TRACTION AND EOTA

1
EFFECTS OF PRONE LUMBAR TRACTION COMPARED WITH SUPINE
LUMBAR TRACTION IN CONJUNCTION WITH EXTENSION ORIENTED
TREATMENT APPROACH (EOTA) RESPECTIVELY FOR CHRONIC LOW
BACK PAIN AND DISABILITY
PROJECT WORK
MAY 2014
SUBMITTED BY
PRABHAKARAN NATRAJ
A Project Work Submitted to the Pondicherry University in Partial Fulfillment of
the requirements for the degree of BACHELOR OF PHYSIOTHERAPY.
SRI VENKATESWARAA
COLLEGE OF PARAMEDICAL SCIENCES,
COLLEGE OF PHYSIOTHERAPY,
ARIYUR, PUDUCHERRY-605102

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SRI VENKATESWARAA COLLEGE OF PARAMEDICAL SCIENCES,
COLLEGE OF PHYSIOTHERAPY
MAY 2014
CERTIFICATE
REGISTER NO: 10BPOO57
This is to certify that this project work entitled “EFFECTS OF PRONE LUMBAR
TRACTION COMPARED WITH SUPINE LUMBAR TRACTION IN
CONJUNCTION WITH EXTENSION ORIENTED TREATMENT APPROACH
(EOTA) RESPECTIVELY FOR CHRONIC LOW BACK PAIN AND
DISABILITY” is done by PRABHAKARAN NATRAJ in partial fulfillment of the
requirements for the award of the Degree of Physiotherapy, Pondicherry University.
PROJECTGUIDE
Mr.C.Rathinasabapathy, M.P.T. (CARDIO-RESP.)
Asst. Professor,
SVCPMS,
College of Physiotherapy.
INTERNAL EXAMINER EXTERNAL EXAMINAR
HEAD OF THE INSTITUTION
Pace:
Date:

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ACKNOWLEDGEMENT
First and foremost I would like to thank the almighty, who showed his
blessings in all walls of my life.
I gratefully acknowledge my indebtedness to our respected Principal
Prof. A. Pahinian.,M.P.T., P.G.D. Fit.M., for granting me permission to do
this project.
I am extremely thankful to my respectful project
guideMr.C.Rathinasabapathy.,M.P.T.,Asst.Prof.,for his helpful suggestions
and guidance which has led to the completion of this project.
I own my sincere thanks to all staffs work in Sri Venkateshwaraa
College of Paramedical Sciences, College of Physiotherapy, for their
encouragement and moral support throughout my study, special mention
during the course of the project.
I am thankful to Dr. E .Susiganesh Kumar, M. Sc., M. Phil.,Ph.D.,
Asst. Prof., Dept. of Community medicine, SVMCH&RC for his valuable
assistance in statistical analysis.
My grateful thanks to all the participants, who contributed their time
and energy in this project as subjects.
I am whole heartedly thankful to my friends who have been with me
throughout this project advising, encouraging and providing materials for this
project.

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DEDICATED TO MY MOTHER
AND FRIENDS

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CONTENTS
S.No. TABLE OF CONTENTS Page No.
I INTRODUCTION
Traction
Extension oriented treatment approach
(EOTA)
II REVIEW OF LITRATURE
III MATERIALS AND METHODOLOGY
Study design
Selection criteria
Materials required
Procedure
IV OUTCOME MEASURES
V STATISTICALTOOLS
VI DATA ANALYSIS AND
PRESENTATION
VII RESULTS
VIII DISCUSSION
IX CONCLUSION
X RECOMMENDATIONS AND
LIMITATIONS
XII REFERENCES
XIII APPENDIX –I
APPENDIX – II

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LIST OF TABLES
LIST OF FIGURES
Figure No. Title Page No.
1 Participant flow through the study
2 Patient in prone lumbar traction
3 Patient in fowler’s position for traction
4 Prone on elbows
5 Prone press up
Table No. Titles Page No.
1
Exercise progression within the extension-oriented treatment
approach.
2 Subject characteristics
3 Group A data of NPRS and ODQ
4 Group B data of NPRS and ODQ
5 Statistical presentation

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INTRODUCTION
70–85% of all people have back pain at some time in life. The annual prevalence of back
pain ranges from 15% to 45%, with point prevalence averaging 30 %.( 1)
Low back pain chronicity implies that those affected suffer more or less continuous pain,
and have few if any, pain-free periods.Definition of chronic (>12 weeks) low back pain
should specifically excludethose patients who experience recurrent episodic low back
pain. (2)
Chronic low backpain is generally considered a result of mechanical causes and is not
related to an underlying condition such as infection, neoplasm, or fracture. Chronic low
back pain is often thought to be the result of disc degeneration, musculoskeletal sprain
or strain, or of disorders associated with the movement or position of the spine. The
causes of chronic low back pain may stem from nociceptive, neuropathic, or
psychological processes, ora combination of these. (3)
MechanicalorActivity-related Causes oflow back pain (4)
:
Segmental and discal degeneration
Myofascial or soft tissue injury/disorder/strain
Disc herniation with possible radiculopathy
Spinal instability with possible spondylolisthesis or fracture
Vertebral bodyfracture
Spinal canal or lateral recess stenosis
Arachnoiditis, including postoperative scarring
Spondylosis
Facet joint dysfunction
Degenerative joint disease of spine

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Red Flags (4)
:
 Presentation age <20 yrs. or onset >55 yrs. (tumor?).
 Violent trauma, e.g. fall from a height, MVA (tumor?).
 Constant, progressive, non-mechanical pain.
 Thoracic pain.
 Previous history
 Carcinoma.
 Systemic steroids.
 Drug abuse, HIV.
 Systemically unwell
 Weight loss.
 Persisting severe restriction of lumbar flexion.
 Widespread neurologic symptoms.
 Structural deformity.
 Caudaequina syndrome.
 Inflammatory disorder (ankylosing spondylitis and other related disorders)
 Positive studies
 ESR > 25.
 Plain x-ray: vertebral collapse or bone destruction.
The management of chronic LBP begins usually with a conservative approach because
surgery is expensive and not always effective. One such conservative approach is
mechanical spinal traction which relies on the application of a continuous or intermittent
distraction-force between the pelvis and ribcage. (5)
TRACTION
The word traction is a derivative of the Latin "tractico", which means "a process of
drawing or pulling." As traction is applied, the movement produced at the segment is a
combination of distraction and gliding. (6) Systematic reviews of literature (7-10) and
evidence- based guidelines (9, 10) have concluded that there is not enough evidence to
support the conventional supine lumbar traction as an effective treatment for patients
with LBP. Epidurography and CT investigations have shown that high-force traction can
reduce disk protrusions and relieve spinal nerve root compressionsymptoms.

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Some of the studies that showed lumbar traction was ineffective were performed with
low forces. In many of the studies, patient selection criteria were poorly defined. (11)
Variables for lumbar traction
Position:
Lumbar traction can be administered in the prone position or supine, with the traction
belts exerting a pull to the anterior or posterior aspect of the joint. (11) The Fowler’s
position (i.e. supine with the hips and knees flexed, and the lower legs supported on a
stool) is clinically important in that it reduces the traction force required to stretch
posterior tissues as compared to traditional supine position. The Fowler’s position
imposes a significant flexion moment on the lumbar spine. (12)
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.(9)It is
possible to apply heating therapy synchronized with traction application and relaxing
muscular spasm in prone position that impossible to be applied in supine position.(13)
Prone position may reduce a patient’s reflex spinal muscle contraction and allows
distraction of the vertebrae, causing a subsequentsymptom reduction.(14-17)
Force:
There is consensus in the literature that a force of 40% to 50% of the patient’s body
weight is necessary to cause vertebral separation. Judovich advocated a force equal to
one half the patient’s body weight on a friction-free surface as the minimum force
necessary to cause therapeutic effects in the lumbar spine. (11)
Mode:
Some conditions, such as herniated disc seem to respond better to sustained traction,
while conditions such as joint hypomobility and muscle guarding are usually treated
more effectively with intermittent traction(6). Herniated disk is usually treated more
effectively in static mode or with longer hold-rest periods (3- to 5-minute hold, 1-minute
rest) in intermittent mode. Joint dysfunction and degenerative disk disease usually
respond to shorter hold-rest periods (1 to 2 minute hold, 30-second rest) in intermittent
mode.(11)

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Time:
As the disk space widens, the intradiskal pressure decreases, causing the herniated disk
material to be retracted into the disk space. The decrease in pressure is temporary,
however, because eventually the decreased intradiskal pressure will cause fluid to be
imbibed into the disk. When pressure equalization occurs, the suction effect on the disk
protrusion is lost, and it is possible for patients to experience a sudden increase in pain
when traction is released. If the traction time is 8 to 10 minutes, this effect is minimized.
For other conditions, a treatment time of up to 20 minutes is often used. As a general
rule, the higher the force, the shorter the treatment time. (11)
EXTENSION ORIENTEDTREATMENTAPPROACH(EOTA)
This approach typically involves some combination of active or passive activities to
promote extension in the lumbar spine (18, 19).Several studies have examined the
effectiveness of an EOTA for subjects with LBP, with most finding no benefit compared
with other treatments. The key criterion for inclusion in the EOTA subgroup is the
presence of the centralization phenomenon with extension movement testing during the
physical examination. Extension exercises are progressed as tolerated starting with static
prone positioning and progressing to sustained and repeated end range prone and
standing extension. (20) The centralization phenomenon occurs when a movement or
position results in the migration of symptoms from an area more distal or lateral in the
buttocks or lower extremity to a location more proximal or closer to the midline of the
lumbar spine. (19)

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NEEDS OF THE STUDY:
1) Although traction is widely used for the treatment of lumbar spine, efficacy and
application method of it remain unresolved. There is not enough evidence of the effects
of prone traction.
2) Systematic reviews of literature and evidence- based guidelines have concluded that
there is not enough evidence to support the conventional supine lumbar traction as
aneffective treatment for patients with chronic LBP.
3) To study the effectiveness of adding a conventional protocol of lumbar mechanical
traction to an extension-oriented treatment approachfor individuals with chronic LBP
OBJECTIVESOF THE STUDY:
1) To compare the outcomes of prone traction and supine lumbar traction in conjunction
with extension-oriented treatment approach(EOTA) in subjects with chronic LBP
2) To evaluate the effectiveness of prone traction along with extension-oriented
treatment approach(EOTA) for chronic LBP.
HYPOTHESIS:
1) Researchhypothesis:
There will be significant difference between prone traction with EOTA and supine
traction with EOTA for chronic LBA in decreasing pain and back disability.
2) Null hypothesis:
There will be no significant difference between prone traction with EOTA and
supine traction with EOTA for chronic LBA in decreasing pain and back disability.

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REVIEW OF LITERATURE
1. Mahmoud Beyki et al. (2007) compared the outcomes of prone and supine
lumbar traction in patients with chronic discogenic low back pain. A 4-week
course of lumbar traction, prone or supine in case and control groups
consecutively, consisting of six 30-minute sessions every other days, followed by
four 30-minute sessions every 3 days was carried out. The study concluded that
Traction applied in the prone position was associated with improvements in pain
intensity and ODI scores at discharge, in a sample of 124 patients with activity
limiting LBP. Prone traction has some superiority on traditional supine traction at
least in early stages after treatment.
2. RemziCevik et al (2007) Aimed to investigate effect of new traction technique on
anatomic structures of lumbar vertebrae, and its’ relation to different application
of heating therapy. Ninety five consecutive patients with persistent low back pain
were applied traction on a new table in prone position. Heating therapy applied
concomitantly with traction (group I, n: 32) and sham traction (group III, n: 31),
and before traction (group II, n: 32). Lateral lumbosacral radiographs were
obtained before and during traction. They concluded that Significant widening in
lumbar intervertebral disc spaces and flattening in lumbar lordosis were
accomplished by new table. Synchronized heating therapy with traction has more
effect on distracion of disc spaces than separately applying. Furthermore, creation
of negative intradiscal pressure with this distraction is important to suck back
herniated disc material in prone position.
3. Lee RYW and Evans JH (2001) Studied to determine the loads acting on the
lumbar spine when traction therapy was given in the Fowler’s position. The study
had two parts: a theoretical analysis which showed that traction produced a
flexion moment on the spine as well as axial distraction; and an experimental
study which measured the flexion moment induced by the adoption of the
Fowler’s position. The Fowler’s position is clinically essential in that it flexes the
spine and takes up the slack of the posterior tissues before the traction force is
applied. Hence the axial tension and flexion moment generated by the traction
force are more effective in stretching the posterior tissues.

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4. Morton C. R.(1957) the purpose of this article was to report the results obtained
in the first hundred cases in which they used cyriax traction device for the relief of
disc syndrome. The patient was positioned either prone or supine, according to
comfort, usually the former. The traction force was of 80 to 200 lb. for about half
an hour. Mechanical traction in this series of cases was proved to be a marked
advance.
5. Paul F Beattie et al. (2008) studied to determine outcomes after administration of
a prone lumbar traction protocol. The numeric pain rating scale and the Roland-
Morris Disability Questionnaire (RMDQ) were completed at preintervention,
discharge (within 2 weeks of the last visit), and at 30 days and 180 days after
discharge. Intention-to-treat strategies were used to account for those subjects lost
to follow-up. Traction applied in the prone position using the VAX-D for 8 weeks
was associated with improvements in pain intensity and RMDQ scores.
6. Hebert et al. (2011) studied to identify subgroups of patients with LBP and
match them with targeted therapies. Sub-grouping patients with LBP using the
treatment-based classification criteria allows for improved identification of those
who are most likely to experience clinical success with spinal manipulation,
stabilization exercise, end-range loading exercise, and traction therapies.
7. David A Browder et al. (2007) Studied to examine the effectiveness of an
extension-oriented treatment approach (EOTA) in a subgroup of subjects with low
back pain (LBP) who were hypothesized to benefit from the treatment compared
with similar subjects who received a lumbar spine strengthening exercise
program.Forty-eight subjects were randomly assigned to groups that received an
EOTA (n=26) or a strengthening exercise program (n=22). Subjects attended 8
physical therapy sessions and completed a home exercise program. Follow-up
data were obtained at 1 week, 4 weeks, and 6 months after randomization. They
concluded that EOTA was more effective than trunk strengthening exercise in a
subgroup of subjects hypothesized to benefit from this treatment approach.
Additional research is needed to explore whether an EOTA may benefit other
subgroups of patients.

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8. Julie M Fritz et al. (2010) studied the effectiveness of a treatment protocol of
mechanical traction with extension-oriented activities for patients with low back
pain and signs of nerve root irritation within the pre-defined sub-group.120
patients with low back pain and signs of nerve root irritation were randomized
based on the presence of the pre-defined sub-grouping criteria. Patients received
12 physical therapy treatment sessions over 6 weeks. Follow-up assessments after
6 weeks, 6 months, and 1 year were taken. The primary outcome measures were
modified Oswestry questionnaire. Secondary outcomes included self-reports of
low back and leg pain intensity, quality of life, global rating of improvement,
additional healthcare utilization, and work absence. They concluded that this
approachmay be effective, particularly in a more specific sub-group of patients.
9. H. Duane Saunders (1979) studied various reviews and came with standardized
variations and application procedures for lumbar traction.
10.Geraldine L. Pellecchia (1994)reviewed various literature evidences and
concluded that clinical effects of lumbar traction are conflicting, many aspects
have not been systematically investigated and classification system that identify
patients likely to benefit from traction must be developed and validated.
11.Davidson M and Keating J (2002) studied 5 commonly used questionnaires for
assessing disability in people with low back pain. Patients with low back pain
completed the questionnaires during initial consultation with a physical therapist
and again 6 weeks later (n_106). Test-retest reliability was examined for a group
of 47 subjects who were classified as “unchanged” and a subgroup of 16 subjects
who were self-rated as “about the same”. They concluded that the Oswestry
Disability Questionnaire, the SF-36 Physical Functioning scale, and the Quebec
Back Pain Disability Scale have sufficient reliability and scale width to be applied
in an ambulatory clinical population with low back problems. The Waddell
Disability Index has insufficient scale width for clinical utility. The Roland-
Morris Disability Questionnaire and the SF-36 Role Limitations–Physical and
Bodily Pain scales did not have sufficient reliability to be recommended as
clinical outcome measures for individual patients.

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MATETRIALS AND METHODOLOGY
STUDY DESIGN:
Comparative study.
SETTING:
Sri Venkateshwaraa Medical College Hospital And Research Centre,
Department Of Physiotherapy, Ariyur, Pondicherry-605 102
SOURCE OF DATA:
Subjects diagnosed with chronic LBA with radicular symptoms from hospitals
and clinics in and around Pondicherry and referred to SVMCH&RC, Department of
Physiotherapy.
METHOD OF COLLECTION OF DATA:
Male and female subjects with chronic LBP and radicular symptoms who satisfy
the selection criteria.
SELECTION CRITERIA:
INCLUSION CRITERIA:
 Chronic (> 3 months) low back pain.
 Age 30-65 years.
 LBP with the presence of associated lower extremity pain.
 Pain that had an average intensity greater than or equal to 4/10 on an 11 point
numeric pain rating scale (NPRS).
 Subjects who have imaging evidence of a degenerative and / or herniated
intervertebral disk at one or more levels of the lumbar spine.
 LBA resulting from factors such as lumbar disc bulging, facet syndrome,
spondylosis.
 Presence of signs of nerve root compression, centralization with extension
movement, positive crossed SLR test or reduction of symptoms by manual lumbar
traction.
 All subjects must have reported a lack of favorable outcomes after at least 1
previous, non-operative interventions (e.g., Joint manipulation, TENS, or oral
medications) for their current symptoms.

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EXCLUSION CRITERIA:
 Unstable spine (bilateral pars defect or spondylolisthesis).
 Spinal surgical implants, recent spinal surgery.
 Spinal pain due to tumor.
 Infection.
 Inflammatory diseases or metabolic diseases.
 Pregnancy.
 Osteoporosis.
 Formal therapeutic or medical intervention within the last three months (e.g.
epidural injection, facet joint block etc.) or the use of prescription anticoagulants,
corticosteroids, or opiate-based pain medications.
 Concomitant severe medical problem preventing participation in the trial (cardiac
conditions, respiratory conditions, neurological disorder or organ disease).
 Subjects were also excluded if there were radiographic or physical examination
evidence of conditions that would represent precautions or contraindications for
traction.
 History of major psychiatric illness.
 History of trauma / fracture.
SAMPLE METHOD AND SAMPLE SIZE:
Sample method: Simple non-consecutive convienent sampling.
Sample size: 52 subjects with 26 in each group.
MATERIALS REQUIRED:
 Mechanical lumbar traction unit
 Oswestry disability questionnaire
 Numeric pain rating scale

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PROCEDURE:
After fulfilling the inclusion criteria and obtained an informed consent subjects were
recruited for this study. Subjects were divided into 2 groups based on patient preference
and condition specific.
Group A: subjects received prone traction and extension oriented treatment approach
(EOTA).
Group B: Subjects received supine lumbar traction in fowler’s position and extension
oriented treatment approach(EOTA).
Figure 1: Participant flow through the study

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At baseline, subjects completed self-report measures and then received a standardized
history and physical examination. Self-report measures included the ODQ and Numeric
Pain Rating Scale (NPRS).
Manual lumbar traction was used to test the patient’s tolerance of traction and to find
most comfortable direction in which to administer the treatment. (6)
A single movement of lumbar extension was assessed first, followed by repeated
extension movements consisting of 10 repetitions performed with the subject standing.
Repeated extension movements also were performed with the subject positioned prone.
Centralization was judged to be present when extension movementabolished symptoms
or caused symptoms to move proximally toward themidline of the lumbar spine in at
least one of these positions. The interraterreliability of determining the presence of
centralization using thisdefinition has been reported to be high. (21)
The electromechanical system used was cervical cum lumbar traction with molded
aluminium gearbox and metal gear by technomed consisting of friction less split table
for lumbar traction.
The traction force was applied for 20 min in prone / supine position to the grouped
subjects respectively. The effective range of force used was 30% to 50% of body weight.
The setting of traction was intermittent hold for 30 seconds, then rest for 10 seconds.
The position for traction is decided by patient comfort and the ability of the patient to
remain relaxed during treatment. For subjects in prone traction, the amount of lumbar
flexion was controlled by pillows under the pelvis (10° of hip flexion).
Intensity of the treatment was set initially to 30% of the weight of the subject and then
increased to 40 - 50% gradually according to patient tolerance up to third week.

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Figure 2: patient in prone lumbar traction
Figure 3:Patient in fowler’s position for traction

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The EOTA intervention involved two components. The goals of each component were
to promote centralization of symptoms of the lumbar spine. The first component was a
series of active extension-oriented exercises (table 1). These exercises consisted of
sustained and repeated extension movements performed with the subject prone or
standing.
Figure 4: Prone on elbows
Figure 5: Prone press up

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Table 1: Exercise progression within the extension-oriented treatment approach. (22)
Extension-Oriented Exercises Goal Options for Progression
1) Prone Lying 5 minutes May use pillow to allow lumbar flexion initially if needed
May shift pelvis laterally if needed
Progress to full lumbar extension without pillows or lateral
shift of pelvis
Progress time up to 5 minutes
2) Prone Lying on Elbows 5 minutes May use partial range of extension motion initially if needed
Progress to full lumbar extension with-out lateral shift of
pelvis
Progress time up to 5 minutes
3) Prone Press-Ups 30
repetitions
May use partial range of extension motion initially if needed
pelvis
Progress to exhalation during the last repetition to promote
increased extension
Progress up to 30 repetitions
4) Extension in Standing 30
repetitions
May use partial range of extension motion initially if needed
pelvis
Progress up to 30 repetitions

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The exercises may be performed with a lateral component (i.e. shifting of the pelvis in
the frontal plane) if this facilitates centralization. Not all exercises will be used for every
subject, only those which promote centralization. Exercise progression will be
accomplished by increasing the exercise time (up to 5 minutes for sustained exercises)
or repetitions (up to 30 repetitions per session) motion is obtained. Subjects will be
instructed to perform all assigned exercise activities once after each traction session and
at home, every 8 hours throughout the day, on days when they do not have a treatment
session. Subject compliance with their home exercise program will be recorded at each
treatment session. The second component of the EOTA will be subject education.
Subjects will be educated to maintain the natural lordosis of the lumbar spine while
sitting, and will be instructed to avoid prolonged sitting. Each subject would be
scheduled for 5 days/ week each for 3 weeks.
OUTCOME MEASURES:
1) Pain intensity: 11 point NPRS(23-25)Anchor points are defined as 0 (none) and
10 (worst imaginable).
2) OswestryDisability Questionnaire(26, 27): Back pain related activity limitation is
assessed byusing 10 items. Each item is measured on a 6 point scale.

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STATISTICAL TOOLS:
All data analyses were done with SPSS statistical software (SPSS)and presented as
mean value ± SD.
For using the above said outcome measures, data were collected regarding the pretest
and posttestvalues. The related paired “t” test was performed to find the significant
changes after treatment using the formula.
S.D. = √∑(d−d)
2
n−1
S.D. =standard deviation
d = mean value of the difference between pretest and posttest
n = no of observations
t =
d
S.D√n

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DATA ANALYSIS AND PRESENTATION
Table 2: subject characteristics
Characteristic Group A Group B
Age(mean±SD)(years) 43.84 45.80
Male/Female
10/16 23/3
Weight(mean±SD)(kg) 56 61

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Table 3: Group A
sr
no.,
NPRS ODQ
Pre
test
Post
test
Pre
test
Posttest
1) 8 4 47 35.5
2) 6 3 44.4 24.4
3) 7 5 52 40
4) 5 0 24.4 17.7
5) 7 4 42.2 33.3
6) 7 4 48.8 33.3
7) 5 0 28.8 17.7
8) 7 2 62.2 37.7
9) 6 1 33.3 24.4
10) 6 1 42.2 28.8
11) 6 3 40 24.4
12) 7 3 64.4 28.8
13) 6 1 44.4 17.7
Sr.
no,.
NPRS ODQ
Pre
test
Post
test
Pre
test
Post
test
14) 5 1 68.8 35.5
15) 7 4 53.3 33.3
16) 8 3 64.4 28.8
17) 6 3 52 24.4
18) 5 1 37.7 17.7
19) 7 2 40 24.4
20) 7 2 53.3 17.7
21) 8 4 57.7 28.8
22) 6 2 37.7 28.8
23) 7 2 44.4 28.8
24) 6 1 40 17.7
25) 6 2 44.4 24.4
26) 5 1 37.7 17.7

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Table 4: Group B
Sr.no.
NPRS ODQ
Pre
test
Post
test
Pre
test
Post
test
1) 5 4 51 40
2) 5 4 57.7 35.5
3) 6 5 48.8 35.5
4) 6 1 42.2 24.4
5) 7 2 53.3 35.5
6) 5 2 51.1 28.8
7) 7 2 60 40
8) 6 1 48.8 37.7
9) 7 3 71 42.2
10) 6 2 60 35.5
11) 7 4 57.7 40
12) 7 2 51.1 33.3
13) 6 2 40 35.5
Sr. no
NPRS ODQ
Pre
test
Post
test
Pre
test
Post
test
14) 6 1 37.7 24.4
15) 8 3 71.1 40
16) 6 3 52 28.8
17) 5 2 42.2 24.4
18) 6 3 33.3 17.7
19) 7 4 68.8 35.5
20) 5 3 37.7 17.7
21) 7 3 64.4 28.8
22) 6 4 53.3 33.3
23) 5 2 42.2 28.8
24) 7 3 57.7 33.3
25) 6 2 40 17.7
26) 5 3 33.3 24.4

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Table 4: statistical presentation of mean
Mean (x) Mean( ) S.D T value P value
Group A
NPRS 6.38 2.26 0.90
1.658 0.110
ODQ 46.36 26.6 8.90
Group B
NPRS 6.11 2.69 8.90
3.023 0.006
ODQ 51.01 31.48 7.4
0
1
2
3
4
5
6
7
Group A Group B
6.38
6.11
2.26
2.69
NPRS
Pre test
Post test

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RESULTS
After confirming the statistical significance between two groups, NPRS decrement (after
intervention) in prone and supine groups, has no meaningful difference (P = 0.110).
After confirming the statistical significance between two groups, ODQ decrement (after
intervention) has meaningful difference (p = 0.05) prominent in prone group.
0
10
20
30
40
50
60
Group A Group B
46.36
51.01
26.6
31.48
ODQ
Pre test
Post test

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DISCUSSION
This study will examine the effectiveness of adding a standardized protocol of lumbar
mechanical traction to an extension-oriented treatment approach for individuals with
LBP and nerve rootirritation.
The study used patients who are likely to respond to the intervention on the basis of
treatment-based classification subgroups with identification criteria and treatment
approaches for patients with low back Pain. (28)
Traction has the advantage of being non-invasive with a relatively low risk of injury to
the patient. Traction can affect metabolism of disc, facilitate the transfer of oxygen and
nutrient into the disc, relieving irritation and compression on pain sensitive structures
enhancing healing and repair. (29)
Synchronized heating therapy with traction has more effect on distracion of disc spaces
than separately applying. Furthermore, creation of negative intradiscal pressure with this
distraction is important to suck back herniated disc material in prone position. (13)
EOTA is a more effective treatment than a strengthening approach for patients with
symptoms extending to the buttocks or more peripherally who demonstrate
centralization with extension movements. (20) EOTA is a stage I exercise protocol for
chronic LBP.
Mckenzie proposed that spinal extension pushes the nucleus pulposus anterior and away
from the spinal nerve roots and other pain producing structures. (30) Although the
magnitude and clinical relevance of nuclear movement with extension is
Controversial. (31, 32)
As extension exercises are contraindicated in patients with spondylolisthesis hence these
patients were not included in the study.
Since the study lacked a randomized control group it is difficult to imply a causal
relationship between the traction applied and outcome.

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CONCLUSION
In conclusion, this is a preliminary study to investigate efficacy of prone lumbar traction
in comparison with supine lumbar traction in fowler’s position in conjunction with
EOTA. Mechanical lumbar traction along with EOTA in both the groups proved to be
effective and showed significant improvement of ODQ in prone lumbar traction group.
Further study is needed using randomized controlled comparison groups of large
population and with longer study duration.

31
RECOMMENDATIONS
1) Heat therapy like hot packs can be synchronized with traction application and
relaxing muscular spasmin prone position that is impossible to be applied in
supine position.
2) Similar studies could be attempted by other direction specific exercises like
flexion and lateral shift.
3) It is recommended that more advanced traction units like vertical axial
decompression(VAX –D) and other decompressiontherapy units may be used for
better analysis however they are more expensive to administer than most
conventional traction protocols.
4) It is also recommended that the third component of the EOTA that is
mobilization (application of a posterior- to-anterior mobilization force directed
over the spinous process, orlaterally over the transverse process using a grade I -
IV mobilization of the lumbar spine) based on the consideration of promoting
centralization and lumbar extension range of motion may be useful in this type of
study method.(22)
5) It is further recommended that to use the low back pain rating scale that was
developed by manniche to address three separate dimensions of LBP, namely
pain, disability and physical impairment. The measures used to evaluate physical
impairment included a back extensor endurance test, a modified schobertest, and
a functional mobility test. (33, 34)
LIMITATIONS
1) There was lack of long time reasonable follow-up, we cannot imply a long lasting
relationship between the traction and outcome, and a long time follow-up is
suggested.
2) This study did not include patients whowere not expected to respond to an EOTA.

32
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34
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35
APPENDIX - I
NAME :
AGE :
SEX :
PATIENT NO. (OP/IP No.) :
ADDRESS :
OCCUPATION :
WEIGHT :
GROUP :
INCLUSION CRITERIAS :
GROUP INTERVENTION :
EXTENSION ORIENTED EXERCISE PROGRESSION :
OUTCOME MEASURES :
MEASUREMENT TOOLS NUMERIC PAIN RATING
SCALE
OSWESTRY DISABILITY
QUESTIONNAIRE
PRE-TEST
POST-TEST

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