PTA 1009 Modalities Power Point #2 PDF

1 PTA 1009 Modalities Power Point #2 Spinal Traction: Mechanical Therapy ©Stanbridge University 2023  2 ©Stanbridge University 2023 SPINAL TRACTION Source: Behrens 2014 ...

1 PTA 1009 Modalities Power Point #2 Spinal Traction: Mechanical Therapy ©Stanbridge University 2023  2 ©Stanbridge University 2023 SPINAL TRACTION Source: Behrens 2014  3 ©Stanbridge University 2023 Objectives By the end of this presentation the student should be able to: 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  4 ©Stanbridge University 2023 Foundations of Spinal Traction Terminology Traction: process of pulling apart, it is a force ▫ Force = push or a pull Not synonymous with Distraction: Separation of surfaces of a joint; is a goal of the applied traction force  5 ©Stanbridge University 2023 Foundations of Spinal Traction Friction: Resistive force that arises to oppose the motion or attempted motion of an object past another in which it is in contact ▫ Occurs due to irregularities of the surfaces of the two bodies Coefficient of static friction between a person lying flat and a treatment table/mattress for the lumbar region is 0.5 (half of body weight).  6 ©Stanbridge University 2023 Foundations of Spinal Traction Lumbar Traction Min Treatment force = BW of segment x 0.5 (coefficient of friction) Body weight of segment for lumbar traction = total weight x 0.5 need to overcome 50% of body weight. Ex:100lbs x 0.5 (1/2 of body)= 50lbs (BW of segment to be moved) 50lbs x 0.5 (coefficient of friction)= 25lbs (Min treatment force) See figure 7.3 & 7.4 in Behrens Static friction is negated with a split table or pneumatic machine!  7 ©Stanbridge University 2023 Foundations of Spinal Traction Cervical Traction Coefficient of friction for cervical spine = 0.62 Average head weighs 10-14 lbs 0.62 x 14lbs = 8.68 lbs (min force needed)  8 ©Stanbridge University 2023 Foundations of Spinal Traction Types of Traction Types of traction units vary from large, in-clinic use to home use using a pulley, hydraulic and pneumatic systems, and inversion tables Mechanical traction: Involves the use of motorized traction units that exert a pulling force through a rope and various halters and straps Manual Traction: Applied by the therapist Gravitational Traction: By weight Source: www.pikrepo.com  9 ©Stanbridge University 2023 Purpose of Spinal Traction Results in the 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 S&Sx include pain (local vs. referred), decreased strength, sensation, reflexes and other neurologic deficits that result in decreased functional mobility, positive neural tension tests  10 Spinal Anatomy ©Stanbridge University 2023 Source: Marieb and Hoehn 2019 Source: Dutton 2019 Source: Netter 2019  11 ©Stanbridge University 2023 Other Important Spinal Structures Intervertebral discs ▫ What is their function ▫ Nucleus pulposus and annulus fibrosis Spinal Nerves and Plexi ▫ How many cervical nerves roots are there? What is the major plexus that makes up C5-T1? ▫ How many thoracic nerves roots are there? ▫ How many lumbar nerve roots are there? What is the major plexus that supplies the LE’s? Ligaments ▫ Anterior and Posterior ▫ Lateral spinal stabilizers  12 ©Stanbridge University 2023 Cervical Spine and Vertebral Artery Source: Netter 2019 Numbered nerve roots exit above same numbered cervical spinal level Source: www.Wikimedia.commons.org  13 ©Stanbridge University 2023 Lumbar Spine Nerve Root Anatomy Numbered nerve roots exit below same numbered lumbar spinal level Source: Netter 2019  14 ©Stanbridge University 2023 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? Muscle O’s and I’s Circulatory and lymphatic systems  15 ©Stanbridge University 2023 Effects of Spinal Traction Stretches facet joint capsules ▫ Improves joint mobility Increases intervertebral foramina space ▫ Increases space for nerve roots to exit spinal cord Elongates posterior muscles ▫ Decreases muscle guarding and sensitivity to stretch  16 ©Stanbridge University 2023 Effects of Spinal Traction (cont.) Reduces intradiscal pressure ▫ Decreasing pressure may reduce bulging of the nucleus pulposus Improves blood supply to posterior muscles and Intervertebral discs ▫ Improved osmotic movement to discs from vertebral endplates due to decrease in pressure Altered nerve root firing patterns when decompressed ▫ Chronically injured nerve roots continuously fire. Traction decreases repetitive firing due to decompression  17 ©Stanbridge University 2023 Joint Space with Traction Elongated Tissue (Decompression) Normal Joint Space Normal Tissue Compressed (pathologic) Joint Space Compressed Tissue Source: www.pikrepo.com  18 ©Stanbridge University 2023 Source: Marieb and Hoehn 2019 Source: www.commons.Wikimedia.org  19 ©Stanbridge University 2023 Spinal Traction- Evidence D Delitto et al, Low Back Pain: Clinical Practice Guidelines. JOSPT, 2012; 42(4): a1-a57 ▫ -Conflicting evidence on 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 either intermittent or static traction for acute, subacute or chronic non-radicular low back pain. B Childs et al., Neck pain: Clinical Practice Guidelines. JOSPT, 2008, 38(9):a1-a34 ▫ -Clinicians should consider the use of mechanical intermittent traction combined with manual and exercise therapy to reduce neck and arm related pain.  20 ©Stanbridge University 2023 Spinal Traction- Evidence II Cavgnaro et al, Lumbar traction in the management of low back pain: A survey of the latest results. J Nov Physiother, 2014; 4(5) ▫ Best results are for radicular pain. Not much support for degenerative or discogenic pain, especially without radiculopathy.  21 ©Stanbridge University 2023 Evidence Based Practice: Considerations The lasting effect of the change in anatomical relationships caused by traction remains in question When the decision is made to use traction, most practitioners will choose a conservative traction dose on the initial application. ▫ Shorter time and lower force Among those practitioners who use C/S traction, there is consensus that it cannot be the sole intervention for patients with C/S mechanical pain syndromes  22 ©Stanbridge University 2023 Evidence Based Practice: KEY POINTS Use of therapeutic exercise and manual therapy techniques are clearly supported by evidence for patients with cervical spine dysfunction; less consistency in research for lumbar pain. Source: www.commons.Wikimedia.org Source: Kisner and Kolby 2012  23 ©Stanbridge University 2023 Indications for Spinal Traction Indications (9)- Giles (Scorebuilders) Disc Herniation Joint hypomobility Muscle guarding, spasm Narrowing of the intervertebral foramen Nerve root impingement Osteophyte formation Spinal ligament or other connective tissue contractures  24 ©Stanbridge University 2023 Precautions for Spinal Traction Some contraindications become precautions if not directly affected by traction. Ligament sprain or hypermobility: ▫ Traction should not incorporate spinal segments that have ligamentous sprains or hypermobility ▫ i.e. can do in C/S if have L/S hypermobility or vice versa Acute stage of injury: ▫ May aggravate inflammation and exacerbate condition If patient is fearful of traction: ▫ Excessive muscle guarding and protective muscle spasm may negate the effects of treatment  25 ©Stanbridge University 2023 Precautions for Spinal Traction (cont.) Cardiac or respiratory insufficiency with lumbar traction ▫ Increased anxiety changes vital signs (HR, RR, BP) ▫ Chronic obstructive pulmonary disease (COPD) Pregnancy: ▫ C/S may be indicated with caution, but manual traction would be preferred if needed. (Never L/S) ▫ Need to consider hormones: increased tissue laxity Claustrophobia Previous single level discectomy: altered anatomy  26 ©Stanbridge University 2023 Contraindications to Spinal Traction Giles (Scorebuilders) Acute spinal trauma: sprains or strains Aortic aneurysm Bone diseases, Osteoporosis Cardiac or pulmonary insufficiency with inversion traction=increases internal pressure Conditions where movement significantly increases symptoms or is contraindicated Vertebral Dislocation, Subluxation, Instability Fracture Hiatal hernia  27 ©Stanbridge University 2023 Contraindications to Spinal Traction 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  28 ©Stanbridge University 2023 Spinal Traction Red Flag If a patient reports pain in the spine that cannot be determined to be of MECHANICAL ORIGIN, always suspect a potentially serous pathology ▫ Symptoms should be affected (positively and/or negatively) with movement ANY person with a history of CANCER should have a thorough diagnostic evaluation before receiving traction (i.e. imaging studies)  29 ©Stanbridge University 2023 So how do you set up a patient on spinal traction? Source: www.pixy.org  30 ©Stanbridge University 2023 General Instructions for Traction Application Mechanical traction is generally used after a trial of manual traction has been successful Instruct the patient regarding what to expect and what you expect of him/her (modest pull or stretch); Should NOT experience increase in pain, radicular symptoms, etc. Therapeutic effects- Giles ▫ Decreased disc protrusion ▫ Decreased pain ▫ Increased joint mobility ▫ Increased soft tissue elasticity ▫ Promote arterial, venous and lymphatic flow  31 ©Stanbridge University 2023 Traction Application General Steps Before starting set up determine 1. Patient position Position the patient appropriately (L/S: prone or supine with hips/knees 0-90°) 2. Apply traction harness Decide if traction will have a bilateral or unilateral pull 3. Selection of parameters Determine force- split or non split table? ▫ Pneumatic traction treated like a split table in respect to friction  32 ©Stanbridge University 2023 General Instructions for Mechanical Traction Application Once Tx outline is determined Ask pt permission ▫ For C/S Tx: Verify the vertebral artery test and alar ligament test has been performed ▫ Apply the appropriate L/S corsets (in standing) Drape the patient for modesty and comfort Program the traction parameters  33 ©Stanbridge University 2023 General Instructions for Traction Application Give the patient a safety switch or bell If using a split table (L/S), unlock the traction table Perform the traction At conclusion of traction, turn off machine, LOCK TABLE and release patient gently from the traction unit and the harness, stay in that position, then help them to sit up slowly. **1st loosen harness: have patient stay in position for up to 5 min. before sitting up If dizzy- stay seated or lay back town, then check vitals  34 Source: www.spineuniverse.com ©Stanbridge University 2023 Applications of L/S Mechanical Traction Both pelvic and thoracic harness are used ▫ Snug ▫ Pelvic harness placed in standing just above iliac crests ▫ Thoracic harness placed on table and placed snugly around ribs #8-10, but below breast tissue ▫ Both harnesses should slightly overlap ▫ Connect the suspender straps of thoracic harness to the spreader bar (if applicable) and attach to rope (double rings); or clip rope to single ring  35 ©Stanbridge University 2023 Source: www.spineuniverse.com Applications of L/S Traction Position patient in supine or prone ▫ In supine: increased POSTERIOR lumbar separation occurs distal to proximal as hips flex from 0→90°, palpation needed to determine level you want to gap 1. Increased separation of all lumbar levels (general hypomobility of all structures): Supine with 70° of hip flexion 2. Lateral Stenosis (not from HNP): Supine 90°/ 90° 3. Posterior Disc protrusion/Posterior Herniated nucleus pulposus (HNP): Supine with knees straight utilizing natural lordosis  36 ©Stanbridge University 2023 Applications of L/S Traction In Prone neutral to extended spine position: May improve symptoms for Posterior disc protrusion/HNP; stretches anterior structures  May load spine posteriorly resulting in anterior movement of nucleus pulposus (NP) May be necessary for L5-S1 level Source: Behrens, 2014  37 ©Stanbridge University 2023 Applications of L/S Traction Position: Unilateral pull (Side bending) Can be used for herniated nucleus pulposus (HNP) or unilateral stenosis Remember structures on opposite the traction side will be compressed Need a harness with a double ring Source: Bellew 2016  38 ©Stanbridge University 2023 Source: www.spineuniverse.com Applications of L/S Traction Position patient based on unilateral pull or bilateral pull is desired. Fig 7-18 pg. 166 Behrens ▫ If unilateral, you will need to laterally side bend the patient at an appropriate angle based on how the patient responded to the trial of manual traction. Raise or lower the table depending on how much flexion or extension you need Unlock/split the table Start machine  39 ©Stanbridge University 2023 General Instructions for Traction Application  40 ©Stanbridge University 2023 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 Source: Marieb and Hoehn 2019  41 ©Stanbridge University 2023 Applications of C/S Traction Apply the head halter or cervical harness and attach to traction unit. It should be snug enough to keep the occiput from moving If applying unilateral traction (C/S lateral flexion) position the C/S in appropriate flexion and lateral flexion to address the segment being treated (in frontal plane)- need to palpate to identify gapping of desired segment while side bending  42 ©Stanbridge University 2023 Dosage Guidelines Source: www.needpix.com Dosage is defined as the administration of a therapeutic agent in prescribed amounts. Dosage for spinal traction = Combination of force, mode, duration, and frequency  43 Source: www.needpix.com ©Stanbridge University 2023 Dosage Guidelines Lumbar spine: 25%-50% of body weight Start lower (25%) if there is a split table or patient’s first time with traction Goals: 25% of body weight to stretch soft tissue (capsule, ligament), muscle spasm, disc herniation 50% of body weight to separate vertebrae; i.e. maximal facet/joint separation  44 ©Stanbridge University 2023 Dosage Guidelines Cervical Spine: 7%-20% of body weight 7%-10% of body weight- stretch soft tissue (capsule, ligament), muscle spasm, disc herniation 13%-20%- joint distraction- maximal facet/joint separation No force greater than 30 lbs!  45 ©Stanbridge University 2023 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- use for Disc herniation (OFF force is 50% of ON force)  46 ©Stanbridge University 2023 Dosage Guidelines Intermittent cycle (cont): 1:1 Cycle (i.e. 10 sec On/10 sec Off) For acute joint conditions (DJD, Stenosis, acute facet joint dysfunction, acute capsule) OFF force is 50% of ON force)  Associated with decreased post traction discomfort (vs. static)  Relieves nerve root compression, increases blood flow, decreases pain  47 ©Stanbridge University 2023 Dosage Guidelines Static hold: Constant On force (no Off cycle)  Use for- Muscle spasm, Chronic DJD/Stenosis, or Chronic facet joint dysfunction  Pneumatic traction typically static for all pathologies  Silences stretch reflex  Low load, long duration stretching  Use of this setting on mechanical traction is typically based on patient responses and goals of traction  48 Source: www.needpix.com ©Stanbridge University 2023 Dosage Guidelines (Cont.) Duration = Time of treatment Measured in minutes ▫ Intermittent or Static = 5-30 minutes  Tx of disc = 10 minutes max (use of shorter time b/c if session is too long → increased fluid imbibition → symptom aggravation once traction is released) Frequency = How often is the treatment ▫ 2x/wk vs. 3x/wk depends on patient response  49 ©Stanbridge University 2023 Responses & Modifications to Spinal Traction See table 10-4 in Hayes, p. 119 General guideline to modification of treatment is based on patient response of the previous traction session What is a sign? ▫ Objective indication of a medical fact or characteristic that the practitioner observes What is a symptom? ▫ Subjective report about how the patient is feeling Increased centralized pain with decreased referred symptoms vs. increased peripheralization and decreased centralization of signs/symptoms  50 ©Stanbridge University 2023 Gravity Assisted Traction Gravity Assisted (Inversion) Traction ▫ Inversion table ▫ Relatively simple and documented to increase lumbar intervertebral space immediately following the procedure. ▫ Can increase intervertebral space by up to 3 mm levels L1-S1 ▫ Traction force of 40% of body weight Source: www.pinterest.com  51 ©Stanbridge University 2023 Gravity Assisted Traction ▫ Dangers due to the prolonged inverted position:  Major increases in intraocular pressure leading to optic nerve dysfunction have been observed  Significant alterations in blood pressure has been observed  Anxiety while inverted has been commonly reported  Overall, safety of getting out of the inverted position and adverse effects are of concern, especially when used at home alone  52 ©Stanbridge University 2023 Inversion Table- Evidence II Prasad et al, Inversion therapy in patients with pure single level lumbar discogenic disease: a pilot randomized trial., Disability & Rehabilitation, 2012; 34(17): 1473–1480 ▫ -Inversion therapy (Six 2 min inversions 3x/wk for 4 wks) can significantly reduce the need for therapy in single disc protrusions with sciatica II Kim et al, Analysis of electromyographic activities of the lumbar erector spinae caused by inversion traction. Journal of Physical Therapy Science, 2016; 28(4): 1238-1240 ▫ -Inversion therapy elicits increased muscle tension in the erector spinae of the lumbar spine  53 ©Stanbridge University 2023 Documenting Spinal Traction Location (C/S or L/S) and position of patient (supine, neutral, prone, unilateral or bilateral setup) Dosage ▫ Force ▫ Mode ▫ Duration ▫ Frequency Patient response before and after treatment  54 ©Stanbridge University 2023 Objectives At this point, the student should be able to: 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