Your Decompression Outcomes Are Better When Technique is Consistent
FEATURE
David A. Bohn
DC
Do you get frustrated when your decompression results are not what you had hoped for or expected? Before you give up on using your table, take some time to review your protocol and technique.
First, review your classification system. In my practice, I follow the acronym LIPID, which stands for location, initiation, provocation, intensity, and duration of pain/symptoms. This will give you a very good first impression as to whether you are dealing with a disc problem or some other issue, such as a motion disorder, combination of disc and motion disorder, or a joint problem.
A patient with lumbar disc protrusion or herniation will experience an increase in pain when additional compression is applied and should have some degree of pain relief with flexion distraction, manual distraction, or axial distraction. Patients with movement disorders due to abnormal or inappropriate muscle activation patterns will see a decrease in pain with compression and more range of motion (ROM) because their symptoms do not originate from a compressive problem. Motion or movement disorders show relief with artificial stabilization, compression belts, realignment, and form/ force-closure tests.
Form/force closure is an excellent screening procedure to determine how much of your patient’s pain is due to abnormal muscle activation and not compression. A quick and effective test can be performed by kneeling or sitting behind your standing patient and applying pressure on both ilia simultaneously while asking your patient to contract their core musculature. Then have your patient bend into flexion and assess for pain in their paraspinals or intradiscal. 1
To assess your patient for cervical disc compression versus motion disorder, look for anterior translation or flexion of their skull associated with extension/posterior translation of the thoracic cage. You will also commonly notice a loss of the cervical lordotic curve, or even a cervical kyphosis or “S” harmonic configuration.
Check the patient with a rotation test. Rotation into the side of pain that results in increased pain is a compression or disc sign. Rotation away from the side of pain is a motion disorder and will be best treated with active therapeutic motion (ATM2). Clinical findings for cervical decompression/traction will also include a positive Spurling’s test (painful compression test) and relief of pain with a cervical distraction test. These compressive patients will do well with decompression protocols.
I also rely on the first one-third versus the last onethird range of motion (ROM) pain rule. Patients with contained discs (HNP) most often create moderate-to-severe pain upon initiation and the first one-third ROM in flexion with increased radicular pain. They also tend to create lower back pain without peripheral or radicular pain in the first one-third of extension. With repetitive extension, ROM will improve as the disc migrates anterior; with repetitive flexion, ROM will usually degrade.
When you find your patient has increased pain in the first one-third ROM of flexion, instruct them to avoid flexion activities, including excessive flexion traction, i.e., supine, hammock position. Prone and prone-extension are meant to limit global flexion but still offer the disc a centripetal effect. If their pain is in the last one-third ROM (or pain coming up from flexion through extension), you should think and treat for a motion disorder.
The underlying cause of many disc problems is static and dynamic instability, muscle weakness, and bad ergonomics. Stuart McGill says that when muscles contract, they create force and stiffness, and this stiffness is very important for stability. The spine is really a flexible rod that needs to be stiffened to carry load, and this is the role of the muscles.2
The human body functions as a linked system with any distal movement requiring proximal stiffness. When we walk, our pelvis must stiffen and become secured to our spine so our left hip doesn’t fall as our left leg swings forward with every step. Without this core stiffness, walking would be impossible. Every movement of our body requires an appropriate coordination of muscles. It is only possible to move, run, sit, or stand because of spine stiffness and core stability.
Core failure overloads the spine with forces that increase the risk of disc injury. Without every spinal muscle playing its part in maintaining dynamic stability, discs will fail and correction will not last without adding rehab to your treatment plan.3
Enhancing the quality of core stiffness requires a different kind of training. This is where I use the ATM2 device for isometric exercises intended to enhance muscular endurance, strengthening, and coordination. Isometric exercise happens when a muscle or group of muscles are activated and contracted, but there is no change in the joints they cross. This is where the ATM2 excels at targeting the core muscles to correct dynamic instability and muscle stiffness or tightness.
Few patients show up in my clinic with a truly “new problem.” Most patients have been working on their problem for years. Consider the UPS driver who lifts 70 packages a day. At 5:00 p.m., he lifts package number 62, and his back “goes out,” or he herniates his L5/S1 disc. There was nothing special about box number 62 or the other 61 boxes he lifted that day, or in his five-year career as a driver for UPS. Weakness, instability, weak core control, and bad ergonomics over time wore down his spine until there was tissue failure. First, fix the disc with spinal decompression therapy and then address his underlying real problem—the core weakness with muscle stiffness and dynamic instability.4
Start with ATM2, rehab, exercise balls, bridges, side planks, step back lunges, dead bugs, etc. In the end, I’d rather have a patient telling everyone they know to see me because I fixed their pain a few years back instead of having that same UPS drive return to my office a few months after finishing his decompression plan with the same or worse pain.5
Finally, getting patients to sign up for your decompression plan comes down to one last acronym.
FACTRR
Find the impairment.
Assess its severity.
Create an awareness in the patient.
Treat it.
Rehab it.
Reevaluate.
Spend the time it takes to follow FACTRR and fix the problems. Soon you’ll find your little-used decompression table is at the center of your practice!
Dr. David A. Bohn, DC, graduated from National University of Health Sciences in 1988 and has since been in continuous practice. Since 2004, Dr. Bohn has pursued development of both documentation and x-ray analysis software. He has extensive experience with developing, marketing, and maintaining a successful practice. Dr. Bohn is a frequent guest speaker for KDT Decompression Seminars and can be reached through his office at 301-777-3710 or through Kdt.
References
1. PMR. 2019 Aug; 11 Suppl 1:S24-S31. doi: 10.1002/ pmrj. 12205. Epub 2019 Jul 22.
2. McGill, SM. Back mechanic: The step-by-step McGill method to fix back pain. Backfitpro Inc. 2015 (www. backfitpro. com).
3. Grenier SG, McGill SM. Quantification of lumbar stability by using 2 different abdominal activation strategies. Arch Phys Rehabil. 2007;88(l):54-62.
4. McGill SM. Grenier S, Bluhm M, Preuss R, et cil. Previous history of LBP with work loss is related to lingering effects in biomechanical physiological, personal, and psychosocial characteristics. Ergonomics. 2003;46:731-746.
5. McGill SM. Core training: Evidence translating to better performance and injury prevention. Strength and Conditioning Journal. 2010; 32(3): 33-46.
