Traction, Low Back Pain, Research Suggests it Doesn’t Work

Traction for low-back pain with or without sciatica. Wegner I, Widyahening IS, van Tulder MW, Blomberg SE, de Vet HC, Brønfort G, Bouter LM, van der Heijden GJ. Cochrane Database Syst Rev. 2013 Aug 19;8

Quotes from abstract (but I read the whole thing)

We included 32 RCTs involving 2762 participants in this review. We considered 16 trials, representing 57% of all participants, to have a low risk of bias based on the Cochrane Back Review Group’s Risk of bias’ tool.

For people with mixed symptom patterns (acute, subacute and chronic LBP with and without sciatica), there was low- to moderate quality evidence that traction may make little or no difference in pain intensity, functional status, global improvement or return to work when compared to placebo, sham traction or no treatment. Similarly, when comparing the combination of physiotherapy plus traction with physiotherapy alone or when comparing traction with other treatments, there was very-low- to moderate-quality evidence that traction may make little or no difference in pain intensity, functional status or global improvement.

For people with LBP with sciatica and acute, subacute or chronic pain, there was low- to moderate-quality evidence that traction probably has no impact on pain intensity, functional status or global improvement.

For chronic LBP without sciatica, there was moderate-quality evidence that traction probably makes little or no difference in pain intensity when compared with sham treatment.

Adverse effects were reported in seven of the 32 studies.

These findings indicate that traction, either alone or in combination with other treatments, has little or no impact on pain intensity, functional status, global improvement and return to work among people with LBP. There is only limited-quality evidence from studies with small sample sizes and moderate to high risk of bias. The effects shown by these studies are small and are not clinically relevant.

To date, the use of traction as treatment for non-specific LBP cannot be motivated by the best available evidence. These conclusions are applicable to both manual and mechanical traction.

Only new, large, high-quality studies may change the point estimate and its accuracy, but it should be noted that such change may not necessarily favour traction. Therefore, little priority should be given to new studies on the effect of traction treatment alone or as part of a package.

My comments:

The authors comments pretty much say it all. Lots of studies done, little to no effect was found and that’s even including studies that are of high risk for bias. I have been following the traction (aka spinal decompression therapy) research for years and this is the strongest wording, as to ineffectiveness, to date coming from Cochrane. Cochrane reviews are usually pretty conservative and lenient with medical claims. Usually they will suggest that more research needs to be done, while these authors seem content to basically say, “save it.”

I had an inversion table in my office for a couple years that was given to me by a patient who no longer used it. I honestly can’t say it did anyone any real good, so my experience is in line with the findings of this review. Plus I thought someone was going to break a leg climbing on and off of it. So I guess you could say I was open to the idea that traction might work, and gave it a shot because it did make a certain amount of intuitive sense. I even have a pair of gravity boots from the 80s, that you can still buy on Amazon collecting dust somewhere.

Reports like this really makes me feel bad for all the physical therapists and chiropractors who went out and purchased Vax D machines, which were not at all cheap. Still I feel more sorry for their patients, so I figured this blog was worth writing. The word was pretty much out on the ineffectiveness of lumbar  traction/Vax-D, (on Chirobase, and Wikipedia) but this most recent Cochrane review added some additional studies strengthening the case against. Given I still see traction promoted around town by some physical therapists and chiropractors for the treatment of low back pain I figured it was worth a blog.

Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember Spinal Flow Yoga for you or someone you know in the future.

Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed Yoga Teacher Training at Sampoorna Yoga in Goa, India.

6 thoughts on “Traction, Low Back Pain, Research Suggests it Doesn’t Work”

  1. Very interesting read, again. It seems the more we think we know about disc injuries and LBP, the less true these ideas seem to be. Question now remains, if traction is indeed ineffective, what is the alternative to regain mobility and get rid of nagging pain? Would it just be strengthening of the core (core as in all of the muscles that connect your lower body to upper body).

    • The history of treatment for low back pain, is a history of treatments that are often placebo at best. I think it’s best not to attempt to regain mobility at all, at least not in the spine, but rather work to increase low back stiffness. In doing so, you give the discs the best chance to heal, such that mobility later returns without trying. It might help to try and increase shoulder and hamstring mobility so that you can bend over with more of the range coming from your hips, but unless you are real tight, that’s usually not a big factor. I would encourage you to read Stuart McGill’s paper on “super stiffness” of the spine, and for that matter his books are great.

      Increasing core strength is good, but you also want to increase total body strength. People with strong cores but weaker legs/hips will often do a lot of their lifting through their core rather, thus stressing their discs, which do seem to be the first structure that fails.

      And you really need good motor control/spine awareness. It doesn’t do your discs a lot of good to be surrounded by strong muscles if it doesn’t occur to you to stop flexing and twisting those discs during your exercise and daily activities.

      The basic formula I use is teaching people to use correct size lumbar supports when they sit, so they aren’t over flexing or extending their spine when they sit. Teaching good motor control/spine awareness during dynamic movements, so as to avoid a lot of spine flexion/extension and twisting. While at the same time working on increasing core and total body strength and endurance. Also, I can’t overstate how much EMS helps. I think it has increased the effectiveness of my program at least 100%. EMS knocks out the pain faster than any modality I have tried, helps strengthen the core, and it’s inexpensive enough for people to have at home.

    • Hi Tom, I had to look up “Cox flexion-distraction” as I hadn’t heard of that one. I saw a youtube video on it and it looks similar to the traction used in the studies, plus flexion added on top.

      For what it’s worth I’m not a big fan of flexion for back pain either, though I suppose combined with traction it would be better than combined with compression. If I had back pain I would expect it to have psychological benefits at best with any good points offset by bad points. So I wouldn’t do it. I was able to find some case studies on it showing it helped in isolated cases…

      …but that doesn’t mean a whole lot because nobody publishes case studies on all the times their treatment gizmo doesn’t work. And it’s known that even the most extreme cases of disc herniations often get better on their own. I hope that helps.

  2. Chad, I’m in a lot of pain right now from a herniated disk and sciatica and feel like I’ve been on a wild goose chase to find good info and your writing has been a breath of fresh air. I wish you were based in St. Louis! Several friends have are convinced that traction and inversion tables have saved them from back surgery so I’m wondering if you’ve seen this study and if you have thoughts on it: “Inversion therapy in patients with pure single level lumbar discogenic disease: A pilot randomized trial” (

    It was a small study but the results seem persuasive?

    • Hi Tim,

      There are a few reasons why I give that study the stink eye. Not the least of which is they apparently lost half their outcome measures. MRI results were no different between groups but it looks like they tested most of them. However, with the SF36 and Roland Morris Disability Index tests only 7/11 patients in the control group turned in tests, 36% were lost. It makes me wonder who’s trying to hide what. With the Oswestry Disability Index only 8/13 (38% lost) of the traction group tests were analyzed, while in the control group only 3/11 were analyzed, implying that 63% were either lost or just not taken. I’ve never heard of such a thing, then they went on to say on the latter test “almost reaches statistical significance.” Well yeah, if you lose all the tests unfavorable to your study you probably can “almost’ show significance on just about anything, but would be cheating.

      The other thing that really bothers me is the main success was determined by whether the surgeon decided to perform surgery or not, but how he made his decision a black box. Apparently, it wasn’t made base on MRI or disability index.

      The study is in the UK where they have socialized medicine, so they might have just used the traction as an excuse to avoid surgery to save money, which is probably a good idea. The patients pain levels at the start in either group only averaged a 3/10 and surgery for radiculopathy isn’t especially successful long term. Also they don’t describe what physical therapy treatment they did. They used the word “derangement” and that combined with it being in the UK (where McKenzie method treatment is popular) makes me think that’s the treatment they got. Here’s my opinion on McKenzie method, which meta-analysis says is no better than “advice to stay active. Thus if I had to choose between McKenzie method and traction, depending on the therapist, I’d choose traction, knowing full well that it’s probably not doing anything.

      Also they say pain and radiculopathy are frequently due to disc herniations, but they gave no indication that they have any idea of what causes disc herniations and degeneration. Here is what causes them. Avoid those causes and your disc should heal.

      The final reason I don’t trust inversion tables to help is over the 19 years I was treating back pain in my clinic I had a couple inversion tables. I couldn’t tell that it helped the first time I had one, and knowing the research on traction was generally unfavorable I tossed it. I bought another one, having a patient with stenosis who I thought, “even though research shows it does not work for most on average, it will probably work for this one guy.” Unfortunately, it didn’t work for him either and letting a number of patients with back pain have a go at the new one, nobody was greatly impressed, so I ended up dumpstering that one as well. That said, you might be the exception, as far as I know they are generally safe and their fairly inexpensive, so if you bought one, tried it and it didn’t work, it’s no great loss.

      The good news now is that I might not need to be in the same town as you to help. I moved all my blogs from my physical therapy website to where I teach my exercise program, what causes spine pain and how to avoid the same for an annual membership of $20. It’s not like regular yoga and in fact is currently the only neutral spine yoga sequence in existence, that’s much more based on increasing strength and endurance than stretching. In fact I don’t stretch the spine at all, which is what makes it unique. Spinal Flow still what I would call a minimal viable product but I’m working on it every day. The still photos in the member area and descriptions will soon be replaced by videos, and I opened comments at the bottom of each flow so I can hear and answer questions, thus better helping members and allowing me to know how to better improve delivery of my program.

      If your sciatic is real bad (in general meaning you are still limping) Spinal Flow might be too much for you, but once you get to the point you can walk normally you should be able to start Level-1 at least. You can read more about it on my main page of Last maybe check out my blogs on electrical stimulation, several of them are back pain related and I think that’s one area where EMS really shines. I haven’t started writing about EMS in relation to Spinal Flow yet, but it’s coming and with the right machine, programs, and electrodes usually helps a ton with back and leg pain.

      I hope that helps.


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