1. Traction

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. 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

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. When to Traction in Radiculopathy

14. When to Traction in Referred pain

15. Headache and Traction

16. 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

17. 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

18. 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

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

20. Flexion Worsens Prone Traction

21. Extension Worsens Supine Traction

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

23. 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)

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

25. 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

26. Traction Options Positional Traction –Self unweighting on desk or counter

27. 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

28. 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

29. 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

30. Joint Play L2 and L3 Hypomobile L4, L5 N L5/S1 Unilateral –Recreates buttock pain L4/5 Unilateral –Sore with empty end feel

31. Special Tests SLR (-) Slump Test (+) Left –Recreates Buttock Pain Palpation to piriformis –Recreates buttock c/o

32. Case What do you suspect is wrong? What category does he fall into? What will his treatment program look like?

33. Case Asymmetrical Sidebending Status Quo or Worsen Indication of Radiculopathy –May argue worsen with extension Closing Restriction

34. Case Treatment Joint Mobs to Hypomoblie segments –Specific mobilizations Traction –Mechanical effects of intervetebral separation –Parameters to maximize

35. Treatment and Traction –130 lbs first day- progressing to 190 over 4 treatments –12 th treatment walk greater than 1 mile with no symptoms and raquetball with no symptoms –16 th treatment- could stand to lecture today –23 rd treatment- walked around campus 3x today Walking is fun –25 th treatment- great weekend but has buttock pain- + SIJ testing