O iginally Decompression Therapy was proposed as a stand-alone treatment. Its potency didn't need to be watered down or confused by the addition of other "lesser" modalities. That proposition appeared to be necessary hyperbole when attempting to sell a $40,000 to $ 150.000 device. Proposing a synergistic effect (the explicit benefit of each component relatively indeterminate) in the sale of an ultracxpensive miracle therapy might cause hesitancy in the buyer. If in fact ultrasound, laser, massage, electrotherapies, etc. were added, then perhaps it was not the $100,000 device doing the lion's share of the work. Furthermore, if in fact a modality was at some level necessary to generate the best outcomes, perhaps the $ 100.000 traction unit wasn't itself a vital component (?). These concepts didn't enter into the conversation until decompression had been in the chiropractic marketplace for nearly a decade and low -cost units began undermining their preeminence. Our proposition (and much of pin sical medicine research) is that there is virtually always a syncrgistic effect to successful treatment for low back and referral pain, due in no small part to the overwhelming evidence that the source of low back pain (LBP) cannot be diagnosed with any degree of certainty (and those conditions that can often require surgical intervention). If the tissue source or site is hidden from discovery in all but a tiny percent of cases, then it is logical to assume a "pinpoint" intervention at an assumed site is mostly wishful thinking. Over the years, this insight hasn't been lost on most open-minded clinicians irrespective of the parsimonious, silver-bullet marketing that comes at us from all manner of manufacturers. I had been weaned on the hyperbole of vertebral axial decompression (VAX-D) and kid in fact avoided any additional therapies (except mild massage) until well into the third or fourth week of care. Upon retrospective review, our success rate (good to excellent) rarely rose above 60%. After the addition of modalities (and McGill's functional assessments and ADL training concepts) success escalated dramatically. The resulting quandary at the time was how to continue to rationalize a $2,500 per month lease on a stand-alone miracle table. The answer was there was no rationalization: we just stuck it out and tried to learn by the relatively untenable experience. This is not to say that there shouldn't be one primary focus to our treatment strategy and any subsequent additions meant as enhancements and adjunctivc. The core premise of the numerous clinical prediction rule (CPR) studies is to categorize through retrospective review those patient-conditions show ing marked improvements to an intervention not watered down by additional modes. This, however, is often impractical in daily practice and we find single-modality clinics becoming less common as well (and further studies suggesting some flaws in the entire CPR theory). The savvy patient tends to come at us with a remarkable amount of information and some difficult-to-answer questions regarding the why and how of what we do. If we offer a single intervention and it fails to give a robust effect, there remains little reason for the patient to continue. Much of the traction of CPR research focuses its attention on the addition of traction/decompression to an otherwise typical (physical therapy, or PT) intcrvcntional program. This program is most often based on facilitated movements, which typically means it is extension oriented, since extension is overwhelmingly the directional preference of the (more responsive) 25- to 50-ycar-old disc derangement patient. Interestingly (and confus-ingly as well), when extension creates peripheral symptoms, it is considered a viable sign for the addition of traction. Since adhesions can be found in at least 25% of sciatic conditions, other motions and facilitated activities arc warranted as well, such as nerve gloss techniques. In fact, two studies in the B-lcvcl of research concluded the addition of traction was warranted when peripheral symptoms were increased with extension is often interforamimil occlusion is a component. An effective extension-oriented program is not "forcing extension" with worsening of symptoms, but is the addition of modalities and traction/decompression, and the judicious rcintroduction of extension as the healing progresses and the assumed space-taking lesion regresses. We see mam patients with marked initial intolerance to extension, but after several traction/modality sessions, extension, as it were, is miraculously regained. In addition, the flexion-lock often appears as extension intolerance, but is not from a nerve encroachment. Judicious use of flexion positioning and laser while in prone decompression can be extremely helpful. Study after study reinforces the proposition that those who cannot extend, or who do not show a directional preference and centralization of pain with certain motions, fare much worse in the long-term than those who do. A 2011 systematic review by May. et al. in JOSPT. showed that research has validate centralization and directional preference as a defined and important clinical phenomenon. The traction CPR study in 2007 by Fritz, et al. was to judge the clinical benefit of adding traction to a facilitated exercise program and determining a potentially reliable CPR for those who would do well with traction. In fact, their outcome suggests, at least in the short term, a statistically significant benefit when traction was added to patients showing sciatic symptoms, pcripheralization with extension, and crossed straight leg raise. Their 2014 cervical traction research concluded that the study supports the use of traction, but limiting it to just this subgroup may. however, result in suboptimal outcomes. Additionally, several other researchers have concluded that limited sessions (fewer than six) may be a reason for poorer outcomes and that limiting traction to just certain discreet subgroups may diminish benefits. Further, avoiding the judicious use of modalities may hamper optimal outcomes as well. Most research on traction (and much on manipulation) has exercise as a cotrcatment (a passive and active component). However, several studies also compare low-level laser, ultrasound, and traction (JMPT 2008) and conclude all can be effective over 8 to 12 week interventions for reducing the pain of acute HNP without exercise as a component. Most doctors also realize the benefit of activity avoidance in the initial stages of healing. This is where heavy doses of passive, physiologic modalities can better address the trouble and allow a smoother transition into active care later. Traction is perhaps the ultimate passive-rest modality. It imparts a physiologic-healing enhancement while imposing very mild (nontraumatic) forces to the body when in a rest and recovery posture. Interestingly, there is very often a concomitant reduction in the size of the hernia in most, but not all. of the patients in studies on modalities utilized for HNP. This probably is more likely a condition of the disc, and its natural tendency to shrink than with a reproducible action of the modality (but this hasn't been proven one way or the other, either). How ever, traction/ decompression has been shown to impart that outcome more reproducibly and consistently than any other treatment over the past 60 years. As with hemorrhoids, one would conclude an actual shrinkage of the tissue is necessary for pain reduction. With hemorrhoids, tliat may well be true, but for disc hernias, it simply isn't directly correlated. It doesn't shock any chiropractor that modalities can effectively reduce pain from a hernia or another disc-related lesion. However, looking to evidence-based research for the answer as to which one will leave a noticeable void. Laser proponents perhaps have the best reasons to be enthusiastic regarding LBP relief as innumerable research projects and authors continue to extol the benefit of the therapy. We see virtually no one who receives treatment with a class IV laser not showing a trend toward quicker improvemcnt(s) and at least a modicum of relief over other modalities. Ultrasound is a bit more dubious, but still, if done over several weeks, is not a just a "worthless trapping of physical medicine." as McKenzie was fond of saying. Yet. even he was quick to point out that a syncrgistic effect when multiple therapies were combined was certainly likeh to be more beneficial than any one of them done alone. Though an incloquent term, the "shotgun approach" effectively describes how mam DCs treat acute disc lesions. A persnickety disc seems to warrant multiple inputs, and. in practical experience, just seems to render quicker results in most patients. Our approach is to determine (within the recognized limitations of actual diagnosis) whether a compression lesion or a motion dysfunction (noncomprcssion) exists. From that starting point, we assess the referral pain and the tendency of the symptoms to worsen with cocontractioa external bracing/fixation/rcpo-sitioning. and facilitated motions, especially extension (or side glide/bend). When decompression tolerance and positioning have been determined, we begin a series of sessions. Since the choice of modality is typically experiential (and based on what the doctor can afford), either ultrasound or laser (class III or IV) is usually chosen as a pretrcatment. However, with the advent of so-called open-modality belts, the application of these healing modalities can be added during the actual decompression treatment. The assumption is that a more potent synergistic effect can be generated if both treatments are done simultaneously. Not only can there be improved physiologic responses, but the potential analgesic effect and placebo effects can't be underestimated or dismissed, and the time savings is a clinical bonus as well. There is little doubt no one will unlock a single reason for or a single treatment of acute low back or neck pain for all cases. Innumerable theories and experts have promoted their preferences over the past hundred years, few have been accepted universally, and many have all but disappeared. However, most doctors do notice there is a synergy response from the judicious and sensible use of multiple modes of treatment in most patients versus a single treatment. This remains true with decompression as well. Dr. Kennedy has developed, tested and taught an effective, easy to leant decompression therapy technique. His protocols have been taught to over 4,500 chimpractors and physical therapists. In over 20 years of practice, he has owned and operated most of the decompression therapy equipment offered bv a range of manufacturers. This has afforded him the position of having done 100's of cmss-comparison treatments with these units. He believes that it is imperative to "put the doctor into Decompression Therapy.
