24/07/1438 Spinal Traction Cervical & Lumbar

Traction Traction is the process of drawing or pulling the spinal column to apply a longitudinal force to the spine & associated structure, this force separates the vertebrae, opening the intervertebral space It is therapeutic tools that falls in the area of exercise because of its effect on the musculoskeletal system and use in stretching and mobilizing techniques.

How Does Traction Relieve Pain? Increasing the space between vertebrae Separating the apophyseal joints Widening the intervertebral foramina Removing pressure on injured tissue Reducing muscle spasm Increasing peripheral circulation Relaxing muscles Changing intervertebral disk pressures Tensing the posterior longitudinal ligament Creating suction to draw protruded disks toward their center Flattening an abnormal lumbar curvature

Physiological effects on Bone Increases spinal movement, overall and between each vertebrae Reverses immobilization-related bone weakness by increasing or maintaining bone density Physiological Effects on Ligament Creates ligament deformation, thereby increasing movement and decreasing impingement problems Long-term effects

Physiological Effects on Articular Facet Joints Increases the separation between joint surfaces Decompresses articular cartilage, allowing synovial fluid exchange to nourish the cartilage May decrease degenerative changes May decrease pain perception

Physiological Effects on Muscles Lengthens tight muscles and allows better muscular blood flow. Activates muscle proprioceptors, further decreasing pain Physiological Effects on Nerves - Decreases compression forces on nerves

General Principles Angle of pull Anatomical differences Neutral: Transverse plane Flexion/Extension: Frontal plane Unilateral: Sagittal plane Multiaxial: Two or more planes Anatomical differences Cervical inferior facet joints angle anteriorly Flexion opens facet joints Lumbar facets angled posteriorly Extension opens facet joints

General Principles Tension No clear formula The traction must overcome the resistance exerted by the soft tissue Use the least amount of tension needed to relieve symptoms Duration is inversely related to tension

Factors that influence the amount of vertebral separation Spinal Position: the greater the amount of flexion that the spine is placed before traction, the greater the vertebral separation. Amount of force applied: In cervical spine: a force of approximately 7% of the body weight separate the vertebrae. A minimum force of 11.25 to 13.5 Kg is necessary to lift the weight of the head when sitting to counteract the resistance of muscle tension. In lumbar spine: a minimum force of half of the body weight is necessary for mechanical separation. Angle of pull: In cervical spine: the angle of pull creating the greatest posterior elongation is 35 degree. In lumbar spine: pulling from the posterior aspect of the pelvis rather than from the sides is necessary to cause flexion of the spine. Position of patient: the patient should be in comfortable and relaxed position. Many patients report feeling more relaxed supine than sitting for cervical traction. Duration of application: 20 to 25 minutes is applicable time.

Types of Traction 1- Static or Constant Traction, which may be: - Continuous or prolonged: static traction in which the force is maintained for several hours. - Sustained: a static traction in which the force is maintained from few minutes up to one-half hour. 2- Intermittent Traction Alternately applied and withdrawn traction at frequent interval.

Mode of application: Mechanical: using various types of equipment. Manual: Administered by the therapist Positional: through positioning to elongate the involved tissue

Indications Muscle spasm Hypomobility of the joints from joint dysfunction or degenerative disk changes Herniated or protruding disks Nerve root compression Facet joint pathology Capsulitis of vertebral joints Anterior/posterior longitudinal ligament pathology

Cervical Disc Herniation

Lumbar Disc Herniation

Contraindications Absolute Spinal infections Spinal Cancer 24/07/1438 Contraindications Absolute Spinal infections Spinal Cancer Spinal Cord pressure Rheumatoid Arthritis Osteoporosis Relative Ligamentous strains and hypermobility Acute stage of injury Traction anxiety Cardiac or respiratory insufficiency Pregnancy May aggravate symptoms in the case of severe serious pathology, such as a large disc prolapse, tumor or severe osteophytes Jt. Capsules, ligs, bones are fragile. Pt’s are subject to atlanto-axial sublux or to developing instability next to areas of hypomobility Bones are fragiliie and subject to fracture

Limitations of Traction The effect of vertebral separation is temporary No consistent protocol exist, rational is hypothetical with inconsistent clinical results. Precautions Complete patient’s evaluation should be done before traction. Close monitoring of patient should be performed throughout treatment. Can cause thrombosis of internal jugular vein if excessive duration or traction weight is used.

Cervical Traction Generally applied with the patient supine or sitting Supine preferred because it eliminates gravity Three main types Manual Positional Mechanical Application of a longitudinal force to the C-spine & structures Tension applied can be expressed in pounds or % of patient’s body weight. At 7% of patient’s body weight, vertebral separation begins Human head accounts for 8.1% of body weight (8-14 lbs.) Greater amount of force is needed widen areas You want force to be about 20% of body weight

Cervical Traction Set-up Neck – placed in 25-30° flexion Straightens normal lordosis of C-spine Must have at least 15° flexion to separate facet joint surfaces Body must be in straight alignment Duration – 10-20 minutes most common Remove any jewelry, glasses, or clothing that may interfere Lay supine, place pillows under knees Secure halter to cervical region placing pressure on occipital process & chin (minor amount)

Cervical Treatment Set-up Align unit for 25-30° of neck flexion Remove any slack in pulley cable On:Off sequence 3:1 or 4:1 ratio Following treatment, gradually reduce tension & gain slack Have patient remain in position for a few minutes after treatment

Manual Cervical Traction To perform manual cervical traction Clinician sits at head of table facing patient Head is cradled to allow distraction of cervical vertebrae without hurting patient Traction is applied Head is slowly moved to maximize relaxation and comfort How to slowly move head into relaxation and comfort Neutral position pain: affecting upper cervical vertebrae Flexed 30° pain: affecting lower cervical vertebrae Lateral flexion pain: pressure on spinal nerves with radiating pain into arms or hands

Cervical Traction Positioning Supine – support lumbar region (bend knees, or hang lower legs over end of table & place feet on chair); allows musculature to relax Therapist standing at the head of the treatment table, supporting the weight of the patient’s head in his hands. Flex the head until motion of the spinous process just begins at the determined level. Support the head with folded towels at the level of flexion, then side bend the head away from the side to be distracted until movement of the spinous process begins.

Mechanical Cervical Traction Harness traction Harness traction device hung over a doorway Amount of tension adjusted by patient As patient pulls one click on the pulley, 1 lb of pressure is applied, separating the vertebrae.

Mechanical Cervical Traction Table traction Mechanical intermittent or sustained table traction Involves use of head harness attached to mechanical device at end of table Device can pull sustained or intermittent traction Usually 30 sec on, 10 sec off

Initiation of Treatment Set controls to zero and turn on unit Remove slack Adjust Ratio Normally 3:1 or 4:1 Tension Approximately 10 pounds or 7% of body weight First exposure use lower tension Duration Corresponding to pathology Termination of Treatment - Tension Gradually reduce over 3 or 4 cycles Gain slack and turn unit OFF - Remove halter from unit and patient - Patient remains in position for 5 minutes after the treatment

Lumbar Traction There are more types of lumbar traction than cervical traction. Some of the most commonly used techniques are presented. To be effective, lumbar traction must overcome lower extremity weight (½ of body weight) Friction is a strong counterforce against lumbar traction Split table is used to reduce friction

Manual Lumbar Traction Allows the clinician to feel patient’s reaction to treatment Can be used as examination technique Clinician uses her hands or a belt to pull on patient’s legs, separating vertebrae

Manual Lumbar Traction Single-leg traction Manual traction Requires two clinicians Patient is prone or supine. One clinician supports patient’s torso, while other puts traction on leg exhibiting radicular pain. After a series of five, 30 sec bouts, patient lies supine at edge of table and stretches affected hip flexors (which are usually tight)

Manual Lumbar Traction (L3-4, L4-5, L5-S1)

Manual Lumbar Traction (T12, L1, L1-2, L2-3)

Unilateral Leg Pull Manual Traction Counter-traction harness needed From ankle flex hip 30, ABD hip 30 and ER fully Apply steady traction along long axis of LE

Mechanical Lumbar Traction Uses a specialized table that separates when adequate forces are applied Patient’s head and trunk are on one half; hips and legs are on other half. One end of belt or strap is attached to patient; other end is attached to mechanical device that separates table

Mechanical Lumbar Traction Traction Force No separation < ¼ BW Can be delivered in either sustained or intermittent mode

Lumbar Positional Traction Bilateral Foramen Opening Athlete in supine Hip/knees flexed

Lumbar Positional Traction Unilateral Foramen Opening Sidelying position Pillow between iliac crest and lower border of ribs Flex hip/knees until LS is forward Trunk rotation toward superior shoulder

Lumbar Positional Traction Supine Knees to chest Forward bend of lumbar spine Separation of Spinous processes Increased size of intervertebral foramen

Unilateral Lumbar Positional Traction

Unilateral Lumbar Positional Traction