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PHYSIOTHERAPY CLINIC
ASSESSMENTS
ASSESSMENT OF PHYSICAL CAPACITY
TRACTION
ASSESSMENT OF SPASTICITY
ASSESSMENT OF SPEECH TRACTION
CONSCIOUSNESS ASSESSMENT
POSTURE ASSESSMENT Traction is the act of drawing or pulling and
DEVELOPMENTAL MILESTONES ASSESSMENT relates to forces applied to the body to stretch
ASSESSMENT OF NEONATAL REFLEXES a given part or to separate 2 or more parts.
ASSESSMENT OF PARAPLEGIA
SENSORY ASSESSMENT
ASSESSMENT OF IMPAIREMENT
PAIN ASSESSMENT
FUNCTIONAL [ ABILITY ] ASSESSMENT
ASSESSMENT OF DISABILITY
CARDIO RESPIRATORY ASSESSMENT
FINGER DEXTRITY ASSESSMENT
GAIT ASSESSMENT
WORK ASSESSMENT

INTRODUCTION
INTRODUCTION TO PHYSIOTHERAPY

PAINS
PAIN
NECK PAIN
BACK PAIN
SHOULDER PAIN
ELBOW PAIN
WRIST HAND PAIN
HIP THIGH PAIN
KNEE PAIN
LEG PAIN
ANKLE FOOT PAIN

AUTHOR
ABOUT AUTHOR
Currently, traction is used effectively in
PANEL OF DOCTORS
treatment of fractures.

TREATMENTS AND MODALITIES                 In physiatric practice, use of traction

EXERCISE THERAPY often is limited to the cervical or lumbar spine
EXERCISE PRESCRIPTION with the goal of relieving pain in, or
THERAPEUTIC EXERCISE originating from, those areas.
MANUAL THERAPY
MASSAGE THERAPY
               Since the days of Hippocrates,
MANIPULATION THERAPY correction of scoliosis also has involved
THERMOTHERAPY traction. There are various types of traction
SUPERFICIAL HEAT currently in clinical use. 
DEEP HEAT
CRYOTHERAPY
The most common are mechanical, hydraulic
ELECTRO THERAPY
or motorized, manual, and autotraction.
TENS
 TRACTION §  Mechanical forms of traction use a
HYDROTHERAPY hydraulic or motorized pulley system
RADIOTHERAPY with weights, along with a harness or
PHOTOTHERAPY sling device to attach to the patient's
MAGNOTHERAPY body. 
MY SOFT TOOLS §  Manual traction involves the therapist
FITNESS ASSESSMENT TOOLS using his or her hands on the patient's
PATIENT ASSESSMENT TOOL
body, with the body weight of the
FIRST AID & INJURY PREVENTION therapist providing the tractive force. 
FIRST AID IN SPORTS INJURY
INJURY PREVENTION TIDBITS
§  Autotraction is controlled by the
patient pulling on bars or handles at the
DIET & NUTRITION head of the table, without direct
DIET CHARTS involvement of a therapist. 
VEG WEIGHT GAIN [ MALE ]
VEG WEIGHT GAIN [ FEMALE ] §  Gravitational traction with a tilt table
NON VEG WEIGHT GAIN [ MALE ] and underwater variations of traction
NON VEG WEIGHT GAIN [ FEMALE ] are also in clinical and home use but are
VEG WEIGHT LOSS [ MALE ] less frequently employed than the other
VEG WEIGHT LOSS [ FEMALE ] forms described.  
NON VEG WEIGHT LOSS [ MALE ]
NON VEG WEIGHT LOSS [ FEMALE ] PHYSIOLOGIC EFFECTS OF TRACTION
NUTRITION
PROTEIN SOURCES In the cervical spine, the most
CARBOHYDRATE SOURCES reproducible result of traction is
FAT SOURCES elongation. In a classic study, Cyriax
DIETARY MINERALS reported applying force of 300 pounds
VITAMINS manually, with a resultant 1 cm increase
WATER in cumulative lumbar spine interspace
ROUGHAGE distance.
DISEASES AND DISORDERS Studies have shown that optimum
ARTHRITIC DISEASES weight for cervical traction to
OSTEOARTHRITIS accomplish vertebral separation is 25
RHEUMATOID ARTHRITIS pounds. Additionally, 2-20 mm
PSORIATRIC ARTHRITIS
elongation of the cervical spine has
SPINAL DISEASES
been shown to be achievable with 25 or
CERVICAL SPINE DISEASES
more pounds of tractive force.
LUMBAR SPINE DISEASES
MUSCULOSKELETAL DISEASES Studies have demonstrated that anterior
UPPER LIMB DISEASES intervertebral space shows the most
LOWER LIMB DISEASES increase in cervical flexion of 30°.
MOVEMENT DISORDERS
Traction in the extended position
PARKINSONS DISEASE
generally is not recommended, because
DYSTONIA
it is often painful and may increase risk
MOTOR UNIT DISORDERS of complications from vertebral basilar
POLIOMYELITIS insufficiency or spinal instability.
POST POLIO SYNDROME
Once friction is overcome in the lumbar
MUSCLE PAIN SYNDROME spine, the major physiologic effect of
FIBROMYALGIA traction is elongation. Investigators
MYO-FASCIAL PAIN
have reported widening of lumbar
POST EXERCISE MUSCLE SORENESS interspaces requiring between 70-300
OVERUSE INJURY pounds of pull.
EXERCISES
This widening averaged up to slightly
EXERCISES IN OSTEOPOROSIS
more than 3 mm at one intervertebral
EXERCISES FOR COMPUTER USERS
level. The length of time that the
EXERCISES AT WORK PLACE
separation persists remains
EXERCISES DURING PREGNANCY
EXERCISES TO CORRECT BAD POSTURE
indeterminate, with studies
documenting distraction durations of
STRETCHING 10-30 minutes after treatment.
INTRODUCTION TO STRETCHING
TYPES OF STRETCHING Data on dimensional and pressure
BODY STRETCHING changes of lumbar disks caused by
NECK STRETCHING traction are not conclusive. Decreases in
BACK STRETCHING interdiskal pressure with 50-100 pounds
UPPER LIMB STRETCHING of traction have been documented, but
LOWER LIMB STRETCHING evidence exists that some applications
STRETCHING ROUTINE actually cause an increase in interdiskal
STRETCHING EXERCISES pressure.
STRETCHING EXERCISES FOR WOMEN
STRETCHING AND BACK PAIN Therefore, evidence is inconclusive,
with much information favoring at least
ERGONOMICS temporary reduction of the herniated
INTRODUCTION TO ERGONOMICS component of an abnormal lumbar disk
ERGONOMIC EXERCISES with concomitant traction. 
ERGONOMIC ERROR - CORRECTION

DRUGS
Some theories on the physiologic effects
INTRODUCTION TO DRUGS
of traction suggest that stimulation of
NSAIDS
proprioceptive receptors in the
PAIN KILLERS vertebral ligaments and monosegmental
MUSCLE RELAXANTS muscles may alter or inhibit abnormal
PHARMACEUTICAL DRUGS neural input from those structures. As
with other theories to explain the
ORTHOTICS physiology of traction, there is little to
UPPER LIMB ORTHOTICS no empirical evidence to fully support
SPINAL ORTHOTICS it.
LOWER LIMB ORTHOTICS

PROSTHETICS
OUTCOME STUDIES RELATED TO
UPPER LIMB PROSTHETICS
TRACTION
LOWER LIMB PROSTHETICS
Very few scientifically rigorous studies
ASSISTIVE DEVICES exist that allow the effect of traction to
ASSISTIVE DEVICES be distinguished from the natural
CANES history of pathology (eg, radiculopathy).
CRUTCHES                                                       
WALKERS
§  Criteria have been suggested that
REHABILITATION would allow the true effects of traction
CARDIAC REHABILITATION to be delineated. These criteria include
PATIENT SELECTION (1) randomized controlled trials, (2)
ALTERNATIVE APPROACHES blind outcome assessments, (3)
PHASES OF CR
equivalent co-interventions, (4)
OUTCOMES OF CR
monitored compliance, (5) minimal
RISK SAFETY & COST ISSUES
GERIATRIC REHABILITATION contamination and attrition, (6)
IMPAIREMENTS adequate statistical power and
DEPRESSION description of study design and
DELIRIUM AND DEMENTIA interventions, and (7) relevant,
OSTEOPOROSIS
functionally oriented outcomes.
FALLS
MALNUTRITION §  No traction outcome study to date has
BURN REHABILITATION incorporated these criteria. Despite
CRITICALLY ILL BURN PATIENT inadequacies in the literature,
RECOVERING BURN PATIENT randomized, controlled trials that meet
UPPER & LOWER LIMB BURNS some of these criteria do provide some
SCAR MANAGEMENT
insight into the efficacy of traction as a
BURN RECONSTRUCTION
treatment modality. A review of
PULMONARY REHABILITATION
randomized, controlled trials of traction
COMPONENTS OF PR
analyzed English language studies done
MEDICAL CARE IN PR
SURGICAL CARE IN PR
between 1966 and 2001. The only
JOINT REPLACEMENT REHABILITATION
conclusion that could be drawn, based
EXERCISE PROTOCOLS
on this review, was that there exists
NEURO MUSCULAR REHABILITATION
poor evidence to support the
CLINICAL OVERVIEW effectiveness of traction for back pain
MEDICAL MANAGEMENT relief. A subsequent review, by
NUTRITIONAL MANAGEMENT Graham and colleagues, arrived at 2
PHARMACOLOGICAL MANAGEMENT clinical conclusions; one conclusion
REHABILITATION favors the use of intermittent traction
NUTRITION IN REHABILITATION over a continuous protocol, and the
NUTRITIONAL ASSESSMENT other does not support the use of
NUTRITIONAL SCREENING continuous traction.  The reviewers felt
EVALUATION OF NUTRITION there was inconclusive evidence overall
NUTRITIONAL NEEDS for either form of traction, based upon
NUTRITIONAL INTERVENTION the methodologic quality of the
NUTRITION AND DISEASE numerous studies reviewed.

A systematic literature review by Clarke

and colleagues further supported the
aforementioned conclusions regarding
traction for low back pain. Through an
examination of randomized clinical
trials, the authors determined that the
evidence did not support
the intermittent or continuous use of
traction alone to treat low back pain in
mixed groups of patients suffering
from this condition, whether or not
sciatica was present.
Owing to inconsistent results and
methodologic problems in most of the
studies involved, the authors also did
not recommend traction for patients
with sciatica. Clarke and his coauthors
also said that because the available
research was insufficient, they could not
 comment on the use of traction in
combination with other therapies.
What can be reasonably derived from
these studies is that more work needs to be
done to be able to make evidence-based
recommendations on the application of
traction for back pain. Additional evidence
is also needed to evaluate the optimal type
and position of the tractive forces for
various clinical conditions, as well as to
assess the use of traction as a component
of a patient's treatment, rather than as an
isolated modality.  
LUMBAR TRACTION

The Agency for Health Care Policy and

Research (AHCPR) review of the literature
on traction resulted in a conclusion that
"spinal traction is not recommended in the
treatment of acute low back problems." In
addition, the 1996 and 1999 guidelines
published by the UK Royal College of
General
Practitioners (RCGP) stated that "there is
little evidence to support the continued use
of traction in the management of acute low
back pain (LBP)."  Despite these
recommendations, the widespread use of
lumbar traction remains relatively high,
with up to 20% of patients in the United
States and 30% of those with low back
pain and sciatica receiving traction as a
treatment. 
Studies that claim improvement after
traction report modest and very short-term
improvements, with limited or no
improvement in overall function.
Additionally, these studies have significant
design flaws. While a particular group of
patients may benefit from a particular type
of traction for either short-term or long-
term improvement in functional outcome,
the literature currently does not identify
this patient population. 
In addition, it is important to note that
although high quality evidence supporting
the use of traction for the treatment of low
 back pain is currently scarce, there is
likewise insufficient data in the literature
to show that traction is not effective for
this problem.
CERVICAL TRACTION

Few randomized, controlled trials address

patient outcomes after cervical traction.
While many studies have produced
statistically significant findings, the actual
clinical significance of those findings is not
clear.  Some studies have been published
on new protocols for cervical traction, as
well as on new devices for traction
application.
The evidence for the efficacy of these
devices and methods appears to need
further study before widespread
application can be made or recommended.
TECHNIQUES FOR APPLYING TRACTION
Cervical traction generally is accomplished
with a free-weight–and–pulley system or an
electrical, motorized device. Adequate pull is
achieved by using a head or chin sling
attached to a system that can provide pull in a
cephalic direction.
Motorized devices are applied easily but
require the patient to be attended. Free-
weight–and–pulley systems often are used in
the home with 20 or more pounds of water or
sand and a pulley system attached to a door. If
a tractive force of only 20 pounds is possible,
the system is likely to fail to achieve
therapeutic results.
Advise patients not to attempt cervical
traction at home alone, because they may find
themselves in uncomfortable positions and
may need assistance doffing the traction
devices.
Most home traction systems are difficult for
patients to set up without assistance. Home
cervical traction may cause increase in pain
or may fail to produce significant pain relief
unless professionally monitored on a periodic
basis. At the initiation of home traction, the
patient should be required to demonstrate
proper use of equipment to the satisfaction of
the prescribing physician or therapist.
In the lumbar spine, adequate pull with
weights and pulleys or motorized devices to
achieve vertebral distraction usually can be
obtained with the proper apparatus.
Generally, a harness is attached around the
pelvis (to deliver a caudal pull), and the upper
body is stabilized by a chest harness or
voluntary arm force (for the cephalic pull).
Motorized units have the advantage of
allowing intermittent traction with less
practitioner intervention. If the goal of
tractive force is to distract lumbar vertebrae,
70-150 pounds of pull usually are needed.
Friction between the treatment table and
patient's body usually requires tractive force
of 26% of the total body weight before
effective traction to the lumbar spine is
possible.                          Many traction devices
use a split table that eliminates the lower
body segment friction.
 
Body weight theoretically should provide
enough pull to distract lumbar vertebrae and
eliminate mechanical devices.
Gravity traction is applied almost exclusively
in the lumbar region. After 10 minutes of
inversion traction, documented increases in
intervertebral separation are noted; however,
side effects also are frequently reported,
including increased blood pressure,
periorbital petechiae, headaches, blurred
vision, and contact lens discomfort. 
A study from Hungary re-analyzed an old
method of applying traction in the treatment
of patients with lumbar or cervical
diskopathy. 
Patients were vertically suspended by a
special harness in a warm-water bath, with a
specified amount of weight applied to the
lower limbs. One harness allowed for traction
on the lumbar spine, while the other focused
on the cervical region. The study participants
had land-based physical therapy exercises
and the weight bath therapy, while a control
group only had the exercises. 
Therapeutic benefit was perceived to be
greater by patients treated with a
combination of the weight bath and exercise
than it was by patients in the control group,
according to result following treatment and at
3-month follow-up.
The treatments were well tolerated, and no
adverse effects were reported. Although the
study concluded that this form of traction
treatment "is a relatively straightforward,
non-invasive, and low-cost intervention that
can be implemented anywhere," further
research may be needed to corroborate the
findings of this pilot study. Such investigation
may need to be supplemented with cost and
feasibility data before widespread
implementation is initiated. 
OTHER TRACTION TECHNIQUE
CONSIDERATIONS
In cervical traction, determining sitting versus
supine position is based upon the patient's
comfort and ability to relax. Maximal
distraction generally occurs between 20-30° of
flexion without rotation or side bending.
Studies have shown that, in the cervical spine,
larger improvement in range of motion (ROM)
with less accompanying pain was noted in
patients subjected to intermittent traction of
20 pounds peak (10 seconds on, 10 seconds
off, for a total of 15 minutes of treatment
time) than in patients subjected to 15 minutes
of manual or static traction of 25 pounds. 
Constant cervical distraction forces of 30
pounds generate maximum vertebral
separation in 7 seconds or less, and no further
separation is gained by applications of up to
60 seconds.
Supine position is chosen most commonly for
lumbar traction since the sitting position may
result in outcome-limiting discomfort from
the harness. Hip flexion of 15-70° routinely is
incorporated to cause relative lumbar spine
flexion; this may facilitate optimal vertebral
separation.
Studies, in addition to patient preference,
suggest that some relative advantage exists to
an intermittent versus continuous protocol of
cervical traction. Some studies report that
continuous traction is necessary in the
lumbar spine to fatigue muscles and allow
strain to fall on joints; however, no statistical
difference has been observed with either
continuous traction of 100 pounds for 5
minutes or intermittent traction of 100
pounds, peaking for 15 minutes. As in traction
on the cervical spine, improved patient
tolerance favors an intermittent protocol.
In the sitting position, application of
approximately 10 pounds is required to
counterbalance the patient's head in cervical
traction. Traction of 30 pounds applied to a
neck flexed up to 24° can cause vertebral
separation, but an increase of force to 50
pounds has been found to produce no clear-
cut additional separation.
In the lumbar spine, a pull, which equals
approximately 50% of the weight of the body
part, is needed to overcome friction. As
previously noted for the lower body, this
amounts to approximately 26% of total body
weight.
In 2006, Akbino and colleagues published a
study examining what the most beneficial
amount of total body weight (TBW) would
be for cervical traction. Trials were done with
patients randomly assigned to 1 of 3 groups,
with each group receiving traction of 7.5%,
10%, or 15% of the patient's TBW. The patients
in the treatment group using 10% of their
TBW demonstrated the highest therapeutic
efficacy with the fewest side effects,
compared with the 7.5% and 15% TBW
groups. 
The optimal duration of traction has not been
demonstrated clearly. Studies have revealed
recommendations varying from 2 minutes to
24 hours in the cervical spine.
Duration of approximately 15-25 minutes
commonly is prescribed. Cervical traction
generally is prescribed at a frequency of daily
for the first week and then every other day
(ie, 3 times per week) for total treatment
duration of approximately 3-4 weeks. 
In the lumbar spine, treatment generally is
recommended in the 8-40 minute range per
session, daily for the first week and then
every other day (ie, 3 times per week) for a
total of 3-4 weeks. In cervical and lumbar
traction, goals of treatment determine the
time course, as well as the end point of
treatment.
Possible treatment end points may include
pain relief, achievement of normal ROM,
return to work or other desired activity, lack
of improvement in symptoms, and inability of
the patient to cooperate with treatment.
INDICATIONS FOR TRACTION
The literature does not give clear indications
what types of neck or low back pain may
improve from traction. Studies strongly
suggest that traction does not produce
significant influence on long-term outcome of
neck pain or low back pain.
Practitioners who rely on sound scientific
advice may use traction rarely. Practitioners
who are receptive to empirical treatments
may be amenable to the concept that traction
may separate vertebrae and decrease the size
of herniated disks, thereby benefiting
radiculopathy; however, no consensus has
been reached among clinicians or researchers
in this area.
In a 2008 review investigating the use of
lumbar traction for patients with chronic low
back pain, Gay and Brault found only 10
randomized, controlled trials addressing this
treatment. As a group, the
studies contained more evidence against the
use of traction than they did for it. The
authors broke the information into
subcategories based on whether the data
covered patients with back and lower limb
pain or with low back pain alone. They
also looked at sustained and intermittent
traction in these patient groups.
The results indicated a lack of benefit in the
use of sustained traction for chronic low back
pain, with or without lower limb
symptoms. Motorized, intermittent traction,
which has been aggressively marketed (eg,
VAX-D, DRX9000), likewise did not seem to
differ in efficacy from simple intermittent
axial traction. 
Gay and Brault cautioned against fully
extrapolating the results of the
available randomized, controlled trials to the
distraction-manipulation therapies at present,
until further research can be completed
specifically assessing their effects. At this
time, there are at least 2 trials of these devices
underway.
CONTRAINDICATIONS TO TRACTION
No scientific reports clearly delineate
contraindications for traction. The
practitioner must rely on empirical
information and opinion.
                      Old age has been cited as a
relative contraindication.
Most practitioners agree that
contraindications to cervical or lumbar
traction include, but may not be limited to, the
following:
1.      Ligamentous instability,
2.      Osteomyelitis,
3.      Diskitis,
4.      Primary or metastatic tumor,
5.      Spinal cord tumor,
6.      Severe osteoporosis,
7.      Clinical signs of myelopathy,
8.      Severe anxiety, and
9.      Untreated hypertension.
In the cervical spine, the practitioner also
must take into account the fact that patients
with vertebral basilar artery insufficiency
may be more susceptible to cerebrovascular
complications. Furthermore, patients with
advanced rheumatoid arthritis or connective
tissue disorders may be at risk for
atlantoaxial instability.
Relative Contraindications:
 1.      Midline herniated nucleus pulposus,
2.      Acute torticollis,
3.      Restrictive lung disease,
4.      Active peptic ulcer,
5.      Hernia,
6.      Aortic aneurysm, and
7.      Pregnancy.
  
REFERRAL CONSIDERATIONS
The Physiatrist who refers patients for
traction must write a detailed and specific
prescription that includes at least the
following patient information:
§  Age,
§  Sex,
§  Diagnosis,
§  Underlying medical conditions,
§  Precautions needed, and
§  Recommended follow-up.
Traction should not be a single treatment
approach but rather should be 1 part of a
comprehensive rehabilitation treatment
program. The most effective use of traction is
likely to improve the patient's activity level,
mobility, and overall function.
Specific items to outline in traction referrals
also should include the following information:
§  Position (of the body, neck, or hip and
knee),
§  Mode of application (continuous or
intermittent),
§  Weight to be applied,
§  Concurrent modalities (eg, heat),
§  Frequency and duration of treatment,
§  Reevaluation guidelines and time
frames,
 §  Guidelines for discontinuation, and
§  Therapeutic goals.

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