Cervical Spine Traction Treatment Guidelines PDF

Cervical Spine Traction Treatment Guidelines The following guidelines are recommended when performing manual or mechanical traction for the cervical spine. Indications for & Effects of Cervical Traction Derangement- Flattens nuclear protrusion ○ Useful in treating both ant...

Cervical Spine Traction Treatment Guidelines The following guidelines are recommended when performing manual or mechanical traction for the cervical spine. Indications for & Effects of Cervical Traction Derangement- Flattens nuclear protrusion ○ Useful in treating both anterior and posterior derangements Stenosis- Opens intervertebral foramen ○ Useful in providing temporary relief of symptoms associated with cervical stenosis Flexion Bias Conditions- Elongate tight muscle following "immobilization" Hypomobility in Spinal Segments- Elongate tight ligament and capsule following "immobilization" ○ Must use enough force to separate joint surfaces & increase intervertebral spaces ○ Affects more than one joint, cannot be isolated to one spinal level ○ Mobilizations are more effective treatment option to isolate a single spinal level Facet Syndrome- Opens and mobilizes facet joints ○ Must position patient and apply enough force to maximally open the facet joint Muscle Spasm- May treat underlying cause of muscle spasm Precautions & Contraindications to Cervical Traction Spinal conditions or disease where motion is contraindicated Acute strains & sprains irritated by traction Joint hypermobility Malignancy / Tumor Infection TMJ Dysfunction (precaution) Osteoporosis (precaution) Rheumatoid Arthritis (precaution) Limitations of cervical traction Decreased symptoms are typically temporary No researched treatment protocols / no best practice guidelines Spinal levels cannot be isolated Basic Cervical Traction Procedures Perform Manual traction first (see image above) ○ Used to assess effectiveness & appropriateness of traction for patient ○ Determine most appropriate mode of traction based on condition (manual vs. mechanical) Position patient for most benefit ○ Open or close specific structures based on patient diagnosis and treatment goals Determine dosage (weight) & duration (treatment time) ○ First treatment lower dosage than needed for vertebral separation (maximum dosage is 7% of patient's body weight) ○ Increase dosage over next several treatments to achieve patient outcomes (do not exceed 7% of body weight) ○ Duration is determined by mode of traction & goals of treatment (typically 20-30 minutes) Factors Influencing Vertebral Separation Spinal Position ○ Increased flexion will increase vertebral separation ○ 35 degrees of flexion for posterior vertebral separation ○ Clinician must consider patient diagnosis is cervical flexion is conraindicated Patient Comfort & Relaxation ○ More relaxation = increased vertebral separation ○ Decreased angle of pull = increased relaxation ○ Cervical spine is most relaxed in supine ○ 20-30 minutes of mechanical traction required for relaxation Amount of Force ○ Maximum of 7% body weight Option for Mechanical Cervical Spine Traction Over-the-Door Traction (see below) Pronex Traction / Saunders Traction (see below for Pronex and above for Saunders) Mechanical Traction Machine (see below) Evidence-Based Practice Guidelines:. Supine, mechanical traction combined with exercise is superior to seated, over-the-door traction combined with exercise or exercise alone for decreasing neck pain, arm pain, and neck disability scores in patients with cervical radiculopathy (n=86) at 4 weeks, 6 months & 12 months (Fritz, JM, et al, J Orthop Sports Phys Ther, 2014). CPR for Traction to Treat Cervical Spine Pain The following clinical prediction rule has been developed to identify patients with cervical spine pain who will benefit from the use of mechanical cervical traction. In this study, 80 patients with cervical spine pain received six treatment sessions of cervical spine traction and exercise at a frequency of 2 times / week and a duration of 3 weeks. The authors defined a successful outcome as a +6 or greater change in the GROC scale. CPR Criteria includes: Age greater than or equal to 55 years Patient reported peripheralization of symptoms with lower cervical spine mobility testing Positive shoulder abduction test Positive Brachial Plexus Test (Elvey's Test) Positive Cervical Distraction Test The chart below outlines the authors' findings from this study. Predictors Sensitivity Specificity + LR - LR Probability of Present Treatment Success 4+ 0.30 1.0 23.1 0.71 95% 3 0.63 0.87 4.81 0.42 79% 2 0.30 0.97 1.44 0.40 53% 1 0.07 0.97 1.15 0.21 48% Cervical Spine Manual Therapy Research Evidence Supporting Cervical Spine Manipulative Therapy The following criteria can be used to determine which patients will have immediate benefit from cervical spine manipulation.1 Initial score on Neck Disability Index Links to an external site. < 11.50 Have bilateral involvement pattern NOT performing sedentary work > 5 hours / day Feel better when moving cervical spine (e.g. preferring to be "on the move") NOT worse when extending cervical spine NO radiculopathy Patients who meet four or more of these predictors have an 89% probability of success when treated with cervical manipulation.1 Authors in a second study treated 82 consecutive patients who reported cervical spine pain with manipulative therapy. In this study, patients demonstrating a +5 or higher score on the GROC scale after 1-2 treatment sessions were deemed to have experienced a successful outcome. Authors concluded that only 39% of patients met this criteria for considering the treatment outcome successful.2 However, when the authors created a second clinical prediction rule to assess patients who are good candidates for cervical spine manipulation, they found that the success rate for manipulative therapy increased from 39% to 90% in patients who met at least 3 of the following 4 inclusion criteria.2 Criteria for this CPR included: Symptom duration < 38 days Positive expectation that spinal manipulation will be helpful Bilateral difference in cervical rotation of >10 degrees Pain with the posteroanterior spring test in the mid-cervical spine A third study compared the benefits of thoracic spine manipulation to cervical spine manipulation in patients with cervical spine pain. In this study 24 patients reporting cervical spine who met at least 4 of 6 criteria for thoracic spine manipulation were randomly assigned to either a thoracic spine manipulation group or a cervical spine manipulation group. Patients were treated for 2 sessions using the assigned manual therapy techniques and cervical ROM exercises. Following manipulative therapy treatment, patients in both groups received three more treatments of cervical spine ROM exercise. Patients were assessed for improvement in pain (using a numeric pain scale) and function (as measured by the Neck Disability Index) at 1 week, 4 weeks, and 6 months from the start of treatment.3 Results demonstrated that the cervical manipulation group showed greater improvement in pain and function at all follow-up times. Both findings were statistically-significant. The authors concluded that patients with cervical spine pain who meet 4 of 6 of the CPR criteria for successful treatment of neck pain with a thoracic spine TJM demonstrate a more favorable response when the manipulative therapy is directed at the cervical spine than at the thoracic spine.3 A final study examined the effects of cervical spine and thoracic spine mobilization versus manipulation in the treatment of patients with mechanical neck pain. The authors found both treatments to be effective and found no difference in treatment outcomes for ROM, pain, disability, or function when comparing the two treatment interventions. This is an important finding to support the use of either manual therapy technique in reducing pain and improving function.4 Evidence Supporting Thoracic Spine Manipulative Therapy Several research studies have examined the benefit of thoracic spine manipulative therapy in decreasing cervical spine pain. These studies have been outlined in the thoracic spine treatment section of this course. Cervical Spine Stenosis Cervical spine stenosis is far less common than lumbar spine stenosis. This is primarily due to the weight-bearing responsibilities of each region of the spine. Cervical stenosis is the result of repeated trauma that results in narrowing of the vertebral foramen. Recall the discussion of Torg Ratio in the previous module. This condition is most likely to occur in athletes who participate in collision sports (e.g. football, ice hockey, men's lacrosse) where trauma to the cervical spine is more common. Typical range of motion findings for patients with cervical stenosis are shown in the table below. Motion(s) Single ROM Repeated ROM Protrusion / Flexion Nil NE Retraction / Extension Min / Mod ERP ^ (P) W ERP Some patients will only experience an increase in symptoms with repeated extension and not with repeated retraction. In cases of severe cervical stenosis. repeated retraction and extension may cause peripheralization of symptoms. Positive special tests for pain (and possible peripheral symptoms) include the Cervical Hyperextension Test, the Cervical Compression Test, Spurling's Compression Test, and the Quadrant Test. One special test will be positive for relief of symptoms, the Cervical Distraction Test. Treatment of patients exhibiting cervical spine stenosis should include all of the following exercises / activities. Postural education Repeated cervical spine flexion range of motion exercises (thousands of repetitions) Muscular strengthening of cervical spine flexors, extensors, and scapular stabilizers Muscular endurance training of cervical spine flexors, extensors, and scapular stabilizers Additionally, clinicians may treat peripheral symptoms (as necessary) using repeated cervical retraction in sitting or lying, if tolerated by the patient. This exercise should be used with caution and only in patients who do not demonstrate increased symptoms with repeated cervical retraction. Finally, clinicians should discuss retirement from collision sports in order to protect the patient from permanent injury to the (central) nervous system. Patients experiencing cervical spine stenosis who suffer an axial loading injury to the cervical spine are more likely to suffer a spinal cord injury resulting in permanent paralysis.