THE SPINE: TRACTION PROCEDURES

2. THE SPINE: TRACTION PROCEDURES • Objectives of the Lecture At the end of the lecture the students will be able to: • Define spinal traction procedure. • Know the ultimate goals and effects of spinal traction. • Be oriented to the indications for spinal traction. • Recognize and define the different types of traction procedures. • Detail the modes of application of spinal traction. • Identify the limitations, precautions and contra-indications to spinal traction application. • Understand cervical and lumbar traction techniques. • Know the general procedure for application of spinal traction.

3. Contents of the Lecture • Introduction to spinal traction. • Effects of spinal traction: • Indications for spinal traction: • Definitions and description of traction: types, modes of application (mechanical, manual, positional), jt. pain, m. spasm or m. guarding. • Limitations of spinal traction. • Contraindications of spinal traction. • Precautions to spinal traction application. • Cervical traction techniques: Positional, mechanical, home traction, self-traction. • Lumbar traction techniques: Positional, mechanical, home traction, self-traction. • Summary on general application procedures.

4. Definition • Spinal traction means drawingorpulling on the spinal column(vertebral column).

6. Effects of Spinal Traction • Mechanical elongation of spine → widens the intervertebral foramina. • Zygopophyseal (facet) joint mobilization. • Muscle relaxation a. relaxation →↓ pain from m. spasm or guarding b. → greater vertebral separation. 4. Reduction of pain.

7. 1.Mechanical Elongation of The Spine • Factors influencing amount of vertebral separation 1. Spinal position.- Flex → post aspect separation of vertebrae. 2. Amount of force.-7% body wt for cervical traction. - 50% body wt for lumbar traction. If less no inefficient, if more lead to trauma. 3. Comfort & relaxation.- → greatest vertebral separation. 4. Angle of pull.- In cervical flex 35°→ greatest post separation. - In lumbar, harness pull from the post aspect pelvis rather than from the sides → spine flexion.

8. 2. Zygapophyseal (facet) Joint Mobilization • Traction→ • Compress, or • Approximate, • Slide, or • Translate facet surfaces. • Factors influencing direction of facet surfaces mov.: • Flexion & longitudinal traction • Side bending of spine • Rotation of spine

9. 3. Muscle Relaxation • Relaxation →↓pain from m. spasm → greater vertebral separation. →↓ pain from m. guard → greater vertebral separation. • Factors influencing amount of relaxation: • Pt. position: To feel secure & well supported, many pts reported feeling more relaxed in supine than sitting for cervical traction. • Duration of traction: After 7: 20-25 mins traction is necessaryfor m. relaxation. • Force: M. relaxation can be achieved at levels < those needed for mechanical separation (only 4.5 : 6.5 kg max.) for cervical spine. • Spinal position: A lesser angle of pull → greater relaxation.

10. 4. Reduction of Pain A. Mechanical effects: • Movement →↑ circulation. & →↓ concentration of noxious chemical irritants. • Vertebral separation → temporary ↑ intervertebral foramina size, which →↓ pressure on impinged n. root. B. Neurophysiologic effects: • Mechanoreceptor stimulation → block nociceptive transmission at spinal cord orbrain stem level. • Inhibition of reflex m. guarding →↓ discomfort from contracting muscles.

11. Factors Influencing Amount of Pain Reduction • Patient position. The pt should be positioned for comfort & ease of application. • Spinal position. A. Acute stage: Usually the involved spinal segment is positioned in a (slack) pain free position. B. Subacute& chronic stage: Usually the involved spinal segment is positioned in a stretched pos. 3.Force & duration. A. Acute stage: Only use low intensity oscillations, for a short period. B. Subacute& chronic stage: Progressively↑ amount o force &duration depending on pt. tolerance.

12. Types of Application of Traction Constant: A steady force is applied & maintained for an extended time. A. Continuous -A static force is maintained for several hours : days. Often it is applied in bed, small amount of wt. is tolerated . -Usually for immobilization. B.Sustained: - A static traction in which the force is maintained from a few minutes up to one-half hour. - Is useful as a prolonged stretch to spinal structures. Intermittent: The force is alternately applied & released at frequent intervals, with greater forces than sustained traction. - Usually in a rhythmic pattern

13. Modes of Application • Mechanical Various types of equipments are available for hospital, clinic or home use. • Manual Through positioning & handling, the PT applies traction force to the desired spinal segment. • Positional Through positioning, a sustained force on specific segment of spinal column can be obtained.

14. Indications • Spinal nerve root impingement from: A. herniated nucleous pulposus. B. spinal or foraminal stenosis caused by spondylosis, edema & spondylolisthesis. 2. Joint hypomobility due to: A. dysfunction B. degenerative changes. 3. Symptomatic facet joints pain. 4. M. spasm. 5. Diskogenic pain& Post-compression #.

15. Contraindications • Acute back strains, sprains & inflammationsaggravated by initial traction ttt. • Rheumatoid arthritis of cervical spinewhere necrosis of supporting ligaments → instability & subluxation or dislocation of a vertebra with spinal cord damage. • Any spinal condition or disease in which movement is contra-indicated. (TB, severe osteoporosis, malignancy, #)

16. Precautions • Osteoporosis. 2. Patients using denturesshouldn’t remove it as →TMJ is forced into an abnormal resting pos. & can be traumatized with pressure from the chinstrap. 3. Patients with respiratory problems. 4. TMJ painmay be provoked with using cervical halter, especially when the chinstrap places a lot of force on the mandible, so manual traction can be applied in this case.

17. General Procedures Determine appropriateness for choice of traction by testing with manual traction at first. -If the traction test relieved or reduced the symptoms, an initial ttt is given. -If the traction test aggravates the symptoms, traction ttt should probably not applied. 2. Determine if manual, positional or mechanical traction will be used.

18. 3. Position the pt for maxemum. comfort & relaxation. 4. Determine duration of traction. 5. Apply safety roles for mechanical traction. – Use ropes that are in good repair. – Secure the equipment to not to move when the traction force is applied. -Check the poundage dial is turned to zero before & after ttt. - Periodically check the poundage calibration. - Use disposable tissues, gauze & halters. –Never leave the pt. alone while receiving traction unless he/she has some means to signal for help.

19. Cervical Traction Techniques • Manual Traction • Position of pt: supine, relaxed as possible on ttt table. • Position of PT:stand at the head of ttt table & support wt of pt head in his hands. • PT hand placement:

21. Mechanical Traction . Position of patient head is determined by: Evaluation as well as the condition being treated. – To obtain maxemum posterior separation of the vertebrae, the head should be positioned in flexion up to 35°. -To obtain greater muscle relaxation position the head closer to neutral. 4. Apply the head halter. –First, line the head halter with gauze or tissue. –Adjust the halter to fit the chin of the pt comfortably. - The major traction force must be against the occiput, not the chin to ↓ compression of TMJ. - Gauze may be placed between the teeth or padding under the chin to absorb pressure. - Don’t remove dentures if the pt. wears them as stress may be placed on TMJs. - Eye glasses should be safely set aside.

22. 5. Attach the halter to the spreader bar of the unit;check that the pt. is aligned for proper pull. 6. Set controls:-The poundage dial should be set at zero before activating the unit.-If the unit has off-on timer for intermittent traction, suggested starting intervals are 30 secondson, 30 secsoff, or1 minon, 30 secsoff. 7. Activate the unit & gradually ↑ traction force:- To avoid ttt soreness the 1stttt poundage shouldn’t exceed 10-15 pounds. -Progression of dosage at succeeding ttts will depend on the goals & pt’s reaction. 8. Treatment duration:-May be from 10-30 mins for sustained or intermittent traction, depending on the pt’s condition & ttt goals.

23. Demonstrate to the pt. how to turn off the unit- if his symptoms get worse. 10. At the end of the ttt:- Turn all controls off & turn dial indicators to zero. - Remove the halter from the spreader bar. - Then remove the head halter. 11. Re-evaluate the pt’s condition:- Be sure he doesn’t feel dizzyornauseated before leaving the ttt area. 12. If the pt complains ofheadache, nausea, faintingor↑symptomsduring or following ttt: -a. Reduce the wt.,or, b. ↓length of ttt time at the next visit, or c. discontinue ttt.

24. Lumbar traction techniques Manual Traction • It isn’t easyas in cervical region because at least ½ body wt. must be moved & the coefficient of friction of the part to be moved must be overcomed. • Pt. position: supine on ttt table. • PT position: varies with position of patient‘s hips & LL – With the LL extended&lumbar in extension, the PT can exert a pull at the ankles. – With the hips flexed 9o° &lumbar spine flexed, the pt’s legs are draped over PT’s shoulders. The PT then exerts the force with his/her arms wrapped across the pt’s thighs

25. When manual traction is used for evaluation: - Vary the amount of flex, ext & side bending & note the pt’s response. 5. During ttt: - Use spinal position that best ↓ the S&S. 6. PT must use his entire body wt to ↑ effect of traction force: - Place the pation on a split traction table to ↓ friction. -When applying a high-dosage traction force, the thorax is stabilized. Put a counter-traction belt around pt’s rib cage & secure it to the head end of the table, or have a second person to stabilize the pt by standing at the head end of the table & holding onto pt’s arms.

26. II. Mechanical Traction • Be familiar with the unit availableby reviewing the manufacturer’s operating instructions. The most effective traction is applied via a split-traction table, as eliminating the need to overcome the coefficient of friction of half of the body’s wt. • Apply traction&counter-traction harness (belt): -traction harness is applied over the skin above pelvis → upper part is secured above the iliac crest. - counter traction harness is attached around lower rib cage → keep pt. from slipping

28. 3. Position the pt either supine or prone: - Thorax should be on the stationary part of the table & pelvis on the movable one so; lumbar spine is positioned over the split of the table. - Whether the spine in flexk ,or ext. is determined by evaluation, pt’s comfort & the condition as well as ttt goal. - To obtain posterior separation of the vertebrae, the lumbar spine should be flexed (flattened): a.when supine, hips are flexed & thighs rest on a padded stool. b. when prone, several pillows are placed under the pt’s abdomen.

29. 4.Attach the anchor straps: a. The counter-traction or stabilizing harness is secured to the end of the traction table. b. The straps from traction harness may attach to a spreader bar attached to the traction rope. If unilateral traction, one anchor only’ll be attached to traction rope. c. Check that the pt. is aligned for proper pull & then take all the slack out of the straps. 5. Set the controls • Be familiar with the type of unit. • If the unit has off-on timers for intermittent traction, set them for the desired time intervals. • Set ttt duration. It may be up to 30 mins for most units. It depends on the goals, pt’s condition & reaction to traction.

30. 6. Unlock the split traction table- so it will separate when the unit is activated. 7. Activate the unit&gradually↑ the force(if the unit hasn’t been pre-programmed to do so automatically). 8. Demonstrate to the pt how to turn off the unit- if his symptoms worsen while the unit is on. Make sure he has a signaling device to call for help if necessary. 9. At the end of the ttt: • Turn all controls off & turn indicators back to zero. • Lock the split of the table before the pt. attempts to get off. • Re-evaluate the pt; note any changes in S, S & ROM.

31. 9.Demonstrate to the pt. how to turn off the unit- if his symptoms get worse. 10. At the end of the ttt:- Turn all controls off & turn dial indicators to zero. - Remove the halter from the spreader bar. - Then remove the head halter. 11. Re-evaluate the pt’s condition:- Be sure he doesn’t feel dizzy or nauseated before leaving the ttt area. 12. If the pt complains ofheadache, nausea, faintingor ↑symptomsduring or following ttt:-a. Reduce the wt. ,or, -b. ↓ length of ttt time at the next visit, or -c. discontinue ttt.

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