Traction

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

Hypothesis of Traction

Biomechanical

• Intervertebral Separation

• Reduction of disc protrusion

• Altered Intradiscal pressure

• Normalization of conduction

• Increased Joint Mobility

Neurophysiological• Pain Relief• Decrease of Radicular

symptoms

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

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

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

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

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

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

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

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)

When to Traction in Radiculopathy

When to Traction in Radiculopathy

When to Traction in Referred pain

Headache and Traction

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

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

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

Traction Dose

• Body Position– Best for goal

• Angle of the pull– Level

– Up at an angle

Flexion Worsens

• Prone Traction

Extension Worsens

• Supine Traction

Monitoring Response

• Oswestry• Neck Disability Index• MMT• Reflexes• Centralization• Pain complaints

• Immediate vs over 2-3 Tx’s

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)

Precautions

• Loose fitting dentures (remove)

• Respiratory conditions

• Claustophobia

• Early pregnancy

– May consider manual traction

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

Traction Options

• Positional Traction– Self unweighting on desk or counter

Case

• 60 year old with back and leg pain– Left buttock, anterior knee and big toe

• Symptoms provoked– Walking < 1 mile– Standing 10-15 minutes

• Symptoms increase – Squatting – Sitting

Case 60 year old

• Oswestry 16%

• LQS

• Left Quad and HS 4+/5 compared to R

• All other = B and Reflexes =B

• Sensation- Slight decrease L3 and S1 on Left

Movement Testing

• Asymmetrical sidebending (decreased L)– Recreates buttock pain

• Flexion and Extension 75% limited pain-free– Left deviation with forward flexion

• Repeated L sidebending increases tingling in toe– symptoms resolve on standing

• L Quadrant closing recreates foot symptoms– Symptoms resolve when return to standing

Joint Play

• L2 and L3 Hypomobile

• L4, L5 N

• L5/S1 Unilateral– Recreates buttock pain

• L4/5 Unilateral– Sore with empty end feel

Special Tests

• SLR (-)• Slump Test (+) Left

– Recreates Buttock Pain

• Palpation to piriformis– Recreates buttock c/o

Case

• What do you suspect is wrong?

• What category does he fall into?

• What will his treatment program look like?

Case

• Asymmetrical Sidebending

• Status Quo or Worsen

• Indication of Radiculopathy– May argue worsen with extension

• Closing Restriction

Case Treatment

• Joint Mobs to Hypomoblie segments– Specific mobilizations

• Traction – Mechanical effects of intervetebral separation– Parameters to maximize

Treatment and Traction

– 130 lbs first day- progressing to 190 over 4 treatments

– 12th treatment walk greater than 1 mile with no symptoms and raquetball with no symptoms

– 16th treatment- could stand to lecture today– 23rd treatment- walked around campus 3x today

• Walking is fun

– 25th treatment- great weekend but has buttock pain- + SIJ testing