TRACTION

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.

OUTCOMES Must be familiar with the application and technique for mechanical cervical traction. Must be familiar with the dosage and progression of mechanical cervical traction. technique for mechanical lumbar traction.

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

TYPES OF TRACTION Continuous traction Sustained traction Intermittent traction Manual traction Auto-traction Positional traction 90/90 traction

TYPES OF LUMBAR TRACTION Inversion traction Gravity traction Pool traction

MECHANICAL EFFECTS Delordosis of the spine Separation of the vertebrae Widening of intervertebral foramen Combination of distraction and gliding of the facet joints Stretching of spinal musculature and ligaments Distraction

MECHANICAL EFFECTS Tensing of posterior longitudinal ligament Suction Relaxation of spinal muscles Joint mobilisation Reduction of herniated nuclear material Increase of interspinous distances Epidural fatty tissue become prominent

MECHANICAL EFFECTS Small pressure changes Normalisation of conduction Pain relief

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

MECHANICAL EFFECT (SUCTION) Krause (2000) negates this statement

CLINICAL EFFECTS OF TRACTION Remains controversial Produced from combination of mechanical and physiological effects

INDICATIONS Severe nerve root pain Recent neurological changes Degenerative 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

CONTRA-INDICATIONS Resent onset of severe lumbar pain Hypermobility 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

CONTRA-INDICATIONS Inadequate investigation Acute traumatic lesions Large central disc Ileofemoral incompetency Uncooperative patient Marked ligamentous insufficiency and segmental instability

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

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

APPLICATION OF TRACTION

PRONE

SUPINE

PRONE INTO FLEXION

UNILATERAL

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

UPPER CERVICAL TRACTION Upper cervical area C1-C4 Neutral position

UPPER CERVICAL TRACTION

LOWER CERVICAL TRACTION Lower cervical area C4-T1 Neck in flexion using pillows or towel roll

METHOD Patient lies with two pillows under his knees Apply gentle traction via spreader bar Know the area and severity of patient’s pain Trial-run for 10 seconds Re-assess the symptoms

PROGRESSION Applied daily Test 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

PROGRESSION Stop traction if no improvement after 4-5 treatments Severe 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

UPPER LUMBAR TRACTION L1-L4 Neutral position

UPPER LUMBAR TRACTION

LOWER LUMBAR TRACTION L4-S1 Patient positioned in Fowler’s position (Thomas-curl position)

LOWER LUMBAR TRACTION

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

LUMBAR TRACTION 12,5 kg to 13 kg for 10 seconds Arms by side Reduce if patient experiences low back pain Re-assess back and leg symptoms after 10-20 seconds

DURING RELEASE Rolling pelvis side to side Rest for a few minutes NB: Do not test patients comparable sign immediately only re-assess following day Warn patient

PROGRESSION Pain less or gone = improvement Signs and symptoms worse Signs and symptoms ISQ Over 3-4 sessions improvement will be small If signs improve - increase time first With no exacerbation - increase kg

REMEMBER There is often a postural component involved with disorders of the lumbar spine

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

RULE OF PROCEDURE (Grieve, 1989) Warn patient about treatment soreness Do not over treat Never push through spasm Treat joint irritability with respect

TREATMENT PROTOCOL Teach spinal stabilisation Dynamic maintenance of postural control Patient reassurance Ergonomic advice Mechanical principles involved Restoration of maximal patient function Pain control

TREATMENT PROTOCOL To educate patient To maintain lumbar muscles Combination of treatments Back school Strengthening exercises

TREATMENT PROTOCOL Flexibility exercises Fitness Total bedrest Encouragement to function despite symptoms Corset Lumbar intervertebral traction