CHAPTER

Traction
13
adhesion
re-orientation
of heal-
manner. By the process
strong
distractive force. Two equal and cal extensible

a tion is the axial tormation can be prevented

and
with the
acting away from each without interfering
directed collinear force
ngsitely ing tissue
will develop,
ather constitute traction.
interver-
movement. of the
increases the size
6. Traction to
the spine over spina
compression
Effects of Traction and relieves
heoretical tebral foramen
radiculopathy.
useful in
through it. So,
structure:
Elongation of soft tissue nerve root exiting
13
the tissue length, as elongation is di-
It increases limitation the Following
Factors

to the load. Thereby, Depend on

rectly proportional tis- Effects of Traction
due to adoptive shortening of soft
of m o v e m e n t 1. Magnitude of Force Load greater
traction. the elongation.
sue can be
improved by greater is
More is the load,
elas-
loss oI
Friction be- microtrauma,
the articulating surfaces. lead to
than yielding point may d e f o r m a t i o n of
distracts s t ruc-
It reduced and
be
tween the articulating surfaces may s t r u c t u r e and
permanent soft
facilitated. It is use- ticity of elongate the
movement may be force should be
applied to
physiological ture. Adequate force may
motion in case of and less
range of
over-stretched

ful in improving joint tissue without being

the structure.
stiffjoint. to the spine, increases intra- not yield
2. Traction, when applied
becomes nega-
intra-discal pressure the Force
discal space, the 2. Direction of the long axis ofjoint
disc may be sucked should be applied along
Ideally, force at an angle
herniated/bulged/prolapsed
tive. The
due to the v a c u u m
effect. Sustained distraction. If the force is applied
back into its space for effective of the
in case of pro- then F Cos 0 component
10-11 min is applied the long axis of joint,
traction for about 0, whereas F Sin 0
to com-
disc. distraction,
intervertebral disc or slipped will cause
tractive force Sometimes move-
lapsed results in
alternate
ofthe part.
when applied movement

ponent will
cause
Intermittent traction undesirable and may
3. As a result, the
intra-articu-
by the traction
becomes
distraction and relaxation. ment caused
fluid ex-
resulting in harm to the patient.
lar pressure changes alternately extra-articular
cause

intra-articular
and
between
change between intra-

It also
facilitates fluid exchange 3. Effect of Friction of Surface individual, area of
weight of the
intracellular-extra-
spaces. on
extra-vascular spaces, Ihe friction depends
vascular and extra-discal spaces.
The surtace area and the surface on

intra-discal and contact between the body

cellular spaces, resulting in of the surface.
fluid escapes out,
nature
which the subject rests, the
and lymphatic promoting the force must exceed
venous
in,
For traction to be effective,
move
arterial blood
pain relief and fresh nutrition to joint
structures
by the surface on
which the
force encountered
also provides rictional
he It
healing. and s e c r e -
products lumbar traction, lower half of
the metabolic waste subject lies. While applying about 1/3rd
by dispersing with frictional force equal to
ion of fresh synovial
fluid.
proprioceptor
body encounters lumbar traction to be ef
stimulates the Therefore, for
4
Intermittent
traction
muscles, Proprioceptor
may Or Doay weight. must be greater than 1/3d of body weight
present aroundjoint and forget pattern
of the t[orce
Iecuveindividual.
disease or may of the
be damaged by injury, polished friction-
due to disuse.
of proprioceptors
Facilitation
To minimize the frictional resistance,
movement
activity is
essential to prevent
less surface should be used.
Traction in split bed is more
to
before returning
movable part of the bed
on which lower

reinjury. immobilization
Occur by the CcvC. ne moves along with the lower
half of
rests,
Healing at rest or during results in
adner
a O c Dody
collagen fibres.
It the lumbar spine effectively with less
cross linking of the tissue
formation.nc
bouy dstracting lower half
inextensible poor
scar While applying lumbar traction,
ent inelastic. and remodelling stage vrorce. of bed mo
the healing tne Dody along with the movable segment
Optimal traction during fibre in a phystolog O
collagen
helps in re-alignment of
 200
PRINCIPLES OF EXERCISE 13. TRACTION 201
THERAPY
ds singe unit, whereas 3. Pelvis Belt 2. Load
upper half
segment of bed remains of the body along with
the
fixed lumbar traction, pelvis belt is used to which the machine For the traction to be effective, the load must exceed the
tional force applied, which imsulis

between the body and stationary otheby the tric

fric- ply confines
ply confines the
the patient to the bed to give rest to the part. weight and pulley circuit is attached and thoracic belt co-efficient of friction between the body and the resting
traction of the
spine with minimal
the bed. It causes
cd. it dis- pauene
tractive force.
Rest promotes healing, relieves pain and spasm that helps
promotes lheanng
in reduction of displacement of bone or joint over time as
fines the thorax
ot lumbar
traction for cffective
to apply countercervical
ror
giving lumbar traction, lower half of the
surface. While
4. State
of Rest or Motion distraction pine. halterbody encounter with frictional force equal to l/3 of body
traction,
of
the upper and Spasm subsides.
with chin and occipital pad is used, the ropes ofwhich is weight. Therefore, the load must be greater than I/3
wit
lower parts of
body move in
opposite attached to the spreader bar and spreader bar Is attached body weight of the individual. While giving cervical trac-
when upper omes eltective with minimal
2.
Sustained Traction 1o the machine or weight and pulley circuit (Fig. 13.1). tion 1/10 of the body weight may be used or start with 5
half is
stationary and lower half moves force.
Comparatvely greater
It is applied in the
Department of Physiotnerapy Dy ma kg load and gradually increase the load up to l0 kg.
force is away chine or weight and Parameters of Traction
anount ol
distraction. required to achieve same puley
If both
upper & lower continuously for the
period Mode: Sustained/Internmittent
laxation in between. SustainedOtraetton
move in same 3. Duration
direction, traction becomes half of body Sustained traction duration should not exceed 10-11
min.
r rction, the upper ineffective. be applied more than 10-11 min. It causesop 2 Load
elongation of
CC Delt and the lower half is trunk is fixed by using
becomes nega-
soft tissue structure, increase in 3. Duration During distraction, the intra-discal pressure
jont space, TCduces till an equi-
PPyng raction at home, the foot pulled caudally. While tra-articular pressure and reabsorption In case of intermittent traction, the hold and rest ratio tive and it absorbs fluid from the surrounding
librium state is reached. As the traction is removed, gradu
plcing DriCKS, So that the counter end ofis bed is raised by distraction phase, joint volume is o iud. So ut g 5. Position of the Patient 15
y, whereas lower part is pulled force increased, ua and intra-discal pressure
exerted by gray- ticular pressure decreases and the fluid ally the elongated tissue relaxes
by minimal load. by the weight effectively trom tne surtou Mode becomes positive. Then, the fluid within
the intervertebral
ing will be absorbed. The
tlurd from vertebral intervertebral aisC till an
body above and below it,reasu
Sustained traction is used in case of acute pain,
disc may hemiate and one may find difficulty
to get out of

. State of equi- characterised by continuous pain, 1.e. pain at rest. Pain the Experimentaly, it has been found
bed. out that the au
Uniformity or ibrium state is reached. When the sustained traction is
when
non-uniform structure is Non-uniformity
of Structure removed, the soft tissue
is severe in intensity, continuous in nature, present even
ration of sustained traction should not exceed 10-11
min.

Strctcnca t0 pulled the weaker part gets

greater extended than
gradually relaxes.
1he Jone vo at rest and highly irritable, 1.e. with slight change in
Intermittent traction can be given to 15-20 min.
As

stretch the the stronger

ume decreases and pressure increases over posture, movement, pressure, the pain aggravates, and relaxation facilitating
stronger part more force part. To in u
herniation of disc material to a greater exICnt. there is alternatecompression
may cause damage to the may be required, which Lunnour which is the indication of sustained the
weaker part. traction, if applied more than 10-11 traction. AS ne the fluid exchange, there is no scope tor Thud pu
should be applied to a Therefore, traction disc
ay
w condition improves over rest & pain subsides, pain is and cause annular injury or herniation of nucleus
uniform structure for herniation. and activity, then sustainedto
Duiid up
traction along
its uniform dis-
length. Traction cannot be reproduced with movement
pulposus.
cervical as well as lumbar applied to the
3. Intermittent Traction traction can be changed to intermittent. To start with,
traction by head spine at the same time. Cervical hold & rest ratio should be more and gradually the ra- 4. Hold and Rest Ratio
halter in case of There is distraction followed
which cervical spondylosis, by relaxation. The load gradu- tion is decreased. intermittent traction, to start with, longer
hold
usually involves the lower ally increases to cause distraction, hold it for some time as
In case of
cervical spine Intermittent mode is used in computerized machine, and rest ratio should be used (60:10 sec).
If the condition
m
stuhnesSS, may pull the resulting set in the
machine, then
uninvolved cervical spine for some time as gradually relaxes to provide rest there are again two ditterent modes - Trapezoidal, Rect be reduced.
before
distracting the involved loweruppercervical spine. Ef pre-set in the machine. Intermitent
mode
improves gradually, the hold and rest ratio can
tluid exchange,
fective distraction
of stiff lower cervical spine with pression and relaxation facilitate fluid exchange, com- angular. In almost all the machines, trapezoidal Frequent traction and
relaxation promotes

proprio- of intermittent traction is available

where the load in-
damage to upper cervical spine. greater ceptive stimulation, etc.
force may cause facilitation, etc.
predeter-Proptoccpuve
creases gradually
maintains (holds) it for the
mined time, then gradually relaxes and rest is given t o r 5 . Position
Types of Traction Apparatus Required
1. Continuous Traction 1. Machine predetermined time. In rectangular moac, Sncc tn Lumbar Traction
It is used for 24 load is increased suddeniy to the predeterneca v Iflumbar flexion is painful and extension is pain Iree, trac
hrs/day. It is of two Electronic/Computerized traction machines are available tion is applied in extension, i.e. prone lying or in supine
types: to apply traction to the provoke muscle Spas and pa, duc
in

A) Skin Traction spine in the Department of Physio- may

load is traumatic; it may help in breaking the adhesion. with leg straight and rolled under the lumbar spine

SKin traction
therapy. Traction can simply be applied by using weight limitation of the movement. and flexion is pain free, traction
is used by adhesive plaster and So may be used in case of If extension is painful
of or belt in case puiey cireuit. and knees
extremities and head halter with Each tissue has got its capacity
to aurng
release tiuidtissue is applied in flexion, i.e. in supine lying with hips
cal spine and spreader bar tor c e e
time is not given for to
flexed (Fig. 13.2).
pelvic belt for lumbar spine. 2. Traction Bed elongation, if adequate
For lumbar traction, bed is release the fluid it may
cause injury.
B) Skeletal Traction required. Traction can be
Skeletal traction
by ordinany bed. Bed with polished surface is applied
is
applied by means of Steinmann's as iriction offered by its surface
preferred,
pin piercing through the bone in case of extremities and
is
relatively less. Various
ypes of specialized bed are available.
Crutch-field traction
piercing the cortex of the skull for Split bed has one
portion fixed to IiX the thoraciC portion and
cervical spine. another portion
movable along with it the
For the traction be effective, the load must
to pelvis and lower limbs are
pulled
the exceed down to distract the lumbar
spine effectively. Bed with
co-effiCient of friction encountered
the
by the part with muluple segments Which can be aligned in various
supporting surface, which cannot be tolerated for 24 10 positions
hrs. For traction to be
tolerated for 24 hrs, less force is
alow iexion extension of spine, side flexion, rotation
are also available. portion Fig 13.2 Traction in flexion
traction in prone
Fig. 13.1Lumbar
 202
PRINCIPLES OF EXERCISE
THERAPY 12.TRACTON 203

1 flexion and extension both

In extension.
are
painful, traction is applied Cervical Spine
the head on a firm object
When traction is
applied in In supine lying position, place
straight, more distraction occurs supine
and
lying lcgs with
(book, newspaper) and the head & neck side
flexed
at lower lumbar
As the
hips and knees are flexed more and spine. rotated away from painful side.
tion shilts more more, distrac
cephalic. When hips and knees are 1lexed, Indication of Traction
legs are
supported by a foot rest. immobilization. In case
Traction 1. Continuous traction is given for
axial distractive force. With
is

Sition, the direction of rope and change in p0 of injury or certain diseases, rest is required for healing

it Is no more
angle of pull alters. When to occur. With traction and rest,
the swelling. pain and
along theaxiS of
spine, its distractive elfect and the malalignment,
reduces and Sin 6 spasm subside gradually
tend to move the
component of the tractive force will sublaxation & dislocation may be
reduced over time.
spine. Accordingly, the load should Home Traction traction is applied in acute paintful con-

adjusted. Depending on be
whether the movement is desir- FIg:13,5 2. Sustained spinal
at rest.
able or not, the dition characterised by pain
position should be selected. Cervical Spine 3. Intermittent traction is applied in subacute & chronic

Cervical Traction requires head halter, spreader bar, rope, pulley and
It painful spinal disorders. 13
weight. The subject is made to sit in a back rest chair at 4. Traction is applied to improve the mobility
Cervical traction while
n o t axia
applied insupine lying position is the door step. The occipital and chin pads are placea n 5. Traction is used to correct the
pOStrC
usually. In
supine lying, head encounters frictional
Fig. 13.3 Cervical traction n position, which is attached to spreader bar. The rope
force. So, more load should be
required to distract the
Sii5 attached to the spreader bar passes over the pulley and to Contraindications
vic Spine effectively, which
the patient and/or
may not be tolerated by difficulties, Saunder's traction unit is useful. The
distractable neck unit is placed at the appropriate level of
other end ofthe rope, weight is attached. Subject is advised 1. Acute traumatic condition: As traction mayOv cause
may cause
injury. to sit looKing down, ensure the rope 1S vertical and weight
Stretch the already injured structure and

r c t i o n in sitting though axial, but line of pull cervical spine that avo1ds unneoessaly aistraction of does not touch the ground. haemorrhage.
y n o t De m a i n t a i n e d t h r o u g h o u t t r e a t m e n t session. T h e uninvolved upper cervical spine. I h e hook o f traction hypermobility/laxity/instability:
2. In case of joint
y weight acts as counter traction, so it is more effective machine is attached to the unit that p u s t o distract the POSITIONALTRACTION further increase the in-
Distraction and elongation may
nan that in lying. The person may not be relaxed properly involved segment without acting on TMJ (Fig. 15.4).
Lumbar Spine stability.
as the head and neck is not headache, vertebra
supported, so effective Traction in Flexion 3. Pain of vascular origin: Migraine
wall w e a k
distraction may not be achieved. HOMETRACTION Subject lies in trunk prone lying position at the edge of the basilar insutficient, aortic
aneurism (vessel

Cervical traction in
sitting position where head is not under the abdomen. The lumbar spine
is and dilated), so may rupture
LumbarSpine bed with pillow
Characterized by
of both the lower
4 . Spinal cord compression: spasticC
supported and does
ettective distraction can
not
encounter with frictional force,
be achieved with minimal load.
Itrequires pelvic belt with traction loops or rings, plastic
rope, bricks or weight. The foot end of the bed should
flexed by pillow
limbs which is about
under abdomen.
of the
weight
body weight distracts
ity, hyper-retlexia, plantar
retlex going up
1/3 toucn tne
5uL, Ihe problem in sitting is that the head position may be be raised by placing bricks under the legs. Subject lies lumbar spine, provided that the foot should not 5. Carcinoma
6. Infective diseases (TB n spine)
atered during treatment session, line of pull may be altered with pelvis belt, the plastic ropes are attached to the loop/ ground.
7. Haemorrhagic diseases (Haemophilia)
and not be achieved
expectedalleffect may
these facts
13.3). (Fig. which passes over the
ring of the belt, pulleys attached at Traction Rotation 8. Prolonged steroid therapy/Anticoagulant
therapy
Taking into consideration, cervical foot endofthe bed and to the other end ofthe rope,weights lies in side lying position at edge ot the bed
witn 9. Sudden of neurological deficit
onset
traction
is applied in half ly1ng position with head and neck are attached. Ensure that the
weight do not touch th Subject deticit
supported. In this position, pull become axial, muscles are ground. Since, the upper half of the body weight acts as underlying scapula protracted,
arm torward,
underiying 10.Rapidly progressive neurological
Rheumatoid arthritis where liga
lower limb backward, overlying upper trunk turns 11.Systemic diseases like
relaxed, position is maintained throughout treatment counter traction with minimal load, effective distraction ment become s o t and liable to injury.
lower limb placed
backward and hand behind, Overlying
session, so effective distraction can be achieved with can be achieved (Fig. 13.5). with one sitting of traction.
forward hanging out ot the bed. By the weignt or
the ieg 12.Pain relief dramatically
minimal load. Cervical raction when applied with head rotation and distraction of
hanging forward, there occurs
and neck in neutral position or with slight extension, more
lumbar of spine. For further distracuon, a Tou Or piloW Danger of Traction
distraction occur at upper cervical spine. duration of time
be used under
side oI tne trunk. 1. Sustained traction applied for longer
can
To apply traction to lower cervical spine, head and lesion.
may w o r s e n disc
neck should be flexed gradually. CCslight extension, applied following
accelerated injury
Traction in Extension 2. Cervical traction
to
CCneutral position, C,C 5° flexion, C,C +5° by hanging over
achieved
the bar. In kneel
may result in a t l a n t o - a x i a l joint subluxation, injury
lt can be
table with soft to medulla and
Optimal distraction of cervical spine occurs at about 24 1s placed on the bed or
spinal cord causing quadriplegia, injury
standing, the hand that the weight of lower also occur. It may happen s0 in case
of neck flexion. 1Then raise the trunk, so sudden death may
padding. absence ot upper
Cervical traction by head halter compresses the lumbar spine, of Rheumatoid arthritis, Congenital
TRITON distract the
half will
TMJ disorders cervical ligament, etc.
temporO-mandibular joint. Persons having
of symptoms, it unnecessarily
may develop aggravation
distracts the upper Persons
cervical spine. wimOs5 Fig. 13.4 Cervical traction Saunder's unit
 204
PRINCIPLES OF EXERCISE THERAPY 43/ TRAT1ON 205
3. Traction with load may cause
over
3. Chow DH Yuen EA, Xiao t, Leung MC. Mechanical effects
raction, if it is not
may worsen the
injury.
applied after thorough evaluation
for long
traction.
time.

t is
I1 it
traction. If
Manual traction is used
not effective,
to test the

mechanical
effect of
tractionis
SELF ASSESMEEVIEW OUESTONS ot traction on lumbar intervertebral discs a magnetic
pain. That is the reason, aion s aoes of manual traction
resonance imaging study. Musculoskelet Sci
Pract.
traction must be why effect of ntag over
determined
before applying mechanically.by applying it manually, recommendcd.
mechanical traction is that along with traction, movement
Long Questions 2017;29:78-83.
manually, mechanical tracO can be given (Figs. 13.6 and 13.7).
In various directions
4. Humphreys SC, Chase J, Patwardhan A, Shuster ,
1Discuss about the factorS on which effect of traction Lomasney L, Hodges SD. Flexion and traction eftect on
For cervical traction, subject lies in supine lying position
MANUALTRACTION With head out of the bed. Therapist stands at head end,
depended. C5-C6 foraminal space. Arch Phys Med Rehab.
raction can be applied by 2. Explain the physiological effect of traction. 1998;79:1105-9.
hand. For lumbar to grasp and ieans 5. Vanlaningham C, Schaller TM, Wise C. Skeletal versus
1S either n
supine or
spine, subject supports the hand with occiput chin 3 What is the effect of traction IV
foramen of spine?
on
prone lying position. One the skin traction before definitive management of pediatric
stands at head end
of the bed to fix assistant
and apply counter
backward to apply traction. Along with manualtraction, 4. DiscusS about the apparatus required for the traction.
femur fractures: a comparison of patient narcotic re-
rdction to upper trunk. Therapist stands at foot end of mobilization can be applied, which is not possible with 5. Explain about the modes of traction.
quirements. J Pediatr Orthop. 2009;29:609-11.
bed, holds above the ankle joint and mechanical traction (g 13.8). 6. Discuss about the cervical traction.
the traction. It
may not be possible to
lean backward to
apply Discuss about the lumbar traction. 6. Mao XH, Yan J. Effect of preoperative skeletal traction
and skin traction on operative indicators and functional
apply manual tractio 8. Write down the
contraindication of traction. Outcome of patients with femur fractures. Zhongguo gu

Shang lChina J Orthop Traumatol|. 2014;27:800-3.

Short Questions 7. Zylbergold RS, Piper MC. Cervical spine disorders. A com- 13

parison of three types of traction. spine. 1985;10:867

9. Define traction. 71.
10. What is coefficient of friction? 8. Borman P, Keskin D, Ekici B, Bodur H. The efficacy of

11. Describe about the factors affecting coefficient of intermittent cervical traction in patents with chronic

tion.
fric neck pain. Clin Rheumatol. 2008;27:1249-53.
12. What is sustained traction? 9. Tanoviä E, Eelik D, Omerovi A. Intermittent traction
13. What is intermittent traction? back pain.
therapy n the treatment of chronic low
14. What is VBI? Is traction helpful in this case or not? Medicinski Glasnik. 2021;18.
10. Saunders HD. Lumbar traction. J Orthop Sports Phys Ther.

1979;1:36-45.
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1. Lai A, Chow DH. Effects of traction structural ture. J orthop Sports Phys Ther. 1994;20:262-7.
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proper S.
ties of degenerated disc using an in vivo rat-tail model. 12.
Ljunggren AE, Weber H, Larsen Autotraction versus
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Fig.13.6 Manual traction Movement in various directions
Spine. 2010;35:1339-45.
Fig.13.7 2. Krause M, Refshauge KM, Dessen M, Boland R. Lumbar tervertebral discs. Scand J Rehabil Med. 1984;16:117-
spine traction: evaluation of effects and recommended 24
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Fig.13.8 Cervical traction