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© 2008 LWW
Chapter 18. Spinal Traction
© 2008 LWW
The Intervertebral DiskThe Intervertebral Disk
• Outer layer: annulus fibrosus– Series of interlacing cross-fibers that are
attached to adjacent vertebral bodies
• Inner layer: nucleus pulposus– A protein gel between the cartilaginous end
plates of the vertebrae and the annulus fibrosus
© 2008 LWW
The Intervertebral Disk (cont.)The Intervertebral Disk (cont.)
• Functions– Shock absorption– Provide flexibility and movement– Provide adequate space between the
vertebrae for exiting nerves
© 2008 LWW
The Intervertebral Disk (cont.)The Intervertebral Disk (cont.)
• As we age, or because of injury, the disk may lose its normal shape– For example, a
bulging disk with weakened annulus fibers might look like the inner tube of a bicycle tire with a weak spot.
© 2008 LWW
The Intervertebral Disk (cont.)The Intervertebral Disk (cont.)
• This is an MRI of a herniated disk at the L3–L4 level; the patient is one of the authors of your text.
• He found some relief from lumbar traction.
© 2008 LWW
The Intervertebral Disk (cont.)The Intervertebral Disk (cont.)
• If a disk is damaged and you move in weight bearing position, the nucleus pulposus will shift according to fluid-dynamic principles.
© 2008 LWW
The Intervertebral Disk (cont.)The Intervertebral Disk (cont.)• For example, if you bend to the right side, the
vertebrae squeeze the nucleus to the left.• If tears develop in the annular fibers, the nucleus
will tend to take the path of least resistance and move in this direction.
© 2008 LWW
TractionTraction• Increases the separation of the vertebrae• Decreases the central pressure in the disk
space• Encourages the nucleus pulposus to return to
a central position • The mechanical tension of the annulus fibrosis
and ligaments surrounding the disk (especially the posterior longitudinal ligament) help push the nucleus pulposus back into its proper place.
© 2008 LWW
Why Use Traction?Why Use Traction?
• Principal reason is pain relief
© 2008 LWW
How Does Traction Relieve Pain?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
© 2008 LWW
Physiological Effects on BonePhysiological Effects on Bone
• Increases spinal movement, overall and between each vertebrae
• Reverses immobilization-related bone weakness by increasing or maintaining bone density
© 2008 LWW
Physiological Effects on LigamentPhysiological Effects on Ligament
• Creates ligament deformation, thereby increasing movement and decreasing impingement problems– Long-term effects
© 2008 LWW
Physiological Effects on Articular Facet JointsPhysiological 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
© 2008 LWW
Physiological Effects on MusclesPhysiological Effects on Muscles
• Lengthens tight muscles and allows better muscular blood flow.
• Activates muscle proprioceptors, further decreasing pain
© 2008 LWW
Physiological Effects on NervesPhysiological Effects on Nerves
• Decreases compression forces on nerves
© 2008 LWW
IndicationsIndications
• Compression of nerve roots• Disk protrusion• Joint hypomobility• Adhesions• Muscle spasm
© 2008 LWW
Indications (cont.)Indications (cont.)
• Disk degeneration• Foraminal stenosis• Contracted connective tissue• Apophyseal joint impingement• Radiating pain that does not improve
with trunk or neck movement
© 2008 LWW
ContraindicationsContraindications• Malignancy
– Primary or metastatic• Infectious diseases of the spine
– Tuberculosis• Uncontrolled hypertension• Rheumatoid arthritis• Spinal cord compression• Osteoporosis• Cardiovascular disease
© 2008 LWW
Contraindications (cont.)Contraindications (cont.)
• Aortic aneurysm• Acute neck or low back pain• Frail older adults• Severe respiratory disease• Hypermobile vertebrae
– Spondylolisthesis
• When traction increases radicular pain
© 2008 LWW
Specific Contraindications for Lumbar TractionSpecific Contraindications for Lumbar Traction
• Pregnancy• Hiatal hernia• Abdominal hernia• Active peptic ulcers• Glaucoma (inversion gravity method)• Do not substitute traction for a more
beneficial treatment– McKenzie extension exercise for a posterior bulging disk
© 2008 LWW
Commonly Used Traction DevicesCommonly Used Traction Devices
• Manual traction– Tractive force is applied by another person
• Mechanical traction– Tractive force is applied with a machine or
other apparatus
© 2008 LWW
Cervical TractionCervical Traction
• Generally applied with the patient supine or sitting– Supine preferred because it eliminates
gravity
• Three main types– Manual– Pneumatic– Motorized
© 2008 LWW
Cervical Traction (cont.)Cervical Traction (cont.)
• Application tip– With cervical traction, always start with
manual traction. Why?
– You can rapidly stop a motion that might be troublesome to the patient.
© 2008 LWW
Cervical Traction (cont.)Cervical Traction (cont.)
• 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
© 2008 LWW
Cervical Traction (cont.)Cervical Traction (cont.)
• 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
© 2008 LWW
Cervical Traction (cont.)Cervical Traction (cont.)
• 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.
© 2008 LWW
Cervical Traction (cont.)Cervical Traction (cont.)• 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
© 2008 LWW
Lumbar TractionLumbar Traction
• There are more types of lumbar traction than cervical traction.
• Some of the most commonly used techniques are presented.
© 2008 LWW
Lumbar Traction (cont.)Lumbar Traction (cont.)
• Manual– 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
© 2008 LWW
Lumbar Traction (cont.)Lumbar Traction (cont.)• 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)
© 2008 LWW
Lumbar Traction (cont.)Lumbar Traction (cont.)• Mechanical
– Uses a specialized table that separates when adequate forces are applied
• Patient’s head and torso 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
– Can be delivered in either sustained or intermittent mode
© 2008 LWW
Lumbar Traction (cont.)Lumbar Traction (cont.)• Autotraction
– Uses a specialized table divided into two sections that can be individually tilted and rotated
– Patients apply traction force by holding onto or pulling on overhead bars.
© 2008 LWW
Lumbar Traction (cont.)Lumbar Traction (cont.)
• Positional traction– Uses pillows and bolsters to position vertebrae so that
there is less pressure on nerves and surrounding tissues
© 2008 LWW
Lumbar Traction (cont.)Lumbar Traction (cont.)
• Pool traction– Flotation belt and
water cuffs cause drag, which result in traction on lumbar vertebrae.
© 2008 LWW
Lumbar Traction (cont.)Lumbar Traction (cont.)• Inversion table
traction– When patient is
suspended upside down, weight of upper body acts as a traction force
– Takes a few sessions to get used to, but has great results• One of the authors of
your book has had positive personal experience.
© 2008 LWW
Lumbar Traction (cont.)Lumbar Traction (cont.)
• Post–inversion traction tip
– Lying prone and extending somewhat on a wedge after inversion traction can be helpful to a patient suffering from a posterior bulging lumbar disk.
© 2008 LWW
Treatment ParametersTreatment Parameters
• Patient position• Treatment mode• Traction force• Duration• Frequency