Page 8 P H Y S I O T H E R A P Y June, 1963 SUSTAINED SPINAL LESIONS By D O R O T H Y S L I M , M . C . S . P R e p r in te d b y k i n d p e r m iss io n o] " P h y s i o t h e r a p y ' ’ J o u r n a l o f th e C h a r te re d S o c ie ty o f P h y sio th e r a p y a n d th e A u th o r . F ig . 1. T h e i n a c t io n a p p a r a t u s . In tro d u c tio n T h e l u m b a r i n t e r v e r t e b r a l di sc c o n s i s t s o f t w o p a r t s — a n r t u l u s f i b r o s u s a n d n u c l e u s p u l p o s u s . P r o t r u s i o n s a r e ol t h r e e s o r t s : o f a f r a g m e n t o f a n n u l u s . a h e r n i a t i o n o f p u l p y m a t e r i a l o r b o t h t o g e t h e r . It h a s be en f o u n d t h a t s u s t a i n e d t r a c t i o n is t h e m o s t effective t r e a t m e n t f o r m o s t p r o t r u s i o n s c o n s i s t i n g o f t h e s o f t e r c e n t r a l p a r t o f t h e disc. H o w e v e r , it is n o t su i t e d t o c a r t i l a g e n o u s d i s p l a c e m e n t s , w h i c h usu a lly d o b e t t e r w i t h m a n i p u l a t i o n . W h e t h e r t h e p a i n is l u m b a r , o r t h e r e is r o o t p a i n in t h e li m b , is i m m a t e r i a l . B e f o r e t h e t i m e t h a t s u s t a i n e d t r a c t i o n w a s s t a r t e d , p a t i e n t s w i t h l e s io n s t h a t di d n o t r e s p o n d t o m a n i p u l a t i o n h a d n o a l t e r n a t i v e b u t t o lie in bed u n t i l t h e y w e r e well. T h i s p o s t u r e r e m o v e s t h e c o m p r e s s i o n s t r a i n s u p o n th e s p i n a l j o i n t s w h i c h a r e p r e s e n t in th e u p r i g h t p o s i t i o n . M o r e r o o m is c r e a t e d w it h i n t he j o i n t c a v i t y , a n d th e di sc s u b s t a n c e is e n a b l e d t o r e t u r n o v e r a p e r i o d o f se ver al m o n t h s . It w as d ec i d e d t o d i s t r a c t t he j o i n t s u r f a c e s in t h e belief t h a t t h e di sc s u b s t a n c e w o u l d b e r e d u c e d m o r e spe edily. T h i s a s s u m p t i o n h a s p r o v e d t o be c o r r e c t , a n d m o s t o f o u r p a t i e n t s l o se t h e i r s y m p t o m s in f r o m 14 t o 21 d ay s . T h i s d e c r e a s e in t i m e fo r r ec o v e r y a n d th e fact t h a t th e p a t i e n t is a b l e t o c o n t i n u e a n o r m a l life w h i l e h a v i n g t h e t r e a t m e n t , c o m p a r e s ver y f a v o u r a b l y w i t h se ver al m o n t h s ' o f c o m p l e t e rest in bed. T h e p u l p y m a t e r i a l o o z e s e i t h e r a b o v e , b e l o w o r t h r o u g h t h e s u r r o u n d i n g f i b r o c a r t i l a g e n o u s r i n g w h e n it is d a m a g e d . I n t i m e it e x e r t s a p r e s s u r e u p o n t h e p o s t e r i o r l o n g i t u d i n a l l i g a m e n t w h i c h a c c o r d i n g l y b u lg es , a n d e x e r t s a p r e s s u r e u p o n n e r v o u s s t r u c t u r e s ly in g in t h e s p i n a l c a n a l . S u s t a i n e d t r a c t i o n in c r e a se s t he d i s t a n c e b e t w e e n the a r t i c u l a r s u r f a c e s a t t h e af fected j o i n t a n d h a s t h r e e ef fects: I . T h e j o i n t s p a c e b e c o m e s l a r g e r a n d t h e o r i g in a l p a t h w a y t h r o u g h w h i c h t h e p u l p e x t r u d e d m a y be r e ­ o p e n e d . 2. T h e p o s t e r i o r l o n g i t u d i n a l l i g a m e n t b e c o m e s t a u t e n e d . A c e n t r i p e t a l f o r c e is ex e r t e d u p o n t h e j o i n t c o n t e n t s w h i c h a r e s q u e e z e d t o w a r d s t h e c e n t r e . 3. S u c t i o n . A s a re su lt th e p u l p y m a t e r i a l is d r a w n t o w a r d s t h e c e n t r e o f th e j o i n t . A p p a r a tu s A c o u c h is n e e d e d a n d t w o h a r n e s s e s (see Fig. I). A n o r d i n a r y h ig h c o u c h m a y be a d a p t e d re la ti v el y c h e a p l y by a local h a n d y m a n . A s u b s t a n t i a l p o s t is fixed at o n e e n d t o w h i c h the t h o r a c i c s t r a p s a r e a n c h o r e d . A m o v a b l e p o st is n ec es sa ry a t th e o t h e r e n d , a n d the pelvic h a r n e s s is a t t a c h e d t o it by a h o o k . T h i s p o s t is a t t a c h e d t o t h e en d o f a s p i n d l e w h i c h is m a d e to m o v e a w a y f r o m t h e en d o f t h e c o u c h by c o n t a c t w it h a co gw h ee l w h e n t h e h a n d l e is o p e r a t e d . A c a r p e n t e r s vice o r c a r j a c k w o r k s o n th e s a m e m e c h a n i c a l pr i n ci p le . It is i m ­ p o r t a n t t o m a k e c e r t a i n t h a t : (a) T h e s p i n d l e is l o n g e n o u g h t o a l l o w a sufficient ’ d i s t r a c t i o n o f t h e t w o h a r n e s s e s t o t a k e place. (/>) T h e o p e r a t i n g h a n d l e o r whe el is at least six in che s in d i a m e t e r o t h e r w i s e it is t i ri n g t o use. It is p o s s i b l e t o p r o d u c e a n a d e q u a t e n u m b e r o f v a r i a t i o n s in t h e a n g l e o f pu ll ev en w i t h t hi s s i m p l e a p p a r a t u s . S o m e c o u c h e s a r e bui lt in s e c t i o n s w h i c h c a n be tilted t o the r e q u i r e d d e g r e e ; t he se m a y p r o v i d e g r e a t e r s c o p e f o r e x ­ p e r i m e n t , b u t a r e m u c h m o r e c o s tly . It is p o s s i b l e t o o b t a i n s u c h a c o u c h f r o m rec og n iz ed m e d i c a l s u p p l y s t o r e s if t h e c o n v e r s i o n o f a n o r d i n a r y c o u c h is i m p r a c t i c a b l e . T h e h a r n e s s e s a r e m a d e o f s t o u t w e b b i n g b a n d s . O n e e n c i r c l e s t he t h o r a x a n d t h e o t h e r t h e pelvis. S h e e t s o f f o a m - r u b b e r a b o u t 2 c m . t h i c k a r e u se d t o p a d b o t h h a r ­ n e s s e s a n d t o p r e v e n t sli p p i n g . TRACTION FOR LUMBAR 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. ) P H Y S I O T H E R A P Y . -* 1 >.*l MUIIMtj VAIblUl KJ | | y | f J I W is t r e a t e d s u p in e . A s m a l l p i ll o w m a y b e i n s e r t e d b e n e a t h t h e l u m b a r s p in e . B a sic A p p lic a tio n (see Fig. 2) A t th e p a t i e n t ' s first a t t e n d a n c e t r a c t i o n is u s u a l ly giv en s u p i n e ; if so, t h e f o l lo w in g m e t h o d is used. T h e pelvic h a r n e s s a n d a h e a d pi llow a r e p lac ed o n t h e t o p o f th e c o u c h . T h e t h o r a c i c h a r n e s s , lined w it h a sheet o f r u b b e r , is a p p l i e d t o t h e p a t i e n t w hi le he s t a n d s . T h i s s h o u l d be pl ace d as lo w d o w n o n t h e t h o r a x a s po ss i b l e in o r d e r t o lo ca li ze t h e t r a c t i o n t o th e l ow er sp in e. T h e belt m u s t be c o m ­ f o r t a b l y firm o r it will slip. T h e p a t i e n t lies o n th e c o u c h on t h e pelvic h a r n e s s . T h e t h o r a c i c s t r a p s a r e p a s s e d b e n e a t h th e p il lo w a n d s e c u re d t o t h e fixed h o o k at th e t o p o f the jcouch. T h e u n d e r s t r a p b e l o n g i n g t o t h e pelvic h a r n e s s s h o u l d be ad j u s te d so t h a t it lies b e n e a t h th e l o w e r p a r t o f the l u m b a r spine. T h e pelvic h a r n e s s m a y be a r r a n g e d in t w o w ay s : (a) T h e s t r a p lies a b o v e t h e a n t e r i o r s u p e r i o r spines, w h e n t r a c t i o n is e x e r t e d f r o m t h e iliac cr es t s . (b ) T h e s t r a p lies below- t h e a n t e r i o r s u p e r i o r spin es , wh en t r a c t i o n is e x e r t e d f r o m t h e g r e a t e r t r o c h a n t e r s o f th e fe m o ra . S o m e p a t i e n t s find t h e o n e p o s i t i o n m o r e c o m f o r t a b l e t h a n t he o t h e r a n d b o t h s h o u l d be tr ied t o see w h i c h the pa ti en t prefers. W h e n t h e p o s i t i o n o f t h e pelvic h a r n e s s h as been de c i d e d , a piece o f f o a m r u b b e r a n d a b l a n k e t fo ld ed t o f o u r t h i c k ­ nesses a r e p la ce d a c r o s s th e p a t i e n t ’s pelvis a s p a d d i n g . T h e s t r a p is t h e n t i g h t e n e d . T h e l e a t h e r s t r a p is p as se d t h r o u g h th e h o o k at the b o t t o m o f t he c o u c h , ge n t l y p u l l e d un t i l it feels firm a n d t h e n s e cu re d . T h e p a t i e n t will feel a n i n c r e a s e in his pelvic tilt, a n d be c o n s c i o u s o f a t e n s i o n in t h e l u m b a r ar ea . ' C a r e is t a k e n t o e n s u r e t h a t t h e pelvic h a r n e s s is p r o p e r l y in place. T h e a p p a r a t u s s h o u l d be c h e c k e d f o r c o m f o r t . If the t r e a t m e n t is p a i n f u l , th e m u s c le s p a s m t h u s set u p will p r eve nt t he p a t i e n t f r o m r e l a x i n g i n t o t h e h a r n e s s . As th e p a t i e n t rel axe s, m o r e t r a c t i o n is a p p l i e d by t u r n i n g the wheel. T h e first visit is i m p o r t a n t ; t h e p a t i e n t ' s r e a c t i o n s to a s h o r t a n d g en tl e pu ll will p r o v i d e t h e p h y s i o t h e r a p i s t with v a l u a b l e i n f o r m a t i o n u p o n w h ic h t o ba s e h er f u t u r e t r e a t m e n t . T h e p a t i e n t ' s c o n f i d e n c e is g a i n e d m o r e eas ily ■f he is i n t r o d u c e d t o a n u n u s u a l e x p e r i e n c e g r a d u a l l y . H e is to ld t o r e p o r t th e sli ght es t d i s c o m f o r t . A n e x p l a n a t i o n o f w h a t t h e t r e a t m e n t in v o l v es a n d re ac ti on s t h a t m a y be e x p e c t e d is given. T h e m e c h a n i c s 0 c° n d i t i o n a r e fu lly e x p l a i n e d , b e c a u s e t h e p a t i e n t ' s c o - o p e r a t io n will be n e c e s sa ry in o r d e r t o m a i n t a i n th e reduciicm as it is ac h i ev ed . (See C y r i a x , O rth o p a e d ic M ed ic in e vol. I., 1957.) June, 1963 T h e p a t i e n t m a y be w a r n e d : (a) N o t t o c o u g h o r sn e eze v io l e n t l y d u r i n g t r e a t m e n t T h e s u d d e n in c r e a se in p r e s s u r e c a u s e d m a y d i s p l a c e th e disc s u b s t a n c e f u rt h e r . (b ) N o t t o m o v e a b o u t w h il e t r a c t i o n is ex e r t e d . T h i s m a y c a u s e a n a l t e r a t i o n in the a n g l e at w h i c h th e j o i n t s a r e b e i n g d i s t r a c t e d . (c) T o ex p ec t o n l y a s l o w a n d p o s s i b l y i r r e g u l a r i m ­ p r o v e m e n t . wit h a c e r t a i n a m o u n t o f stiffness i m m e d i a t e l y a f t e r e a c h t r e a t m e n t . T h e p a t i e n t ' s c o m f o r t is e n s u r e d by: (a) P a d d i n g t h e h a r n e s s by i n s e r t i n g f o a m r u b b e r sh ee ts, e s p ec i al l y at b o n y p r o m i n e n c e s . (b ) T a k i n g c a r e in a p p l y i n g t h e t h o r a c i c h a r n e s s in su c h a w a y t h a t b r e a t h i n g is n o t a p p r e c i a b l y re str ic te d w h e n p a t i e n t s s u f f e ri n g f r o m r e s p i r a t o r y o r c a r d i a c c o m ­ p l a i n t s a r e t r e a t e d . W h e n th e w e b b i n g belt c a n n o t be b o r n e t i g h tl y , a sh e et o f f o a m r u b b e r pl aced b e n e a t h th e p a t i e n t will i n c r e a s e t h e f r i c t i o n a l r e s i s t a n c e b e t w e e n his t h o r a x a n d t h e c o u c h . (c) T e a c h i n g a p i c a l b r e a t h i n g w h e n p a t i e n t s feel t h a t th e t h o r a c i c b a n d will p r e v e n t a d e q u a t e b r e a t h i n g . (d ) A v o i d i n g a l ar ge m e a l b e f o r e t r e a t m e n t . (e) In sc i a t ic a , p l a c i n g a pi llow b e n e a t h t h e k n e e o f th e p a i n f u l l im b. T h i s will relax t h e t e n s i o n o n th e ner ve ro ot . A t t h e e n d o f a b o u t t w e n t y m i n u t e s the t e n s i o n is released s l ow ly a n d t he h a r n e s s s t r a p s u n b u c k l e d . C a r e is t a k e n to a v o i d j o l t i n g th e p a t i e n t , b e c a u s e a s t h e j o i n t se ttl es t o w a r d s its o r i g i n a l p o s i t i o n , p r e s s u r e u p o n n e r v o u s s t r u c ­ t u r e s m a y r e t u r n , c a u s i n g sev ere tw i n g e s o f p a i n . T h i s is a r a r e o c c u r r e n c e , b u t if it d o e s h a p p e n , th e p a t i e n t rests o n t h e c o u c h u n ti l t h e d i s c o m f o r t h a s w o r n ofT. It is a n a d v a n t a g e t o t h e p a t i e n t t o rest f o r se ve ra l m i n u t e s a f t e r t r e a t m e n t : (a) b e c a u s e t h e j o i n t s a r e a l l o w e d t o set tle i n t o p o s i t i o n w i t h o u t t h e s u d d e n a p p l i c a t i o n o f c o m p r e s s i o n s t r a i n , su ch a s w o u l d be ex e r t e d in t h e u p r i g h t po si t i o n . (b) b e c a u s e he s h o u l d be a l l o w e d t i m e t o r e c o v e r hi mself. 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. ) Page 10 P H Y S I O T H E R A P Y June, 1963 D u r a tio n a n d F re q u e n c y o f T re a tm e n t I f t h e r e h a s been n o u n t o w a r d r e a c t i o n f r o m th e first t r e a t m e n t t h e l e n g t h o f t i m e m a y be i n cr ea se d t o 35 o r 40 m i n u t e s s u b s e q u e n t l y . T h e p h r a s e , ‘a c o u r s e o f t r a c t i o n t r e a t m e n t ’ is m i sl e a d i n g , [t su g g e s t s t h a t a se rie s if e v e n t s t a k e p la ce i d e n t i c a l l y ea c h d a y f o r a c e r t a i n l e n g t h o f ti m e , a f t e r w h i c h th ey s t o p . T h i s i m p l i c a t i o n is fa lse . T r e a t m e n t is u s u a l l y giv en d ai l y a t first f o r a n a v e r a g e p e r i o d o f a f o r t n i g h t t o t h r e e weeks. H o w e v e r , this is o n l y a very r o u g h g u i d e a n d it is nec es sa ry f o r t h e p h y s i o t h e r a p i s t t o w o r k o u t her o w n r eg im e fo r e a c h pa t i e n t . T h e p l a n f o r t r e a t m e n t is d e c i d e d u p o n f r o m d a y t o d a y . A t ea c h a t t e n d a n c e t he cl i n i ca l sig ns a r e re-ass es se d by t e s ti n g th e l u m b a r m o v e m e n t s a n d s t r a i g h t - l e g r a i si n g ; s y m p t o m s a r e r e l a t e d by t h e p a t i e n t a n d t h e f in di ng s a r e c o m p a r e d w i t h t h o s e f o u n d o n th e p r e v i o u s visit. In this w a y t h e d e g r e e o f s uc ce ss o r f a i l u r e c a n be e s t i m a t e d , t h u s e n a b l i n g t h e p h y s i o t h e r a p i s t t o d e c i d e h o w t h e t r e a t m e n t s h o u l d b e c o n t i n u e d : e.g. (а) I f t h e r e h a s been a n i m p r o v e m e n t , t h e t e c h n i q u e u se d d u r i n g t h e p r e v i o u s visit s h o u l d be r e p e a t e d . (б) I f t h e c o n d i t i o n h a s r e m a i n e d t h e s a m e or d e t e r i o r a t e d , t h e n a n a l t e r n a t i v e m e t h o d o f a p p l y i n g t h e h a r n e s s s h o u l d be tried. E x p e r i ­ m e n t s h o u l d be c o n t i n u e d unt il a s t e a d y i m p r o v e m e n t begins. W h e n g r e a t i m p r o v e m e n t ha s bee n m a i n t a i n e d f o r se v e ra l d a y s a n d th e cli n ic al si gn s h a v e b e c o m e m i n i m a l , a few d a y s w i t h o u t t r e a t m e n t m a y be a l l o w e d . A f t e r t h is t i m e e i t h e r : (a) r e d u c t i o n h as a l r e a d y been init i­ a t e d sufficiently f o r t h e i m p r o v e m e n t to c o n t i n u e s p o n t a n e o u s l y ; if s o the p a t i e n t m a y be p u t o f f t r e a t m e n t a n d a s k e d t o r e p o r t bis p r o g r e s s a t t h e en d o f a wee k. V er y o f t e n he will be q u i t e well by t he n . (b ) r e d u c t i o n is still i n c o m p l e t e . F u r t h e r se ss io n s , p e r h a p s t w o o r t h r e e t r e a t m e n t s a w ee k s h o u l d be gi ven, u n t i l t h e p a t i e n t is pa in - fr ee . I f sligh t r e l a p s e s o c c u r a f t e r r e d u c t i o n h a s been effec ted, it is s o m e t i m e s n e c e s s a r y to give a m a i n t e n a n c e d o s e o f t r a c t i o n o n c e o r tw ice a w e e k un t i l th e s e ha v e c e a s e d . V a ria tio n s o f A p p lic a tio n A ba s i c t e c h n i q u e f o r giv ing s u s­ t a i n e d s p i n a l t r a c t i o n h a s been d e s ­ c r i b e d , b u t t h e v a r i a t i o n s o f this a r e m a n i f o l d . T h e p h y s i o t h e r a p i s t c a n n o t see t he p r o t r u d i n g i n t e r v e r t e b r a l m at er i al that h a s t o be r e l p a c e d , so s h e w a t c h e s it m o v e by i nt er p re t i n g c h a n g e s in s y m p t o m s a n d signs. S h e s h o u l d vary her t e c h n i q u e un ti l t h e d i s t r a c t i o n o f a d j a c e n t v e r t e b ra e occu rs in t he w a y best c a l c u l a t e d t o b r i n g a b o u t re d u ct i o n . F o r e x a m p l e : if th e sc ia tic a in c r e a se s a s s o o n as t r a c t i o n is a p p l i e d , a n d persi st s, it is of t e n p o s s i b l e to a b o l i s h th e pain b y r e a d j u s t i n g th e h a r n e s s . S u c h a c h a n g e al ter s t h e force a c t i n g o n t he i n t e r v e t e b r a l j o i n t , a n d c o n s e q u e n t l y the r e l a t i o n s h i p b e t w e e n t h e n e r v e r o o t a n d th e p r o t r u s i o n . D i s c l es io n s va r y n o less t h a n t e m p e r a m e n t , a n d the t r a c t i o n a p p a r a t u s s h o u l d t h e r e f o r e be us ed im aginatively. A few v a r i a t i o n s o f t h e b a s i c t e c h n i q u e follow, bu t there is e n d l e s s s c o p e fo r e x p e r i m e n t . 1. D i s t r a c t i o n m a i n l y at t h e a n t e r i o r p a r t o f th e jo i n t , i.e. d u r i n g e x t e n s i o n o f t h e l u m b a r spine. T h e p a t i e n t is t r e a t e d : (a) S u p i n e . A s m a ll p il lo w m a y be inserted b en ea th t h e sp i n e . (Fig . 2) (b ) P r o n e . T h e t h o r a c i c h a r n e s s is ap p l i e d so that th e s t r a p s r u n b e n e a t h th e p at ie n t. (See Fig. 3.) 2. D i s t r a c t i o n o f th e j o i n t s wit h t he a r t i c u l a r su rf ac es held pa ra ll el . T h e p a t i e n t is t r e a t e d p r o n e a n d t h e t h o r a c i c h a r n e s s is a r r a n g e d s o t h a t th e s t r a p s p a s s beh in d th e p a t i e n t 's head. ( Fi g. 4.) F ig . D i s t r a c t i o n m a i n l y a i t h e a n t e r i o r p a r t o f t h e j o in t , i.e. d u r in g e x te n s io n o f t h e l u m b a r s p in e . 'I he p a t i e n t is t r e a t e d p r o n e . T h e t h o r a c ic h a rn e s s is a p p li e d s o t h a t t h e s t r a p s r u n b e n e a t h t h e p a ti e n t. F ig . 4 . D i s t r a c t i o n o f t h e j o i n t s i ih t h e a r t i c u l a r s u rf a c e s held p a ra lle l. T h e p a ti e n i is t r e a t e d p r o n e , a n d t h e t h o r a c i c h a r n e s s is a r r a n g e d s o t h a t th e s tr a p s p a s s b e h i n d th e p a t i e n t ’s h e a d . 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. ) June, 1963 P H Y S I O T H E R A P Y Page 11 F ig . 5. D i s t r a c t i o n m a i n l y a t t h e p o s t e r i o r p a r t o f t h e jo in t . T h e p a t i e n t is t r e a t e d p r o n e : t h e p e lv ic h a r n e s s is a p p l i e d s o t h a t t h e Y - s h a p e d s t r a p p a s s e s o v e r t h e t o p o f t h e p a t i e n t . T h e t h o r a c i c h a r n e s s is a p p l i e d s o t h a t t h e s t r a p s p a s s b e h i n d t h e p a t i e n t 's h e a d . 3. F o u rth S a c r a l R e fe re n c e . H e r e m a n i p u l a t i o n is c o n t r a - i n d i c a t e d bu t t r a c t i o n m a y be gi ve n c a u t i o u s l y a n d is o f t e n suc ces sfu l, 4. (a ) Firm a n d S e c o n d L u m b a r D isc L e sio n s . (/>) R e c u rre n c e a fte r L a m in e c to m y . H e r e m a n i p u l a t i o n u s u a l ly fails, b u t t r a c t i o n is o f t e n a success. C o n tr a -In d ic a tio n s to T ra ctio n 1. C a r tila g in o u s D isp la c e m e n ts. T h e s e a r e d i s t i n g u i s h e d by a s u d d e n o n s e t , t o g e t h e r w i t h sign s s h o w i n g t h a t m a n i p u l a t i o n will be su cc ess fu l, n a m e l y : (a) T r u n k si de -fl exi on a w a y f r o m the p a i n f u l s i d e in cr ea se s t h e l u m b a r pai n. (b ) L u m b a r m o v e m e n t s d o n o t c a u s e p a i n in t h e lim b. 2. L u m b a g o w ith A c u te Tw inges. T h i s is u s u a l l y a g g r a v a t e d by t r a c t i o n a n d is a n i n d i c a t i o n f o r th e i n d u c t i o n o f e p i d u r a l lo cal a n a e s t h e s i a . Fig- 6. W h e n t r e a t i n g h ig h l u m b a r o r lo w t h o r a c i c l e s io n s t h e p a ti e n t is p la c e d in th e re v e r s e d i r e c t i o n o n t h e c o u c h s o t h a t t h e t h o r a c i c h a r n e s s is f ix e d t o t h e m o b il e e n d . 3. D i s t r a c t i o n m a i n l y at t h e p o s t e r i o r p a r t o f the j o i n t i.e. in sligh t flexion o f th e l u m b a r sp in e. T h e p a t i e n t is t r e a t e d p r o n e : T h e pelvic h a r n e s s is a p p l i e d so t h a t t h e Y - s h a p e d s t r a p pas se s o v e r t h e t o p o f t h e p at i e n t . T h e t h o r a c i c h a r n e s s is a p p l i e d s o t h a t t h e s t r a p s p a s s beh in d t he p a t i e n t ' s head,. (Fig . 5.) 4. W h e n t r e a t i n g high l u m b a r o r lo w t h o r a c i c les ion s the p at i en t is pl ace d in t h e re ve rse d i r e c t i o n o n th e c o u c h so t h a t t h e t h o r a c i c h a r n e s s is fixed t o t h e m o b i l e en d. (Fig. 6 .) In d ica tio n s f o r T ra ctio n 1. P u lp y p ro tru sio n s. T h e s e a r e d i s t i n g u i s h e d by a g r a d u a l o n s e t , t o g e t h e r with signs o f i r re d u c i b i l i t y by m a n i p u l a t i o n — n a m e l y : (a) T r u n k side -fle xio n t o w a r d s t h e p ai nf ul si d e i n ­ cre as es th e p ai n. (b) T r u n k m o v e m e n t s o t h e r t h a n flexion give rise t o pain d o w n t h e l o w e r limb. (c) P r i m a r y p o s t e r o - l a t e r a l p r o t r u s i o n . 2. M i x e d L esio n s. B o t h c a r t i l a g e a n d p u l p m a y p r o t r u d e t o g e t h e r . T h e s e m a y be o n l y p a r t i a l ly r e d u c i b l e by m a n i p u l a t i o n . A few se ss ion s o f t r a c t i o n o f t e n c o m p l e t e s t h e r e d u c t i o n . 3. A w a itin g S p o n ta n e o u s R e c o v e r y . S ucc es sfu l r e d u c t i o n is u n d e s i r a b l e in t h o s e w h o will get well a f t e r a few m o n t h s if left u n t r e a t e d . O n c e s p o n ­ t a n e o u s re co ve r y h a s t a k e n place , f u t u r e r e c u r r e n c e s a r e rare . ( C y r i a x , 1957.) W h e n T ra c tio n sh o u ld b e A b a n d o n e d . 1. T h e r e h a s b ee n n o i m p r o v e m e n t a f t e r a b o u t t we lv e sess ions . 2. T h e r e is s t e a d y d e t e r i o r a t i o n d u r i n g t h e first few d a y s in sp i t e o f v a r i a t i o n s in t h e w a y in w h i ch t h e t r e a t m e n t is given. 3. N e u r o l o g i c a l signs, p r e v i o u s l y a b s e n t a p p e a r . In s u c h c a s e s t h e m o s t s u i t a b l e t r e a t m e n t is th e i n d u c t i o n o f e p i d u r a l l o ca l a n a e s t h e s i a a n d so t h e d o c t o r s h o u l d be i n f o r m e d o f t h e p a t i e n t ’s sta te . ( C y r i a x . 1957.) C o n d u s io n S t a t i s t i c s s h o w th a t 13 p e r ce n t, o f all ca s es o f b a c k a c h e , a n d 25 p e r c e n t , o f all c a s e s o f s c i a t ic a h a v e been f o u n d su i t e d t o t r e a t m e n t by t r a c t i o n . O f th e s e t h e s u r p r i s i n g fact e m e r g e s t h a t in b a c k a c h e 57 p e r c e n t , w er e p u t right o r m a d e m u c h b e t t e r by t r a c t i o n , w h e r e a s in sc iat ica t he figure is 80 per c e n t . ( C y r i a x , 1957.) T h e t e c h n i q u e s , d e s c r i b e d he re h a v e been e l a b o r a t e d as a re su lt o f D r . C y r i a x ’s t e a c h i n g a n d a r e t h o s e used by his staff. A C K N O W L E D G E M E N T S M y g r a t e f u l t h a n k s a r e d u e t o D r . J a m e s C y r i a x , M . R . C . P . , a n d to M r s . U . V i d l e r . M . C .S . P . , M .A .O .T . , P r i n c i p a l o f t h e P h y s i o t h e r a p y S c h o o l a t S t. T h o m a s ' H o s p i t a l , S .E . 1, f o r t h e i r h e lp in t h e p r e p a r a t i o n o f t h e m a n u s c r i p t . 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. )