0196-6011/85/0605-0281$02.

00/0
THEJOURNAL OF ORTHOPAEO~C AN0 SPORTS PHYSICAL THERAPY
Copyright 0 1985 by The Orthopaedic and Sports Physical Therapy Sections of the
American Physical Therapy Association

Effects of Gravity-Facilitated Traction

on lntervertebral Dimensions of the
Lumbar Spine*
MICHAEL D. KANE, LT, AMSC, MPT,t ROBERT D. KARL, COL, MC, MD,*
JAMES H. SWAIN, MAJ, AMSC, MPT,§

The purpose of this study was to determine the effects of gravity-facilitated traction
(inversion) on intervertebral dimensions of the lumbar spine. Fifteen normal male
subjects were fully inverted for a period of 10 minutes. Vertebral separation was
measured on lateral roentgenograms both pre- and postinversion by outlining the
margins of the intervertebral bodies both anteriorly and posteriorly and the greatest
vertical heights of the intervertebral foramina. Fine point engineering calipers were
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used to facilitate measurements. A student t-test for paired data was used to
determine significance of separation between lumbar segments, following 10 minutes
of inversion. The a level was set at 0.05 for statistical significance. Gravity-facilitated
traction produced increased separation at all levels measured. Significant increases
in total mean anterior separation, total mean posterior separation, and total mean
intervertebral foraminal separation were determined. Mean anterior separation was
significant at all levels except L3-L4. Mean posterior separation was significant at all
Copyright © 1985 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

levels except L1-L2 and L5-S1. Mean intervertebral foraminal separation was
significant at all levels but L5-S1. If increases in intervertebral dimensions play a role
in the relief of low back syndrome, then gravity-facilitated traction may be an
effective moda1i;y in the treatment of this condition.

Spinal traction has been used for the treatment niques used to apply spinal traction have varied
Journal of Orthopaedic & Sports Physical Therapy®

of dysfunction and painful conditions of the ver-
tebral column since the era of Hippocrates. The
precursor of the present-day traction table was
the "Scamnum Hippocratis," the bench of Hippo-
crates. The patient was hung upside down with
his feet tied to the rungs of a ladder. By ropes
over a pulley, the ladder was hoisted vertically
and dropped, imparting an abrupt tractive force
to the spine. Medical men of those early eras used
traction to correct spinal scoliosis, kyphoscoliosis,
and hyperlord~sis.~~ Since that time, the tech-
'The opinions expressed herein are solely those of the authors and
may not be construed as an official position or product endorsement
by the A n y Medical Department or the U.S. Army.
t This study was completed by LT Kane in partial fulfillment of the
requirements for the Masters of Physical Therapy Degree from the U.S.
Any-Baylor University Program in Physical Therapy. Academy of
Health Sciences. Ft. Sam Houston. TX 78234. LT Kane is currently a
staff physical therapist at Madigan Army Medical Center. Tacoma, WA
98431.
$ COL Karl is currently Chief of the Radiology Department, Madigan
Army Medical Center, Tacoma, WA 98431.
5 MAJ Swain is currently Chief of the Musculoskeletal Evaluation
Section, Brooke Army Medical Center. Physical Therapy Clinic, San
Antonio, TX 78234.
considerably. Traction has been applied manually,
with weights, with mechanical pulley devices, con-
tinuously or intermittently, and in horizontal or
vertical'positions.
In the last three decades heavy lumbar traction
has been a standard means of treating low back
pain. Although experimental research is limited
and the results have been somewhat contradic-
tory, lumbar traction is used with varying degrees
of success for treatment of low back pain resulting
from trauma, degenerativejoint disease, and bulg-
ing or herniated discs.&9,13, '5919820.23-25,29,30
More recently, the use of gravity-facilitated trac-
tion, which places the subject in an inverted po-
sition with gravity providing the tractive force, has
become increasingly popular within the medical
and nonmedical community as a means of treating
low back pain. The gravity inversion apparatus
can be found in health clubs, gymnasiums, sports
medicine and physical therapy clinics, and is
claimed by its proponents to be useful in the
control of low back pain. This technique appears
 KANE
to be a convenient and efficient means of applying
tractive forces to the lumbar spine.
Well documented medical and economic impli-
cations of discogenic and nondiscogenic back
pain mandate a serious consideration of all mo-
dalities that offer a potentially efficacious mode of
treatment and rehabilitation. The development
and aggressive marketing of gravity-facilitated
traction devices necessitates a scientific evalua-
tion of this modality. Research to determine
whether significant distraction of the lumbar ver-
tebrae is produced in subjects under the influence
of gravity-facilitated traction has not been under-
taken to date. Thus, the present study was de-
signed to determine the effects of the inverted
position on specific intervertebral dimensions of
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the lumbar spine.
PATHOMECHANICS AND TREATMENT
The lumbar spine plays a role in many ortho-
paedic ailments, low back pain being by far the
Copyright © 1985 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
most common.'.21 Epidemiological studies have
shown that sometime during the course of active
life, more than 70% of adults experience some
degree of low back Often the etiology
of low back pain is unknown. There are several
unproven theories regarding the pathogenesis of
low back pain, and while any of the anatomic
structures of the lumbar spine may play a role,
the intervertebral disc is thought to be a major
Journal of Orthopaedic & Sports Physical Therapy®
f a ~ t o r . ' ~ - 'There
~ ~ ~ 'exists a wide variety of treat-
ment regimens aimed at relieving low back pain,
ranging from surgical intervention to conservative
management. Conservative measures include an-
algesic drugs, application of ice or heat, massage,
manipulation, and bed rest. Extended bed rest is
often effective since the supine position de-
creases intradiscal pressures and protects the
impaired disc from the compressive forces of
gravity. lntravital disc pressure measurements as
performed by Nachemson indicate that the lowest
intradiscal pressure occurs in the supine posi-
tion.I4 Proponents of traction claim that it can
achieve the same effects as extended bed rest in
a shorter time.5.16.23 In essence, "the patient is
put to bed for weeks in a few hours."25
Prior investigators have reported that the ther-
apeutic effects of traction are due to stretching of
the musculature, widening of the intervertebral
heights, opening of the intervertebral foramina,
and stretching of the anterior and posterior lon-
gitudinal ligament^.^^ 13.'7.23* 24*28 Traction can also
produce negative intradiscal pressure or "suction
JOSPT Vol. 6, No. 5
force" capable of drawing nuclear material from
the epidural space into the intradiscal
6. 20s22 Saunders2' states that in order to
administer therapeutically effective traction, the
tractive force must be great enough to effect a
structural change at the spinal segment. Grays
states that radiographic proof of a significant de-
gree of distraction would support the argument
for its adoption in refractory cases of lumbar disc
protrusion. If the proclaimed mechanisms of pain
relief are true, then maximum distraction of the
lumbar segments would seem desirable.
LITERATURE REVIEW
The use of the inverted position for spinal trac-
tion was first described and used by Sheffield.29
A motorized, highly polished tilt table was used,
with the patient being inverted to an angle of 90'
from the horizontal. A pelvic harness, adjustable
by means of straps and buckles, was used to
firmly stabilize each patient to the table. Of the
155 patients with known or suspected herniated
discs, 133 (88%) were able to return to their full
time jobs following an average of eight treat-
ments, each of approximately 5 minutes duration.
Using a cadaver stripped of lumbar muscula-
ture, Coste et aL4reported that a 9;kg force (19.8
Ib) was necessary to separate two lumbar verte-
brae by 1.5 mm. N e ~ w i r t reported
h~~ that approx-
imately 100 kg (220 Ib) of tractive force was
needed to produce the same effects in living
subjects. DeSeze and Leverneaux6reported that
770 Ib of traction was necessary to obtain a
separation of 1-2 mm between each lumbar seg-
ment in a living subject. Of the total tractive force,
over 300 Ib was required just to overcome the
resistance of the apparatus. Frazer7 considered
the tractive forces used by DeSeze and Lever-
neaux excessive and advocated 300-400 Ib as
adequate for spinal traction.
The first attempt to accurately measure lumbar
intervertebal separation both anteriorly and pos-
teriorly using lateral lumbar radiographs was un-
dertaken by Lehmann and runner." Nineteen
volunteers were given 300 Ib of upright traction
for a period of 5 minutes. They measured a seg-
mental midvertebral separation at L5-S1 of 2.6
mm, 1.5 mm at L4-L5, and 1.3 mm at L3-L4.
Separation of the posterior margins of the lumbar
vertebral bodies was found to be significant while
separation of the anterior margins was not.'
Colachis and Strohm2administered supine lum-
bar traction to 10 healthy medical students. The
 JOSPT MarlApr 1985 EFFECTS OF INVERSION ON THE LUMBAR SPINE 283
hips of each student were placed in 70' of flexion
while intermittent traction was applied for 15 min-
utes. Each subject received 50 Ib of traction fol-
lowed by 100 Ib of traction with a 10-minute break
in between bouts. In addition, 5 of the subjects
received 100 Ib of continuous traction for 5 min-
utes following the 100 Ib of intermittent traction.
Lateral radiographs were taken both before and
immediately following traction. These authors
showed that the total mean posterior separation
of the lumbar vertebral segments increased as
the tractive force increased. Total mean anterior
separation decreased during traction. Following 5
minutes of continuous traction at 100 Ib, signifi-
cant posterior separation was measured from L2-
L3 to L4-L5. The values were significant at the
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0.01 level.
More recently, Reilly et aL2' administered 70 Ib
of intermittent lumbar traction while varying the
degree of hip flexion in 10 female subjects. Lateral
radiographs of the lower spine were taken and
absolute differences were evaluated for both an-
Copyright © 1985 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

terior and posterior margins from T I 2 to L1. Each

subject was exposed to three consecutive bouts
of traction at 0, 45, and 90' of hip flexion. Each
traction period lasted 15 minutes followed by 15
minutes of rest. The most significant separation
Fig. 1 . Erect positioning for preinversion lateral lumbar x-ray.
occurred with hips flexed at 90'. Reilly's data Uprights were used to stabilize patient and prevent any forward
showed an increase in posterior intervertebral and backward oscillation.
heights from T I 2 to S1. No changes in anterior
intervertebral heights were reported.
Journal of Orthopaedic & Sports Physical Therapy®

jects were gradually exposed to both increasing

METHODS
Sixteen males between 20 and 30 years of age
volunteered as subjects for the study. An all male
population was selected since the gonadal doses
from lumbar spine radiography are significantly
lower in males than females. None of the subjects
had a prior history of back trauma or lumbar spine
complaints. Subjects with a history of chronic
headache, stroke, glaucoma, severe cerebral vas-
cular disease, hypertension, cardiac anomalies,
osteoporosis, or severe joint laxity were excluded
from the study since these medical problems were
considered contraindications to the inverted po-
s i t i ~ n .Each
~ * ~subject
~ was presented with a writ-
ten explanation of the study procedures and de-
scription of the potential risks of irradiation. Due
to recent reports of marked heart rate and blood
pressure changes during inversion,'' and the un-
familiarity of all subjects with the inverted position,
progressive acclimation was undertaken to elimi-
nate undue apprehension and discomfort. Sub-
angulation and duration of inversion, while blood
pressure and heart rate were closely monitored.
The acclimation process occurred on consecutive
days. Each subject was fitted with gravity inver-
sion boots and positioned in front of the series
1120 Gravity Guide$ inversion apparatus (Gravity
Guidance, Inc., 150 S. Los Robles Ave., Pasa-
dena, CA 91109). Left arm brachial blood pres-
sure and resting heart rate were recorded with
the subject standing and the arm held in the
anatomical position. A standard sphygmomanom-
eter was used to evaluate blood pressure. The
radial pulse was palpated to determine heart rate.
Following resting measurements, the subject was
positioned on the inversion device and lowered
slowly to an inverted position of 150' from the
vertical. A standard long arm goniometer was
used to assess the inversion angle. The apparatus
was stabilized at the desired angle by a rope
securely knotted between the oscillating bed and
the base of the supporting frame. The total accli-
mation procedure required six visits.
 284
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Copyright © 1985 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Fig. 2. Subject suspended in full inversion.
During the first three sessions the subjects
were inverted to 1500 for "7' and minutes'
Journal of Orthopaedic & Sports Physical Therapy®
respectively. During the following three sessions,
the were inverted for and
59
minutes' Blood pressures and rates were
recorded by the minute.
Six days elapsed between the final acclimation
procedure and the final data collection. This delay
was allowed to negate any possible tractive ef-
fects On the lumbar from the previous pe-
riods of inversion. Radiographic studies were ob-
tained On the same day Of consecutive weeks
during the evening hours to control possible
variations in disc heights at different times of the
day.
An erect lateral Of the lumbar 'pine
was obtained for each subject using a horizontal
beam with a tube to film distance of 10 feet to
minimize magnificationerror (Fig. 1). Radiographic
techniques consisted of 1 10 kilovolts peak (Kvp)
and approximately 600 milliampere seconds
(mAs), varying the mAs according to the subjects
somatotype in order to obtain a correctly exposed
film. Each subject was then placed on the inver-
sion apparatus and fully inverted for 10 minutes
KANE ET AL JOSPT Vol. 6, No. 5
Fig. 3. Blood pressure monitoring with subje~tin fully inverted
position.
(Fig. 2). During this time, pulse and blood pressure
were closely monitored (Fig. 3). There were no
signs of cardiovascular distress or discomfort
71
noted during the period of inversion. At the con-
clusion of 10 minutes of inversion, a second lateral
radiograph was obtained with the subject still in
the inverted position, and using the same radi-
ographic techniques as previously described.
The radiographs were analyzed by a board-
radiologist. The bodies were
identified and labeled using fine-point engineering
calipers. The heights of the anterior and posterior
margins of the vertebral end plates and the su-
perior and inferior margins of the
foramina were then measured and compared (Fig.
4). Each measurement was repeated at a later
date to control intra-obse,,,er variability. these
measurements formed the data base for the
study.
RESULTS
Descriptive data for all subjects is presented in
Tables 1-4.Means and standard deviations were
computed for all measurements both pre- and
 JOSPT MarlApr 1985 EFFECTS OF INVERSION ON THE LUMBAR SPINE 285
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Copyright © 1985 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®

Fig. 4. Lateral radiographs of lumbar spine. A, subject is in the erect posture. B, subject is fully inverted. Note the dots used to
identify the intervertebral dimensions.

TABLE 1
Total mean change in intervertebral dimensions of the lumbar spine following 10 minutes of inversion (mm)
IntervertebralDimension N Preinversion Postinversion Total Mean Change
Anterior intervertebral heights 72 13.44 +. 2.31 14.70 -t 2.25 1.26 + 0.95'
Posterior intervertebral heights 72 5.62 + 0.49 7.47 + 1.30 1.85 .+ 1.03t
Intervertebral foramina height 66 +
20.87 2.21 22.91 + 2.91 2.04 + 1.04t
'P < 0.025.
tP<0.01.

postinversion. The means were compared using
a student t-test for paired data, with the a level
set at 0.05 for statistical significance. Two of the
subjects were found to have spondylitic defects
at the L5-S1 level; therefore, their measurements
at this level were not included in the data base. In
an additional six subjects, the intervertebral fora-
men at L5-S1 could not be properly visualized,
and in one other subject, the intervertebral dimen-
sions at the L1-L2 segment were obscured due
to improper positioning. Therefore, the number of
measurements obtained at these levels did not
equal 15.
The mean difference between the preinversion
and postinversion measurementsfor total anterior
separation, total posterior separation, and total
intervertebral foramina separation were all signif-
icant (Table 1). At each vertebral level, mean
 KANE ET AL JOSPT Vol. 6, No. 5
TABLE 2
Mean change in anterior intervertebral heights in the lumbar spine following 10 minutes of inversion (mm)
Levels N Preinversion Postinversion Mean Separation &Value

TABLE 3
Mean changes in posterior intervertebral heights in the lumbar spine following 10 minutes of inversion (mm)
Levels N Preinversion Postinversion Mean Separation t-Value
L1-L2 14 +
5.19 1.77 +
5.8 1.48 0.61 + 1.01' 1.69
L2-L3 15 +
5.59 1.39 +
8.22 1.34 2.63 + 0.91t 11.22
6.05 + 0.91 + + 0.88t
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L3-L4 15 8.69 1.09 2.66 10.57

L4-L5 15 +
6.18 1.04 8.71 + 1.07 2.53 + 1.32t 7.42
L5-S1 13 +
5.09 1.61 +
5.94 1.19 0.85 + 1.93* 1.58

TABLE 4
Copyright © 1985 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Mean change in intervertebral foramina heights in the lumbar spine following 10 minutes of inversion (mm)
Levels N Preinversion Postinversion Mean Se~aration t-Value
Journal of Orthopaedic & Sports Physical Therapy®

anterior separation was significant except at L3-
L4, with the greatest separation occurring at L5-
S1 (Table 2). There was an increase in mean
posterior separation following inversion at every
level. Mean posterior separation was significant
at L2-L3 through L4-L5, with the greatest sepa-
ration occurring at L3-L4. The mean separations
at L2-L3 and L4-L5 were only slightly less (Table
3). The mean difference between preinversion and
postinversion measurements for intervertebral
foramina height were significant at every level but
L5-S1 (Table 4). Again the greatest separation
was produced at L3-L4, followed by L2-L3 and
L4-L5, respectively.
DISCUSSION
A review of the available literature reveals that
lumbar traction applied in a variety of positions
and with tractive forces ranging from 70 to 300 Ib
is capable of producing significant mean posterior
separation at various levels in the lumbar
i pine.^^'^^^^ No significant increase in anterior
intervertebral height or intervertebral foramina
height has been documented. In two of the better
controlled studies, the greatest mean difference
between pre- and post-traction measurementsfor
posterior separation was produced following the
third of three consecutive applications of trac-
t i ~ n . ' ~ .Cumulative
*~ effects from consecutive
bouts of traction may be possible.
The present study demonstrated significant in-
creases in mean anterior intervertebral height at
all levels of the lumbar spine except L3-L4 follow-
ing 10 minutes of inversion. Mean posterior inter-
vertebral height also increased significantly at all
levels except L1-L2 and L5-S1. In addition, mean
intervertebral foramina height increased signifi-
cantly at every level but L5-S1. The lack of sig-
nificant posterior separation at L5-S1 is in agree-
ment with the study performed by Colachis and
S t r ~ h mThis. ~ lack of significant posterior distrac-
tion at the L5-S1 level is possibly due to the
strong limitations imposed on the segment by the
iliolumbar ligamentous complex. Additionally, po-
 JOSPT MarlApr 1985 EFFECTS OF INVERSION ON THE LUMBAR SPINE
sitioning during inversion precluded accurate
measurements of the intervertebral foramen at
this level in 8 of the 15 subjects, significantly
decreasing the data base available for analysis.
The increase in mean intervertebral foramina
height following inversion should produce in-
creased space available for the nerve roots and
may, therefore, give gravity-facilitatedtraction po-
tential clinical application in the treatment of low
back pain of nondiscogenic origin, specifically
nerve root inflammation and degenerative joint
disease.
The increases measured in mean anterior inter-
vertebral height coupled with increased mean
posterior intervertebral height have potentially
strong clinical implications in the treatment of low
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back broblems of discogenic origin. If both ante-
rior and posterior intervertebral heights increase,
the potential volumetric increases and subse-
quent intradiscal pressure decreases are greater
than if the anterior intervertebral height remains
unchanged or is decreased. Of possible interest
Copyright © 1985 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
is the documentation of separation between each
of the identified vertebral dimensions at every level
of the lumbar spine following inversion (Tables 2-
4). Although all of the mean height changes were
not statistically, significant, it is possible that the
separation produced at these particular levels has
clinical significance.
The clinical application of lumbar traction with
the patient horizontal and the forces acting hori-
Journal of Orthopaedic & Sports Physical Therapy®
zontally is often ineffective due to the friction
between the patient's body and the table. The
massive tractive forces reported in some of the
studies cited are clinically impractical, since many
patients cannot tolerate the thoracic compression
associated with heavy traction of this type. If
lesser forces can be used effectively to produce
vertebral distraction, then such techniques could
be reasonably employed for patient comfort and
ease of application. Judovich and Nobel15 advo-
cate a friction-free force of one-half the body
weight as a minimum to produce therapeutic ef-
fects in the lumbar spine. With gravity-facilitated
traction, the value of the tractive force is a function
of the body weight and the force of gravity. Since
approximately one-half the body weight lies above
the L3-L4 interspace,l5gravity-facilitated traction
clearly meets the minimum requirements with all
of the tractive force exerted on the lumbar spine
and none being dispersed in overcoming the sur-
face resistance of the lower body.
Recent investigation has shown that the in-
287
verted position can produce marked changes in
heart rate and blood pressure in normal young
adult^.^ Gravity-facilitated traction may be dan-
gerous for hypertensive individuals and those with
cardiac anomalies or cerebral vascular disease. In
any case, blood pressure, heart rate, and patient
comfort should be closely monitored during inver-
sion.
In the strictest sense, the results of this study
may only be applicable to normal subjects in the
age group utilized. However, radiographic evi-
dence has been presented which warrants further
investigation into the potential clinical benefits of
this modality.
CONCLUSION
Gravity-facilitated traction produces significant
separation in the intervertebral dimensions of the
lumbar spine including previously undemon-
strated separation at the anterior intervertebral
margins and intervertebral foramina. This sepa-
ration is achieved in a nontraumatic manner with-
out the use of weights or mechanical pulleys. If
separation of the lumbar -vertebrae indeed plays
a role in the symptomatic relief of low back pain
of both discogenic and nondiscogenic origin, then
gravity-facilitatedtraction may be an effective mo-
dality in the treatment of these conditions.
My deepest gratitude to MAJ Allyn L. Woeman for his constant
support and critical review of the original manuscript. Special thanks to
Gravity Guidance, Inc., for use of the gravity inversion device.
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