1 / 35

Traction

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

daryl
Download Presentation

Traction

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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. Biomechanical Intervertebral Separation Reduction of disc protrusion Altered Intradiscal pressure Normalization of conduction Increased Joint Mobility Neurophysiological Pain Relief Decrease of Radicular symptoms Hypothesis of Traction

  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

  13. 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 • 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

More Related