Mechanical Traction Therapeutic Modalities in Physical Therapy

Mechanical Traction

Therapeutic Modalities in

Physical Therapy

General Information

•Traction means to draw or pull• Distraction means to separate joint surfaces

Effects

– Separation of vertebral bodies

– Distract and glide facet joints

– Tensing of the ligamentous structures

– Widening of the intervertebral foramen

– Straightening of spinal curves

– Stretching of spinal musculature

Types of Traction

• Continuous

– Tx applied for several hours at a time

– Constant tension

– Limited weight tolerated due to long duration

– Ineffective in creating separation

– Normally applied with suspended weights

Types of Traction

• Sustained (static)

– Tx applied with constant tension for several minutes up to ½ hour

– May be applied via suspended weights or a mechanical device

Types of Traction

• Intermittent Mechanical

– Tx applied via a mechanical device with tension alternately applied and then released

– Termed hold and rest

– Hold and rest times usually vary from a few seconds up to 1 minute

Types of Traction

• Manual

– Tx applied by the therapist grasping the patient and utilizing his or her own force to create traction

– May be applied for a several second hold or as a quick thrust

– Limited by strength and endurance of the therapist

– Very accommodating and provides feedback

– Some possible apprehension by patient

Types of Traction

• Positional

– Tx applied by use of gravity and positioning to effect spinal structures with minimal intervention

– Utilizes pillows, blocks, bolsters

– Normally has a unilateral effect

Types of Traction

• Gravity– Tx utilizing the force of gravity acting on the

patients body weight to effect spinal structures

– 2 types: • Vest that suspends the lower body by exerting

pressure on the rib cage• Boots that attach to a rod at the ankles with

patient in inverted position

Treatment Indications

• Disc herniation

– In an erect posture the disc helps to dissipate compressive forces

– With movement into flexion/extension/lateral flexion, the pressure changes


• Nucleus pulposus does not move

– With rupture of the annulus fibrosis the nucleus is allowed to move out of the intervertebral space

– Increases space available, creates suction force, and allows fluid exchange to get rid of waste and allow in fresh nutrients

– Effects are transient


• Reversed with weight bearing and flexion (corset, brace)

– Need neutral spine position to get disc back in– Extension maintained for scar tissue formation– Some researchers report increased fluid in the

nucleus pulposus drawn from the vertebral body during tx

– This will explain the increase in pain in some patients with disc prolapses, immediately following tx

– They recommend using 30 pounds as an initial tx force with disc patients to assess their tolerance


• Degenerative disc disease

– Narrowing of intervertebral spaces

– Pressure on nerve roots, increased load on facets

– Traction widens space and decreases pressure temporarily

– May result in realignment that decreases pressure


• impinged capsule• Joint hypomobility– Mobilization, passive joint movement, non-

specific– Pain control by synovial fluid exchange to facet capsules

and the meniscus for nutrition, and proprioceptive response from moving facet

structures gives a gate control response


• Nerve root impingement– From bulging disc, osteophytes (spurs), narrowed foramen– Tingling usually associated with nerve compression– Continued pressure gives demyelination with slowing of nerve

impulses and can progress to axon death with resulting numbness, weakness and diminished reflex responses

– Muscle spasms may develop in paraspinals with the same innervation level

– Widens foramen– May need unilateral or rotation added– May realign to decrease pressure– Decreases spasms that may be the cause of compression– Nerve irritation can cause muscle spasms as the root levels may

be the same, just different axons


• Muscle tightness, spasms

– Stretches, inhibits

– Decreases load on other structures (nerve root, facets, disc) that may result in spasms

– Fluid exchange

– Initial stretch should come form positioning

– EMG activity will decrease with proper technique, increase with improper


• Scoliosis

– Pulls towards a more correct alignment

– Stretches out tight musculature or other joint structures

• Pain

– Traction may decrease pressure on sensitive structures and give a gate control effect with movement of these structures

Contraindications

• Acute conditions – Tx to acute sprains and strains may overwhelm already

weakened soft tissue• Already weakened soft tissue• Joint instability – hypermobility• Structural disease secondary to infection, tumor, etc.• Vascular compromise• Fractures• Tumors• Bone disease or infection• Cardiac conditions

Relative Contraindications

• Pregnancy

• Osteoporosis

• Hiatal hernia

• Claustrophobia

General Technique for Applying Lumbar Tx

• Force must be great enough to effect change to the target structure

– 20-50% to move body– Coefficient of friction is about 0.5– Usually attempt to move 50% of the patient’s body weight– 65-100 lbs of force to separate vertebrae on average• May not be necessary for all treatments (spasms, pain)• May not get to 65-100 lbs on first treatment– Split table to reduce friction, must separate at target tissue– Damage not reported until somewhere in the 400-800 lb range– Instability is a problem with the sedentary, weak, elderly, and

young


• Patient must be able to relax– Cannot out pull musculature– No pain– Use adjunctive treatments– Research shows a decrease in joint space

with poor traction technique– EMG activity will increase with a pull that is

too strong or with poor, uncomfortable positioning


• Traction harness use– Clip buckle versus velcro– Vinyl versus cotton– Adjustable lengths, pads– Placement of lumbar belts • skin versus clothes – dissipate traction force)– Use of thoracic belts on lower, lateral ribs• Not in axilla– The thoracic belt is placed on after the pelvic belt


• Patient position– Prone versus supine (comfort, goals)– Prone • Disc• Pillows under abdomen to flatten lordosis, under

thighs or chest to increase extension– Supine• Mobilization• pillows under knees to decrease lordosis– Initial soft tissue stretch on soft tissue should come

from positioning


• Adjustments to belts, positioning and poundage

– Made with first few pulls before split table is released

– All slack is taken up before table is released and release is only during rest phase

Effects of Lordosis (supine)• Leg Position– Up on a stool, decreases lordosis– Flat, normal lordosis is maintained– 90/90 position should flatten back, less than that decreases in increments• Rope Angle– Flat low pull maintains– With increased (elevated) rope angle, lordosis decreases• Pelvic Harness– Greatest effect on lordosis– Posterior pull decreases lordosis– Lateral pull maintains lordosis– Anterior pull increases lordosis– Positions between these will result in incremental changes

Effects on Lordosis (prone)• Patients with sever pain and muscle spasms may tolerate prone

traction better• Pillows and harness to control lordosis• Rope angle– Always low– Pillows can decrease or increase lordosis• Pelvic harness– May be placed to effect lordosis, as with supine– Harness is never placed posteriorly in prone– Rarely anterior– As a rule, it is placed laterally to maintain other positional effects• Treatment in prone – Allows performance of other modalities without position changes – Allows for easy palpation of the interspinous spaces to determine the

level and degree of spinal motion

Traction Type (mode)

• Sustained

– Well suited for disc herniations, muscle spasms other soft tissue tightness

– Less poundage is tolerated than with intermittent

– Mechanical devices are most effective

– Pulleys with weights do not take up slack well over time to sustain constant tension


• New digital tx devices– Are programmable– Poundage (tension) can be increased in steps pre-set by therapist– Protocols for hold/rest times, steps to increase tension

incrementally, etc– Can all be programmed into many devices and saved– Gradual build up allows patient to accommodate to increases in

tension – Studies show a greater degree of ligament deformation with a low

rate of loading compared to a more rapid rate– Long term shortening with contractures from positioning over the

years responds well to this low rate


• Intermittent

– Patients can tolerate greater poundages with the rest periods

– Works well for joint hypomobility and degenerative disc disease with shorter rest and hold times (mobilizing effect)

Traction Type (mode)• Positional– Normally sidelying over a bolster or blanket– Well suited for scoliosis treatment and other long term treatments– Can be performed at home by the patient– If tightness is severe enough, the tightened structures may result in a scoliosis– Concavity will be on the tight side– Patient is placed in sidelying on the convex side with the apex of the curve on the

bolster– Allows gravity to effect a traction force on the patient’s body weight– Creates unilateral separation on the opposite side of the spine– Flexion of the hips and knees to forward bend the spine – Trunk rotation towards the side of the superior shoulder will increase the opening

of the spine on that side– In supine, with hips and knees flexed allows opening of the intervertebral foramen,

bilaterally– Also useful with patients on very restricted activity due to pain


• Manual– Very adaptable– Various angles may be applied with combinations of rotation, long

axis distraction, lateral flexion and flexion/extension– Allows tx to be applied to a specific level as it is palpated– May be utilized as a evaluation tool to aid in determining a

diagnosis and to assess tolerance and effectiveness of traction– Limited by strength and endurance of therapist– Better suited for cervical than lumbar traction– Allows constant adjustments by the therapist based on constant

feedback– Can be applied unilaterally to one leg to effect the iliofemoral joint

or the sacroiliac joint

Treatment Time

• Generally 20 minutes for sustained or intermittent

• May be adjusted downward as tolerated, especially with initial treatments

• Disc: 8 minutes or less if sustained tx is used

• Traction creates a suction force as vertebrae are separated, pulls disc back in place

– suction effect is eliminated with time as pressures across membrane equalize

Cervical Traction

• Objectives and concepts are much the same as for lumbar traction

• Some adjustments are required in techniques of application and occurrence rates of particular dysfunctions vary (less disc, more ligamentous)

• In the cervical spine, the vertebral arteries, part of the blood supply to the brain, lie within the bony structures of the spine

Positioning for Cervical Tx

• Sitting

– Less desirable, but occasionally necessary

• Ex. Necessary with reflux esophagitis

– Unable to relax musculature

– Halter pulls on mandible, puts pressure on TMJ

– Flexion is applied by use of a posterior tilting traction chair or by the use of pillows behind the low back, sliding the hips forward and resulting in forward flexion of the neck when the traction force is vertical

Positioning for Cervical Tx

• Supine– In halter, more load is placed on the occiput by gravity– Increased ability to relax– Facilitates the use of Saunders and other new devices which

avoid TMJ loading– Position of choice– 20-30 degrees of flexion is needed to place the spine in neutral

and flatten the normal lordosis– Exception is treatment to the atlanto-axial and atlanto-

occipital joints• These joints should be treated with maintenance of the

normal lordosis of the cervical spine according to Saunders

Effects on Cervical Flexion

• Rope Angle

– To effect 25-30 degrees of flexion on the neck the rope angle will need to approach 45 degrees due to the flexibility of the rope resulting in a sagging with the weight of the head

– The angle is 0, or flat for atlanto-occipital and atlanto-axial traction

General Technique for Applying Cervical Tx

• Halter– The position of the halter will have the most significant effect on

cervical spine flexion – A halter placed and tightened too low on the neck will result in

head on neck extension and the inability to eliminate the cervical lordosis

– A halter placed to high on or past the occiput or placed too loosely will slip off when a traction force is applied

– Ideally, the occipital pad is placed directly on the occiput and tightened snugly enough to prevent slipping

– A poor set-up will result in head on neck extension and uncomfortable loading of the mandible and in effect the TMJ

– Halters should not be utilized on patients with a history of TMJ dysfunction or patients with poor dental occlusion


• Saunders

– Saunders or similar traction devices utilize a sliding track, with placement of the head on a pad on the carriage to decrease the tension load necessary to produce a traction force by eliminating most of the friction

– Stabilization is provided by a head strap and posterior pads that are tightened against the occiput and the mastoid processes


Poundage– Research reports separation of vertebral bodies with ranges from

25-40 pounds– 10 pounds for the atlanto-occipital and atlanto-axial joints– Cadaveric studies did not show damage until 120 pounds of

traction– Less than 25 pounds may be effective if separation of vertebral

bodies is not the goal– Stretching of posterior musculature and opening of the

intervertebral foramen can occur at lesser poundages– Normally greater than 10 pounds is required just to offset the

weight of the head


Manual Traction

• Can be highly effective in the cervical spine with good orthopaedic skills

• Highly flexible, constant feedback

• High load on the therapist

• Manual traction also allows for pressure over trigger points for pain control as traction is being applied

Documents

Mechanical Traction Therapeutic Modalities in Physical Therapy