"Serial MRI of 20 patients treated with the decompression table shows in our study up to 90% reduction of subligamentous nucleus herniation in 10 of 14. Some rehydration occurs detected by T2 and proton density signal increase. Torn annulus repair is seen in all."

Eyerman, Edward MD. Simple pelvic traction gives inconsistent relief to herniated lumbar disc sufferers. Journal of Neuroimaging. Paper presented to the American Society of Neuroimaging, Orlando, Florida 2-26-98.

SIMPLE PELVIC TRACTION GIVES INCONSISTENT RELIEF TO HERNIATED LUMBAR DISC SUFFERERS.

EDWARD L. EYERMAN, MD
Journal of Neuroimaging June 1998

A new decompression table system applying fifteen 60 second tractions of just over one half body weight in twenty one-half hour sessions was reported to give good or excellent relief of sciatic and back pain in 86% of 14 patients with herniated discs and 75% of patients with facet joint arthrosis. (Shealy, C.N.,Borgmeyer, V., AMJ. Pain Management 1997,7:63-65).

Herniated and degenerated discs can be shown at discography-discomanometry to have elevated intradiscal pressures made even worse by sitting and standing, thus preventing proper disc nutrition. Therefore decompressing the over pressurized disc should allow for healing and repair of disc prolapse, herniation and annulus tears. Serial MRI of 20 patients treated with the decompression table shows in our study up to 90% reduction of subligamentous nucleus herniation in 10 of 14. Some rehydration occurs detected by T2 and proton density signal increase. Torn annulus repair is seen in all. Transligamentous ruptures show lesser repair. Facet arthrosis can be shown to improve chiefly by pain relief. Follow up studies for permanency or relapses are in progress.

The DRS Mechanical Decompression Distraction System was described by Shealy and Borgmeyer (1) to give relief of lumbar herniated disc and facet joint arthrosis superior by 50% to conventional pelvic traction. Twenty DRS treatments produced on midsagittal MRI a 50% reduction in one case, and a 7mm distraction of 1.5 on SI was shown on lateral x-ray. (2) Clinical improvement in 75 to 85% of subjects was reported. Does clinical betterment correlate directly to improvement in MRI image and can MRI shed any light on the mechanism of improvement?

That the abnormal disc has an elevated pressure can be appreciated at discogram. It is postulated that this elevated pressure interferes both with diffusion of nutrients from surrounding vessels into the nucleus and with adequate patching or repair of the tom annulus. Nachemson's group has emphasized lowering intradiscal pressure for 30 years. (3) & (4) Neurosurgeons Rainon and Martin (5) at operation on a similar decompression table measured in an L45 herniated disc a lowering of intradiscal pressure from 30 to 50 mm above the normal 90 to 100 mmHg into the negative range of minus 100 to 150 mmHg during 90 to 95 LB traction. Will such negative pressures heal the annulus, rehydrate the nucleus?

The aim of the present study was to do before and after MRI to correlate clinical improvement with any MM evidence of disc repair in annulus, nucleus, facet joint or foramen as a result of DRS treatment. A course of 20 DRS Lumbar De-compression treatments were given in 4 to 5 weeks to 18 patients, and a double course of 40 in 10 weeks to 2 more. Pull of distraction was adjusted to one half-body weight plus IO lbs. Each session consisted of 20 repetitions in 30 minutes of full distraction for 60 seconds and 30 seconds of relaxation to 50 lbs. Distraction angle on pelvic harness was varied from 10% for L5-S I to 20 to 25% for L4-5 herniations and above.

Subjects comprised 12 males and 8 females from age 26 to 74. Radiculopathy in 14 patients was from herniated discs of varying sizes. (L5-S I level in 6, L4-5 in 6, and 1 each at L3-4 and L2-3). Radiculopathy without disc herniation was present in 6 patients from foraminal stenosis facet arthropathy and lateral spinal stenosis. EMGs confirmed radiculopathy in all. MRI's before and after were obtained on high and mid field units. Clinical status was assessed before, during, and after treatment with standard analog pain rating scale of 0- I0 and a neuro exam.

Range of motion for spinal mobility (initially impaired in all), myotomal weakness reflex and dermatomal sensory loss were tested.

A) MRI OUTCOMES

a) Disc Herniation: 10 of 14 improved significantly, some globally, some at least local at the site of the nerve root compression. Measured improvement in local or general disc herniation size varied in range of 0% in 2 patients, 20% in 4 patients, 30 to 50% in 4 patients and a remarkable 90 % in 2 patients who had the number of treatments at 40 sessions in 8 weeks. b) Facet joint arthropathy and foraminal compression cases showed no demonstrable change save 2 cases with slight increase in height but not in hydration.

B) CLINICAL OUTCOMES

Irrespective of MRI status all but 3 patients had very significant pain relief, complete relief of weakness when present, and of immobility and of all numbness (save in 1 patient with herniation and 2 with foraminal stenosis without herniation). With disc herniation, 10 patients of 14 had 10 to 90% improvement in pain and disability. Two had 40 to 50%, one had only 20% with foraminal syndrome without herniation, 4 had 70 to 100 % improvement, one had 40 to 50 %, one with severe spinal stenosis had only 25% and was sent for surgery. Degree of clinical improvement roughly followed MRI changes but not totally with full correlation.

Improvement from DRS treatment clinical outcome of radiculopathy whether from disc herniation or foraminal syndromes is more impressive than most improvement shown consistently by MRI, at least with today's techniques and short time of follow-up. Relief of pain and disability by reduction of disc size is easy to argue in a small majority of this series. A few patients have dramatic anatomic improvement. The others with minimal or no significant MRI improvements are harder to explain. Also, many patients improved very early in treatment, probably before MRI change could be seen.

Nutrient diffusion increase and tom annulus healing resulting from lowering intradiscal pressures are likely causes of clinical improvement when MRI anatomy is not much altered by distraction. Leaking of important sulfates and carboxylates from the nucleus and posterior annulus have been shown in recent studies. (6) and (7) lowering of intradiscal pressure by DRS treatment likely can start to reverse these processes by allowing fibroblast repair of the annulus outer layers and some nutrition to the nucleus. Also penetration of nerves into inner annulus and nucleus of degenerated prolapsed discs has been recently demonstrated and could play a role in pain production. (8) Mechanical intradiscal pressure relief may help this feature as well as giving structural stability.

(1) DRS distraction treatments afforded good or excellent relief of pain and disability whether from herniated disc or foraminal or lateral spinal stenosis.

(2) MRI showed imperfect correlation with degree of clinical improvement but 10 to 90% reduction in disc herniation size could be seen at least at the critical point of nerve root impingement in 10 of 14 patients.

(3) Two patients with extended courses of treatment showed 90% disc reduction and one of these had early rehydration of the degenerated disc at L4-5. An "empty pouch" sign on MRI at the site of previous herniation was seen in these 2 patients.

(4) Foraminal and lateral spinal or facet arthrosis cases causing radiculopathy without herniation also improved but without MRI change.

(5) Annulus healing or patching in the herniated disc can be shown by MRI and is postulated to be a primary factor in clinical and MRI improvement.

"Eighty-six percent of ruptured intervertebral disc (RID) patients achieved 'good' (50-89% improvement) to 'excellent' (90-100% improvement) results with decompression. Sciatica and back pain were relieved." "Of the facet arthrosis patients, 75% obtained 'good' to 'excellent' results with decompression."

C. Norman Shealy, MD, PhD, and Vera Borgmeyer, RN, MA.
Decompression, Reduction, and Stabilization of the Lumbar Spine: A Cost-Effective Treatment for Lumbosacral Pain. American Journal of Pain Management Vol. 7 No. 2 April 1997

American Journal of Pain Management Vol. 7 No. 2 April 1997
Emerging Technologies: Preliminary Findings

DECOMPRESSION, REDUCTION, AND STABILIZATION OF THE LUMBAR SPINE: A COST-EFFECTIVE TREATMENT FOR LUMBOSACRAL PAIN

C. Norman Shealy, MD, PhD, and Vera Borgmeyer, RN, MA

C. Norman Shealy MD, PhD, is Director of The Shealy Institute for Comprehensive Health Care and Clinical Research and Professor Of Psychology at the Forest Institute of Professional Psychology. Vera Borgmeyer is Research Coordinator at the Shealy Institute for Comprehensive Health Care and Clinical Research. Address reprint requests to: Dr. C. Norman Shealy, The Shealy Institute for Comprehensive Health Care and Clinical Research , 1328 East Evergreen Street, Springfield, MO 65803.

INTRODUCTION

Pain in the lumbosacral spine is the most common of all pain complaints. It causes loss of work and is the single most common cause of disability in persons under 45 years of age (1). Back pain is the most dollar-costly industrial problem (2). Pain clinics originated over 30 years ago, in large part, because of the numbers of chronic back pain patients. Interestingly, despite patients' reporting good results using "upside-down gravity boots," and commenting on how good stretching made them feel, traction as a primary treatment has been overlooked while very expensive and invasive treatments have dominated the management of low back pain. Managed care is now recognizing the lack of sufficient benefit-cost ratio associated with these ineffective treatments to stop the continued need for pain-mitigating services. We felt that by improving the "traction-like" method, pain relief would be achieved quickly and less costly.

Although pelvic traction has been used to treat patients with low back pain for hundreds of years, most neurosurgeons and orthopedists have not been enthusiastic about it secondary to concerns over inconsistent results and cumbersome equipment. Indeed, simple traction itself has not been highly effective, therefore, almost no pain clinics even include traction as part of their approach. A few authors, however, have reported varying techniques which widen disc spaces, decompress the discs, unload the vertebrae, reduce disc protrusion, reduce muscle spasm, separate vertebrae, and/or lengthen and stabilize the spine (3-12).

Over the past 25 years, we have treated thousands of chronic back pain patients who have not responded to conventional therapy. Our most successful approach has required treatment for 10-15 days, 8 hours a day, involving physicians, physical therapists, nurses, psychologists, transcutaneous electrical nerve stimulator (TENS) specialists, and massage therapists in a multidisciplinary approach which has resulted in 70% of these patients improving 50-100%. Our program has been recognized as one of the most cost-effective pain programs in the US (I 3). The average cost of the successful pain treatment has been cited as less than half the national average (13).

Our protocol combined traditional, labor-intensive physical therapy techniques to produce mobilization of the spinal segments. This, combined with stabilization, helped promote healing. In addition we used biofeedback, TENS, and education to reinforce the healing processes. We wanted to produce a simpler and more cost-effective protocol that could be consistently reproduced. The biofeedback and education could be easily replicated. The problem was producing spinal mobilization to the degree that we could decompress a herniated nucleus and relieve pain. Stabilization would come after pain relief.

The DRS System was developed specifically to mobilize and distract isolated lumbar segments. Using a specific combination of lumbar positioning and varying the degree and intensity of force, we produced distraction and decompression. With fluoroscopy, we documented a 7-mm distraction at 30 degrees to L5 with several patients. In fact, we observed distraction at different spinal levels by altering the position and degree of force.

We set out to evaluate the DRS system with outpatient protocols compared to traditional therapy for both ruptured lumbar discs and chronic facet arthroses.

Subjects. Thirty-nine patients were enrolled in this study. There were 27 men and 12 women, ranging in age from 31 to 63. Twenty-three had ruptured discs diagnosed by MRI. Of these, all but four had significant sciatic radiation, with mild to moderate L5 or S1 hyperalgesic. All had symptoms of less than one year.

The facet arthrosis patients also underwent MRI evaluations to rule-out ruptured discs or other major pathologies. They had experienced back pain from one to 20 years. Six had mild to moderate sciatic pain with significant limitations of mobility.

METHODOLOGY

Patients were blinded to treatment and were randomly assigned to traction or decompression tables. Traction patients were treated on a standard mechanical traction table with application of traction weights averaging one-half body weight plus 10 pounds, with traction applied 60-seconds-on and 60-seconds off, for 30 minutes daily for 20 treatments. Following the traction, Polar Powder ice packs and electric stimulation were applied to the back for 30 minutes to relieve swelling and spasm, and patients were then instructed in use of a standard TENS use to be employed at home continuously when not sleeping. After two weeks, the patients received a total of three sessions with an exercise specialist for instruction in and supervision of a limbering/strengthening exercise program. They were re-evaluated at five to eight weeks after entering the program.

Decompression patients received treatment on the DRS System, designed to accomplish optimal decompression of the lumbar spine. Using the same 30 minute treatment interval, the patients were given the same force of one-half the body weight plus 10, but the degree of application was altered by up to 30 degrees. The effect was to produce a direct distraction at the spinal segment with minimal discomfort to the patient.

Eighty-six percent of ruptured intervertebral disc (RID) patients achieved "good" (50-89% improvement) to "excellent" (90-100% improvement) results with decompression. Sciatica and back pain were relieved. Only 55% of the RID patients achieved "good" improvement with traction, and none excellent."

Of the facet arthrosis patients, 75% obtained "good" to excellent" results with decompression. Only 50% of these patients achieved "good" to "excellent" results with traction.

DISCUSSION

Since both traction and decompression patients received similar treatment (except for the differences in the traction table versus the decompression table) with similar weights, ice packs, and TENS, the results are quite enlightening. The decompression system is encouraging and supports the considerable evidence reported by other investigators stating that decompression, reduction, and stabilization of the lumbar spine relieves back pain. The computerized DRS System appears to produce consistent, reproducible, and measurable non-surgical decompression, demonstrated by radiology.

Of equal importance, the professional staff facilities required, as well as the time and cost, are all significantly reduced. Since the more complex treatment program of the last 25 years has already been shown to cost 60% less than the average pain clinic, the cost of this simpler and more integrated treatment program should be 80% less than that of most pain clinics-a most attractive solution to the most costly pain problem in the US. In addition, patients follow a 30-day protocol that produces pain relief yet allows them to continue daily activities and not lose workdays.

SUMMARY

We have compared the pain-relieving results of traditional mechanical traction (14 patients) with a more sophisticated device which decompresses the lumbar spine, unloading of the facets (25 patients). The decompression system gave "good" to "excellent" relief in 86% of patients with RID and 75 % of those with facet arthroses. The traction yielded no "excellent" results in RID and only 50% "good" to "excellent" results in those with facet arthroses. These results are preliminary in nature. The procedures described have not been subjected to the scrutiny of review nor scientific controls. These patients will be followed for the next six months, at which time outcome-based data can be reported. These preliminary findings are both enlightening and provocative. The DRS system is now being evaluated as a primary intervention early in the onset of low back pain-especially in workers' compensation injuries.

REFERENCES

1. Acute low back problems in adults: assessment and treatment. US Department of Health and Human Services; 1994 Dec; Rockville, MD.

2. Snook, Stover. The costs of back pain in industry. occupational back pain, State-of-art review. Spine 1987; 2(No. 1): 1-4.

3. Gray FJ, Hoskins MJ. Radiological assessment of effect of body weight traction on lumbar disk spaces. Medical Journal of Australia 1963;2:953-954.

4. Andersson GB, Gunnar BJ, Schultz, AB, Nachemson AL. Intervertebral disc pressures during traction. Scandinavian Journal of Rehabilitation Medicine 1968; (9 Supplement): 8891.

5.Neuwirth E, Hilde W, Campbell R. Tables for vertebral elongation in the treatment of sciatica. Archives of Physical Medicine 1952; 33 (Aug):455-460.

6. Colachis SC Jr, Strohm BR. Effects of intermittent traction on separation of lumbar vertebrae. Archives of Physical Medicine & Rehabilitation 1969; 50 (May):251-258.

7. Gray FJ, Hosking HJ. A radiological assessment of the effect of body weight traction on the lumbar disc spaces. The Medical Journal of Australia 1963; (Dec 7):953-955.

8. Gupta RC, Ramarao MS. Epidurography in reduction of lumbar disc prolapse by traction. Archives of Physical Medicine & Rehabilitation 1978; 59 (Jul):322-327.

9. Cyriax J. The treatment of lumbar disc lesions. British Medical Journal 1950; (Dec 23):1434-1438.

10. Lawson GA. Godfrey CM. A report on studies of spinal traction. Medical Services Journal of Canada, 1958; 14 (Dec):762-77 1.

11. Cyriax JH. Discussions on the treatment of backache by traction. Proceedings of the Royal Society of Medicine 1955; 48:805-814.

12. Mathews JA. Dynamic discography: a study of lumbar traction. Annals of Physical Medicine 1968; IX (No.7):265279.

13. Managed Care Organization Newsletter (American Academy of Pain Management). July 1996.

"All but two of the patients in the study improved at least 30% or more in the first three weeks.""Utilizing the outcome measures, this form of decompression reduces symptoms and improves activities of daily living."

Bruce Gundersen, DC, FACO; Michael Henrie, MS II, Josh Christensen, DC. A Clinical Trial on Non-Surgical Spinal Decompression Using Vertebral Axial Distraction Delivered by a Computerized Traction Device. The Academy of Chiropractic Orthopedists, Quarterly Journal of ACO, June 2004

A Clinical Trial on Non-Surgical Spinal Decompression Using Vertebral Axial Distraction Delivered by a Computerized Traction Device

Bruce Gundersen, DC, FACO; Michael Henrie, MS II, Josh Christensen, DC.  The Academy of Chiropractic Orthopedists Quarterly Journal of ACO - June 2004

INTRODUCTION

Hypothesis: Axial traction of the spine produces remission of symptoms in specific conditions that have not responded to traditional manipulative protocols when computerized decompression traction, electrical stimulation and biofeedback exercise stabilization are applied under a controlled regimen.

The study is a pilot project and was not considered by an IRB for the initial phase. Continued investigation is suggested. The equipment for the study was provided by Calhoon Health Products. No fees for treatment were charged to any patients and no subjects were paid to participate in the study.

REVIEW OF THE LITERATURE

There are many studies on traction in the current literature. We have sited 20 indicating a broad interest in this concept and a continued search for alternatives to surgical decompression of the spine. The articles with a brief synopsis are listed at the end with the reference. The primary clinical point of the literature review is that compression of the neuronal elements of the spine seems to be a leading cause or generator of the pain in chronic situations. Decompression has proven effective and various forms of decompression are elaborated. In conclusion from analyzing these articles, vertebral axial distraction can be accomplished several ways and reports of reduction of intradiscal pressure, reduction of disc herniations, and associated symptoms are cited.

CURRENT RESEARCH

A trial was designed to measure the improvement on low back and leg pain and neck and arm pain patients. Patients who had reported symptoms in those areas were notified of the project and invited to participate. Other providers of physical medicine were notified as well and encouraged to have patients with similar unresponsive conditions inquire. All patients admitted to the study had a lengthy history of pain with multiple episodes of chiropractic manipulation and physical therapy with limited success.

METHODS

A combination of questionnaires were used to compute an intake score for each patient. The score was computed using the formula, the sum of the total score from each questionnaire. Categories of severity were created as follows: 0-150; 151-175; 176-200; and > 200.

Protocols were determined based on total intake score and ranged from 3 to 6 treatment sessions per week. Traction protocols were determined based on patient history and symptoms, chronicity and extent of radicular signs. Treatment frequency was determined by total points: under 150 - 3 days per week, 151 to 175 - 4 days per week, 176 to 200 - 5 days per week and over 200 - 6 days per week.

The Axial Disc Compression Traction Therapy unit, manufactured by Chattanooga, was utilized in this study. Directions contained in the D.T.S. Information manual, copyright 2002 by Jay Kennedy were followed.

In this study, there were nine men and 5 woman ranging in age between 26-64. The range in chronicity for LB/Leg pain was 6 months to 29 years and neck to arm pain 1 year to 7 years. Exclusion criteria included, those with spinal fusions from hardware implant, those with non-disc related central spinal stenosis, those over age 70 or under age 18.

Intake measurements include modified Oswestry Low Back Pain Disability Questionnaire (Fairbanks, 1980) and the Neck Disability Index (Vernon and Mior, 1988) Activities Discomfort Scale (Turner, 1983) and a quadruple visual analogue pain scale (Yeomans, 2000). Each item was scored and the total recorded and compared to the exit scores. For this project, no objective tests were obtained on intake or exit, only standardized outcomes assessment tools.

THE PROCEDURE

Patients who qualified to enter into the study were measured and fitted to the traction unit. Both prone and supine protocols were considered for lumbar decompression. The prone position is usually recommended but can be modified per patient ability to tolerate the position. Cervical decompression is done in the supine position. Precise positioning for each patient is critical for outcomes to be optimized A 100% compliance was expected from each subject accepted into the study in order to optimize the statistical analysis.

The specific treatment protocol was determined by the doctor after assessing the intake examination and evaluation. The computer controls the variations in the traction allowing for spinal decompression and attempting to reduce the muscle reaction and subsequent compression that can occur with some types of traditional or conventional traction devices. The preprogrammed patterns for ramping up and down the amount of axial distraction allows for optimal levels of spinal decompression and disc hydration when possible.

Proper patient positioning and specific technique insure expected results.

RESULTS

Of the 14 patients that were admitted into the study on May 17, 2004, the group was divided into the neck and arm pain group with 4 patients and the low back and leg pain group with 10 patients.

The three outcomes assessment tools were scored and totaled for each patient on intake and after three weeks of the study.

Using a single tool, the Revised Oswestry form for low back, it is noted that improvement parallels, in all but one case, the combination of the three tools.

The neck patients all responded well but not with as high an average as the low back patients.

Following the three-week initial phase of the study, the patient sample in this study continued to receive decompression at variable rates based on improvement. The outcome measurements are repeated at one month intervals to determine if the disability levels and perceived improvement parallel each other.

DISCUSSION

It is interesting to note that the measured results parallel the perceived or reported improvement in all but one case. That case would not be included in a long term study due to non-compliance but was included here because that is a regular obstacle in daily clinical practice.

Decompression of the spine is possible using axial distraction as a modality. Study limitations include remission of symptoms may also be linked to electrochemical effects and biomechanical stabilization. All but two of the patients in the study improved at least 30% or more in the first three weeks. Two did not. One drove 2 hours to and 2 hours from treatment sessions and was not expected to achieve much improvement notwithstanding. He did report considerable relief immediately after each session and understood that the driving more than negated any improvements. The other patient who did not measure any improvement did not comply with the protocol as outlined and would have been dismissed from the study due to poor treatment compliance.

Continued follow- up with this patient sample is recommended in Part II of this study at 1, 3, 6 and 12 month results with and without additional treatment. Studies on surgical decompression procedures of the spine are often designed to include a 2-3 year follow-up as well as reporting any associated morbidity during the study time for up to 5 years. Additional patients should be likewise admitted and studied and the 5 year plan should be instituted. Patients will also be instructed in regular use and frequency of the stabilization exercises.

This study utilized an outcomes based research design. Given the significant improvements reported in this study, it is hopeful that a randomized, controlled trial where sham traction (placebo) can be compared to decompression therapy. Also, separate subject groups can also be randomized to electrical stimulation, pelvic stabilization groups, and a combined therapies group.

CONCLUSIONS

Utilizing the outcome measures, this form of decompression reduces symptoms and improves activities of daily living. Long-term benefits were not studied but will be reported in another study. The future study will include regular follow-up measurements to determine if the remission continues with or without recurrence. Also, the future study will investigate whether or not periodic supportive treatment sessions are needed to maintain symptom satisfaction.

REFERENCES

1. Mackenzie R: Mechanical diagnosis and therapy for disorders of the low back. In Taylor JR, Twomey LT (Eds.): Physical therapy of the low back. Churchill Livingstone, New York, 2000 p.26 & 143.

2. Kushlich SD, Ulstrom RN, Michael CJ: Tissue origin of low back pain and sciatica. Orthop Clin North Am (22): 181,1991.

3. Nachenson AL, Elfstrom G: Intravital dynamic pressure measurements of Lumbar discs. Scand J Rehabil Med 2 Supp 1:1-40, 1970.

4. Yong, Hing K., Kirkaldy-Willis WH:' Pathophysiology of degenerated discs of the lumbar spine. Phila. The Ortho Clinics of N. Am. Vol.(14) #3 July 83, p.p. 493504.

5. Bogduk N., Twomey L.: Clinical anatomy of the Lumbar Spine. ChurchillLivingstone New York. 1992. p.p. 68-69 & 151-173

6. Twomey LT.: Sustained lumbar traction: An experimental study of long spine segments. Spine 1985; (10): 146-149.

7. Judkovich BD.: Lumbar traction therapy-elimination of physical factors that prevent stretch. JAMA 1955; 159.

8. Gose E, Naguszewski L.: Vertebral axial decompression therapy: an outcome study. Neuro Resarch. (20)#3, April 1998.

9. Mathews JA.: Dynamic Discograhy: A study of lumbar traction. Annals of Phy Med, IX (7) 1968, p.p. 265-279.

10. Colachis SC.et al: Effects of intermittent traction on vertebral separation. Arch of Phy Med & Rehab 1972 (50), p.p.251-258.

11. Shealy CN. Borgmeyer V.: Decompression, reduction, stabilization of the Lumbar spine: A cost effective treatment for lumbosacral pain. AJPM 1997, 7(2), 663 -665.

12. Winkle D, et al.: Diagnosis & treatment of the lumbar spine. Aspen: Maryland: 1996 p.p. 303-313.

13. Degenerative disorders of the spine. In: Hochschuler SH, Cotler HB, (Eds.) Rehab of the Spine. Mosby MO. 1993 p.p.464-465 & p.260,

14. Cyriax JH: Illustrated Manual of orthopaedic med, London, Butterworths, 1983 p.p. 30-40.

15. Schiotz E, Cyriax JH: Manipulation, past and present. London, Heinemann, 1975

16. Biomechanics. In: Hochschuler SH, Cotler HB, (Eds.) Rehab of the Spine. Mosby MO.1993 p.p. 146.

17. Kushlich S: Tissue origin of mechanical low back pain and sciatica. In: Hochschuler SH, Cotler HB, (Eds.) Rehab of the Spine. Mosby, MO. 1993 p.p.595-599.

18. Natural history of the lumbar spine. In Taylor JR, Twomey LT,(Eds):Physical Therapy of the Low Back, Churchill Livingstone, New York, 2000, p.p 25-26 & 43-51.

19. Onel D et al. Computed tomographic investigation of the effects of traction on lumbar disc herniations. Spine 1989; 14(1):82-9

20. Hides J, Stokes, M, et al: Evidence of lumbar multifidus wasting ipsilateral to symptoms in patients with low back pain. Spine 1995, 19(2): p. 165

21. Anderson DBJ, Nachemson, AL. Intervertebral disc pressures during traction. Scand J of Rehab Supple 1983; (9):88-91.

22. Colachis S, Strom J: Cervic al traction. Arch Phys Med 1965 (64):815.

23. Harris P: Cervical traction: Review of liturature and treatment guidelines. Phys Ther (57):910, 1977.

24. Braaf MM, Rosner S. Recent concepts in treatment of headache. Headache, (5):3844 1965.

25. Cyriax J: The treatment of lumbar disc lesions. British Medl Jour Dec.23 14341438.

26. McElhannon JE: Physio-therapuetic treatment of myofascial disorders. Anaheim Hills, CA.: James McElhannon.

27. Deyo RA, Loeser JD, Bigos SJ. Herniated lumbar intervertebral disc. Ann Intern Med 1990:(112): 598-603.

28. Breig A, Troup J: Biomechanical considerations in the straight leg raise test. Spine 1979; (4):242.

29. Mazion JM, Haynes LM: Mazion's illustrated reference of orto/neuro/physio diagnostic techniques. Casa Grande, Mazion publisher, 4th ed, 1980

30. Greenstein GM: Clinical assessment of neurological disorders. St. louis, Mosbyyear book, Inc. 1995.

31. Weber H: The natural history of disc herniation and the influence of intervention. Spine 1994 (19): p.p. 2234-2238.

32. Saal JA, Saal JS: The non-operative treatment of HNP with radiculopathy: an outcome study. Spine 1989 (14): p.p. 431-437.

33. Komori H, Shinomiya K, et al., The natural history of HNP with radiculopathy. Spine (21): 225-229, 1996.

34. Quain MB, Tecklin JS,: Lumbar traction: it's effect on respiration. Phys Ther 1985; 65 (9): 1343-6.

35. Krause M, et al: Lumbar traction: evaluation of effects and recommended application for treatment. Man Ther 2000, May;5 (2): 72-81.

36. Gillstrom P, Erickson K,: CT exam of influence of autotraction on herniation of lumbar disc. Arch Orthop Trauma Surg 1985; 104(5):289-93.

37. Beurskens AJ et al: Efficacy of traction for non-specific back pain. Spine 1997 Dec 1 ;(23): 2756-62.

38. Laban MM et al: Intermittant cervical traction: a progenitor of lumbar radicular pain. Arch Phys Med Rehab 1992 Mar;73 (3):295-6.

39. Pellecchia GL: Lumbar traction: a review of the liturature. J Orthop Sports Phys Ther 1994 Nov:20 (5): 262-7.

40. Austin R: Lumbar traction a valid option. Aust J Physio 1998; 44 (4):280.

41. Constantoyannis C, et al: Intermittent cervical traction for radiculopathy due to large-volume herniated discs. JMPT 2002 Mar; 25 (3).

42. Adams M, Bogduk Net al: Biomechanics of back pain. Churchill Livingstone NY, 2002: p,p 163-167

43. Grieve G: Mobilization of the spine. Churchill Livingstone NY, 1991: p.p 273283.

44. Martin M, Ramos G: Effects of vertebral axial decompression on intradiscal pressure. J Neur 81: 350-353, 1994.

45. Richardson C, Jull Get al: Therapeutic exercises for spinal segmental stabilization in low back pain. Churchill Livingstone NY, 1999.

46. Dullerud R, Nakstad P: CT changes after conservative treatment for lumbar disc herniation. Acta Radiol Sept;35(3):415-9, 1994.

47. Quain MB, Tecklin JS: Lumbar traction: its effect on respiration. Phys Ther Sept;65 (9):1343-6, 1985.

48. Mcgill S: Low back disorders (evidence-based prevention and rehabilitation). Human Kinetics, 2002.

49. Hseuh TC, Ju MS: Evaluation of the pulling angle and force on intermittent cervical traction. JFMed Assoc 1991 Dec;90(12): 1234-9

50. Saal JS, Saal JA: Nonoperative management of herniated cervical IVD with radiculopathy. Spine 1996 Aug 15;21(16): 1877-83.

51. Weatherall VF: Comparison of electrical activity in the sacrospinalis musculature during traction in two different positions. J Ortop Sports Phys Ther 1995;(8): 382390.

52. Letchuman R, Deusinger RH: Comparison of sacrospinalis myoelectric activity and pain levels in patients undergoing static and intermittent lumbar traction. Spine 1993;18(10): 1361-1365.