1 TRACTION
2 OUTCOMES Must be familiar with the types of mechanical traction.Must be familiar with the mechanical effects of Must be familiar with the indications for mechanical traction. Must be familiar with the contra-indications for mechanical traction.
3 OUTCOMES Must be familiar with the application andtechnique for mechanical cervical traction. Must be familiar with the dosage and progression of mechanical cervical traction. technique for mechanical lumbar traction.
4 DEFINITION Traction is derived from the Latin word“tractico” which means a process of drawing or pulling. It is used in the same way as ordinary passive mobilisation techniques
5 TYPES OF TRACTION Continuous traction Sustained tractionIntermittent traction Manual traction Auto-traction Positional traction 90/90 traction
6 TYPES OF LUMBAR TRACTIONInversion traction Gravity traction Pool traction
7 MECHANICAL EFFECTS Delordosis of the spine Separation of the vertebraeWidening of intervertebral foramen Combination of distraction and gliding of the facet joints Stretching of spinal musculature and ligaments Distraction
8 MECHANICAL EFFECTS Tensing of posterior longitudinal ligament SuctionRelaxation of spinal muscles Joint mobilisation Reduction of herniated nuclear material Increase of interspinous distances Epidural fatty tissue become prominent
9 MECHANICAL EFFECTS Small pressure changes Normalisation of conductionPain relief
10 MECHANICAL EFFECT (SUCTION)Onel (1989) - negative intradiscal pressure “sucks back” the herniated nucleus material and widening of IV disc space causes a stretch on the ant and post longitudinal ligaments
11 MECHANICAL EFFECT (SUCTION)Krause (2000) negates this statement
12 CLINICAL EFFECTS OF TRACTIONRemains controversial Produced from combination of mechanical and physiological effects
13 INDICATIONS Severe nerve root pain Recent neurological changesDegenerative conditions Widely distributed areas of thoracic and lumbar pain Pathological Trauma to ligaments Spondilolisthesis and spondilolysis No further improvement with mobilisation Lumbar conditions where movements are painless during objective evaluation
14 CONTRA-INDICATIONS Resent onset of severe lumbar painHypermobility or instability Undiagnosed pain Persistent cough Cardio-vascular conditions Spinal malignancy Cord compression Spinal infection Hiatal hernia Uncontrolled hypertension Aortic aneurysm Abdominal hernia Severe haemorrhoids
15 CONTRA-INDICATIONS Inadequate investigation Acute traumatic lesionsLarge central disc Ileofemoral incompetency Uncooperative patient Marked ligamentous insufficiency and segmental instability
16 CONTRA-INDICATIONS Dizzy, nauseated and sick after first careful attempt - cervical Vertebrobasilar insufficiency Patient unable to relax - cervical Appreciable involuntary head or neck movements - cervical
17 TRACTION FORCE NEEDED Researcher Weight (traction force) Maitland< 13 kg for first time Average weight between 30 kg and 45 kg Cyriax 40 kg to 85 kg Grieve 13 kg to 34 kg Hicklings 32 kg to 68 kg
18 APPLICATION OF TRACTION
19 PRONE
20 SUPINE
21 PRONE INTO FLEXION
22 UNILATERAL
23 TREATMENT DURATION Researcher Weight Time Saunders (1995:286)Few min to 40 min Onel, et al. (1987:82) 45 kg 40 min Maitland (2001:376) Determine by dummy-trial Not exceeding 10 for 1st time, duration not exceed 15 min Cyriax (Harte, et al. 2003:1543) 30 – 45 min Hicklings (Harte, et al. 2003:1543) 20 – 40 min with average 30 min Grieve (Harte, et al. 2003:1543) 10 min initial treatment; 15 min thereafter
24 UPPER CERVICAL TRACTIONUpper cervical area C1-C4 Neutral position
25 UPPER CERVICAL TRACTION
26 LOWER CERVICAL TRACTIONLower cervical area C4-T1 Neck in flexion using pillows or towel roll
27 METHOD Patient lies with two pillows under his kneesApply gentle traction via spreader bar Know the area and severity of patient’s pain Trial-run for 10 seconds Re-assess the symptoms
28 PROGRESSION Applied dailyTest neck movements directly after traction except with severe nerve root pain Time should be increased first Strength can be increased in small stages Treatment usually 15 minutes Severe nerve root: 30 minutes
29 PROGRESSION Stop traction if no improvement after 4-5 treatmentsSevere nerve root pain sometimes at least 7-8 treatments, but Movement test must improve by 4th to 5th session NB: Carefully assess signs and symptoms before, during and after treatment
30 UPPER LUMBAR TRACTION L1-L4 Neutral position
31 UPPER LUMBAR TRACTION
32 LOWER LUMBAR TRACTION L4-S1Patient positioned in Fowler’s position (Thomas-curl position)
33 LOWER LUMBAR TRACTION
34 LUMBAR TRACTION Attach the thoracic harness in standing and re-adjust in supine Assess area and degree of pain before pull Knees flexed over pillows to put joint in mid-position Trial run
35 LUMBAR TRACTION 12,5 kg to 13 kg for 10 seconds Arms by sideReduce if patient experiences low back pain Re-assess back and leg symptoms after seconds
36 DURING RELEASE Rolling pelvis side to side Rest for a few minutesNB: Do not test patients comparable sign immediately only re-assess following day Warn patient
37 PROGRESSION Pain less or gone = improvement Signs and symptoms worseSigns and symptoms ISQ Over 3-4 sessions improvement will be small If signs improve - increase time first With no exacerbation - increase kg
38 REMEMBER There is often a postural component involved with disorders of the lumbar spine
39 RULE OF PROCEDURE (Grieve, 1989)Bear in mind contra-indications Examine thoroughly Try and localise the problem Keep treatment under control by frequent reassessment and precise recording Each step should be reasoned Modify techniques which are unproductive
40 RULE OF PROCEDURE (Grieve, 1989)Warn patient about treatment soreness Do not over treat Never push through spasm Treat joint irritability with respect
41 TREATMENT PROTOCOL Teach spinal stabilisationDynamic maintenance of postural control Patient reassurance Ergonomic advice Mechanical principles involved Restoration of maximal patient function Pain control
42 TREATMENT PROTOCOL To educate patient To maintain lumbar musclesCombination of treatments Back school Strengthening exercises
43 TREATMENT PROTOCOL Flexibility exercises Fitness Total bedrestEncouragement to function despite symptoms Corset Lumbar intervertebral traction