Spinal Traction, Knight & Draper 2008

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Chapter 18. Spinal Traction

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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

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The Intervertebral Disk (cont.)The Intervertebral Disk (cont.)

• Functions– Shock absorption– Provide flexibility and movement– Provide adequate space between the

vertebrae for exiting nerves

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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.

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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.

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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.

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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.

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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.

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Why Use Traction?Why Use Traction?

• Principal reason is pain relief

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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

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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

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Physiological Effects on LigamentPhysiological Effects on Ligament

• Creates ligament deformation, thereby increasing movement and decreasing impingement problems– Long-term effects

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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

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Physiological Effects on MusclesPhysiological Effects on Muscles

• Lengthens tight muscles and allows better muscular blood flow.

• Activates muscle proprioceptors, further decreasing pain

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Physiological Effects on NervesPhysiological Effects on Nerves

• Decreases compression forces on nerves

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IndicationsIndications

• Compression of nerve roots• Disk protrusion• Joint hypomobility• Adhesions• Muscle spasm

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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

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ContraindicationsContraindications• Malignancy

– Primary or metastatic• Infectious diseases of the spine

– Tuberculosis• Uncontrolled hypertension• Rheumatoid arthritis• Spinal cord compression• Osteoporosis• Cardiovascular disease

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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

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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

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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

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Cervical TractionCervical Traction

• Generally applied with the patient supine or sitting– Supine preferred because it eliminates

gravity

• Three main types– Manual– Pneumatic– Motorized

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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.

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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

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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

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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.

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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

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Lumbar TractionLumbar Traction

• There are more types of lumbar traction than cervical traction.

• Some of the most commonly used techniques are presented.

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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

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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)

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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

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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.

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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

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Lumbar Traction (cont.)Lumbar Traction (cont.)

• Pool traction– Flotation belt and

water cuffs cause drag, which result in traction on lumbar vertebrae.

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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.

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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.

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Treatment ParametersTreatment Parameters

• Patient position• Treatment mode• Traction force• Duration• Frequency