MANUAL CERVICAL TRACTION The objectives for using traction in the cervical region do not vary much from

the objectives for using traction in the lumbar region. Reasonable objectives for cervical traction include stretch of the muscles and joint structures of the vertebral column, enlargement of the intervertebral spaces and foramina, centripetally directed forces on the disk and soft tissue around the disk, mobilization of vertebral joints, increases and changes in joint proprioception, relief of compressive effects of normal posture, and improvement in arterial venous and lymphatic flow.5,10,15,24,35,40,44 In the clinical setting, diagnoses and symptoms requiring traction are found infrequently.30 These diagnoses are more typically found in older populations. In most cases involving sprains and strains, simple manual traction used to produce a rhythmic longitudinal movement will be very successful in helping decrease pain, muscle spasm, stiffness, and inflammation, and also in reducing joint compressive forces. Manual traction is infinitely more adaptable than mechanical traction, and changes in the direction, force, duration of the traction, and patient position can be made instantaneously as the therapist senses relaxation or resistance.1,2,5,8,24 The patient's head and neck are supported by the therapist. The hand should cradle the neck and provide adequate grip for the effective transfer of the traction force to the mastoid processes. One hand should be placed under the patient's neck with the thenar eminence (base of the thumb) in contact with one mastoid process and the fingers cradling the neck reaching across toward the other mastoid process (Fig. 15-27A).2 Treatment Tip Manual traction is considerably more adaptable than mechanical traction, and changes in the direction, force, duration of the traction, and patient position can be made instantaneously as the therapist senses relaxation or resistance on the part of the patient. The therapist then provides a gentle (less than 20 lb) pull in a cephalic direction. Intervertebral separation is not desired because of the damage to the ligaments or capsule. A head halter or similar harness may also be used to deliver the force (Fig. 15-27B). The force should be intermittent, with the traction time between 3 and 10 seconds. The rest time may be very brief, but the traction force should be released almost completely. The total treatment time should be between 3 and 10 minutes.1,2,5,8 When pain is limiting or affecting movement, a bout of traction should be followed by a reassessment of the painful motion to determine increases or decreases in pain or motion. Successive bouts of traction can be used as long as the symptoms are improving. When the symptoms stabilize or are worse on the reassessment, the traction should be discontinued.5 A variety of head and neck positions can be used in cervical traction. Different head and neck positions will place some vertebral structures under more tension than others. Good knowledge of cervical kinesiology and biomechanics, and good knowledge and skill in joint mobilization, are required before the therapist should experiment with extensive position changes (Fig. 15-28).2,5,8

At the completion of the traction treatment, in cases of strain or sprain, protection of the neck with a soft collar is often desirable to prevent extremes of motion, minimize compressive forces, and encourage muscle relaxation. Instructions in sleeping positions and regular support postures are also important in caring for patients with cervical problems.2,5 Figure 15-27. A. Manual cervical traction. B. Patient in the supine position with the therapists's fingertips and thenar eminence contacting the mastoid process of the patient's skull.

Figure 15-28. Manual cervical traction. The patient is positioned with neck in flexion and with some neck rotation to the right. Laterally flexed positions also may be used. MECHANICAL CERVICAL TRACTION The literature does provide a relatively clear protocol to use in trying to achieve vertebral separation using a mechanical traction apparatus. The patient should be supine or long-sitting with the neck flexed between 20 and 30 degrees (Fig. 15-29). A sitting posture can be used, but this is clinically more cumbersome and is not supported by the research as an optimal position of cervical traction.41 The traction harness must be arranged comfortably so that the majority of pull is placed on the occiput rather than the chin. Some cervical traction harnesses do not have a chin-piece. These harnesses may have an advantage, provided that the traction force is effectively transferred to the structures of the cervical spine.8,10 A traction force above 20 lb, applied intermittently for a minimum of 7 seconds' traction time and with adequate rest time for recovery, is recommended (Fig. 15-30). This traction should be continued over 20-25 minutes. Higher forces up to 50 lb may produce increased separation, but the other parameters should remain the same. The average separation at the posterior vertebral area is 1-1.5 mm per space, while the anterior vertebral area separates approximately 0.4 mm per space. Greater separations are expected in the younger population than in the older population. Within 20-25 minutes from the time traction is stopped and normal sitting or standing postures are resumed, the vertebral separation returns to its previous heights. The upper cervical segments do not separate as easily as lower cervical segments.8,10,24 The addition of pain-reducing and heating modalities will add to the benefits gained by the traction.1,2,5,10,24 Figure 15-29. Mechanical cervical traction; patient in the supine position with traction harness placed so that maximum pull is exerted on the occiput and the patient is in a position of approximately 20-30 degrees of neck flexion. Figure 15-30. Control panel of traction machine with parameters adjusted for intermittent cervical traction.

CASE STUDY 15-3: SPINAL TRACTION: CERVICAL

Background: A 47-year-old woman noted an ache in the right midcervical area upon awakening this morning. While driving to work, she turned her head to the right before changing lanes, and noted an audible click with severe pain in the right midcervical area. After arriving at work, she continued to experience localized pain that gradually worsened over the next hour. She presented to the emergency room, where an examination (including radiographic) revealed no neurologic or bony injury. She was referred for treatment of an acute neck sprain. She does not have radiating pain, and the neurologic examination is negative. She holds her head tilted and rotated to the left, and any attempt at side bend or rotation to the right produces severe, localized right midcervical pain. She is very tender over the right articular pillar at C4-5, and passive mobility testing reveals a markedly restricted joint play at C4-5. Impression: Acute locking of the cervical spine (C4-5). Treatment Plan: Manual cervical traction. With the patient supine on a treatment table, the therapist placed one hand under the patient's head, with the palm over the occiput, thumb over one mastoid process, and the fingertips over the opposite mastoid process. The therapist's other hand was placed over the patient's forehead to avoid compressive forces on the temporo-mandibular joint. A gentle distraction force was applied (approximately 5 kg), with the line of force parallel to the long axis of the spine. The force was held for 3 seconds, then released for 10 seconds. This was repeated 10 times, with the distraction force gradually increased to a maximum of approximately 15 kilograms. Response: A reassessment was performed after the 10th force application, and the patient was able to hold her neck in a neutral position. The cycle was repeated four more times, with a gradual improvement in cervical range of motion and a reduction in pain each time. After the fifth cycle, she was able to attain rotation and side bending to the right equal to approximately 80 percent that of the motion to the left. She was treated the following day with the same approach, and attained full, pain-free range of motion. Discussion Questions What tissues were injured or affected? What symptoms were present? What phase of the injury-healing continuum did the patient present for care in? What are the physical agent modality's biophysical effects (direct, indirect, depth, and tissue affinity)? What are the physical agent modality's indications and contraindications? What are the parameters of the physical agent modality's application, dosage, duration, and frequency in this case study? What other physical agent modalities could be used to treat this injury or condition? Why? How? What is the mechanism for acute locking of the cervical spine? What are the advantages of manual traction over mechanical (motorized) traction for this patient? Disadvantages? Why was the distraction force applied parallel to the long axis of the spine? What advantages or disadvantages would there be to applying the force along an oblique axis? The rehabilitation professional employs physical agent modalities to create an optimum environment for tissue healing while minimizing the symptoms associated with the trauma or condition.

INDICATIONS AND CONTRAINDICATIONS As discussed throughout this chapter, there are a number of conditions for which spinal traction may be useful, including cases where there is impingement on a nerve root resulting from disk herniation, spondylolisthesis, narrowing within the intervertebral foramen, or osteophyte formation; degenerative joint diseases, subacute pain; joint hypomobility; discogenic pain; and muscle spasm. Traction, except as a light mobilization, is contraindicated in acute sprains or strains (first 3-5 days), acute inflammation, or in any conditions in which movement is either undesirable or exacerbates the existing problem. In cases of vertebral joint instability, traction may perpetuate the instability or cause further strain. Certainly, the serious problems associated with tumors, bone diseases, osteoporosis, and infections in bones or joints are also contraindications. Patients who can potentially experience problems relating to the fitting of a harness, such as those with vascular conditions, pregnant females, or those with cardiac or pulmonary problems, should also avoid traction. SUMMARY 1. Traction has been used to treat a variety of cervical and lumbar spine problems. The effect of traction on each system involved in the complex anatomic makeup of the spine needs to be considered when selecting traction as a part of a therapeutic treatment plan. 2. The traction protocol should be set up to manage a particular problem rather than applied in the same manner regardless of the patient or pathology. Traction is a flexible modality with an infinite number of variations available. This flexibility allows the therapist to adjust protocols to match the patient's symptoms and diagnosis. 3. Traction is capable of producing a separation of vertebral bodies; a centripetal force on the soft tissues surrounding the vertebrae; a mobilization of vertebral joints; a change in proprioceptive discharge of the spinal complex; a stretch of connective tissue; a stretch of muscle tissue; an improvement in arterial, venous, and lymphatic flow; and a lessening of the compressive effects of posture. Any of these effects can change the symptoms of the patient under treatment and help to normalize the patient's lumbar or cervical spine. REVIEW QUESTIONS 1. What is traction and how may it be performed by the therapist? 2. What are the physical effects and therapeutic value of spinal traction on bone, muscle, ligaments, facet joints, nerve, blood vessels, and intervertebral disks? 3. What are the clinical advantages of using positional lumbar traction and inversion traction? 4. What are the clinical applications for using manual lumbar traction techniques, including level specific manual traction, and unilateral leg pull manual traction? 5. What are the setup procedures and treatment parameter considerations for using mechanical lumbar traction?

6. What are the advantages of using a manual traction technique of the cervical spine? 7. What is the setup procedure for mechanical and wall-mounted traction techniques for the cervical spine? Indications and Contraindications for Spinal Traction

Indications Impingement on a nerve root Disk herniation Spondylolisthesis Narrowing within the intervertebral foramen Osteophyte formation Degenerative joint diseases Subacute pain Joint hypomobility Discogenic pain Muscle spasm or guarding Muscle strain Spinal ligament or connective tissues contractures Improvement in arterial, venous, and lymphatic flow Contraindications Acute sprains or strains Acute inflammation Fractures Vertebral joint instability Any condition in which movement exacerbates the existing problem Tumors Bone diseases Osteoporosis Infections in bones or joints Vascular conditions Pregnancy Cardiac or pulmonary problems