American Journal of Pain Management
Vol. 7 No. 2
April 1997
Emerging Technologies: Preliminary Findings
DECOMPRESSION, REDUCTION, AND STABILIZATION OF THE
LUMBAR SPINE: A COST-EFFECTIVE TREATMENT FOR LUMBOSACRAL PAIN
C. Norman Shealy, MD, PhD, and Vera Borgmeyer, RN,
MA
C. Norman Shealy MD, PhD, is Director of The Shealy
Institute for Comprehensive Health Care and Clinical Research and Professor
Of Psychology at the Forest Institute of Professional Psychology. Vera Borgmeyer
is Research Coordinator at the Shealy Institute for Comprehensive Health
Care and Clinical Research. Address reprint requests to: Dr. C. Norman Shealy,
The Shealy Institute for Comprehensive Health Care and Clinical Research
, 1328 East Evergreen Street, Springfield, MO 65803.
INTRODUCTION
Pain in the lumbosacral spine is the most common
of all pain complaints. It causes loss of work and is the single most common
cause of disability in persons under 45 years of age (1). Back pain is the
most dollar-costly industrial problem (2). Pain clinics originated over 30
years ago, in large part, because of the numbers of chronic back pain patients.
Interestingly, despite patients' reporting good results using "upside-down
gravity boots," and commenting on how good stretching made them feel, traction
as a primary treatment has been overlooked while very expensive and invasive
treatments have dominated the management of low back pain. Managed care is
now recognizing the lack of sufficient benefit-cost ratio associated with
these ineffective treatments to stop the continued need for pain-mitigating
services. We felt that by improving the "traction-like" method, pain relief
would be achieved quickly and less costly.
Although pelvic traction has been used to treat
patients with low back pain for hundreds of years, most neurosurgeons and
orthopedists have not been enthusiastic about it secondary to concerns over
inconsistent results and cumbersome equipment. Indeed, simple traction itself
has not been highly effective, therefore, almost no pain clinics even include
traction as part of their approach. A few authors, however, have reported
varying techniques which widen disc spaces, decompress the discs, unload
the vertebrae, reduce disc protrusion, reduce muscle spasm, separate vertebrae,
and/or lengthen and stabilize the spine (3-12).
Over the past 25 years, we have treated thousands
of chronic back pain patients who have not responded to conventional therapy.
Our most successful approach has required treatment for 10-15 days, 8 hours
a day, involving physicians, physical therapists, nurses, psychologists,
transcutaneous electrical nerve stimulator (TENS) specialists, and massage
therapists in a multidisciplinary approach which has resulted in 70% of these
patients improving 50-100%. Our program has been recognized as one of the
most cost-effective pain programs in the US (I 3). The average cost of the
successful pain treatment has been cited as less than half the national average
(13).
Our protocol combined traditional, labor-intensive
physical therapy techniques to produce mobilization of the spinal segments.
This, combined with stabilization, helped promote healing. In addition we
used biofeedback, TENS, and education to reinforce the healing processes.
We wanted to produce a simpler and more cost-effective protocol that could
be consistently reproduced. The biofeedback and education could be easily
replicated. The problem was producing spinal mobilization to the degree that
we could decompress a herniated nucleus and relieve pain. Stabilization would
come after pain relief.
The DRS System was developed specifically to mobilize
and distract isolated lumbar segments. Using a specific combination of lumbar
positioning and varying the degree and intensity of force, we produced
distraction and decompression. With fluoroscopy, we documented a 7-mm distraction
at 30 degrees to L5 with several patients. In fact, we observed distraction
at different spinal levels by altering the position and degree of
force.
We set out to evaluate the DRS system with outpatient
protocols compared to traditional therapy for both ruptured lumbar discs
and chronic facet arthroses.
Subjects. Thirty-nine patients were enrolled in
this study. There were 27 men and 12 women, ranging in age from 31 to 63.
Twenty-three had ruptured discs diagnosed by MRI. Of these, all but four
had significant sciatic radiation, with mild to moderate L5 or S1 hyperalgesic.
All had symptoms of less than one year.
The facet arthrosis patients also underwent MRI
evaluations to rule-out ruptured discs or other major pathologies. They had
experienced back pain from one to 20 years. Six had mild to moderate sciatic
pain with significant limitations of mobility.
METHODOLOGY
Patients were blinded to treatment and were randomly
assigned to traction or decompression tables. Traction patients were treated
on a standard mechanical traction table with application of traction weights
averaging one-half body weight plus 10 pounds, with traction applied
60-seconds-on and 60-seconds off, for 30 minutes daily for 20 treatments.
Following the traction, Polar Powder ice packs and electric stimulation were
applied to the back for 30 minutes to relieve swelling and spasm, and patients
were then instructed in use of a standard TENS use to be employed at home
continuously when not sleeping. After two weeks, the patients received a
total of three sessions with an exercise specialist for instruction in and
supervision of a limbering/strengthening exercise program. They were re-evaluated
at five to eight weeks after entering the program.
Decompression patients received treatment on the
DRS System, designed to accomplish optimal decompression of the lumbar spine.
Using the same 30 minute treatment interval, the patients were given the
same force of one-half the body weight plus 10, but the degree of application
was altered by up to 30 degrees. The effect was to produce a direct distraction
at the spinal segment with minimal discomfort to the patient.
Eighty-six percent of ruptured intervertebral disc
(RID) patients achieved "good" (50-89% improvement) to "excellent" (90-100%
improvement) results with decompression. Sciatica and back pain were relieved.
Only 55% of the RID patients achieved "good" improvement with traction, and
none excellent."
Of the facet arthrosis patients, 75% obtained "good"
to excellent" results with decompression. Only 50% of these patients achieved
"good" to "excellent" results with traction.
Table 1. Patient assessment of pain relief secondary
to decompression and to traction.
DISCUSSION
Since both traction and decompression patients received
similar treatment (except for the differences in the traction table versus
the decompression table) with similar weights, ice packs, and TENS, the results
are quite enlightening. The decompression system is encouraging and supports
the considerable evidence reported by other investigators stating that
decompression, reduction, and stabilization of the lumbar spine relieves
back pain. The computerized DRS System appears to produce consistent,
reproducible, and measurable non-surgical decompression, demonstrated by
radiology.
Of equal importance, the professional staff facilities
required, as well as the time and cost, are all significantly reduced. Since
the more complex treatment program of the last 25 years has already been
shown to cost 60% less than the average pain clinic, the cost of this simpler
and more integrated treatment program should be 80% less than that of most
pain clinics-a most attractive solution to the most costly pain problem in
the US. In addition, patients follow a 30-day protocol that produces pain
relief yet allows them to continue daily activities and not lose
workdays.
SUMMARY
We have compared the pain-relieving results of
traditional mechanical traction (14 patients) with a more sophisticated device
which decompresses the lumbar spine, unloading of the facets (25 patients).
The decompression system gave "good" to "excellent" relief in 86% of patients
with RID and 75 % of those with facet arthroses. The traction yielded no
"excellent" results in RID and only 50% "good" to "excellent" results in
those with facet arthroses. These results are preliminary in nature. The
procedures described have not been subjected to the scrutiny of review nor
scientific controls. These patients will be followed for the next six months,
at which time outcome-based data can be reported. These preliminary findings
are both enlightening and provocative. The DRS system is now being evaluated
as a primary intervention early in the onset of low back pain-especially
in workers' compensation injuries.
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