1 Spinal Traction Jennifer Doherty-Restrepo, ATC, LATEntry-Level Athletic Training Education Program PET 4995: Therapeutic Modalities

2 Traction Process of drawing, or pulling apart, of a body segmentMechanical Traction - using a traction machine or ropes/ pulleys to apply a traction force Manual Traction - clinician positions patient and applies traction force to joints of the spine or extremities

3 Effects of Traction: SpineEncourages movement between each individual spinal segment Amount of movement varies according to… Position of spine, Amount of force, and Length of time the force is applied Transient effect

4 Effects of Traction: Spine pain, paresthesia, or tingling Due to physical separation of vertebral segments thus decreasing pressure on sensitive structures As long as positive physiologic effects occur, traction should be continued

5 Effects of Traction: BoneNo immediate effects due to traction May result in increased spinal movement that reverses bone weakness associated with immobilization May assist with increasing or maintaining bone density

6 Effects of Traction: LigamentsStretching effect Structural changes occur slowly due to viscoelastic properties Ligaments resist shear forces and return to original form following removal of a deforming load Sensitivity to rate of loading Ligament deformation results in lengthening of a ligament caused by traction loading Slow loading rates allow for more deformation

7 Effects of Traction: DisksNormal disk in non-compressed position Internal pressure (indicated by arrows) is exerted equally in all directions Internal annular fibers contain nuclear materials

8 Effects of Traction: DisksIn an injured disk, sitting or standing compresses the disk causing the nucleus to become flatter Pressure in this instance still remains relatively equal in all directions

9 Effects of Traction: DisksIn an injured disk, movement in weight-bearing causes a horizontal shift in nuclear material If this was forward bending, the bulge would occur in the posterior annular fibers Anterior annular fibers would be slackened and narrow

10 Effects of Traction: DisksHerniation of the nuclear material occurs if the annular wall becomes weak Herniation may possibly put pressure on sensitive structures in the area

11 Effects of Traction: DisksWhen placed under traction, intervertebral space expands thereby decreasing pressure on the disk Taut annular fibers create a centripetally directed force Decreases herniation and pressure on sensitive structures in the area

12 Effects of Traction: Articular Facet JointsFacet joints are separated releasing impinged structures Dramatic reduction in symptoms Joint separation decompresses articular cartilage allowing synovial fluid exchange to nourish cartilage Decreases rate of degenerative changes Increased proprioception from facet joint structures provide sensation of pain relief

13 Effects of Traction: MusclesVertebral muscles can be stretched Initial stretch should come from body positioning Stretch lengthens tight muscle Allows for better muscular blood flow Activates muscle proprioceptors providing sensation of pain relief Gate Control Theory

14 Effects of Traction: NervesFocus of most traction treatments Pressure on nerves or nerve roots often associated with spinal pain Unrelieved pressure on a nerve will cause Slowing, eventual loss of impulse conduction Motor weakness, numbness, and loss of reflex Pain, tenderness, and muscular spasm

15 Traction Treatment TechniquesLumbar Positional Traction Inversion traction Manual Lumbar Traction Level-specific Unilateral leg pull Mechanical Lumbar Traction Manual Cervical Traction Mechanical Cervical Traction

16 Lumbar Positional TractionPatient typically on restricted activity program “Trial and error” process to determine position that offers maximum comfort

17 Side-lying Position: Unilateral Foramen OpeningLateral Herniation Patient leaning away from painful side Lie painful side up Lie on right side over blanket roll

18 Side-lying Position: Unilateral Foramen OpeningLateral Herniation Patient leaning away from painful side Lie painful side up Lie on right side over blanket roll Medial Herniation Patient leaning toward painful side Lie painful side down

19 Side-lying Position: Unilateral Foramen OpeningSide-lying with a blanket roll between iliac crest and rib cage Increases intervertebral foramen size of superior side of lumbar spine

20 Side-lying Position: Unilateral Foramen OpeningMaximum opening of intervertebral foramen Achieved by flexing upper hip and knee and rotating shoulders in opposite directions Maximum opening of left side

21 Supine Position: Bilateral Foramen OpeningKnees to chest position increases size of lumbar intervertebral foramen bilaterally Separation of spinous processes

22 Inversion Traction Hang upside downLengthens spinal column due to stretch provided by weight of trunk Repeat inversion times Observe for signs of vertigo, dizziness, or nausea

23 Manual Lumbar TractionUsed prior to mechanical traction Helps determine degree of lumbar flexion, extension, or side-bending that is most comfortable Most comfortable position is usually best therapeutic position

24 Level-Specific Manual TractionPosition patient for maximum effect at a specific spinal level Lumbar spine flexed using upper leg as lever Palpate interspinous space Upper spinous process is where maximum effect is desired

25 Level-Specific Manual TractionWhen motion of lower spinous process can be palpated, place foot against opposite leg to prevent further flexion Trunk is then rotated toward the upper shoulder until motion of upper spinous process can be palpated

26 Level-Specific Manual TractionPlace chest against ASIS and upper hip Lean toward patient’s feet Use enough force to cause a palpable separation of the spinous processes at desired level

27 Unilateral Leg Pull Manual TractionHip joint problems or difficult lateral shift corrections Thoracic counter-traction harness is used Hold ankle and move hip into 30o flexion, 30o abduction, and full external rotation Apply steady traction force until noticeable distraction occurs

28 Unilateral Leg Pull Manual TractionSacroiliac problems In addition to thoracic counter-traction harness, strap is placed through groin and secured to table Hold ankle and move hip into 30o flexion and 15o abduction Apply steady traction force

29 Mechanical Lumbar Traction: EquipmentUse split table to eliminate friction between body segments Non-slip traction harness stabilizes trunk

30 Mechanical Lumbar Traction: SetupPelvic harness Applied while standing Contact pads and upper belt placed at, or just above, iliac crest Rib pads Positioned over lower rib cage

31 Mechanical Lumbar Traction: Body PositioningNeutral spinal position Allows for largest intervertebral foramen opening before traction is applied Usually position of choice whether prone or supine

32 Mechanical Lumbar Traction: Body PositioningFlexion Increases posterior opening Puts pressure on disk nucleus to move posterior Other soft tissue may also close foramen opening

33 Mechanical Lumbar Traction: Body PositioningExtension Closes foramen because bony arches come closer together

34 Mechanical Lumbar Traction: Body PositioningProne position Used with normal to slightly flattened lumbar lordosis Best for disk protrusions Place pillows under abdomen Other modalities may be applied Allows for assessment of spinous process separation

35 Mechanical Lumbar Traction: Body PositioningSupine position Produces posterior intervertebral separation Optimal at 90o hip flexion Unilateral pelvic traction recommended if stronger force is desired Scoliosis, Unilateral joint dysfunction, or Unilateral lumbar muscle spasm

36 Traction Force No lumbar vertebral separation will occur with traction forces less than 1/4 of body weight Effective traction force ranges between 65 and 200 pounds Traction force recommended = 1/2 body weight Must use progressive steps to comfortably reach therapeutic loads

37 Intermittent vs. Sustained TractionIntermittent Traction Effective for posterior intervertebral separation No firm recommendations for on/off times Sustained Traction Recommended for disk protrusion and rupture

38 Treatment Duration With suspected disk protrusions, total treatment time should be relatively short 10 minutes or less If treatment reduces symptoms, treatment time should remain at 10 min or less If the treatment is partially successful or unsuccessful in relieving symptoms, gradually increase time over several treatments up to 30 min

39 Progressive and Regressive StepsTraction equipment may be built with progressive and regressive modes Progressive mode Increases traction force in a pre-selected number of steps Allows slow accommodation to traction Regressive mode Decreases traction force in a pre-selected number of steps Patient comfort is primary consideration!

40 Manual Cervical TractionStretches muscles and joint structures Enlarges intervertebral spaces and foramen Creates centripetally directed forces on disk and surrounding soft tissue Mobilizes vertebral joints Increases joint proprioception Relieves compressive effects of normal posture Improves arterial, venous, and lymphatic flow

41 Manual Cervical TractionVariety of head and neck positions Hand should cradle neck contacting one mastoid process Other hand on chin Gentle pull, < 20 pounds Intermittent pull, sec Treatment time, min

42 Mechanical Cervical TractionSupine Neck flexed o Traction harness pulls on occiput Intermittent pull > 20 pounds Minimum of 7 seconds Adequate rest time for recovery Treatment time, min Forces up to 50 pounds may produce increased intervertebral separation.

43 Mechanical Cervical TractionWall-mounted device Inexpensive Static traction most easily employed Use weight plates, sand bags, or water bags Intermittent traction may be used Sitting or prone Gentle pull, pounds Treatment time, min

44 Indications for Spinal TractionNerve root impingement Disk herniation Spondylolisthesis Narrowing within intervertebral foramen Osteophyte formation Degenerative joint diseases Subacute pain Joint hypomobility Discogenic pain Muscle spasm or guarding Muscle strain Spinal ligament or capsular contractures Improvement in arterial, venous, and lymphatic flow

45 Contraindications for Spinal TractionAcute sprains or strains Acute inflammation Fractures Vertebral joint instability Any condition in which movement exacerbates existing problem Bone diseases Osteoporosis Infections in bones or joints Vascular conditions Pregnant females Cardiac or pulmonary problems