Decompression Therapy: Avoiding Patient Misapplication
TECHNIQUE
Jay Kennedy
Fortunately, as chiropractors, the interventions most of us use on a daily basis are considered relatively risk-free— i.e., death or severe disability is very unlikely. That’s not to minimize the occasional negative outcomes that can occur and foster some loss of confidence for both the doctor and the patient. With continued practice experience, most of us are able to mitigate negative treatment effects. Decompression, however, is often added into an established practice, and therefore, there may be little or no tangible experience to help recognize risks, dangers, or contraindications.
With the exception of stroke risk from rotary manipulation, most mobilization techniques aie considered safe and free from distinct danger. Decompression—axial mechanical traction—is a grade I to IV mobilization procedure (the grade is dependent on the tension applied and speed of application). As such, joint cavitation (grade V mobilization) isn’t the intended outcome (though it is not uncommon) and any danger from rotational strain is nonexistent.
In the cervical or lumbar regions, axial elongation doesn’t pose a definitive threat to the vascular components. However, a few studies have examined cardiovascular variables during cervical traction and have found some patients do exhibit increased cardiovascular stress, such as, for example, changes in blood pressure. The potential stress and/or insult that can occur to neurological and ligamentous components is a bit more complex. Poisson’s effect is a physics characteristic ascribed to malleable tube with a cross-sectional diameter that can decrease upon stretch or elongation. Since the spinal cord and nerves aie by definition tubular and deformable, it is reasonable to imagine their cross-sectional diameter may be compromised upon exces-
■ "Decompression, however, is often added into an established practice, and therefore, there may be little or no tangible experience to help recognize risks, dangers, or contraindications. J Ï
sive tension, especially if extensive stenosis is present.
A few studies suggest that high-force cervical traction may promulgate an episode of sciatic nerve pain, as well as vertigo and nausea in some susceptible patients. The assumption being that, in the face of moderately severe spinal degenerative changes, there is a compromise in distraction-tolerance and exceeding it creates a physical deformation or inference with the cord or nerve roots. How this occurs is, at the present time, speculative, but it may be via the piezoelectric effect, or pressure electricity. A current can be created in living tissue, which may create interference to the body’s transducer effect. This was proposed by Panjabi twenty years ago, however it wasn’t suggested as an immediate phenomena, but instead as time dependent. This is also an underlying theory (Harrison CBP) for global, postureinduced “subluxation,” when postural permutations alter nerve conduction via the piezoelectric effect from the deformed bone and soft tissues.
I personally have witnessed a patient develop severe sciatic symptoms during the first five minutes of somewhat aggressive
“In the cervical or lumbar regions, axial elongation doesn’t pose a definitive threat to the vascular components. 5 J
(30 pounds) cervical traction. The immediacy of the onset diminishes a pressureelectric effect and more likely suggests a neurologic-compromise effect, such as Poisson’s (or some other). It was discontinued, ultrasound was applied, and within several minutes, the pain was gone. It is difficult to say if more disastrous consequences would have resulted if the traction had continued for several more minutes (thus the importance of handing the “stop” switch to the patient during each treatment).
Most mobilization techniques involve distraction, flexion, or extension as primary vectors. Decompression as a mechanical technique is an axial-mobilization with the intension of reduction in compression on the discs and nerves. When assessing patients for traction treatment, both the physiological necessity (they have signs of a compression syndrome) and the mechanical tolerance must be considered. The patient may well have compression components to their symptoms, but axial elongation (distraction) may be untenable due to severity of the pain, local inflammation, adhesion, or associated sprain/strain. These secondary mechanistic considerations give rise to most of traction’s negative outcomes or reactions during treatment.
Reactions after treatment are a bit more frustrating since any novel mechanical treatment to someone in pain can create soreness or stiffness that can be considered annoying. However, it may be a necessary component to healing, and discussing this phenomenon prior is always a good clinical and patient-management strategy.
Secondarily, decompression is in effect a “swelling” of the disc brought about by a combination of recumbent position and a distraction tension applied at the waist (or occiput). This is a deliberate and celeritous act of creating
diffusion via a centripetal force. If the disc is hydrostatic and its “container” is intact, it will tend to draw fluid inward upon distraction. Not every patient or every condition is tolerant of this disc diffiision/swelling (especially those who have excess pain and flexion intolerance after getting out of bed), and as such, a percentage will suffer when rising from the treatment (and some will continue to suffer for hours or days). Typically, the more acute the patient, then the more traumatic the onset of pain, and the more localized the symptoms, then the more likely decompression may be untenable. The good news is that proper classification can obviate this from daily practice in most cases.
^When assessing patients for traction treatment, both the physiological necessity (they have signs of a compression syndrome) and the mechanical tolerance must be considered. ï Ï
Contraindications for traction vary from author to author and can read like ice cream labels; some have just three or four ingredients while others have an entire chemical warehouse. Initially, we would list innumerable reasons why not to use traction, but in recent years we have convinced ourselves there are actually very few direct contraindications. Obviously, the biggest is the practical suggestion to avoid “acute or subacute” sprains, which show localized pain, no referral, and no directional preference.
^Typically, the more acute the patient, then the more traumatic the onset of pain, and the more localized the symptoms, then the more likely decompression may be untenable. 5 *
In terms of pathologic indicators, any severe, bone-compromising disease and cardiovascular risk factors that could be problematic upon restrictive belting and applied force should be off limits. These are rare, of course, in daily practice. Aortic aneurysms have been thought to be a direct contraindication, however many patients have these unbeknownst to them or their DC and have safely and successfully undergone traction. If I have imaging of said lesion, I typically call the MD and run it by him or her. Up to this point, I’ve yet to hear, “Absolutely not.” In most cases, the MD says, “I can’t imagine how traction could have any adverse effect on it.”
Finally, for osteopenia and osteoporosis, it is difficult to present a cogent argument as to the mechanism of injury with axial stretch. Since there is no impact or rotational impaction, the force is applied at the pelvic rim, and there is no contact to
any compromised structure, so we don’t believe it to be a direct contraindication. Practice is both an art form as well as a scientific endeavor, and as such, opinions and experiences of contraindications and treatments can vary widely
References:
1. Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA study. Hurwitz EL, Morgenstern H. Spine Jul; 30(13) 2005.
2. Physical agents in rehabilitation, p. 309-310. Cameron M. Churchill Livingston 2006.
3. Effects of cervical traction on cardiovascular and ECG variables using various weights. Akinbo SR et al. Nigeri Postgrad Med J. Jun; 13(2) 2006.
4. Blood pressure and pulse rate changes associated with cervical traction. Utti VA et al Nigeri J Med. Apr-Jun; 15(2) 2006.
5. Mobilization of the spine. Maitland, G. Churchill Livingstone 2001.
6. CBP structural rehab of the cervical spine. Harrison D et al. Harrison CBP seminars.
7. Cameron M. op cit. p. 307.
8. Effects of traction on the size of herniated material in lumbar herniation. Ozturk B, et al. Rheumatol Int. Oct; 25 (1). 2005.
9. Modem manual therapy. Grieves G. Churchill Livingstone p. 386. 1996.
Kennedy is a 1987 graduate of Palmer Chiropractic College and maintains a full time practice in western Pennsylvania. He is the principal developer of the Kennedy Decompression Technique. Dr. Kennedy teaches his non-machine specific technique to practitioners who want to learn clinical expertise required to apply this increas-
ingly mainstream therapy. Kennedy Decompression Technique Seminars are approved for CE through various Chiropractic Colleges. The author can be contacted (adrdecompression, (afiennedytechnique. com.
