Back to Basics

Who would have thought that a man could lift 1,000 pounds? But he can. At least two men hold official records for bench pressing more than 1,000 pounds, and the Internet is home to numerous videos offering proof of more men. But just because records can be broken doesn’t mean they always should be, particularly by the average gym-goer egged on by well-meaning friends.

Jim Arnoux, PT, owner of Arnoux Physical Therapy in Portland, Ore, has seen the results of these misguided efforts. He once saw three patients in a row with thoracic disk problems caused by incorrect bench presses. Neither gender nor age is immune; one of the three thoracic disk patients was a woman. Another patient with a more serious injury by the same cause was only 15 years old.

Of course, back pain is not felt solely by overzealous weight lifters; there is a wide range of conditions that can cause enough pain to require treatment. Certain causes can be alleviated with back traction, which uses force to open space between the vertebrae. The resulting effect can help to alleviate back pain and muscle spasms by decreasing pressure, increasing disk hydration, and stretching muscles.

Both the lumbar and cervical regions can be treated with traction, though greater effect has been reported in the cervical area. The literature has been inconclusive regarding the lumbar region.

The force itself can be applied in a variety of ways, ranging from body positioning to mechanical pull; the angle can cover one plane or many; and the tension can be sustained or intermittent. The method used will reflect the condition, the patient, and the equipment, and should be multidisciplinary. “If everyone—the PT, physician, chiropractor, patient—is on the same page, the right combination of exercise, medication, and care can make it possible to avoid surgery,” Arnoux says.

WHEN TO BACK OFF

Unfortunately, it won’t make it possible for every patient. The 15-year-old male with weight lifting-related injuries found some relief with traction but ultimately required surgery. “The traction did alleviate some of the pain, but it was obvious it would not create permanent change,” Arnoux says.

Patients who will benefit from traction include those with radicular compression, facet joint pathology, muscle spasms, and disk problems, such as disk protrusions and degenerative disk disease. Arnoux treats both the cervical and lumbar regions with traction despite the lack of supportive literature for lumbar traction. “I can point to more cases where surgery has been avoided with cervical traction than with lumbar, but I have had several successful lumbar patients,” Arnoux says.

Though lumbar pain is not a contraindication, there are patients for whom traction is not recommended. Contraindications include patients with acute injury, bowel or bladder conditions (“pressure from the belt compresses the bladder,” Arnoux says), cancer or tumors, cardiovascular or pulmonary conditions, claustrophobia (“the belt can overwhelm them,” Arnoux says), fractures, hernias, infectious diseases, joint instability, osteoporosis (“these patients’ bones are brittle, and you don’t want to overstress them,” Arnoux says), pregnancy, meningitis, rheumatoid arthritis, and unstable spinal segments.

In some situations, such as those where the structural integrity of the spine is threatened (for example, osteoporosis and tumors), traction could create more problems. “Obviously, where traction makes the problem worse, its use is discontinued immediately,” Arnoux says.

To avoid more damage or wasted time, treatment must therefore be tailored to the patient. Arnoux notes the PT’s role is not diagnosis, which falls into the physician’s realm, but clarification. “We clarify where the pain is coming from and what the patient is doing that is causing the back to be painful,” Arnoux says, citing posture, weak core muscles, and lifting methods as potential contributors to back pain.

Arnoux estimates that about 10% of his patients come in with a primary diagnosis of back pain, but closer to 50% have back pain as a secondary diagnosis. “Patients with a primary diagnosis of back pain have often suffered injury on the job, overuse, car accidents, and poor posture mechanics, and the obesity epidemic claims a portion of back patients as well,” Arnoux says.

“Traction has been used since Hippocrates, but there is still controversy regarding its use. It’s important to move away from compression and toward stretching to achieve the benefits of traction,” Arnoux says. He aims to stretch structures within their normal limits to allow proper function. There are various traction methods by which to achieve this.

These include mechanical, motorized, manual, autotraction, and gravity. Mechanical and motorized systems require devices that use simple physics or advanced electronics to create and apply traction force. Manual traction is applied by the therapist or, in some instances, by a partner or family member. Autotraction is controlled by the patient using a table and his or her own body weight. Gravitational traction uses the force of gravity to create pull; patients may be placed on a tilt table or hang upside down. “This method would not be recommended for persons with low blood pressure,” Arnoux says.

The force may be sustained over an extended period of time (for example, 15 minutes) or applied intermittently. With sustained traction, pain is alleviated during the stretching or the application of force; with intermittent application, pain relief is felt during application of force but may be appreciated over a longer period of time. The angle of pull can vary as well and be administered on transverse, frontal, sagittal, or multiple planes.

BEHIND THE BACK

According to Arnoux, the gold standard is the PT’s hands. “We can appraise muscle tone and relaxation as well as what the muscle is doing when the patient is in certain positions,” Arnoux says. He uses a variety of manual treatment techniques, including strain/counterstrain, soft-tissue and joint-tissue mobilization, massage, muscle energy, Mulligan techniques, and, of course, manual traction.

The hands-on approach may require more time than the average patient visit. Arnoux estimates he spends at least an hour with each patient; he sees about 25 to 35 patients per week. “In addition to being an exercise guide to help patients realize their wellness potentials, I integrate active listening, relaxation, and encourage self-pacing skills,” Arnoux says.

This isn’t always accomplished manually, however; Arnoux also uses a variety of equipment to achieve traction, moving from the simplest to the most complex.

Traction tables employ basic principles but can be expensive, running as high as $7,000 and more. Advanced systems feature moveable sections; some have as many as six. The head and foot sections may incline and decline, and the height may be adjustable or fixed. Less flexible tables work in conjunction with roller bars or smaller traction systems that use belts, bars, pulleys, or other methods to create force.

These smaller units are often portable and can be used outside the clinical setting. Some systems, such as those using harnesses and straps, work with a door or on the floor. Others are singular devices, such as collars, and require no accessories. Others are more complicated, featuring pumps and other patented designs.

One of Arnoux’s preferred cervical traction devices is the Starr Traction device by Care Rehab and Orthopaedic Products Inc of McLean, Va. Force is created through a hand pump and a memory pillow, wedges, and an adjustable angle of incline, which tailor the traction.