Traction and Stabilization Sub-Groups

Question 1

Traction SubGroup

Proposed Biomechanical effects: *TEMPORARY*

6:

Answer 1

1. Distraction/separation of VB’s
2. Combo of distraction/gliding of facet joints
3. tensing of ligamentous structures related to spinal segments
4. Widening of IV Foramina
5. Straightening of spinal curves
6. Stretching of spinal musculature

Question 2

Traction SubGroups

Indications

aka WHY???

Answer 2

• Disc herniation/protrusion
• DEC protrusion and DEC compression of nerve root
• component of a comprehensive therapy program
• DJD, hypOmobility of spinal jts

Question 3

Traction SubGroups

CONTRAINDICATIONS

DO NOT USE

*REMEMBER THIS!!!

Answer 3

• Disease
  
  • tumor
  • infection
• Vascular compromise
• ANY CONDITION for which mvmt is contraindicated
  
  • ​Fx
  • Dislocation
• Pregnancy, osteoporosis, claustrophobia
• Cord Compression==> CE Syndrome
• Uncontrolled HTN
• Hiatal hernia
• Severe respiratory dis.
• Aortic aneurysm
• RA
• Worsening neurologic signs

Question 4

According to studies….

Just an FYI…

Answer 4

Studies gen. unsuccessful in demo’ing efficacy of traction, thus traction is NOT RECOMMENDED for heterogenous groups of pts w/ LBP w/ or w/out sciatica

Question 5

**IMPORTANT**

Delitto et. al 1995 proposed following criteria for classifying pts into this subgroup: Traction

Who WOULD benefit?

Answer 5

• Presence of LE symptoms
• Signs of Nerve root compression:
  
  • ​reflexes
  • myotomes
  • dermatomes
  • +SLR, +Cross SLR**
  • +Slump Test **
• Absence of centralization w/ mvmt testing
  
  • aka trying McKenzie method or NO directional preference

Question 6

In a study looking @ traction + exercise together

Traction + extension oriented exercise

Answer 6

Traction + Ex. group BETTER

-less disability, less fear avoidance @ 2 wks

NO DIFF @ 6 wks compared to exercise alone….WHY?

Traction effects are short-term/temporary

Question 7

The Traction Subgroup is characterized by

4 things:

Answer 7

1. Presence of sciatica
2. Signs of nerve root compression
   
   1. ​+slump
   2. +cross-SLR
   3. hypERreflexia
   4. myos/dermos
3. Peripheralization w/ EXT mvmt
4. +Cross SLR ***

Question 8

Predictors of successful response to traction

ID of Subgroup

Defined:

Answer 8

Pts that exp peripheralization of sx’s w/ EXT mvmts AND have +Cross SLR test

==> BETTER likelihood of success w/ traction

Question 9

Cai et al 2009: Development of CPR (clinical prediction rule) for Traction Subgroup

This is the actual CRITERIA for Tx

CPR for traction NOT YET definitive

BUT…start here…

IMPORTANT***

Answer 9

• FABQ-work subset-score <21
• NO neurological deficit
• Older than 30yo
• NON-manual job work status

***NOTE: If ALL 4 ABOVE PRESENT, INC likelihood of + response to traction from 20% to 69%

Question 10

THACKERY ET AL. 2016

Basic jist?

Answer 10

Looked @ nerve root compression

2 groups

BOTH received EXT ex’s

1 ALSO mech. traction

NO sig. pain or disability diffs b/w groups

NO evidence traction is superior to EXT ex’s in nerve root compress

Question 12

Is traction beneficial??

Answer 12

DEPENDS!!!!

Question 13

Traction Parameters:

4:

Answer 13

1. Constant vs. Intermittent–pt. tolerance
2. Amt of force
   
   1. *start @ 50% pts bw
      
      1. never >120lbs
3. Pt. positioning during tx
   
   1. Prone
   2. Supine w/ hip slight flexed
4. Duration of tx
   
   1. typ 20mins

Question 14

LS Traction Lab

Mech. LS Traction: TYPES

2:

Answer 14

• 1. Clinic Systems
     * traction table
     * inversion traction
• 2. Home Units
     * pneumatic systems
     * inversion boots

Question 15

Procedure for Lumbar Traction w/ typical Clinic Traction Table:

Answer 15

see pics

Question 16

Stabilization Sub-group

*NOTE: shift in perspective from immobilization to stabilization ex’s

—–>

Answer 16

THIS subgroup historically tx’d w/ immobilization or sx stabilization

NOT ANYMORE

Question 17

Research on stabilization and control of LBP—> inconsisten results

Answer 17

******

conflicting results suggest stabilization ex’s are effective for SOME but not ALL pts w/ LBP

Question 18

Stabilization Subgroup:

CPR for stab. subgroup

Based on definition of 50% reduction of self-reported disability

4 Factors found to be predictive of improvement:

Answer 18

1. Age <40
2. Avg (of B/L LEs) SLR ROM >91degs
3. Abberant mvmts during sag plane lumbar ROM**
4. Postivie prone instability test** (one w/ bent over table & lift legs—if pain disappears== + Test

**CPR defined as POSITIVE when 3 or more of above factors present

**+ LR 4.0

**INCs probability of successful outcome to 80%

Question 19

Predicting those pts NOT LIKELY to respond to Stabilization Tx

4 Factors:

Answer 19

1. NEGATIVE Prone Instability Test
2. ABSENCE of Abberant mvmts during sag plane lumbar ROM
3. ABSENCE of Lumbar HypERmobility assessed via P-A segmental lumbar spring test
4. Score of 9 or HIGHER on FABQ phys activity subscale

**The presence of 3 or more of above HIGHLY PREDICTIVE of failure— 86% probability of failure to respond

Question 20

Rabin et al.

more on stabilization ex’s

Answer 20

Prone Instability and Aberrant Mvmts may possess better predictive validity for those benefitting from Lumbar Stabilization***

Question 21

Tx Considerations regarding Stabilization Subgroups

Answer 21

• 1. Old School Focus
     * ​focused on restricting motion deemed to be too excessive for the pts tolerance
• 2. Current Evidence
  
  • ​shifted focus from avoiding to controlling movement

Question 22

2 Basic Areas of Focus w/ Stabilization Group

Answer 22

• 1. Deep Mm’s of the spine for stabilization
     * ​TA
     * Multifidus
     * *NOTE: Stabilizers NOT endurance mm’s
• 2. Strength and Endurance of larger spinal mm’s
     * ​Erector Spinae
     * Obliques
     * QL

Question 23

Koumantakis et al.

Specific retraining group focus on multifidus and TA

vs.

Gen. strengthening focus on lg spinal mm’s—erectors, obliques

Answer 23

**No diff’s after 20wks

Specific strengthening protocols are superior to tx’s NOT including well-defined ex’s

Question 24

Special Tests for Instability

Prone Instability Test

Answer 24

see pics

Question 25

Special Tests for Instability

Passive Lumbar Instability Test

Answer 25

see pics

Question 26

Special Tests for Instability

*Specialized Group–post-partum women w/ pelvic girdle pain*

Criteria to define this sub-group

AND

Name the tests

Answer 26

• Positive Composite of Tests
  
  • ​Posterior Pelvic Pain Provocation (P4 Test)
  • • Active SLR (ASLR) Test
  • Provocation of Long Dorsal SI Ligament
  • Provocation of the Pubic Symphysis w/ Palp
  • Modified Trendelenburg Test

Question 27

Special Tests for Instability

*Specialized Group–post-partum women w/ pelvic girdle pain*

P4 Test

Answer 27

see pics

Question 28

Special Tests for Instability

*Specialized Group–post-partum women w/ pelvic girdle pain*

ASLR Test

Answer 28

Pt is asked to score the task on a 6-pt scale

0= No diff

1= Min diff

2= Somewhat diff

3= Fairly diff

4= Very diff

5= Unable to do

Any score >0 is + Test ***

Question 29

Special Tests for Instability

*Specialized Group–post-partum women w/ pelvic girdle pain*

1. Provocation of Long Dorsal SI Lig

2. Provocation of Pubic Symphysis w/ Palp

Answer 29

NOTE: For POSITIVE TEST

Pain persists for @ least 5s AFTER palp for BOTH

Question 30

Special Tests for Instability

*Specialized Group–post-partum women w/ pelvic girdle pain*

Modified Trendelenburg Test

Answer 30

see pics

+ Test= hips will lean INTO side of pain, shoulders lean AWAY from painful side

Question 31

Stabilization Ex’s

IN GENERAL…

Answer 31

• Teach pt to engage Multifidi
  
  • ​Kegel+TA contraction (suck in stomach like vacuum)
• Progress to engaging multifidi while performing simple tasks
• From here have pt engage multifidi while performing higher lvl functional tasks
• PROGRESSIONS:
  
  • Anything engaging TA!!!