Traction for low-back pain with or without sciatica (Review)

Clarke JA, van Tulder MW, Blomberg SEI, de Vet HCW, van der Heijden GJMG, Bronfort G

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2005, Issue 4
http://www.thecochranelibrary.com

Traction for low-back pain with or without sciatica (Review)

Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Traction for low-back pain with or without sciatica (Review) i

Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Traction for low-back pain with or without sciatica

JA Clarke, van MW Tulder, SEI Blomberg, de HCW Vet, van der GJMG Heijden, G Bronfort

Contact address: Judy Clarke, Research Associate, Institute for Work & Health, 481 University Avenue, Suite 800, Toronto, Ontario,
CANADA. jclarke@iwh.on.ca.

Editorial group: Cochrane Back Group.

Publication status and date: Unchanged, published in Issue 1, 2007.

Citation: Clarke JA, van Tulder MW, Blomberg SEI, de Vet HCW, van der Heijden GJMG, Bronfort G. Traction for
low-back pain with or without sciatica. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003010. DOI:
10.1002/14651858.CD003010.pub3.

Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT
Background
Various types of traction are used in the treatment of low-back pain (LBP), often in conjunction with other treatments.
Objectives
To determine the effectiveness of traction in the management of LBP.
Search strategy
We searched The Cochrane Library 2004, Issue 4, MEDLINE, EMBASE, and CINAHL to November 2004, references in relevant
reviews, and our personal files.
Selection criteria
Randomized controlled trials (RCTs) examining any type of traction for the treatment of acute (less than four weeks duration), sub-
acute (four to 12 weeks) or chronic (more than 12 weeks) non-specific LBP with or without sciatica.
Data collection and analysis
Study selection, methodological quality assessment and data extraction were done independently by sets of two reviewers. As available
studies did not provide sufficient data for statistical pooling, a qualitative analysis was performed.
Main results
Twenty-four RCTs, involving 2177 patients (1016 receiving traction) were included in the review. Five trials were considered high
quality.
There is strong evidence that there is no significant difference in short or long-term outcomes between either continuous or intermittent
traction and placebo, sham, or other treatments for patients with a mixed duration of LBP, with or without sciatica.
There is moderate evidence that:
autotraction is more effective
other forms of traction are no more effective

than placebo, sham or no treatment for patients with a mixed duration of LBP with sciatica.
There is limited evidence that:
Traction for low-back pain with or without sciatica (Review) 1
Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 there is no significant difference in outcomes between a standard physical therapy program with continuous traction and the
same program without traction, for patients with a mixed duration of LBP, with or without sciatica

autotraction on its own is more effective than a physical therapy program that includes Tru-Trac traction

for patients with a mixed duration of LBP with sciatica.

There is conflicting evidence regarding the short-term effectiveness of either continuous or intermittent traction compared to placebo,
sham or other treatments, in the management of patients who have either chronic LBP or a mixed duration of LBP with sciatica.

Authors conclusions

The evidence suggests that traction is probably not effective.

Neither continuous nor intermittent traction by itself was more effective in improving pain, disability or work absence than placebo,
sham or other treatments for patients with a mixed duration of LBP, with or without sciatica. Although trials studying patients with
sciatica had methodological limitations and inconsistent results, there was moderate evidence that autotraction was more effective than
mechanical traction for global improvement in this population.

PLAIN LANGUAGE SUMMARY

The evidence suggests that traction is probably not effective.

For patients with a mixed duration of low-back pain (LBP), with or without sciatica, continuous or intermittent traction by itself was
no more effective than placebo, sham or other treatments in improving pain, function or work absenteeism.

In studies that examined only patients with sciatica, the evidence was inconsistent as to whether continuous or intermittent traction was
more effective than placebo, sham or other treatments for improving pain and function. There was moderate evidence that autotraction
was more effective than mechanical traction for global improvement in the same population.

This review included 24 RCTs, and 2177 patients with a mix of acute, sub-acute or chronic LBP, with or without sciatica. Traction
was compared to placebo, sham, no treatment, or other treatments. Different types of traction were examined by themselves or as part
of a multi-treatment program.

BACKGROUND
Low-back pain (LBP) is a major health problem among popula-
tions in western industrialized countries, and a major cause of med-
ical expenses, absenteeism and disablement (van Tulder 1995). Al-
though LBP is usually a self-limiting and benign condition which
tends to improve spontaneously over time, a large variety of ther-
apeutic interventions is available for treatment of the condition
(van Tulder 1997b). Sciatica can result when the nerve roots in
the lower spine are irritated or compressed. Most often, sciatica
is caused when the L5 or S1 nerve root in the lower spine is ir-
ritated by a herniated disc. Degenerative disc disease may irritate
the nerve root and cause sciatica, as can mechanical compression
of the sciatic nerve, such as from spondylolisthesis, spinal stenosis,
or arthritis in the spine. For the purposes of this review, we define
Traction for low-back pain with or without sciatica (Review)
Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
sciatica as pain radiating down the leg(s) along the distribution of
the sciatic nerve (which is usually related to mechanical pressure
and/or inflammation of lumbosacral nerve roots) (Bigos 1994).
One treatment for LBP and sciatica is traction, which is used rela-
tively frequently in North America (e.g. up to 30% of patients with
acute LBP and sciatica in Ontario, Canada) (Li 2001) and to a
lesser extent in the UK, Ireland and the Netherlands (Harte 2005).
Traction is often provided in combination with other treatment
modalities (Harte 2005). The most commonly used traction tech-
niques are mechanical or motorized traction (where the traction
is exerted by a motorized pulley), manual traction (in which the
traction is exerted by the therapist, using his/her body weight to
alter the force and direction of the pull), and autotraction (where
the patient controls the traction forces by grasping and pulling
2
bars at the head of the traction table). There are also less common
forms, such as underwater (where the patient is fixed perpendic-
ularly in a deep pool, a bar is grasped under the arms and trac-
tion is applied) and gravitational traction (e.g. bed rest traction,
in which the person is fixed to a tilted table or bed, and the force
is exerted by their own lower extremities), and more recently, a
form in which computer technology (VAX-D) is involved in the
application of tension in continuous cycles.
Lumbar traction uses a harness (with velcro strapping) that is put
around the lower rib cage and around the iliac crest. Duration
and level of force exerted through this harness can be varied in
a continuous or intermittent mode. Only in motorized traction
can the force be standardized. With other techniques, total body
weight and the strength of the patient or therapist determine the
forces exerted. In the application of traction force, consideration
must be given to counterforces such as lumbar muscle tension,
lumbar skin stretch and abdominal pressure, which depend on
the patients physical constitution. If the patient is lying on the
traction table, the friction of the body on the table or bed provides
the main counterforce during traction.
The exact mechanism through which traction might be effective
is unclear. It has been suggested that spinal elongation, through
decreasing lordosis and increasing intervertebral space, inhibits
nociceptive impulses, improves mobility, decreases mechanical
stress, reduces muscle spasm or spinal nerve root compression (due
to osteophytes), releases luxation of a disc or capsule from the
zygo-apophysial joint, and releases adhesions around the zygo-
apophysial joint and the annulus fibrosus. So far, the proposed
mechanisms have not been supported by sufficient empirical in-
formation.
A more recent rationale, adapted to available neurophysiologi-
cal research, suggests that stimulation of proprioceptive recep-
tors in the vertebral ligaments and in the monosegmental mus-
cles may modify and halt what is being conceptualized as a dys-
function. Dysfunction is a relatively generalized disturbance in-
volving higher cerebral centres as well as peripheral structures for
postural control. The dysfunction involves self-maintaining pain-
provoking neuromuscular reflex patterns. In relation to benefits
of traction, this rationale involves the shocking of dysfunctional
higher centres by means of relaying unphysiological propriocep-
tive information centrally, and thus resetting the dysfunction
(Blomberg 2005). So far, the proposed mechanisms have not been
supported by sufficient empirical information.
Little is known about the adverse effects of traction. Only a few
case reports are available, which suggest that there is some dan-
ger for nerve impingement in heavy traction, i.e. lumbar traction
forces exceeding 50% of the total body weight. Other risks de-
scribed for lumbar traction are respiratory constraints due to the
traction harness or increased blood pressure during inverted posi-
tional traction.
Traction for low-back pain with or without sciatica (Review)
Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
There is some debate about the effect of low traction forces.
Beurskens (Beurskens 1997) says that a certain amount of force is
required to achieve separation of the vertebra and widening of the
intervertebral foramina, and that forces below 20% of body weight
constitute a placebo (sham or low dose) traction. Others (Harte
2003; Krause 2000) say that these forces can still be expected to
produce positive results, as even low traction forces can produce
intervertebral separation due to flattening of lumbar lordosis, and
relaxation of spinal muscles.
A systematic review of the effectiveness of traction for back and
neck pain was conducted previously (van der Heijden 95a), with
the literature search ending with 1992 publications. The reason
for the present review is to update that review, as a number of new
studies have been published in the interim.
OBJECTIVES
The objective of this systematic review was to determine the effec-
tiveness of traction for patients with LBP with or without sciatica.
RESULTS
The relevant comparisons for which data were available were as
follows.
1. Traction versus placebo, sham or no treatment
1a. Traction versus placebo, sham or no treatment for patients
with a mix of acute, subacute and chronic LBP with or without
sciatica
Two high quality RCTs (Beurskens 1997; Heijden 1995b) involv-
ing continuous traction found no statistically significant differ-
ences on measures of pain, function, work absence, disability or
overall improvement, with the duration of follow-up ranging from
one to two weeks to six months. Duration of LBP in patients was
as follows: chronic (at least three months) in Heijden 1995b; sub-
acute and chronic (at least six weeks) in Beurskens 1997.
There is strong evidence (two high quality RCTs, 176 people) that
continuous traction is no more effective on pain, function, overall
improvement or work absenteeism than placebo, sham or no treat-
ment in the therapeutic management of a group of LBP patients
with a mix of symptoms (i.e. those with or without sciatica) and
symptom duration.
1b. Traction versus placebo, sham or no treatment for patients
with a mix of acute, subacute and chronic LBP with sciatica
Ten trials were identified, only one of which was of high quality
(Larsson 1980; Lidstrm 1970; Lind 1974; Mathews 1975; Pal
1986; Reust 1988; Sweetman 1993; Walker 1982; Weber 1973;
Weber 1984). Four trials involved continuous traction (Mathews
3
1975; Pal 1986; Reust 1988; Sweetman 1993); three involved
intermittent traction (Lidstrm 1970; Weber 1973; Weber 1984);
two (Larsson 1980; Lind 1974) involved autotraction.
In the eight trials involving continuous and intermittent traction,
there were no statistically significant differences in outcomes of
pain, or a global measure of well-being at follow-up, which varied
between one and five weeks, or on work absence, measured at
one to two years. Neither Weber 1973 nor Reust 1988 found
significant differences in traction treatments using different levels
of force.
There were positive findings in two low quality trials (Larsson
1980; Lind 1974). Larsson 1980 compared autotraction plus
corset to treatment by a corset only and concluded that auto-
traction produced better pain relief in the short term (i.e. at one
and three weeks), but no significant difference at three months.
Lind 1974 compared autotraction to sham shortwave, adminis-
tered along with bedrest and analgesics, in a group of patients
where most (12/15) of the autotraction and all of the sham short
wave patients had sciatica. Mean duration of low-back pain in the
sham shortwave and autotraction groups were 44 and 57 days re-
spectively. This trial reported extraordinarily positive findings in
favour of the autotraction group on all outcome measures (pain,
change in mean distance radiated, straight leg raising, regression
of neurological deficits, patients own evaluation, recovery based
on all measures).
There is moderate evidence (two RCTs, 112 people) that auto-
traction is more effective on pain, global improvement or work
absenteeism than placebo, sham or no treatment in the treatment
of LBP in patients with sciatica.
There is moderate evidence (eight RCTs, 783 people) that other
forms of traction are no more effective on pain, global improve-
ment or work absenteeism than placebo, sham or no treatment in
the treatment of LBP in patients with sciatica.
2. Traction versus other treatments
2a. Traction versus other treatments for patients with a mix of
acute, subacute or chronic LBP with or without sciatica
One high quality study (Werners 1999) compared intermittent
traction to interferential treatment in a population with chronic
LBP. This trial did not find statistically significant group differ-
ences on pain and function at three months post-treatment.
There is moderate evidence (one high quality RCT, 147 people)
that traction is not more effective than other treatments (when
measured up to three months post-treatment) for patients with
LBP of mixed duration, in a population that included patients
both with and without sciatica.
2b. Traction versus other treatments for patients with a mix of
acute, subacute and chronic LBP with sciatica
Traction for low-back pain with or without sciatica (Review)
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Six RCTs compared traction to other treatments for patients with
LBP and sciatica (Bihaug 1978; Coxhead 1981; Lidstrm 1970;
Mathews 1988; Sweetman 1993; Weber 1984). All but Bihaug
1978 had quality assessment scores of four or less and were consid-
ered low quality. Duration of symptoms were quite variable or not
clearly defined (mean duration 9.7 weeks, range three to 52 weeks
in Bihaug 1978; 14 weeks (SD 16.1 weeks) in Coxhead 1981; at
least one month, with approximately 50% longer than one year
in Lidstrm 1970; longer than one week in Sweetman 1993).
One trial (Coxhead 1981) compared intermittent mechanical trac-
tion with spinal manipulation and a corset. No statistically signif-
icant differences were seen on measures of pain, global well-being
or return to work at three to five weeks, or global well-being at
12 to 16 weeks. One trial (Mathews 1988) compared mechanical
traction to treatment with infra-red lamp, and found no statisti-
cally significant differences in pain scores after two weeks and one
year. One trial (Lidstrm 1970) compared intermittent traction
plus strengthening exercises and instruction on Fowler position to
conventional physiotherapy (hot packs, massage, mobilizing and
strengthening exercises), and found that the group receiving trac-
tion did significantly better on a measure of global well-being af-
ter three to five weeks of treatment than did the physiotherapy
group (in which several patients were judged to have undergone
a noticeable change for the worse). The traction patients results
were, however, no better than the control group in this study, who
received hot packs only.
One study (Sweetman 1993) compared continuous traction with
exercise and shortwave diathermy in a population of mixed
chronicity. There were no statistically significant group differences
on pain and global measure at one to two weeks. This study posited
differences in results among patients with different diagnostic pat-
terns, and concluded that larger studies are required to arrive at
definitive conclusions in this regard.
One study (Coxhead 1981) compared traction to a catalogue
of exercises, which brought in all ranges of motion and mus-
cle groups. No statistically significant differences were shown on
measures of pain at three to five, or 12 to 16 weeks. One study
(Weber 1984) compared manual traction to isometric exercise. No
statistically significant differences were shown on a global measure
of improvement.
One study (Bihaug 1978) compared autotraction (using a combi-
nation of Linds method (Lind 1974) and Myrins method (Myrin
1972)) to isometric exercises of abdominal and pelvic floor mus-
cles. The authors reported positive results on a four-point scale
of global improvement after treatment but not at one or three
months after treatment.
There is conflicting evidence (six RCTs, 931 people) on whether
traction is more effective than other treatments in the management
of patients with a mix of acute, subacute and chronic LBP and
sciatica.
4
2c. Traction versus other treatments for patients with chronic
LBP and sciatica
Three RCTs compared traction to other treatments for patients
with chronic LBP and sciatica (Ljunggren 1992; Sherry 2001;
Weber 1984). In the studies by Ljunggren and Weber, the com-
parison was to isometric exercise. No statistically significant differ-
ences were shown on a global measure of well-being at one to two
weeks (Ljunggren 1992; Weber 1984). In the Sherry trial, results
regarding improvements in pain and disability were positive in
favour of traction compared to a TENS group, in which patients,
on average, got worse on both pain and disability.
There is moderate evidence (two RCTs, 144 people) that traction
is not more effective than isometric exercise in the treatment of
patients with chronic LBP and sciatica.
There is limited evidence (one RCT, 40 people) that traction
is more effective than TENS in the treatment of patients with
chronic LBP and sciatica.
3. Different types of traction
3a. Comparison of different types of traction for patients with
a mix of acute, sub-acute and chronic LBP with or without
sciatica
One RCT (Letchuman 1993) compared static traction and inter-
mittent traction for this group of LBP with and without sciatica,
and concluded that there was no statistically significant difference
in pain relief in the two groups. One RCT (Reust 1988) com-
pared light (15 kg) to normal force (50 kg) continuous mechanical
traction, for a LBP patients with sciatica (duration of pain was
not specified). There was no significant difference in pain relief
between the two groups.
There is limited evidence (two RCTs, 66 people) that there is
no significant difference in effectiveness of static and intermittent
traction or normal force versus light force in LBP patients with
and without sciatica.
3b. Comparison of different types of traction for patients with
chronic LBP with or without sciatica
One cross-over RCT (Tesio 1993) compared autotraction to me-
chanical traction in a mixed group of patients, some of whom had
sciatica, and most of whom were in the chronic phase. Results of
patients in the autotraction group were significantly better than
the mechanical traction group post-treatment, on a measure of
global improvement. Outcomes on measures of pain and function
were reported only for those patients responding to treatment. The
studys authors conclusion regarding autotraction was positive.
There is moderate evidence (one RCT, 44 people) that autotraction
is more effective than mechanical traction on global improvement,
but not on pain and function, in chronic LBP patients with or
without sciatica.
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Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
3c. Comparison of different types of traction for patients with
chronic LBP and sciatica
One RCT (Ljunggren 1984) was identified that involved this com-
parison. Ljunggren compared autotraction to manual traction and
concluded that there was no statistically significant difference in
results of the two groups. We note, however, that the groups were
not comparable at baseline.
There is limited evidence (one RCT, 49 people) that there is no
significant difference in effectiveness between autotraction and
manual traction in patients with sciatica in the chronic phase.
4. Other comparisons
One study (Konrad 1992) compared underwater traction with
two other underwater treatments (underwater massage, and bal-
neotherapy, which involves immersion in warm mineral water)
with a control group that received no treatment, for a mixed group
of patients who did or did not have sciatica. Within-group dif-
ferences were statistically significant for the underwater traction,
balneotherapy and underwater massage groups, but not for the
control group, on measures of pain and analgesic consumption.
The authors concluded that there were no significant differences
between the three treatment groups, but that after one year, anal-
gesic consumption was significantly lower in the treatment groups
than in the control group. However, as specific reporting of be-
tween-group comparisons was lacking, and naming of the differ-
ent groups is inconsistent in the report, valid conclusions cannot
be drawn from this study.
One study (Lind 1974) compared autotraction to physiotherapy
(which included Tru-Trac traction and a range of other treatments)
in a group where most patients had sciatica. The mean duration
was 57 days in the traction group, 39 days in the physiotherapy
group. This study reports extraordinarily positive results on all
outcomes measured, but does not always give statistical analyses.
One RCT (Borman 2003) compared a standard physical therapy
program including continuous traction to the same program with-
out traction, for chronic LBP patients with or without sciatica.
This study found no statistically significant between-group differ-
ences in pain, function, global recovery or satisfaction. No signif-
icant differences were observed in outcome measures for patients
with and without sciatica.
There is limited evidence (one RTC, 45 people) that autotraction
is more effective on pain and global improvement, when com-
pared to physiotherapy which included Tru-Trac traction, in the
treatment of LBP in patients with sciatica.
There is limited evidence (one RCT, 42 people) that there is no sig-
nificant difference in effectiveness between standard physical ther-
apy including continuous traction and the same program with-
out traction, for a mix of patients with or without sciatica in the
chronic phase of LBP.
5
Adverse effects
Of the 24 studies, two (Konrad 1992; Walker 1982) stated that
there were no adverse effects; six studies reported some adverse
effects, e.g., increased pain in 31% of static traction group and
15% of intermittent traction group (Letchuman 1993); tempo-
rary deterioration in 4/24 of traction (and 4/26 of exercise group)
(Ljunggren 1992); subsequent surgery in 7/83 in lumbar traction
group versus none in control group (Mathews 1988); aggravation
of neurological signs in 5/18 of traction group, 4/20 of light trac-
tion group and 4/20 of placebo group (Reust 1988); aggravation
of symptoms in 5/43 of traction and 1/43 of sham (Weber 1973).
Borman 2003 reported that 25% of the group receiving traction
as part of standard physical therapy (and 37% of the physical ther-
apy without traction group) felt probably or definitely worse at
the three-month follow-up. The remaining 16 studies made no
mention of adverse effects.
Clinical Relevance
In all but four studies (Letchuman 1993; Reust 1988; Weber 1973;
Weber 1984), patients were described with sufficient detail to allow
practitioners to decide whether they were comparable to those seen
in their own practices. Also, interventions and treatment settings
were described well enough to allow for provision of the same
treatment in all but two studies (Coxhead 1981; Konrad 1992).
At least one clinically relevant outcome (pain, functional status,
work status or global improvement) was reported in all studies.
The size of the effect reported was judged clinically important in
only two studies (Lind 1974; Sherry 2001). The benefits versus
the potential harms were judged negative in all but the Lind study.
Sensitivity Analyses
Our first sensitivity analysis changed the cut-off for high quality
studies from six criteria met to five. In Comparison 1b - Trac-
tion versus placebo, sham or no treatment for patients with a mix of
acute, subacute and chronic LBP with sciatica - this changed the
conclusion (that continuous or intermittent traction are no more
effective on pain, global improvement or work absenteeism than
placebo, sham or no treatment in the treatment of LBP patients
with sciatica) from moderate to strong evidence. In Comparison
4 - Other comparisons - this changed one of the conclusions (that
autotraction is more effective on pain and global improvement,
when compared to physiotherapy which included Tru-Trac trac-
tion, in the treatment of LBP patients with sciatica) from limited
to moderate evidence.
An additional sensitivity analysis was done, in which half of the
methodological quality items that had been scored uncertain in
each trial were given a positive score. This analysis increased the
level of evidence in the same two comparisons (from moderate to
strong evidence in Comparison 1b - Traction versus placebo, sham
or no treatment for patients with a mix of acute, subacute and chronic
LBP with sciatica; and from limited to moderate evidence in Com-
parison 4 - the conclusion that autotraction is more effective on
Traction for low-back pain with or without sciatica (Review)
Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
pain and global improvement, when compared to physiotherapy
which included Tru-Trac traction, in the treatment of LBP patients
with sciatica. The levels of evidence in the other comparisons did
not change.
DISCUSSION
Effectiveness of traction
We used a qualitative analysis in the review, because many stud-
ies did not provide sufficient data for statistical pooling. Several
new trials have been published since the previous review (van
der Heijden 95a) was done, but the results have not substantially
changed. Our main result is that the evidence suggests that trac-
tion is not more effective than placebo, sham or no treatment, or
other treatments for patients with LBP.
It has been argued (Sherry 2001; Krause 2000) that LBP patients
with sciatica are those most likely to benefit from traction. In this
review, there are conflicting results regarding the effectiveness of
traction compared to placebo, no treatment or other treatments in
patients with sciatica. Although the majority of the 16 studies in-
volving patients with sciatica did not show statistically significant
differences, three early low-quality studies involving autotraction
(Lind 1974, Bihaug 1978; Larsson 1980), each reported positive
results. Lind 1974 studied 45 patients, (40 of whom had sciat-
ica) and reported extraordinarily consistent positive results favour-
ing autotraction, in comparison to both sham shortwave and to
physical therapy which included Tru Trac traction. Bihaugs trial
(Bihaug 1978) involved 42 patients and compared autotraction
to isometric exercises of the abdominal and pelvic floor muscles.
Larsson 1980 reported positive findings at one to three weeks, but
no significant difference at three months. More recently, Sherry
2001 reported positive findings post-treatment, between VAX-D
traction patients and a comparison group of TENS patients; the
latter group,on average, deteriorated over the course of treatment.
Longer term results were reported only for the traction group. Re-
viewers noted methodological problems in most of these studies,
which could lead to biased results; these included the size of the
study populations; adequacy of statistical methods, choice of out-
come measures. Potential conflict of interest is also an issue in one
trial (Sherry 2001). In order to have more conclusive evidence re-
garding autotraction and VAX-D, replication would be required,
using adequate numbers of patients and methods that limited the
possibility of bias.
We lack strong, consistent evidence regarding the use of traction
due to the lack of high-quality studies, the heterogeneity of study
populations, and lack of power. Some studies included hospital-
ized patients with demonstrated herniated discs, neurological find-
ings and sciatica, while other studies included patients recruited
from primary care or workers recruited through internal company
newspapers. Also, many of the 24 studies seemed to have had sam-
6
ple sizes that were too small to detect a clinically significant dif-
ference.
With respect to traction as a single-intervention therapy in LBP,
there are very few data in the literature (i.e., no high quality stud-
ies) supporting possible positive effects achieved by any of the trac-
tion modalities included in this review. No studies evaluated the
role of traction modalities as one of the items in broad and multi-
modal pragmatic management programs. However, one RCT did
evaluate the role of traction added to other treatments; traction
was added to a standard physiotherapy program which included
hot packs, ultrasound, and active exercise (Borman 2003). The
addition of traction was not associated with significantly better
results, which is consistent with the overall finding of this review,
i.e., the lack of positive effects. The fact remains, however, that
high quality studies within the field are scarce, and many are un-
der-powered, and do not distinguish between patients with differ-
ing pain duration with or without radicular symptoms. The liter-
ature allows no firmly negative conclusion, i.e. that traction, in a
generalized sense, is not an effective treatment for LBP patients.
Two recent articles (Krause 2000; Harte 2003) have raised the
issue of the level of physical force applied in the treatment, and
argued that even a low level of force may be effective. Beurskens
1997 maintained that traction at levels below 25% of body weight
and using a split table can be regarded as sham (or low-dose) trac-
tion, and the sham traction group in their trial received treatment
involving a force of 10% to 20% of their body weight. In the
other trials classifying their control groups as sham traction the
force applied varies, e.g. less than 25% of body weight in Heijden
1995b; 10 lb. (4.5 kg) in Letchuman 1993, 1.8 kg in Pal 1986, 5
kg in Reust 1988, and a maximum of 20 lb. (9 kg) in Mathews
1975. No statistically significant differences between traction and
sham traction were demonstrated in any of these trials.
Methodological quality of trials
Although three recent high-quality studies have increased our level
of certainty regarding tractions lack of efficacy in the treatment
of LBP, most available studies have methodological problems,
with the potential for biased results. However, studies with more
methodological flaws are more likely to have positive findings com-
pared with high quality studies with only few flaws (Moher 1998).
Only four of the 11 criteria included in the quality assessment were
fulfilled by more than half of the trials, these being the avoidance
of co-interventions, acceptable levels of withdrawal during the in-
tervention, compliance and blinding of the outcome assessor. The
items that were most frequently scored negative were the blind-
ing of the treatment provider, and patient, and intention-to-treat
Traction for low-back pain with or without sciatica (Review)
Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
analysis. Blinding of the treatment provider is virtually impossi-
ble, given the nature of the intervention. The high proportion of
negative scores on blinding of the patients (n = 12) reflects the
small number of trials in which sham or simulated traction was
used. Twelve of the 23 trials did not include an intention-to-treat
analysis, eight did, and one was scored unclear.
In many cases (29% of the total), it was judged unclear whether the
trial fulfilled the individual methodological quality criteria. The
criteria for which this was most often the case included method of
randomization (n = 15), treatment allocation by an independent
person (n = 20), and similarity of groups at baseline (n = 13).
Because many of the trials had been carried out in the 1970s and
1980s, we did not attempt to contact the authors for clarification.
We note that the two most recent trials were reported in a relatively
comprehensive fashion, having only one item marked unclear in
each case. Both the CONSORT statement and this review provide
information that can be used during the design of trials. Therefore,
we are optimistic that future trials on traction for LBP, if there are
any, will be conducted and reported in an adequate manner.
AUTHORS CONCLUSIONS
Implications for practice
The evidence suggests that traction is probably not effective.
The available studies consistently showed that neither continuous
nor intermittent traction as a single treatment was effective for
patients with a mix of acute, sub-acute and chronic LBP with or
without sciatica. In trials studying patients with sciatica, the results
were inconsistent and most of the studies had methodological
problems.
Implications for research
Any future research on the use of traction for LBP patients should
distinguish between symptom pattern and duration, and should
be carried out according to the highest methodological standards
to avoid potential bias. Such research would clarify the picture
regarding the use of autotraction.
ACKNOWLEDGEMENTS
We acknowledge and thank Dr. L. Bouter for his contribution
to the previous review (van der Heijden 95a), of which this is an
update.
7
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manual traction in patients with prolapsed lumber
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Pal 1986 {published data only}
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mcaniques des lombosciatalgies avec ou sans dficit
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8
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9
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References to other published versions of this review

van der Heijden 95a

van der Heijden GJMG, Beurskens AJHM, Koes BW,
Assendelft WJJ, de Vet HCW, Bouter LM. The efficacy
of traction for back and neck pain: A systematic, blinded
review of randomized clinical trials methods. Physical
Therapy 1995;75(2):1829.

Indicates the major publication for the study

SOURCES OF SUPPORT

External sources of support

No sources of support supplied

Internal sources of support

Institute for Work & Health CANADA
Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam NETHERLANDS
Department of Public Health and Caring Sciences, Family Medicine, Uppsala Science Park SWEDEN
Northwestern Health Sciences University, Wolff-Harris Center for Clinical Studies USA
Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht NETHERLANDS

INDEX TERMS

Medical Subject Headings (MeSH)

Low Back Pain [complications; therapy]; Pain Measurement; Randomized Controlled Trials; Sciatica [complications; therapy];
Traction

MeSH check words

Humans

Traction for low-back pain with or without sciatica (Review) 10

Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.