Types of Distraction

Distraction can be manual or mechanical. Manual distraction is applied via hands. Alternatively, mechanical distraction is delivers a force that can be sustained or intermittent.

Manual distraction can be (1) inhibitory, (2) graded, (3) rhythmic, (4) adjustive, or (5) positional. Mechanical distraction can be three dimensional or three dimensional with autotraction.

Inhibitory or inhibitive distraction is compression placed over muscles or tendons of insertion, while the joint underneath is stretched.¹ An example of this is subcranial distraction. This type of distraction is based on the theory that pressure on the origin or insertion of a muscle fires the Golgi tendon apparatus (GTO) which, as a result, relaxes the muscle. With the muscles relaxed (inhibited), they do not resist the stretch being applied to the underlying joints.

Graded distraction has three grades of joint play movement. The joint surfaces in grade I are nearly unweighted; grade II takes up the slack of the capsule; and grade III stretches the capsule and ligaments. Grade II is used to evaluate end feel. If the slack is taken up too early, then treatment is applied to restore joint play. Grade III is a stretch treatment.

Rhythmic distraction is a series of distraction motions with alternate rest periods. With this, there is a possibility of “gating the pain”, “pumping fluids”, or both. This technique is used to decrease pain, not to increase range of motion.

Adjustive distraction is a high velocity thrust often used in a joint such as the hip. The gross degree of distraction available can be determined by placing the patient supine, stabilizing one foot against the clinician’s thigh, and then applying traction on the thigh to be examined.

Positional traction by Paris ² is most useful in the spine where two vertebrae are so positioned that the intervertebral foramen between them opens to relieve nerve root pressure. The patient lies over pillows and perhaps is held or assisted by straps.

The three-dimensional mechanical traction table allows positioning of the patient such that the traction force results in a distraction at the spinal level and the side that is desired. The most recent traction tables are designed by Kaltenborn, Paris, and others.²

Three-dimensional mechanical autotraction allows the patient to perform traction themselves against gravity or with the assistance of a distraction table. Some traction tables can help the patient find the position of maximum comfort and allow the patient to apply the traction force.

Therapeutic Effects

When performed correctly, cervical and lumbar traction can cause many effects such as distraction or separation of vertebral bodies; a combination of distraction and gliding of the facet joints; tensing of the ligamentous structures of the spinal segment; widening of the intervertebral foramen; straightening of the spinal curves; and stretching of the spinal musculature.³ Some practitioners believe fluid exchange occurs within the spinal disc during traction.⁴

The therapeutic efficacy of traction will be determined by the following: (1) strength of the applied force; (2) direction of the applied force; (3) position of the body; (4) state of rest or motion of the body to which the force is applied; (5) contour and texture of the body to which the force is applied; and (6) the surface on which the body rests.

It is generally accepted that cervical and lumbar traction can be helpful in centralizing a pain process and in reducing radicular symptoms.⁵^–⁸ Xin⁹ suggests that cervical traction helps with vertebrobasilar insufficiency resulting from spondylosis when combined with enhanced external counterpulsation. Others believe more definitive studies are needed to fully understand the benefits of traction.^10,¹¹

Sustained or Intermittent Mechanical Traction and Manual Traction

Keep in mind that traction is a force and not a result.¹ Results of sustained or intermittent mechanical traction include: (1) foraminal distraction; (2) flattening of any disc bulge; (3) relief of pressure on the nerve root. Conversely, manual traction can be sustained only for a short period of time. The techniques are often much stronger than mechanical traction techniques and the results include stretch to the myofascia; stretch to facet capsules; and occasional repositioning of vertebrae.

Clinical Studies

Katavich,¹² indicated in her research, that a stretch generated in cervical muscles and skin during cervical traction has the potential to influence the excitability of motor neurons. She believes manual cervical traction relieves pain and muscle spasm in the neck and upper quartile. In her study, she postulated that afferent input generated by these procedures may lower the excitability of X motor neurons of upper limb muscles. Therefore, an understanding of the receptors and mechanisms underlying manual therapy may allow more effective stimulation, and hence, improved clinical outcomes.

Briem,¹³ and others, have evaluated the immediate effects of inhibitive distraction on active range of cervical flexion in patients with neck pain. This study did not confirm the immediate effects of inhibitive distraction on cervical flexion AROM, but did provide indications for potential subgroups likely to benefit from this technique. Cai¹⁴ described positive predictors for lumbar traction to be noninvolvement of manual work, low-level fear avoidance beliefs, absence of neurologic deficits, and age >30 years. Raney¹⁵ described positive predictors for cervical traction to be when the patient reports peripheralization with lower cervical spine (C4-7) mobility testing, positive shoulder abduction test, age ≥55 years, positive upper limb tension test, and positive neck distraction test.

Creighton ¹⁶ confirmed the merits of positional distraction as a means to open the lumbar neuroforamen. A lateral radiograph was taken of the left lumbar neuroforamen in 10 subjects. The average foraminal opening was >4 mm at L3, L4, and L5. It is possible that even greater opening could have been achieved if towel rolls had been individually fitted—as is done in the clinical setting. Both supine and prone lumbar traction should be attempted to maximize traction benefits.¹⁷

Indications for Spinal Traction

Clinically, traction is usually prescribed for the following conditions: (1) discogenic pain from bulges, protrusions, and herniations; (2) degenerative disc or joint disease; (3) radiculopathies; (4) facet joint syndrome; (5) joint hypomobility; (6) muscle spasms; (7) foraminal stenosis; and (8) postlaminectomy syndromes.

Contraindications for Spinal Traction

Traction is known to be a safe procedure with therapeutic value in helping patients with spine-related pain. It is recommended that a detailed history, physical examination, and radiologic studies be performed prior to implementing cervical and lumbar traction techniques. Although the literature is lacking in studies reporting clear contraindications to traction, the clinician must rely on empirical information and opinion. These contraindications include (1) ligamentous instability (prior trauma or rheumatoid arthritic patients); (2) spinal infections, such as osteomyelitis, or discitis; (3) severe osteoporosis or osteopenia; (4) primary bone or spinal cord and metastatic tumors; (5) myelopathies; (6) uncontrolled hypertension or vertebral basilar artery insufficiency (for cervical traction);¹⁸ (7) the very young and the very old frail patients; and (8) acute or subacute spinal fractures. Relative contraindications for lumbar traction include pregnancy, abdominal or inguinal hernias, and aortic aneurysms.

Cervical Traction Techniques

Inhibitive Distraction

Subcranial inhibitive distraction is a myofascial technique described by Paris ² that is aimed at releasing tension in suboccipital soft tissue and suboccipital musculature. The patient lies supine with head supported. The physical therapist places the three middle fingers just caudal to the nuchal line, lifts the finger tips upward resting the hands on the treatment table, and then applies a gentle cranial pull, causing a long axis extension. The procedure is performed for 2 to 5 minutes (see Fig. 47-1).

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