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Traction

Traction. Tara Manal PT, OCS, SCS. Spine Pain with Radiculopathy. Neurological deficits Mechanical compromise Ischaemia of the nerve nerve root/nerve/dorsal root Mechanical compromise of venous outflow Ischemia and fibrosis Inflammation of the nerve root/nerve/dorsal root

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Traction

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  1. Traction Tara Manal PT, OCS, SCS

  2. Spine Pain with Radiculopathy • Neurological deficits • Mechanical compromise • Ischaemia of the nerve nerve root/nerve/dorsal root • Mechanical compromise of venous outflow • Ischemia and fibrosis • Inflammation of the nerve root/nerve/dorsal root • Intervertebral disc lesion/disease • Osteophytic encroachment • Facet inflammation • Chemical response of the nerve to nucleus material

  3. Biomechanical Intervertebral Separation Reduction of disc protrusion Altered Intradiscal pressure Normalization of conduction Increased Joint Mobility Neurophysiological Pain Relief Decrease of Radicular symptoms Hypothesis of Traction

  4. Intervertebral Separation • Strong in vivo and in vitro evidence of separation of intervertebral segments • 9kg (20lbs)for 30 minutes to l-spine in vitro • Most with hips 90º/ cervical ~30º • In vivo occurred at 50lbs • Clinical Implications are unknown • Colachis & Strohm 1969, Twomey 1985, Lee & Evans 1993

  5. Reduction of Disc Protrusion • Weak Evidence • Contrast dye injected in 3 patients • Pre and post traction radiographs • Saw reduction gone in 14 minutes • Study re-done in 1992 with CT • 4 patients with traction until recovery • 2 had disc reduction/ 2 did not • All recovered • Matthews 1968 David 1992

  6. Altered Intradiscal Pressure • Weak Evidence • Single study of healthy discs • No pressure change with mechanical • Increased pressure with patient generated traction (500N) • Anderson et al 1983

  7. Normalization of Conduction • Weak Evidence and Mixed Results • Some authors show normalized sensation, reflexes and muscle power others do not • Increased intervertebral foramen • Reducing ischemia to nerve • Improving removal of inflammatory agents • Reduce mechanical compression • Knutsson 1988, Onel 1989, Tesio 1989, Pal 1986

  8. Increased Joint Mobility • Transitory Increase in cervical range following traction • Elongation of tissue is greater in healthy than in presence of DJD • Longer duration needed (30min) in old vs young • Some evidence for transitory increases

  9. Neurophysiological • Ectopic Impulse Generators • Spontaneous signals in dorsal root resulting from inflammation • Separation may silence these impusles • Mechanical stimulation of large diameter fibers overrides DRG • Moderate evidence in the animal model • Howe 1977, Bini 1984

  10. Neurophysiological • Response to Pain Generation • Central Sensitization • Expansion of Receptive Fields • Thamus and PAG (decreased inhibition) • Peripheral Receptor Hyperactivity • Hypothesis of Traction effects • Increased non-nociceptive input • Recruitment of descending inhibition • Untested

  11. Application of Traction • Patient Selection • Radiculopathy • Nerve root • Stenosis • Worsens with active movement testing • Acute Phase (<6 – 12 wks) • Don’t rule out long standing (stenosis)

  12. Traction Dose • Type of Traction • Mechanical vs. Manual • At 25lbs cervical traction for radicular and non radicular complaints • No difference between intermittent, static and manual

  13. Traction Dose • Magnitude • Minimum needed to achieve goal • ~20-50% BW needed to separate IV • ~4% BW needed to overcome friction • Split table reduces friction • Split table at level of most desired traction • Cervical- 20-25lbs to overcome lordosis • 50lbs had greater separation than 30

  14. Traction Dose • Duration • Minimum needed to achieve goal • Static vs Intermittent • Some evidence need static to overcome muscle contraction • Intermittent often less aggressive and less rebound at end

  15. Traction Dose • Body Position • Best for goal • Angle of the pull • Level • Up at an angle

  16. Flexion Worsens • Prone Traction

  17. Extension Worsens • Supine Traction

  18. Monitoring Response • Oswestry • Neck Disability Index • MMT • Reflexes • Centralization • Pain complaints • Immediate vs over 2-3 Tx’s

  19. Contraindications • Compromised spinal integrity • Malignancy, osteporosis, tumor, infection • Unstable fracture • Ligamentous instability (ie alar lig) • Recent Fusion (3-6mo) • Pregnancy (when can’t use belts)

  20. Precautions • Loose fitting dentures (remove) • Respiratory conditions • Claustophobia • Early pregnancy • May consider manual traction

  21. Traction Options • Occipital head contact • Chin halter strap • Autotraction • Pelvis is secure and traction forces are generated by grasping and pulling and pushing on bars on the ends of the table

  22. Traction Options • Positional Traction • Self unweighting on desk or counter

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