Download Mechanical Modalities

Mechanical Traction
Therapeutic Modalities in
Physical Therapy
General Information
•Traction means to draw or pull
• Distraction means to separate joint surfaces
Effects
– Separation of vertebral bodies
– Distract and glide facet joints
– Tensing of the ligamentous structures
– Widening of the intervertebral foramen
– Straightening of spinal curves
– Stretching of spinal musculature
Types of Traction
• Continuous
– Tx applied for several hours at a time
– Constant tension
– Limited weight tolerated due to long duration
– Ineffective in creating separation
– Normally applied with suspended weights
Types of Traction
• Sustained (static)
– Tx applied with constant tension for several
minutes up to ½ hour
– May be applied via suspended weights or a
mechanical device
Types of Traction
• Intermittent Mechanical
– Tx applied via a mechanical device with
tension alternately applied and then released
– Termed hold and rest
– Hold and rest times usually vary from a few
seconds up to 1 minute
Types of Traction
• Manual
– Tx applied by the therapist grasping the patient and
utilizing his or her own force to create traction
– May be applied for a several second hold or as a
quick thrust
– Limited by strength and endurance of the therapist
– Very accommodating and provides feedback
– Some possible apprehension by patient
Types of Traction
• Positional
– Tx applied by use of gravity and positioning to
effect spinal structures with minimal
intervention
– Utilizes pillows, blocks, bolsters
– Normally has a unilateral effect
Types of Traction
• Gravity
– Tx utilizing the force of gravity acting on the
patients body weight to effect spinal
structures
– 2 types:
• Vest that suspends the lower body by exerting
pressure on the rib cage
• Boots that attach to a rod at the ankles with
patient in inverted position
Treatment Indications
• Disc herniation
– In an erect posture the disc helps to dissipate
compressive forces
– With movement into flexion/extension/lateral
flexion, the pressure changes
Treatment Indications
• Nucleus pulposus does not move
– With rupture of the annulus fibrosis the
nucleus is allowed to move out of the
intervertebral space
– Increases space available, creates suction
force, and allows fluid exchange to get rid of
waste and allow in fresh nutrients
– Effects are transient
Treatment Indications
• Reversed with weight bearing and flexion (corset,
brace)
– Need neutral spine position to get disc back in
– Extension maintained for scar tissue formation
– Some researchers report increased fluid in the
nucleus pulposus drawn from the vertebral body
during tx
– This will explain the increase in pain in some patients
with disc prolapses, immediately following tx
– They recommend using 30 pounds as an initial tx
force with disc patients to assess their tolerance
Treatment Indications
• Degenerative disc disease
– Narrowing of intervertebral spaces
– Pressure on nerve roots, increased load on
facets
– Traction widens space and decreases
pressure temporarily
– May result in realignment that decreases
pressure
Treatment Indications
• impinged capsule
• Joint hypomobility
– Mobilization, passive joint movement, nonspecific
– Pain control
by synovial fluid exchange to facet capsules
and the meniscus for nutrition, and
proprioceptive response from moving facet
structures gives a gate control response
Treatment Indications
• Nerve root impingement
– From bulging disc, osteophytes (spurs), narrowed foramen
– Tingling usually associated with nerve compression
– Continued pressure gives demyelination with slowing of nerve
impulses and can progress to axon death with resulting
numbness, weakness and diminished reflex responses
– Muscle spasms may develop in paraspinals with the same
innervation level
– Widens foramen
– May need unilateral or rotation added
– May realign to decrease pressure
– Decreases spasms that may be the cause of compression
– Nerve irritation can cause muscle spasms as the root levels may
be the same, just different axons
Treatment Indications
• Muscle tightness, spasms
– Stretches, inhibits
– Decreases load on other structures (nerve
root, facets, disc) that may result in spasms
– Fluid exchange
– Initial stretch should come form positioning
– EMG activity will decrease with proper
technique, increase with improper
Treatment Indications
• Scoliosis
– Pulls towards a more correct alignment
– Stretches out tight musculature or other joint
structures
• Pain
– Traction may decrease pressure on sensitive
structures and give a gate control effect with
movement of these structures
Contraindications
• Acute conditions
– Tx to acute sprains and strains may overwhelm already
weakened soft tissue
• Already weakened soft tissue
• Joint instability
– hypermobility
• Structural disease secondary to infection, tumor, etc.
• Vascular compromise
• Fractures
• Tumors
• Bone disease or infection
• Cardiac conditions
Relative Contraindications
• Pregnancy
• Osteoporosis
• Hiatal hernia
• Claustrophobia
General Technique for Applying
Lumbar Tx
• Force must be great enough to effect change to the target
structure
– 20-50% to move body
– Coefficient of friction is about 0.5
– Usually attempt to move 50% of the patient’s body weight
– 65-100 lbs of force to separate vertebrae on average
• May not be necessary for all treatments (spasms, pain)
• May not get to 65-100 lbs on first treatment
– Split table to reduce friction, must separate at target tissue
– Damage not reported until somewhere in the 400-800 lb range
– Instability is a problem with the sedentary, weak, elderly, and
young
General Technique for Applying
Lumbar Tx
• Patient must be able to relax
– Cannot out pull musculature
– No pain
– Use adjunctive treatments
– Research shows a decrease in joint space
with poor traction technique
– EMG activity will increase with a pull that is
too strong or with poor, uncomfortable
positioning
General Technique for Applying
Lumbar Tx
• Traction harness use
– Clip buckle versus velcro
– Vinyl versus cotton
– Adjustable lengths, pads
– Placement of lumbar belts
• skin versus clothes – dissipate traction force)
– Use of thoracic belts on lower, lateral ribs
• Not in axilla
– The thoracic belt is placed on after the pelvic belt
General Technique for Applying
Lumbar Tx
• Patient position
– Prone versus supine (comfort, goals)
– Prone
• Disc
• Pillows under abdomen to flatten lordosis, under
thighs or chest to increase extension
– Supine
• Mobilization
• pillows under knees to decrease lordosis
– Initial soft tissue stretch on soft tissue should come
from positioning
General Technique for Applying
Lumbar Tx
• Adjustments to belts, positioning and
poundage
– Made with first few pulls before split table is
released
– All slack is taken up before table is released
and release is only during rest phase
Effects of Lordosis (supine)
• Leg Position
– Up on a stool, decreases lordosis
– Flat, normal lordosis is maintained
– 90/90 position should flatten back, less than that decreases in
increments
• Rope Angle
– Flat low pull maintains
– With increased (elevated) rope angle, lordosis decreases
• Pelvic Harness
– Greatest effect on lordosis
– Posterior pull decreases lordosis
– Lateral pull maintains lordosis
– Anterior pull increases lordosis
– Positions between these will result in incremental changes
Effects on Lordosis (prone)
• Patients with sever pain and muscle spasms may tolerate prone
traction better
• Pillows and harness to control lordosis
• Rope angle
– Always low
– Pillows can decrease or increase lordosis
• Pelvic harness
– May be placed to effect lordosis, as with supine
– Harness is never placed posteriorly in prone
– Rarely anterior
– As a rule, it is placed laterally to maintain other positional effects
• Treatment in prone
– Allows performance of other modalities without position changes
– Allows for easy palpation of the interspinous spaces to determine the
level and degree of spinal motion
Traction Type (mode)
• Sustained
– Well suited for disc herniations, muscle
spasms other soft tissue tightness
– Less poundage is tolerated than with
intermittent
– Mechanical devices are most effective
– Pulleys with weights do not take up slack well
over time to sustain constant tension
Traction Type (mode)
• New digital tx devices
– Are programmable
– Poundage (tension) can be increased in steps pre-set by therapist
– Protocols for hold/rest times, steps to increase tension
incrementally, etc
– Can all be programmed into many devices and saved
– Gradual build up allows patient to accommodate to increases in
tension
– Studies show a greater degree of ligament deformation with a low
rate of loading compared to a more rapid rate
– Long term shortening with contractures from positioning over the
years responds well to this low rate
Traction Type (mode)
• Intermittent
– Patients can tolerate greater poundages with
the rest periods
– Works well for joint hypomobility and
degenerative disc disease with shorter rest
and hold times (mobilizing effect)
Traction Type (mode)
• Positional
– Normally sidelying over a bolster or blanket
– Well suited for scoliosis treatment and other long term treatments
– Can be performed at home by the patient
– If tightness is severe enough, the tightened structures may result in a scoliosis
– Concavity will be on the tight side
– Patient is placed in sidelying on the convex side with the apex of the curve on the
bolster
– Allows gravity to effect a traction force on the patient’s body weight
– Creates unilateral separation on the opposite side of the spine
– Flexion of the hips and knees to forward bend the spine
– Trunk rotation towards the side of the superior shoulder will increase the opening
of the spine on that side
– In supine, with hips and knees flexed allows opening of the intervertebral foramen,
bilaterally
– Also useful with patients on very restricted activity due to pain
Traction Type (mode)
• Manual
– Very adaptable
– Various angles may be applied with combinations of rotation, long
axis distraction, lateral flexion and flexion/extension
– Allows tx to be applied to a specific level as it is palpated
– May be utilized as a evaluation tool to aid in determining a
diagnosis and to assess tolerance and effectiveness of traction
– Limited by strength and endurance of therapist
– Better suited for cervical than lumbar traction
– Allows constant adjustments by the therapist based on constant
feedback
– Can be applied unilaterally to one leg to effect the iliofemoral joint
or the sacroiliac joint
Treatment Time
• Generally 20 minutes for sustained or intermittent
• May be adjusted downward as tolerated,
especially with initial treatments
• Disc: 8 minutes or less if sustained tx is used
• Traction creates a suction force as vertebrae are
separated, pulls disc back in place
– suction effect is eliminated with time as pressures
across membrane equalize
Cervical Traction
• Objectives and concepts are much the same as for
lumbar traction
• Some adjustments are required in techniques of
application and occurrence rates of particular
dysfunctions vary (less disc, more ligamentous)
• In the cervical spine, the vertebral arteries, part of the
blood supply to the brain, lie within the bony structures of
the spine
Positioning for Cervical Tx
• Sitting
– Less desirable, but occasionally necessary
• Ex. Necessary with reflux esophagitis
– Unable to relax musculature
– Halter pulls on mandible, puts pressure on TMJ
– Flexion is applied by use of a posterior tilting traction
chair or by the use of pillows behind the low back,
sliding the hips forward and resulting in forward
flexion of the neck when the traction force is vertical
Positioning for Cervical Tx
• Supine
– In halter, more load is placed on the occiput by gravity
– Increased ability to relax
– Facilitates the use of Saunders and other new devices which
avoid TMJ loading
– Position of choice
– 20-30 degrees of flexion is needed to place the spine in neutral
and flatten the normal lordosis
– Exception is treatment to the atlanto-axial and atlantooccipital joints
• These joints should be treated with maintenance of the
normal lordosis of the cervical spine according to Saunders
Effects on Cervical Flexion
• Rope Angle
– To effect 25-30 degrees of flexion on the neck
the rope angle will need to approach 45
degrees due to the flexibility of the rope
resulting in a sagging with the weight of the
head
– The angle is 0, or flat for atlanto-occipital and
atlanto-axial traction
General Technique for Applying
Cervical Tx
• Halter
– The position of the halter will have the most significant effect on
cervical spine flexion
– A halter placed and tightened too low on the neck will result in
head on neck extension and the inability to eliminate the cervical
lordosis
– A halter placed to high on or past the occiput or placed too loosely
will slip off when a traction force is applied
– Ideally, the occipital pad is placed directly on the occiput and
tightened snugly enough to prevent slipping
– A poor set-up will result in head on neck extension and
uncomfortable loading of the mandible and in effect the TMJ
– Halters should not be utilized on patients with a history of TMJ
dysfunction or patients with poor dental occlusion
General Technique for Applying
Cervical Tx
• Saunders
– Saunders or similar traction devices utilize a
sliding track, with placement of the head on a
pad on the carriage to decrease the tension
load necessary to produce a traction force by
eliminating most of the friction
– Stabilization is provided by a head strap and
posterior pads that are tightened against the
occiput and the mastoid processes
General Technique for Applying
Cervical Tx
Poundage
– Research reports separation of vertebral bodies with ranges from
25-40 pounds
– 10 pounds for the atlanto-occipital and atlanto-axial joints
– Cadaveric studies did not show damage until 120 pounds of
traction
– Less than 25 pounds may be effective if separation of vertebral
bodies is not the goal
– Stretching of posterior musculature and opening of the
intervertebral foramen can occur at lesser poundages
– Normally greater than 10 pounds is required just to offset the
weight of the head
General Technique for Applying
Cervical Tx
Manual Traction
• Can be highly effective in the cervical spine
with good orthopaedic skills
• Highly flexible, constant feedback
• High load on the therapist
• Manual traction also allows for pressure over
trigger points for pain control as traction is
being applied