Transcript Worsen/Improve

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
• Osteophytic encroachment
• Facet inflammation
– Chemical response of the nerve to nucleus material
Hypothesis of Traction
Biomechanical
• Intervertebral Separation
• Reduction of disc
protrusion
• Altered Intradiscal
pressure
• Normalization of
conduction
• Increased Joint Mobility
Neurophysiological
• Pain Relief
• Decrease of Radicular
symptoms
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
Reduction of Disc Protrusion
• Weak Evidence
• Contrast dye injected in 3 patients
• Pre and post traction radiographs
• Saw reduction gone in 14 minutes
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Study re-done in 1992 with CT
4 patients with traction until recovery
2 had disc reduction/ 2 did not
All recovered
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
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
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
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
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
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)
When to Traction in Radiculopathy
When to Traction in Radiculopathy
When to Traction in Referred pain
Headache and Traction
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
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
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
Traction Dose
• Body Position
– Best for goal
• Angle of the pull
– Level
– Up at an angle
Flexion Worsens
• Prone Traction
Extension Worsens
• Supine Traction
Monitoring Response
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Oswestry
Neck Disability Index
MMT
Reflexes
Centralization
Pain complaints
• Immediate vs over 2-3 Tx’s
Contraindications
• Compromised spinal integrity
– Malignancy, osteporosis, tumor, infection
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Unstable fracture
Ligamentous instability (ie alar lig)
Recent Fusion (3-6mo)
Pregnancy (when can’t use belts)
Precautions
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Loose fitting dentures (remove)
Respiratory conditions
Claustophobia
Early pregnancy
– May consider manual traction
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
Traction Options
• Positional Traction
– Self unweighting on desk or counter
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
Case 60 year old
• Oswestry 16%
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LQS
Left Quad and HS 4+/5 compared to R
All other = B and Reflexes =B
Sensation- Slight decrease L3 and S1 on
Left
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
Joint Play
• L2 and L3 Hypomobile
• L4, L5 N
• L5/S1 Unilateral
– Recreates buttock pain
• L4/5 Unilateral
– Sore with empty end feel
Special Tests
• SLR (-)
• Slump Test (+) Left
– Recreates Buttock Pain
• Palpation to piriformis
– Recreates buttock c/o
Case
• What do you suspect is wrong?
• What category does he fall into?
• What will his treatment program look like?
Case
• Asymmetrical Sidebending
• Status Quo or Worsen
• Indication of Radiculopathy
– May argue worsen with extension
• Closing Restriction
Case Treatment
• Joint Mobs to Hypomoblie segments
– Specific mobilizations
• Traction
– Mechanical effects of intervetebral separation
– Parameters to maximize
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