Flexion and cervical distraction is a non-invasive procedure used to provide symptomatic relief for a variety of spinal pathologies. The practice of spinal traction goes back to the fourth century BC, where Hippocrates first described it as a treatment for kyphosis. It was subsequently implemented in other spinal pathologies including cervical pain and myelopathy. In the 1600s, the Germans employed cervical traction in their medical practice, as an adjunct to open reduction of cervical dislocations, and fractures. In 1929, the Halter device was introduced for the reduction of cervical injuries; then several other devices followed to ensure more efficient traction. The theory behind its efficiency emphasizes the widening of the intervertebral foramen upon traction, with separation of the facet joint. This will relieve the sustained pressure on the nerve roots, and hence alleviate symptoms of radiculopathy. Other theories suggest that traction also allows for muscle relaxation.

Flexion and cervical distraction can be defined as an unassisted multilevel traction force applied to the spine with the following capabilities:

1. Distraction of the vertebral bodies with enlargement of the intervertebral space producing a suction effect.
2. Stretching of muscles with the tautening of the posterior longitudinal ligament exerting a centripetal force on the adjacent annulus fibrosis.
3. Separation of the apophyseal joints.
4. Enlargement of the intervertebral foramina.

It can be used for the following indications:

1. Herniated discs.
2. Mobilisation and stretching of soft tissue; muscle spasms especially in the trapezius, suboccipital and quadratus lumborum regions.
3. Opening of the neural foramina (IVF) i.e. osteophytes, such as in IV nerve root encroachment.
4. Headaches
5. Increase spine mobility i.e. hypomobility.
6. Degenerative disc disease or degenerative joint disease i.e. OA.
7. Facet joint impingement i.e. OA
8. Neck pain (with neural signs, i.e. radiation and pins and needles into the arm).
9. Capsulitis of the vertebral joints.

The force needed to separate the IV space depends on the joints C0/C1, C1/C2 need 4.5kg while the lower spine needs 10-18kg of force. Post treatment muscle soreness is common.

The suggested treatment follows the rule of 3. The patient must receive traction on 3 consecutive days. On the first day of traction the patient may experience an increase in pain. On the second and the third treatment the patient should have accommodated however the patient must understand that some reaction is still expected. Treatment then continues 3 times weekly until the desired effect is achieved. For chronic conditions ongoing traction may be needed to manage symptoms.

Physiological effects:

• Decreased spine neuromuscular activity.
• Decreased muscle spasm.
• Decreased pain.
• Increase in blood flow.
• Decrease in disc lesions (widening of the IVF, widening of the disc space, traction of the prevertebral muscles and ligaments, correction of joint deformities, increase in disc tissue volume) and myofascial adhesions.

When treating disc herniations the time of traction should be short. Intradiscal pressure drops under traction and this needs to be maintained only for a short period as osmotic forces will soon equalise the pressure. Therefore treatment time is kept under 10 minutes.

In facet problems distraction may be used initially before adjustments in conditions such as degenerative disc disease, facet hyperextension subluxation with telescoping of the superior facet of the inferior vertebra into the IVF, lateral stenosis, spondylolisthesis, transitional segment and retrolisthesis subluxations.

Beneficial effects:

1. Suction: a sub atmospheric pressure is induced when the bones move· apart, with a centripetal force on the contents.
2. Distraction: the increase in distance between the articular edges may disengage a protrusion that was too large to shift during mere avoidance of compression during recumbency.
3. Ligamentous tautening: separation of the vertebrae tautens the posterior longitudinal ligament, which then exerts centripetal force on a central protrusion.