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patient presentation
- 1. Intervertebral Differential Dynamics(IDD) SPINAL DISTRACTION THERAPY Doing more to beat back pain, neck pain, sciatica and trapped nerves Spine Plus Chigwell 2a Oak Lodge Ave, Chigwell, Essex, IG7 5HZ Tel: (020) 8501 0937 www.spineplus.co.uk/iddtherapy
- 2. The Back PainTreatment Gap 1/ Despite a variety of treatment options, the number of people with chronic back pain shows no sign of decreasing 2/ A significant population of back pain and neck pain sufferers exists who do not achieve desired outcomes from existing manual therapy and exercise techniques. 3/ Patients want non-invasive treatments, they wish to avoid injections and/or surgery and are seeking new solutions to help them resume normal active lives Providing technologically-advanced solutions for low back pain sufferers gives health providers to do more for their patients and attract new patients to their clinics. 2
- 3. Conservative Treatment Invasive Treatment IDD Therapy– Helping to Bridge the Treatment Gap
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- 5. IDD Therapy SpinalDecompression 1. Improve Disc Health 2. Re-educate soft tissues 3. Re-align spinal structures Three Principal Treatment Goals IDD Therapy Treatment Protocols developed to treat targeted segments of the spine as part of tripartite treatment programme including manual therapy and rehabilitation.
- 6. 1 - ImproveDisc Health • Precisely angled pulling force distracts targeted spinal segments • Joints distracted in longitudinal plane, not anterior -posterior • Vertebrae opened to create pressure differentials in the disc space • Negative pressure to promote retraction of bulging nucleus • Stimulate fluid exchange by diffusion to help improved disc health • Improve mobility to free natural nutritional pathways for the disc.
- 7. The Effects ofCompression A compressed sponge loses water and is unable to absorb water. Decompressing (taking pressure off) the sponge allows it to absorb water.
- 8. 2 - Re-educateSupporting Tissues • Works soft tissues by stretching weak muscles and working tight ligaments • Increase flexibility to improve joint mobility and range of motion • Creates a platform for strengthening exercises to support the joint and relieve pressure on the disc • Reduced tension and greater freedom of movement opens nutritional pathways to the disc
- 9. 3 - RealignSpinal Structures • Joint mobilisation in longitudinal Plane • Promotes fluid transfer around the joint • Gently mobilises the facets to reduce stiffness and increase range of motion • Targeted distraction to help realign spinal structures and balance load
- 10. Working Together Manual TherapyIDD Therapy Rehabilitation Tripartite solutions to resolve chronic back pain and neck pain
- 11. How does IDDTherapy work?
- 12. Understand the origins •1995 Study by Ramos & Martin – measured the effects of vertebral axial decompression (Journal of Neurosurgery ) • Recorded a reduction in intradiscal pressure from +60mm Hg to -100mm to -160mm Hg Pressure differentials promote fluid exchange within the disc space to aid improved disc health and to help retract a bulging nucleus pulposus. Ramos G and Martin 1. Effects of vertebral axial decompression on intradiscal pressure. J Neurosurg. June 1995. 82 (6): 1095
- 13. • Leads tothe creation of the IDD Therapy spinal decompression protocols. • Distraction observed at different spinal levels by altering the angle of application and the amount of distraction force. 1997, Shealy & Bourgmeyer test established scientific principles to to develop new thinking for treating targeted spinal segments. They perform a single blind RCT comparing traditional traction with new distraction decompression techniques, (American Journal of Pain Management). Origins cont/ With fluoroscopy, measure a 7mm distraction at L5 Shealy CN and Borgmeyer V. Decompression, Reduction and Stabilization of the Lumbar Spine: A Cost- Effective Treatment for Lumbosacral Pain. American Journal of Pain Management 1997. 7:63-65
- 14. Fy Fx Vector Illustration ofAltered Pulling Force Angles As the angle which a pulling force makes with the horizontal increases, the component of force in the horizontal direction (Fx) decreases and the vertical component of force (Fy) increases. This causes the relative direction of the pulling force to change and therefore the focus point of application of the pulling force to move progressively along the X-Axis. AB
- 15. Pulling forces angledto treat targeted segments Note: Angles shown for illustrative purposes, not to scale. Increasing the angle causes the point of application of the pulling force to move along the spine Further increase enable us to target different spinal segments The Effects of Increasing Pulling Angles on the Spine
- 16. Linear vs SinosoidalWaveform • Mechanical linear force is unnatural to the body • May prompt muscle spasm • Cause actual increase in intradiscal pressure • Natural to body, non linear pull • Applying slow stretch to Golgi Tendon Organ causes it to fire, inhibits tension in the muscle • Allows parallel elastic component (sarcomere) of the muscle to remain relaxed and lengthened
- 17. Intermittent Distraction • Withconventional intermittent traction, the force is typically ON or OFF • Spinal decompression has a maximum high tension and a low tension • The low force does not go to zero, so tension is maintained throughout treatment High Force Low Force Distraction maintained
- 18. • Cycles oftension force with a maximum distraction applied for one minute with thirty seconds rest • One minute is enough to effect an autogenic inhibition on the multifidi and erector spinae muscles • Using a continuous cycle of inhibition for fifteen minutes will result in a relaxed muscular state and better trunk range of motion • Tight ligaments, especially the posterior longitudinal ligament, will also benefit. • Collagen fibres exposed to continuous stretch can increase in length by up to 10% of the original length • Ligaments including the anterior longitudinal ligament, interspinous ligament and supraspinous ligament may also loosen to de-restrict the joint and increase mobility. Intermittent Distraction cont/
- 19. Oscillation & JointMobilisation • Patented oscillation feature which is achievable by having the sinusoidal waveform • Top of the high hold when the joint is under distraction, oscillation mobilise targeted joints • Mobilisation in a longitudinal plane rather than an anterior-posterior plane
- 20. Benefits of Mobilisationin Longitudinal Plane • Eliminates problems associated with repeated frictioning of the facet joint surfaces • Facet joints glide over one another • Relieve pressure on the discs and neural structures of the spine • Pressure differentials create pumping action to promote fluid exchange in the joint • Works tight muscles and stiff ligaments to promote increased joint mobility. • This is not possible with traction devices and impossible to achieve manually at such forces and for such duration.
- 21. Longer Treatment Duration •Typically traction is applied for ten to fifteen minutes only • Insufficient time to bring about physiological changes • IDD Therapy spinal decompression lasts for twenty-five minutes • The application of the force is comfortable so that higher pulling forces can be maintained FULL TWENTY FIVE MINUTE TREATMENT
- 22. Improved Harnessing Techniques •Old harnesses did not lock the pelvis and thus were prone to slippage • Uncomfortable nature of old harnesses could constrict the patient uncomfortably as higher application forces are applied. • Improve the harness design using modern materials and design techniques, including an inbuilt air bladder at the rear. • Harness is secured comfortably on the pelvis and patient is secured at the top of the bed, with the harness following the lines of the rib cage.
- 23. • Measured angleof distraction targeted to specific levels • Sinusoidal waveform pulling force to avoid spasm • Stronger pulling forces to achieve distraction • Twenty five minute treatment duration for soft tissue change • 13 minutes of maximum disc decompression to promote fluid exchange • 13 full minutes of Oscillation / joint mobilisation for improved mobility • Treatment components occur concurrently, not successively IDD Therapy – Treatment Summary High Force Low Force Constant Distraction Joint mobilisation Twenty-five minute treatment Sinusoidal Waveform
- 24. IDD Therapy Protocols TheIDD Therapy Guidelines exists of a constantly expanding set of protocols for keeping today’s medical standards en best pratices: • Herniated Discs Protocol, L5-S1, L4-L5, L3-L4, L2-L3, L1-L2 • Degenerative Disc Disease Protocol, L5-S1, L4-L5, L3-L4, L2-L3, L1-L2 • Posterior Facet Syndrome Protocol, L5-S1, L4-L5, L3-L4, L2-L3, L1-L2 • Sciatica Protocol • General Low Back Pain Protocol North Amdericam Medical and its distributros accept no medical liability for the applications of these protocols, in whole or in psrt. • The IDD Therapy treatment protocols were developed to help guide clinicians treating targeted spinal segments. • The standard protocol is based on a series of 20 treatments spread over a 6 week period. Five treatments per week for two weeks - No Exercises. Three treatments per week for two weeks - Passive Exercises Only Two treatments per week for two weeks - Active Exercises • Herniated Discs Protocol, L5-S1, L4-L5, L3-L4, L2-L3, L1-L2 • Degenerative Disc Disease Protocol, L5-S1, L4-L5, L3-L4, L2-L3, L1-L2 • Posterior Facet Syndrome Protocol, L5-S1, L4-L5, L3-L4, L2-L3, L1-L2 • Sciatica Protocol • General Low Back Pain Protocol See IDD Therapy Protocol Book for full details
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- 26. Optional Treatment adjuncts FARinfrared before IDD Therapy for deep tissue heat:- increase blood flow, relax muscles, warm ligaments and aid healing Cold Therapy after treatment. Stretching creates “micro trauma” as soft tissues adapt. Helps reduce soreness Anti-inflammatories may be taken in the initial stages of treatment at the guidance of the clinician Some patients with joint problems may also choose to take dietary supplements to support the joints.
- 27. EXERCISE • Treatment formspart of a rehabilitation programme which includes exercise training • As well as education
- 28. •Sciatica or radiculopathy •Herniatedor bulging discs •Degenerative discs and joint diseases •Spinal stenosis •Facet syndrome •Chronic low back and neck pain •General low back pain IDD THERAPY - Indications A typical patient has back or neck pain > 3 months. Has had one or more types of conservative treatment and yet is still in pain. Is likely to be taking pain killers and may or may not be considering invasive procedures.
- 29. • Pregnancy • Patientyounger than 15 • Patient weight greater than 425lbs • Severe osteoporosis (T-score -2.5 to -2.8 or greater) • Congenital abnormalties of the spine • Pacemakers • Unstable post-surgical conditions • Any kind of surgical hardware (if in the area being treated) • Spine instability (Doctor’s precaution) • Recent vertebral fracture(s) • Open growth plates • Severe canal stenosis • Rotatory or severe scoliosis • Abdominal aortic aneurysm • Some annular tears (Doctor’s precaution) • Spondylolysis • Spondylolithesis (Grade II or higher) • Vertebral fusions, less than 6 months old • Inflammatory, infectious or neoplastic conditions • Meningitis • HNP (sequestered/ free floating fragment) • Multiple myeloma • Osteosaracoma • Osteomyelitis • Hemiplegia • Cauda equine syndrome • Severe peripheral neuropathy • Paraplegia • Pelvic or abdominal cancer • Pars defect IDD THERAPY - Contraindications
- 30. • A suitablescan is recommended to assist the clinician in ruling out contraindications. • The scan may also help the supervising clinician to confirm diagnosis of the pathology and to the targeted level. • It is recommended that IDD Therapy patients undergo a suitable scan, although treatment may be given without a scan at the direction of the supervising clinician. PATIENT SCAN
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- 32. McClure & Farrisexamine 415 patients treated with IDD Therapy programmes. Treatment success measured as 50%+ decrease in average pain scores taken at 2 months and 2 years. (European Musculoskeletal Review, 2006 IDD Therapy Spinal Decompression cont/ 92% Success rate in 129 patients categorised as surgery candidates McClure D and Farris B, Intervertebral Differential Dynamics Therapy – A New Direction for the Initial Treatment of Low Back Pain. European Musculoskeletal Review 2006. 45-48.
- 33. MRI Evidence “Not onlyprovided symptom- atic improvements, but also showed reduced disc herniation and improved disc hydration after only 11 sessions.” Eyerman EL, Journal of Neuroimaging 1998 Eyerman EL. Simple Pelvic Traction Gives Inconsistent Relief to Herniated Lumbar Disc Sufferers. Presented to the American Society of Neuorimaging and printed in the Journal of Neuroimaging. June 1998.
- 36. • Clinic openedin 2000 • Clinic director (Robert Shanks) felt that we were not doing enough for patients with disc problems and that their only other treatment options were injection and surgery. • Looked into experiences of Alan Stoddard (famous osteopath and orthopaedic physician in the 60’s. Alan Stoddard’s booked had section on treating disc problems using regime of “intermittent sustained spinal distraction”. • Robert had a replica of Alan Stoddard’s cervical distraction harness made and started treating appropriate patients using Alan Stoddards protocols. • The results more or less replicated those described in Stoddard’ book. • Subsequently bought lumbar traction machine from America capable of exerting intermittent sustained traction on the lower back. • Soon started seeing positive outcomes for lower back disc problems in addition to disc problems in the neck. • Was introduced to IDD therapy by the European distributor in 2009, at which time there were only two clinics in the UK offering IDD therapy. • Within 18 months this had grown to 5 clinic. • Robert Shanks visited the Brighton to try personally try their machine in late 2010. Very impressed by the result “feel” of the machine and ability to target segments of the spine. • Machine installed at Chigwell in April 2011. Chigwell Osteopathy & Physiotherapy Practice Our history with traction based treatment for discogenic disorders
- 37. Patient 1 (RT):Had been attending the practice intermittently for the last 3 years due to persistant pain and back spasms around the thoroco-lumbar area. MRI revealed small herniation and spondylosis with secondary mild facet inflammation at L1/2. She had had two opinions from spinal surgeons, both of whom deemed her inappropriate for surgery. Two rounds of facet injections / denervation failed to produce any improvement lasting more than a few weeks. The only thing keeping her going was the acupuncture and (old style) traction at the practice. After just 3 sessions of IDD targetted to the L1/2 disc she has been virtually pain free (no muscles spasms) for over 6 weeks, back doing housework, cleaning windows etc. Patient 2 (DC): MRI showed general wear and tear in her lower lumbar segments. Her symptoms wear general back ache with some vague referral to her leg on exertion (in keeping with the stenosis picture). She booked in for 3 IDD sessions in one week but cancelled after the second session as she felt so good. Darren checked up with her last week and she has remained virtually symptom free, she is extremely please with the result (and Darren is amazed!). Patient 3 (SM). Completed the full 20 session programme. He came to us with a 4+ year history of sciatica. He had previously been seen several other therapists including a chiropractor who had been performed numerous sessions of tradional traction and acupuncture – without any improvement in symptoms. Two year old scans showed a massive L5/S1 disc extrusion with a sequested portion, this was mainly in the canal (not formamina - hence his SLRT was better than expected). Initially I gave him quite a bad prognosis and encouraged him to look into having a microdiscectomy, however he had heard about IDD and wanted to pursue it. On completion of the 20 session programme (incorporating IDD, medical acupuncture and a home Pilates exercise programme) he noticed some functional improvement and reduced pain levels and number of “bad days”. He had a fresh MRI which has revealed total resolution of the sequestration and definite reduction in the size of the extrusion. Theses scans were two years apart - and one could suspect that the improvements in disc structure could had have happened anyway (i.e. in absence of IDD). HOWEVER, I had Dr Sajid Butt (consultant MSK radiologist from the Royal National Orthopaedic Hospital in Stanmore) go through the two scans with me and he was amazed to see that the most recent scan showed definite regeneration of the nucleus pulposus i.e. rehydration of the disc (original scan show a very diffuse, broken down nucleus whereas the new scan had clearly deliniated edges and more intense T2 (white) signal. Dr Butt encouraged me to keep going with this chap and to avoid sending him for microdiscectomy, at least for now! Case Studies From patients treated with IDD at Chigwell Osteopathy & Physiotherapy Practice since April 2011