Traction review

Cervical and LumbarCervical and Lumbar
Traction ReviewTraction Review
Casey Christy, MA, ATC, CSCSCasey Christy, MA, ATC, CSCS

Disc AnatomyDisc Anatomy
Jelly donut analogyJelly donut analogy
Annulus FibrosisAnnulus Fibrosis
Outer layer of disc attached to vertebralOuter layer of disc attached to vertebral
bodybody
Nucleus PulposusNucleus Pulposus
Inner layer, protein gelInner layer, protein gel
Water loss with agingWater loss with aging
85-90% water at birth, 70% age 70.85-90% water at birth, 70% age 70.22
Image courtesy of
flickr.com

Disc InjuryDisc Injury
Bulging or herniated discBulging or herniated disc
Stretched or weakened annulus fibrosisStretched or weakened annulus fibrosis
AF bulges or protrudes from pressure ofAF bulges or protrudes from pressure of
NPNP
Similar to overinflating a bicycle inner tubeSimilar to overinflating a bicycle inner tube
with a weak spotwith a weak spot22

Disc InjuryDisc Injury
““Slipped discSlipped disc””
Lay term but inaccurateLay term but inaccurate
Discs do not slip out of place like a hockeyDiscs do not slip out of place like a hockey
puck but deform or bulgepuck but deform or bulge22

Traction BasicsTraction Basics
Traction: Latin originTraction: Latin origin traciotracio
which means “drawing orwhich means “drawing or
pulling apartpulling apart””22

Indications include but notIndications include but not
limited to:limited to:
Nerve root compressionNerve root compression
Disk protrusion, bulging discDisk protrusion, bulging disc
Muscle spasmMuscle spasm
Joint hypomobilityJoint hypomobility
Disc degenerationDisc degeneration22

Traction can reduce nerveTraction can reduce nerve
root impingement,root impingement,
temporarily decreasing paintemporarily decreasing pain
and breaking the pain-and breaking the pain-
spasm-pain cycle.spasm-pain cycle.44

Spinal traction is theSpinal traction is the
application of a distractingapplication of a distracting
force to separate vertebralforce to separate vertebral
joint surfaces. It can bejoint surfaces. It can be
applied manually,applied manually,
mechanically or through amechanically or through a
motorized device.motorized device.44

In the cervical spine, traction appliedIn the cervical spine, traction applied
with the spine in mild flexion results inwith the spine in mild flexion results in
greater separation of the posteriorgreater separation of the posterior
structures (facet joints, intervertebralstructures (facet joints, intervertebral
foramen, nerve roots).foramen, nerve roots).
With the cervical spine in slightWith the cervical spine in slight
extension, traction separates theextension, traction separates the
anterior structures (vertebral bodiesanterior structures (vertebral bodies
and disks).and disks).44

Traction can “centralizeTraction can “centralize”” aa
herniated nucleus pulposus,herniated nucleus pulposus,
reducing a protruding orreducing a protruding or
““bulgingbulging”” disk.disk.44

Pressure from the elongatingPressure from the elongating
posterior longitudinalposterior longitudinal
ligament as it tightens duringligament as it tightens during
traction also helps force thetraction also helps force the
nucleus pulposus inwardnucleus pulposus inward
towards the disktowards the disk’’s center.s center.44

When traction is applied, theWhen traction is applied, the
resulting increase in fluidresulting increase in fluid
(from decreased disk(from decreased disk
pressure) contributes topressure) contributes to
healing the annulus fibrosis.healing the annulus fibrosis.44

Traction applied too long canTraction applied too long can
cause the disc to absorb toocause the disc to absorb too
much fluid (imbibe) andmuch fluid (imbibe) and
overhydrate, predisposing itoverhydrate, predisposing it
to rupture. This process isto rupture. This process is
similar to overfilling a watersimilar to overfilling a water
balloon.balloon.33

Traction ApplicationTraction Application
Athletic training studentsAthletic training students
should observe traction beingshould observe traction being
applied by an experiencedapplied by an experienced
clinician first and be closelyclinician first and be closely
supervised when applyingsupervised when applying
traction techniques.traction techniques.22

Traction can be applied in aTraction can be applied in a
sustained or intermittent manner.sustained or intermittent manner.
Motorized units and weight-and-Motorized units and weight-and-
pulley systems can administerpulley systems can administer
sustained or intermittent traction.sustained or intermittent traction.
Intermittent traction is suggestedIntermittent traction is suggested
when applying manual traction.when applying manual traction.44

Sustained traction isSustained traction is
recommended when treatingrecommended when treating
degenerative disc disease, muscledegenerative disc disease, muscle
spasm and nerve rootspasm and nerve root
impingement. Intermittentimpingement. Intermittent
traction is recommended fortraction is recommended for
treating facet joints and disctreating facet joints and disc
protrusion.protrusion.44

When applying intermittentWhen applying intermittent
traction, the “resttraction, the “rest”” period involvesperiod involves
aa reductionreduction of traction force (aboutof traction force (about
50%), not the complete removal of50%), not the complete removal of
force.force.1,41,4
Another recommendation is toAnother recommendation is to
reduce the force by 1/3 during thereduce the force by 1/3 during the
rest phase.rest phase.22

Cervical TractionCervical Traction
ApplicationApplication
A minimum of 15 degreesA minimum of 15 degrees
of flexion is necessary toof flexion is necessary to
open the cervical posterioropen the cervical posterior
facets.facets.44

Traction in the neutralTraction in the neutral
cervical spine position causescervical spine position causes
the greatest separation in thethe greatest separation in the
upper cervical spine; 30upper cervical spine; 30
degrees of flexion directs thedegrees of flexion directs the
forces more to the lowerforces more to the lower
cervical spine.cervical spine.1,21,2

To optimally separate the cervicalTo optimally separate the cervical
posterior facet articulations, openposterior facet articulations, open
the intervertebral space, widen thethe intervertebral space, widen the
intervertebral foramen and stretchintervertebral foramen and stretch
the posterior tissues, 25-30 degreesthe posterior tissues, 25-30 degrees
of flexion is recommended. Thisof flexion is recommended. This
position also straightens theposition also straightens the
normal cervical lordosis.normal cervical lordosis.44

Always start with manualAlways start with manual
cervical traction before applyingcervical traction before applying
mechanical or motorizedmechanical or motorized
traction. This way any painfultraction. This way any painful
movements can be noted ormovements can be noted or
immediately stopped.immediately stopped.22

ApplicationApplication
methodsmethods
Both hands underBoth hands under
the occiputthe occiput
One hand underOne hand under
the occiput and thethe occiput and the
other under theother under the
mandiblemandible
One hand underOne hand under
occiput and otherocciput and other
over foreheadover forehead1,41,4
Image courtesy of Starkey,
www.therapeuticmodalities.com FA
Davis Publishers

Cervical traction should beCervical traction should be
applied in a supine positionapplied in a supine position
for optimal benefit.for optimal benefit.22

Intermittent manualIntermittent manual
cervical traction may becervical traction may be
applied for 5-10 secondsapplied for 5-10 seconds
followed by a very shortfollowed by a very short
rest time.rest time.
Total treatment time isTotal treatment time is
typically 3-10 minutes.typically 3-10 minutes.22

Additional methods of cervicalAdditional methods of cervical
traction (other than manual)traction (other than manual)
Mechanical (ie: over door harness)Mechanical (ie: over door harness)
Note that “mechanicalNote that “mechanical”” andand
““motorizedmotorized”” are sometimes usedare sometimes used
interchangeablyinterchangeably
Mechanical refers to the use of aMechanical refers to the use of a
device to apply tractiondevice to apply traction1,21,2

Additional methods of cervicalAdditional methods of cervical
traction (other than manual)traction (other than manual)
MotorizedMotorized
Up to 25 lbs force recommendedUp to 25 lbs force recommended22
Start with 15 lbs with smallerStart with 15 lbs with smaller
individualsindividuals11
Starting force of 7% of body weightStarting force of 7% of body weight
is another recommendationis another recommendation

Additional motorizedAdditional motorized
traction recommendationstraction recommendations
SustainedSustained
10 minutes10 minutes
IntermittentIntermittent
20 seconds on, 5 seconds off20 seconds on, 5 seconds off
for 20-25 minutesfor 20-25 minutes22

Lumbar TractionLumbar Traction
ManualManual
Single Leg tractionSingle Leg traction
Patient supinePatient supine
One clinician stabilizes torsoOne clinician stabilizes torso
Another clinician applies tractionAnother clinician applies traction
on single leg (steady pull untilon single leg (steady pull until
traction is felt)traction is felt)
5, 30 second bouts recommended5, 30 second bouts recommended22

Manual cont…Manual cont…
Hip flexor stretch to follow singleHip flexor stretch to follow single
leg tractionleg traction
Supine edge of table, hang leg offSupine edge of table, hang leg off
table while other knee is pulledtable while other knee is pulled
towards chesttowards chest
Similar position to Gaenslen’s SignSimilar position to Gaenslen’s Sign
These muscles are often tightThese muscles are often tight
with radicular painwith radicular pain22

Mechanical lumbar tractionMechanical lumbar traction
Traction TableTraction Table
Start with 25% body weight,Start with 25% body weight,
then work up to 50% of bodythen work up to 50% of body
weightweight
 SustainedSustained
Slightly lower force usedSlightly lower force used
10-30 minute treatment time10-30 minute treatment time22

Mechanical lumbar tractionMechanical lumbar traction
Traction Table continued…Traction Table continued…
IntermittentIntermittent
30 seconds on, 15-30 seconds off30 seconds on, 15-30 seconds off
Longer on time up to 60 secs forLonger on time up to 60 secs for
disk injurydisk injury
Shorter on time (15 secs) for facetShorter on time (15 secs) for facet
joint dysfunctionjoint dysfunction1,21,2

Positional TractionPositional Traction
Examples of positional traction include:Examples of positional traction include:
Knees to chest (bilateral intervertebralKnees to chest (bilateral intervertebral
foramen separation)foramen separation)
Sidelying with pillow or blanket rollSidelying with pillow or blanket roll
between iliac crest and the ribcagebetween iliac crest and the ribcage
(unilateral intervertebral foramen(unilateral intervertebral foramen
separation)separation)
InversionInversion
Pool TractionPool Traction33
Image courtesy of
accessphysiotherapy.com

Positional TractionPositional Traction
For sidelying, the side on which theFor sidelying, the side on which the
increased foramen opening is desiredincreased foramen opening is desired
should be in the superior position,should be in the superior position,
with the pillow or blanket roll at thewith the pillow or blanket roll at the
affected spinal level.affected spinal level.
However, take note of patient self-However, take note of patient self-
positioning (leaning towards or awaypositioning (leaning towards or away
from pain) to determine positioningfrom pain) to determine positioning
for side-lying traction.for side-lying traction.33

Inversion tableInversion table
Patient suspended upside downPatient suspended upside down
Weight of upper bodyWeight of upper body
applies tractionapplies traction
Special contraindicationsSpecial contraindications
due to increased pressuredue to increased pressure
Hypertension (140/90+)Hypertension (140/90+)
Heart DiseaseHeart Disease
GlaucomaGlaucoma2,32,3
Image courtesy of
vitalityweb.com

Inversion traction delivers traction
equivalent to approximately 40% of
the patient’s body weight.
Blood pressure should be
monitored. If BP increases 20mm
above the resting diastolic during
treatment, the treatment should be
discontinued for that day.3

Those with a detached retina, sinus
problems, thyroid issues, diabetes,
migraines, a hiatal hernia, recent
surgery, or musculoskeletal issues
should consult a physician before
doing inversion traction.
For patient comfort, meals or snacks
should be avoided for the hour
before treatment.3

Start slowly with a minute or twoStart slowly with a minute or two
of inversion traction and progressof inversion traction and progress
to a maximum of 10-20 minutesto a maximum of 10-20 minutes
per session.per session.33

Have the patient perform a simple testHave the patient perform a simple test
to see if inversion traction can beto see if inversion traction can be
tolerated by assuming a hands and kneestolerated by assuming a hands and knees
position and then placing their head onposition and then placing their head on
the floor, remaining in this position forthe floor, remaining in this position for
one minute. Vertigo, dizziness, or nauseaone minute. Vertigo, dizziness, or nausea
may indicate the patient is a poormay indicate the patient is a poor
candidate for inversion traction.candidate for inversion traction.33

Pool TractionPool Traction
Flotation belt around torsoFlotation belt around torso
(ie: aqua jogger)(ie: aqua jogger)
Cuff weights around anklesCuff weights around ankles22

Passive prone extensionPassive prone extension
recommended immediately followingrecommended immediately following
lumbar traction treatment.lumbar traction treatment.22
Image courtesy of health.com

Passive prone extension facilitatesPassive prone extension facilitates
the posterior longitudinal ligamentthe posterior longitudinal ligament
pushing the nucleus pulposus backpushing the nucleus pulposus back
into position.into position.22

TractionTraction
ContraindicationsContraindications
Traction is contraindicatedTraction is contraindicated
for any acute neck or backfor any acute neck or back
injury (acute injury in thisinjury (acute injury in this
case refers tocase refers to anyany injuryinjury
caused by trauma orcaused by trauma or
excessive force).excessive force).1,21,2

TractionTraction
Fractured dens (odontoid process)Fractured dens (odontoid process)
of 2of 2ndnd
cervical vertebrae (axis)cervical vertebrae (axis)
Due to trauma, often whiplashDue to trauma, often whiplash
May go undiagnosed, not particularlyMay go undiagnosed, not particularly
painfulpainful
Traction can causeTraction can cause fatalfatal injury due toinjury due to
dislocation of 1dislocation of 1stst
or 2or 2ndnd
vertebraevertebrae
This is one reason why traction isThis is one reason why traction is
contraindicated in acute injuriescontraindicated in acute injuries
Fracture must be ruled outFracture must be ruled out

TractionTraction
Traction is contraindicatedTraction is contraindicated
in individuals with Downin individuals with Down’’ss
Syndrome, who often haveSyndrome, who often have
C1-C2 instability.C1-C2 instability.44

TractionTraction
Vertebral Artery TestVertebral Artery Test
A bony anomaly in the cervicalA bony anomaly in the cervical
spine can put pressure on thespine can put pressure on the
vertebral artery, which suppliesvertebral artery, which supplies
blood to the brain. Always performblood to the brain. Always perform
the vertebral artery test to ascertainthe vertebral artery test to ascertain
a patienta patient’’s circulatory status befores circulatory status before
applying traction…applying traction…

TractionTraction
Vertebral Artery TestVertebral Artery Test
... ask the patient to rotate and extend... ask the patient to rotate and extend
his or her head (active ROM) as far ashis or her head (active ROM) as far as
possible in one direction and then thepossible in one direction and then the
other. Hold each position for 30other. Hold each position for 30
seconds. If the patient becomes dizzyseconds. If the patient becomes dizzy
or nauseated, or slurs their speech,or nauseated, or slurs their speech,
traction is contraindicated.traction is contraindicated.1,41,4

TractionTraction
Additional contraindicationsAdditional contraindications
include but are not limited to:include but are not limited to:
MalignancyMalignancy
Infectious disease of the spineInfectious disease of the spine
Rheumatoid arthritisRheumatoid arthritis
OsteoporosisOsteoporosis
Uncontrolled hypertensionUncontrolled hypertension22

TractionTraction
Hypermobile jointsHypermobile joints
Older adults who are frailOlder adults who are frail
Respiratory or cardiovascularRespiratory or cardiovascular
diseasedisease
Aortic aneurysmAortic aneurysm22

TractionTraction
Spinal cord compressionSpinal cord compression
When traction increasesWhen traction increases
radicular painradicular pain22

TractionTraction
Special lumbarSpecial lumbar
contraindications include butcontraindications include but
are not limited to:are not limited to:
PregnancyPregnancy
Hiatal herniaHiatal hernia
Abdominal herniaAbdominal hernia
Active peptic ulcerActive peptic ulcer22

TractionTraction
Additional mechanical lumbarAdditional mechanical lumbar
traction concernstraction concerns
May not be able to adjust beltsMay not be able to adjust belts
tight enough on thin individualstight enough on thin individuals
Belts may not fit obese individualsBelts may not fit obese individuals
Claustrophobic individuals mayClaustrophobic individuals may
have difficulty when belts arehave difficulty when belts are
tightenedtightened11

ReferencesReferences
1. Denegar et al, Therapeutic Modalities for
Musculoskeletal Injuries, 3rd
edition
2. Knight and Draper, Therapeutic
Modalities: The Art and Science
3. Prentice, Therapeutic Modalities: For
Sports Medicine and Athletic Training. 5th
ed.
4. Starkey, Therapeutic Modalities, 3rd
edition

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