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Lumbar Traction

Original Editors - Sarah Neubourg

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Introduction

Lumbar traction is a treatment technique that applies stretching forces to the lower spine using various methods like body weight, weights, or pulleys. The goal is to separate individual joints of the lumbar spine[1]. This technique has been used since ancient times for pain relief. James Cyriax popularized it in the mid-20th century as a treatment for disc problems. It remains commonly used for back and leg pain today.

  • Cyriax proposed that lumbar traction could increase space between vertebrae, tense ligaments to exert force on joints, and help reposition disc protrusions. Other suggested effects include widening nerve openings and separating spinal joints.
  • However, recent clinical trials have questioned its effectiveness. Current guidelines from health authorities in several countries no longer recommend traction for treating low back pain..[2][3][4][5][6][7] [8][9][10]

Clinically Relevant Anatomy

The lumbar spine consists of five vertebrae (L1-L5) that form the lower back's concave curve. Located between the thoracic spine and the sacrum, these vertebrae support the upper body's weight, provide trunk flexibility, and protect the spinal cord and nerves.

Intervertebral disks connect adjacent vertebrae. These disks have a tough outer layer (annulus fibrosus) for strength and flexibility, and a jelly-like center (nucleus pulposus) for shock absorption.

Lumbar vertebrae are among the largest in the spine. Each has a cylindrical vertebral body that bears most of the body's weight. The vertebral arch, connected to the body, surrounds the vertebral foramen, which houses the spinal cord and related structures.

Several bony processes extend from the vertebral arch, serving as attachment points for muscles. These include the spinous process at the back and the transverse processes on the sides.

The fifth lumbar vertebra (L5) is distinct, with a larger front than back and a smaller, differently shaped spinous process. Unlike cervical vertebrae, lumbar vertebrae lack transverse foramina and lateral body facets.[11]

Types of Lumbar Traction

Several types of lumbar traction are described in literature but the most used include:

  1. Continuous Traction - Continuous or bed traction uses low weights for extended periods of time (up to several hours at a time). This long duration requires that only small amounts of weight be used. It is generally believed that this type of traction is ineffective in actually separating the spinal structures. In other words, the patient cannot tolerate weights great enough to cause separation of the vertebrae for that length of time.
  2. Sustained Traction - This type of traction involves heavier weights applied steadily for short periods of time (for periods from a few minutes up to 1 hr). Sustained traction is sometimes referred to as static traction.
  3. Intermittent Mechanical Traction - Intermittent traction is similar to sustained traction in intensity and duration but utilises a mechanical unit to alternately apply and release the traction force at preset intervals
  4. Manual Traction - Manual traction is applied as the clinician's hands and/or a belt are used to pull on the patient's legs. It is usually applied for a few seconds duration or can be applied as a sudden, quick thrust. In conclusion, manual traction is recommended as an effective approach for alleviating lumbosacral spine pain in patients experiencing symptoms resulting from irritation or compression of a spinal nerve root.[12]
  5. Autotraction - Autotraction utilises a specially designed table that is divided into two sections that can be individually tilted and rotated. The patient provides the traction force by pulling with the arms and/or pushing with the feet. Investigations of autotraction have reported favourable clinical results but no change in size or location of lumbar disc herniation
  6. Positional Traction - This form of traction is applied by placing the patient in various positions using pillows, blocks, or sandbags to effect a longitudinal pull on the spinal structures. It usually incorporates lateral bending and is only affected to one side of the spinal segment
  7. Gravity lumbar traction - This involves using a chest harness to secure the patient as the treatment table is tilted to a vertical position, thereby using the weight of the lower half of the body to provide a traction force.

Mechanism of Action

Several theories attempt to explain the potential clinical benefits of lumbar traction therapy:

  1. Distraction of the motion segment may alter the position of the nucleus pulposus relative to the posterior annulus fibrosus or change the disc-nerve interface.
  2. Traction has been shown to separate vertebrae, reduce nucleus pulposus pressure, and increase foraminal area.
  3. The effects of traction on the mechanobiology of the motion segment or neural tissues may lead to lasting clinical responses.
  4. Different forms of traction may have varying effects on disc and joint repair or degradation, depending on the amount, frequency, and duration of loading.
  5. The impact of traction may differ based on the patient's clinical presentation (e.g., back-dominant vs. leg-dominant low back pain).

However, it's important to note that mechanical changes observed during traction in a prone position may not persist when the patient resumes an upright, weight-bearing posture. Additionally, systematic reviews have typically not considered the potential for different effects based on force and time parameters. While these theories are plausible, there is currently insufficient evidence to fully support them.[13][2][14].[15][16].[17].[18] [19] . [20]

Distraction-manipulation and positional distraction differ from traditional lumbar traction methods in the following ways:

  1. They concentrate forces in a smaller area rather than dispersing them throughout the lumbar tissues.
  2. Autotraction (AT) allows patients to find the position that most relieves their pain and apply distraction there.
  3. Distraction-manipulation techniques are often used by physical therapists.
  4. These techniques use specialized treatment tables that allow the practitioner to control the direction and timing of the distractive force.
  5. Examples of distraction-manipulation techniques include the FD (Cox technique), Leander technique, and Saunders Active Trac method.

These approaches aim to provide more targeted and controlled traction compared to traditional methods like intermittent or sustained traction..[20]

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Evidence 

Summary evidence in recent systematic reviews and clinical practice guidelines concludes that mechanical lumbar traction is not effective for treating acute or chronic nonspecific low back pain (LBP); however, many physical therapists continue to use it, primarily as an additional modality.[21] Indeed, expert clinical opinion, theoretical models, and some research evidence suggest that certain patients with LBP respond positively to traction. A study published by Thackeray et al. (2016) concluded that there is no evidence that mechanical lumbar traction in combination with an extension-oriented treatment is superior to extension-oriented exercises alone in the management of patients with lumbar nerve root compression.[22]

Traction Effects

This summary covers the effects of lumbar traction on three conditions:

Lumbar Disc Herniation:

  • Many cases improve within 6 weeks with conservative therapy.
  • Autotraction doesn't change herniation size but improves clinical symptoms.
  • Some studies show traction combined with other therapies can reduce pain and improve function.
  • However, one study found no benefit for acute herniated disc syndrome.

Low Back Pain:

  • Traction, alone or combined with other treatments, has little to no impact on pain, function, or return to work.
  • No significant difference observed between traction and sham traction.
  • Adding intermittent mechanical traction to standard therapy shows no extra benefit.
  • Some research suggests certain patient characteristics may predict better response to traction.

Lumbago-Sciatica:

  • Lumbar autotraction appears more effective than using a corset and rest.
  • It provides immediate pain relief and normalizes the straight leg raise test.
  • However, traction and exercise therapy were found to be significantly less effective than surgery for this condition.

Overall, the evidence for lumbar traction's effectiveness is mixed, with some studies showing benefits and others showing no significant improvement over other treatments or placebo.[23][24][25][26][27][28][29][30][31][32][33][34].[35]. [36]

How much Percent of body weight must be used?

When determining the appropriate weight for lumbar traction, two factors must be considered:

  1. Overcoming friction between the patient's body and the treatment surface
  2. Exerting sufficient force on the lumbar spine

Research by Judovich showed that a traction force of 26% of the patient's body weight is necessary to overcome friction. Using a split tabletop with friction-free rollers can reduce this requirement to a negligible amount. Without such equipment, a force exceeding 26% of body weight must be applied to affect the lumbar spine.

Optimal traction weights have been investigated based on the assumption that intervertebral widening or reduction of disk protrusion produces the desired effect. However, only intervertebral widening has been experimentally demonstrated.

Despite numerous studies, it remains unclear what magnitude of force is required to cause the desired effect in the intact human spine. The mechanism by which lumbar traction may have its effects is not fully understood, and the neuromodulation of pain, which may require very low weight, must also be considered as a possible effect.

Clinical experts recommend using motorized traction on a friction-free surface and advocate a wide range of traction weights:

  • Maitland: 10 to 65kg (average 30 to 45kg)
  • Cyriax: 40 to 85kg
  • Grieve: 13 to 34kg
  • Hicklings: 32 to 68kg

. [37]

Of all kinds motorized traction is the most interesting, because it is the only type of traction that can be adequately standardized and is commonly used in clinical practice. It is also the only form of traction that can be adequately standardized in respect to weight applied. [37]

Placebo comparison

From a systematic review[37] six studies compared traction with sham traction (table 6). Sham traction is a low-weight or placebo traction that the given researcher considers to be ineffective. Three studies used motorized traction (2 on a split tabletop, 1 on a plain tabletop)), 1 used autotraction, 1 used gravitational traction, and 1 used traction as part of bedrest. Only the study by Beurskens et al was of a high quality, and all gave negative results except for the inconclusive result of Moret et al.[37]

Outcome Measures

  • The McGill Pain Questionnaire (MPQ) is a self-reporting measure of pain used for patients with a number of diagnosis. It is composed of 78 words, of which respondents choose those that best describe their experience of pain. [38] 
  • The Roland-Morris Disability Questionnaire (RMDQ) is designed to assess self-rated physical disability caused by low back pain.[39]
  • Oswestry Low Back Pain Disability Questionnaire is to assess pain-related disability in persons with low back pain (LBP). It consists of 10 questionnaires about how pain affects daily activities, scored from 0 to 5 for each section, with higher values indicating more severe impact; and a 12-item short-form health survey (SF-12) that consists of 12 questions concerning general health and can be divided into two aggregate summary measures: the physical component summary (PCS) and the mental component summary (MCS). [40]
  • VAS-pain: intensity of pain. which is a horizontal scale graded from zero, representing no pain, to 100mm, re- presenting the worst imaginable pain.VAS-Lu: intensity of pain for lumbar pain. VAS-Le: intensity of pain for leg pain. [40]
  • Numerical pain rating scale (NPRS): on a box scale from 0–10 describing ‘usual level of pain in the last week’.[41]

References

  1. ↑ Saunders HD. Lumbar traction*. J Orthop Sports Phys Ther. 1979; 1(1): 36-45. (LEVEL 1A)
  2. ↑ 2.0 2.1 Pellecchia GL. Lumbar traction: a review of the literature. Journal of Orthopaedic & Sports Physical Therapy. 1994 Nov;20(5):262-7. (LEVEL 1A)
  3. ↑ Lee RY, Evans JH. Loads in the lumbar spine during traction therapy. Australian journal of physiotherapy. 2001 Jan 1;47(2):102-8. (LEVEL 3B)
  4. ↑ Wegner I, Widyahening IS, van Tulder MW, Blomberg SE, de Vet HC, Brønfort G, Bouter LM, van der Heijden GJ. Traction for low-back pain with or without sciatica. . Cochrane Database Systemic Reviews, 2013; 8:CD003010. doi: 10.1002/14651858.CD003010.
  5. ↑ Clarke JA, van Tulder MW, Blomberg SE, de Vet HC, van der Heijden GJ, Bronfort G, Bouter LM.Traction for low-back pain with or without sciatica. Cochrane Database Systemic Reviews, 2007; 2:CD003010.
  6. ↑ Schimmel JJ, de Kleuver M, Horsting PP, Spruit M, Jacobs WC, van Limbeek J. No effect of traction in patients with low back pain: a single centre, single blind, randomized controlled trial of Intervertebral Differential Dynamics Therapy. European Spine Journal, 2009; 18(12):1843-50. doi: 10.1007/s00586-009-1044-3. 
  7. ↑ Harte AA, Baxter GD, Gracey JH. The effectiveness of motorised lumbar traction in the management of LBP with lumbo sacral nerve root involvement: a feasibility study. BMC Musculoskeletal Disorders, 2007; 8: 118.  doi:  10.1186/1471-2474-8-118
  8. ↑ National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. NICE guideline [NG59]. London: NICE, 2016. https://www.nice.org.uk/guidance/ng59
  9. ↑ Van Wambeke P, Desomer A, Ailliet L, et al. Summary:Low back pain and radicular pain: assessment and management. KCE report 287Cs. Brussels: Belgian Health Care Knowledge Centre (KCE), 2017. https://kce.fgov.be/sites/default/files/atoms/files/KCE_287C_Low_back_pain_Summary.pdf
  10. ↑ Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2017; 166: 514-530.
  11. ↑ Tim Taylor. Lumbar Vertebrae. n.d. Available from http://www.innerbody.com/anatomy/skeletal/lumbar-vertebrae-lateral (accessed 28 August 2018)
  12. ↑ Studnicki R, Szymczyk P, Adamczewski T, Studzińska K, Hansdorfer-Korzon R, Silva AF, Kawczyński A. https://www.sciencedirect.com/science/article/pii/S2405844024070440. Heliyon. 2024 May 30;10(10).Available:https://www.sciencedirect.com/science/article/pii/S2405844024070440 (accessed 2.4.2025)
  13. ↑ Cox JM, Feller J, Cox-Cid J. Distraction chiropractic adjusting: clinical application and outcomes of 1,000 cases. Topics Clin Chiropractic 1996;3:45–59. (level of evidence 3a)
  14. ↑ Knutsson E, Skoglund CR, Natchev E. Changes in voluntary muscle strength, somatosensory transmission and skin temperature R.E. Gay and J.S. Brault / The Spine Journal 8 (2008) 234–242 241
  15. ↑ Ramos G, Martin W. Effects of vertebral axial decompression on intradiscal pressure. J Neurosurg 1994;81:350–3. (level of evidence 2b)
  16. ↑ Gudavalli MR, Cox JM, Baker JA, Cramer G, Patwardhan AG. Intervertebral disc pressure changes during a chiropractic procedure. Adv Bioeng 1997;36:215–6. (level of evidence 3a)
  17. ↑ MacLean JJ, Lee CR, Alini M, Iatridis JC. The effects of short-term load duration on anabolic and catabolic gene expression in the rat tail intervertebral disc. J Orthop Res 2005;23:1120–7. (level of evidence 2b)
  18. ↑ Kroeber M, Unglaub F, Guehring T, et al. Effects of controlled dynamic disc distraction on degenerated intervertebral discs: an in vivo study on the rabbit lumbar spine model. Spine 2005;30:181–7. (level of evidence 2a)
  19. ↑ Iatridis JC, MacLean JJ, Ryan DA. Mechanical damage to the intervertebral disc annulus fibrosus subjected to tensile loading. J Biomech 2005;38:557–65. (level of evidence 1b)
  20. ↑ 20.0 20.1 Ralph E. Gay, et al. Evidence-informed management of chronic low back pain with traction therapy. The Spine Journal 8 (2008) 234–242 (level of evidence 1a)
  21. ↑ Madson TJ, Hollman JH. Lumbar traction for managing low back pain: a survey of physical therapists in the United States. J Orthop Sports Phys Ther. 2015;45:586-595. http://dx.doi.org/10.2519/jospt.2015.6036 (level of evidence 3b)
  22. ↑ Thackeray A, Fritz JM, Childs JD, Brennan GP. The effectiveness of mechanical traction among subgroups of patients with low back pain and leg pain: a randomized trial. J Orthop Sports Phys Ther. 2016;46:144-154. http://dx.doi.org/10.2519/jospt.2016.6238 (level of evidence 1a)
  23. ↑ Tesio L et al. Autotraction versus passive traction: an open controlled study in lumbar disc herniation. Arch Phys Med Rehabil. 1993 Aug; 74(8): 871-876. (LEVEL 1B)
  24. ↑ Deyo RA, Mirza SK. Clinical practice – Herniated Lumbar Intervertebral Disk. N Engl J Med. (2016 May 5). http://www.nejm.org/doi/10.1056/NEJMcp1512658 (Level of evidence: 5 )
  25. ↑ Gillström P, Ericson K, Hindmarsh T. Autotraction in lumbar disc herniation. Archives of orthopaedic and traumatic surgery. 1985 Nov 1;104(4):207-10. (LEVEL 1B)
  26. ↑ Ljunggren AE et al. Autotraction versus manual traction in patients with prolopsed lumbar intervertebral discs. Scand J Rehabil Med. 1984; 16(3): 177-124. (LEVEL 1B)
  27. ↑ Gagne AR et al. Lumbar extension exercises in conjunction with mechanical traction for the management of a patient with a lumbar herniated disc. Physiother Theory Pract. 2010 May; 26(4): 256-266. (LEVEL 3B)
  28. ↑ Ozturk et al. Effect of continuous lumbar traction on the size of herniated disc material in lumbar disc herniation. Rheumatol Int. 2006 May; 26(7): 622-626. (LEVEL 1B)
  29. ↑ Rattanatharn R et al. Effectiveness of lumbar traction with routine conservative treatment in acute herniated disc syndrome. J Med Assoc Thai. 2004 Sep; 87 (2): 272-277. (LEVEL 1B)
  30. ↑ Wegner I, Widyahening IS, van Tulder MW et.al. Traction for low-back pain with or without sciatica. Cochrane Database systematic review. (2013 aug 19). https://www.ncbi.nlm.nih.gov/pubmed/23959683 (Level of evidence: 1a)
  31. ↑ Beurskens AJ et al. Efficacy of traction for nonspecific low back pain, 12-week and 6-month result of a randomized clinical trial. Spine. 1997 Dec1; 22(23): 2756-2762. (LEVEL 1B)
  32. ↑ Schimmel JP et al. No effect of traction in patients with low back pain: a single centre, single blind, randomized controlled trial of Intervertebral Differential Dynamics Therapy. Eur Spine J. 2009 (18): 1843-1850. (LEVEL 1B)
  33. ↑ Borman P et al. The effect of lumbar traction in the management of patients with low back pain. Rheumatol Int. 2003; 23(2): 82-86. (LEVEL 1B)
  34. ↑ Cai C et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with mechanical lumbar traction. Eur Spine J. 2009; 18(4): 554-561. (LEVEL 1B)
  35. ↑ Larsson U et al. Auto-traction for the treatment of lumbago-sciatica, a multicentre controlled investigation. Acta orthop Scand. 1980; 51; 791-798. (LEVEL 1B)
  36. ↑ Ruth A. Lewis et. al, Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. The Spine Journal. Volume 16. (2015 June 1). http://www.sciencedirect.com/science/article/pii/S1529943013014976 (Level of evidence: 1a)
  37. ↑ 37.0 37.1 37.2 37.3 Harte, A., et al.,The efficacy of traction for back pain: a systematic review of randomized controlled trials, Arch Phys Med Rehabil, Volume 84, Issue 10, Pages 1542–1553 October 2003 (Level of evidence: 1A)
  38. ↑ http://www.physio-pedia.com/McGill_Pain_Questionnaire (level of evidence: 2A)
  39. ↑ http://www.physio-pedia.com/Roland%E2%80%90Morris_Disability_Questionnaire (level of evidence: 2A)
  40. ↑ 40.0 40.1 Konstantinovic, L.M., et al., Acute Low Back Pain with Radiculopathy: A Double-Blind, Randomized, Placebo-Controlled Study, Photomedicine and Laser Surgery Volume 28, Number 4, 2010 (level of evidence: 1B)
  41. ↑ Glazov, G., et al., Low-dose laser acupuncture for non-specific chronic low back pain: a double-blind randomised controlled trial, Acupunct Med, 2014;32:116–123 (Level of evidence: 1B)


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