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0000-0000/79/0001-0036$02.00/0 THE JOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyright O by The University of Kansas Lumbar Traction* H. DUANE SAUNDERS, BS, PT The aim of this article is to present and discuss: 1) types of lumbar traction; 2) effects of lumbar traction; 3) indications and contraindications for lumbar traction; 4) effective lumbar traction techniques. There is a review of important points that have been presented in earlier literature, as well as the introduction of new ideas and concepts. A portion of this article deals with the rationale-of using lumbar traction for the treatment of herniated disc and other lumbar spinal nerve root syndromes. There is considerable discussion of poundages necessary to achieve therapeutic results. Detailed description of positioning is presented. The importance of the use of proper equipment for mechanical lumbar traction is stressed. That lumbar traction can be a beneficial treatment for certain musculoskeletal disorders is stressed, but that effective treatment is not as easy and simple to administer as it may seem. Various forms of spinal traction have been described, since the time of Hippocrates, for the relief of pain. Much of the literature is incomplete and seldom describes such things as the exact techniques used, the body type and weight of the subjects, the poundages used, or the dura- tion of the treatments. Opinion varies as to indi- cations, contraindications, poundages, and techniques. Many physicians, therapists, and patients recall the continuous or "bed" traction that was used for many years with poor results. All of this misunderstanding and confusion has caused many physicians and therapists to be- come disinterested in using spinal traction. How- ever, when used correctly on appropriate con- ditions, traction can be a very effective and ben- eficial method of treatment."-14. l8 The word traction is a derivative of the Latin "tractico", which means "a process of drawing or pulling." Various authors have suggested the word "distraction" as being more descriptive. If the terminology "distraction" is used, the refer- ence relates to the joint surfaces and suggests that the joint surfaces move perpendicular to one another. This is not always the case, as one can From the Central Kansas Medical Center, Great Bend, KS 67530. Reprinted by permission.

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Page 1: Lumber Traction

0000-0000/79/0001-0036$02.00/0 THE JOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyright O by The University of Kansas

Lumbar Traction* H. DUANE SAUNDERS, BS, PT

The aim of this article is to present and discuss: 1) types of lumbar traction; 2) effects of lumbar traction; 3) indications and contraindications for lumbar traction; 4) effective lumbar traction techniques. There is a review of important points that have been presented in earlier literature, as well as the introduction of new ideas and concepts. A portion of this article deals with the rationale-of using lumbar traction for the treatment of herniated disc and other lumbar spinal nerve root syndromes. There is considerable discussion of poundages necessary to achieve therapeutic results. Detailed description of positioning is presented. The importance of the use of proper equipment for mechanical lumbar traction is stressed. That lumbar traction can be a beneficial treatment for certain musculoskeletal disorders is stressed, but that effective treatment is not as easy and simple to administer as it may seem.

Various forms of spinal traction have been described, since the time of Hippocrates, for the relief of pain. Much of the literature is incomplete and seldom describes such things as the exact techniques used, the body type and weight of the subjects, the poundages used, or the dura- tion of the treatments. Opinion varies as to indi- cations, contraindications, poundages, and techniques. Many physicians, therapists, and patients recall the continuous or "bed" traction that was used for many years with poor results. All of this misunderstanding and confusion has caused many physicians and therapists to be- come disinterested in using spinal traction. How- ever, when used correctly on appropriate con- ditions, traction can be a very effective and ben- eficial method of treatment."-14. l8

The word traction is a derivative of the Latin "tractico", which means "a process of drawing or pulling." Various authors have suggested the word "distraction" as being more descriptive. If the terminology "distraction" is used, the refer- ence relates to the joint surfaces and suggests that the joint surfaces move perpendicular to one another. This is not always the case, as one can

From the Central Kansas Medical Center, Great Bend, KS 67530. Reprinted by permission.

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Summer 1 979 LUMBAR TRACTION 37

see at the spinal segment. As traction is applied, the movement produced at the segment is a combination of distraction and gliding.''

EFFECTS OF SPINAL TRACTION

Correctly performed traction can cause the following effects: 1) distraction or separation of the vertebral bodies; 2) a combination of distrac- tion and gliding of the facet joints; 3) tensing of the ligamentous structures of the spinal seg- ment; 4 ) widening of the intervertebral foramen; 5) straightening of spinal curves; and 6) stretch- ing of the spinal musculature.

TYPES OF SPINAL TRACTION

Spinal traction can be classified into five cat- egories.

Continuous Traction

Continuous spinal traction is applied for up to several hours at a time. This long duration re- quires 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 poundages great enough to cause sep- aration of the vertebrae for that length of time.

Sustained Traction

This term denotes that a steady amount of traction is applied for periods from a few minutes up to % hr. This shorter duration is usually cou- pled with stronger poundage. This method is most widely used in Europe and much of the literature describes various applications of sus- tained traction. Sustained traction is sometimes referred to as static traction.

Intermittent Mechanical Traction

This form of traction involves a mechanical device with traction alternately applied and with- drawn every few seconds. This is probably the most popular form of traction being used in the United States.

Manual Traction

Manual traction is usually applied for a few seconds duration or can be applied as a sudden, quick thrust.

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.

INDICATIONS AND CONTRAINDICATIONS OF SPINAL TRACTION

Spinal traction has been used for treatment of the following conditions: 1 ) spinal nerve root impingement: a) herniated disc; b ) ligament en- croachment; c) narrowing of the intervertebral foramen; d ) osteophyte encroachment; e ) spinal nerve root swelling; and f ) spondylolisthesis. 2) joint hypomobility; 3) degenerative joint disease; 4) extrinsic muscle spasm and muscle guarding; 5) discogenic pain; 6) joint pain; and 7) compres- sion fracture.

Spinal traction is indicated for the treatment of the herniated disc.=, l4 There is evidence that the bulging protrusion of the disc can be reduced and spinal nerve root compression symptoms relieved when spinal traction is a ~ p l i e d . ' ~ 23 Ma- thews has studied patients thought to have lum- bar disc protrusion, by epidurography. Epidu- rography is a radiological technique for outlining disc protrusions by injecting a water soluble contrast medium into the epidural space. Using sustained traction forces of 120 pounds, Ma- thews was able to show that the protrusions were flattened and that the contrast material was drawn into the disc spaces. He also found that the situation was somewhat unstable, in that partial reoccurence of the bulging defects reap- peared later.237 24

The inferences from these studies are that traction can indeed separate lumbar vertebrae; lead to a decreased pressure at the disc space with a resulting suction force; and that material can be drawn from the epidural space into the disc space. Similarly, one may deduce that any anatomical correction produced is unstable.

As with all conservative treatment approaches of the herniated disc, patient education and gradual, cautious return to activities is absolutely necessary if the traction treatment is to be suc- cessful. Once a lumbar herniation is reduced and the spinal nerve root symptoms have been relieved, the patient may need the support of a modified-Taylor, or chair-back brace. This brace limits the patient's activities, especially forward

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38 SAUNDERS Vol. 1 , No. 1

bending, and also relieves some of the compres- sion force on the disc, when the patient is stand- ing or sitting.

N a c h e m ~ o n ' s ~ ~ work on intradiscal pressures should be taken into account when educating the patient concerning unsafe positions and ac- tivities for them while convalescing (see Scheme 1). He found that sitting causes more intradiscal pressure than standing. Forward bending also increases intradiscal pressure and causes pos- terior movement of the nucleus pulposa." The patient should avoid these positions and activi- ties during early treatment of the herniated disc. Return to normal activities should be gradual and only after the injured disc has had a chance to heal and stabilize itself. If the patient is hospital- ized the first few days of treatment, he should be confined to bedrest, except for bathroom privi- leges. Since sitting increases the intradiscal pressure, the patient may need to be taken to and from physical therapy on a cart for the first few days of treatment. He should then progress to walking to and from physical therapy, thus avoiding sitting postures until more stabilization has occurred. No absolute rules can be estab- lished for the patient recovering from herniated disc, but he should understand potentially harm- ful positions and activities. He should understand that progress and the return to activities will be gradual.

When treating a herniated disc with spinal traction the treatment time should be short. As the disc space is widened, the intradiscal pres- sure is decreased in relation to its surroundings. This is a beneficial effect and is the reason

Mathews was able to demonstrate the movement of contrast medium into the disc space. This decrease in pressure is only maintained for a short time as the osmotic forces soon equalize pressure with that of the surrounding tissue. When the pressure is equalized the "suction" effect upon the herniation is lost. If this has occurred and the patient is then released from traction the intradiscal pressure could, at least theoretically, increase in relation to the sur- rounding tissue. If this is the case, increased pain may appear after the treatment is com- pleted. We have not observed this adverse effect if treatment times are kept under 15 minutes for intermittent and under 10 minutes for sustained traction.

The poundages should be relatively high to cause separation of the spinal structures. One- half of the patient's body weight is the minimum force for lumbar spinal traction. Sustained trac- tion is probably superior to intermittent, when treating a herniated disc, although favorable re- sults have been reported with both.

Swelling and/or thickening of the ligamentum flavum can cause encroachment upon the spinal nerve root in the intervertebral foramen. Traction may be an effective treatment for this syndrome. If the traction is of sufficient force to widen the intervertebral foramen it would allow the spinal nerve root more space, perhaps relieving the impingement. This same rationale can be applied in cases of the narrowed disc space and the resulting encroachment caused by the narrowed intervertebral foramen.

Osteophyte encroachment of the nerve root is

Scheme 1 . lntradiscal pressures in various positions and activities (adopted from NachemsonZ5).

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Summer 19 79 LUMBAR TRACTION 39

another cause of nerve root syndrome that can sometimes be relieved by traction. This condition is more common in the cervical spine but does occur in the lumbar spine.

The argument is often raised that even though traction can cause a separation and widening of the intervertebral foramen, the effect will only be temporary. It is true that the separation shown on x-ray will at least partially disappear soon after the traction has been discontinued. If a patient with a degenerative, narrow disc space is given traction it will not restore that disc space to its original size and structure. What then causes these patients to have relief with the traction treatments? We know that many people have narrowing of the disc space and interver- tebral foramen without signs and symptoms of nerve root impingement. The same can be said of the presence of osteophytes that do not cause symptoms. There must be a very fine line be- tween those cases that do and those that do not encroach upon the nerve root. Sometimes the traction treatment must mobilize or separate the segment in such a way to relieve the impinge- ment.

Nerve root swelling or neuritis may also pro- duce nerve root impingement signs and symp- toms. If this is the case, spinal traction should give relief, although rest and treatment with mo- dalities would probably be more appropriate.

Cyriax5 advocates spinal traction for relief of spondylolisthesis, if nerve root encroachment signs are present. Consideration should be given to the possibility of an unstable or hypermobile spondylolisthesis. In this case, traction would probably aggravate the condition, rather than allow relief. It is also common to see patients with a herniated disc at the level above the spondylolisthesis and care should be taken to evaluate the patient correctly. Often the patient is given the label "spondylolisthesis" because of the x-ray findings, when they are actually suffering from a herniated disc at the level above.2

Joint Hypomobility

Traction can be regarded as a form of mobili- zation, since it involves the passive movement of joints by mechanical or manual means. Any con- dition of joint stiffness or joint hypomobility may respond favorably to traction. One argument against using traction for mobilization is that it is nonspecific and affects several joints at one time.

With this in mind, one might select a more spe- cific technique, but traction should not be over- looked as a possible method of mobilization.

Degenerative Joint Disease

Degenerative joint disease is often related to joint hyp~mob i l i t y .~~ Many patients with degen- erative joint disease also have limited range of motion in the involved segments. Traction can be an effective method of restoring the move- ment of these segments; thus, at least theoreti- cally, interrupting the degenerative process. It is certainly true that many of these patients expe- rience pain relief as mobility is restored to the joints.

Extrinsic Muscle Guarding & Spasm

Traction is usually beneficial in reducing ex- trinsic muscle guarding and spasms, and may be effectively used when these conditions are pres- ent. Intermittent traction is usually preferred over sustained traction when it is used for mobilization of a hypomobile spinal segment or in the treat- ment of muscle guarding and muscle spasm.

Discogenic Pain

Spinal pain of a discogenic nature may re- spond favorably to traction treatment. Theoreti- cally, pain that is of a discogenic nature is caused by anatomical changes in the disc struc- t ~ r e . ~ . " Any modification or restoration of this anatomy may produce favorable effects.

Joint Pain

Both Ka l tenb~rn '~ and Maitland*' report mo- bilization and traction within the normal range of joint movement for relief of joint pain. One expla- nation of why small movements within normal range of motion relieves pain is that it causes stimulation of the mechanoreceptors. The im- pulses from these fast conducting sensory fibers can "block" pain arising from slower conducting pain fibers.

Compression Fracture

Some patients with compression fractures continue to have pain in the subacute stage and even after the fracture is completely healed. Although traction is not considered routine treat- ment for a compression fracture, the patient who

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continues to have pain beyond the subacute stage may respond remarkably well to traction treatments. Of course, many compression frac- tures are in the thoracic spine where traction cannot be used effectively.

Contraindications for spinal traction include disease processes and other conditions for which movement is contraindicated. Acute strains, sprains, and inflammations may be ag- gravated by traction. Traction given to patients with hypermobility of the spine may cause further strain. Some attention should be given to the patient with respiratory problems or patients who develop claustrophobia with traction, a s ~ o d i f i - cations will need to be made.

~ rha rd " recommends a trial of normal traction and compression tests to ascertain if a patient is a suitable candidate for traction. He maintains that if manual traction causes no pain or gives the patient relief, they are suitable candidates for traction. If, however, traction aggravates the patient's condition, they are not candidates for traction. The trial treatments of manual traction should be given in varying degrees of flexion, extension, and lateral bending. The most com- fortable position is more apt to be the most therapeutic.

LUMBAR TRACTION TECHNIQUE

As previously mentioned, the disappointment of continuous or "bed" traction has caused many physicians and physical therapists to lose interest in using any form of lumbar traction. Even some patients will be reluctant to have "traction" treatment recalling the continuous traction they may have had at an earlier time. Any benefit accredited to this technique has probably been the result of the rest and immo- bilization that the patient has had while undergo- ing treatment.l4, "

The coefficient of friction of the human body lying on a couch or mattress is 0.5. In other words, a force equal to % of the patient's body weight is required to move the body horizontally. As one-half the body weight lies beneath L-3, a force equal to % x 0.5 = '/4 of the body weight is lost in overcoming friction. Therefore, that amount of weight between '/4 and '/2 of the pa- tient's body weight is all that can effectively cause a traction force, if conventional bed trac- tion techniques are applied. Any less than '/4 of the patient's body weight will not be enough to

cause the patient to slide to the foot of the bed. ~othenberg,~' at surgery, observed no change in the disc or no separation between vertebrae with traction weights of 25 pounds. Nowhere in the literature were we able to find any evidence that traction weights of 'h of the patient's body weight affected any change in the structures of the lumbar spine.

How much force is necessary to affect struc- tural changes in the lumbar spine? Hood and Chrismani4 report favorable results with a series of patients using 65-70 pounds of intermittent lumbar traction. Cyriax7 reported a visible sepa- ration with sustained traction of 120 pounds for 15 minutes. Other studies report measurable separation in the lumbar spine at poundages ranging from 80-200 pound^.'^^ 15. ''. 23 Judov- ichi5 advocates a friction free force equal to '/2

of the patient's body weight as a minimum to cause therapeutic effects in the lumbar spine. This does not mean that the first treatment has to be given at that poundage, nor does it mean that the minimum amount necessary to cause a measurable separation will always be enough to achieve satisfactory results. It is important in every case that the patient's reaction and the results of the treatment be assessed with adjust- ments being made until satisfactory results are achieved.

Research has been done concerning the poundages to effect damage to vertebral struc- tures. The most often quoted is a study by Rainer using fresh cadavers. DeSeze and LevernieuxQ reported that Rainer found a force of 440 pounds was necessary to produce a rupture of the dor- sal-lumbar spine (T-11, T-12).

Harrisi3 indicated that enormous traction forces were necessary to cause damage to the lumbar spine, and that the breaking load may be as high as 880 pounds.

overcome friction, and any more than % will Fig. I . Split table for lumbar traction.

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Summer 1979 LUMBAR TRACTION 4 1

Fig. 2. A type of sustained lumbar traction.

As mentioned previously, it is the effective traction force on the spine that is important and any friction involved must be considered. A split- table essentially eliminates friction (Fig. 1).

There are special techniques, such as the one in Figure 2, that have proven beneficial. Such a technique would involve heavier total poundages than those using a split-table because of the necessity of lifting % of the patient's body weight off of the table.

The amount of force alone does not determine the effectiveness of the traction treatment. The comfort of the patient is of utmost importance. If the patient is unable to relax with the treatment, it will probably be ineffective. Evidence shows that a narrowing of the intervertebral spaces can occur with inability to relax.' For the patient to relax, the treatment must not aggravate his/her condition, and he/she must feel secure and well supported. It may be beneficial to administer modality treatments before the traction applica- tion. Such treatment as ice, heat, ultrasound, or massage is often effective.

The use of a heavy duty nonslip traction har- ness is essential. If the patient does not feel secure he or she will almost certainly remain tense during the treatment. An effective, one size fits all, heavy duty lumbar traction harness is seen in Figure 3.

This harness is lined with a vinyl material that causes it to adhere to the patient's skin, thus eliminating the slipping that is common with cot- ton-lined belts. Both the pelvic and thoracic pads should be placed next to the patient's skin. If clothing is left under the harness, it will be more likely to allow slippage. Clothing can also take some of the traction force if it is bound tightly under both belts. Even something as simple as

tient's thighs may support them better and help them relax (Fig. 4).

Brodin' discusses varying the patient's leg position or amount of lumbar flexion to focus the tractive force to specific levels. He states that traction occurs in the lower lumbar region when there is little or no lumbar flexion and that the tractive force is directed to the upper lumbar and lower thoracic region when the knees are flexed against the chest. Although Brodin's reasoning may have some applications, flexing the lumbar

Fig. 3. Heavy duty lumbar traction harness.

a velcr0 strap pictured below, around the pa- Fig. 4. Velcro strap used to stabilize patient's thighs

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42 SAUNDERS Vol. 1 , No. 1

spine to a point that the lumbar lordosis is re- moved seems to be a more reasonable position. It is the neutral or straight position of the spine that offers the largest intervertebral foramen opening for the spinal nerve root.21 Flexing be- yond neutral causes the ligamentum flavum, and other soft tissue to be pulled across the interver- tebral foramen. Extension from neutral causes a narrowing of the boney structure of the foramen.

One should remember that it is not only the position of the legs and the rope angle to the table that control the amount of lumbar flexion. The position of the legs control hip flexion and has little effect on lumbar lordosis. Likewise, the rope angle to the table does not always effec- tively control the amount of spinal flexion. The choice of pelvic harness is probably the most important determinent of the amount of spinal flexion achieved. If the pelvic harness pulls from the sides only, it is possible to maintain consid- erable lumbar lordosis. For this reason a pelvic harness that pulls from the posterior is essential. The knees and hips can be flexed moderately for comfort, while the rope angle to the table should remain relatively straight. This is especially true, if heavier poundages are used. It should be noted that certain commercial traction tables are not recommended for heavy poundages unless a straight or 0" rope angle to the table is main- tained (Fig. 5).

Lumbar traction can be effectively adminis- tered in the prone position as well as supine. Patient comfort and the ability of the patient to remain relaxed during the treatment are consid- ered when choosing which position to use. When using prone traction, the amount of lumbar flex- ion can be controlled by pillows under the pelvis and, as mentioned above, using the correct pel-

Fig. 6. Prone lumbar traction with the correct amount of spinal flexion.

vic harness. Prone traction can be especially effective with the patient who has moderate to severe pain and/or muscle guarding. The patient can be positioned prone for modality treatments and the traction can follow without moving the patient. Another advantage of prone traction is that the therapist can palpate the interspinous spaces to ascertain the amount of movement that is taking place during the treatment (Fig. 6).

As previously mentioned, some conditions, such as herniated disc seem to respond better to sustained traction, while conditions such as joint hypomobility and muscle guarding are usu- ally treated more effectively with intermittent traction. It is important to remember that the patient's comfort and his ability to relax with the treatment is the most important consideration when choosing between intermittent or sus- tained technique.

Some mechanical traction devices are rela- tively ineffective in administering sustained or static traction because of the inability to take up slack during the course of the treatment time. To be effective it is essential that a mechanical traction device continue to take up slack as the patient relaxes.

The heavy duty lumbar traction harness de- scribed earlier can also be used to administer unilateral lumbar traction by simply coupling only one side of the pelvic harness to the traction source. It has been theorized that unilateral lum- bar traction is superior to bilateral in cases that involve unilateral pathology and/or a protective scoliosis. Using this method, unilateral traction can be administered either prone or supine (Fig. 7).

Fig. 5. Supine lumbar traction with the correct amount of uses manual lumbar traction for treat- spinal flexion. ment of the herniated disc. These techniques are

Page 8: Lumber Traction

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44 SAUNDERS Vol. 1 , No. 1

Fig. 8. Lumbar manual traction techniques.

Fig. 9. A, posit ional traction side bend only. 6, posit ional traction side bend and rotation

on the side opposite of the roll. The technique can involve only sidebending or can also incor- porate rotation (Fig. 9).

SUMMARY

Lumbar traction can be an effective method of treatment for a number of common musculo- skeletal disorders. Effective treatment is not as easy and simple to administer as it may seem. Many variations of technique exist and some of these techniques are of questionable value. The physical therapist who intends to treat patients with spinal traction must become familiar with the most effective techniques, and their appli- cation. Finally, one must not forget the impor- tance of the musculoskeletal evaluation, for if the information gathered in the evaluation is in- correct, the treatment plan will have very little chance of being effective.

REFERENCES:

1. Brodin H: Manuell Medicin och Manipulation. Lakartidningen 63: 1037-1 038. 1966

2. Brown CR: Great Bend, Kansas (Personal Communication) 3. Chrisman D: A Study of the Results Following Rotatory Manipu-

lation in the Lumbar lntervertebral Disc Syndrome. J Bone Joint Surg. 46A:517-524. 1964

4. Crisp E: Discussion on the Treatment of Backache by Traction. Proc Roy Soc Med 48:805. 1955

5. Cyriax J: The Treatment of Lumbar Disc Lesions. Brit Med J 2: 1434, 1950

6. Cyriax J: Textbook of Orthopaedic Medicine, vol II, London. Bailliere Tindell 8 Cassell, 1954

7. Cyriax J: Discussion on the Treatment of Backache by Traction. Proc Roy Soc Med 48:808. 1955

8. Deets D, Hands K, Hopp S: Cervical Traction: A Comparison of Sitting and Supine Positions. Phys Ther 57: 1977

9. DeSeze S, Levernieux J: Les Tractions Vertebrales. Sem Hop Paris 27:2075. 1951

10. Erhard R: Proceedings, International Federation of Orthopaedic Manipulative Therapists. Edited by B Kent. Vail. Colorado. 1977

11. Farfan H: Proceedings, lnternational Federation of Orthopaedic Manipulative Therapists. Edited by B Kent. Vail. Colorado, 1977

12. Frazer E: The Use of Traction in Backache. Med J Aust 2:694. 1954

13. Harris R: Massage, Manipulation and Traction. New Haven, E Licht. 1960

14. Hood L. Chrisman D: Intermittent Pelvic Traction in the Treatment of the Ruptured lntervertebral Disc. J Am Phys Ther Assoc 48: 21 -30, 1968

15. Jodovich B: Lumbar Traction Therapy. JAMA, 159:549-550. 1955

16. Kaltenbom F: Proceedings, lnternational Federation of Ortho- paedic Manipulative Therapists. Edited by B Kent. Vail. Colorado, 1977

17. Kapandji I: The Physiology of the Joints. Vol 3, Second Edition. London Churchill Livingstone. 1974

18. Lawson G. Godfrey C: A Report on Studies of Spinal Traction. Med Serv J Can 14:762. 1958

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Summer 19 79 LUMBAR TRACTION 45

19. Lehmann J. Brunner G: A Device for the Application of Heavy Lumbar Traction; It's Mechanical Effects. Arch Phys Med 39: 696-700, 1958

20. Maitland G: Vertebral Manipulation. Second Edition. London, Butterworth and Co. Ltd. 1968

21. Maslow G. Rothman R: The Facet Joints: Another Look. Bull. NY Acad Med 51 :1294-1311. 1975

22. Masturzo A: Vertebral Traction for Sciatica. Rheumatism. 11 :62. 1955

23. Mathews J: Dynamic Discography: A Study of Lumbar Traction. Ann Phys Med 9:275-279. 1968

24. Mathews J: The Effects of Spinal Traction. Physiotherapy 58: 64-66, 1972

25. Nachemson A: The Lumbar Spine: An Orthopaedic Challenge. Vol 1, 59-71 Spine. 1976

26. Paris S: Course Notes, The Spine. Atlanta, Atlanta Back Clinic 27. Parsons W, Cummings J: Mechanical Traction in the Lumbar

Disc Syndrome. Can Med Assoc J 77:7-11. 1957 28. Ranier J. Quoted by DeSeze S. Levernieux J: Les Tractions

Vertebrales, Sem Hop Paris. 27:2075. 1951 29. Rothenberg S: The Effect of Leg Traction on Ruptured Interver-

tebral Discs. Surg Gynec Obstet 96565-566, 1953