I am frequently asked about the difference between traction and decompression. It is unfortunate that there is very little education in chiropractic about the true difference between spinal decompression and traction.
Doctors of chiropractic regularly misrepresent the truth, sometimes unknowingly. They also mislead the rest of the chiropractic community and their patients about the real difference between traction and spinal decompression.
In medicine, the definition of spinal decompression is the relief of pressure upon a nerve, which is itself a surgical procedure. There is no medical definition of traction because it is simply an action — the application of a force for some purpose.
Dr. Perry Bard, my son, and I work with Norman Shealy, MD, PhD, a neurosurgeon who taught at Harvard Medical School. We have taught the difference between decompression and traction as an event. I have also had many conversations with Dr. Allen Dyer about it.
If you are unaware, nonsurgical spinal decompression (NSSD) was originally developed in the 1980s by the eminent Allen Dyer, MD, PhD, who was once Canada’s minister of health care. Dr. Dyer is recognized as one of the inventors of spinal decompression and the creator of an advanced new therapeutic modality called Vax-D. He proved that his treatment provided a change in intradiscal pressure, causing the “event” of spinal decompression, which was formalized by the Ramos and Martin study.
It is important to know there have been few studies on traction versus decompression. The main study was a Shealy Bergmeyer study; they all can be found in The Ultimate Spinal Disc Treatment Book, as well as interviews with both Dr. Shealy and Dr. Dyer.
Additional studies to review:
In July 2005, the American Journal of Pain Management published “Long-term Effect Analysis of Spinal Decompression Therapy in Low Back Pain: A Retrospective Clinical Pilot Study” by C. Norman Shealy, MD, PhD, Nirman Koladia, MD, and Merrill M. Wesemann, MD. They observed the outcome of 24 study participants. Each reported consistent pain relief and continual improvement of symptoms one year later. Improvement in pain continued after the treatment sessions were completed.
In the April 2005 issue of Practical Pain Management from Technology Review, Norman Shealy, MD, PhD, found that “spinal decompression treatment leads to satisfactory pain relief and improved quality of life in up to 88% of patients, many of whom had failed other ‘conventional’ approaches.” Based on the author’s review of recent study results, spinal decompression appears to be the current optimal recommendation for most lumbar pain syndromes.
The Journal of Neuroimaging published an article in April 1988 titled “MRI Evidence of Nonsurgical, Mechanical Reduction, Rehydration, and Repair of the Herniated Lumbar Disc.” Regarding NSSD, L. Eyerman, MD, found that “all but three of 20 patients reported significant pain relief and complete relief of weakness and immobility, when present.” This study also showed a correlation between the improvement on the MRI and the reported improvement in pain.
In April 1988, the Journal of Neurological Research published “Vertebral Axial Decompression for Pain Association with Herniated or Degenerated Discs or Facet Syndrome” by E. Gose, PhD, W. Naguszewski, MD, and R. Naguszewski, MD. The authors found the following results of spinal decompression: “Pain, activity and mobility scores greatly improved for 71%of the 778 patients studied.” The authors considered Vax-D to be a primary modality for low back pain due to lumbar herniations, degenerative disc disease, and facet arthropathy. The authors concluded that postsurgical patients with persistent pain or “failed back pain syndrome” should try Vax-D before further surgery.
Traction is often known in medical circles as an action instead of a medical procedure. It is more commonly known as isotonic traction, which is when the amount of force does not change. In fact, an article published in the February 1995 issue of Physical Therapy stated that “the proposed mechanisms of traction, however, have not been supported by enough sufficient research.” The AHCPR Publication No 95-0642 has the following summary of findings: “Evidence does not demonstrate traction to be effective in the treatment of patients with acute low back problems.”
The history of modern traction can be traced back to the 18th century with the work of Jean-Andre Venel. He tried to apply the Hippocratic idea to modern surgery. Orthopedic specialists of that time were mostly preoccupied with using corsets, but traction became popular when neurologists paid attention to a similar method of suspension.
In 1889, traction became popular in treating tabes dorsalis and other neurological diseases. Then, a Russian neurologist proposed a combination of body suspension and cervical traction in 1893. Some years later, Dr. Gilles de la Tourette promoted the use of spinal traction in his neurologic clinic.
Unfortunately, neurologists worked without the cooperation of orthopedic specialists. In the 20th century, suspension was replaced by traction in neurology. Years later, the field lost interest in traction but found new uses for it in traumatology, such as using isotonic traction to treat fractures.
Traction originated hundreds of years ago, and it started to be used more as a muscular or joint forward-pull technique. Traction has never been a medical procedure, and medicine has never embraced traction.
Decompression differs because it is an event for which the conditions can be created. In a conversation with Dr. Dyer, I told him of my own personal conviction about the misrepresentation by certain traction equipment manufacturers and sellers of chiropractic tables. I also spoke about the lack of a more precise designation of the Code of Federal Regulations, Title 21, under which all decompression machines fall. We are working to get this updated.
This federal code is a regulatory guide mandated by the FDA for classifying medical and physiotherapy devices. It is a classification for all powered equipment and does not distinguish between spinal decompression and traction, thus creating the opportunity for confusion and misrepresentation.
The average chiropractor’s lack of general knowledge about the differences between traction and decompression, coupled with advertisement claims about traction devices being able to perform decompression, has created intense market confusion. Dr. Dyer noted that while there are similarities in the use of traction and spinal decompression, they are very different. He compared the differences to those of an X-ray and a CT scan; both utilize film and create an image, but X-rays and CT scans are quite different in use and application.
Traction and spinal decompression have the same differences. Drs. Shealy and Dyer became friends, and we shared ideas. Dr. Dyer said that when he originally took his decompression device to market, the classification from the FDA in CFR 21 was not even traction as it is today.
WebMD.com states:
Allan E. Dyer, MD, PhD, who developed Vax-D, explains how the treatment “fixes” herniated disks, a frequent cause of lower back pain: “Your bones are separated by a cushion. That cushion is always under positive pressure, even at rest. Vax-D lowers that pressure to negative levels by creating a partial vacuum that can retract the disk. Even a large, protruding disc can be retracted where it’s supposed to be,” he says. Dyer recommends that patients undergo 20 treatment sessions for optimal results.
Regular traction stretches your spine and muscles simultaneously. If you only stretch the spine, though, your body naturally “braces” for the next stretch, limiting the effectiveness of the treatment. The “overall stretching” commonly used in traction can also trigger painful muscle spasms, according to Dr. Shealy.
Traction is often described as any mechanical traction using force to create tension or separation between joints. The different types of traction are very different from each other. Mechanical traction is the application of sustained or intermittent mechanical unloading to the spine. The mechanical traction force produces distraction between the vertebrae, thereby relieving pain and increasing tissue flexibility, generally for the cervical and lumbar spines.
Mechanical traction devices may include the use of a table, vest, weights, or pneumatic devices. The standard CPT definition for mechanical traction is “97012: Application of a modality 1 or more areas; traction, mechanical,” but decompression is mandated (we bill S9090).
So again, I went to the expert for more clarification. At Disc Centers of America, we recommend Dr. Marty Kotler and even purchase time and webinars from him for our doctors. In our opinion, he’s the best.
He stated, “CPT code 97012 is mechanical traction. Mechanical traction is a supervised modality. The application of mechanical traction does not require direct (one-on-one) patient contact. The scope of practice in some states allows staff members to assist with mechanical traction. Please check with your state’s scope of practice. A qualified healthcare professional or staff member will position the patient on the table, enter the settings, and will check in with the patient every few minutes. In this scenario, constant attendance is not typically provided. Without constant attendance, without any clinical skill, this procedure cannot be categorized as constant attendance or a therapeutic procedure.
“CPT code 97012 is payable by most carriers, but it has a minimal relative value unit (RVU), so reimbursement is low. Only one unit of this code can only be reported per session, regardless of the number of body parts being treated because the code descriptor states, ‘application of a modality to one or more areas.’”
Dr. Koller also said, “HCPCS code S9090 is vertebral axial decompression, per session. Many years ago, CMS issued HCPCS code S9090 to describe decompression therapy rather than create a new CPT code. Decompression table manufacturers wanted to get a new code based on patient results.
“Unfortunately (or fortunately in certain circumstances), HCPCS code S9090 is considered invalid. S9090 is not payable by Medicare and does not have an associated RVU. Subsequently, most insurance plans consider decompression therapy to be a non-payable, ‘experimental/investigational’ service. Other codes associated with spinal decompression therapy are 97039 (unlisted modality), 97139 (unlisted therapeutic procedure), and 97799 (unlisted physical medicine/rehabilitation service).
“According to Medicare, CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 160.16, spinal decompression therapy is not covered. Examples of this type of non-covered procedure include, but are not limited to, Vax-D, DRX-3000, DRX9000, Decompression Reduction Stabilization (DRS) System, IDD, MedX., Spina System, Accu-Spina System, SpineMED Decompression Table, and Lordex Traction Unit.”
Spinal decompression therapy is different from conventional spinal traction because it alternates between stretching and relaxation. — progression and regression. The relaxation stages trick your body into staying relaxed, so it maximizes the load and effectiveness of the treatment.
A true decompression table allows doctors to target your treatment area in three different dimensions. This allows us to target our treatment by isolating specific spinal discs, while traction often just “stretches” the entire spine. Dr. Shealy worked on this with the fixed tower in a supine position.
Many machines today can also completely customize patients’ decompression treatment by changing the amount of stretch (load), the number of stretch/relax stages, the time it takes to reach each peak stretch/relax stage, and many other settings. These options allow the doctor to personalize the session for your age, weight, and condition and adjust your treatments as we track your results.
The concept of decompression is very different from that of inversion tables (which more resembles traction), and because of computer algorithms, it’s much more advanced. An inversion table keeps the legs in place while inverted to allow for the weight of your body from the knees to your head to be pulled down by gravity when inverted. That can actually increase disc pressure, which can exacerbate pain. To receive the “event” of decompression, you want to get decreased disc pressure as studied and reviewed in the Ramos and Martin study.
According to both Drs. Shealy and Dyer, traction alone cannot address the source of the problem. The goal of spinal decompression is to create negative pressure or a vacuum inside the disc. This effect causes the disc to pull in the herniation, and the increase in negative pressure also causes the flow of blood and nutrients back into the disc, allowing the body’s natural fibroblastic response to heal the injury and rehydrate the disc.
Traction and inversion tables can lower the intradiscal pressure from +50 to +30 mmHg. Spinal decompression is clinically proven to reduce intradiscal pressure to -150 to -200 mmHg, according to the Ramos and Martin study.
Traction triggers the body’s normal response to stretching by creating painful muscle spasms that worsen the pain in the affected area. Today, patients don’t have to live with that pain anymore. Thanks to the concerted efforts of a team of top physicians and medical engineers, spinal decompression was developed to effectively treat lower back pain and sciatica resulting from herniated or deteriorated discs. Spinal decompression significantly reduces back pain in many patients and enables most patients to return to more active lifestyles.
The major difference between traction and decompression is that decompression utilizes motorized axial (head-to-toe) distraction of the lumbar or cervical spine. This machine is often capable of taking constant measurements of the forces being exerted between the machine and the patient, which is done to determine any muscle guarding occurring during the decompression treatment.
These measurements allow the machine to adjust the distraction forces in real-time to avoid pulling “too hard.” If there is too much force distracting the patient, they may start to have pain or discomfort and, as a result, muscle guarding. When the muscles are guarding and firing, the decompression is then fighting against the patient, making the treatment potentially less effective.
Decompression is a great tool for patients with acute pain due to disc bulge or herniation because of its ability to reduce forces in real-time and avoid pulling against the patient’s natural response to pain. Decompression is technically different from traction, and depending on the type of traction, it can be substantially different (more on that later).
Before buying any piece of equipment, ask to see their research studies. A medical doctor usually checks out white papers and clinical studies on any device, medicine, or procedure before embracing it.
Orthopedic equipment makers are required to perform medical studies in universities and hospitals, proving the claims made and expected outcomes are true and genuine. Medical doctors require empirical evidence, whereas chiropractors are often swayed by advertising claims.
The lack of general knowledge that the average chiropractor has about the differences between traction and decompression has created intense market confusion, especially when coupled with advertisement claims about traction devices being able to perform decompression.
At Disc Centers of America, all our treatments are drug-free, nonsurgical, safe, and pain-free. We use a unique, comprehensive treatment approach that provides lasting relief so patients can regain their quality of life. Treatment for spine-related conditions often includes nonsurgical spinal decompression to reduce nerve pressure and repair damaged discs with chiropractic adjustments and joint mobilization to restore proper motion.
At Disc Centers of America, we also use high-dose laser to reduce pain and accelerate nerve repair and electroanalgesia to reduce pain, combined with gentle manual therapy, SOT, and often Activator or the Pro Adjuster to restore muscle balance.
There has never been a better time for chiropractic than there is today, and doctors need to learn about spinal decompression. Our next CEU event will be at Life University in February. We will also discuss the neuropathy-decompression connection. Please contact Life University for more information.
Dr. Eric Kaplan and Dr. Perry Bard, are business partners of over 32 years. They have developed Disc Centers of America & Concierge Coaches. Currently, they have over 150 clinics using their Disc Centers of America brand and lead ongoing success training events throughout the year. For more information on coaching, spinal decompression, or seminars, visit www.thechiroevent.com or www.decompressioncertified.org, or call the Chiropractic Q&A Hotline at 888-990-9660.
Dr. Jason Kaplan is a graduate of Parker University. Along with his wife Dr. Stephanie Kaplan, they practice in Wellington Florida. Jason is an Instructor for Disc Centers of America, one of the Nation’s largest collection of doctors specializing in Disc Injuries. He has been recognized and honored by the International Disc Education Association and teaches technique at the National Certification Program at Life University and is considered a Master on Non Surgical Spinal Decompression. www.wellingtondisccenter.com.
