NOTE: This article originally appeared in Canadian Chiropractic magazine, May 2010.

Our profession has a wonderful track record for helping Canadians reach a higher level of health, and maintain it naturally. But there is a certain group of patients who do not respond to traditional chiropractic care as well as we’d like them to. Often, these challenging back and neck pain patients are suffering from bulging or herniated discs or advanced degenerating discs. Spinal decompression therapy is one option that has demonstrated a degree of success in many of these cases. By its very nature, it is a procedure that complements our approach, as it is non-invasive, non-surgical, and requires no drugs or medications.

While one might expect an article on this topic to launch into the available spinal decompression therapy technology, comparing performance, maintenance and costs, I firmly believe that the topic of patient selection for candidacy must be discussed first. Not every patient with spinal disc pathology is a candidate for spinal decompression therapy. It is through a meticulously performed consultation and examination that the doctor will be able to determine how well a patient is suited for spinal decompression therapy or whether they are suitable for this option, at all. Inappropriately selected patients may suffer poor or even damaging results with this therapy. (Of course, this could be true for any misdiagnosed or mistreated patient, in any area of the health-care system.) Furthermore, patients want desperately to trust their doctor’s recommendations. It is therefore imperative that we are comprehensive in both our consultation and examination steps and in communicating the outcomes and implications of these with our patients. We find that only when the patient is properly determined by the doctor to be an ideal candidate (for any therapy), and doctor and patient have established a trusting relationship and developed a true healing partnership, will the best possible outcomes be achieved.

Therefore part 1 of this article will focus on the consultation and examination process to select, or deselect, patients to ensure safe and effective spinal decompression therapy. For most doctors most of this information should be an important and welcomed review as this process is relevant in all patient situations but the importance of some particulars, here, cannot be overstated when deciding to include spinal decompression therapy within a patient’s program of care.

EVALUATING THE PATIENT’S OVERALL STATE
Ideally, you should schedule sufficient, uninterrupted time for each patient consultation and examination. Allow yourself to truly get to know your patient.

It’s helpful, also, to recognize the profile of a typical patient with a disc herniation, bulging disc, degenerative disc as well as stenosis and then decide if spinal decompression therapy might be an option for that patient. Look for the following features:

• suffering from serious chronic pain, lasting anywhere from a few months to 20-30 years, or more
• age ranges usually from 30 to 75 years old
• is experiencing long-standing, serious lumbar or cervical pain
• pain can include radicular/sciatica signs and symptoms, and may include
• organic disorders such as bladder dysfunction
• patient has tried many forms of care without success, including physiotherapy, registered massage therapy, drug therapy, homeopathy, acupuncture,  surgical interventions (though some surgeries are contraindications for spinal decompression therapy, please see below) and even other chiropractic options
• may be taking anti-inflammatories, muscle relaxants or even narcotic pain relievers
• patient is often considered to be disabled
• all aspects of patient’s life are affected – work, hobbies, family
• patient’s emotional health is affected, with some even showing signs of depression

This profile highlights a patient that is complicated and sensitive. The patient brings anger, frustration, fear, skepticism, and even depression to your office. The consultation can be a very emotional time for the patient, as they share their story and unburden themselves. They are hopeful, and open to a new suggestion, yet wary. Remember, this patient likely has visited many doctors and tried many modes of care before seeing you.

CONSULTATION – TRULY GET TO KNOW YOUR PATIENT
Prior to the consultation, advise patients to bring copies of X-rays, MRIs, CT-scans, films or disks, or reports, to their consultation appointment. You need to know which tests have been done and which diagnoses have been made. This will help you determine which tests you may need to order.

When the patient is in your office, create a safe, trusting environment where he/she can fully explain and share their pain, the circumstances that led to their pain, the impact the pain has made on their life, and all the forms of care they have sought. It’s cathartic, and that’s part of healing. Be as empathetic as possible.  Also, and equally importantly, give the patient permission to express exactly what their outcome goals are.

Conduct and record a traditional interview to collect all the details of the patient’s condition. Perform a thorough systems review. Collect and review previous traumas, health problems and familial history. Review all films, disks and reports the patient has brought in. And ask the patient what they think might be going on.

While listening, you can pick up clues that highlight the patient’s true condition as well as their potential with respect to various therapies, including non-surgical spinal decompression.  Learn as much as possible about the patient’s lifestyle, hobbies, physical fitness, work environment, etc. These factors are of great importance in understanding the source/cause of the spinal problem and, further down the line, in advising the patient on how to protect themselves going forward. When you really listen, the patient sees you as a compassionate and trustworthy doctor. It’s the first step toward creating a healing partnership with a new possibility of success.

Do not rush your consultation. This may seem obvious, but it’s essential. Patients are sensitive to feeling pushed through. I’ve heard firsthand from many that it made them feel the doctor was not fully paying attention to them and, worse, hastily led them to a diagnosis and treatment.

Compile all the information you have. Proceed with a thorough examination regardless of what your impressions may be, at this point, but if you are considering spinal decompression therapy, be vigilant regarding features that may actually be contraindications to this therapy.  Simple pre-screening questions should help you easily rule out unqualified candidates. Contraindications include:

• complete laminectomies
• advanced spondylolisthesis
• pregnancy
• surgical spinal hardware implants
• cancer
• spinal fractures
• advanced osteoporosis
• possibly ankylosing spondylitis

EXAMINATION – COMPLETE THE PICTURE
You now have a puzzle with a few pieces missing. You have a pretty good – but not complete – understanding of the patient’s condition. The examination will fill in these missing pieces.

As with the consultation, do not whiz through an examination. This is not appropriate ever – especially not with vulnerable patients.

Patient comfort is a priority. You will know, from results of previous tests, if a patient is suffering from a degenerative or bulging/herniated disc. If this is the case, be very conscious of not causing the patient any additional discomfort or pain where possible.

Doctors should always begin with complete spinal examination including palpation and range of motion tests. The examination must include a visual inspection, note any visible antalgic compensations. Observe general posture and anatomical landmarks (noting any asymmetries), gait analysis and body weight, and general health as factors. Perform muscle tests, noting both weakness and areas of spasms. Conduct a full range of appropriate neurological and orthopedic tests (including straight-leg raises and Valsalva tests). If your office offers high-tech assessment tools such as surface EMG, perform an appropriate workup. This will help to uncover any neurological deficits, further identify which nerves are involved and ultimately help with forming an appropriate diagnosis.

If there is any doubt of the patient’s diagnosis, it may be necessary to take steps to arrange for appropriate tests such as X-rays, CT-scans or MRIs.

Keep in mind that, if you do refer your patient for spinal decompression therapy, it will be important to perform ongoing follow-up assessments throughout the care program to objectively monitor the patient’s progress.

BE A TRUE HEALING PARTNER
Only when you know everything you possibly can about a patient is it appropriate to make recommendations such as spinal decompression therapy.

Whether or not your patient is a good candidate for care, the patient will respect your involvement. You have established a relationship based on compassion, expertise, wisdom and trust. For those who do begin spinal decompression therapy care, this foundation can only help in the quest to achieve healing relief. Many of these patients feel they have been on an endless search for pain relief and, with your high standard of consultation and examination, they may be hopeful for the possibility of a bright, pain-free future just ahead. •
Dr. Ron Nusbaum graduated from CMCC in 1989 and began practising in a multidisciplinary clinic in his first year, associating with Dr. Howard Vernon. He has been practising in Richmond Hill for more than 20 years. Dr. Nusbaum is the director of Back Clinics of Canada where he also provides spinal decompression therapy while serving patients from the greater Toronto area, Richmond Hill, and across Canada. He works closely with each patient to diagnose the underlying causes of their condition, and determine the appropriate treatment.  Learn more about spinal decompression athttps://backclinicsofcanada.ca or by calling 1(877) 724-6373.