Traction is a physical force which brings about separation of the joint through the bone along its long axis. This can be done manually or mechanically and provides several beneficial effects.

1. Traction
- Dr. Ameya Kakodkar (PT)

2. Objectives
• Discuss the physical properties of traction
• Identify physiological effects of traction
• Indications and contraindications and precautions
• Types of traction

3. Application of a mechanical force
to the body in a way that
separates, or attempts to
separate the joint surfaces and
elongate the surrounding soft
tissues
Traction can be applied
manually by the clinician or
mechanically by a machine
Can also be applied by the
patient using body weight
and the force of gravity to
exert a force
Can be applied to spinal or
peripheral joints

4. EFFECTS OF SPINAL TRACTION
JOINT
DISTRACTION
REDUCTION OF
DISC
PROTRUSION
SOFT TISSUE
STRETCHING
MUSCLE
RELAXATION
JOINT
MOBILIZATION
PATIENT
IMMOBILIZATIO
N

5. Joint
distraction
The separation of articular surfaces
perpendicular to the plane of articulation
Distraction reduces compression on the joint and
widens the intervertebral foramina, reducing
pressure on articular surfaces, intraarticular
structures, or the spinal nerve roots
Reduce pain originating from joint injury or
inflammation or from nerve compression.

6. • Distraction of the apophyseal joints has been
demonstrated with a equal to 50% of total
body weight; in contrast, approximately 7%
total body weight been reported to be
sufficient to distract the cervical vertebrae

7. Reduction of
Disc
Protrusion
According to Cyriax, "traction is the
treatment of choice for small nuclear
protrusion
The proposed mechanisms for disc
realignment includes clicking back of a disc
fragment, suction due to decreased
intradiscal pressure pulling displaced parts
of the disc back toward the center or tensing
of the PLL

8. • 60 lb or 27 kg
• The symptomatic improvements may
be the result of reducing the discal
protrusion or may be due to
concurrent changes in other associated
structures, such as increased size of
the neural foramina, changes in the
tension on soft tissues or nerves, or
modification of the tone of the low
back muscles

10. Soft tissue stretching
• Traction elongates the spine and increase the
distance between the vertebral bodies and the
facet joint surface
• These effects are due to increased length of the
soft tissues in the area, including the muscles,
tendons, ligaments, and disc
• Soft tissue stretching using a moderate-load,
prolonged force, such as that provided by spinal
traction, has also been shown to increase the
length of tendons and to increase joint mobility

11. Muscle
Relaxation
Spinal traction has been reported to facilitate
relaxation of the paraspinal muscle
This effect may be the result of pain
reduction due to reduced pressure on pain-
sensitive structures or gating of pain
transmission by stimulation of
mechanoreceptors
Static traction may cause muscle relaxation
as a result of the depression in monosynaptic
response caused by stretching the muscles
for several seconds

12. Intermittent traction may cause
small changes in muscle tension by
stimulating the Golgi tendon organ
to inhibit alpha motor neuron
firing

13. Joint
Mobilization
• Traction has been recommended as
a means to mobilize joints in order
to increase joint mobility or
decrease joint-related pain
• High force traction stretches
surrounding soft tissue structure
improving mobility
• Intermittent low force traction
causes repetitive oscillatory
movements causes stimulation of
mechanoreceptors and gates pain

14. Patient
immobilization
• Very low load, prolonged static
traction, using 4.5 to 9 kg (10 to 20 lb)
applied for long periods of hours to
days, can be used to temporarily
immobilize a symptomatic spinal area
and thereby relieve symptoms that
would be aggravated by spinal motion
• Benefits of such treatment are thought
to be the result of the enforced limited
mobility and bed rest produced by the
belts and harnesses used to apply the
traction, rather than being a direct
effect of the traction force

15. Clinical
indications
• Disc bulge or herniation
• Nerve root impingement
• Joint hypomobility
• Subacute joint inflammation
• Paraspinal muscle spasm

16. Contraindications
• Where Motion is contraindicated- unstable
fracture/ cord compression
• Acute joint injury or inflammation
• Joint hypermobility or instability- a recent
fracture, joint dislocation or surgery, or it can
be due to an old injury high relaxin levels
during pregnancy and lactation, poor
posture, or congenital ligament laxity
• Peripheralization of symptoms with traction

17. Precautions
• Structural diseases or conditions affecting
the spine (e.g.. tumor, infection, rheumatoid
arthritis, osteoporosis, or prolonged
systemic steroid use)
• When pressure of the belts may be
hazardous (e.g., with pregnancy. hiatal
hernia, vascular compromise, osteoporosis)
• Displacement of annular fragment

18. Medial disc protrusion
Claustrophobia
Patients unable to tolerate the prone or
supine position
Disoriented patients
Temporomandibular joint (TM) problems
Dentures

19. Traction used
by
Orthopedicians
• Skin Traction-
Adhesive strap applied on the skin
and traction is given . Traction
force transmitted through deep
fascia and intermuscular septae
• Skeletal Traction-
Applied directly on bone by
inserting a K wire or Steinmann pin
through bone

20. Skin
traction

21. Skeletal traction

22. Feature Skin Traction Skeletal Traction
Required for providing: Mild- Moderate force Moderate- severe force
(Age) Children Adults
Applied with Adhesive plaster K wire, Steinmann pin
Applied on Skin Skeleton
Common site Below knee Upper tibial pin traction
Weight permitted upto 3-4 kgs Upto 20 kgs
Used for Shorter durations Longer durations

23. Traction used by
physiotherapists
• Manual Traction
• Mechanical Traction/ Electrical
Traction

24. Manual
traction
Application of force by the therapist in
the direction of distracting the joints
Can be used for providing cervical and
lumbar traction
A part of manual therapy

25. Manual
Cervical
Traction
• Patient position- Supine lying on plinth with head out of plinth
• Therapist position- Sitting at head end of patient
• Procedure- Place one hand on the occiput and other on chin of
patient. Therapist applies traction force by assuming stable
stance and leans backward in controlled manner through hips.
Done intermittently
OR
1.Position the patient supine.
2. Position yourself. Stand at the head of the patient
3. Place your hands in the appropriate position. Supinate your
forearms so your hands are faced up; place the lateral border of
your second finger in contact with the patient's occiput and your
thumbs behind the patient's ears.
4. Apply traction. Apply force through the occiput by leaning
back, keeping your spine in a neutral

27. Using belt

28. Manual Lumbar traction
Position
Position the
patient in the
position of least
pain. This is
usually supine,
with the hips and
knees flexed.
Position yourself.
Kneel
Kneel at the
patient's feet,
facing the
patlent.
Place
Place your hands
in the
appropriate
position behind
the patient's
proximal legs,
over the muscle
belly of the
triceps surae
Apply
Apply traction
force to the
patient's spine by
leaning your
body back and
away from the
patient, keeping
your spine in a
neutral position
Adjust
Adjust the force
of the traction
according to the
desired outcome
and the patient's
report. Manual
traction may be
static, of
constant force, or
intermittent, of
varying force

29. With hip- knee flexion

30. Manual lumbar traction with knee
extended
• Patient position: Supine
• Position of therapist: Feet end of patient
• Procedure: Therapist holds the ankle and
lifts patient’s limb slightly off the bed/
plinth with the patient’s limb in slight
abduction, pulls the limb towards himself
• Leads to traction at hip, knee and also at
SI joint
• Can also be given with the belt in figure
of 8

31. Advantages of Manual Traction
No equipment
required
Short setup time
Force can be finely
graded
Clinician is present
throughout treatment to
monitor and assess the
patient's response
Can be applied briefly,
prior to setting up
mechanical traction, to
help determine if longer
application of traction
will be beneficial
Can be used with patients
who do not tolerate
being placed in halters or
belts

32. Disadvantages of Manual Traction
Limited maximum
traction force, probably
not sufficient to distract
the lumbar facet joint
Amount of traction force
cannot be easily located
or specifically recorded
Cannot be applied for a
prolonged period time
Requires a skilled clinician
to apply

33. Mechanical
Traction
• Can be applied to Cervical and Lumbar spine
• A variety of belts and halters, and number of
different patient treatment positions, be used
to apply traction to different areas of the spine
and to focus the effect on different segments or
structures
• Can apply static or intermittent force of varying
magnitudes
• With static traction, the same amount of force
is applied throughout treatment sessions

34. • With intermittent type, the traction force
alternates between two set points every
few seconds throughout the treatment
session
• Hold period: The duration for which the
force is applied
• Relax period: Force is reduced by approx.
50%
• Weighted mechanical traction units apply
static traction only, with the amount of
force being determined by the amount of
weight used

35. • It is generally recommended that static traction
be used if the area treated is inflammed, or if the
patient's symptoms are aggravated by motion, or
if the patient's symptoms are related to a disc
protrusion
• Intermittent traction with long hold times may
also be effective for treatment of symptoms
related to disc protrusion
• Shorter hold and relax times are recommended
for symptoms related to joint dysfunctions.

36. Equipment check!!!

37. Electrical
Mechanical
Traction Units
(EMTUs)
• These units use a motor to apply traction
forces to the Iumbar or cervical spine,
statically or intermittently, and can be used
to apply forces of up to 70 kg (150 lb).
• Allow fine, accurate control of the forces
being applied
• Also allow considerable variation in patient
position

39. Advantages of
Mechanical
Traction
Force and time well controlled, and graded and
replicable
Provides option of intermittent or static

40. Disadvantages
Expensive
Time consuming to set up
Passive treatment; no patient
participation
Can get claustrophobic due to belts and
harnesses
Mobilizes the spine broadly, may induce
hypermobility in normal segments

41. Mechanical
Cervical
Traction
Select the appropriate mechanical traction device
Choice depends on the region of the body to be
treated, the amount of force to be applied, whether
static or intermittent traction is desired, and the
setting in which the treatment will be applied
Optimal patient position
Try to achieve a comfortable position that allows
muscle relaxation while maximizing the separation
between the involved structures

42. • Relative degree of flexion or extension of the spine
during traction determines which surfaces separate
• In most cases a symmetrical central force is used, in
which the direction of force is in line with the
central sagittal axis of the patient, however, if the
patient presents with unilateral symptoms, a u/l
traction force that applies more force to one side of
the spine than to the other may prove to be more
effective
• U/l force can be applied by off-setting the axis of the
traction in the direction which most reduces the
patient's symptoms

43. • For the application of cervical traction to the spine, the patient may
be in the supine or the sitting position

44. Sitting vs. supine
Placing the cervical spine in a neutral or slightly extended position focuses
the traction forces on the upper cervical while placing the cervical spine
in a flexed position focuses the traction forces on the Iower cervical spine
Maximum posterior elongation of the cervical spine is achieved when the
neck and angle of pull are at approximately 25 to 35 degrees of flexion

45. Types of halters
Saunders Halter Mandibular Halter

46. The adjustability of the halter, the patient position, and the status of
the TMJs should all be considered in selecting the most appropriate
cervical halter for a particular patient
The halter should be adjustable to accommodate variations in the
shape and size of patients' head and neck and to allow for different
angles of traction pull
Saunders halter only applicable in supine while soft can be applied in
sitting as well as supine

47. Dosimetry
Cameron, M.H. (2017) Physical Agents in rehabilitation: From research to practice. Elsevier - Health Sciences
Division.

48. Hold –Relax
times
• If intermittent traction is selected, the maximum
traction force is applied during the hold time and a
lower traction force is applied during the relax time
• Times depend on the patient condition
• For a discal problem, longer hold times of approx. 60 sec
and shorter relax times of 20 sec

49. Clinically,
For a spinal joint
related problem,
shorter hold and relax
times of approx. 15
sec are recommended
Symptom severity
should be considered

50. Force
• Differs according to authors
• In general, recommended to start with a low force in order to avoid relative
muscle guarding and spasm
• It is recommended that, for all applications, the traction force to the cervical
spine start at 3 and 4 kg (8 to 10lb)
• 7% of patient’s body weight to separate the facets

51. More force if patient
is in sitting as
compared to supine
Force should not
exceed 50% of
patient’s head or 13.5
kg
Relax force should be
50% lesser than hold
force

52. Duration
• For first session, 5 min if symptoms are severe; 10 min if symptoms are
moderate
• If the patient's symptoms are partially relieved after 10 minutes of traction,
it is recommended that the duration of the initial treatment not be
extended: however, if symptoms are unchanged after 10 minutes, the hold
force may be increased slightly or the angle of pull modified, and
treatment may be continued for a further 10 minutes
• Treatment more than 40 min produces no benefit!!!

53. Frequency
• No definite evidence
• Some authors recommend daily treatment

54. General guidelines
Observe
Observe the
patient for the first
5 min to check if
halter is staying in
place, patient is
comfortable and
there are no
adverse effects
Stop and adjust
Stop and adjust if
need be
Give
Give the patient a
means to call you.
Most devices are
armed with a safety
switch with alarm
Release
Release tension on
ropes post
completion,
provide a brief rest
to the patient
before re assessing

55. Mechanical
Lumbar
traction
The relative degree of flexion or extension of
the spine during traction determines which
surfaces are most effectively separated
A symmetrical central force is used, in which
the direction of force is in line with the
central sagittal axis of the patient
Supine position most commonly used,
however prone position works for those who
are unable to tolerate it

56. Discal problems are relieved with
body in prone and facet problems
relieved with body in supine with
hip-knee flexion

57. Procedure
• The patient should lie on a split traction table, with the area of the spine to be
distracted positioned over the split. Split tables reduce the friction between table
and patient’s body
• Apply the appropriate belts or halter.
• The belts must be placed with the non-slip surface directly in contact with the
patient’s skin, and not over the clothing, and both belts must be securely
tightened in order to prevent slipping when the traction force is applied

58. Thoracic and pelvic belts
• Used to stabilize the upper body above the level at which traction
force is desired
• Prevents patient from being pulled down by the pelvic belt
• The thoracic belt should be placed so that its lower edge aligns with
the superior limit at which the traction force is desired, and with its
upper edge aligned approximately with the xiphoid immediately
below the greatest diameter of the thorax

60. • Pelvic belt should be placed such that its
superior edge aligns with the inferior limit at
which traction force is desired, generally just
superior to the iliac crests (or superior to the
superior edge of the sacrum if patient is in
prone)
• Connect the belts or halter to the traction
device

61. • When the patient is prone, with
the lumbar spine in neutral or
slight extension, as indicated to
maximize distraction of the
anterior spinal structures, the
pelvic belt may be placed with
the fastening posteriorly and the
rope anteriorly so that pull is
primarily from the anterior
aspect of the pelvis

62. • When the patient is supine with
the lumbar spine in slight flexion,
as indicated to maximize
distraction of the posterior spinal
structures, the pelvic belt should
be placed with the fastening
anteriorly and the rope
posteriorly so that the pull is
primarily from the posterior
aspect of the pelvis

63. Dosimetry for lumbar traction
Cameron, M.H. (2017) Physical Agents in rehabilitation: From research to practice. Elsevier - Health Sciences Division.

64. Summary
Different types of traction
Physiological effects of traction
Manual vs. Mechanical traction
Skeletal vs. skin traction
Dosimetry

65. Reference: