Is Lumbar Traction Really Effective for Low Back Pain?

Lumbar traction is often used for the treatment of low back pain, disc herniations with nerve root compression and degenerative disc disease.  But while the mechanical effects of lumbar traction are well documented, its clinical effectiveness is still a subject of debate.

I see you coming.  Several studies have found no evidence that the addition of lumbar traction to an extension-oriented treatment is superior in the management of patients with lumbar nerve root compression.  Other studies that have investigated the effect of traction on lumbar disc herniations showed no change in location or size of the herniation.  Does that mean we should never use it?  Hardly.

Many of the conflicting results when comparing studies are due to the fact that the type of traction, the treatment technique and the other aspects of the treatment (exercise interventions, other modalities, etc.) make it difficult to compare results and make definitive conclusions about the clinical effectiveness of traction.

Despite these conflicting results, lumbar traction remains a common intervention in treating clients with low back pain.  If you’re starting to know me, you know that I believe there is place and time for most things (except maybe for bands between the knees during squats, LOL!).  It’s not just about studies and results.

As a general rule, whenever we use a tool or intervention, we should always have a specific task in mind that will benefit from that intervention.  The capacity for lumbar traction to provide an immediate effect on pain opens up a huge window of opportunity to get people moving.  That is the task.

TRACTION FOR LOW BACK PAIN

Of course, I always start with this: When dealing with a client with low back pain, if in doubt, refer out.  Don’t assume, don’t diagnose, and make sure you surround yourself with a network of health care providers that you can work in collaboration with.

That said, who hasn’t dealt with a client who has low back pain?  It is one of the leading causes of activity limitation and workplace disability, in fact, four out of five adults will experience at least one episode of back pain at some time in their lives.

As much as 85-90% of patients present clinically with non-specific LBP, meaning there is no pathoanatomical cause for the pain.  This means that there is a possibility to mediate and change pain via movement, which represents an important opportunity to help get your clients out of pain and optimize movement to avoid the recurrence of pain.

Traction refers to pulling on one articulating segment to produce separation of two joint surfaces.  When we apply traction to the lumbar spine, we reduce the compressive force on the vertebral articulating surfaces.

Intermittent traction consists of alternately applying and releasing traction.  Typically, shorter hold-rest periods are used to treat joint hypomobility, but the small-amplitude oscillations created by intermittent traction can also stimulate mechanoreceptors within the joints that can limit the transmission of pain perception.  Intermittent traction can also reduce muscle spasm, which in turn will have an effect on pain.

THE PAIN EXPERIENCE

You will often hear me say that there is much more to rehab than manual therapy.  If you haven’t, read my article on the blog on that exact topic.

That said, there is a valid reason why manual therapy is an integral part of an effective rehabilitation plan.  Why do you believe manual therapy has become so popular?  Because it makes people feel better.  It is effective in managing musculoskeletal pain.

The neurophysiological effects of manual therapy include decreased pain sensitivity, increased serotonin (mood regulator) and b-endorphin (pain management) release and decreased resting activity of muscles.  These all provide an immediate effect in managing pain.

However, pain has several dimensions, namely a sensory-discriminative dimension, the affective-motivational dimension and the cognitive-evaluative dimension.  I will briefly describe each below, but urge you to refer to the Melzack R, Casey KL. (1968) article for a very interesting read on pain.

Sensory-discriminative dimension: identifies the location on or within the body and the characteristics (mechanical, chemical and heat, among others) of the pain, and prompts the response to prevent or limit tissue damage.

Affective-motivational dimension: is associated with the emotions related to pain and engages behaviors related to recovering from pain.

Cognitive-evaluative dimension: considers the consequences and meanings of pain such as pain apprehension, anticipation of pain, catastrophizing, etc.

The reason I always say that there is more to rehab than manual therapy is that manual therapy only treats one aspect of the pain experience, but it does not address how pain has changed movement behavior. Essentially, people FEEL better, but they don’t GET better.

The capacity for manual therapy to provide an immediate effect on pain opens up a huge window of opportunity to get people moving within that window, yet that is what is lacking in most rehab interventions.

Remember what I said earlier, whenever we use a tool or intervention, we should always have a specific task in mind that will benefit from that intervention.  This is true for pain as well.  If we use an intervention that decreases pain, we need to use that opportunity to include a task that can benefit from that decrease in pain.  That task is movement.  Restoring pain-free movement allows us to tap into the affective-motivational and cognitive-evaluative dimensions of pain.

THE WHY AND THE WHEN

The objective of the Movement Optimization strategy is to provide structure to the rehab process so that we can get the most benefit out of the intervention.  Low back pain tends to dictate how the client will move and also has an effect on a person’s willingness to move, even if this pain is subjectively evaluated as a 3 to 5 out of 10.  A lot of clients will say they have ongoing discomfort but claim it doesn’t prevent them from doing anything, yet you will notice they move in a purposeful, somewhat guarded way.  If you hope to make their movement more optimal, a good place to start is to get pain and discomfort out of the way first.

Lumbar auto-traction, because it can have an effect on pain and can address pain as a barrier to movement, can find its way in the Mobilization sequence, where the objective is to create space or better space to move within.  Watch the video above for two auto-traction exercises that you can program for your clients.

What’s most important is that we use lumbar traction in the Mobilization sequence to modulate pain, so that we can then get people moving and create awareness and behavior in the Activation and Integration sequences that follow.  This way, we address and correct movement-related consequences of pain.

Here is an example of what a Mobilization-Activation-Integration sequence might look like for someone with low back pain or discomfort:

Mobilization: The objective is to decrease pain using auto-traction and mobilize the lumbar spine which tends to become stiff in case of LBP.

1. Intermittent auto-traction for 3 mins using 5s on 5 s off cycle
2. Cat-cow or low cat-cow exercise 2 sets of 1 min

Activation: The objective is to down-regulate the excessive bracing that comes with LBP and stabilize the lumbar spine now that we have created better mobility.

1. Lower extremity rolling pattern (supine to prone) 2 sets of 5 reps/side
2. Deadbug with overhead activation 2 sets of 5 reps/side

Integration: The objective is to decrease apprehension for specific movements, for example, the hip hinge.

1. Kneeling hip hinge 2 sets of 8 reps with a slow eccentric

IT’S ALL ABOUT THE STRATEGY

Despite conflicting results on the efficacy of traction for the treatment of low back conditions, we can certainly make use of the effect it has on a client’s pain experience to optimize our movement strategy. If we use an intervention that decreases pain and use that response as an opportunity to restore pain-free movement, we can get people out of pain and moving better.

Traction (or auto-traction) can help decrease pain by reducing the compressive force on the vertebral articulating surfaces and intermittent traction can stimulate mechanoreceptors within the joints that can limit the transmission of pain perception and reduce muscle spasm.  Including traction in a Mobilization sequence can thus help set the stage to create awareness and behavior in the Activation and Integration sequences.

Changing the pain experience with the application of traction can allow you to remove aversive behavior and movement apprehension to get clients out of pain and avoid the recurrence of pain.

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References:

Melzack R, Casey KL. Sensory, motivational and central control determinants of chronic pain: a new conceptual model. In: The Skin Senses. Kenshalo DR (Ed.). Thomas, IL, USA, 423–443 (1968).

Bishop, M., Torres-Cueco, R., Gay, C., Lluch-Girbés, E., Beneciuk, J., & Bialosky, J. (2015). What effect can manual therapy have on a patient’s pain experience?. Pain Management, 5(6), 455-464. doi: 10.2217/pmt.15.39

Pellecchia, G. (1994). Lumbar Traction: A Review of the Literature. Journal Of Orthopaedic & Sports Physical Therapy, 20(5), 262-267. doi: 10.2519/jospt.1994.20.5.262

Gillström P, Ericson K, Hindmarsh T. Autotraction in lumbar disc herniation. Archives of orthopaedic and traumatic surgery. 1985 Nov 1;104(4):207-10.

Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U