Traction

1
Traction

• Tara Manal PT, OCS, SCS

2
Spine Pain with Radiculopathy

• Neurological deficits
• Mechanical compromise
• Ischaemia of the nerve nerve root/nerve/dorsal
  root
• Mechanical compromise of venous outflow
• Ischemia and fibrosis
• Inflammation of the nerve root/nerve/dorsal root
• Intervertebral disc lesion/disease
• Osteophytic encroachment
• Facet inflammation
• Chemical response of the nerve to nucleus
  material

3
Hypothesis of Traction

• Biomechanical
• Intervertebral Separation
• Reduction of disc protrusion
• Altered Intradiscal pressure
• Normalization of conduction
• Increased Joint Mobility

• Neurophysiological
• Pain Relief
• Decrease of Radicular symptoms

4
Intervertebral Separation

• Strong in vivo and in vitro evidence of
  separation of intervertebral segments
• 9kg (20lbs)for 30 minutes to l-spine in vitro
• Most with hips 90º/ cervical 30º
• In vivo occurred at 50lbs
• Clinical Implications are unknown
• Colachis Strohm 1969, Twomey 1985, Lee Evans
  1993

5
Reduction of Disc Protrusion

• Weak Evidence
• Contrast dye injected in 3 patients
• Pre and post traction radiographs
• Saw reduction gone in 14 minutes
• Study re-done in 1992 with CT
• 4 patients with traction until recovery
• 2 had disc reduction/ 2 did not
• All recovered
• Matthews 1968 David 1992

6
Altered Intradiscal Pressure

• Weak Evidence
• Single study of healthy discs
• No pressure change with mechanical
• Increased pressure with patient generated
  traction (500N)
• Anderson et al 1983

7
Normalization of Conduction

• Weak Evidence and Mixed Results
• Some authors show normalized sensation, reflexes
  and muscle power others do not
• Increased intervertebral foramen
• Reducing ischemia to nerve
• Improving removal of inflammatory agents
• Reduce mechanical compression
• Knutsson 1988, Onel 1989, Tesio 1989, Pal 1986

8
Increased Joint Mobility

• Transitory Increase in cervical range following
  traction
• Elongation of tissue is greater in healthy than
  in presence of DJD
• Longer duration needed (30min) in old vs young
• Some evidence for transitory increases

9
Neurophysiological

• Ectopic Impulse Generators
• Spontaneous signals in dorsal root resulting from
  inflammation
• Separation may silence these impusles
• Mechanical stimulation of large diameter fibers
  overrides DRG
• Moderate evidence in the animal model
• Howe 1977, Bini 1984

10
Neurophysiological

• Response to Pain Generation
• Central Sensitization
• Expansion of Receptive Fields
• Thamus and PAG (decreased inhibition)
• Peripheral Receptor Hyperactivity
• Hypothesis of Traction effects
• Increased non-nociceptive input
• Recruitment of descending inhibition
• Untested

11
Application of Traction

• Patient Selection
• Radiculopathy
• Nerve root
• Stenosis
• Worsens with active movement testing
• Acute Phase (lt6 12 wks)
• Dont rule out long standing (stenosis)

12
Traction Dose

• Type of Traction
• Mechanical vs. Manual
• At 25lbs cervical traction for radicular and non
  radicular complaints
• No difference between intermittent, static and
  manual

13
Traction Dose

• Magnitude
• Minimum needed to achieve goal
• 20-50 BW needed to separate IV
• 4 BW needed to overcome friction
• Split table reduces friction
• Split table at level of most desired traction
• Cervical- 20-25lbs to overcome lordosis
• 50lbs had greater separation than 30

14
Traction Dose

• Duration
• Minimum needed to achieve goal
• Static vs Intermittent
• Some evidence need static to overcome muscle
  contraction
• Intermittent often less aggressive and less
  rebound at end

15
Traction Dose

• Body Position
• Best for goal
• Angle of the pull
• Level
• Up at an angle

16
Flexion Worsens

• Prone Traction

17
Extension Worsens

• Supine Traction

18
Monitoring Response

• Oswestry
• Neck Disability Index
• MMT
• Reflexes
• Centralization
• Pain complaints
• Immediate vs over 2-3 Txs

19
Contraindications

• Compromised spinal integrity
• Malignancy, osteporosis, tumor, infection
• Unstable fracture
• Ligamentous instability (ie alar lig)
• Recent Fusion (3-6mo)
• Pregnancy (when cant use belts)

20
Precautions

• Loose fitting dentures (remove)
• Respiratory conditions
• Claustophobia
• Early pregnancy
• May consider manual traction

21
Traction Options

• Occipital head contact
• Chin halter strap
• Autotraction
• Pelvis is secure and traction forces are
  generated by grasping and pulling and pushing on
  bars on the ends of the table

22
Traction Options

• Positional Traction
• Self unweighting on desk or counter