12 F I S I O T E R A P I E S EPTEM B ER i 9 ? 8 SPINAL TRACTION* B. W IN T E R , D ip l. P h y s io . P ta ., T h is f o r m o f t r e a tm e n t h a s b e en u sed in T u r k e y since 1465 a n d sin c e th e d a y s o f H ip p o c r a te s (1544) in Italy . A b e n ch f o r tra c tio n a n d m a n ip u la tio n m a d e to his d e sig n a n d f o u r h u n d re d y e a rs o ld s ta n d s to d a y in the W e llc o m e H i s to r ic a l M u s e u m in L o n d o n . ((1) P re fa c e p. (xii); (6 ) P la te s 7 & 8 , p. 74) T h e p u rp o s e o f th is a rtic le is th e re fo re n o t to c o n tr ib u te a n o r ig in a l c o n ­ c e p t b u t to c o m p ly w ith a r e q u e s t to d isc u ss the a p p ro a c h e s o f C y ria x a n d M a itla n d to th is m e th o d o f tre a tm e n t. I t is p ro p o s e d to disc u ss th e m a in fe a tu re s o f e a c h b rie fly a n d to r e fe r th e r e a d e r to th e b i b li o ­ g r a p h y a t th e e n d o f th is a rtic le f o r f u r th e r in f o r m a ­ tio n . D r. Ja m e s C y ria x is a n h o n o r a ry c o n s u lta n t in o rth o p a e d ic m e d ic in e (m o re c o m m o n ly k n o w n as p h y sic al m e d ic in e ) a t St. T h o m a s ’ H o s p ita l, L o n d o n a n d v isitin g p r o fe s s o r in o rth o p a e d ic m e d ic in e a t th e U n i­ v e rsity o f R o c h e s te r M e d ic a l C e n tre , N e w Y o rk . H e h a s b e e n p ra c tis in g h is sp e c ia lity s in c e 1929. H is m o st c o m p re h e n s iv e p u b lic a tio n is h is “T e x tb o o k o f O r th o ­ p a e d ic M e d ic in e ”. (V o lu m es I a n d II. (1), (2)). M r. G e o ffre y M a itla n d is a p a r t- tim e le c tu re r in p h y s io th e r a p y a t th e S o u th A u s tr a lia n I n s ti tu t e o f T e c h n o lo g y , A d e la id e . H e is th e p r in c ip a l t u to r a t the 3 m o n th s p in a l m a n ip u la tio n c o u rse (A u s tra lia n P h y s io ­ th e ra p y A s s o c ia tio n ) a n d 12 m o n th g ra d u a te d ip lo m a in m a n ip u la tiv e a r th r o lo g y (S.A. In s titu te o f T ec h n o lo g y ). H e w as a w a rd e d a n h o n o r a r y F e llo w s h ip b y th e C h a r te r e d S o c ie ty o f P h y s io th e r a p y f o r h is w o rk in th is field. H is b e st-k n o w n p u b lic a tio n s a re “V e rte b ra l M a n i p u la tio n ” (3) a n d “ P e r ip h e r a l M a n ip u la t io n ” (4). T h e f o r m e r c o n ta in s d e ta ils o f s p in a l tr a c tio n f o r the ce rv ic a l, th o ra c ic , a n d l u m b a r re g io n s . I t in c lu d e s a d e s c rip tio n o f h is “ f r i c ti o n - f r e e ’ tr a c tio n ta b le a nd a d ju s ta b le c e rv ic a l h a lte r, (pp. 93-101, 109-115, 138- 145). I t w a s m y p riv ile g e to b e ta u g h t b y b o th th ese m en. I h a v e b e e n u s in g D r. C y r ia x ’s m e th o d s in S o u th A f r ic a sin c e 1960 a n d M r. M a itla n d ’s sin c e 1970. S p in a l t r a c tio n as a n o u t- p a tie n t p ro c e d u re m u s t b e use d a t th e d is c re tio n o f th e p h y s io th e r a p is t w h e n in d ic a te d ((2) p. 118, 45; (6 ), p. 76; (5)) as p a r t o f th e o v e ra ll tr e a tm e n t p ro g ra m m e f o r a p a tie n t. I t sh o u ld n e v e r b e a r o u tin e te c h n iq u e c a r r ie d o u t f o r a set p e r io d o f tim e , b u t s h o u ld b e d is c o n tin u e d if th e sy m p to m s a n d sig n s a re n o t im p ro v in g 'o r if th e y get w o rse. T h is is p r o b a b ly o n e o f th e re a so n s w h y c lin ica l tr ia ls o f tr a c tio n ((8); (9)) f a il to sh o w its u n d o u b te d benefit. P a tie n ts a re a llo c a te d to th e tr a c ti o n g ro u p a t r a n d o m , irre s p e c tiv e o f th e p a th o lo g y , sp e e d o f onset, b e h a v io u r o f sy m p to m s , etc. A ll th a t is ta k e n in to a c c o u n t is t h a t th e y c o m p la in o f p a in in a c e rta in a re a , e.g. th e n e c k a n d a rm . S uch se le c tio n f o r tra c tio n is b o u n d to le a d to fa ilu re . D R . C Y R IA X ’S A P P R O A C H D r. C y r ia x d e v ised a m e th o d o f d ia g n o s is o f so ft tis su e le s io n s b a se d u p o n se le c tiv e tis su e te n s io n . A c o m p re h e n s iv e h is to ry is ta k e n a n d a d e ta ile d p h y sic a l e x a m in a tio n is c o n d u c te d ((1) pp. 64 et seq.). H e re c e n tly sta te d (C a p e T o w n , J a n , 1976) t h a t h e m a y ta k e 45 m in u te s f o r a n in itia l b a c k e x a m in a tio n . E v e n w ith h is e x p e rie n c e th is is e sse n tia l b e c a u se d ia g n o s is is n o t easy y e t su b s e q u e n t t r e a tm e n t c an o n ly b e se lec te d a c c o rd in g to th e d ia g n o s is . H e re g a rd s th e v a lu e o f th e X -ra y e x a m in a tio n as m o s tly n e g a tiv e (( 1) p. 1 2 1 ; (6 ) p. 46). H e h a s u se d tr a c ti o n sin c e 1950 to t r e a t le sio n s in v o lv in g * R e p r in t b y k in d p e rm is s io n o f th e R h o d e s ia n P h y s io ­ th e ra p y A s so c ia tio n , In i. o f R h o d . P h y s io th e r. A sso c ., 2, 7, 1976. M .C .S .P ., D ip . T .P ., M .M .T .A .A . th e n u c le u s p u lp o s u s th a t he c o n sid e rs re d u c ib le rrn p. 454 et seq.). " ' A t the cervical sp in e m a n u a l tr a c tio n is u se d durino m a n ip u la tio n ((1) p. 150) f o r r e d u c tio n o f a displaced a n n u lu s . H a l te r tr a c tio n is se ld o m u se d a n d is a p p ije[i as se v e ra l s h o r t p u lls w ith th e p a tie n t s ittin g on a c h a ir (h e a d su s p e n s io n ) ((1) p. 157). T r a c tio n in re c u m ­ b e n c y is u s e d f o r a sm a ll n u c le a r p r o tr u s io n , o r to a llo w th e p a tie n t w ith se v e re b r a c h ia l p a in to g e t some sle e p ( ( 1) p . 158 & (2) p . 45). H o s p ita l tra c tio n is used o c c a s io n a lly ( ( 1) p. 158 & (2 ) p. 122 ). E x e rc ise s are a v o id e d ((1) p. 154). T h oracic traction is se ld o m u se d (fo r in d ic a tio n s see r e fe re n c e (2) p. 45). A t the lum bar sp in e tr a c tio n is a p p lie d on a fixed- to p co u ch b y m e a n s o f th o r a c ic a n d l u m b a r harnesses T h e p u ll is e x e rte d th ro u g h the p e lv ic h a rn e s s by & f o r m o f w in c h so th a t a stro n g , c o n s ta n t p u ll is o b i tia n e d ((1) p. 463 e t seq.). T h e p a tie n t m a y b e supine o r p ro n e w ith f u r t h e r a d ju s tm e n ts m a d e by placing p illo w s a n d a p p lic a t io n o f th e h a rn e ss e s . T h e s e are m a d e a c c o rd in g to th e c o m fo rt o f th e p a tie n t and re su lts a c h ie v e d . I t is u sed fo r le s io n s in v o lv in g the n u c le u s p u lp o s u s w h e re tr a c tio n is th o u g h t to be b e tw e e n a b o u t 40 to 85 kgs d e p e n d in g p a r tia lly o n body b u ild ; a n a m o u n t e q u a l to 26% o f th e b o d y w e ig h t is th e in d ic a te d fo rm o f tre a tm e n t. T h e a m o u n t o f pull v a rie s, d is s ip a te d in o v e rc o m in g th e f r i c ti o n o f th e couch (7). It is g iv e n d a ily f o r 30 - 45 m in u te s . P ro g re s s io n is assessed d a ily b e fo re tre a tm e n t b e g in s u sin g an a p p ro ­ p r ia te sign su c h as th e s tr a ig h t leg ra is in g test. T re a t­ m e n t m a y h a v e to b e g iv en fro m 1 - 3 w eek s to a b olish th e s y m p to m s a n d signs. I t m ay ta k e up to 10 daily se ssio n s to p ro v e effective. T r a c tio n is n o t c o m b in e d w ith m a n ip u la tio n o r any o th e r f o r m o f p h y s io th e ra p y . C o rse ts o r s u p p o rts m ay b e u se d a f te r r e d u c tio n if a d is p la c e m e n t ten d s to re c u r e asily. E x e rc is e s a re n o t u se d b e c a u s e th e d isc is c o m p re ss e d w h e n e v e r th e m u sc le s s p a n n in g it co n tra ct. T h is h a s d ire c tly th e o p p o s ite effect (11) to th e tra c tio n w h ic h a im s a t d is tra c tin g th e jo in t ((6 ) p la te 6 ; (9)). P re v e n tio n o f d isc tr o u b le s h o u ld c o m m e n c e as so o n as a b a b y s ta r ts to w a lk ((6) p p . 85-109). M R . M A I T L A N D ’S A P P R O A C H s B e ca u se h e is a p h y s io th e ra p is t, M r. M a itla n d tr e a t! p a tie n ts o n m e d ic a l re fe r r a l a n d is d e p e n d e n t o n the re fe r r in g d o c to r f o r th e d ia g n o s is ((3) p re fa c e , p. (x) a n d pp. 1-8). A n y o n e f a m i lia r w ith th is k in d o f w ork w ill k n o w w h a t a v a r ie ty o f c lin ic a l la b e ls m a y b e a tta c h e d to p a tie n ts c o m p la in in g o f p a in o f spinal o rig in ((6 ) p. 135). W h e n e v e r a re lia b le d ia g n o s is is o b ta in e d it h e lp s in th e s e le c tio n o f tr e a tm e n t a n d the e s tim a tio n o f th e re su lts t h a t c a n b e exp ec te d . T h e c lin ic a l s y m p to m s a n d signs fo u n d o n q u e s tio n in g and e x a m in in g th e p a tie n t ((4) pp. 1-20; 155-169) a re a f u r th e r g u id e to se le c tio n a n d p ro g re s s io n ; o r m ay be th e o n ly re lia b le g u id e a v a ila b le to th e p h y s io th e ra p is t ((3) pp. 156-157; T a b le 3, tra c tio n ). A t th e cervical sp in e: ((3) p. 93-101) h a lte r tr a c tio n is u se d r a th e r th a n m a n u a l tr a c tio n , th e la tte r b e ing a p p lie d w h e re in d ic a te d as a lo n g itu d in a l m o b ilisin g te c h n iq u e ((3) p. 71). T h e h a lt e r is a d ju s ta b le fo r d iffe re n t siz ed h e a d s a n d f o r h e a d -o n -n e c k p o sitio n ((10); (3) p. 94). T r a c tio n m a y b e a p p lie d in sittin g o r s u p in e ly in g . T h e p u llin g fo r c e m a y b e s u p p lie d by d o u b le p u lle y b lo c k s a n d ro p e , h a n g in g w e ig h ts or a n e le c tro n ic in te r m itte n t tr a c tio n a p p a ra tu s . T h e la tte r is c a p a b le o f a p p ly in g c o n s ta n t tr a c tio n a t a se t p u ll, or in te r m itte n t tr a c tio n w ith “ h o l d ” a n d “ re s t” p e rio d s R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) jab le f r o m 0 to 14 se c o n d s. C o n s ta n t t r a c ti o n m a y b e oplied o n a 24 h o u r b a s is in h o s p ita l o r a t h o m e a nd • i n d i c a t e d f o r p a tie n ts w ith se v e re ro o t p a in . C o n s ta n t Iraction m ay b e a p p lie d as a n o u t- p a tie n t p ro c e d u re fo r periods o f u p to 15 m in u te s (30 m in u te s o r lo n g e r fo r j j i s c p ro tru s io n s ). I t m a y b e u se d d a ily o r se v e ra l tim e s day. M a x im u m d is tr a c tio n o f a jo in t is o b ta in e d o>hen it is p o s itio n e d in th e m id -p o s itio n s o f all its ranges o f m o v e m e n t. In th e n e u tr a l (o r a n a to m ic a l) position, th e u p p e r c e rv ic a l jo in ts a re in m id ra n g e , but th e lo w e r c e rv ic a l jo in ts a re n e a r e r th e i r e x te n d e d position. T r a c tio n f o r th e u p p e r c erv ica l s p in e is d o n e in sittin g as a n e u tr a l p u ll is c o m fo rta b le a n d e asily applied. ̂ . . . . . . . , F o r th e lo w e r c e rv ic a l s p in e it is d o n e in ly in g w ith neck in flexion ( ± 3 0 ° ) and the upper cervical sp in e (“head-neck” p o sitio n ) in neutral ((3) p. 97). T h e am ount of pull m ust b e sufficient to cause m ovem en t at the d e s ire d level, so th e jo in t is palpated w h ile interm ittent traction is app lied and the pull adjusted until m o v e ­ ment is felt. I t is then held (for constant traction) or , the “h o ld ” and “rest” period s are set (for interm ittent, Variable traction) for the desired treatm ent tim e. T h e poundage and duration o f traction are governed by the changes in sym p tom s and signs — the p o sitio n is not. Treatment is g iv en daily at first bu t m ay at a later stage be given less freq uently esp e c ia lly in the case o f inter­ mittent variab le traction. P ro g re s s io n in v o lv e s c h a n g in g th e d u r a tio n o f p ull, a m o u n t o f p u ll, c h a n g in g th e ty p e o f tr a c tio n g iv en o r d isc o n tin u in g t r e a tm e n t b y tra c tio n . P ro g re s s io n is based o n th e a sse ssm e n t o f th e re le v a n t s y m p to m s a n d signs fo u n d o n e x a m in a tio n a t th e b e g in n in g o f e a c h tre a tm e n t session. T r a c tio n m a y be u se d d u rin g th e same session, a t e n d (u su a lly fo llo w in g ) m a n ip u la tio n . ((3) p. 152, T a b le 2). T r e a tm e n t in c lu d in g tr a c tio n tak e s a b o u t 1-3 w e ek s to a b o lis h a ll s y m p to m s a n d signs (o r reduce th e m as f a r as p o ssib le ). (See “ p r in c ip le s a p p li e d ” cases N o . 1, 2, 4, 5, 7, 9, 14, 17, 19, 21, 22 fro m “V e rte b ra l M a n i p u la tio n ” (3)). T ra c tio n is d is c o n tin u e d if n o b e n efit a c c ru e s a fte r the f o u r th tr e a tm e n t (or, o f c o u rse , if th e p a tie n t gets worse). A c o lla r m a y b e u se d a t th e sa m e tim e if it is fe lt t h a t th is w o u ld re d u c e re la p se s a n d p ro d u c e a m ore f a v o u ra b le p ro g ress. A t the Lum bar S p in e h a rn e s s tr a c tio n is d o n e w ith a th o ra c ic a n d p e lv ic h a rn e ss . T h e co u ch to p is m o v a b le to e lim in a te as m u ch f r i c ti o n as p o ssib le . T h is is e ssential f o r in te r m itte n t v a r ia b le tr a c tio n (w ith set jo ld a n d re st p e rio d s ). T h e tr a c tio n is a p p lie d th ro u g h i h e p e lv ic h a rn e ss ((3) p. 141) b y m e a n s o f d o u b le p u lle y blocks a n d a r o p e (c o n sta n t) o r b y m e a n s o f a n in te r ­ m itte n t t r a c tio n a p p a r a tu s (c o n sta n t a n d in te rm itte n t v a ria b le ). T h e m a n u f a c tu r e r o f th e e le c tro n ic tra c tio n a p p a ra tu s s u p p lie s a co u ch w ith a m o v a b le to p , b u t it m ay b e m a d e m o re e c o n o m ic a lly u sin g a c o u c h w ith a flat, u n u p h o ls te r e d to p ((3) pp. 112-115; pp. 138-145— lu m b a r tra c tio n ). T h oracic T raction is a p p lie d v ia a c e rv ic a l h a lte r a n d a p e lv ic h a rn e s s (u p p e r th o ra c ic ) o r lo w e r th o r a c ic tra c tio n b y p la c in g th e th o r a c ic h a rn e ss as h ig h as p o ss ib le u n d e r th e a x illa e ((3) pp. 109-112). T h e p a tie n t m a y lie s u p in e o r p ro n e , a c c o rd in g to c o m fo rt b u t th e b e s t p o s itio n is t h a t w h ic h p la c e s the affected jo in t in a n e u tr a l p o sitio n . F o r th e u p p e r lu m b a r sp in e th e legs s h o u ld be ex te n d ed (no p illo w s); f o r th e m id -lu m b a r s p in e o n e p illo w m a y b e p la c e d u n d e r th e k n e es a n d f o r th e low lu m b a r s p in e tw o (o r m o re ) u n d e r th e k n e es in o rd e r to p ro d u c e m o re lu m b a r flexion. T h e a m o u n t o f p u ll s h o u ld b e sufficient to p ro d u c e p a lp a b le m o v e m e n t to th e affe c te d level a n d th e r e a f te r it is c o n tro lle d b y th e b e h a v io u r o f th e sy m p to m s w h ile o n tr a c tio n , a n d th e p ro g re s s o f s y m p to m s a n d signs o v e r th e tre a tm e n t p e rio d . O n a fr ic tio n -f r e e SEPTEMBER 1978 13 co u ch it c o u ld b e as l ittle as 10 kgs. I t is g iv en d a ily f o r a m a x im u m o f 15 m in u te s u n le s s it is a case o f d isc p a th o lo g y w h e re 30 m in u te s o r m o r e c o u ld b e g iven. O th e r f a c to rs c o n tro llin g tre a tm e n t a re as fo r th e c e rv ic a l sp in e . U ltr a s o u n d m a y b e u se d , b u t n o t s h o rtw a v e d ia th e rm y . A c o rse t m a y b e w o rn w h ile tre a tm e n t b y tr a c ti o n is g iven (b u t n o t d u r in g t r e a t­ m e n t o f c o u rse). A c o rse t d e c re a s e s th e in tra d is c a l p re s s u re by 25% (11). H o s p ita l tra c tio n m a y b e re q u ire d f o r p a tie n ts w ith se v e re r o o t p a in . E x e rc is e s m a y fo llo w su c c essfu l tre a tm e n t b y tra c tio n . T h e s e m a y b e o f a m o b ilis in g ty p e in cases o f d e g e n e ra ­ tiv e c h a n g e s, w h ic h a r e u s u a lly tre a te d b y in te r m itte n t v a r ia b le tra c tio n o r o f a s ta b ilis in g type. T h a t m e a n s th a t m u sc le s s u p p o r tin g th e v e rte b ra l c o lu m n a re s tre n g th e n e d in o r d e r to p re v e n t re c u rre n c e , im p ro v e p o s tu re a n d p re v e n t s t r a in o n jo in ts. A n e x e rc is e u s e d b y M a itla n d f o r th is p u rp o s e m a y b e m e n tio n e d h e re. T h e b a c k a n d a b d o m in a l m u sc le s a r e in v o lv e d in a s tro n g c o -c o n tra c ­ tio n w ith th e s p in e s u p p o rte d a n d th e m u sc le s w o rk in g in th e ra n g e in w h ic h th ey a re n o r m a lly r e q u ir e d to w o rk . T h e p a tie n t p la c e s a p illo w o n th e e d g e o f a la rg e ta b l e (o r tre a tm e n t c o u c h in th e p ra c tic e ) a n d lies w ith h is h ip s level w ith th e edge, h o ld in g o n to th e sides. H e ta k e s in a b re a th a n d h o ld s it, lif tin g his fe e t f r o m th e g r o u n d f o r a b o u t 6 se c o n d s, a n d lo w e rs th e m , b r e a th in g o u t. T h is is re p e a te d a b o u t te n tim es. P ro g re s s io n is in th e n u m b e r o f tim e s a n d d e g re e o f difficulty, w h ic h is in c re a s e d b y m o v in g th e p elv is f u r t h e r o v e r th e edge o f th e ta b le . T o m y k n o w le d g e fe w c lin ic a l tr ia ls u s in g tra c tio n h a v e b e en re p o rte d in th e E n g lish lite r a tu r e ((8); (9)) a n d th e y te n d to c o n c lu d e t h a t tr a c tio n is n o t a v ery w o rth w h ile te c h n iq u e . T h is is u n f o r tu n a te , b e c a u se w h e n o n e re a d s h o w th e tr ia l s w e re c o n d u c te d , the te c h n iq u e s o f tr a c tio n u se d , th e f r e q u e n c y o f a p p lic a ­ tio n a n d h o w o th e r m o d a litie s w e re u se d in c o n ju n c ­ tio n w ith th e tr a c tio n , th e r e is m u c h to b e c o m m e n te d u p o n . T h o s e o f us w h o h a v e b e e n u s in g tra c tio n , p r o p e rly a p p lie d , f o r y e ars k n o w f r o m o u r clin ica l re su lts t h a t it is a m o d a lity f r o m w h ic h p a tie n ts m ay benefit. S o m e tim e s i t is th e o n ly tr e a tm e n t to w h ic h a p a tie n t re sp o n d s. H a v in g u se d b o th m e th o d s I find th e y a r e a ll o n e n e e d s to c o p e w ith a n y p a tie n t th a t com es a lo n g r e q u ir in g tra c tio n . R eferen ces 1. C y riax . J. T e x tb o o k o f O r th o p a e d ic M e d ic in e ; V o lu m e I: D ia g n o sis o f s o f t tissue lesions. 6th E d ., B a illie re T in d a ll, L o n d o n (1975). 2. C y ria x , J., T e x tb o o k o f O r th o p a e d ic M e d ic in e , V o lu m e II. T r e a tm e n t by M a n ip u la tio n , M assage a n d In je c tio n . 8 th E d ., B a illie re T in d a ll, L o n d o n (1971). 3. M a itla n d , G . D ., V e r te b r a l M a n ip u la tio n , 3rd E d ., B u tte rw o rth & C o. L o n d o n 1973. 4. M a itla n d , G . D ., P erip h e ra l M a n ip u la tio n , 1st E d ., B u tte rw o rth & C o. L o n d o n (1970). 5. Y a te s , D . A . H „ In d ic a tio n s a n d C o n tra -in d ic a tio n s f o r S p in a l T ra c tio n P h y s io th e r. Jnl. o f C .S.P ., 58, 2. 55, (1972). 6 . C y riax , J. T h e S lip p ed D isc. G o w e r P re ss, 1970. 7. Ju d o v itc h , B. a n d N o b e l, G . R ., T r a c tio n T h e ra p y — A S tu d y o f R e sista n c e F o rc e s. A m . Jnl. Surg. 93, 108, (1957). . . 8 . B ritish A s so c ia tio n o f P h y s ic a l M e d icin e. P a in in th e N e c k a n d A rm ; A M u ltic e n tre T r ia l o f th e E ffects o f P h y s io th e ra p y . B rit. M e d . / . , 7, 253-258. (1966). 9. E d ito ria l: T ria l by T ra c tio n B rit. M e d . / ., 1. 2-3, (1976). 10. M a itla n d , G . D . P h y s io th e ra p y A p p a ra tu s . A u str. Jn l. P h y sio th e r.. 2, 20 (1956). 11. N a c h e m so n , A . a n d M o rris, J. M . in V iv o — M e a su re m e n ts o f In tra d is c a l P re ss u re . Jnl. o f B o n e a n d J o in t Surg., 46A . 5, 1091, (1964). P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )