Which kind of traction is best?
This is probably the most asked question and also the one for which I don't have a good answer. There isn't much research to indicate convincingly that any particular type traction is ncessarily better than another.
Likewise there is no compelling evidence that any particular traction method is better than another for any particular cervical curve configuration in spite of much conjecture to the contrary.
It appears to many doctors (me included) that the counter stressing methods may have some advantage in terms of patient comfort bccause of the support provided by the counterstressing strap. On the other hand, IF a patient can tolerate the pure compression loading of the Dakota method then that is what I prefer to use.
IF the patient cannot do any of the above methods, I will generally fall back to either a CET-1 unit used supine with a fulcrum or wedge placed so as to help with any discomfort.
Occasionally I run into people who simply can't find a comfortable method of traction for one reason or the other. In these cases I generally have the patient rehab the neck for 4-6 weeks and then try again as long as there are no contraindications to proceeding. If they simply cannot tolerate traction then I will generally resort to simply having them remodel the curves using the S.M.A.R.T. orthotics.
Final thoughts- I always tell my patients to work through discomfort and boredom but to stop traction if they feel pain. If pain persists I generally just try another method. Some doctors approach this differently. Some doctors will encourage their patients to tough it out through spinal pain and discomfort, but I generally think this is a mistake. Our patients look to us for relief of pain. Anything that makes them hurt significantly is likely to encourage them to discontinue care. (NOTE: we are talking about simple spinal discomfort here, NOT radiating or radicular pain or any of the other serious symptoms described as contraindications in the Extension Traction Testing Protocol. If you aren't familiar with the protocol we will be glad to send you a FREE COPY.)
Finally, support and encourage your patients and remember, each method is just a tool. The more tools you have in your bag of tricks the more likely you are to find one that will work for any given individual.
Can patients get themselves into and out of traction in the office?
Yes. Patients can easily get themselves into and out of the traction units both in your office and at home. They generally need a bit of help and isntruction the first few times and then they can do it without problems.
If you are using traction in your office, there is no need for your staff to be tied down with this other than showing them the first few times and to just keep an eye on them to make sure they are continuing to perform traction correctly.
Suggested treatment protocols:
Once I have screened my patients using the Extension Traction Testing Protocol and determined there are no contraindications, I generally start my patients with in office traction at about three minutes. Treatment times are generally increased by about one or two minute (s) per session until the patient can comfortably tolerate 10-12 minutes of traction. This generally takes a couple of weeks if the patient is being seen 3X weekly.
Once the patient has demonstrated in the office a good tolerance for the procedure as well as a familiarity with getting into and out of the traction unit, a home unit is prescribed. I recommend that patients increase their traction times at home to approximately 30 minutes. Thirty minutes gives an optimum amount of tissue stretch for the time invested.
There are various folks out there teaching 5, 7, or 10 minutes but I do not believe these times are going to yield ideal results. The exception to this is in-office traction where I generally limit my traction times to 10-12 minutes. I (as well as most other doctors) often compromise on traction time in order to better expedite the flow of patients through the office. It is simply not practical to keep patients in traction for 20-30 minutes on each office visit so we rely on the patient to do longer session when tractioning at home. Once the patient can tolerate 20-30 minutes they can add weight or force to the unit. On the next session the patient should do as close to 30 minutes as they con comfortably tolerate. When the thirty-minute goal is achieved again then weight/force is increased again and the above procedure is repeated. This will generally be done two or three times and then most patients will find that the increased weight makes it difficult to traction for much more than 25-30 minutes.
In my humble opinion, this is the combination of weight and time that will produce the most tissue stretch in the least amount of time. I do not recommend any weight or force be added to the traction device until the patient had reached the doctors recommended target times for treatment. Some doctors prefer to add weight sooner in the process but I believe it is counterproductive as longer treatment times are necessary to effect viscoelastic deformation of soft tissues.
How much correction should I expect at the time of Re-Xray?
Results vary from patient to patient, however noth in my experience and in most of the studies to date, patients seem to average about about 12-14 degrees over approximately a twelve week period.
How should I position the patient on the Dakota Traction?
The important thing about positioning is that the patient's head be "free hanging". **By that I mean that the head should NOT touch either the foam wedge of the Dakota Traction or the floor. Usually this positioning is best achieved with the apex of the wedge at about T-2-3 or so.
If the head touches the foam, the patient will need to position the wedge just a bit lower into the thoracic spine. If the head should touch the floor you (fairly unusual except with the most flexible of individuals) you may need to place a small book beneath the Dakota traction so as to "lift" or elevate the wedge slightly above the surface of the floor.
What is the best set up for my weight bags for IN-Office Traction?
The best method I have found,if using the Stynchula method, is to have three weighted bags and one CETPRO with Counter Stressing Strap at each traction station.
One bag is weighted with two lbs of lead, one bag is weighted with three lbs, and the third bag is weighted with four lbs. I clearly mark the weight on each bag with a piece of tape. This bag set up allows me to easily change bags/weights in order to add or subtract weight for each patient. Using this setup, I can easily combine bags to have weights of 2, 3, 4, 5 (2 +3), 6 (4 + 2), 7 (3 + 4), and 9 lbs (2 + 3 + 4). In the unlikely event I need more weight there is always an extra bag or two lying nearby.
Why use weight bags instead of lead balls?
I prefer weight bags to the old style lead balls for several reasons. Most importantly, they are more of a "soft" weight which helps reduce any chance of injury. The same cannot be said for the lead ball weights.
The second reason has to do with lead to skin contact. Lead can be absorbed through the skin by repeatedly handling un-coated lead balls. Lead is both toxic and cumulative in the system. Our bag system uses rolled pennies for weight (3 rolls = approx. 1 lb.) so there is no chance of lead exposure.
Is traction ever contraindicated?
Yes! Basically you should never traction any patient for whom extension of the neck is contraindicated. Another way to put it is...Never traction anyone for whom adjustment (manipulation) of the cervical spine is contraindicated.
We have put together a testing protocol to help simplify the process of screening out patients for whom extension traction might be contraindicated. Please follow the testing protocol with every patient.
A printed copy is free upon request.
Troubleshooting common problems with the Dakota Traction
A. Torn foam head pads
Generally, this is due to patients pinching the foam rubber portion of the head pad as they “pull” it up and over the head. This can be easily remedied by instructing your patients to place their fingers underneath the headband and gently press or “lift” the head pad up and over the forehead.
Replacement pads are available at a very low cost.
B. Broken elastic bands (bungee cords)
This one is a bit more serious since it indicates a common misuse of the unit.
If your patient should actually break a bungee cord (very hard to do), it indicates that your patients may be using the units in a way that will not only damage the unit but almost surely will result in a very poor correction. Allow me to explain.
It is vital the patient be positioned so as to have the head hanging completely free from the foam wedge. When properly positioned, the uppermost edge of the foam wedge should strike the patient at around the T3 area. This will allow the head to "free hang" from the wedge and extend into a much more pronounced cervical arc. If improperly positioned, the back of the head will merely rest against the foam fully. In this position, many patients will mistakenly keep tightening the elastic band thinking they are getting a more pronounced and effective traction effect. In reality, since the head cannot extend any further backward, all they are doing is pressing harder against the forehead.
Some patients have tensioned the elastic bands so tightly as to break the elastic bands and tear the foam head pads. If this occurs with a patient you should immediately suspect improper positioning on the unit. Please take a few moments and check your patients for proper form and use of the units.
When the head is "free hanging" and not supported by the foam wedge, you will find that very little tension is needed on the elastic band in order to produce a profound sensation of traction. If you find that some of your patients need to be re- coached on proper positioning, they will also need to relax the tension on the elastic bands considerable in order to accommodate the new and correct position.