Traction review

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Traction review

  1. 1. Cervical and LumbarCervical and LumbarTraction ReviewTraction ReviewCasey Christy, MA, ATC, CSCSCasey Christy, MA, ATC, CSCS
  2. 2. Disc AnatomyDisc AnatomyJelly donut analogyJelly donut analogyAnnulus FibrosisAnnulus FibrosisOuter layer of disc attached to vertebralOuter layer of disc attached to vertebralbodybodyNucleus PulposusNucleus PulposusInner layer, protein gelInner layer, protein gelWater loss with agingWater loss with aging85-90% water at birth, 70% age 70.85-90% water at birth, 70% age 70.22Image courtesy offlickr.com
  3. 3. Disc InjuryDisc InjuryBulging or herniated discBulging or herniated discStretched or weakened annulus fibrosisStretched or weakened annulus fibrosisAF bulges or protrudes from pressure ofAF bulges or protrudes from pressure ofNPNPSimilar to overinflating a bicycle inner tubeSimilar to overinflating a bicycle inner tubewith a weak spotwith a weak spot22
  4. 4. Disc InjuryDisc Injury““Slipped discSlipped disc””Lay term but inaccurateLay term but inaccurateDiscs do not slip out of place like a hockeyDiscs do not slip out of place like a hockeypuck but deform or bulgepuck but deform or bulge22
  5. 5. Traction BasicsTraction BasicsTraction: Latin originTraction: Latin origin traciotraciowhich means “drawing orwhich means “drawing orpulling apartpulling apart””22
  6. 6. Traction BasicsTraction BasicsIndications include but notIndications include but notlimited to:limited to:Nerve root compressionNerve root compressionDisk protrusion, bulging discDisk protrusion, bulging discMuscle spasmMuscle spasmJoint hypomobilityJoint hypomobilityDisc degenerationDisc degeneration22
  7. 7. Traction BasicsTraction BasicsTraction can reduce nerveTraction can reduce nerveroot impingement,root impingement,temporarily decreasing paintemporarily decreasing painand breaking the pain-and breaking the pain-spasm-pain cycle.spasm-pain cycle.44
  8. 8. Traction BasicsTraction BasicsSpinal traction is theSpinal traction is theapplication of a distractingapplication of a distractingforce to separate vertebralforce to separate vertebraljoint surfaces. It can bejoint surfaces. It can beapplied manually,applied manually,mechanically or through amechanically or through amotorized device.motorized device.44
  9. 9. Traction BasicsTraction BasicsIn the cervical spine, traction appliedIn the cervical spine, traction appliedwith the spine in mild flexion results inwith the spine in mild flexion results ingreater separation of the posteriorgreater separation of the posteriorstructures (facet joints, intervertebralstructures (facet joints, intervertebralforamen, nerve roots).foramen, nerve roots).With the cervical spine in slightWith the cervical spine in slightextension, traction separates theextension, traction separates theanterior structures (vertebral bodiesanterior structures (vertebral bodiesand disks).and disks).44
  10. 10. Traction BasicsTraction BasicsTraction can “centralizeTraction can “centralize”” aaherniated nucleus pulposus,herniated nucleus pulposus,reducing a protruding orreducing a protruding or““bulgingbulging”” disk.disk.44
  11. 11. Traction BasicsTraction BasicsPressure from the elongatingPressure from the elongatingposterior longitudinalposterior longitudinalligament as it tightens duringligament as it tightens duringtraction also helps force thetraction also helps force thenucleus pulposus inwardnucleus pulposus inwardtowards the disktowards the disk’’s center.s center.44
  12. 12. Traction BasicsTraction BasicsWhen traction is applied, theWhen traction is applied, theresulting increase in fluidresulting increase in fluid(from decreased disk(from decreased diskpressure) contributes topressure) contributes tohealing the annulus fibrosis.healing the annulus fibrosis.44
  13. 13. Traction BasicsTraction BasicsTraction applied too long canTraction applied too long cancause the disc to absorb toocause the disc to absorb toomuch fluid (imbibe) andmuch fluid (imbibe) andoverhydrate, predisposing itoverhydrate, predisposing itto rupture. This process isto rupture. This process issimilar to overfilling a watersimilar to overfilling a waterballoon.balloon.33
  14. 14. Traction ApplicationTraction ApplicationAthletic training studentsAthletic training studentsshould observe traction beingshould observe traction beingapplied by an experiencedapplied by an experiencedclinician first and be closelyclinician first and be closelysupervised when applyingsupervised when applyingtraction techniques.traction techniques.22
  15. 15. Traction ApplicationTraction ApplicationTraction can be applied in aTraction can be applied in asustained or intermittent manner.sustained or intermittent manner.Motorized units and weight-and-Motorized units and weight-and-pulley systems can administerpulley systems can administersustained or intermittent traction.sustained or intermittent traction.Intermittent traction is suggestedIntermittent traction is suggestedwhen applying manual traction.when applying manual traction.44
  16. 16. Traction ApplicationTraction ApplicationSustained traction isSustained traction isrecommended when treatingrecommended when treatingdegenerative disc disease, muscledegenerative disc disease, musclespasm and nerve rootspasm and nerve rootimpingement. Intermittentimpingement. Intermittenttraction is recommended fortraction is recommended fortreating facet joints and disctreating facet joints and discprotrusion.protrusion.44
  17. 17. Traction ApplicationTraction ApplicationWhen applying intermittentWhen applying intermittenttraction, the “resttraction, the “rest”” period involvesperiod involvesaa reductionreduction of traction force (aboutof traction force (about50%), not the complete removal of50%), not the complete removal offorce.force.1,41,4Another recommendation is toAnother recommendation is toreduce the force by 1/3 during thereduce the force by 1/3 during therest phase.rest phase.22
  18. 18. Cervical TractionCervical TractionApplicationApplicationA minimum of 15 degreesA minimum of 15 degreesof flexion is necessary toof flexion is necessary toopen the cervical posterioropen the cervical posteriorfacets.facets.44
  19. 19. Cervical TractionCervical TractionApplicationApplicationTraction in the neutralTraction in the neutralcervical spine position causescervical spine position causesthe greatest separation in thethe greatest separation in theupper cervical spine; 30upper cervical spine; 30degrees of flexion directs thedegrees of flexion directs theforces more to the lowerforces more to the lowercervical spine.cervical spine.1,21,2
  20. 20. Cervical TractionCervical TractionApplicationApplicationTo optimally separate the cervicalTo optimally separate the cervicalposterior facet articulations, openposterior facet articulations, openthe intervertebral space, widen thethe intervertebral space, widen theintervertebral foramen and stretchintervertebral foramen and stretchthe posterior tissues, 25-30 degreesthe posterior tissues, 25-30 degreesof flexion is recommended. Thisof flexion is recommended. Thisposition also straightens theposition also straightens thenormal cervical lordosis.normal cervical lordosis.44
  21. 21. Cervical TractionCervical TractionApplicationApplicationAlways start with manualAlways start with manualcervical traction before applyingcervical traction before applyingmechanical or motorizedmechanical or motorizedtraction. This way any painfultraction. This way any painfulmovements can be noted ormovements can be noted orimmediately stopped.immediately stopped.22
  22. 22. Cervical TractionCervical TractionApplicationApplicationApplicationApplicationmethodsmethodsBoth hands underBoth hands underthe occiputthe occiputOne hand underOne hand underthe occiput and thethe occiput and theother under theother under themandiblemandibleOne hand underOne hand underocciput and otherocciput and otherover foreheadover forehead1,41,4Image courtesy of Starkey,www.therapeuticmodalities.com FADavis Publishers
  23. 23. Cervical TractionCervical TractionApplicationApplicationCervical traction should beCervical traction should beapplied in a supine positionapplied in a supine positionfor optimal benefit.for optimal benefit.22
  24. 24. Cervical TractionCervical TractionApplicationApplicationIntermittent manualIntermittent manualcervical traction may becervical traction may beapplied for 5-10 secondsapplied for 5-10 secondsfollowed by a very shortfollowed by a very shortrest time.rest time.Total treatment time isTotal treatment time istypically 3-10 minutes.typically 3-10 minutes.22
  25. 25. Cervical TractionCervical TractionApplicationApplicationAdditional methods of cervicalAdditional methods of cervicaltraction (other than manual)traction (other than manual)Mechanical (ie: over door harness)Mechanical (ie: over door harness)Note that “mechanicalNote that “mechanical”” andand““motorizedmotorized”” are sometimes usedare sometimes usedinterchangeablyinterchangeablyMechanical refers to the use of aMechanical refers to the use of adevice to apply tractiondevice to apply traction1,21,2
  26. 26. Cervical TractionCervical TractionApplicationApplicationAdditional methods of cervicalAdditional methods of cervicaltraction (other than manual)traction (other than manual)MotorizedMotorizedUp to 25 lbs force recommendedUp to 25 lbs force recommended22Start with 15 lbs with smallerStart with 15 lbs with smallerindividualsindividuals11Starting force of 7% of body weightStarting force of 7% of body weightis another recommendationis another recommendation
  27. 27. Cervical TractionCervical TractionApplicationApplicationAdditional motorizedAdditional motorizedtraction recommendationstraction recommendationsSustainedSustained10 minutes10 minutesIntermittentIntermittent20 seconds on, 5 seconds off20 seconds on, 5 seconds offfor 20-25 minutesfor 20-25 minutes22
  28. 28. Lumbar TractionLumbar TractionApplicationApplicationManualManualSingle Leg tractionSingle Leg tractionPatient supinePatient supineOne clinician stabilizes torsoOne clinician stabilizes torsoAnother clinician applies tractionAnother clinician applies tractionon single leg (steady pull untilon single leg (steady pull untiltraction is felt)traction is felt)5, 30 second bouts recommended5, 30 second bouts recommended22
  29. 29. Lumbar TractionLumbar TractionApplicationApplicationManual cont…Manual cont…Hip flexor stretch to follow singleHip flexor stretch to follow singleleg tractionleg tractionSupine edge of table, hang leg offSupine edge of table, hang leg offtable while other knee is pulledtable while other knee is pulledtowards chesttowards chestSimilar position to Gaenslen’s SignSimilar position to Gaenslen’s SignThese muscles are often tightThese muscles are often tightwith radicular painwith radicular pain22
  30. 30. Lumbar TractionLumbar TractionApplicationApplicationMechanical lumbar tractionMechanical lumbar tractionTraction TableTraction TableStart with 25% body weight,Start with 25% body weight,then work up to 50% of bodythen work up to 50% of bodyweightweight SustainedSustainedSlightly lower force usedSlightly lower force used10-30 minute treatment time10-30 minute treatment time22
  31. 31. Lumbar TractionLumbar TractionApplicationApplicationMechanical lumbar tractionMechanical lumbar tractionTraction Table continued…Traction Table continued…IntermittentIntermittent30 seconds on, 15-30 seconds off30 seconds on, 15-30 seconds offLonger on time up to 60 secs forLonger on time up to 60 secs fordisk injurydisk injuryShorter on time (15 secs) for facetShorter on time (15 secs) for facetjoint dysfunctionjoint dysfunction1,21,2
  32. 32. Positional TractionPositional TractionExamples of positional traction include:Examples of positional traction include:Knees to chest (bilateral intervertebralKnees to chest (bilateral intervertebralforamen separation)foramen separation)Sidelying with pillow or blanket rollSidelying with pillow or blanket rollbetween iliac crest and the ribcagebetween iliac crest and the ribcage(unilateral intervertebral foramen(unilateral intervertebral foramenseparation)separation)InversionInversionPool TractionPool Traction33Image courtesy ofaccessphysiotherapy.com
  33. 33. Positional TractionPositional TractionFor sidelying, the side on which theFor sidelying, the side on which theincreased foramen opening is desiredincreased foramen opening is desiredshould be in the superior position,should be in the superior position,with the pillow or blanket roll at thewith the pillow or blanket roll at theaffected spinal level.affected spinal level.However, take note of patient self-However, take note of patient self-positioning (leaning towards or awaypositioning (leaning towards or awayfrom pain) to determine positioningfrom pain) to determine positioningfor side-lying traction.for side-lying traction.33
  34. 34. Lumbar TractionLumbar TractionApplicationApplicationInversion tableInversion tablePatient suspended upside downPatient suspended upside downWeight of upper bodyWeight of upper bodyapplies tractionapplies tractionSpecial contraindicationsSpecial contraindicationsdue to increased pressuredue to increased pressureHypertension (140/90+)Hypertension (140/90+)Heart DiseaseHeart DiseaseGlaucomaGlaucoma2,32,3Image courtesy ofvitalityweb.com
  35. 35. Lumbar TractionLumbar TractionApplicationApplicationInversion traction delivers tractionequivalent to approximately 40% ofthe patient’s body weight.Blood pressure should bemonitored. If BP increases 20mmabove the resting diastolic duringtreatment, the treatment should bediscontinued for that day.3
  36. 36. Lumbar TractionLumbar TractionApplicationApplicationThose with a detached retina, sinusproblems, thyroid issues, diabetes,migraines, a hiatal hernia, recentsurgery, or musculoskeletal issuesshould consult a physician beforedoing inversion traction.For patient comfort, meals or snacksshould be avoided for the hourbefore treatment.3
  37. 37. Lumbar TractionLumbar TractionApplicationApplicationStart slowly with a minute or twoStart slowly with a minute or twoof inversion traction and progressof inversion traction and progressto a maximum of 10-20 minutesto a maximum of 10-20 minutesper session.per session.33
  38. 38. Lumbar TractionLumbar TractionApplicationApplicationHave the patient perform a simple testHave the patient perform a simple testto see if inversion traction can beto see if inversion traction can betolerated by assuming a hands and kneestolerated by assuming a hands and kneesposition and then placing their head onposition and then placing their head onthe floor, remaining in this position forthe floor, remaining in this position forone minute. Vertigo, dizziness, or nauseaone minute. Vertigo, dizziness, or nauseamay indicate the patient is a poormay indicate the patient is a poorcandidate for inversion traction.candidate for inversion traction.33
  39. 39. Lumbar TractionLumbar TractionApplicationApplicationPool TractionPool TractionFlotation belt around torsoFlotation belt around torso(ie: aqua jogger)(ie: aqua jogger)Cuff weights around anklesCuff weights around ankles22
  40. 40. Lumbar TractionLumbar TractionApplicationApplicationPassive prone extensionPassive prone extensionrecommended immediately followingrecommended immediately followinglumbar traction treatment.lumbar traction treatment.22Image courtesy of health.com
  41. 41. Lumbar TractionLumbar TractionApplicationApplicationPassive prone extension facilitatesPassive prone extension facilitatesthe posterior longitudinal ligamentthe posterior longitudinal ligamentpushing the nucleus pulposus backpushing the nucleus pulposus backinto position.into position.22
  42. 42. TractionTractionContraindicationsContraindicationsTraction is contraindicatedTraction is contraindicatedfor any acute neck or backfor any acute neck or backinjury (acute injury in thisinjury (acute injury in thiscase refers tocase refers to anyany injuryinjurycaused by trauma orcaused by trauma orexcessive force).excessive force).1,21,2
  43. 43. TractionTractionContraindicationsContraindicationsFractured dens (odontoid process)Fractured dens (odontoid process)of 2of 2ndndcervical vertebrae (axis)cervical vertebrae (axis)Due to trauma, often whiplashDue to trauma, often whiplashMay go undiagnosed, not particularlyMay go undiagnosed, not particularlypainfulpainfulTraction can causeTraction can cause fatalfatal injury due toinjury due todislocation of 1dislocation of 1ststor 2or 2ndndvertebraevertebraeThis is one reason why traction isThis is one reason why traction iscontraindicated in acute injuriescontraindicated in acute injuriesFracture must be ruled outFracture must be ruled out
  44. 44. TractionTractionContraindicationsContraindicationsTraction is contraindicatedTraction is contraindicatedin individuals with Downin individuals with Down’’ssSyndrome, who often haveSyndrome, who often haveC1-C2 instability.C1-C2 instability.44
  45. 45. TractionTractionContraindicationsContraindicationsVertebral Artery TestVertebral Artery TestA bony anomaly in the cervicalA bony anomaly in the cervicalspine can put pressure on thespine can put pressure on thevertebral artery, which suppliesvertebral artery, which suppliesblood to the brain. Always performblood to the brain. Always performthe vertebral artery test to ascertainthe vertebral artery test to ascertaina patienta patient’’s circulatory status befores circulatory status beforeapplying traction…applying traction…
  46. 46. TractionTractionContraindicationsContraindicationsVertebral Artery TestVertebral Artery Test... ask the patient to rotate and extend... ask the patient to rotate and extendhis or her head (active ROM) as far ashis or her head (active ROM) as far aspossible in one direction and then thepossible in one direction and then theother. Hold each position for 30other. Hold each position for 30seconds. If the patient becomes dizzyseconds. If the patient becomes dizzyor nauseated, or slurs their speech,or nauseated, or slurs their speech,traction is contraindicated.traction is contraindicated.1,41,4
  47. 47. TractionTractionContraindicationsContraindicationsAdditional contraindicationsAdditional contraindicationsinclude but are not limited to:include but are not limited to:MalignancyMalignancyInfectious disease of the spineInfectious disease of the spineRheumatoid arthritisRheumatoid arthritisOsteoporosisOsteoporosisUncontrolled hypertensionUncontrolled hypertension22
  48. 48. TractionTractionContraindicationsContraindicationsAdditional contraindicationsAdditional contraindicationsinclude but are not limited to:include but are not limited to:Hypermobile jointsHypermobile jointsOlder adults who are frailOlder adults who are frailRespiratory or cardiovascularRespiratory or cardiovasculardiseasediseaseAortic aneurysmAortic aneurysm22
  49. 49. TractionTractionContraindicationsContraindicationsAdditional contraindicationsAdditional contraindicationsinclude but are not limited to:include but are not limited to:Spinal cord compressionSpinal cord compressionWhen traction increasesWhen traction increasesradicular painradicular pain22
  50. 50. TractionTractionContraindicationsContraindicationsSpecial lumbarSpecial lumbarcontraindications include butcontraindications include butare not limited to:are not limited to:PregnancyPregnancyHiatal herniaHiatal herniaAbdominal herniaAbdominal herniaActive peptic ulcerActive peptic ulcer22
  51. 51. TractionTractionContraindicationsContraindicationsAdditional mechanical lumbarAdditional mechanical lumbartraction concernstraction concernsMay not be able to adjust beltsMay not be able to adjust beltstight enough on thin individualstight enough on thin individualsBelts may not fit obese individualsBelts may not fit obese individualsClaustrophobic individuals mayClaustrophobic individuals mayhave difficulty when belts arehave difficulty when belts aretightenedtightened11
  52. 52. ReferencesReferences1. Denegar et al, Therapeutic Modalities forMusculoskeletal Injuries, 3rdedition2. Knight and Draper, TherapeuticModalities: The Art and Science3. Prentice, Therapeutic Modalities: ForSports Medicine and Athletic Training. 5thed.4. Starkey, Therapeutic Modalities, 3rdedition

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