One of the first "facts" I learned about traction in medical school was that since the lumbar ligaments are so powerful and vertebral distraction impossible, the only action that traction could possibly have was to keep the patient in bed; I learned this lesson from a professor who was deservedly among the most respected orthopaedic surgeons then at UCLA. I did not fault him. Without realizing it, he was parroting the "accepted wisdom" that traction must be a mechanistic procedure. My purpose in this edition of Goodley intentions is to refute this position and demonstrate a critically important perspective whose general realization will revolutionize the use of this ancient therapy.
In the 1970s, I began my decade + of low back pain. After a few days I checked out of the hospital and rented a traction bed. It hadn't much relieved me, but I didn't have much else. I can't remember why I decided to do what I did, but with it I had delivered about 70 lbs of weights in 5-pound increments.
I had one 5-pound weight added every 5 minutes. From 0 to 20 degrees, there was no change in my pain. With the fifth weight I was virtually instantly pain free! I was stunned. I had no expectation that anything like that could happen. With the sixth weight, the pain immediately began to return, again the unexpected, and by the ninth weight, the pain was approaching an unbearable level. Playing the weights up and down like a musical scale, I had them applied and removed several times over the next few days. Every time the results were exactly the same. Amazing!
Discussing it with my colleagues nonplussed them. It was off the wall, and the only refuge they had was the almost all-powerful seduction of denial. It reminded me of another instance, the reason why, for most of my career, my logo has been a snake walking away from a staff with a snake in its mouth. (The story is in my Web site: https://www.drgoodley.com.)
But to me -- at least in my case -- which I couldn't accept was unique -- the conclusion was unavoidable. Something vastly more subtle than simplistic mechanistic pulling was happening.
The acceptance of the exclusively mechanistic rationale was reinforced by a paper by Colachis, who applied cervical traction with the usual Sayre type sling (which I will discuss) to healthy students at UCLA. He increasingly added weights until visible joint distraction was seen on x-ray. This was declared the therapeutic threshold. As with the Sayre sling, the appearance of science seemed self-evident, and the present mess of cervical traction was further reinforced.*
As I write this, something else happened from which my possible participation is now regrettably concluded but it is potentially important, and perhaps this will somehow be an influence for the good.
You may be aware that The World Congress on Neck Pain will convene in Los Angeles in January, 2008. When I very recently learned of it, my first impression concerns the title. For such an important theme and impressively advertised event, I would have wished that the powerful words that denote its purpose did not set a trap. To me, Neck Pain does that to the unaware, and the burden is particularly disadvantageous in the circumstance in which pain in the neck is such a major problem in society. From word flow and the perspective of syntax, there may be some justification for "neck pain,"
but at least, in my opinion, its almost subliminal message needs a modifier, and the words I just used -- pain in the neck -- avoids the hazard and appropriately establishes the frame of investigation. There is a vast difference in the implications of thinking "neck pain" and thinking "pain in the neck." Please think about it.
When I teach, I usually start with the shoulder because so many principles become hands-on real that can then be applied to other examinations as palpatory skill develops. I insist that my student(s) approach the study as, again, pain in the shoulder -- that is, pain that is experienced in the shoulder -- and not "shoulder pain." To the mind, shoulder pain constructs an invisible box that is real nonetheless and that implicitly acts to limit the thinking to that particular site. But that's not life. Premature focus can be deadly to successful therapeutics. Pain can refer to the shoulder from the neck, the heart, the spleen, as examples.
As I stated in a previous issue, pain must be seen as a liar. In every case, its location must never be casually accepted as the site of its origin. If 1 sacroiliac joint is locked, thus silent, the other will become overburdened and will eventually complain. Treating the squeaky wheel will be permanently fruitless, and we see such fruitless misfortune "all the time." Obviously, the dysfunctional joint must be relieved, so the offended joint can heal.
And, conversely, I once consulted on a case of a woman with temporomandibular joint (TMJ) pain, the etiology of which I found in her shoulder, who was immediately relieved by injecting her glenohumeral joint. While it was a novel and gratifying experience to me, she really couldn't have cared less. Her gratitude came from her relief, however it happened.
Returning to the World Congress, I promptly, innocently, and enthusiastically submitted an abstract to relate my findings concerning traction, much of what I am presenting here. This issue is of fundamental importance that extends well beyond this therapy because its failure is an embodiment of the entire general failure to appreciate the essentials of orthopaedic medicine, osteopathy, chiropractic -- historic medicine.**
I met the Congress' Executive Director 2 years ago at the National Institutes of Health, in Bethesda, Maryland, at the Conference on Biology of Manual Therapies, the follow-up to a meeting 30 years before at The National Institutes of Neurological Diseases' (Bethesda, Maryland) first conference on The Research Status of Manipulation. (As a little brownie point, the moderator, Murray Goldstein, DO, and I were the only individuals who had attended both.)
I whizzed off my 500-word abstract, Resurrecting Cervical Traction, in narrative form to him. He was kind and promptly responded, informing me that I had to comply with the Congress' rigid protocol, and so I transformed it under headings concerning purpose of the paper, participants, etc. and resubmitted it, but again he informed me I had a long way to go as he provided elaborate and remote streams of phraseological suggestions how I might make my paper "scientific" and referred me to a recently published paper on traction as an example of what was expected. It is a review article, and it is revealing. In a word, the paper uncritically accepts as legitimate certain contentions and its analytical distillation of the issues that, in my facts, have been prime contributors to traction's descent to discredit for decades because of its failures and many complications. Its expression even starts in the title, "...Mechanical...." Please keep it in mind. I'll return to it after I establish the foundation, but to conclude my story about the Congress, I tried again.
Again I learned that my abstract wasn't using the correct words. The few illustrative clinical cases I could only very briefly discuss were referred to as "cherry picking." They weren't digits buried in statistics. I wasn't offended but countered that I saw their specific selection to emphasize their "Eureka" experience qualities that opened the vista on what traction in acute cases is about and that amplified on my surprising 'discovery' of 25 lbs relieving my low back pain. With these revelations I envisioned formally trained investigators having their field day elaborating on what I had observed. Being exposed to a vitally important revelation, they could do their dance on a rational base instead of from dysfunctional mythology. But that was not to be, at least not at the Congress -- perhaps as the result of this discourse.
I'll begin with my conclusion: The "modern" controversial story of traction is about a chronically abused, iatrogenically inflicted, ignorantly discredited, essential therapy whose mistreatment has caused countless grief. I have a lot to explain.
This issue is not an isolated story. Its origins pervade almost 150 years of the allopathy/osteopathy/chiropractic history that I've previously described and what https://www.drgoodley.com is dedicated to. When the schism shattered and scattered essential principles, the rational foundations of traction were commensurately lost as well so that it now essentially embodies the problem. Reconciling traction's concepts with the anatomy, neurology, and biomechanics of the neck will resolve this issue as a powerful seed.
The most common generally uncritically accepted traction device utilizes the Sayre sling that was never intended for cervical traction. Dr. Sayre was an orthopedic surgeon who at the turn of the 20th century attempted a novel treatment for thoracic scoliosis. He constructed a tall tripod outside his office (presumably -- I have the photos) and devised the sling, likely for 1 time, to hoist the patient to straighten the scoliosis. Then a plaster body jacket was applied. It didn't work, but the effort was reasonable, and the sling was there.
With the advent of the motor age, cervical injury exponentially increased. Traction use increased and the Sayre device insinuated itself into traditionalism obviously with no analysis of real requirements whatsoever. To me, incomprehensibly, osteopathy and chiropractic followed along.
The Sayre sling attaches to the head at the occiput and jaw. It is a head puller that delivers nonspecific force into the neck. The neck is not a spring. Its function is not unitary. However much, the allopathic mind has been indoctrinated to treat the neck that way, and essentially totally ignore the anatomy, the obvious is self-evident:
The cervical osteology comprises a series of interarticulating joints whose gross motion results from the exquisitely fine, dynamically modulated summation individual contributions mediated by myriads of proprioceptive reflexes in which normalcy is dependent on their coordinated interplay. The reflexes are sensitive and easily disordered by injury. The critical importance of this fundamental cannot be overemphasized and will always be the basis for successful therapies.
Under usual circumstances, I believe that the orthopedic aspects of the neck are primarily (not exclusively) neurological in essence, and the common injuries primarily damage and disorder the delicate sensors that provide proprioceptive input. Loss of fine control means loss of gross control in which the dynamically deteriorative cascade registers as pain, weakness, limitation of motion...
I came to that conclusion beginning with my low back traction experience and from a number of cases that dramatically illustrate this view (three of which I briefly described in my Congress abstract).
The first concerned a patient who I had previously treated who virtually instantly sustained an explosive herniation of a cervical disc while doing nothing unusual. Within minutes Gloria was in excruciating pain and losing strength in her left arm. At the time, I was on staff at Memorial Hospital of Glendale, adjacent to Los Angeles. It was a Sunday, and there was a short delay in reaching me. The hospital and I had an excellent trust relation. They admitted her and called in the neurosurgeon I referred to who scheduled her for surgery a few hours later.
The Sayre-type sling traction had been procedurally applied with more than 10 lbs hanging weight. She experienced no pain relief. Morphine was administered. When they notified me of her admission, they apologized that Gloria had almost died of asphyxiation. The pressure from chin strap on the base of her tongue prevented swallowing. Obtunded by the narcotic, she had almost drowned in her own saliva.
Only a week before, for the x hundredth time I applied manual traction to the neck of an injured young Chicano (of Mexican extraction). I had given up on Sayre sling traction years before and resorted to an old trick. I would make a sling from a Turkish towel, place it under the patient's neck and teach a "significant other" how to apply the necessary gentle force. And long before, I'd learned that the universal constant was the predictable failure of compliance because the "other" was never available when the spasm and pain promptly required traction. But I had continued to implore, and I told him he needed to bring someone in the next day.
His mother may have been 45 years old. She looked 65 and probably had x kids at home and the worries of the world on her back. As I spoke in the Spanish I know imploring, imploring her to reliably help her son as she looked away blankly, I was suddenly dizzy and literally fell back against the wall muttering "It can't be that simple. It can't be that simple." But it was.
As I looked at the young man, I saw the answer. Truly, it was so simple, the (original) traction harness encircled the entire dorsal neck like a second skin and closed over the forehead. Onto it, a strap with Velcro could be attached at any cervical level completely avoiding pressure on the floor of the mouth or impacting the TMJs! The traction became segment specific! Through a spreader bar in which I drilled extra holes so asymmetric force could provide rotation (another first) a cord went to a universally fixable pulley from which it could either go the patient's feet or with which hanging traction could be applied. With the former, the traction is self-powered, the patient literally built into the system.
The (mis)adventures of trying to get "Polyaxial" traction out will fill a book. It has been a river of sweat and tears. But it works beautifully -- simple (now simpler), safe and sound. I'd gone home, cut up a sheet, and it worked. I'd taken it to a tailor by my institute and had him make the first prototype. It was in my car. I got it, put it on Gloria, hung 3 lbs and she was instantly pain-free. I almost always have a camera with me. I captured the joy on her face. It's one of my favorite shots. She still needed the surgery, but the traction proved itself. (Release From Pain has much more of this story.)
The second was a patient of Peter Edgelow, a well-deserved famous physical therapist and dear friend who lives in Union City, near San Francisco. He had been treating a young woman with a slender princess neck for a few years. She'd been injured in an auto accident. She worked as a professional representative who had to travel much of the time, and every time she returned to driving she had to return to disability. Her area of pain covered her neck and flowed over his scapular areas. Peter asked if I might be able to help. Of course, I didn't know, but after examining her, I suggested prolonged low weight traction. Three days in hospital with near-constant 3-lb traction cured her -- and my concepts about how traction can work further crystallized.
The third case I was going to present was a woman who also sustained cervical injury in a vehicular accident. I think she had come about as close as one can before sustaining actual neurological damage. Immediately hospitalized, she was in severe pain in bed. I attached the traction and applied weights (obviously behind her, not telling her how much). I started with 2 lbs. Her pain instantly increased and she developed nausea, headache and vertigo. I removed 1 lb. One pound traction! Almost immediately her pain markedly improved. I confirmed once with the same result.
This finding was not unique. It was surprising reading in Orthopaedic Clinics of North America July 1992 (Volume 23 - Number 3) The Degenerative Neck. It reported a paper also quoted in the Review Article I mentioned in the beginning. Klaber-Moffett and colleagues found greater muscle relaxation in the group with 2-lb placebo (Italics mine) traction than in the group with 6- to 12-lb traction... These investigators commenced with the fixed conclusion that 2 lbs traction is placebo. It has to be! Don't you see? They missed the whole opportunity for major discovery, as a number of others quoted did. Instead of dispassionately listening to what their subjects were telling them and struggling to readjust their conceptual formulation, they could only conclude that placebo was operating.
The Sayre type traction got its big push when Tru Wilhelm started his business making over-the-door units in his garage. That was maybe 60 years ago.
One of the most tragic-comic experiences of my medical school years happened 1 evening at a fraternity meeting with alumni. I was a complete innocent. The subject of the traction came up. One doctor stood and said that over-the-door worked only when the patient faced away from the door; another promptly arose and declared that the patient had to face the door, and in an instant a third was on his feet insisting that it works only when the patient sits sideways to the turn. The argument got hot. From here, none of them knew what they were talking about, but in their desperation to seem professional in the treatment of neck injuries, and obviously being aware of the complication rate, they had to blurt something to try to mask the inflicted ignorance of the Fundamental Flaw.*** If you have been following my series, you may recall the moderator who opened a meeting on "Neck pain" by complaining "People with neck pain are a pain in the neck."
When I last reviewed Sayre type sling traction usage, it was the second most common cause of malpractice suits for TMJ damage. Thus cervical traction entered a time of neglectful lassitude, a "cheapy" item largely in inventory for accounting purposes or an attachment means for an expensive machine with no association to a patient's potential to almost immediately develop a sense of intuitive "tidal" application of traction with the feet.
I discuss the issues of traction further in Release From Pain.
Along with the Congress' rejection that could have encouraged serious discussion about sound, effective traction, even opening an avenue for research that is acceptable to those professionals, who thus far had shunned imagination so they avoid discovery, other memories of the difficulties to move the pillars returned. As when I hoped to stir serious thinking in a former contribution when I took issue with the official AAOS book, Musculoskeletal Medicine, these few vignettes may have good seeds in them. From our battle against self perpetuated, patient-harming rigidity, hopefully these few stories will personalize this sufficiently to ignite your attention.
Thirty-five years ago, I was visiting Rancho Los Amigos Hospital, in Downey, California, affiliated with the University of Southern California, where I was teaching in the Department of Emergency Medicine at the time. I don't know what its status is now but then it was a major rehabilitation center dominated by the orthopaedic surgeons. I was there to present a short paper on manipulation and attempt to solicit the department's cooperation for a study. Dr. Verne Nickel, the Chief, would have none of it. He had spent the better part of the morning glowing about the merits of the Symes amputation that they had reevaluated after it had been discarded about a century ago, which showed him to be so broad-minded and investigative. I asked him if he was so interested in reevaluation then why not manipulation. Instantly he flared, "Those who know the back cold say it doesn't work. SO IT DOESN'T! " I asked him who knew the back that cold. If looks could kill...
Dr. Jacqueline Perry was there. She sat down next to me and sympathetically explained that orthopods don't like the word 'manipulation.' "Paul, call it transverse sheer force or something else and we'll listen to you." I looked at her plaintively and responded, "Jackie, a hammer's a hammer," to which she riposted with a wink, "That's why we call ours a mallet." Touché. Cute story, but I'm truly trying to cut with this recollection.
Another time, I was displaying my exhibits on thermography and my cervical traction, both of which were excellent, at an orthopaedic surgical meeting in the room where the luncheon was held. It may have been my defense at being completely ignored, but it became an unexpected experience for me to observe them for the better part of an hour. Not one of them even glanced at me or the posters. These weren't all strangers. Some I knew well. The implications are interesting and consistent. These very human issues retard us from advancing.
And, during the session on hand pain at a national orthopaedic surgical meeting I had stood and briefly described the easiest, likely one of the most dramatically successful manipulations that virtually instantly cures an extraordinarily painful, essentially disabling condition: dysfunction of the triangular cartilage (ulno-menisco-triquetral joint), which can be learned in less than a minute. I offered to meet with any of the few hundred in the room to teach it to them. I haven't yet met the orthopaedic surgeon who knows it. So, how many came over to me during the break, obviously visible to their colleagues? Not one. So there is a continually compounding population that unnecessarily remains in pain. The chain of potential dissemination never germinated from any of those individuals. Can't we do something in our lifetimes about that?
Before closing, I have one more windmill to saunter at. Anyone who had read my work is aware of my association and critique of chiropractic for decades. During the past year I've truly had the privilege of being force-fed as a new experience concerning some of the issues.
I mentioned Dr. Moti Taler in a past issue. He finished medical school at the U. of Texas but didn't receive his diploma on the technicality of being an Israeli citizen, finished his PhD in Exercise Physiology at the same time, and then graduated from Los Angeles Chiropractic College. So I cannot view his remarkable abilities and deem them pure products of his chiropractic training. But I can't forget when this brilliant mind told me that learning chiropractic was a distinctly more difficult labor for him than medical school.
During this time I have carried on an intensive, initially aggressive correspondence with a DC from Georgia, Jim Smith. I read his novel and some of his prolific work. And, I have been accepted as the only MD to participate in a select chiropractic group that periodically erupts with emails. In other words, I am being exposed to some of the best that chiropractic can produce, and I increasingly see the reality that my dream about the development of orthopaedic medicine is so trapped in mire that it will be major triumph in medicine if only some of its principles achieve some degree of understanding in the general medical community.
From all this, I conclude that the association of ethical physicians and chiropractors offers the only possibility today for noticeably improving this vital area of medicine in the foreseeable future. (This does not diminish the potential for such happening in places where there are physical therapists of equivalent training.) In both cases, it's already happening, of course. It couldn't be otherwise.
But, particularly concerning chiropractic it is being resisted for reasons kin to why orthopaedic surgeons wouldn't look at a nonsurgeon's work or would feel resentful at having a nonsurgeon teach them something. This has obviously been a central theme in my professional life. From all this, I'm unambiguously articulating this now.
Paul H. Goodley, MD
*Decades ago, Dr. Sam Colachis saw my solution, a rational, simple, efficient, safe traction apparatus completely consistent with the neurophysiological, biomechanical needs of the neck. Years later, I learned that when Tru Wilhelm (Founder of TruEze Traction), who trusted him, became interested in it, he questioned him about it. Colachis never tried it but told him it doesn't work. The incidental events that twist history.
**The best definition of medicine that I ever heard was from one of my psychiatry professors at UCLA. "Medicine is concerned with all that is constant and grave in the affairs of humankind." (The original was "mankind.")
***Explained in previous articles and obviously on my Web site.
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Cite this: Goodley Intentions: Resurrecting Traction - Medscape - Feb 06, 2008.