DISTRACTION
     TECHNIQUES
     FOR LUMBAR PAIN
     Inter-vertebral decompression—
     utilizing distraction techniques...
D i s t r a c t i o n Te c h n i q u e s f o r L u m b a r P a i n



   On top of all this, the physician must      throu...
D i s t r a c t i o n Te c h n i q u e s f o r L u m b a r P a i n



                                                    ...
D i s t r a c t i o n Te c h n i q u e s f o r L u m b a r P a i n



ence some pain relief and improved             ment ...
D i s t r a c t i o n Te c h n i q u e s f o r L u m b a r P a i n



traction. The prospective double blind          cond...
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DISTRACTION TECHNIQUES

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DISTRACTION TECHNIQUES

  1. 1. DISTRACTION TECHNIQUES FOR LUMBAR PAIN Inter-vertebral decompression— utilizing distraction techniques— widens disk spaces, lowers intradiscal pressure and promotes disk recovery. by Alan E. Ottenstein, MD t the dawn of the 21st century there exact diagnosis is rarely clear cut. A are still a great many patients still suffering from common lumbar pain Using only the anatomical informa- tion found on imaging studies such as syndromes. Fortunately, unlike just a MRI and CT, the physician typically few decades ago, we now have many has a very low probability of making treatments to help these patients. the proper etiological diagnosis for These treatments run the gamut from lumbar pain. The physician must also doing “nothing” (eg. bed rest or pas- consider the patient’s complaint, ab- sive modalities only) to doing “every- normalities on neurological examina- thing” (for example, open spinal sur- tion, limitations in activities of daily gery, discectomy, laminectomy, and/or living, functional limitations, objec- interbody fusion). Choosing an ap- tive studies such as magnetic reso- propriate treatment for a particular nance imaging, EMG and nerve con- patient, however, is a complex process. duction studies, and other special Unfortunately for all concerned, the studies that may be needed. 18 Practical PAIN MANAGEMENT, Mar/Apr 2003
  2. 2. D i s t r a c t i o n Te c h n i q u e s f o r L u m b a r P a i n On top of all this, the physician must through a small incision less than one inch axial decompression technology (VAX-D®) factor in the patient’s preferences. The long such as microscopic discectomy. developed in 1991 by Alan E. Dyer, PhD, patient’s lifestyle, personal preferences, There are also many “less invasive” pro- MD, formerly a Deputy Minister of Health prejudices, and philosophy toward med- cedures performed with only the insertion in Ontario, Canada. This VAX-D® device ical interventions are the key final factors of a large needle or catheter into the spine was shown to actually improve lumbar disk in determining which treatment will ulti- or perispinal tissues. These treatments in- injuries and neurological symptoms in mately be given. Evaluation of any large clude using a laser, rotors, clips, suction some patients. Despite a significant inci- group of patients—all having the same devices, or application of heat energy or dence of side effects, the procedure gained symptoms, findings, test results, diag- radiofrequency energy to remove or alter rapidly in popularity throughout Canada noses, and the same objective degree of part of the annulus or of the nucleus pul- and the United States over the past decade disability—will reveal a wide range of posus. Injection of agents that dissolve or because it could do what no other proce- prejudice in regards to suitable treat- chemically alter the nucleus or other dure had done before. This procedure ments. Some patients do not wish to take spinal tissues have been used in this coun- could actually decrease the disability due any medications whatsoever, while other try and abroad for over two decades. to a herniated disk and actually affect the patients may wish to use medications ex- These treatments have been well de- herniated disk without the need to physi- clusively and not consider any other ther- scribed in this and other publications. cally invade the body. apy. Still other patients will wish to have A study conducted by Ramos and Mar- whatever therapy is available—no matter tin in 1995 directly measured the effects how aggressive and risky the treatment ...interventional but non- of vertebral axial decompression on in- may be—as soon as possible. These pa- tradiscal pressure utilizing the VAX-D® tients are not unreasonable, they simply and recorded significant reduction in desire to do whatever may be necessary to invasive therap(ies)... pressure—up to -100 mm Hg—with ap- get them back to “normal” as quickly as plied tension in the upper range.1 possible. VAX-D® began its use in the United actively intervene in the States in the early 1990s and was quite Background widespread by the late 1990s. However, We now have the benefit of many years of many physicians became disenchanted research to demonstrate that old treat- disease process and help to with several of the drawbacks of the VAX- ments that we once thought were benefi- D®. The device transmitted a general cial (for example passive physical thera- force to the lumbar spine and could not py modalities and lumbar traction) are no bring about improvement individually select a vertebral level. The longer believed to be useful or beneficial device required a patient’s cooperation, to patients suffering from serious lumbar and was dependent upon relaxation of spinal or neurological injuries. It has also in the patient’s symptoms, the lumbar paravertebral muscles to allow become more widely appreciated that tra- distraction to take place while, at the same ditional lumbar surgery—with or without time, the therapy required the patient to discectomy, laminectomy or interbody fu- and the disease itself—but maintain contraction of the shoulder gir- sion, with or without installation of surgi- dles and cervical paraspinal muscles. cal hardware—can help some severely in- Physiologically, this is a very difficult task jured and disabled patients. However, do so without penetrating to accomplish. surgery is not a panacea for most spinal Despite some complications, VAX-D® problems. We now understand that there therapy has remained popular through- are great limitations to what surgery can the patient’s body. out the United States due to the continu- accomplish. For example, open surgery ing benefit to many people with disabling performed for relief of pain alone rarely spinal injuries—without the risks and has a successful outcome. Surgeries per- Over the past decade a new procedure costs associated with almost any surgical formed for reasons of progressive neuro- category has arisen: that of intervention- procedure. There are still many VAX-D® logical deficit, on the other hand, are al but noninvasive therapy. Fortunately units in clinical practice. more often successful. Recent years have for today’s patients, therapies in this class seen a decrease in the percentage of pa- actively intervene in the disease process Lumbar Distraction with IDD Therapy® tients undergoing these types of surgery and help to bring about improvement in In the late 1990’s a team of neurosur- as a result of more stringent selection cri- the patient’s symptoms, and the disease geons, orthopaedic surgeons and other teria. As a result, a much higher propor- itself—but do so without penetrating the physicians headed by C. Norman Sheely, tion of these surgically treated patients patient’s body. The most useful of these— MD, developed a device that had most of now enjoy good outcomes. and the most widely used at present—are the advantages of the VAX-D® but without Many of our patients that only a decade the lumbar distraction techniques. the primary complications seen in VAX- or two ago would have undergone open D® therapy. This device called the DRS spinal surgery can now be helped by treat- Pioneering Lumbar Distraction (distraction reduction stabilization) ments that are far less invasive. These The first lumbar distraction technique to gained FDA clearance for use in the Unit- treatments include procedures performed enjoy widespread use was the vertebral ed States in January of 1998. The DRS Practical PAIN MANAGEMENT, Mar/Apr 2003 19
  3. 3. D i s t r a c t i o n Te c h n i q u e s f o r L u m b a r P a i n treatment.4 An actual before and after L2 L2 comparison of MRIs of one of the author’s patients—presenting with a disk hernia- tion at L3-4 —demonstrated marked im- provement after IDD Therapy® (see Fig- ure 1). Herniation of the disk was re- duced, disk height was increased and the L3 L3 disk was rehydrated after only 11 sessions during a 7-week period. Treatment Protocols The goal of the distraction treatment is significant relief of pain with restoration L4 L4 or improvement of physical spinal and neurological injury. The treatment proto- cols include: 1. Mechanical distraction to widen the intervertebral disk space resulting in de- creased intradiscal pressure on nerves L5 L5 and blood vessels in the spine. The re- duced pressure encourages shrinkage or a retraction of the herniated or bulged portion of the nucleous pulposus. The re- S1 S1 duced pressure also allows improved dif- fusion of oxygen, nutrients, and hydra- tion to the injured annulus and speeds FIGURE 1A. Pre-treatment MRI (2/2/2000) FIGURE 1B. Post-treatment MRI (3/20/2000) healing. of a patient with disk desiccation at L3-4 of the same patient after 11 sessions of 2. Nutrition (foods and supplements) with rupture of the annulus. treatment. to provide the necessary precursors to provide building blocks necessary for disk device, currently marketed as the SPINA treatment with decreased complications. repair. System by Adagen Medical Internation- TM In particular, usage of IDD Therapy® has 3. Precautions to avoid re-injury during al, Inc., Atlanta, GA, has since rapidly so far demonstrated a noticeable im- the healing phase. gained market share and has replaced the provement in both the theoretical and ac- 4. Mobilization, daily stretching, and use of VAX-D® in many physicians’ offices tual complication rate. This improved exercises to strengthen the muscles and because of increased efficacy and de- safety factor is one of the main reasons we prevent recurrence. This phase is initiat- creased degree of complications. This usually suggest IDD Therapy® instead of ed after the disk has been stabilized and next generation technology utilizes inter- VAX-D® if it’s geographically available to healing is well under way. nal disk decompression protocols known the patient. as IDD Therapy®. The precise technical description of the Patients’ Perspective Prospective double blind studies per- DRS device is beyond the scope of this ar- The treatment experiences on the part of formed in the mid 1990s, comparing con- ticle. What the DRS device with IDD patients have been overwhelming posi- ventional lumbar traction with the dis- Therapy® does is create and focus a dis- tive. The actual procedure is generally traction decompression techniques of traction force at a given level of the lum- pain free, fast and safe. First the patient IDD Therapy® in a series of patients, re- bar spine through adjustment of the ap- is custom-fitted to upper and lower spinal vealed that the latter was much more ben- plied forces.3 The patient undergoing this harnesses by a trained technologist. eficial to patients than lumbar traction. treatment does not need to do anything These harnesses and other applied de- The patients studied had been suffering to cooperate with the treatment other vices help position the lumbar spine for from various lumbar pain syndromes in- than relax. Unlike the VAX-D®, no force comfort, as well as for proper alignment cluding lumbar radiculopathy, lumbar or strength on the part of the patient is in the treatment process. Once fitted to disk degeneration and herniation, and needed. As a result, relaxation of the pa- the harnesses, the patient is slowly re- lumbar facet syndrome.2 tient’s muscles-especially lumbar par- clined to the treatment position. The We believe that the DRS device, utiliz- avertebral muscles can be accomplished. therapist then applies distractive forces ing IDD Therapy®, is inherently more ef- Edward L. Eyerman, MD, wrote that according to the patient’s physical char- fective at accomplishing the spinal dis- DRS mechanical decompression distrac- acteristics (ie. weight, body type) and di- traction than is the older VAX-D® tech- tion provided not only symptomatic im- rected to specific disk levels per the physi- nology, although we are not aware of any provement in patients with lumbar pain cian’s specific orders. Through a series of specific comparative studies. However, syndromes described above—but also im- treatments, each lasting twenty to thirty early experience with this device has provement in magnetic resonance imag- minutes, the patient’s pain is quickly im- shown that it is superior to the VAX-D® ing findings from pre-treatment to post- proved. Once patients begin to experi- 20 Practical PAIN MANAGEMENT, Mar/Apr 2003
  4. 4. D i s t r a c t i o n Te c h n i q u e s f o r L u m b a r P a i n ence some pain relief and improved ment in disk height and disk hydration as longer needed medications for pain. She spinal function, they usually find the well as some improvement in disk herni- noted improved ability to walk, bend and treatments comfortable, relaxing, and ation at the L3-4 level. The patient sub- stoop. She also regained the ability to even enjoyable—many even look forward sequently returned back to work and re- drive and regained the ability to walk to their treatments. sumed all hobbies including actively while shopping, both in the grocery store hunting, fishing and boating, and has and in the mall. A follow-up MRI study Case Study 1: Neo been stable. He continues to have im- showed improvement in disk hydration Neo is a 32-year-old white male comput- proved pain, ADLs, and can still engage and height. Follow up evaluation revealed er programmer. He had been working for in all his favorite vocations and avoca- that she had again been happily garden- six years at his job and never missed a day tions. ing, playing bridge, shopping, cooking, of work. One day he was working at home and entertaining friends at her home. and injured his back. The pain was so se- Case Study 3: Great-grandma vere he could not get off the floor and lay An 89-year-old retired schoolteacher Discussion on the floor for three weeks. Despite mul- complained of severe low back pain with The concept of using a distractive force tiple visits to various physicians including radiation to her legs. She was ultimately to increase disk height and decrease the treatment with medications, narcotics and unable to follow her daily activities, which amount of herniation has been concep- epidural injections, the pain did not re- tually attractive to physicians for most of solve. He remained essentially house- the last century. Unfortunately, attempts bound and unable to stand, walk or sit for The concept of using with various treatments and devices over any appreciable period of time. the past 100 years have yielded no sig- This patient was evaluated and found to nificant benefit to patients from lumbar have a herniated disk at L4-5, which ap- a distractive force to traction. The current consensus of most peared acute to sub-acute on MRI. His physicians specializing in spine care and symptoms and clinical lumbar radiculopa- back pain organizations, and the conclu- thy syndrome correlated with his exami- increase disk height sion of the U.S. Agency for Health Care nation and with his abnormal EMG and Policy and Research (AHCPR) in a 1994 NCV studies. The patient underwent 20 report on treatments for lumbar pain,5 DRS treatments using IDD Therapy®. Fol- and decrease the was that lumbar traction was of no use in lowing the treatments, the patient noted the treatment of the lumbar pain syn- marked improvement in his pain. He also drome. We now know that lumbar trac- noted improved activities of daily living amount of herniation tion does not benefit most patients—fur- and was able to return to work full-time thermore, we now understand why lum- with no restrictions. In follow-up, the pa- bar traction does not work. tient was stable and remained improved. has been conceptually Not only is lumbar traction ineffective in treating lumbar pain, but it can actu- Case Study 2: The Hospital Executive ally increase intradiscal pressure through The hospital executive is a 52-year-old attractive to a variety of mechanisms. These mecha- president and CEO of a community hos- nisms include promoting a reflex co-con- pital in Pennsylvania, about one hour traction of lumbar paraspinal muscles. from the author’s offices. This individual physicians for most This contraction increases the axial load noted onset of severe lumbar pain while on the local disk segments and promotes lifting a heavy object. Evaluation at his increased intradiscal pressure. This in- hospital showed herniated disk posteri- of the last century. creases the pressure on the annulus and orly at L3-4. He underwent nine months may worsen an existing herniation, of physical therapy with some slight im- and/or raise the pressure enough to cause provement in his pain but no improve- she had enjoyed for many years. Her a new herniation. ment in his disability. The patient was sub- symptoms progressed to the point where Studies over the past decade have sequently evaluated at our institution, she was unable to do any of the things that demonstrated that the new spinal dis- and DRS with IDD Therapy® adminis- gave her the most pleasure. She liked to traction techniques discussed here, in- tered. Despite the 20 treatments that were play bridge, but was unable to sit at the cluding VAX-D® and DRS with IDD Ther- advised, the patient felt well enough after card table. She liked to entertain guests apy,® are not traction. These new tech- 11 treatments that he did not wish further but was no longer able to cook, serve her niques work in an altogether different way therapy. Upon discharge—after six weeks guests, nor load her dishwasher without than traction and, more importantly, they of IDD Therapy® consisting of only 11 of pain and so she ceased cooking and en- are effective—whereas lumbar traction is the 20 recommended treatments—he had tertaining. She also became unable to not. In recognition of this distinction, the much improved range of motion, de- tend her small garden. United States government awarded a sec- creased pain, and improved abilities to This patient was evaluated and then un- ond level HCPCS code to VAX-D® effec- perform activities of daily living and ac- derwent 20 DRS treatments utilizing IDD tive January 1, 2000 to differentiate this tivities at work. An MRI performed at the Therapy®. Following treatment, she noted effective treatment from the older, non- same time showed substantial improve- improved freedom from pain and no effective treatments—namely, lumbar Practical PAIN MANAGEMENT, Mar/Apr 2003 21
  5. 5. D i s t r a c t i o n Te c h n i q u e s f o r L u m b a r P a i n traction. The prospective double blind conditions and injuries producing spinal Alan E. Ottenstein, MD, specializes in the treat- study published by Dr. Shealy demon- pain—including disk herniations, disk ment of neurological pain at Lawrenceville strated the effectiveness of distraction bulges, disk damage, disk degeneration, Neurology Associates, Lawrenceville, New Jer- techniques for disk injury, herniation, and and facet syndrome. There is interest in sey, and at the Neurology Pain Center in degeneration as well as for lumbar facet using these therapies for other conditions Hamilton Township, NJ. Dr. Ottenstein is pres- syndrome.2 and investigations are currently under- ident of the Neurological Association of New way. We do not use this technology for Jersey. He may be contacted at 609-896-3100; Conclusion simple back pain at this time, nor do we www.LNA.neurohub.net These distraction devices are gaining use DRS with IDD Therapy® for spinal market share in physician’s offices—and strains or sprains alone. The IDD Thera- References for good reason. DRS with IDD Therapy® py® appears most beneficial to patients 1. Ramos G and Martin W. Effects of vertebral axial decompression on intradiscal pressure. J Neurosurg. and the older VAX-D® treatments are part with disk or facet joint pain, with or with- June 1995. 82(6):1095. of the continuum in available treatments out accompanying lumbar and/or sacral 2. Shealy CN and Borgmeyer V. Decompression, Re- —from simple physical therapy and ex- radicular irritation. duction, and Stabilization of the Lumbar Spine: A ercise to interventional surgery. As the While we have come to appreciate that Cost-Effective Treatment for Lumbosacral Pain. Amer- above case studies demonstrate, distrac- passive physical therapy is not considered ican Journal of Pain Management. 1997. 7:63-65. tion treatments that provide internal disk to be of long term benefit in most patients 3. Shealy CN and Leroy PL. Chapter 20: New Con- decompression have proven to be of very with lumbar spine syndromes—active cepts in Back Pain Management, Decompression, Reduction, Stabilization. Pain Mangement: A Practical real benefit to these different patients, de- physical therapy, exercise and stretching, Guide for Clinicians. Volume 1. St. Lucie Press. Boca spite the differences in ages and patholo- and aerobic and other exercises under- Raton, FL. 1998. gies. We have not yet determined all of gone with the patient’s cooperation are 4. Eyerman EL. Simple Pelvic Traction Gives Inconsis- the different pathologies that are quite beneficial indeed. We believe that tent Relief to Herniated Lumbar Disc Sufferers. Paper amenable to treatment by this technolo- after an acute injury is properly treated Presented To The American Society Of Neuroimag- gy. We recommend at this time that physi- and healed, a commitment to the appro- ing. Orlando Florida, 2-26-98 and printed in Journal of Neuroimaging. June 1998 cians using this technology restrict their priate exercises and simple lifestyle 5. Acute Low Back Pain Problems in Adults: Assess- treatments to the FDA approved indica- changes can give our patients a good ment and Treatment. Quick Reference Gudie for Clini- tions. This technology is currenlty cleared chance of life-long freedom from a recur- cians. Clinical Practice Guideline #14. U.S. Agency by the FDA as being safe and effective for rence of spinal symptoms and disability. I for Health Care Policy and Research. 1994 PUBLISHERS PRESS DROP IN AD Pearson Assessment 22 Practical PAIN MANAGEMENT, Mar/Apr 2003

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