Clinical Protocols for Decompression Cases

By Bryan Hawley, DC

Dcompression therapy has been firmly established in the health care arena for
some time now; however, very little has been written about actual clinical
protocols for decompression. Various table manufacturers provide some form
of “training” with their devices, as do some management companies, but overall,
it’s up to you to determine the specific protocols. Let’s fix that right now by
exploring clinical protocols for providing decompression therapy to your
patients.

What I will not do here is attempt to cover pull patterns, table
designs, traction versus decompression, or marketing. In this author’s opinion,
lines have been drawn in the sand at nausea on these subjects already. I would
rather take a very basic disc pathology case and show what our typical protocol
of treatment would be. (Keep in mind that we are talking here only about the
“mechanical” component of care. Typically there is also the “chemical component
to be dealt with.)

Let’s begin by looking at a basic decompression case that comes to our office
and how we treat them. When a patient comes into one of our clinics, we do a
full physical work-up. If the patient has not taken any radiographs, they are
over a year old or their symptoms have changed since the last films, then we
send them out for basic plain films. If a spondylolisthesis is demonstrated on
film, then we obtain stress films to observe stability. If at this point there
appears to be degeneration showing up on the films and the physical exam
findings indicate possible disc pathology (usually the patient presents with
radiculopathy as well), then we obtain a basic MRI (with contrast if the patient
has had surgery; possible CT if hardware is older than 10 years). We also rule
out other complicating factors such as facet syndromes, peripheral entrapments,
and biomechanical abnormalities that be contributing to the patient’s
complaints.

If osteoporosis is suspected, we or their family doctor obtains
a DEXA scan. If the T score is -1 to positive, it is normal; if it is -1 to
-2.4, osteopenia is suspected. Negative 2.5 and greater means osteoporosis is
present. In these latter scenarios, our staff MD or the patient’s family doctor
will get involved and assist in case management. We typically don’t do
decompression on patients with T scores of -2.3 or greater.

Patients who are candidates for decompression follow a structured program.
This program varies from patient to patient. Our plans vary from 15 visits to 25
visits depending on the pathology. We normally have the patient start off four
times a week for 1-2 weeks and progress them to three times a week for the
duration of the program. We typically don’t accept anyone in the program if they
cannot adhere to the guidelines. We also never start anyone right before a
weekend on the program.

Our typical program consists of an “assembly line approach” that we have set
up in our 4,000 square-foot facility. The decompression patient gets adjusted,
then treated by assistant staff members assigned to different areas of care, and
travel through different departments on each visit. Each department has its own
agenda for the treatment of the patient. For the decompression department, we
typically increase the distractive force incrementally on each visit until there
comes a point that the patient’s pain or numbness ceases or drastically
diminishes. Then we stay at that poundage for the remainder of the program. This
is also a good indicator of when we can start more advanced rehab with the
patient.

During the first few visits, the patient receives general modalities to the
affected area and start getting passively stretched (ART/PNF). As they are
progressing, we move them over to the rehab tracks. Each track consists of
several exercises, each progressing in difficulty. We have developed seven
standard tracts for lumbar and six standard tracts for cervical cases. We
usually start resistive exercise once the patient can demonstrate close to
normal range of motion without additional pain. During the tissue resolution and
remodeling phases, we are careful not to disrupt or tear any new scar tissue
formation.

We typically perform re-evaluations that consist of basic physicals with ROM
testing. These are documented and sent to the patient’s family MD or
referring doctors. In some cases, we send the patient back to their family
doctor so they can perform the final evaluation. This makes it clear that we are
not “stealing” their patient, which makes them more inclined to send us more
referrals. At the end of the program the patient is usually place on a HEP (home
exercise program) and seen monthly for general chiropractic care.

In difficult cases such as spondylolisthesis (grade 2 or less), we typically
adjust the angle of the force vector so that the primary distractive force is
not on the spondylolisthesis itself, but rather the adjacent segment. For
example if the disc is L5/S1 and the patient has a grade 1 spondylolisthesis, we
typically angle the table so that the primary force vector is hitting L3/L4.
This way, it will exert a secondary pull on the affected disc. After a few
visits and if the patient is tolerating the treatment, we decrease the angle and
start moving into the involved segment directly. This also works well for past
surgical cases (non-hardware) such as discectomies and laminectomies.

Our clinic complex features 12 orthopedic surgeons, neurosurgeons and pain
management specialists; this case described above is what we would call a
typical non-complicating case. There are several complicating factors that can
and will present themselves for decompression therapy. These we typically deal
with on a case-by-case basis and develop treatment protocols and parameters
accordingly. We also find it helpful to do random case reviews to make sure we
are providing optimal care. We also review case outcomes and long-term outcomes
of our patients.

Over the years, we have managed several thousand decompression cases and are
amazed at the results seen when combined with chiropractic care. With the
emerging technology, there are table designs that fit basically every clinic,
budget and doctor style. There are even decompression tables that provide
flexion along with rotation for the patients while undergoing decompression,
which we find to be of great benefit for hemi-laminectomies and other types of
pathology for which isolation is beneficial.

In future articles, I will attempt to cover the tracts we use and when we use
them, as well as the ancillary procedures we use with our decompression
cases.