Where does “evidence” come from?

Recent reviews have pointed out that most of our treatment-techniques are likely based on individual ‘convictions’ vs. valid, widely accepted protocols i.e. established evidence. Through studies (of numerous types) data is collected then eventually synthesized into reviews; meta-analysis or systematic. Theoretically these reviews create as definitive a representation of the knowledge available as is possible. Many times our interventions feel the sting of the relative dearth of high-quality studies or perhaps less optimistically our procedures have difficulty demonstrating their superiority. In 2004 and 2007 Cochrane review summaries states:

“There was little or no difference in pain reduction or ability to perform everyday activities between people with LBP who receive spinal manipulation and those receiving other therapies”.

Traction added to a PT regimen offered no additional benefit to those with LBP”.

 In 2010 a systematic review (Sportschaden Mar;24) concludes:

“For LBP spinal segmental stabilization is more effective than a minimal intervention but no more effective than any other PT intervention”.

Ann of Int Med Oct;2(14) 2007:

“There is good evidence for a moderate benefit to the use of heat for acute LBP”.

Spinal manipulation shows fair evidence for a small benefit in acute back pain”.

Chronic LBP & neck pain show moderate effect with cognitive behavior therapy, manipulation, acupuncture, massage & yoga”.


Kettlebell-Swing perhaps should be part of many patients exercise prescription

McGill S, Marshall L J Strength Cond Res Jan;26(1) 2012

McGill and associates examined the Kettlebell swing due to its increasing popularity to determine its viability and impact on muscle activation and spinal compression. It was found the swing creates a hip-hinge squat pattern characterized by rapid muscle activation-relaxation cycles nearly 50% of MVC of the LB extensors and 80% of gluteal (this with a ~32pound KB…which in my experience is not for the faint-of-heart or beginner!). This is in addition to 3200N of spinal compression, which is a fairly high magnitude. They concluded: “KB swings create abdominal muscular pulses together with the muscle bracing giving KB specific training opportunities”. “Some unique loading patterns discovered during the KB swing included the posterior shear of the L4 vertebra on L5, which is opposite in polarity to a traditional lift…thus explaining why many credit KB-swings with restoring their back health and function, although perhaps due to this a few find that they irritate tissues”.

“Maintenance” Decompression

Post a treatment regimen (assuming the patient had a successful intervention with the traction component of care) invariably in my experience the patient asks about “continuing once a month…” If not the patient then clearly you or the staff needs to be suggestive about “minimal dose” decompression maintenance. We have typically ramped up the discussion by the 10-15th session as close to 75% are turning-the-corner in their subjective and objective findings and “stabilization” is likely commencing. Ideally in your ROF the (3) phases of care should be delineated with the: “reduction phase” first, “stabilization” second and “maintenance” of function third. Maintenance “axial traction/decompression”, like manipulation needs to be dispensed judiciously in this phase so as to not routinely create “reactions” of pain and/or excess stiffness. I have found the simplest way to avoid this is asterisk (*) those patients who demonstrated ANY adverse reactions during (or at the outset) of treatment and be sure the staff sets the tension approx. 20% LESS than during the “reduction phase” and often choose the Vax-short protocol. A very mild 10 minute session to another wise asymptomatic patient is well accepted and appreciated if the doctor & staff explain: “maintenance decompression is always less-intense”. Of course some patients are enthusiastic to get “really stretched out” at each monthly session…your experience and their outcome must dictate. And of course IF the patient comes in with the findings of a “sprain” and manifests moderate to severe AM pain etc be VERY cautious of traction, just as you would at the initiation of care.

Stress in Lumbar Intervertebral Discs during Distraction

Spine J. 2008; 8(6): 982–990.

A Cadaveric Study

Ralph E. Gay, M.D., D.C et al


All distraction conditions markedly reduced nucleus pressure compared to either simulated standing or lying. There was no difference between distraction with flexion and distraction with extension in regard to posterior annulus compressive stress. Discs with little or no degeneration appeared to distributed compressive stress differently than those with moderate or severe degeneration.

Dr. Kennedy comment: I point to this study to iterate that the effects of distraction are not dependent on “flexion” (or extension). Proponents of F/D seem to believe that there are necessary benefits to the flexion-phase, however it’s benefits are that of distraction: flexion achieved just 65% the ‘decompression’ achieved via ‘distraction’. IF your goal is to create decompression axial distraction-traction is the biomechanical choice…flexing just adds a less-effective transmission of distraction and often untenable stress/strain on spinal structures that prefer NOT being flexed.

Pain vs pathology in your report of findings (part 3 of 3)

Inevitably most patients seek health care based on fear of their condition worsening or being inherently too serious to self-treat. In presenting your ROF there needs to be some ‘directing’ of the patient toward understanding the “worst-case-scenario”. We also need the ability (confrontational tolerance) to “enhance” the story of their ‘problem’ and our ‘solution’ when they falter at accepting care. I am certainly not recommending inappropriate falsifying or exaggerating either the problems “potential” or the potential “benefits” of treatment. The key is a sensible, forthright yet slightly tilted report toward the side of future trouble and the prevention of such and how the treatments offered will help win the battle by addressing both the pain/disability AND the structural “lesion” behind it. Patient retention is far cheaper than new patient acquisition…and unless you have virtually NO overhead and can afford to run a “triage” practice e.g. 1-3 treatments each patient, patient acceptance of a 10-20 treatment protocol (and a properly structured maintenance program) is a necessity. It is no coincidence that doctors who can convincingly add subtle but well intended intimidation are simply the most successful.

That most of our treatments lack true scientific proof of long-term outcomes (as demonstrated by the Cochrane collaboration studies) is of course not at all a bad thing for our businesses. In fact it affords us a certain amount of latitude and “product differentiation” i.e. IF a particular treatment was absolutely proven everyone would use it and it would be offered in innumerable places and price would be the only dictate. Our Decompression therapy, Laser, modalities, adjusting and rehab protocols are our individual choices, and their success or failure are dependent on both their effective implementation but also on our ability to “compel”, “convince” and “control” the patient and their perceptions regarding them and what they are intended to do…that is key in your ROF.

Pain vs. pathology in your ROF (part 2 of 3)

We have found 3 primary areas of focus to improve the Decompression ROF:

  1. Making the patient aware there is a disc “lesion” likely creating the pain.
  2. The lesion will benefit from the treatment modalities we offer because: “decompression (and Laser etc) enhances blood contact, reduces inflammation and can often reduce the size of the herniated or protruding portion. This reduction-phase of treatment will be followed by a stabilization and rehab phase necessary to reduce the likelihood of recurrence”.
  3. Correlate the exam findings e.g. directional preference, pressure pain threshold, form closure/”stability”, location, intensity and disability profile with the disc lesion (and if an MRI report is available further validate it to those findings).

We always need to create a compelling story as to why accepting the recommended care is an imperative if the fullest relief is to be achieved.  However, don’t shy away from a “fall back” position (triage or a reduced number of treatments) when the full complement of care is simply not going to be accepted.

BJ Palmer first developed the idea that “pain” was the patients’ calling card, but “subluxation” must be the Chiropractors’ calling card. IF we take the focus off the spine “lesion” and place it squarely on the patient’s “pain” we dedicate ourselves to a false paradigm.

If you think about surgeons, their focus is on the structural stuff they are working on…IF the patient comes out pain-free so much the better…but the patients’ pain is in effect “peripheral” to the surgeons skill and focus.



Pain vs. pathology in your report of finding (part 1 of 3)

As a doctor the ‘extent’ to which you promote treatment of a patient’s “pathology” (and the “fear” engendered with it) is inherently up to you. The interaction is almost always behind closed doors. The FDA however place severe limits on manufacturers (of FDA cleared devices) regarding what they claim the machine and procedure actually treat e.g. the “pain associated with disc or joint pathology”, not the pathology per se. The FDA recognizes that connecting “pathology” (e.g. MRI/x-ray findings etc) to pain is dubious at best. Reliability and validity regarding tests & MR findings are still inherently non-existent.

We as doctors have much looser restraints as to how we can “sell” our treatments to the public (though each state board does set standards).

Given your own unique Chiropractic perspective (which, within rational limits you’re rightly entitled to) you can readily suggest in your ROF that in your professional opinion not getting the treatments may well create ominous future health trouble e.g. the “pathology” that is causing the trouble may/will inevitably worsen. Many Chiropractors have used the “pain vs. pathology” in their ROF for generations (e.g. the “silent subluxation”; “without adjustments your spine will decay” etc).

The basic reason we may be restrained (by state laws and insurance regulations) is inherent in the Latin expression: Credat Emptor (“buyer have faith”). We are health care professionals/doctors and the public fairly assumes we won’t lie to them or exaggerate their condition for our own economic ends. However since “standards” of care are so widely divergent (there are over 100 “techniques”, some suggesting 1-3 treatments, others daily care for years) it isn’t unfair to say Chiropractic’s “standard of care” is wrapped up in the “convictions” held by the individual Chiropractor.

(Continued in Blog 28)

The reduction of cLBP through control of early morning flexion Snook SH, et al Spine 1998 Dec.

Conclusions: “The treatment group was given instructions in reduction of morning flexion; the control group was given six exercises shown to be ineffective for LBP. Significant reductions in pain intensity were found in treatment group vs, control. After similar instructions to the control group the response was similar reductions in pain”.


Dr. Kennedy comment: this is a consistently cited study and we’ve discussed the implications at the seminars for years…the natural disc swelling after sleeping imposes ligament tension changes which reduce the neutral-zone in flexion (and rotation). With instruction and specific efforts to dramatically reduce flexion (as well as rotation) soon after arising (and my experience suggests this “control of flexion is always a prudent idea throughout the day) most patients with cNSLBP (the majority of us) can be well served and have days & weeks of disability reduced or eliminated. Interestingly the sham-exercises served no apparent benefit even though they are the most often prescribed for LBP. McGill has referred to such exercises: knee-to-chest, hip side-to-side rolls, toe touches, side bends and the like as “silly and pointless”.

There appears to be less efficient “disc-fluid-reduction” in some patients with cLBP and reduction of flexion for several hours (not just the first hour after arising) serves them even better.

Posterior-to-anterior segmental testing in cLBP

Several studies have been published assessing the accuracy and association of pain with PA segmental motion testing (manual and algometry). An in vivo assessment in MRI in 2007 concluded lumbar-segmental hypermobility was likely associated with LBP. A PT study by Blinkley et al assessed inter-tester reliability of P-A testing and concluded; “there is poor inter-tester agreement reliability of P-A testing. Caution should be exercised when using P-A testing to assess segmental motion”. In 2005 (Beneck et al J Ortho Sport PT) examined the association between painful segment with P-A testing vs. hyper/hypo mobility with MRI utilized to determine actual motion. L5 was the most painful segment in nearly half the subjects with L4/L5 the least mobile. Their conclusions: “Assumptions of segmental motion cannot be inferred from pain associated with P-A pressure testing”.

Dr. Kennedy comment: These studies can be instructive for our clinical examination of motion disorders as well as re-assessing the accuracy of our palpation. The Mcgill shear instability test affords us the ability to add muscle-contraction (force-closure) to assess the effects of contraction on segmental pain and motion. Where P-A testing alone may afford inaccurate information adding “force-closure” can add substantial reliability and possible validity.

IDAP/IDET & Discogenic pain

MD’s and engineers have worked for many years to try to unlock the mystery and treatment of discogenic pain. Annular tears and compromises of the outer annulus of degenerated discs arguably disable untold millions of 40-60 year olds. IDAP/Intradiscal annuloplasty (Smith & Nephew name brand: IDET/intradiscal endothermic therapy) is a 20 year old procedure which initially appeared to show tremendous promise but failed to really materialize. The premise is similar to cauterizing a wound; a super-heated needle attempts to both ‘hypercollagenate’ torn tissue and obliterate pain nerves. Freeman and colleagues (2005 Anesthesia) conducted a study on individuals with discogenic back pain and annular tears who failed to improve with conservative treatment. No participant met the criteria for a successful outcome. The findings of this study suggest there is no significant benefit of IDAP over placebo. A Cochrane review suggested the same. Discogenic pain (of which annular “tears” constitute a substantial affect) remains an oft recalcitrant problem. Thus far no one else has come up with a significant and validated treatment. Laser, core control, ergonomics, meds and judicious decompression (when pre-tolerance-classified) are still the most sensible treatments.