SYMPTOMS OF BACK PAIN.

HIGHLIGHTS:

STATIC TRACTION IS ASSOCIATED WITH AN INCREASE IN ADC IN OLDER DISCS, NOT YOUNGER.

INVERSE RELATIONSHIP BETWEEN BASELINE ADC AND PERCENT INCREASE WITH TRACTION.

FINDINGS SUGGEST PRESENCE OF AGE-RELATED CHANGES IN THE RATE OF DIFFUSION RESPONSE.

 

SAAL, JEFFREY A., MD; SAAL, JOEL S., MD Nonoperative Treatment of Herniated Lumbar Intervertebral Disc with Radiculopathy: An Outcome Study, Spine: April 1989 - Volume 14 - Issue 4 - p 431-437

64 PATIENTS WITH LUMBAR HERNIATED NUCLEUS PULPOSUS WITHOUT SIGNIFICANT STENOSIS WERE TREATED NON SURGICALLY.

90% GOOD OR EXCELLENT OUTCOME WITH A 92% RETURN TO WORK RATE.

FOR THE SUBGROUPS WITH EXTRUDED DISCS AND SECOND OPINIONS, 87% AND 83% HAD GOOD OR EXCELLENT OUTCOMES, RESPECTIVELY, ALL (100%) OF WHOM RETURNED TO WORK.

SICK LEAVE TIME FOR THESE SUBGROUPS WAS 2.9 MONTHS (+/- 1.4 MONTHS) AND 3.4 MONTHS (+/- 1.7 MONTHS), RESPECTIVELY. THESE RESULTS COMPARED FAVORABLY WITH PREVIOUSLY PUBLISHED SURGICAL STUDIES. FOUR OF SIX PATIENTS WHO REQUIRED SURGERY WERE FOUND TO HAVE STENOSIS AT OPERATION.

 

Sari H, Akarirmak U, Karacan I, Akman H. Computed tomographic evaluation of lumbar spinal structures during traction. Physiother Theory Pract. 2005 Jan-Mar;21(1):3-11. PMID: 16385939.

DURING TRACTION OF INDIVIDUALS WITH ACUTE LDH THERE WAS A REDUCTION OF THE SIZE OF THE HERNIATION, INCREASED SPACE WITHIN THE SPINAL CANAL, WIDENING OF THE NEURAL FORAMINA, AND DECREASED THICKNESS OF THE PSOAS MUSCLE.

 

Park WM, Kim K, Kim YH. Biomechanical analysis of two-step traction therapy in the lumbar spine. Man Ther. 2014 Dec;19(6):527-33. doi: 10.1016/j.math.2014.05.004. Epub 2014 May 22. PMID: 24913413. A

COMBINATION OF GLOBAL AXIAL TRACTION AND LOCAL DECOMPRESSION WOULD BE HELPFUL FOR REDUCING TENSILE STRESS ON THE FIBERS OF THE ANNULUS FIBROSUS AND LIGAMENTS, AND INTRADISCAL PRESSURE IN TRACTION THERAPY. THIS STUDY COULD BE USED TO DEVELOP A SAFER AND MORE EFFECTIVE TYPE OF TRACTION THERAPY

 

Chow DHK, Yuen EMK, Xiao L, Leung MCP. Mechanical effects of traction on lumbar intervertebral discs: A magnetic resonance imaging study. Musculoskelet Sci Pract. 2017 Jun;29:78-83. doi: 10.1016/j.msksp.2017.03.007. Epub 2017 Mar 20. PMID: 28347933.

HORIZONTAL TRACTION WAS EVIDENTLY EFFECTIVE IN INCREASING THE DISC HEIGHT OF LOWER LUMBAR LEVELS, PARTICULARLY IN THE POSTERIOR REGIONS OF THE DISCS. FURTHER EVIDENCE OF THE EFFECTS OF TRACTION OF DIFFERENT MODES, MAGNITUDES, AND DURATIONS ON THE CHANGE IN DISC HEIGHT IS REQUIRED FOR PROPER CONTROL OF TRACTION APPLIED TO SPECIFIC DISC LEVELS.

HIGHLIGHTS:

MECHANICAL EFFECTS OF TRACTION ON LUMBAR DISCS WAS EVALUATED USING MRI.

HORIZONTAL TRACTION USING 42% OF BODY WEIGHT WAS ASSOCIATED WITH AN INCREASED DISC HEIGHT OF LOWER LUMBAR DISCS.

HORIZONTAL TRACTION ALSO RESULTED IN REDUCED LORDOSIS AND CHANGE IN TILT ANGLE.

THE EFFECTS WERE MORE PROMINENT AT THE POSTERIOR DISCAL REGIONS.

 

Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514-530. doi: 10.7326/M16-2367. Epub 2017 Feb 14. PMID: 28192789. a  systematic  review  of  randomized, controlled  trials  and  systematic  reviews  published  through  April 2015  on  noninvasive  pharmacologic  and  nonpharmacologic treatments  for  low  back  pain.  Updated  searches  were  performed through  November  2016.

Recommendation  1: Given  that  most  patients  with  acute  or subacute  low  back  pain  improve  over  time  regardless  of  treat-ment,  clinicians  and  patients  should  select  nonpharmacologic treatment  with  superficial  heat  (moderate-quality  evidence),  massage,  acupuncture,  or  spinal  manipulation  (low-quality  evidence). If  pharmacologic  treatment  is  desired,  clinicians  and  patients should  select  nonsteroidal  anti-inflammatory  drugs  or  skeletal muscle  relaxants  (moderate-quality  evidence).  (Grade:  strong recommendation)

Recommendation  2: For  patients  with  chronic  low  back  pain, clinicians  and  patients  should  initially  select  nonpharmacologic treatment  with  exercise,  multidisciplinary  rehabilitation,  acupuncture,  mindfulness-based  stress  reduction  (moderate-quality  evidence),  tai  chi,  yoga,  motor  control  exercise,  progressive relaxation,  electromyography  biofeedback,  low-level  laser therapy,  operant  therapy,  cognitive  behavioral  therapy,  or  spinal manipulation  (low-quality  evidence).  (Grade:  strong recommendation)

Recommendation  3: In  patients  with  chronic  low  back  pain  who have  had  an  inadequate  response  to  nonpharmacologic  therapy, clinicians  and  patients  should  consider  pharmacologic  treatment with  nonsteroidal  anti-inflammatory  drugs  as  first-line  therapy,  or tramadol  or  duloxetine  as  second-line  therapy.  Clinicians  should only  consider  opioids  as  an  option  in  patients  who  have  failed  the aforementioned  treatments  and  only  if  the  potential  benefits  out-weigh  the  risks  for  individual  patients  and  after  a  discussion  of known  risks  and  realistic  benefits  with  patients.  (Grade:  weak  recommendation,  moderate-quality  evidence)

Low  back  pain  is  one  of  the  most  common  reasons for  physician  visits  in  the  United  States.  Most  Americans  have  experienced  low  back  pain,  and  approximately  one  quarter  of  U.S.  adults  reported  having  low back  pain  lasting  at  least  1  day  in  the  past  3  months  (1).Low  back  pain  is  associated  with  high  costs,  including those  related  to  health  care  and  indirect  costs  from missed  work  or  reduced  productivity  (2).  The  total  costs attributable  to  low  back  pain  in  the  United  States  were estimated  at  $100  billion  in  2006,  two  thirds  of  which were  indirect  costs  of  lost  wages  and  productivity  (3).Low  back  pain  is  frequently  classified  and  treated on  the  basis  of  symptom  duration,  potential  cause, presence  or  absence  of  radicular  symptoms,  and  corresponding  anatomical  or  radiographic  abnormalities. Acute  back  pain  is  defined  as  lasting  less  than  4  week

 

Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt ED. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017 Apr 4;166(7):493-505. doi: 10.7326/M16-2459. Epub 2017 Feb 14. PMID: 28192793.

Background: A  2007  American  College  of  Physicians  guideline addressed  nonpharmacologic  treatment  options  for  low  back pain. The  current  evidence  on  non-pharmacologic  therapies  for  acute  or  chronic  nonradicular  or  ra-dicular  low  back  pain from  MEDLINE  (January  2008  through  February 2016),  Cochrane  Central  Register  of  Controlled  Trials,  CochraneDatabase  of  Systematic  Reviews,  and  reference  lists.

Evidence  continues  to  support  the  effectiveness  of  exercise,  psychological  therapies,  multidisciplinary  rehabilitation,  spinal  manipulation,  massage,  and  acupuncture  for  chronic  low  back  pain.

Funding  Source:Agency  for  Healthcare  Research  and Quality.  (PROSPERO:  CRD42014014735)Ann  Intern  Med.2017;166:xxx-xxx.  doi:10.7326/M16-2459Annals.org

the  American  College  of  Physicians  (ACP)and  American  Pain  Society  (APS)  recommended  spinal manipulation  as  a  treatment  option  for  acute  low  back pain  and  several  nonpharmacologic  therapies  for  sub-acute  or  chronic  low  back  pain. 

 

Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M, Andersen MØ, Fournier G, Højgaard B, Jensen MB, Jensen LD, Karbo T, Kirkeskov L, Melbye M, Morsel-Carlsen L, Nordsteen J, Palsson TS, Rasti Z, Silbye PF, Steiness MZ, Tarp S, Vaagholt M. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018 Jan;27(1):60-75. doi: 10.1007/s00586-017-5099-2. Epub 2017 Apr 20. PMID: 28429142.

Purpose: To summarise recommendations about 20 non-surgical interventions for recent onset (

If treatment is needed, the guidelines suggest using patient education, different types of supervised exercise, and manual therapy.

The guidelines recommend against acupuncture, routine use of imaging, targeted treatment, extraforaminal glucocorticoid injection, paracetamol, NSAIDs, and opioids.

 

Krekoukias G1, Gelalis ID1,2, Xenakis T1, Gioftsos G3, Dimitriadis Z4, Sakellari V3. Spinal mobilization vs conventional physiotherapy in the management of chronic low back pain due to spinal disk degeneration: a randomized controlled trial. J Man Manip Ther. 2017 May;25(2):66-73. doi: 10.1080/10669817.2016.1184435. Epub 2016 Jun 23.

MANUAL THERAPY SPINAL MOBILIZATION IS PREFERABLE TO CONVENTIONAL PHYSIOTHERAPY IN ORDER TO REDUCE THE PAIN INTENSITY AND DISABILITY IN SUBJECTS WITH CHRONIC LBP AND ASSOCIATED DISK DEGENERATION. THE FINDINGS OF THIS STUDY MAY LEAD TO THE ESTABLISHMENT OF SPINAL MOBILIZATION AS ONE OF THE MOST PREFERABLE APPROACHES FOR THE MANAGEMENT OF LBP DUE TO DISK DEGENERATION.

 

REFERENCES FOR 25% RELIEF PAPER BY WIRTH ET AL

Wirth B1, Riner F1, Peterson C1, Humphreys BK1, Farshad M2, Becker S3, Schweinhardt P1. An observational study on trajectories and outcomes of chronic low back pain patients referred from a spine surgery division for chiropractic treatment. Chiropr Man Therap. 2019 Feb 5;27:6. doi: 10.1186/s12998-018-0225-8. eCollection 2019.

Refs on minimal clinical improvement determination:

  1. Farrar JT, Young JP, Jr, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94:149–158. doi: 10.1016/S0304-3959(01)00349-9. [PubMed] [CrossRef]
  2. Kovacs FM, Abraira V, Royuela A, Corcoll J, Alegre L, Cano A, et al. Minimal clinically important change for pain intensity and disability in patients with nonspecific low back pain. Spine (Phila Pa 1976) 2007;32:2915–2920. doi: 10.1097/BRS.0b013e31815b75ae. [PubMed] [CrossRef]
  3. Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. Eur J Pain. 2004;8:283–291. doi: 10.1016/j.ejpain.2003.09.004. [PubMed] [CrossRef]
  4. Robinson-Papp J, George MC, Dorfman D, Simpson DM. Barriers to chronic pain measurement: a qualitative study of patient perspectives.Pain Med. 2015;16:1256–1264. doi: 10.1111/pme.12717. [PMC free article] [PubMed] [CrossRef]
  5. Ostelo RW, Deyo RA, Stratford P, Waddell G, Croft P, Von Korff M, et al. Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change. Spine (Phila Pa 1976) 2008;33:90–94. doi: 10.1097/BRS.0b013e31815e3a10. [PubMed] [CrossRef]
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Chung TS1, Yang HE, Ahn SJ, Park JH. Herniated Lumbar Disks: Real-time MR Imaging Evaluation during Continuous Traction. Radiology 2015 Jan 22:141400.

CONTINUOUS TRACTION ON HERNIATED LUMBAR DISKS AND SURROUNDING STRUCTURES RESULTED IN CHANGE IN DISK SHAPE, DISK REDUCTION WITH OPENING IN THE INTERVERTEBRAL DISK, REDUCTION OF HERNIATED DISK VOLUME, SEPARATION OF THE DISK AND ADJOINING NERVE ROOT, AND WIDENING OF THE FACET JOINT. 

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Wong A, Parent E, Dhillon S, Prasad N, Kawchuk G: Do Participants With Low Back Pain Who Respond to Spinal Manipulative Therapy Differ Biomechanically From Nonresponders, Untreated Controls or Asymptomatic Controls? Spine: 01 September 2015 - Volume 40 - Issue 17 - p 1329–1337  doi: 10.1097/BRS.0000000000000981

PARTICIPANTS WITH LBP AND ASYMPTOMATIC CONTROLS ATTENDED 3 SESSIONS FOR 7 DAYS. ON SESSIONS 1 AND 2, PARTICIPANTS WITH LBP RECEIVED SMT (+LBP/+SMT, N = 32) WHEREAS ASYMPTOMATIC CONTROLS DID NOT (−LBP/−SMT, N = 57). IN THESE SESSIONS, SPINAL STIFFNESS AND MULTIFIDUS THICKNESS RATIOS WERE OBTAINED BEFORE AND AFTER SMT AND ON DAY 7. RESULTS.

AFTER THE FIRST SMT, SMT RESPONDERS DISPLAYED STATISTICALLY SIGNIFICANT DECREASES IN SPINAL STIFFNESS AND INCREASES IN MULTIFIDUS THICKNESS RATIO SUSTAINED FOR MORE THAN 7 DAYS;

THESE FINDINGS WERE NOT OBSERVED IN OTHER GROUPS. SIMILARLY, ONLY SMT RESPONDERS DISPLAYED SIGNIFICANT POST-SMT IMPROVEMENT IN APPARENT DIFFUSION COEFFICIENTS.

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Wong AYL1,2, Parent EC3, Dhillon SS4, Prasad N5, Samartzis D6, Kawchuk GN3. Differential patient responses to spinal manipulative therapy and their relation to spinal degeneration and post-treatment changes in disc diffusion. Eur  Spine J. 2019 Jan 2. doi: 10.1007/s00586-018-5851-2.

NON-SPECIFIC LOW BACK PAIN PATIENTS WHO RESPOND WITH >30% RELIEF SHOW HIGHER APPARENT DIFFUSION COEFFICIENT DISC DIFFUSION OF WATER THAN NON POSITIVE RESPONDERS. MRI WAS PERFORMED BEFORE AND AFTER SMT ON DAY 1 OF CARE. OSWESTRY DISABILITY TEST WAS ALSO USED.

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Beattie PF, Butts R, Donley JW, Liuzzo DM. The Within-Session Change in Low Back Pain Intensity Following Spinal Manipulative Therapy is Related to Differences in Diffusion of Water in the Intervertebral Discs of the Upper Lumbar Spine and L5-S1. Orthop Sports Phys Ther. 2013 Nov 21.
Doctoral Program in Physical Therapy, Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC.

STUDY TO DETERMINE DIFFERENCES IN THE CHANGES IN DIFFUSION OF WATER WITHIN THE LUMBAR INTERVERTEBRAL DISCS BETWEEN THOSE SUBJECTS WITH LOW BACK PAIN (LBP) WHO DID, AND DID NOT, REPORT A WITHIN-SESSION REDUCTION IN PAIN INTENSITY FOLLOWING A SINGLE TREATMENT OF SPINAL MANIPULATIVE THERAPY (SMT) WAS DONE.

CHANGES IN THE DIFFUSION OF WATER WITHIN THE LUMBAR INTERVERTEBRAL DISCS AT THE L1-2, L2-3, AND L5-1 LEVELS APPEAR TO BE RELATED TO DIFFERENCES IN WITHIN-SESSION PAIN REPORTS FOLLOWING A SINGLE TREATMENT OF SPINAL MANIPULATIVE THERAPY. PARTICIPANTS UNDERWENT T2- AND DIFFUSION-WEIGHTED LUMBAR MAGNETIC RESONANCE IMAGING SCANS IMMEDIATELY BEFORE, AND AFTER, RECEIVING A SINGLE TREATMENT OF SMTJ

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Kuo, Ya-Wen PhD; Hsu, Yu-Chun MS; Chuang, I-Ting MS; Chao, Pen-Hsiu Grace PhD; Wang, Jaw-Lin PhD Spinal Traction Promotes Molecular Transportation in a Simulated Degenerative Intervertebral Disc Model. Spine: April 20th, 2014 - Volume 39 - Issue 9 - p E550

Traction biomechanics studied in the porcine model biomechanical benefits include disc height recovery, foramen enlargement, and intradiscal pressure reduction.

48 thoracic discs were dissected from 8 porcine spines and then divided into 3 groups: intact, degraded without traction, and degraded with traction.

From Day 4 to Day 6, half of the degraded discs received a 30 min traction treatment per day (traction force: 20 kg, loading: unloading = 30 sec: 10 sec).

Traction treatment is effective in enhancing nutrition supply and promoting disc cell proliferation of the degraded discs.

 

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