Stanbridge - T4 - Modalities - W2 - Mechanical/Pneumatic Spinal Traction

Spinal Traction: Mechanical Therapy

• Spinal traction is a therapy that involves pulling apart spinal segments.
• Force is a push or a pull.
• Traction is not synonymous with distraction, which is the separation of joint surfaces.
• Friction is a resistive force that opposes movement of surfaces in contact.
• The coefficient of static friction between a person and a treatment table for the lumbar region is 0.5 (half of body weight).
• The minimum treatment force for lumbar traction equals the body weight of the segment being moved multiplied by 0.5 (coefficient of friction).
• The average head weighs 10-14 lbs. The minimum force needed for cervical traction on the cervical spine is 0.62 x 14 lbs= 8.68 lbs.
• Different types of traction units exist from large, in-clinic units, to home use units using pulleys, hydraulic, and pneumatic systems, and inversion tables.
• Mechanical traction uses motorized units to exert a pulling effect through ropes, halters, and straps.
• Manual traction is applied by the therapist.
• Gravitational traction is by weight (e.g. inversion table).

Objectives

• Understand and explain the foundations and purpose of spinal traction.
• Review spinal anatomy.
• Explain the biomechanical and physiological effects of spinal traction.
• Explain the indications, precautions, and contraindications for spinal traction.
• Describe the steps to apply C/S and L/S traction.
• Describe spinal traction dosage and frequency.
• Properly document spinal traction treatment.

Foundations of Spinal Traction

• Traction is the process of pulling apart; force is push or pull.
• Distraction is the separation of joint surfaces; a goal of the applied traction force.
• Friction is the resistive force opposing motion.

Foundations of Spinal Traction: Friction

• Friction occurs due to irregularities of surfaces.
• The coefficient of static friction between the body and treatment table for the lumbar region is 0.5.

Foundations of Spinal Traction: Lumbar Traction

• Minimum treatment force = body weight of segment x 0.5 (coefficient of friction)
• Body weight for lumbar traction = total weight x 0.5 to overcome 50% of body weight.
• Example: 100 lbs x 0.5 = 50 lbs (body weight of segment to be moved)
• 50 lbs x 0.5=25 lbs (minimum treatment force).
• Static friction is overcome using a split table or pneumatic machine.

Foundations of Spinal Traction: Cervical Traction

• Coefficient of friction for cervical spine = 0.62.
• Average head weighs 10-14 lbs.
• Minimum force needed = 0.62 x 14 lbs= 8.68 lbs.

Types of Traction

• Traction units vary from large clinic units to home use inversion tables.
• Mechanical traction uses motorized units and ropes, halters, and straps.
• Manual traction is applied by the therapist.
• Gravitational traction is by weight.

Purpose of Spinal Traction

• Results in longitudinal separation and gliding apart of C/S and L/S vertebra.
• Main purpose is to reduce signs or symptoms of C/S or L/S compression.
• Symptoms include pain (local versus referred), decreased strength, sensation, reflexes, neurologic deficits, decreased functional mobility, and positive neural tension tests
• Spinal Traction is not for Acute, subacute, or chronic non-radicular low back pain.

Spinal Anatomy

• Diagrams of spinal anatomy showing different vertebrae and associated structures are included in the documentation.

Other Important Spinal Structures

• Intervertebral discs function.
• Nucleus pulposus and annulus fibrosis
• Spinal nerves and plexuses
• Number of cervical, thoracic nerves and lumbar roots. Relevant plexuses
• Ligaments (Anterior, Posterior, and Lateral spinal stabilizers).

Cervical Spine and Vertebral Artery

• Numbered nerve roots exit above the same numbered cervical spinal level.

Lumbar Spine Nerve Root Anatomy

• Numbered nerve roots exit below the same numbered lumbar spinal level.

Other Important Spinal Structures

• Spinal cord: What is the thickened area of the spinal cord called that attaches to the brain stem?
• What are the layers of dura that surround the spinal cord?
• What is CSF and what is its purpose?

Effects of Spinal Traction

• Stretches facet joint capsules which improves joint mobility.
• Increases intervertebral foramina space increasing space for nerve roots to exit spinal cord.
• Elongates posterior muscles decreasing muscle guarding and sensitivity to stretch.
• Reduces intradiscal pressure which reduces bulging of the nucleus pulposus.
• Improves blood supply to posterior muscles and intervertebral discs through improved osmotic movement to discs.
• Alerted nerve root firing patterns when decompressed reducing repetitive firing due to decompression.

Elongated Tissue

• Normal tissue versus compressed tissue diagrams demonstrating how traction elongates tissue

Imaging of Spinal Vertebrae and Herniated Disc

• Median section of three vertebrae and superior view of a herniated intervertebral disc.

Spinal Traction- Evidence

• Conflicting scientific evidence regarding the use of intermittent traction for low back pain.
• Most promising evidence for those who exhibit signs of nerve root compression, with peripheralization of symptoms, or a positive crossed straight leg raise.
• Do not use intermittent or static traction for acute, subacute, or chronic non-radicular low back pain.
• Clinicians should consider mechanical intermittent traction combined with manual and exercise therapy to reduce neck and arm related pain.
• Best results are for radicular pain. Not much support for degenerative or discogenic pain, especially without radiculopathy.

Evidence-Based Practice: Considerations

• The lasting effect of the change in anatomical relationships caused by traction remains in question.
• When using traction, most practitioners choose a conservative traction dose on initial application.
• Shorter time and lower force.
• Consensus that traction cannot be the sole treatment for C/S mechanical pain syndromes.

Evidence-Based Practice: Key Points

• Use of therapeutic exercise and manual therapy techniques are clearly supported by research for cervical spine dysfunction.
• Less research consistency for lumbar pain.

Indications for Spinal Traction

• Disc herniation
• Joint hypomobility
• Muscle guarding and spasm
• Narrowing of the intervertebral foramen
• Nerve root impingement
• Osteophyte formation
• Spinal ligament or other connective tissue contractures

Precautions for Spinal Traction

• Some contraindications can become precautions, like ligament strains or hypermobility.
• Traction should not incorporate spinal segments with ligamentous sprains.
• Do not use traction in the acute phase of injury, as it may aggravate inflammation and conditions.
• Excessive muscle guarding negates the effects of traction.

Precautions for Spinal Traction (continued)

• Cardiac or respiratory insufficiency with lumbar traction (increased anxiety- vital signs- COPD).
• Pregnancy (C/S, avoid L/S).
• Hormones affect tissue laxity.
• Claustrophobia
• Previous single-level discectomy (altered anatomy).

Contraindications to Spinal Traction

• Acute spinal trauma (sprains or strains)
• Aortic aneurysm
• Bone diseases (osteoporosis)
• Cardiac or pulmonary insufficiency (especially with inversion traction, increases internal pressure).
• Conditions where movement significantly exacerbates symptoms (contraindications to movement).
• Vertebral dislocation, subluxation, or instability
• Fracture
• Hiatal hernia

Contraindications to Spinal Traction (continued)

• Increased symptoms with traction (peripheralization of symptoms with Tx)
• Infections in bones or joints (meningitis)
• Positive alar ligament or vertebral artery test (C/S)
• Pregnancy (L/S)
• Rheumatoid arthritis (C/S- advanced)
• Temporomandibular joint disorder (use of C/S halter)
• Trauma (without dx)
• Vascular conditions
• Tumors

Spinal Traction-Red Flags

• Pain of unknown origin should be investigated thoroughly.
• Suspect serious pathology if symptoms are exacerbated or affected by movement.
• Patients with a history of cancer require thorough diagnostic evaluation (e.g., imaging studies) before traction.

How to Set up a Patient for Spinal Traction

• Determine patient position (L/S: prone or supine with hips/knees 0-90°)
• Apply traction harness (bilateral or unilateral)
• Determine force (split or non-split table)
• • Pneumatic traction is treated similarly to a split table regarding friction.

General Instructions for Traction Application

• Provide patient with safety switch or bell.
• For split tables (L/S), unlock the table.
• Conduct traction.
• Once concluded, secure and release the patient to a sitting position.
• Monitor vitals and precautions if needed.

Applications of L/S Mechanical Traction

• Both pelvic and thoracic harnesses.
• Snug pelvic harness placed just above the iliac crests and thoracic harness placed on the treatment table, placed snugly around ribs 8-10, below breast tissue.
• Overlapping harnesses.
• Connecting suspender straps to spreader bar (if applicable) and to a rope (double rings).

Applications of L/S Traction: Position

• Supine or Prone (patient)
• Increased posterior lumbar separation if they are supine with flexion of hips- palpation needed to locate level desired to gap.
• General mobility: supine with 70° of hip flexion.
• Lateral stenosis (not from HNP): supine 90°/90°
• Posterior disc protrusion/posterior herniated nucleus pulposus( HNP) : supine with knees straight utilizing natural lordosis.

Applications of L/S Traction: In Prone

• Neutral to extended spine position.
• May improve symptoms from posterior disc protrusion/HNP; may stretch anterior structures
• May place load on the spine posteriorly, resulting in an anterior movement of the nucleus pulposus (NP). May be necessary at the L5-S1 level.

Applications of L/S Traction: Unilateral

• Unilateral pull (Side bending)
• Used for herniated nucleus pulposus (HNP) or unilateral stenosis
• Structures on the opposite side will be compressed
• Need a harness with a double ring

Applications of L/S Traction: Patient Positioning

• Based on desired unilateral or bilateral pull (fig 7-18 pg. 166 Behrens).
• Lateral side-bending to the appropriate angle is needed based on how the patient responded to the trial of manual traction.
• Raise or lower the table based on the necessary flexion or extension.
• Unlock/split the table.
• Start the machine.

General Instructions for Traction Application

• Image of a patient in a supine position with traction equipment.

Applications of C/S Traction: Position

• Supine with pillow under knees; head in halter or cervical harness.
• Upper cervical (C0-C2) spine position halter at 0°- 5°/level with the table.
• Mid cervical (C2-C5) spine 10°- 20° of flexion
• Lower cervical (C5-T1) spine 25°- 35° of flexion.

Applications of C/S Traction

• Apply head halter or cervical harness and attach to the traction unit.
• Secure halter/harness to be snug so the occiput doesn't move.
• Unilateral traction: position the C/S into the proper flexion and lateral flexion needed to address the segment being treated. Palpate to identify the gapping of the segment during side bending. This is done in the frontal plane.

Dosage Guidelines

• Dosage is the administration of a therapeutic agent in prescribed amounts.
• Spinal traction dosage is a combination of force, mode, duration, and frequency.

Dosage Guidelines: Lumbar Spine

• 25%-50% of body weight.
• Start lower (25%) if it is a split table or patient's first time.
• Goals: 25% of body weight for tissue stretching (capsule, ligament), muscle spasm, and disc herniation
• 50% of body weight to separate vertebrae(maximal facet/joint separation).

Dosage Guidelines: Cervical Spine

• 7%-20% of body weight.
• 7%-10% of body weight stretches soft tissue (capsule, ligament), muscle spasm, and disc herniation.
• 13%-20% of body weight helps to maximize facet/joint separation.
• Avoid forcing a total force greater than 30 lbs, especially in relation to cervical spine treatment.

Dosage Guidelines: Mode

• Sustained vs. intermittent pull/cycle
• Intermittent -ON:OFF ratio with intermittent cycle (1:3 or 1:1 On:Off Cycle) -1:3 Cycle (20 seconds at maximal tension, 60 seconds of reduced tension- mainly used for disc herniation) -(OFF force is 50% of the ON force)
• 1:1 Cycle -Used for acute joint conditions (DJD, Stenosis, acute facet joint dysfunction, acute capsule). -(OFF force is 50% of ON force).
• Static hold -Constant ON force (no OFF cycle) -Used for muscle spasm, chronic DJD/stenosis, or chronic facet joint dysfunction. -Pneumatic traction is typically static for all pathologies. -- Silences stretch reflex.

Dosage Guidelines: Duration

• Measured in minutes
• Intermittent or Static = 5-30 minutes
• Disc tx: 10 minutes max(may need shorter time if high risk for fluid imbibition symptom aggravation once traction is released).

Dosage Guidelines: Frequency

• Frequency = how often the treatment.
• 2x/wk vs 3x/wk depends on the patient's response.

Responses & Modifications to Spinal Traction

• See table 10-4 in Hayes.
• Guideline based on patient response.
• Define signs/symptoms.
• Increased centralized pain may be associated with decreased referral symptoms versus increased peripheralization and decreased centralization of symptoms.

Gravity Assisted Traction

• Inversion table traction.
• Relatively simple and documented to increase lumbar intervertebral space immediately after procedure.
• Can increase intervertebral space by up to 3 mm in the L1-S1 level.

Gravity Assisted Traction: Dangers

• Major increase in intraocular pressure leading to optic nerve dysfunction.
• Significant alterations in blood pressure.
• Anxiety in the inverted position.
• Overall concern for safety due to getting out of the inverted position and adverse effects in home-users.

Inversion Table - Evidence

• In patients with pure single-level lumbar discogenic disease.
• A pilot randomized trial for disability and rehabilitation involving inversion therapy (six 2-minute inversions 3x/week for 4 weeks) can significantly reduce.
• Single disc protrusions in patients with sciatica.
• Analysis of electromyographic activity in lumbar erector spinae caused by traction.
• Increased muscle tension in lumbar erector spinae due to inversion therapy.

Documenting Spinal Traction

• Location (C/S or L/S) and position of the patient (supine, neutral, prone, unilateral or bilateral setup).
• Dosage( Force, Mode, Duration, Frequency)
• Patient response pre- and post- treatment.

Objectives

• Understand the foundations and purpose of spinal traction.
• Review spinal anatomy.
• Explain the biomechanical and physiological effects of spinal traction.
• Explain the indications, precautions, and contraindications for spinal traction.
• Describe the steps to apply C/S and L/S traction.
• Properly document spinal traction treatment.

This quiz evaluates your understanding of spinal traction therapy, including its benefits, applications, and treatment parameters. Test your knowledge on the duration, frequency, and differentiation between symptoms and signs in this therapeutic approach.