MANAGEMENT A Practical Guide for Clinicians FIFTH EDITION Chapter 20: New Concepts in Back Pain Management: Decompression, Reduction, and Stabilization C. Norman Shealy, M.D., Ph.D., FA.C.S. Pierre L. Leroy, M.D., F.A.C.S.
C Norman Shealy, M.D., Ph.D., F.A.CS. Pierre L. LeRoy, M.D., F.A.CS. ABSTRACT A thorough evaluation of previous traction techniques reveals no consistent pattern in prior literature. We have evaluated a variety of devices and found that seven major factors are important in achieving optimal clinical results. These include: (1) split table design to minimize effects of gravity; (2) flexion of the knees for hip relaxation; (3) controlled flexion of the lumbar spine during treatment which alters the location of distraction segmentally; (4) comfort and nonslippage of the pelvic restraining belt; (5) comfort and nonslippage of the chest restraint; (6) concomitant use of TENS, heat, ice, and myofascial release; and (7) a graduated limbering, strengthening, and stabilization exercise program. Using this system, successful pain control was achieved in 86% of patients studied with ruptured intervertebral discs and 75% of those with facet arthrosis. INTRODUCTION New advances centering on the use of specific segmental distraction as an adjunct to managing low back pain with and without neuropathic sciatica are reported here. These should be of special interest to both primary care and multidisciplinary medical specialists when symptoms persist despite comprehensive management of acute back pain.
The utility of physical modalities has been well established in many forms (Wall & Melzack, 1984);however, the use of traction techniques has been largely empirical. Relatively few studies have specificallydiscussed ergonomics and the biomechanics of spinal pathology as it relates to practical clinical outcomesemploying powered or weight distraction forms of therapy. Previous outcome studies have lacked theapplied principles of quantifications and biomechanics that correlated clinical data with a specific diagnosisresulting from structural abnormalities such as discal herniation, lumbar facet arthropathy, foraminalstenosis, and motion segment abnormality syndromes or their comorbid combinations (Anderson, Schultz,& Nachemson, 1968; Lind, 1974; Bettmann, 1957; Binkley, Strafford, & Gill, 1995). Anatomically, thelow back is relatively clinically inaccessible. A reevaluation of mechanical therapy is needed since thevarious etiologies have overlapping features. Different symptom complexes associated with dysfunctiondue to complex ipsilateral, contralateral, and segmental neural networking, as well as combined somaticand autonomic neural interactions, may serve to confound the clinician. A novel approach tomechanotherapy is presented to review these six considerations: (1) outcomes validation, (2) relativesafety, (3) ease of use by the patient or healthcare professional, (4) introduction of new principles oftreatment, (5) appropriate utilization, and (6) cost effectiveness resulting in shortened morbidity withoptimal improvement. TYPES OF LOW BACK PAIN Classically, there are four broad categories of low back pain syndrome, each requiring different treatment pathways (O’Brien, 1984; Bogduk, 1987): I . Acute muscular- low back pain which is usually self-limiting
2. Acute low back pain involving sciatic radiation:
3. Chronic low backpain which has recurring symptoms modified by therapy
4. Neoplastic low back pain syndrome which is recurring, but eventually becoming progressive,
Each type of low back pain syndrome has common features which vary with the intensity of symptoms: (1) regional pain, (2) impairment and mechanical dysfunction
exacerbated by activities of daily living, and (3) mood and behavioral changes. All need to be addressed foroverall successful outcome. PRINCIPLES OF BIOMECHANICS Mechanical traction is the technique of applying a distracting force to produce either a realignment of a structural abnormality or to relieve abnormal pressure on nociceptive receptor systems (Colachis & Strohm, 1969; Cyriax, 1950; Gray & Hosking, 1963; Judovich, 1954; Nachemson, 1966). Frequently, both problems co-exist in differing combinations, which generates a number of clinical concerns. Should
treatment be constant or intermittent? What is the reasonable duration of treatment? Should gravity or aweight formula based on the patient’s weight be utilized to determine the amount of force for thetreatment? Can both mechanoreceptors and chemoreceptors that produce unwanted symptoms be integratedand harmonized? It has been previously described that the distracting force must be greater than thespecific pathophysiology causing symptoms, and these mechanisms must be individualized for each patient(Judovich, 1995). Caution not to exacerbate symptoms should always be exercised. The old maxim “nopain, no gain” is both passe and disingenuous. The magnitude of the force correlates with the amount ofdistraction and must be closely monitored. At what force do we obtain better and more successful results,while reducing costs and morbidity?
Katz et al. (1986) reported that 25% of the body weight as a traction force applied to
Section lll: Treatment of Commonly Occurring Pain Syndromes
15 degrees positive elevation from the parallel prone plane for a 14-day series was found to be effective. We differ in our findings, as will be reported below (Katz et al., 1986).
When successful, the patient clinically reports symptomatic improvement of well-being and objectiveclinical verification of (1) improved range of motion, (2) reduction of verifiable regional muscle spasm, (3)improvement in regional tenderness by evaluating health professionals, and (4) improved neuropathic signswhen compared to pretreatment findings. How can there be more individualized bioclinical integration?Pathophysiology of regional low back pain syndromes varies on a highly personal, individualized basis insuch factors as etiology, causation, resulting activity dysfunction, and psychopathological considerations. These factors must not be overlooked or underestimated in prescribing treatment.
HISTORY OF TRACTIONA review of the “Annotated Bibliography on the History of Traction” (Appendix A) summarizes 41articles, from Neuwirth, Hilde, and Campbell in 1952 to Engel, Von Korff, and Katon in 1996. The readeris referred to Appendix A for a review from medieval times to the present. A summary of this bibliographyleads to the following conclusions:
1. Clinical outcomes are highly variable.
2. There are different types of traction techniques, such as intermittent or constant.
3 . Variable angles of traction i-nay be applied.
4. Differing weight sequences may be utilized.Suspension devices are useful.
6. Time-scheduled sequences are described, but without specific guidelines and with many variables.
The present chapter is not intended to criticize the previous authors or data presented, but demonstrates thatmany variables being considered lack quantification. Neurological surgeons have gained extensiveexperience dealing with and managing problems of intracranial pressure using methods of quantificationand have now applied those principles to the intradiscal pressure manometry for clinical correlation of lowback pain syndrome. The first application of quantification by relatively recent studies of quantitativeintradiscal pressure changes has been reported by Ramos and Martin (1994). By cannulizing the nucleuspulposus of L4-5 and monitoring intradiscal pressure via a pressure transducer, three patients wereobserved to have lowered pressures below I 00 mm Hg as a result of traction technique. Other methodsemploying visualization were advanced by Gray (Gray et al., 1968). Radiological assessment of the effectof body traction was reported by Gray et al. (1968). Using only the body’s weight with a thoracic restraintand only a 12-degree incline, significant lengthening of the spine occurred within 5 minutes and even moresignificantly after this modified gravity reduction traction for 25 minutes. Combined studies by Anderson,Schultz, and Nachemson (1968) of intervertebral disc pressures during traction demonstrated byradiographic studies concluded that disc space increases in height and lumbar disc protrusion can be
reduced during traction. Myelographic evidence of disc herniation was found to disappear after traction(Anderson, Schultz, & Nachemson, 1968). Shealy and Borgmeyer (1997) introduced a new biomedicalapplication device that can apply all these positive effects to individual disc levels. To clinically documentimprovement, clinical data combined with radiofluoroscopy was employed. This new approach deliversprecise treatment to decompress the lumbar disc space and then stabilize once asymptomatic through aprogram of physical rehabilitation. THE DRS SYSTEM The major goal of the DRS System (Fig. 1) is decompression, reduction, and stabilization of the lumbar spine. In a series of 50 patients with chronic pain, 23 having ruptured intervertebral disc and 27 with facet joint pain, it was noted that conventional spinal traction was less effective and biomechanically insufficient for optimal therapeutic outcome. Extensive observations led to the conclusion that five major factors were important for lumbar traction efficacy:
Fig. 1. The DRS decompression - reduction-stabilization device. 1 . Separation of the lumbar component of the joint
3. Flexion of the lumbar spine by raising the angle of distraction
4. Comfort and nonslippage of the pelvic belt
5. Comfort and nonslippage of the chest restraint
X-rays confirmed that significant distraction of the lumbar vertebrae required a weight of at least 50% ofthe patient’s body weight (see Figs. 2 to 7). Thus, we have set the parameters of distraction to build up to50% of the patient’s body weight plus 10 pounds. The knees are flexed over a comfortable bolster thatgives optimal relaxation. When the major focus of the patient’s pain is at the L5-Sl intervertebral disc, noelevation of the pelvis is necessary. At L4-5, optimal focus of the distraction is obtained by raising theangle of distraction 10 degrees. For L3-4 or L2-3, an elevation of 20 degrees is generally optimal. There isenough variation in the normal lumbar lordotic curvature that manual palpation of the tension on thelumbar spine, as well as the patient’s assessment of the focus of distraction, can help in making minoradjustments to these angles. With the DRS System, the distraction angle is accurately determined via alaser pointer to give precise angulation. The table on which the patient lies is divided with a smoothhydraulic component to separate the lumbar division as traction/distraction is applied. The traction/distraction is achieved with a computerized device that allows gradual build-up over a 2-minute period tothe desired distraction force. Automatically, the optimal distraction weight is maintained for I minute, andthen the pressure is reduced to 50 pounds for 20 seconds before the process repeats itself. The entiretreatment process requires 30 minutes. To minimize muscle spasm during the treatment, heat and amechanical myofascial-release device providing alternating vacuum pressure to the muscles of the lumbarspine is applied for 30 minutes prior to the treatment. Immediately following the procedure, a cold pack isapplied to the lower back for 30 minutes. The patient is then instructed in the use of a TENS unit applied tospecific anatomical points to be used at home throughout the entire waking day until returning thefollowing day for the next sequential treatment. The initial 2 weeks of this treatment program are donedaily, Monday through Friday, followed by three times per week, for a total of 20 sessions. Patients whoare improving adequately by the end of the second week are instructed in a standard series of exercises forlimbering, stretching, and stabilizing the lumbosacral and pelvic musculature. These exercises include amodified Williams’ flexion exercise which involves raising actively the legs with the knees flexed and thehips abducted, flexing the ankle as far as comfortable toward the pelvis and the chest, alternately on eachside. Patients are instructed in active exercises to rotate the left knee outward, while pulling it as strongly ascomfortable toward the right axilla, then alternatively pulling the right knee toward the left axilla. At themaximum point of the exercise, the patient holds the described position for 30 slow breaths. Instruction isprovided for exercises performed while supported on the elbows and simultaneously raising the extendedlegs 8 inches off the floor, followed by hip abduction, adduction, back to neutral, and finally lowering thelegs to the floor. Patients start with I to 3 such exercises and build to 50 repetitions. When patients arecapable of perf6n-ning 50 repetitions, they begin slow sit-ups with their knees bent, starting with I to 3repetitions and building up to 50 repetitions. Patients continue using the TENS device throughout the 4-
week period. After the active treatment phase, patients are encouraged to continue with the TENS unit foran additional 3 months as they complete the limbering, strengthening, and stabilization exercises. Thecomplete protocol for selection and exclusion criteria regarding patients is included in Appendix B. Forpatients with ruptured intravertebral discs who have not experienced significant improvement or at least a50% reduction in their pain level after five DRS sessions (I week), addition of colchicine is helpful; I mg ofintravenolis colchicine, with 2 g of magnesium chloride and 100 mg of vitamin B6, is administered dailyfor 5 days (Appendix C). If significant improvement occurs during the 5-day colchicine treatment, then thepatient continues with the DRS System and continues to take oral colchicine (0.6 mg daily) for 6 months,along with magnesium oral spray (allowing at least 200 mg of magnesium for sublingual absorption daily). As an anti-inflammatory, we concentrate upon the use of bromelain proteolytic enzyme, 1,000 mg 30minutes prior to each meal and at bedtime (Seligman, 1962; LotzWinter., 1990). If this is not sufficient, thepatient may take any desired over-the-counter nonsteroidal anti-inflammatory drug (Benedetti & Butler,1990). Obviously, patients often choose these and use a wide variety. The major complications ofnonsteroidals include gastric erosion/ulceration and potential liver, kidney, and/or bone marrow toxicity. CLINICAL RESULTS In our study, 19 of 23 patients (86%) with ruptured intervertebral discs were markedly improved, and 75% of those with facet arthrosis (20 of 27) similarly reported a 50% reduction in pain. These results are based upon a pain analog scale with patient evaluation before and no later than 1-4 weeks after completion of therapy. All patients with pain reduction of 50-100% showed improvement in flexibility and total physical activity. CONCLUSION A thorough evaluation of the literature reveals no clinical outcomes to correlate with different techniques. In our review and experience, no single device incorporates all seven major factors that are important in achieving clinical results. These include: (1) split table separation; (2) flexion of the knees; (3) flexion of the lumbar spine to raise the angle and distraction segmentally; (4) comfort and, nonslippage of the pelvic restraining belt; (5) comfort and nonslippage of the chest restraint; (6) concomitant use of TENS, heat, ice, and myofascial release; and (7) a graduated limbering, strengthening, and stabilization exercise program. Using this system, successful pain control is achieved in 86% of patients with ruptured intervertebral discs and 75% of those with facet arthrosis. Because of space constraints, we did not discuss the psychological and psychiatric management of pelvic pain technique, and the reader is referred to other sources. It is worthwhile to consider also that by alternating the pathophysiology of the macro- mechanoreceptor-pain pathway, we may secondarily affect the chemoreceptors as well as reduce noxious stimuli of the richly enervated somatoautonomic lumbar spine, thereby reducing the chronicity of activity- related lumbar pain syndrome. This benefit may also reduce need for medications. The new DRS System is a welcome addition to the problematic low back pain syndrome. The DRS System appears to be cost effective it merits more widespread utilization and awaits additional ergonomic studies. This approach can provide pain relief, and physicians are invited to take advantage of this gratifying treatment approach.
REFERENCESAnderson, G. B. J., Schultz, A. B., & Naclieinson, A. L. (1968). Intervertebral disc pressures duringtraction. Scandinavian Journal of Rehabilitation Medicine, Suppl. 9, 88-91.
Benedetti, C., & Butler, S. H. (1990). Systemic analgesics. In J. Bonica (Ed.). The Management of pain(Vol. 11, pp. 1640 1675). Philadelphia: Lea and Febiger.
Bettmann, E. H. (1957). Therapeutic advantages of intermittent traction in musculoskeletal disorders. GP,16(5), 84-88.
Binkley, J., Strafford, P. W., & Gill, C ‘ (1995). Interrater reliability of lumbar accessory motion nobilitytesting. Physical Therapy,, 75(9), 786-795.
Bogduk, N. (I 987). Pathological anatomy of the lumbar spine. Clinical anatomy of the lumbar spine. NewYork: Churchill Livingstone.
Colachis, S. C. Jr., & Strohm, B. R. (1969). Effects of intermittent traction on separation of lumbarvertebrae. Archives of Physical Medicine and Rehabilitation, 50, 251-258.
Cyriax,J.(1950).The treatment of lumbar disc lesions. Briitish Medical Journal, December 23, 1434-1438. Chapter 20: New Concepts in Back Pain Management: Decompression, Reduction, and Stabilization 249
Gray, F. J., & Hosking, H. J. (I 963). A radiological assessment of the effect of body weight traction on thelumbar disc spaces. The Medical Journal of Australia, December 7, 953-955.
Gray, F. J. et al. (1968). Intervertebral disc pressures during traction. Scandinavian Journal ofRehabilitation Medicine, Suppl 9, 88-91.
Judovich, B. D. (1954). Lumbar traction therapy dissipated force factors. Lancet, 74, 411-414.
Judovich, B. D. (1995). Lumbar traction therapy-Elimination of physical factors that prevent lumbarstretch. Journal of the American Medical Association, 159(6), 549-550. Katz et al. (1986). Constantinclined pelvic traction for treatment of low back pain. Orthopaedic Review @. 15(8), 8.
Lind, G. (1974). Auto-traction: Treatment of low back pain and sciatica. Dissertation. Sweden: Universityof Linkoping.
Lotz-Winter, H. (1990). On the pharmacology of bromelain: An update. Plant Medicine, 56, 249- 253.
Nachemson, A. (1966). The load on lumbar discs in different positions of the body. ClinicalOrthopaedicsand Related Research, 45, 107-122.
O’Brien, J. P. (1984). Mechanisms of spinal pain. In P. D. Wall & R. Melzack (Eds.), Textbook of pain(Section 2.A.5, pp. 240-25 1). New York: Churchill Livingstone.
Ramos, G., & Martin, W. (1994). Effects of vertebral axial decompression on intradiscal pressure. Journalof Neurosurgery, 81, 350-353.
Seligman, B. (I 962). Bromelain: An anti-inflammatory agent. Angiology,, 13, 508-510.
Shealy C. N., & Borgmeyer, V. (1997). Decompression, reduction, and stabilization of the lumbar spine: Acost effective treatment for lumbosacral pain. American Journal of Pain Management, 7(2), 663-665.
Wall, P. D., & Melzack, R. (Eds.) (I 984). Textbook of pain (Section 3.E, pp. 717-750). New York:Churchill Livingstone. APPENDIX A: ANNOTATED BIBLIOGRAPHY ON THE HISTORY OF TRACTION Anderson, G. B. J., Schultz, A. B., & Nachemson, A. L. (1968). Intervertebral disc pressures during traction. Scandinavian Journal of Rehabilitation Medicine, Suppl. 9. 88-91. Pressures in the third lumbar discs were measured in individuals during active and passive traction. During active traction, an increase in pressure was always recorded, with larger increases corresponding to larger traction forces. During passive traction, the pressure remained close to the resting pressure, sometimes increasing and sometimes decreasing slightly. An advertisement for something called a Back-A-Traction, a Swedish gravity traction table, currently being sold for $995 (which is similar to an ad from 1978), states: “The unique feature of Back-A-Traction is a sliding backrest. You will experience an unloading of pressure from your joints and vertebrae even at an angle of 15 degrees.” At 30 degrees, the traction is greater. The author states that the traction “relieves the pressure on pinched nerves and gives the vital fluids free access to lubricate your joints, helps align your pelvis and correct spinal curvatures, improves blood circulation, etc.”
Bettmann, E. H. (1957). Therapeutic advantages of intermittent traction in musculoskeletal disorders. GP,XVI(5), 84-88. Treatment was directed at 210 patients with intermittent traction; 190 derived good results,with only 38 requiring some additional treatment. Sixteen of the 190 who did well required subsequenttreatment after 3-6 months. In no case was any harmful effect observed. The author even reportsimprovement in patients with arthritis of the knees and hips, as well as stiff shoulders. Weak and constantpull was found to be ineffective, and strong and constant pull led to ligamentous overstretching andneurovascular tension, but intermittent gradual increasing pull, with complete relaxation and maximumtraction, restored anatomic and physiologic equilibrium. Contraindications were inflammation, infection,acute arthritis, trophic changes with disc protrusion, acute torticollis, myositis, and cases which respond tothe first treatment with increasing pain. For lumbar traction’, the author reports that elevation of thepatient’s legs with flexion of the knees or supporting them at an angle of 45 degrees gave much morecomfort. The average treatment was 30 minutes. Only 50 pounds of pressure was used in the lumbar spine.
Binkley, J., Strafford, P. W., & Gill, C. (1995). Interrater reliability of lumbar accessory motion mobilitytesting. Physical Therapy,, 75(9), 786 795. In 18 subjects with low back pain, six different “orthopedicphysical therapists” evaluated posterior-anterior accessory motion mobility at each of six levels, L I to thesacral base, with the mobility being recorded on a nine-point scale. There was only 69% intraclasscorrelation coefficients. Conclusions are: “There is a poor interrater agreement on determination of thesegmental level of a marked spinous process. There is poor interrater reliability of P-A accessory mobilitytesting in the absence of corroborating clinical data. Caution should be exercised when physical therapistsmake clinical decisions related to the evaluation of motion at a specific spinal level using P-A accessorymotion testing.”
Bogduk, N. (1987). Pathological anatomy of the lumbar spine. Clinical anatomy of the lumbar spine. NewYork: Churchill-Livingstone. Bogduk defines mechanical disorders of the lumbar spine as follows.
Acute locked back: “A painful condition of sudden onset that occurs during attempted lifting.” This pain iseased by flexion and aggravated by straightening.
Zygapophysial joint mechanism: He considers this meniscus entrapment, which is capsular traction, whichmay include a fibro-adipose meniscoid tissue which fails to re-enter the zygapophysial joint cavity aftersome type of movement. In such a case, “the meniscoid impacts the margin of the articular process andenters the subcapsular recess at the upper or lower pole of the joint.” Again, flexion reduces impaction. Hepoints out that fragments of articular cartilage resembling the meniscoids may be formed in these joints anda plate of cartilage may be tom and moved.
Intervertebral disc mechanisms: Another cause of an acute locked back might be posterolateral extrusion ofdisc nuclear material along a fissure in the posterolateral annulae.
Lumbar disc herniation: Expulsion through the annulus fibrosa of some portion of the nucleus pulposus. Hecomments that disc protrusion and disc prolapse are “sometimes used in relation to this phenomena-toimply subtle difference’s. He describes end-plate fractures, with vertebral end plates being more prone to
fracture than failure of an annulus fibrosus. They are considered a “normal feature of aging anddegeneration.”
Disc degradation: The mechanisms by which disc degeneration or degradation become symptomatic areadditional stresses on the annulus fibrosis during weight bearing and flexion and arthrosis of thezygapophysial joint.
Braaf, M. M., & Rosner, S. (1960). Chronic headache: A study of over 2,000 cases. New York StateJournal of Medicine, 60, 3987 3994.
Braaf and Rosner consider that lesions of the cervical spine are one of the principal causes of persistentheadache, chronic headache of cervical origin is a referred symptom caused by compression or irritation ofone or more cervical nerve roots or portions thereof, trauma to the cervical spine is the prime factor inproducing cervical nerve root irritation, and headache can be treated successfully by cervical traction. Theystate that 80% are completely relieved on a permanent basis with traction. Another 15% obtain satisfactoryrelief to carry on normal existence with this approach. They consider cervical traction specific for headacheof cerebral origin and by far the most effective method, and maximum benefit is obtained only when it iscarried out in a supine position. Traction should be performed as an office procedure, with treatmentcontinued at least 3 months.
Braaf, M. M. & Rosner. S. ( 1 963). The treatment of headaches. New York State Journal of Medicine,March 15, pp. 687 693.
“In chronic headache definite, physical signs have been found consistently in the neck. Localized cervicaltenderness, spasm of the muscles at the back of the neck, and restrictive movements of the neck are themost common physical findings . especially pronounced during the headache phase.” A wide variety ofabnormalities of the cervical spine, including tenderness all the way down to the base of the lower cervicalspine, is seen. There are often motor, sensory, and reflex changes in the upper extremity. Major radiologicfindings of the cervical spine are “usually very definite,” especially on lateral films, both with the patient inneutral and with the head hyperextend. ‘similar to those found in lesions of the cervical disks.” There isoften loss of lordosis, narrowing of intervertebral spaces, osteophytic growths, and narrowing ofintervertebral foramina, but at least loss of normal cervical Curve is very consistent. The best treatment inthese authors’ opinion is a combination of head traction and an intramuscular injection of 200mg of thiaminchloride. Thiamin chloride gives poor therapeutic results, but the addition of thiamin chloride to headtraction makes the head traction more effective. Treatments “may have to be carried out daily, for the firstweek” and then three times a week for up to 2 3 months. “it has been demonstrated conclusively that head-traction, to be effective, must be carried Out in the supine position.” Sitting or standing traction oftenmakes the patient worse. “The position of the head can be varied according to the angulation of the cervicalcurve” found on x-ray. That is, they change the angle to optimize normal lordosis, They use 560 pounds ofweight, but never more than is comfortably tolerated. They begin with 5-10 pounds and gradually increasethe weight. Aggravation of pain indicates too much force. They obtained complete alleviation of headachein 60% of patients, good results in an additional 30% (that means over 50% improvement), and poor resultsin only 10%. For migraine, figures are “slightly less favorable” and therapy takes longer, but the’/ stillconsider this quite remarkable. They have found this type of head traction therapy effective in Horton’scephalgia, idiopathic headache, posttraumatic (postconcussion) headache, tension headache, psychogenicheadache, headaches due to temporal arteritis, atypical trigeminal neuralgia, sphenopalatine neuralgia,headaches due to cervical arthritis, and Meniere’s syndrome. Interestingly, the researchers reported thatintranasal spheniopalatine ganglion block with 2% pontocaine helped, “even though this therapy neverresulted in complete alleviation of the headache.” They report that injection of 2% pontocainehydrochloride in the upper cervical region is effective in relieving headaches in most cases, but resultsunfortunately are only temporary. Injection of IO cc of I% procaine intravenous over a 2- to 3-minuteperiod was reported, with dramatic results in 100 consecutive cases. Exercise of neck muscles essentiallymaintains the improvement obtained in traction because the muscles are i-markedly weak. “Exercises aredirected toward strengthening muscles at the back of the neck as well as muscles of the shoulder- girdle.”Diathermy and massage of the muscles are often helpful as well. They emphasize that the diagnosis ofpsychogenic headache is inappropriate, since many of these patients are cured with this type of treatment.
Braaf, M. M., & Rosner, S. (1965). More recent concepts on the treatment of headache. He4idiche, 5, 38-44.
“Cervical traction is the most effective method, not only for giving symptomatic relief, but also forpreventing the occurrence of headache on a permanent basis . Chronic headache can be prevented byearly recognition of the cervical lesion as a cause of the headache followed by adequate treatment directedtowards the cervical spine.”
Burton, C. & Nida, G. (1976). Gravity lumbar reduction therapy Minneapolis: Sister Kenny Institute.
In 1972, Dr. Burton started using a type of traction by a canvas chest harness, which lie designed, in whichlie “hung” daily for 10 days a patient with a classic ruptured disc at L5-SI. This became the basis forgravity lumbar reduction, with the patient-tilting upright in a chest harness, with the body’s weight hangingbelow that from 30 degrees to 90 degrees. The harness was designed to have its lowest strap tightenedunder the rib cage and the upper straps grasp the rib cage to effect an equal distribution of pressure. Theybuilt up to a total of 4 hours of hanging traction per day and said that anything less than 4 hours with aminimum of 40 degrees elevation of the body was inadequate. They continued such treatment for 1-4weeks, with those with ruptured discs being maintained an average of 10-14 days. The most significantcomplication was intolerance because of increased pain or a drop in blood pressure. They stated that thegreatest value was when there was low back pain with sciatica due to a ruptured disc.
Colachis, S. C. Jr., & Strohm, B. R. (1969). Effects of intermittent traction on separation of lumbarvertebrae. Archives of Physical Medicine & Rehabilitation, 50, 251 258.
Ten subjects (from 22 to 25 years of age) were placed in the Supine position with the thighs flexed 70degrees and legs parallel to a split traction table. They used an angle of rope Pull Of 18 degrees and atraction force of 50 pounds applied for 10 seconds, followed by a rest period of 5 seconds, with tractiongiven intermittently for 15 minutes. After a rest period of 10 minutes, a 100-pound traction force wasapplied in the same manner for 15 minutes intermittently, and after another rest period of 5 minutes,another 100-poLind traction force was applied continuously for 5 minutes. Lateral radiographs were takenbefore, during, and after the application of the traction force. There was a statistically significant increase intotal mean posterior vertebral separation with 50 pounds of traction force and a significant increase in totalmean anterior and posterior separation when a traction force . e of 100 pounds was applied. The greatestincrease in posterior vertebral separation during traction occurred at the L4-5 and the least at the L5-S Iinterspace with this particular approach with the rope at I 8 degrees, but it is worth noting that there werechanges all the way to T12-LI. For instance, at 100 pounds of intermittent traction, there was an increase inthe posterior vertebral separation at T12-LI of 0.7mm, 0.4 at LI-2, 1.5 at L2-3, 1.4 at L3-4, 1.55 at L4-5,and 0.1 at L5-SI, an actual total elongation of the entire lumbar spine of 4.95 mm. With continuous tractionof 100 pounds for 5 minutes after 5-minute rests, the mean total was still 5.25 mm longer than prior to thetraction.
Cyriax, J. (1950). The treatment of lumbar disc lesions. British Medical Journal, December 23, 1434-1438.
Cyriax states, “Sustained traction is the method of choice for ambulant patients with pulpy herniationswhose symptoms warrant treatment. Distraction at the affected joint has two effects. (1) Increase in theinterval between the vertebral bodies, thus enlarging the space into which the protrusion must recede. (2)Tautening of the joint capsule. Naturally, when the slack is taken up, the ligaments joining the vertebralbodies exert centripetal force all around the joint; this tends to squeeze the pulp back into place. Thus,sustained traction merely represents a way of achieving in a very short time the same effect as rest in bedfor some weeks.” Bands around the mid-chest and pelvis with 200-300 pounds of pressure were appliedfor 2-3 periods of 20 minutes each, with 5 minutes rest in between. Treatment was carried out daily untilthe patient was well, usually 1-2 weeks. Sustained traction was described as using “the greatest possibletraction” that the patient will permit for “as long as is reasonable.”
Cyriax, J. H. (1955). Discussion on the treatment of backache by traction. Proceedings of the Royal SocietyOf Medicine, 48, 805-814.
Cyriax mentions that some people do better prone and some supine. Patients were treated once or twice aday for half to one hour each time. Traction weight may be only 100 pounds with a small woman,” but upto 200 pounds in a large man.” He emphasized, “As soon as the traction becomes effective, certainalterations in the pain are felt by the patient.” The changes are that the pain usually ceases, but a unilaterallumbar pain may become central, a root pain may become a lumbar pain, a root pain may shorten (that is,move from the calf to the thigh above it), a root pain may remain in the same place but become less intense,or the pain may remain unaltered. He emphasized that the patient must be treated daily-, otherwise, it is notworth doing. He abandons treatment if pain is not improved after 12 sessions, and treatment is continued upto at least 4 weeks if necessary. In some patients with constant backache, adequate therapy may require 2-3months. The indications, in his opinion, are a protrusion of a disc, failure of manipulation, impaired nerveconduction (a weak muscle, absent ankle jerk, or cutaneous analgesia), failure of epidural local anesthetics,reference of pain to the coccyx or genital area, first and second lumbar disc lesions, and recurrence of painafter laminectomy. He considers contraindications to traction as “purely annular displacements,” painfularc during trunk flexion, pain caused by side flexion away from the painful side, pain which ceases as soonas the traction is applied but increases significantly when traction is released, and patients with impairedcardiac or respiratory function.
Deets, D., Haupt, K., & Haupt, S. S. (1977). Cervical traction: A comparison of sitting and supinepositions. Physical Therapy, 57(3), 255-261. These authors also feel that a supine position is much moreeffective than a sitting position. There is greater posterior intervertebral separation, increased relaxation,decreased muscle guarding, and increased stability, with less force needed. Deep heat and massage prior totraction was recommended. They measured separation of the disc space in the same subjects sitting andsupine, using 30 or 40 pounds of weight, and they got greater increase in interspace measurement in thesupine position.
Dettori, J. R., Bullock, S. H., Sutlive, T. G., Franklin, R. J., and Patience, T. (1995) . The effects of spinalflexion and extension exercises and their associated postures in patients with acute low back pain. Spine. 20, 2303-2312.
Subjects (149) with acute back pain were given flexion exercises, extension exercises, and posturalextension exercises . . There was no difference in outcome between flexion or extension exercise groups. However, either exercise was slightly more effective than no exercise.
Engel, C. C., Von Korff, M., & Katon, W. J. (1996). Back pain in primary care: Predictors of high health-care costs. Pain, 65(‘-),3), 197-204.
The authors studied 159 back pain patients consecutively presenting in a primary clinic of an HMO. Theirconclusion is that a minority of primary care back pain patients account for a majority of healthcare costs. Increasing chronic pain was the strongest independent predictor of high back pain costs. Increasing painpersistence and a disc disorder with or without sciatica were also significantly predictive of high back paincosts. Arthritis was weakly associated with high cost variables, compared to nondisc, nonarthritis pain. Increasing depression was weakly but not statistically associated with high back pain costs. They quoteother statistics suggesting that the etiology of back pain is unclear in at least 79% of men and 89% ofwomen. Only 2% of patients ultimately require surgery, and only 16.9% have a disc disorder and/orsciatica. They emphasize, “Often, however, prescribed therapies such as bed rest, opioid analgesics, andmuscle relaxants or sedatives do not reliably ameliorate chronic pain and may acutely diminish patientfunctioning.”
Goldish, G. D. Lumbar traction (source of this book undetermined). Among other things, the author statesthat no significant distraction of the lumbar disc was produced at less than 50 pounds of traction. Hementions that Cyriax has hypothesized that traction could actually produce negative intradiscal pressure,strong enough to suck the herniated disc back in.
Gose, E. (1996). Clinical study,.The efficacy o f V,AX-D therapy. Chicago: University of Illinois, April10.
The author states that 20 treatments of VAX-D therapy have been proven to be effective in aboutthree-quarters of all patients who have any combination of facet syndrome, degenerative disc, orsingle disc herniation.
Private transmittal. On April 12, 1978, the senior author received a package from GravityGuidance, Inc. (8 16 Union, Pasadena, California), The material discussed an inversion gravitysystem where people were hung upside-down by the ankles. The following are statements fromthese materials: “Realign vertebrae, correct internal derangement-visceral, vascular, and skeletal,relieves pressure on nerves and articular surfaces. Permits the protrusion of the disk to be drawnback and heal in the proper position. Sucks the nucleus to a more central position-away from thesensitive posterior part of the annulus. Pulpy protrusions are reducible by full body load. Increases the range of motion and joint play. Distributes pressure equally in all directions anddissipates force. Decompresses the body (SPINE). Increases the volume capacity of the nuclearspace (disk). Reduces degenerative changes in the disk and bone.” Attached to that is mention ofa patent number, 3,380,447. Gray, F. J., & Hosking, H. J. (1 963). A radiological assessment of the effect of body weight traction on thelumbar disc spaces. The Medical Journal of Australia, December 7, 953-955. These authors used a tractiontable with the patient supine. The thoracic harness holds the body as the table is tilted a foot down, so thepatient’s body is really doing the traction. They used only a 12-degree incline, and after 85 minutes theynoticed that even a higher angle of 70 degrees gave no significant further lengthening, but 5 minutes at 12degrees was quite significant. These results indicate that “compared with the horizontal supine position, thelumbar disc spaces were widened significantly at an incline of 12 degrees after traction for 5 minutes, andeven more significantly after traction for 85 minutes.”
Gupta, R. C., & Ramarao, M. S. (1978). Epidurography in reduction of lumbar disc prolapse by traction. Archives of Physical Medicine & Rehabilitation, 59, 322-327.
Fourteen patients, 7 of whom had multiple disc protrusions and the others a single disc protrusion, weretreated for 10-15 days with traction applied by bilateral skin traction with a heated plaster on both sides,with 60-80 pounds of weight and the foot of the bed elevated 9-12 inches. Patients with massive discprolapse tolerated the heavy skin traction better than those with less protrusion. Ten of the 14 patientsshowed definite clinical improvement, with decrease in back pain and sciatica, normal straight leg raising,and complete or partial recovery of sensory deficit. In all these cases, the lateral epidurograms revealednormal anterior contrast column, and the PA epidurogram showed no defect in nine cases, showing that thedisc had reduced to its normal position. In one case, although there was definite clinical improvement anddecrease, there was still a slight persistent defect. Two patients with motor deficits showed improvement. In two cases, only minimal improvement in clinical condition occurred after the traction, and, interestingly,their epidurograms showed persistence of the same defects. They showed an average vertebral distractionduring traction of 0.5 mm. The authors followed nine of the cases for 1-2 years with no recurrence ofsymptoms.
Hadler, N. M., Carey, T. S., Garrett, J., & the North Carolina Back Pain Project (1995). The influence ofindemnification by workers’ compensation insurance on recovery from acute backache. Spine, 20, 210-215.
Of 1,633 patients seen, 505 were insured by workers’ compensation. These 505 were compared with 861who had been employed on any job for pay within 3 months of the onset of backache, but whose care wasnot underwritten. “Those with compensable back pain were more likely to categorize their tasks asphysically demanding and had taken more time off work in the month before the baseline interview. Recovery of the sense of wellness they enjoyed before the episode of back pain was delayed. Recovery offunction or return to work was not delayed.” The conclusion: “Each of these associations is a reproach tothe fashion in which workers’ compensation insurance for regional back pain serves the ethic that is itsraison d’etre.”
Hirschberg, G. G. (1974). Treating lumbar disc lesion by prolonged continuous reduction of intradiscalpressure. Texas Medicine, 70, 58-68.
The author mentions treating several hundred patients with sciatica resulting from lumbar disc lesion. Conservative treatment usually consisted of bed rest and pelvic traction. There are no real details abouttraction, and he really emphasizes prolonged bed rest.
Hood L., & Chrisman, D. (1968). Intermittent pelvic traction in the treatment of the ruptured intervertebraldisk. Journal of the American Physical Therapy Association, 48(l), 21-30. “The present survey indicatesthat intermittent pelvic traction is of value in treating the patient with a ruptured intervertebral disk . Thepatient with a nerve root compression from above and list away from the affected side would be expectedto have the best results.” One year or more later, they presented excellent results in 15%, good results in52.5%, and poor results in 47.5%. Excellent meant asymptomatic and employed full-time; good meantsymptoms greatly improved with occasional minor low backache and fatigue.
The treatment consisted of heat with hydrocollator packs or ultrasound, followed by intermittent pelvictraction. The patient was placed on a traction table with the legs raised to flatten the lumbar spine. Theyused a canvas traction belt around the pelvis and a thoracic corset around the rib cage to restrain the upperbody. Traction force was most frequently set at 65-70 pounds, although initial treatments were usuallygiven at 55 pounds. Interestingly, they show a photograph from 1544 with an accrued traction table withthe patient being hanged from above. This looks very much like what Chuck Burton did. They quoteNeuwirth et al,, in which up to 220 pounds of traction was used. Judovich, back in the 1950s, presented anew method of intermittent traction, and he stated that a constant pull was intolerable to the average patient,but intermittent traction could be tolerated and would give improved results. Cyriax, as early as 1950, alsosuggested that sustained traction gave much more effective results than bed rest. Cyriax used 200-300pounds of pelvic traction for two or three periods of 20 minutes, with 5 minutes of rest between periods,given daily for up to 2 weeks. Cyriax stated that traction “creates an increased space between the vertebrae,permitting the return of the prolapsed material.” He also stated that the tightened ligaments helped tosqueeze the protrusion back in place. The authors also report a study by Chrisman et al. on patients withback pain, sciatica, and a positive sciatic nerve stretch test with either weakness or loss of a tendon reflex; 51 % of the patients had good or excellent results with traction.
Judovich, B. D. (1954). Lumbar traction therapy dissipated force factors. Lancet, 74, 411-414.
In the cervical area, this author reported that it required 30-40 pounds to demonstrate a beginning wideningof the intervertebral spaces. In the lumbar spine, he used 80-85 pounds of traction in most people, but atleast 90 pounds or more in heavier patients. Keeping the bed level, he found that raising the legs in slingsduring the traction helped significantly. Even in heavy patients, it required 10 pounds less traction if thelegs were flexed over a firm bolster. Hyperextension increases pain. Flexion of the spine decreases pain andimproves results. In both live people and cadavers, “the average surface traction resistance of the body isapproximately 54% of total body weight. The lower body segment-transverse section through L3, L4interspace-weighs approximately 48% of total body weight. Approximately 54% of the weight of the lowerbody segment is also required to overcome its surface traction resistance. This is equal to approximately26% of the total body weight. The force, therefore, that is dissipated with leg or pelvic traction isapproximately 26% of the entire body weight. Only adequate weight in excess of this amount has a stretcheffect upon the lumbar spine.”
Judovich, B. D. (1995). Lumbar traction therapy-Elimination of physical factors that prevent lumbarstretch. Journal of the American Medical Association, 159(6), 549-550.
The author emphasizes that in a living being, the force necessary to overcome “surface traction resistance”is approximately 54% of the weight of the body. “Tone and elasticity of tissues appear to have no practicalbearing upon the required force.” Interestingly, he emphasizes that the lower body from the L3-4 interspacecomposes 49% of the entire body weight; thus, 26% of the entire body weight is calculated as anapproximate average necessary to overcome resistance of the lower half of the body. This is called the“dissipated force factor.” This particular force is “completely neutralized and lost as a stretch force to thelumbar spine.” He emphasizes thus that the first 40-45 pounds are “lost” as a lumbar stretch force. Thus, heemphasizes further that one must exceed an average of 80 pounds of weight in order to begin to produceany type of effective lumbar traction.
Lawson, G. A., & Godfrey, C. M. (1958). A report on studies of spinal traction. Medical Services Journalof Canada, 14, 762-771. These authors used spinal traction with weights up to I 00 pounds on the cervicalarea and 150 pounds on the lumbar region for varying amounts of time and showed increases of up to 4 mmwith the disc spaces in the lumbar area.
Lehmann, J. F., & Brunner, G. D. (1958). A device for the application of heavy lumbar traction: Itsmechanical effects. Archives of Physical Medicine & Rehabilitation, 39, 696-700.
These authors describe a hydraulic device that delivers heavy lumbar traction in an upright position. Theystate that “under traction the proper alignment of the vertebrae of the lumbar spine is maintained. Themachine produced a statistically significant widening of the intervertebral spaces and a therapeutic stretchof the lumbar musculature.”
Lidstrom, A., & Zachrisson, M. (1970). Physical therapy of low back pain and sciatica. ScandinavianJournal of Rehab Medicine, 2, 37-42.
In 62 patients treated with sciatica, use of intermittent traction as recommended by B. Judovich in 1954,using one-half of the body weight plus an additional 30-40 pounds of intermittent traction, revealed a“statistically significant priority” for those treated with traction an average of ten times. In addition to thepelvic traction, they treated patients with “isometric training of the abdominal muscles.” They used theFowler position for the traction. Actually, the traction force was in general given over a 20-minute periodwith 4 seconds of hold and 2 seconds of rest. The traction force used for a patient weighing 50 kg was 58pounds; for one weighing 55 kg, 61 pounds; for one weighing 60 kg, 63 pounds; and for one weighing 70kg, 69 pounds. Basically, they had improvement in 100% of those treated with traction.
Lind, G. (1974). Auto-traction: Treatment of low back pain and sciatica. Dissertation. Sweden: Universityof Linkoping.
Radiographic studies performed during traction have demonstrated that the disc space increased in heightand that lumbar disc protrusion was reduced. Myelographic evidence of disc herniation was found todisappear after traction. In active traction, the subject’s pelvis was fitted with a harness attached to a solidmetal frame. The subject applied traction by pulling with the arms on another frame at the head end of thetable. The pressure is exerted by the patient. They called this auto-traction. Patients were all lying on theirleft side when this was done. Passive traction was produced by two investigators, one pulling on the patientunder the arms and the other on the pelvis. No specific weights in either case were listed.
Loeser, J. (I 996). Editorial comment: Back pain in the workplace. 11. Pain, 65(l), 7-8.
Dr. Loeser reports that “malingering is rare, delusions of pain even rarer.” He further goes on to state that80% of the adult population has back pain at some time or another, and at any one time 14% have had backpain in the previous 2 weeks. Loeser states that the overwhelming majority of those who do submit a claimfor their back pain return to work within a few weeks, but that there are two million chronic disabled backpain patients in the United States. “There is increasing evidence that the treatments rendered to those withnonspecific back pain have no efficacy.” Loeser emphasizes that the rate of surgery for low back pain isdirectly related to the number of surgeons and not to the population. He also wagers “that the number ofchiropractic treatments is related to the number of chiropractors, not citizens.” He goes on to say that thesame could be said for acupuncture treatments, physical therapy, or any other treatments for low back pain. “Health care is a social convention, driven only in small part by anatomy, pathology, or physiology.” Hebelieves that “a good argument can be made that our current method for diagnosing, treating, andcompensating claimants with nonspecific low back pain leads to increased pain, suffering, impairment,disability, and costs. Patients are told things by their doctors that lead to inactivity and depression.”
Mathews, J. A. (1968). Dynamic discography: A study of lumbar traction. Annals of Physical Medicine,IX(7), 265-279.
These authors describe the radiographic findings in three patients with sciatica and used visualization withepidural contrast injections while the lumbar spine was injected to track. In two patients with multiple discprotrusion, protrusion was lessened by the traction, created by “vertebral distraction.” Traction was appliedwith the patient prone on a conventional “couch,” with a thoracic corset and a pelvic harness. They usedtraction of up to 120 pounds for 38 minutes, with the improvement as noted.
McElhannon, J. E. (1984). Physio-therapeutic treatment of myofascial disorders. Anaheim Hills, CA:James E. McElhannon.
McElhannon considers the contraindications to traction to be primary metastatic malignancy, cordcompression, infectious disease of the spine, cardiovascular disease, arthritis, old age, pregnancy, activepeptic ulcers, hernia, aortic aneurysm, or gross hemorrhoids. But traction is indicated in conditions whereyou want to achieve “distraction of the vertebral bodies with enlargement of the intervertebral spaceproducing an inward suction effect on the disk-, stretching of muscles and ligaments with a tautening of theposterior longitudinal ligament exerting a centripidal effect on the adjacent annulus fibrosis; separation ofthe apophysial joints; and enlargement of intervertebral foramina.” He recommends mechanical massage ofthe lumbar spine prior to traction. He states that the angle of pull in cervical traction will vary from 5 to 50degrees. In the upper three vertebrae, the angle will be 5-15 degrees. For cervical vertebrae 4 through 7 anddorsal vertebrae 1, 2, and 3, the angle would be 30-50 degrees. “The lower you treat in the cervico-thoracicspine, a greater angle of pull is required, up to 50 degrees, for maximum and consistent results.” Properangle pull for thoraco-lumbar conditions is 1550 degrees. To affect low thoracic and lumbar vertebrae Ithrough 3, the angle of pull must be 15-30 degrees. To affect L3 through L5 and SI, the angle of pull mustbe 30-50 degrees. “The lower in the spine you treat, the greater angle of pull required.”
He believes that mechanical massage should not be done after traction. He also believes that static tractionfor 20 minutes is preferable to intermittent traction for patients with acute discogenic disease, severeradiculitis, or severe muscle spasms and that a patient with severe muscle spasm should never haveintermittent traction. For more chronic problems, intermittent traction (pulling for 30 seconds, followed byrelease of 10 seconds) is best and gives the greatest results. In the cervical area, he states that traction of thecervical spine should never start with less than 15 pounds, and never less than 50 pounds in the lumbar, asthis poundage is necessary to overcome muscle tension, and less pounds will actually aggravate the patientby introducing reflex spasm. He recommends 3 days of steady traction and then three times a week for 6-8weeks, with considerable improvement expected after three to five treatments. If the patient does notimprove after three treatments, the poundage is increased by 10 pounds. Cervical traction goes up to 60pounds, and even higher in large male patients, and lumbar traction goes up to 125 pounds. He states thatsome type of bolster should always be placed under the patient’s knees to flatten the lordotic curve whiletraction is being given.
Nachemson, A. (1966). The load on lumbar discs in different positions of the body. Clinical Orthopaedicsand Related Research, 45, 107 122.
“The load on the lumbar discs is related both to the body weight of the subject and the position of thebody. For a subject weighing 70 kg, the load on the L3 disc in the sitting position is approximately 140 kg. Approximate loads in the other positions are as follows: standing, 100 kg; sitting and forward tilting of 20degrees, 190 kg; with an additional kg in hands, 270 kg; reclining, lateral decubitus, 70 kg; relaxed supine,anesthetized reclining, 20 kg. If such a subject tilts forward 20 degrees in the standing position and lifts 50kg by his hands, the total load on the L3 disc will be about 300 kg.” In moderate degenerative discs, thepressures are approximately 30% lower than in comparable normal discs.
Nachemson, A. L. (1981). Disc pressure measurements. Spine, 6, 93 97.
Intradiscal pressure was measured in over 100 individuals, and it was found that reclining reduces thepressure by 50-80%, but unsupported sitting increases the load by 40%. Forward lifting and weight liftingincreased the pressure by more than 100%, and upward flexion and rotation by 400%. “Largeaugmentations in pressure were also observed in subjects performing various commonly prescribedstrengthening exercises.”
Nachemson, A., & Elfstrom, G. (1970). Intravital dynamic pressure measurements in lumbar discs. A studyof common movements, maneuvers, and exercises. Scandinavian Journal of Rehabilitation Medicine,Suppl. 1, 1-49. This publication refers back to the original material, much of which has already been presented in otherpapers by Nachemson, but it is a much more comprehensive review.
Neuwirth, E., Hilde, W., & Campbell, R. (1952). Tables for vertebral elongation in the treatment ofsciatica. Archives of Physical Medicine, 33, 455-460.
The authors state that the intervertebral discs constitute about one-fourth of the entire length of thevertebral column. They record data referring to vertebral traction as early as the fifth century B.C. in thewritings of Hippocrates. He described various procedures to redress kyphosis and in particularrecommended the use of a ladder to which the patient was bound, head up or down, and then lifted by arope which ran over a pulley attached to the roof of a house. Then the ladder with the patient was droppedonto a hard pavement. They describe a table which can be tilted in either direction, head up or head down,using a handwheel on a worm gear. They mount pulleys at either end of the table to pass straps to the heador the chest or the pelvis. They always provide preliminary use of heat and sedative massage to the area ofthe vertebral segment to be elongated and then apply traction, with the intensity gradually increased. At theend of a few minutes, the traction is slowly and gradually reduced to the starting point. Then, after a shortpause, traction is reapplied and increased to a higher level, with progressive stages to maximum traction,with 30-60 minutes of rest at the completion of the complete treatment. They gave treatment daily or everyother day, and they report that “vertebral elongation” relieves muscle spasm, promotes the return of theprotruded disc and the slightly displaced vertebrae to their original lodging, and facilitates reduction ofsubluxated apophyseal joints, with reduction of pressure upon nerve root blood vessels and lymphatic andconsequent relief of pain. They report that in a cadaver stripped of muscles, 9 kg of traction force wasnecessary to separate two lumbar vertebrae by 1 _ MM. In the living, I 00 kg of traction force must beemployed to obtain the same results. They report overall, from their work and that of others, 68% goodresults in some 400 patients, 69% in another 240 patients, and 58% in another 156 patients. They state thatvertebral traction has been found to exert significant beneficial effect in patients with sciatica.
Pal, B., Mangion, P., Hossain, M. A., & Diffey, B, L. (1986). A controlled trial of continuous lumbartraction in the treatment of back pain and sciatica. British Journal of Rheumatology, 25, 181-183.
These authors compare a controlled trial of continuous lumbar traction in the hospital in patients with backpain and sciatica with a similar group treated with sham traction. However, they used only a maximum of8.2 kg, which obviously would be of no value.
Ramos, G., & Martin, W. (1994). Effects of vertebral axial decompression on intradiscal pressure. Journalof Neurosurgery, 81, 350-353.
A cannula was connected to the patient’s L4-5 space with a pressure transducer. The patient was placed in aprone position on a VAX-D therapeutic table. Changes in intradiscal pressure were recorded. At a restingstate, controlled tension was applied to the pelvic harness. Tension in the upper range was observed todecompress the nucleus pulposus, to below -1 00 mm Hg. This was only done in three patients.
Snook, S. (1987). The costs of back pain in industry. Occupational back pain, state-of-the-art review. Spine, 2(l), 1-5.
In 1987, the average direct healthcare and compensation cost for an individual with back sprain was$5,739. The estimated cost of industrial low back pain in the United States in 1983 was $25.25 billion.
The author quotes an estimate of $14 billion expended on the treatment and compensation of low back painsufferers in 1976, with an estimate of $25.25 billion in 1983. Lost wages alone were estimated at $11billion per year in 1975-78. In 1985, it was estimated that 33% of the cost of managing. compensable backpain was due to medical care and 67% to “indemnity costs.” It appears that we could conservativelyestimate that compensable back pain, both in medical costs and lost wages, in 1996 would be around $ 1 00billion. If we include noncompensable back pain, which is at least another similar amount, the total cost ofsignificant back pain in the United States in 1996 would be somewhere between $200-300 billion, countingwages lost or paid out, as well as medical costs, with approximately one-third of that total amount beingtotal medical costs. An ad from Spinal Designs International (2400 Chicago Avenue, S., Minneapolis, NM55407) states that the LTX 3000 Lumbar Rehabilitation System (a chair in which the patient sits with abelt around the chest and the bottom of the chair drops out) leads to “lumbar stabilization, intradiscalpressure unloading, free movement and exercise, gentle musculature stretching, and neutral spinepositioning.”
Wall, P. D. (I 996). Editorial comment: Back pain in the workplace. 1.Pain, 65(t), 5.
Commenting on a task force on “Pain in the Workplace,” Dr. Wall states that the “report is an uncriticallurch back 150 years when chronic pain without lesions was already a major problem.” He mentions thatCharcot considered angina and Parkinsonism to be neuroses because of unknown causative lesion. He,further quotes Tate describing back pain without lesion as hysteria, but could be caused by “irritation of theupper dorsal portion of the spinal marrow.” Wall goes on to state that the authors of the task force “displayno caution in their uncertainty that there is no lesion” and that “there is nothing left to study.” He criticizesthe task force’s consideration of low back pain as “a problem of activity intolerance, not a medicalproblem.” Dr. Wall advises that surgeons should not operate under such circumstances and not prescribedrugs, and he particularly criticizes the fact that the task force recommends abruptly at 6 weeks that “thosestill complaining of nonspecific low back pain should be labeled activity intolerant and unemployed with aremoval of medical and wage benefits.” His conclusion is that. Back Pain in the Workplace’ is at best anidiosyncratic, largely untested series of recommendations on how to treat the first six weeks of low backpain, after which advice ends abruptly with the reassignment of the patient to the diagnosis of ‘activityintolerance’ which is ‘not a medical problem.”’
Weisfeldt, S. C. (I 97 1). Ambulatory approach to the treatment of low back pain. Journal of OccupationalMedicine, 13, 384-387.
Ice packs and traction were used for acute back pain. The use of ice and later moist heat with intermittenttraction plus ambulation and exercise afforded excellent relief of pain and earlier return to work, even inindustrial accidents. Patients received an average of 8.3 treatments. They actually treated a total of over 500patients. Of 316 industrial accident patients treated by intermittent traction and ice, 76.6% lost an averageof 5.9 days of work. Unpublished study. An acute low back distress study from the University Hospital,London, Ontario, 1987-88. This unpublished study reports that 66% of patients had a positive outcomefrom VAX-D therapy. The criterion for success was a reduction to 50% of the baseline aggregate score forpain and disability. APPENDIX B: BACK PAIN PROTOCOL I. Inclusion criteria
A. Pain present for I week or more due to ruptured intervertebral disc
B. Pain present for I month or more for other causes of back pain
C. Patient will be available for 4 weeks of continuous therapy
D. Patient has adequate financial resources to cover therapy
E. Patient is at least 18 years old or has parental consent if at least 15 years old
D. Severe osteoporosis, with estimates by radiol6gical interpretation of lumbar plain x-rays showing
E. Bilateral spondylolisthesis or spondylolysis
F. Compression fracture of lumbar spine below LI
G. Aortic aneurysm by physical examination or x-ray
M. Significant opioid, alcohol, or tranquilizer dependency
N. Weight greater than 290 pounds (possible exclusion at 250 pounds depending upon weight distribution)
O. Significant uncontrolled intercurrent medical disorder
A. Smoking-Patients need to know that results will be 50% less effectiveB. Consumption of greater than 20 mg/day equivalent of diazepam or four Percodan/Percocet/Tylox(oxycodone/aspirin or acetaminophen), which will a. Vital signs (height, weight, blood pressure, require adetoxification plan pulse, respiration, temperature)
C. Consumption of greater than two cups of coffee, three cups or glasses of tea, or two cans soda pop perday
D. Obesity of greater than 20% above ideal body weight
E. Consumption of prednisone or steroids other than DHEA
G. Serious language barrier preventing effective communication
H. Significant negative attitude on the part of the patient
1. Comprehensive general medical assessment v. Posture
a. Details concerning the onset of the pain complaint compared to leg
b. Factors which decrease or increase pain
c. Location of center of pain, spread, and/or a. Lumbar flexion, extension, side bending, and radiation
d. Intensity (average, high, and low, with estimate of percent of time being high or low) upright)
f. Mattress (type, quality, and condition)
g. Sensory symptoms (tingling, numbness) torsion
i. Bowel, bladder, and sexual dysfunctions
k. Recent or remote spinal surgery 1.
l. Recent or remote diagnostic spinal studies (lumbar puncture, discogram, myelogram, CT, MRI, plainspinal x-rays)
m. Any spinal anesthetic or epidural or steroid injections
n. Trigger point injections or nerve blocks in the past 6 months
o. Acupuncture therapy in the past 6 months
p. Any physical therapy in the past 6 months
q. Any use of a back brace (other than work- 4. required lifting belt) in the past 6 months
r. Family history of significant spinal problems
t. Any personal history of collagen disease
u. Any chiropractor or osteopathic adjustments or manipulation in the past 6 months
NUVARING NAME OF THE MEDICINAL PRODUCT NuvaRing® 2. QUALITATIVE QUANTITATIVE COMPOSITION NuvaRing contains 11.7 mg etonogestrel and 2.7 mg ethinylestradiol. The ring releases etonogestrel and ethinylestradiol at an average amount of 0.120 mg and 0.015 mg, respectively per 24 hours, over a period of 3 weeks. For excipients, see 6.1. 3. PHARMACEUTICAL NuvaRing is flexible,
Nucleic Acids Research, 1995, Vol. 23, No. 9 1557–1560 Versatile vectors to study recoding: conservation of rules between yeast and mammalian cells Guillaume Stahl*, Laure Bidou1, Jean-Pierre Rousset1 and Michel Cassan Institut de Génétique et Microbiologie, URA CNRS 1354, Bâtiment 400, Université Paris-Sud, 91405 OrsayCedex, France and 1UFR 927, Université Pierre et Marie Curi