Re: L5 spondy

November 8, 2001

Bob - Dan wrote some articles about treatment of spondylolysis with inversion tables in the Journal of Clinical Chiropractic. I believe (from memory) he radiographically observed a reduction in the spondylolisthesis when the patient was on an inversion table. The pelvic suspension type of inversion chair was less effective. You might see if you could find the article on www.idealspine.com

Might be a good home therapy for the patient. Stony used to always talk about hamstring hypertonicity being an indication for surgical stabilization, so maybe intensive hamstring stretches are in order also.

Don , DC

Corvallis

L5 spondy

Listmates:

Have a 31 year old muscular male who was T Boned in an MVC a month ago and has developed acute symptom in L5 area.

The ER x-rays show a umm anterior gravitation of L5. Yesterday we did Maximum flexion/extension standing lateral lumbar films which show 12mm anterior slippage during flexion; 15mm anterior slippage during extension accompanied by 10/10 pain in the area!

During flexion the L5 disc spacing is reduced approx 25% ; while in extension the posterior portion of the disc space is reduced 5mm. with the severe pain ( in flexion the pain was 3-4/10)

Yes! the y has a collar!

Treatment will be a thoaco/pelvis fiberglass traction cast ,applied with slight flexion. Will monovalve in 5 days if comfortable. Anticipate wearing time to be 60 to 90 days. If symptoms persist will refer for surgical evaluation.

Comments appreciated

DrBob

P.O. Box 606Pendleton, 0reg 97801541.276.2550

November 8, 2001

As I recall, Dan himself has a spondy which responded with reduction, at least temporarily, as demonstrated with radiography, using the orthopod inversion device. This utilizes suspension from the thighs. He used to hang himself regularly.

Terry Petty

Ashland

Re: L5 spondy

Bob - Dan wrote some articles about treatment of spondylolysis with inversion tables in the Journal of Clinical Chiropractic. I believe (from memory) he radiographically observed a reduction in the spondylolisthesis when the patient was on an inversion table. The pelvic suspension type of inversion chair was less effective. You might see if you could find the article on www.idealspine.com

Might be a good home therapy for the patient. Stony used to always talk about hamstring hypertonicity being an indication for surgical stabilization, so maybe intensive hamstring stretches are in order also.

Don , DC

Corvallis

November 8, 2001

Is there anyway to prove or document that the spondy was caused by the accident ? Of course pre-accident oblique films would help but what about any imaging studies now ?

Also, I am interested in getting an inversion chair, ie invertrac, does anyone know of any used ones for sale or rent ?

vty,

sharron fuchs dc

Re: L5 spondy

Bob - Dan wrote some articles about treatment of spondylolysis with inversion tables in the Journal of Clinical Chiropractic. I believe (from memory) he radiographically observed a reduction in the spondylolisthesis when the patient was on an inversion table. The pelvic suspension type of inversion chair was less effective. You might see if you could find the article on www.idealspine.com

Might be a good home therapy for the patient. Stony used to always talk about hamstring hypertonicity being an indication for surgical stabilization, so maybe intensive hamstring stretches are in order also.

Don , DC

Corvallis

November 8, 2001

Sharron,

I recently talked with an Orthopedic Radiologist and asked him the same

question- How do you evaluate the age of a spondy and he suggested a

limited CT scan of the area with 2mm slices instead of a bone scan. I

did just that and Epic Imaging radiologists were able to tell that it was

an old injury by looking at the margins, etc. A bone scan may be hot but

that could just raise more questions.

Mike Underhill

On Thu, 8 Nov 2001 11:10:15 -0800 Sharron Fuchs <SharronF@...>

writes:

> Is there anyway to prove or document that the spondy was caused by

> the

> accident ? Of course pre-accident oblique films would help but what

> about

> any imaging studies now ?

>

> Also, I am interested in getting an inversion chair, ie invertrac,

> does

> anyone know of any used ones for sale or rent ?

>

> vty,

>

> sharron fuchs dc

>

> Re: L5 spondy

>

> Bob - Dan wrote some articles about treatment of

> spondylolysis with

> inversion tables in the Journal of Clinical Chiropractic. I believe

> (from

> memory) he radiographically observed a reduction in the

> spondylolisthesis

> when the patient was on an inversion table. The pelvic suspension

> type of

> inversion chair was less effective. You might see if you could find

> the

> article on www.idealspine.com <http://www.idealspine.com>

>

> Might be a good home therapy for the patient. Stony used to always

> talk

> about hamstring hypertonicity being an indication for surgical

> stabilization, so maybe intensive hamstring stretches are in order

> also.

>

> Don , DC

> Corvallis

>

November 8, 2001

Hi, Thanks for reply. I don't know if the patient is a plaintiff or not, but

if a study ie as you suggest is medically indicated then I think that would

be important information to know. Spondys are such a pain and can progress

despite active management. If they then went on to surgical stabilization

they are then down yet another path with its own consequences.

sharron fuchs dc

Re: L5 spondy

>

> Bob - Dan wrote some articles about treatment of

> spondylolysis with

> inversion tables in the Journal of Clinical Chiropractic. I believe

> (from

> memory) he radiographically observed a reduction in the

> spondylolisthesis

> when the patient was on an inversion table. The pelvic suspension

> type of

> inversion chair was less effective. You might see if you could find

> the

> article on www.idealspine.com <http://www.idealspine.com>

>

> Might be a good home therapy for the patient. Stony used to always

> talk

> about hamstring hypertonicity being an indication for surgical

> stabilization, so maybe intensive hamstring stretches are in order

> also.

>

> Don , DC

> Corvallis

>

November 8, 2001

"Dr. Yocum asserted that a spondy can be as stable or unstable as any other

spine."

I totally agree and that is exactly what Yochum says in his spondy talks that I have heard at least 3 or 4 times. He warns of making your patient a "chiropractic invalid" by erroneously concluding that a spondylolytic spondylolisthesis is definately the source of pain and unstable and then placing unwarranted activity restrictions on them.

P.S. A grade 5 spondylolytic spondylolisthesis can be stable.

Tim Stecher, DC, DACBR

In a message dated 11/8/2001 6:25:47 PM Pacific Standard Time, drscott@... writes:

In Dr. Yocum's seminar, he introduced an iatorgenic imaginary disability:

a physician takes an x-ray for some reason and arbitrarily or incidently

diagnoses a spondy. The patient is then forbidden from playing contact

sports.

It was been found that the best footy player (either soccer, football, or

rugby) in Australia, (Motto: We can drink tons of beer and still not fall

off the earth") had a grade 4+ spondy. That is the sacrum and L5 hardly knew

one another and hadn't been in touch for years. Symptom free.

Dr. Yocum asserted that a spondy can be as stable or unstable as any other

spine.

All of this is from my cloudy memory. Ask Bev or the Tyrone 9000 computer

for clarification of Dr. Yocum's findings.

--

Dr. Abrahamson

November 8, 2001

You could find a lot more docs who will testify that a spondy is VERY

UNLIKELY to be caused by an accident...much more likely to be a silent

spondy which is injured and made unstable in an accident...to which the

defense says the patient was a wreck waiting to happen and the plaintiff

lawyer says the patient could dead lift 800# with no problem before the

accident and the Taliban says they will not be swayed by Spondy's, tanks, or

bombs but educated women in positions of power make them want to go onto a

cave and wait for judgement day which by the sound of things rattling off

the shelves, may be getting very close...stay tuned for an update every 15

minutes.

--

Dr. Abrahamson

> From: Sharron Fuchs <SharronF@...>

> Date: Thu, 8 Nov 2001 11:10:15 -0800

>

> Subject: RE: L5 spondy

>

> Is there anyway to prove or document that the spondy was caused by the

> accident ? Of course pre-accident oblique films would help but what about

> any imaging studies now ?

>

> Also, I am interested in getting an inversion chair, ie invertrac, does

> anyone know of any used ones for sale or rent ?

>

> vty,

>

> sharron fuchs dc

>

> Re: L5 spondy

>

> Bob - Dan wrote some articles about treatment of spondylolysis with

> inversion tables in the Journal of Clinical Chiropractic. I believe (from

> memory) he radiographically observed a reduction in the spondylolisthesis

> when the patient was on an inversion table. The pelvic suspension type of

> inversion chair was less effective. You might see if you could find the

> article on www.idealspine.com <http://www.idealspine.com>

>

> Might be a good home therapy for the patient. Stony used to always talk

> about hamstring hypertonicity being an indication for surgical

> stabilization, so maybe intensive hamstring stretches are in order also.

>

> Don , DC

> Corvallis

>

November 8, 2001

Yes, doctor and what if , just what if ,the person could document that the

spondy wasn't there prior and that they could indeed dead lift even educated

women pre-accident and now they have to crawl (into their caves) and await a

dreadful demise if not shear pain with every breath they take. Proof would

be nice. If medically indicated, of course.

sharron fuchs dc

Re: L5 spondy

>

> Bob - Dan wrote some articles about treatment of spondylolysis with

> inversion tables in the Journal of Clinical Chiropractic. I believe (from

> memory) he radiographically observed a reduction in the spondylolisthesis

> when the patient was on an inversion table. The pelvic suspension type of

> inversion chair was less effective. You might see if you could find the

> article on www.idealspine.com <http://www.idealspine.com>

>

> Might be a good home therapy for the patient. Stony used to always talk

> about hamstring hypertonicity being an indication for surgical

> stabilization, so maybe intensive hamstring stretches are in order also.

>

> Don , DC

> Corvallis

>

November 8, 2001

Aha! You said, " shear pain " which means that you presume that the patient

incurred injuries from a specific direction (shearing forces) which you

could not know as you were not with the patient and you are not a board

certified accident reconstructionist with circles and arrows and a paragraph

on the back explaining what each item is. Case dismissed!

Plus, documentation only HELPS prove something. In this era of right, wrong,

and much in between it all depends upon what you mean by " IS " , as in " is my

back killing me or is this claim ever going to settle? "

It's all very complicated even for educated women who like educated men of

course must weigh more as the have heavy thoughts, heavy issues, and heavy

burdens. Some even have to tote a heavy chip but some do not.

--

Dr. Abrahamson

> From: Sharron Fuchs <SharronF@...>

> Date: Thu, 8 Nov 2001 15:50:22 -0800

> ' Abrahamson' <drscott@...>, Sharron Fuchs

> <SharronF@...>,

> Subject: RE: L5 spondy

>

> Yes, doctor and what if , just what if ,the person could document that the

> spondy wasn't there prior and that they could indeed dead lift even educated

> women pre-accident and now they have to crawl (into their caves) and await a

> dreadful demise if not shear pain with every breath they take. Proof would

> be nice. If medically indicated, of course.

>

> sharron fuchs dc

>

> Re: L5 spondy

>>

>> Bob - Dan wrote some articles about treatment of spondylolysis with

>> inversion tables in the Journal of Clinical Chiropractic. I believe (from

>> memory) he radiographically observed a reduction in the spondylolisthesis

>> when the patient was on an inversion table. The pelvic suspension type of

>> inversion chair was less effective. You might see if you could find the

>> article on www.idealspine.com <http://www.idealspine.com>

>>

>> Might be a good home therapy for the patient. Stony used to always talk

>> about hamstring hypertonicity being an indication for surgical

>> stabilization, so maybe intensive hamstring stretches are in order also.

>>

>> Don , DC

>> Corvallis

>>

November 8, 2001

In Dr. Yocum's seminar, he introduced an iatorgenic imaginary disability:

a physician takes an x-ray for some reason and arbitrarily or incidently

diagnoses a spondy. The patient is then forbidden from playing contact

sports.

It was been found that the best footy player (either soccer, football, or

rugby) in Australia, (Motto: We can drink tons of beer and still not fall

off the earth " ) had a grade 4+ spondy. That is the sacrum and L5 hardly knew

one another and hadn't been in touch for years. Symptom free.

Dr. Yocum asserted that a spondy can be as stable or unstable as any other

spine.

All of this is from my cloudy memory. Ask Bev or the Tyrone 9000 computer

for clarification of Dr. Yocum's findings.

--

Dr. Abrahamson

> From: " lumsden " <lumsden@...>

> Date: Fri, 9 Nov 2001 16:45:43 -0800

> " ' Abrahamson' " <drscott@...>, " Sharron Fuchs "

> <SharronF@...>, < >

> Subject: Re: L5 spondy

>

> That much slippage is significant and is to be considered an unstable

> spondy. I have never heard of that much slip without some symptoms, such as

> pavement scrapes on the navel. Don't you think it would be hard to make the

> " silent spondy " argument? If the patient did develop neuro/bowel/bladder

> signs he may get cranky about not having the option of surgical

> stabilization. I'd get the surgical consult, then treat after a 'full PAR'.

> Steve Lumsden

>

> Re: L5 spondy

>>>

>>> Bob - Dan wrote some articles about treatment of spondylolysis

> with

>>> inversion tables in the Journal of Clinical Chiropractic. I believe

> (from

>>> memory) he radiographically observed a reduction in the

> spondylolisthesis

>>> when the patient was on an inversion table. The pelvic suspension type

> of

>>> inversion chair was less effective. You might see if you could find the

>>> article on www.idealspine.com <http://www.idealspine.com>

>>>

>>> Might be a good home therapy for the patient. Stony used to always talk

>>> about hamstring hypertonicity being an indication for surgical

>>> stabilization, so maybe intensive hamstring stretches are in order also.

>>>

>>> Don , DC

>>> Corvallis

>>>

November 8, 2001

My question, one of my patients has a grade 1 L5 sponde, and has virtually no ability to flex her lumbars, can't touch below her knees. When we did flexion/extension films, they were useless, she has very little motion in the lumbars, the films looked identical.

I think its possible that her muscle spasm in the lumbars, and lack of motion in lumbars, is secondary to compensation around an unstable sponde,

but how do we evaluate the joint,

this is a longstanding condition, not due to recent trauma

any ideas??

thanks

Marc Heller,DCmheller@...987 Siskiyou Blvd.Ashland, OR 97520541-482-0625

-----Original Message-----From: timitee@... [mailto:timitee@...]Sent: Thursday, November 08, 2001 7:13 PM Subject: Re: L5 spondy"Dr. Yocum asserted that a spondy can be as stable or unstable as any otherspine."I totally agree and that is exactly what Yochum says in his spondy talks that I have heard at least 3 or 4 times. He warns of making your patient a "chiropractic invalid" by erroneously concluding that a spondylolytic spondylolisthesis is definately the source of pain and unstable and then placing unwarranted activity restrictions on them. P.S. A grade 5 spondylolytic spondylolisthesis can be stable.Tim Stecher, DC, DACBRIn a message dated 11/8/2001 6:25:47 PM Pacific Standard Time, drscott@... writes:

In Dr. Yocum's seminar, he introduced an iatorgenic imaginary disability:a physician takes an x-ray for some reason and arbitrarily or incidentlydiagnoses a spondy. The patient is then forbidden from playing contactsports. It was been found that the best footy player (either soccer, football, orrugby) in Australia, (Motto: We can drink tons of beer and still not falloff the earth") had a grade 4+ spondy. That is the sacrum and L5 hardly knewone another and hadn't been in touch for years. Symptom free.Dr. Yocum asserted that a spondy can be as stable or unstable as any otherspine.All of this is from my cloudy memory. Ask Bev or the Tyrone 9000 computerfor clarification of Dr. Yocum's findings.-- Dr. Abrahamson

November 9, 2001

At WSCC we use both flexion/extension and traction/compression. Neither usually reveals much motion (ie <4mm translation). What we tell our students is that most spondylolytic spondylolistheses are stable and usually don't slip any more after 18 years of age.

Lately when we use dynamic imaging we have been doing more flexion/ext since the literature as of late has supported that more....but it is a toss up.

One article a few years ago found that 30% of asymptomatic spondylolytic spondylolistheses patients that they examined with flexion/ext had >4mm of translation. The take home there is base your treatment on patient presentation vs radiographic findings.

Tim Stecher DC, DACBR

Assistant Professor of Radiology

WSCC

In a message dated 11/9/2001 10:47:53 AM Pacific Standard Time, drmfreeman@... writes:

The most helpful x-rays that I have seen for a determination if the spondy

(or any other listhesis) is unstable are compression and traction. You put a

trapeze bar above the patient that they can pull on for traction and give

them a back pack with 40lbs in it for compression. In my experience this

will show instability far more clearly than flex/ext.

D Freeman

Mailing address: 2480 Liberty Street NE Suite 180

Salem, Oregon 97303

phone 503 763-3528

fax 503 763-3530

pager 888 501-7328

November 9, 2001

The most helpful x-rays that I have seen for a determination if the spondy

(or any other listhesis) is unstable are compression and traction. You put a

trapeze bar above the patient that they can pull on for traction and give

them a back pack with 40lbs in it for compression. In my experience this

will show instability far more clearly than flex/ext.

D Freeman

Mailing address: 2480 Liberty Street NE Suite 180

Salem, Oregon 97303

phone 503 763-3528

fax 503 763-3530

pager 888 501-7328

Re: L5 spondy

> >>

> >> Bob - Dan wrote some articles about treatment of spondylolysis

with

> >> inversion tables in the Journal of Clinical Chiropractic. I believe

(from

> >> memory) he radiographically observed a reduction in the

spondylolisthesis

> >> when the patient was on an inversion table. The pelvic suspension type

of

> >> inversion chair was less effective. You might see if you could find

the

> >> article on www.idealspine.com <http://www.idealspine.com>

> >>

> >> Might be a good home therapy for the patient. Stony used to always

talk

> >> about hamstring hypertonicity being an indication for surgical

> >> stabilization, so maybe intensive hamstring stretches are in order

also.

> >>

> >> Don , DC

> >> Corvallis

> >>

November 9, 2001

Marc:

I can

appreciate all of the comments you must be getting. We are fortunate to be able

to participate. Here are my thoughts:

If her

lumbar spine is not acute, don’t fix it. Check the atlas to determine systemic neural

tone. If the atlas is subluxated adjust the atlas. If her lumbar spine is acute

you might consider stabilizing the spondy and facilitating the recovery of the

tissue by improving local circulation and reducing local joint inflammation. There

must be movement of the adjacent superior segments to enable local circulation

to maintain joint function at the spondy. The description you give is one of a

very stable spondy, probably one that has been ignored and now needs months of

rehab. To include stretches, exercises, and work limitations.

Willard

-----Original

Message-----

From: Marc Heller

[mailto:mheller@...]

Sent: Thursday, November 08, 2001

9:36 PM

timitee@...;

Subject: RE: L5 spondy

My question, one of my

patients has a grade 1 L5 sponde, and has virtually no ability to flex her

lumbars, can't touch below her knees. When we did flexion/extension films, they

were useless, she has very little motion in the lumbars, the films looked identical.

I think its possible that

her muscle spasm in the lumbars, and lack of motion in lumbars, is secondary to

compensation around an unstable sponde,

but how do we evaluate

the joint,

this is a longstanding

condition, not due to recent trauma

any ideas??

thanks

Marc Heller,DC

mheller@...

987 Siskiyou Blvd.

Ashland, OR 97520

541-482-0625

-----Original

Message-----

From: timitee@...

[mailto:timitee@...]

Sent: Thursday, November 08, 2001

7:13 PM

Subject: Re: L5 spondy

" Dr. Yocum asserted that a spondy can

be as stable or unstable as any other

spine. "

I totally agree and that is exactly what Yochum says in his spondy talks that I

have heard at least 3 or 4 times. He warns of making your patient a

" chiropractic invalid " by erroneously concluding that a spondylolytic

spondylolisthesis is definately the source of pain and unstable and then

placing unwarranted activity restrictions on them.

P.S. A grade 5 spondylolytic spondylolisthesis can be stable.

Tim Stecher, DC, DACBR

In a message dated 11/8/2001 6:25:47 PM Pacific Standard Time,

drscott@... writes:

In Dr.

Yocum's seminar, he introduced an iatorgenic imaginary disability:

a physician takes an x-ray for some reason and arbitrarily or incidently

diagnoses a spondy. The patient is then forbidden from playing contact

sports.

It was been found that the best footy player (either soccer, football, or

rugby) in Australia, (Motto: We can drink tons of beer and still not fall

off the earth " ) had a grade 4+ spondy. That is the sacrum and L5 hardly

knew

one another and hadn't been in touch for years. Symptom free.

Dr. Yocum asserted that a spondy can be as stable or unstable as any other

spine.

All of this is from my cloudy memory. Ask Bev or the Tyrone 9000 computer

for clarification of Dr. Yocum's findings.

--

Dr. Abrahamson

Your use of

is subject to the

Terms of Service.

November 9, 2001

Thanks, Tim, great info.

D Freeman Mailing address: 2480 Liberty Street NE Suite 180Salem, Oregon 97303phone 503 763-3528fax 503 763-3530pager 888 501-7328

Re: L5 spondy

At WSCC we use both flexion/extension and traction/compression. Neither usually reveals much motion (ie <4mm translation). What we tell our students is that most spondylolytic spondylolistheses are stable and usually don't slip any more after 18 years of age. Lately when we use dynamic imaging we have been doing more flexion/ext since the literature as of late has supported that more....but it is a toss up.One article a few years ago found that 30% of asymptomatic spondylolytic spondylolistheses patients that they examined with flexion/ext had >4mm of translation. The take home there is base your treatment on patient presentation vs radiographic findings.Tim Stecher DC, DACBRAssistant Professor of RadiologyWSCCIn a message dated 11/9/2001 10:47:53 AM Pacific Standard Time, drmfreeman@... writes:

The most helpful x-rays that I have seen for a determination if the spondy(or any other listhesis) is unstable are compression and traction. You put atrapeze bar above the patient that they can pull on for traction and givethem a back pack with 40lbs in it for compression. In my experience thiswill show instability far more clearly than flex/ext. D FreemanMailing address: 2480 Liberty Street NE Suite 180Salem, Oregon 97303phone 503 763-3528fax 503 763-3530pager 888 501-7328

November 9, 2001

frankly all the heavy thoughts, heavy issues and heavy burdens cause my own

back to hurt. tis true that i was not there with patient to witness nor am i

the treating dr. to ask all the relevant questions about flying about the

car, seatbelts, directions of force etc. nor do i have the expertise like

the accident reconstructionist to put in all together in a comprehensible

form. gee i don't even know if the patient was at fault...of clinical

interest to me however is whether or not this spondy pre-existed the

accident and although it may matter legally it also may matter as far as

treatment and prognosis. so why not explore the question a bit further ?

should adolescents with spondys slide tackle ? (soccer term) a 17 year old

female asked me this given her low back pain and recent diagnosis. i told

her no, especially on hard fields. it made sense at the time but now i'm not

sure.

as far as 'is' is concerned i don't know anything about that. nor did

clinton.

sharron fuchs dc

Re: L5 spondy

>>

>> Bob - Dan wrote some articles about treatment of spondylolysis

with

>> inversion tables in the Journal of Clinical Chiropractic. I believe

(from

>> memory) he radiographically observed a reduction in the spondylolisthesis

>> when the patient was on an inversion table. The pelvic suspension type

of

>> inversion chair was less effective. You might see if you could find the

>> article on www.idealspine.com <http://www.idealspine.com>

>>

>> Might be a good home therapy for the patient. Stony used to always talk

>> about hamstring hypertonicity being an indication for surgical

>> stabilization, so maybe intensive hamstring stretches are in order also.

>>

>> Don , DC

>> Corvallis

>>

November 9, 2001

There is a video at WSCC of demonstrating his flexion traction yadda

yadda. Now he demands you travel to Chicago (Motto: " Da Bears! Da Bulls!

What's so funny about dat? " ) and take a 2 part seminar. Sheesh!

THere may be plenty of info on that video. It's been awhile since I watched

it. The #1 item I remember from it is to divide force vectors into 1/3

pushing the legs down and 2/3 on the spinous process of the upper vertebra

when flexing (Unless you have motorized traction and you can run to

Starbuck's while the patient is flexion tractioning themselves.)

--

Dr. Abrahamson

> From: " Marc Heller " <mheller@...>

> Date: Thu, 8 Nov 2001 21:36:06 -0800

> <timitee@...>, < >

> Subject: RE: L5 spondy

>

> My question, one of my patients has a grade 1 L5 sponde, and has virtually

> no ability to flex her lumbars, can't touch below her knees. When we did

> flexion/extension films, they were useless, she has very little motion in

> the lumbars, the films looked identical.

>

> I think its possible that her muscle spasm in the lumbars, and lack of

> motion in lumbars, is secondary to compensation around an unstable sponde,

> but how do we evaluate the joint,

>

> this is a longstanding condition, not due to recent trauma

>

> any ideas??

> thanks

>

> Marc Heller,DC

> mheller@...

> 987 Siskiyou Blvd.

> Ashland, OR 97520

> 541-482-0625

>

> Re: L5 spondy

>

> " Dr. Yocum asserted that a spondy can be as stable or unstable as any

> other

> spine. "

>

> I totally agree and that is exactly what Yochum says in his spondy talks

> that I have heard at least 3 or 4 times. He warns of making your patient a

> " chiropractic invalid " by erroneously concluding that a spondylolytic

> spondylolisthesis is definately the source of pain and unstable and then

> placing unwarranted activity restrictions on them.

>

> P.S. A grade 5 spondylolytic spondylolisthesis can be stable.

>

> Tim Stecher, DC, DACBR

>

> In a message dated 11/8/2001 6:25:47 PM Pacific Standard Time,

> drscott@... writes:

>

> In Dr. Yocum's seminar, he introduced an iatorgenic imaginary

> disability:

> a physician takes an x-ray for some reason and arbitrarily or incidently

> diagnoses a spondy. The patient is then forbidden from playing contact

> sports.

> It was been found that the best footy player (either soccer, football,

> or

> rugby) in Australia, (Motto: We can drink tons of beer and still not

> fall

> off the earth " ) had a grade 4+ spondy. That is the sacrum and L5 hardly

> knew

> one another and hadn't been in touch for years. Symptom free.

> Dr. Yocum asserted that a spondy can be as stable or unstable as any

> other

> spine.

> All of this is from my cloudy memory. Ask Bev or the Tyrone 9000

> computer

> for clarification of Dr. Yocum's findings.

> --

> Dr. Abrahamson

>

November 9, 2001

That much slippage is significant and is to be considered an unstable

spondy. I have never heard of that much slip without some symptoms, such as

pavement scrapes on the navel. Don't you think it would be hard to make the

" silent spondy " argument? If the patient did develop neuro/bowel/bladder

signs he may get cranky about not having the option of surgical

stabilization. I'd get the surgical consult, then treat after a 'full PAR'.

Steve Lumsden

Re: L5 spondy

> >

> > Bob - Dan wrote some articles about treatment of spondylolysis

with

> > inversion tables in the Journal of Clinical Chiropractic. I believe

(from

> > memory) he radiographically observed a reduction in the

spondylolisthesis

> > when the patient was on an inversion table. The pelvic suspension type

of

> > inversion chair was less effective. You might see if you could find the

> > article on www.idealspine.com <http://www.idealspine.com>

> >

> > Might be a good home therapy for the patient. Stony used to always talk

> > about hamstring hypertonicity being an indication for surgical

> > stabilization, so maybe intensive hamstring stretches are in order also.

> >

> > Don , DC

> > Corvallis

> >

November 9, 2001

Mark;

Tried surging sinusoidal muscle stimulation????

Ultra sound to tolerance with a coupling agent containing 1 1/2% lidocain???

Intermittant motorized traction ???

Gentle rotational side posture manipulation.

DrBob

November 9, 2001

Correction of Spondylolithesis by

the Correction of Global Posture

by W. Meyer, D.C.Dr. W. Meyer graduated with honors from the Los Angeles College of Chiropractic in 1981. He maintains a full-time practice in Fountain Valley, CA. In 1986, he founded Circular Traction Supply, Inc. to provide extension traction-oriented products to the chiropractic profession. In 1999, he developed a wearable head retraction brace called Cervical Remodeling Collar™. Last year, he introduced a wearable thoraco-lumbar, posture corrective, traction brace called the Lumbar Remodeling Brace™. This year, Dr. Meyer has created a new design for posture corrective body weighting called the Posture Corrective Exercise Belt™. He has combined these devices into a new therapy entitled Ambulatory Postural Remodeling™. INTRODUCTIONT here is ample evidence in the literature that abnormalities of global posture can account for spinal histopathology, myopathology, neuropathophysiology and kinesiopathology.1 There is also increasing evidence that the correction of global posture could have strong implications for the prevention of disc, ligament, myofascial and bony degenerative changes.1 The case report presented here demonstrates the possibility of reducing and stabilizing a common spinal pathology by the correction or improvement of global posture and raises the question whether the pathology caused the aberrant posture or the aberrant posture caused the pathology?CASE REPORTA 60-year-old female presented for treatment of chronic, intermittent right buttock and lower lumbar pain that she rated as a four on a 0-10 visual pain scale. She also denoted havingchronic low back tension and tightness. The patient is moderately overweight, but physically active.A computerized range of motion test was performed on her lumbar spine as well as a visual postural inspection. The lateral global posture revealed anterior translation of the thorax in relation to the pelvis and a hypokyphotic thoracic region. The AP global posture demonstrated a right lateral translation of the thorax to the pelvis with a left axial rotation of the entire pelvic girdle. Because of the axial rotation of the pelvis, inspection of the foot stance was performed and found a collapse of the medial longitudinal arch of the right foot with associated pronation. Flexibility testing of the piriformis muscles revealed bilateral increased tonus with restricted mobility, especially on the right. Straight leg testing was negative for radicular involvement as was reflex and dermatome testing of the legs. There was some increase of buttock pain on standing lumbar flexion, no increase of pain on left lateral flexion and there was mild lower lumbar pain with extension and right lateral flexion. Increased tenderness was elicited upon digital pressure to the lower right lumbar paraspinal region and the piriformis musculature, especially on the right. Standing radiographic studies demonstrated an anterior thoracic translation of 42 millimeters with an associated increased sacral base angle of 51 degrees. The segmental analysis of the lumbar spine revealed an increased mid to upper lumbar lordosis with a decreased L5/S1 angle. An eight millimeter spondylolisthesis was also observed.(See X-ray A) A bilateral pars defect was noted on the oblique views. The AP view showed a nine and a half degree right lumbosacral angle and a two degree right superior sacral base line.

The diagnosis was as follows: 1. Right-sided lower lumbar facet syndrome secondary to the patient’s altered thoraco-pelvic posture and associated L5/S1 isthmic spondylolisthesis (grade 1).2. Right-sided piriformis syndrome secondary to the collapsed longitudinal arch of the right foot.A treatment plan of CBP® Mirror-Image® diversified spinal adjustments,Ambulatory Postural Remodeling™ utilizing the Lumbar Remodeling Barace™ with lateral translation traction belts, transverse abdominis strengthening on a Torso-Track™, home lumbar and piriformis stretching exercises and Spenco™ shoe orthotics was initiated. The Lumbar Remodeling Brace™ is an adjustable, padded steel device that is wore by the patient and can pre-stress the patient’s thoraco-lumbo-pelvic posture back to a normal lateral alignment (eliminating either anterior or posterior thoracic translation) while also applying an anteriortraction force into the mid to lower lumbar spine to restore its normal elliptical configuration (See Picture 1).Lateral translation traction belts were also used to Mirror-Image® her thoracic translation during the treatment. The patient should be ambulatory during this therapy, so it was applied with the patient walking at two to three miles per hour on a treadmill. These closed-chain, weight-bearing traction/exercise sessions were started at five minutes and progressed to 15 minutes in length. The patient would then perform a 10 repetition set of abdominal strengthening on a Torso-Track™. She started with cable assistance and progress to no cable assistance on this device. The patient then received a CBP® Mirror-Image® spinal adjustment. Treatment was rendered at a frequency of three times per week.After 18 treatment sessions, the first re-evaluation revealed an improvement in lumbar extension, left lateral flexion and rotation. Flexion remained mildly restricted at 52 degrees. The patient’s buttock pain had been eliminated. She now rated her lower lumbar pain as a one on the 0-10 visual pain scale. Her Revised Oswestry pain questionnaire demonstrated only an eight percent interference with her activities of daily living. Her post lumbar radiographic findings denoted a reduction of anterior thoracic translation to 28 degrees, a decrease of the excessive sacral tilt to 46 degrees and a reduction of the spondylolisthesis to five millimeters (See X-Ray . The AP lumbosacral angle (and therefore the lateral translation) reduced to seven degrees and the sacral base line remained two degrees right superior. Because the patient’s sacral base line did not level and there were indications on the x-ray of a left anatomical leg length deficiency, a left-sided seven millimeter heel lift was prescribed. After 12 more treatments, a second re-evaluation showed improvement in lumbar flexion to 57 degrees, no lumbar pain and only occasional, mild right buttock pain. The patient ratedher improvement at 90 percent. Her new post lumbar radiographic findings exhibited no further change in anterior thoracic translation, sacral tilt or spondylolisthesis slippage. The patient’s AP lumbosacral angle reduced to four degrees and the sacral base line reduced to level. Since no further structural improvement of the spondylolisthesis or the anterior thoracic translation had occurred, the patient was released to monthly maintenance care.DISCUSSION Spondylolisthesis among the Caucasian population is estimated to be five to seven percent with an equal sex distribution.2 Approximately 90% of all spondylolistheses involve the fifth lumbar vetebra.3 Common non-degenerative spondylolisthesis is classified as either dysplastic or isthmic.3 Dysplastic includes those spondylolistheses with a congenital abnormality in the upper sacrum or the neural arch of L5 that allows displacement to occur. Isthmic involves an alteration to the pars interarticularis either by an acute fracture, lytic or stress fracture or an elongated but intact pars. The source of the symptomatology associated with an L5/S1 isthmic spondylolisthesis is considered unclear, although it appears that the facet joint pain referral patterns of the lumbar spine parallels those of “classic” spondylolisthesis and that it is highly likely that this joint is a major source of the pain.2 The etiology of the spondylolysis that allows the spondylolisthesis to occur is also controversial. Presently, the most commonly proposed etology leading to a pars interarticularis defect is that of a stress fracture that commonly occurs in childhood.3 Except for a single case reported at C4 in a gorilla, the defect of spondylolysis has not been reported in mammals other than man.3 Because of this, the upright posture of man combined with additional repetitive mechanical stress is considered the significant etiologicalfactor.3 Upon examination, Yochum and Rowe state that distinct postural changes will be seen. A hyperlordosis of the lumbar spine and an anterior shift of the gravitational weightbearingline is often noted. Decreased anterior trunk flexion and reduced straight leg raising are often present due to hamstring muscular tightness that is often associated with spondylolisthesis. These findings are also found in patients with chronic anterior thoracic translation with or without spondylolisthesis. Anterior thoracic translation will cause a hyperlordotic tendency with an increased pelvic tilt and sacral inclination.4 This posture is also generally associated with a decrease of the thoracic kyphosis. Some bio-mechanical researchers, such as Berlemann, et al., now are concluding that further studies should focus on the analysis of spinal alignment and lower lumbar end-plate orientation to identify patients at risk for development of Degenerative Spondylolisthesis or lower lumbar retrolisthesis. They have found that the overall lordosis of thelumbar spine and end-plate inclination were considerably reduced in patients with retrolisthesis and that the end-plate inclination in patients with DS was greater.5,6 In another study, the sacral base angle was found to be greater in spondylolisthesis patients and a significantly greater incidence of hyperextension at L4/L5 was found in symptomatic spondylolisthesis patients.2 These recent findings raise the question whether chronic thoracic anterior translation with its associated increased sacral inclination and hyperlordosis is not the underlying cause of the additional repetitive mechanical shear stress that results in pars interarticularous stress fractures in children as well as being a main cause of Degenerative Spondylolisthesis in the elderly.CONCLUSIONMuscles attaching onto the rib cage have been found to be important for control of the overall spinal posture and maintenance of equilibrium.7 The deep Transverse Abdominis muscle is now being considered vital to lumbar spine stability.8 The Torso-track™ is an excellent, progressive, in-office method to tone and strengthen this deep superior abdominal muscle. Stretching of the hamstrings and strengthening of the back extensor musculature has also been found to encourage a more normal lumbar lordosis and thoracic kyphosis.9,10,11,12 These two benefits occur naturally during ambulatory exercise.Weight bearing activities require the co-contraction of accessory and stabilizing muscles. They also stimulate proprioceptive input from receptors in the muscles, connective tissues, and joint capsules. This is why it is so important to perform spinal rehabilitative exercises in a closed-chain, weight bearing posture that is closer to real life positions. The specific adaptation of imposed demands (SAID) concept tells us to expect that closed chain, weight bearing exercises generally will be more effective.13I hope that it is clear from these references, and this article, that adopting a weight-bearing, posture corrective rehabilitation program in the treatment of your patient will not only result in improved patient outcomes, but also allow you to better deal with numerous spinal pathologies that are directly influenced by global posture. REFERENCES1. Troyanovich, SJ. et al. Structural Rehabilitation of the Spine and Posture: Rationale for Treatment Beyond the Resolution of Symptoms. J Manipulative Physiol Ther 1998; Vol. 21, 1:37-49.2. Bull, P, Hayek, R. The Effects of Spondylolisthesis on the Lumbar Spine. World Federation of Chiropractic 1999, Auckland, NZ.3. Yochum, TR, Rowe, LJ. Essentials of Skeletal Radiology, Volume One. & Wilkins, Baltimore, MD. 1987. 243-272.4. Korovessis, PG, Stamatakis, MV, Baikousis, AG. Reciprocal Angulation of Vertebral Bodies in the Sagittal Plane in an Asymptomatic Greek Population. Spine 1998; Vol. 23, 6:700-705.5. Berlemann, U, Jeszenszky, DJ, Buhler, DW, Harms, J. The Role of Lumbar Lordosis, Vertebral End-Plate Inclination, Disc Height, and Facet Orientation in Degenerative Spondylolisthesis. J Spinal Disorders 1999; Vol. 12, 1:68-73.6. Berlemann, U, Jeszenszky, DJ, Buhler, DW, Harms, J. Mechanisms of Retrolisthesis in the Lower Lumbar Spine. A Radiographic Study. Acta Orthop Belg 1999 Dec.; 4:472-7.7. Kiefer, A. et al. Synergy of the Human Spine in Neutral Postures. Springer-Verlag 1998.8. Hodges, PW. Is There a Role for Transversus Abdominis in Lumbo-Pelvic Stability? Man Ther 1999; Vol. 4, 2:74-86.9. McCarthy, JJ, Betz, RR. The Relationship Between Tight Hamstrings and Lumbar Hypolordosis in Children with Cerebral Palsy. Spine 2000; Vol. 25, 2:211-213.10. Stokes, IA, Abery, JM. Influence of the Hamstring Muscles on Lumbar Spine Curvature in Sitting. Spine 1980; Vol. 5, 6:525-529.11. Sinaki, M. et al. Correlation of Back Extensor Strength with Thoracic Kyphosis and Lumbar Lordosis in Estrogen-Deficient Women. Am J Phys Med Rehabil 1996; 75:370-374. 12. Itoi, E, Sinaki, MS. Effect of Back-Strengthening Exercise on Posture in Healthy Women 49-65 Years of Age. Mayo Clin Proc 1994; 69:1054-1059.13. Christensen, K. Functional Re-Training and Spinal Support. Dynamic Chiro. July 10, 2000; Vol. 18, 15. Search for:

Back to CBP OnLine

L5 spondy

Listmates:

Have a 31 year old muscular male who was T Boned in an MVC a month ago and has developed acute symptom in L5 area.

The ER x-rays show a umm anterior gravitation of L5. Yesterday we did Maximum flexion/extension standing lateral lumbar films which show 12mm anterior slippage during flexion; 15mm anterior slippage during extension accompanied by 10/10 pain in the area!

During flexion the L5 disc spacing is reduced approx 25% ; while in extension the posterior portion of the disc space is reduced 5mm. with the severe pain ( in flexion the pain was 3-4/10)

Yes! the y has a collar!

Treatment will be a thoaco/pelvis fiberglass traction cast ,applied with slight flexion. Will monovalve in 5 days if comfortable. Anticipate wearing time to be 60 to 90 days. If symptoms persist will refer for surgical evaluation.

Comments appreciated

DrBob

P.O. Box 606Pendleton, 0reg 97801541.276.2550

November 9, 2001

Clinical Investigations of Gravity Inversion Traction and Spondylolytic Anterolisthesis

by J. , DC, FACO

Dan graduated magna cum laude from Western States Chiropractic College in 1978, and has more than 20 years of practice experience. He received Diplomat status in Chiropractic Orthopedics in 1986. Since 1982, Dr. has served part-time as undergraduate faculty at Life Chiropractic College West, currently teaching classes to seniors in the management of spinal disorders. Dr. is on the post-graduate faculty of several chiropractic colleges. His post-graduate continuing education classes include “Whiplash and Spinal Trauma” and “Pain Neurology.” Dr. is the coordinator of a year-long certification program in “Chiropractic Spinal Trauma,” now (2000) in its twelfth year of being offered. This year, the program is being offered through the International Chiropractors Association of California. He has taught more than 700 post-graduate continuing education seminars. Dr. is a contributing author to the book Motor Vehicle Collision Injuries, published by Aspen, 1996; and to the book Pediatric Chiropractic, published by & Wilkins, 1998. He writes a quarterly column in the Journal of Clinical Chiropractic. In 1987, 1991 and 1995 Dr. received the Post-graduate Educator of the Year award, given by the International Chiropractic Association. In 1997, he received The Carl S. Cleveland, Jr., Educator of the Year award, given by the International Chiropractic Association of California.

There are multiple causes and classifications of spondylolisthesis (, ; Jayson, 1987; White and Panjabi, 1990; Yochum, 1987). This article pertains to a study regarding spondylolytic anterolisthesis (spondylolytic anterior spondylolisthesis), which is an adaptation of the language used by Yochum (1987). This means that there is a defect in the pars interarticularis and an anterior slippage or displacement of the vertebral body. No attempt was made here to classify the anterolisthesis by cause of the spondylolysis.

Hypotheses as to cause of spondylolytic anterolisthesis are many. A leading hypothesis indicates that the separation of the pars interarticularis is a stress fracture, meaning it is caused from a series of stresses in the region rather than by a single traumatic event (, Yochim). Between 5% to 7% of the adult white population will have an anterolithesis. Approximately 90% of anterlisthesis are found at L5 (Yochum). Therefore, this study primarily evaluates the L5-sacrum articulation.

Gravity inversion traction has been around for several decades. Its formal usage can be traced back to Dr. M. (1975 and 1982) who has claimed to have multiple degrees, including that of medical physician, osteopath, and chiropractor. Dr. spearheaded the current trend in gravity inversion traction devices within chiropractic through his Gravity GuiderTM system. This is the traditional ankle gravity boot inversion system that has been used both with, and without, a swinging bed. In the past decade, numerous other gravity inversion traction devices have surfaced. These other gravity inversion traction devices are marketed directly to the health care provider for in-office use, as well as being marketed directly to the consumer. Each unit is different in design in terms of ease of use and patient comfort. Also, there are mechanical differences to the clinician, using different varieties of gravity inversion traction units.

The most significant mechanical differences are those attributed to the inversion traction devices in which one hangs primarily from the thighs. My intention for this article is to discuss the mechanical differences between the two basic, different varieties of gravity inversion traction units as well as discussing indications and contradictions for their usage. I will also describe a clinical protocol for the safe introduction of inversion gravity traction for patient care.

I have a particular interest in the usage of gravity inversion traction devices, as I have used them extensively in my private practice for the last ten years, and personally over the past twelve years. The following information is based upon my own clinical experiences and personal clinical research, performed in my office over the past ten years. My clinic has used inversion traction on approximately one thousand different patients in the past decade. Approximately 10% of these, or one hundred patients, eventually purchased a home gravity inversion device for home use. This study specifically relates to gravity inversion traction and spondylolytic anterolisthesis.

When one views a lateral lumbar radiograph, there is a lumbar lordosis and an angulation to the sacral base.

This sacral base angle is approximately 40 degrees in normal standing averages (Janik, 1998). When viewing the lumbosacral spine in the lateral dimension, if we were to eliminate the forces in this region created by the ligaments, muscles, discs, and pars interarticularis, etc., we would have, in simple terms, a block on an inclined plane (Fig. 1). This is not to say that the forces produced by these other tissues are negligible in comparison to the force of gravity. The force of gravity will now affect the lumbosacral spine as a block on an inclined plane. With this analysis, we will have two forces that affect the articulation (Fig. 1). These forces are:

1) Those that are parallel to the joint surface.

2) Those that are perpendicular to the joint surface.

By doing a simple force vector addition, we would have the straight vertical force of gravity. In dealing with the topic of anterolisthesis (Fig. 2), it is noted that when there is an interruption of the pars interarticularis, it is the force component that is parallel to the joint surface that will pull the L5 vertebra forward on the sacral base. The average appearance of our patient with an anterior spondylolisthesis is that there is also a narrowing of the disc spacing between L5 and S1. This narrowing is attributed to the perpendicular component of the forces that are acting over the L5-S1 interbody articulation.

When one is hanging in an inverted position, the vectors are reversed (Fig 3). The component vector, that is parallel to the joint surface, will pull the vertebrae toward posterior, or toward correction, while the component that is perpendicular to the surface, will enlarge the disc space. This simple vector analysis for the temporary reduction of spondylolytic anterolisthesis is verified with radiographic studies mentioned below. Before proceeding, however, an understanding of the principles of viscoelastic creep is necessary.

Viscoelastic creep is a characteristic of biological tissue. Discussions regarding viscoelastic creep can be found in tests by White and Panjabi, 1990, and Bogduk, 1987. An example of a typical creep curve from White and Panjabi is noted in Fig. 4. In a creep curve, deformation of the tissue is plotted as a function of time. The principle of creep is that the tissues will continue to deform over time, even though the load on the tissues will take place, creating a lasting alteration in the tissue mechanics, giving a lasting benefit to the forces that were applied to the tissues.

Over the past ten years, we have done a radiological study of 30 patients with spondylolytic anterolisthesis. Our study consisted of exposing radiographs in the upright and inverted, gravity traction positions. We carefully analyzed these radiographs for millimeters of anterior slippage, and also measured the height of the intervertebral disc. The subjects used in this study were all patients seen in the general practice of a chiropractor. Their ages ranged between 11-70 years of age. Twenty of the patients were male, ten were female. No patient had an anteriolisthesis greater than Grade II. All of these patients were suspended straight, vertically using Gravity GuiderTM boots when the inverted gravity traction radiographs were exposed. A few of these patients also were radiographed using thigh-gravity (OrthopodTM) inversion traction as well. All patients were radiographed in a least the lateral dimension. Some were also radiographed in the AP dimension. In all patients, gravity inversion radiographs were exposed at intervals of one minute. A second radiograph was exposed either at an interval of five minutes, or ten minutes of traction, depending on the tolerance of the patient. This was done in an effort to observe the phenomenon of visoelastic creep.

The average amount of reduction in anterior millimeters of displacement throughout this entire series was seven millimeters in patients with spondylolytic anterolisthesis. The additional reduction of forward slippage, caused by creep, averaged two additional millimeters per patient, within the five to ten minute time frame used. The spacing of the intervertebral disc, on average, approximately doubled in size between L5 and S1. The smallest millimetric reduction, while under gravity inversion traction, was 4mm. The largest millimetric reduction was 12mm.

Cases I (26 year old male) and Case II (18 year old male), discussed below are representative of the study. These drawings Figs. 5, 6, 7, 8, 9, and 10 for Case I, and 11, and 12 for Case II are proportional reduction of actual tracings of the radiographs. Figure 5 is an upright, neutral lateral, lumbar radiography. Figure 6 was exposed after 60 seconds of inversion gravity traction. Figure 7 was exposed after 10 minutes of inversion gravity traction. Note the additional creep between the 60 second and 10 minute radiographs. Note that the size of the intervertebral disc has more than doubled. Note, that within 10 minutes, the anterolisthesis has completely reduced.

Figure 11 is an upright, neutral of a different patient, (Case II). Note that the 60 second vertical inversion traction radiograph is the same patient in Figure 12.

We have done one long-term follow-up study on one of the subjects involved in this study. The long-term study is the same patient as in Case I, above. The long-term benefits of inversion, noted in this single study, reveal a progressive reduction in the millimetric magnitude of the anterior displacement of L5 on the sacrum, and a gradual increase in the height of the intervertebral disc. Figure 8 and 9 are tracings of upright radiographs, exposed on the same patient as in Figures 5, 6, and 7. Figure 8 was exposed in 1983, and Figure 9 was exposed in 1991. The original radiographs (Figs. 5, 6, and 7) were exposed in 1981.

An interesting comparison is made in Case I by overlapping the original upright radiograph (Fig. 5) with the ten minute inversion radiograph (Fig. 7). This is done in Figure 10. Note the complete reduction of the anterolisthesis, and that the intervertebral disc has more than doubled in size.

Our study showed that, when doing straight vertical ankle inversion, the lumbar lordosis is increased in size. This is apparently because the sacroiliac articulation rocks forward, when one is inverted to align with the acetabulum. This forward-rocking projects as a greater curve in the lumbar lordosis. As a result, this will increase the magnitude of the vector, that is parallel with the joint surface, making it more advantageous for the reduction of the anterior slippage (Fig. 13).

The major difference between ankle inversion and thigh (OrthopodTM) inversion is that, for the most part, in the latter, there is an elimination of the component of force, that is parallel to the joint surface. Therefore, the major and, in some cases, the only vector remaining is that which is perpendicular to the joint surface (Fig. 14).

Anterolisthesis is, however, still reduced through thigh gravity inversion traction because of the crisscross micro-mechanics of the annular disc fibers. This was clearly shown on the additional radiographs of two of the thirty people involved in this study. A comparison of the differences between OrthopodTM (thigh inversion) and ankle vertical gravity inversion follows:

Straight, vertical ankle inversion has the largest (parallel-to-joint surface) component of force for the reduction of the anterior slippage in a spondylolisthesis. This component is minimized in thigh inversion, yet there is still a positive benefit on reduction of anterolisthesis with thigh inversion because of the crisscross alignment of the annular disc fibers. However, individuals with a retrolisthesis at L5 or L4 should use vertical ankle gravity inversion with caution, as the retrolisthesis tend to be displaced more toward the posterior. This principle is clearly seen at the L-4 level on Case I, when inverted. This adverse vector component is minimized during thigh (OrthopodTM) inversion and, therefore, it is the inversion traction of choice for those with retrolisthesis.

With thigh (OrthopodTM) inversion, one is either inverted all the way or not inverted at all. An additional advantage to the ankle inversion, particularly with the addition of the swing or bed apparatus, is that the degrees of angulation can be controlled. None of us would invert an eight-month pregnant woman on a thigh (OrthopodTM) inversion unit. However, we can easily put this same woman in an ankle inversion apparatus, with the swing or bed, at approximately ten degrees of angulation, with the head being slightly lower than the feet, and achieve a traction benefit.

The protocols for inversion therapy that we have developed in our office follow:

1. Be aware of the medical contradictions to gravity-inversion therapy. These include: high blood pressure, retinopathy, diabetes, obesity, age or cardiovascular disease, etc. (This list is not all-inclusive and common sense should be used.)

2. Be aware of the mechanical contradictions to gravity inversion therapy. The most noted mechanical contradiction for ankle inversion, in the authorÕs opinion and experience, is the presence of a retrolisthesis of the lumbar or lumbossacral spine. Again, there are other mechanical contradictions, and the provider should use common sense.

A second mechanical consideration for inversion traction is the presence of lumbar spine central canal spinal stenosis. During thigh inversion (Fig. 14), the lumbar spine is flexed, enlarging the central canal sagittal dimension by two to three millimeters (). This does not adversely affect those with lumbar spine central canal spinal stenosis, and our clinical studies suggest a benefit to the patient. However, as noted above, ankle inversion increases the lumbar lordosis, thereby narrowing the sagittal dimension of the central canal. This mechanical change could potentially adversely affect those with pre-existing absolute or relative lumbar spine central canal spinal stenosis. Therefore, we discourage the use of straight vertical ankle gravity inversion traction for those with lumbar spine central canal spinal stenosis.

If no obvious medical or mechanical contradictions to inversion traction are noted, one can proceed. The following protocols were developed by the author over the past ten years, using both ankle and thigh gravity inversion in clinical practice. It is recommended that the first time inverting, the patient be inverted for a maximum of 60 seconds. The doctor should remain with the patient the entire 60 seconds to make sure there are not problems. Questioning the patient throughout the procedure assures that he/she is getting along adequately. If, during this 60 second initial trial period of inversion, the patient complains of dizziness, nausea, headache, or significant increase in back pain, inversion should be discontinued, and possibly attempted once again on another day. The patient should arise promptly at the end of 60 seconds and, if this rising causes no immediate or subsequent increase in symptomatology, the second session of inversion therapy can be increased to two minutes, and third visit to three minutes, the fourth visit to four minutes. The ultimate goal would be achieved on the fifth visit Ñ and that would be five minutes. We do not recommend that anyone use gravity inversion traction in excess of five minutes at any given time. It is duly noted, that inversion therapy increases blood pressure, as do most forms of exercise. We discourage the use of inversion for those with systolic pressure greater than 150 mm of mercury.

It is noted in GuytonÕs physiology, that when one exercises, blood pressure increases. Part of the reason is caused by a vasodilation of the muscles that are being exercised, with a vasoconstriction in other regions of the body. Therefore, the common practice of having a patient do exercises, while inverted, does not make rational sense and in fact, could be dangerous. Recalling that blood pressure increases while inverted, if one then exercises, causing a reflex vasoconstriction in regions that are not be exercised, there could be a dramatic increase in overall systolic blood pressure, potentially dangerous consequences. Therefore, our recommendation is that inversion should be done with the greatest degree of relaxation, and no exercise should be performed during inversion. This is also how one takes best advantage of the visoelastic creep forces which are necessary when attempting to reduce spondylolytic anterolisthesis. It is this authorÕs opinion and experience that the use of gravity inversion traction is a useful and beneficial mechanical adjunct to chiropractic health care in the management of spondylolytic anterolisthesis.

It is not the intent of this paper to promote specific brands of gravity inversion devices, or to discourage the use of others not mentioned. Rather, the purpose is to share clinical investigations using inversion gravity devices.

References

Bogduk, Nikolai and Twomey, Lance T, Clinical Anatomy of the Lumbar Spine, Churchill Livingstone, (1987).

M., D.C., Low Back Pain, and Wilkins, (1990).

Jayson, Malcom, I.V., M.D., The Lumbar Spine and Back Pain, Churchill Livingstone, (1987).

Janik TJ, on DD, Cailliet R, Troyanovich SJ, on DE. Can the Sagittal Lumbar Curvature be Closely Approximated by an Ellipse? J. Orthop Res. 1998; 16(6):766-770

M., M.D., The Gravity Guiding System, Gravity Guidance Inc., (1982).

White A.A., M.D., and Panjabi M.M., PhD., Clinical Biomechanics of the Spine, Lippincott, (1990).

Yochum Terry, and Rowe , Essentials of Skeletal Radiology, and Wilkins, (1987).

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CONTENTS

European Spine to Publish CBP

NYCC Teaches CBP

Oklahoma Board Limits IMEs

Web Based Postural Analysis

Dr. Kim Given Jail Sentence for Practicing

Clinicians Vs. IME's

Where are We Going, Anyway?

Mechanocsensitive Desensitization and Nociceptive Sensitization

When Patients with chest Pain Need Chiropractic care

Inversion Traction and Spondylolytic Anterolisthesis

It's our Light, Not our Darkness That Frightens Us...

Diversified is the reason DCs Fail at Spinal Correction

18 Papers with Rene Cailliet, MD

Practice Growth: Forced or Natural

Soft Drinks

L5 spondy

Listmates:

Have a 31 year old muscular male who was T Boned in an MVC a month ago and has developed acute symptom in L5 area.

The ER x-rays show a umm anterior gravitation of L5. Yesterday we did Maximum flexion/extension standing lateral lumbar films which show 12mm anterior slippage during flexion; 15mm anterior slippage during extension accompanied by 10/10 pain in the area!

During flexion the L5 disc spacing is reduced approx 25% ; while in extension the posterior portion of the disc space is reduced 5mm. with the severe pain ( in flexion the pain was 3-4/10)

Yes! the y has a collar!

Treatment will be a thoaco/pelvis fiberglass traction cast ,applied with slight flexion. Will monovalve in 5 days if comfortable. Anticipate wearing time to be 60 to 90 days. If symptoms persist will refer for surgical evaluation.

Comments appreciated

DrBob

P.O. Box 606Pendleton, 0reg 97801541.276.2550

November 9, 2001