Who is Pulling on What? Manual Traction

Yesterday, I was running through an NPTE practice exam the other day and couldn’t believe that there was five questions regarding traction. Five. I genuinely can’t remember the last time I used traction on an actual patient, or even thought about it outside of school. It’s wild how much modality stuff used to feel like the most important thing in the world, and now it’s buried somewhere in the back of my brain next to trigonometry. Don’t get me wrong, traction has its place but it’s not exactly a front-line treatment anymore. Still, since the exam (and some patients) refuse to let it die, it’s probably worth a quick refresher on what manual traction is, when it makes sense, and what the evidence actually says.

What is Manual Traction?

Manual traction is a passive therapeutic technique where a clinician applies controlled longitudinal force to the spine to reduce pressure on neural structures, stretch soft tissues, and potentially relieve pain. It can be applied to the cervical or lumbar spine, typically using the therapist’s hands, body weight, and positioning. Mechanical traction is also a thing but tables and other advanced systems are often not in clinics.

Mechanically, traction aims to:

• Separate vertebral bodies slightly

• Reduce disc pressure and nerve root compression

• Decrease muscle spasm through prolonged stretching

• Promote relaxation and pain relief

Evidence for Manual Traction

While traction doesn’t get much love in everyday practice, there’s still legitimate support for it in certain situations, especially when symptoms line up just right.

According to a 2021 Lumbar Clinical Practice Guideline (CPG), traction may be indicated for patients with acute low back pain with related (referred) lower extremity pain when symptoms are aggravated by movement but eased with unloading. These are typically the patients who find brief relief when lying down or offloading their spine, the patients who say, “It just feels better when I hang or bend my knees.” That said, much of the evidence for lumbar traction is mixed if not against its use.

On the cervical side, traction makes an appearance twice in the a recent Neck Pain CPG:

• First, under “Neck Pain with Mobility Deficits,” where it’s recommended (particularly for chronic cases) as part of a multimodal plan with manual therapy and exercise.

• Second, in “Neck Pain with Radiating Pain,” again primarily for chronic presentations, where intermittent mechanical or manual traction can help reduce nerve root compression and improve comfort.

Clinically, traction tends to work best for people who respond positively to manual distraction tests, those whose radicular symptoms ease when you gently offload the spine. These are the “traction responders,” and when you find one, you’ll know it. Used right, it can create just enough decompression to calm things down and buy time for the active interventions to do their job.

The Ideal Patient

Traction isn’t for everyone, but when it works, it’s usually pretty obvious. The ideal patient is someone whose symptoms point toward mechanical compression or irritation, especially when you see referred or radicular pain that improves with unloading.

Think about patients who say things like:

“It feels better when I lay down.” or “When I pull my head up, my arm stops tingling.”

Those are your potential traction responders. During the session, you’re looking for clear, immediate indicators that it’s helping, things like:

• Decreased or centralized symptoms (pain moving closer to the spine rather than down the limb)

• Reduced radicular pain or numbness

• Improved tolerance for sitting, standing, or movement after traction

• Easier initiation of active motion or strengthening afterward

If those changes show up, traction earned its keep. That’s when it becomes a temporary tool to calm things down and get the patient moving so they can actually tolerate and buy into exercise.

If there’s no change after a couple of well-dosed sessions, or if symptoms worsen (more distal pain, increased irritability, new numbness), traction probably isn’t the right move. The goal isn’t to chase temporary relief, it’s to make movement and participation in active therapy more doable.

Contraindications & Precautions

Absolute contraindications:

• Spinal joint instability

• Acute fracture or dislocation

• Spinal infection or malignancy

• Recent spinal surgery with hardware

• Severe osteoporosis or prolonged steroid use

• Pregnancy

• Ankylosing Spondylitis

Precautions:

• Claustrophobia (for mechanical setups)

• TMJ dysfunction (with cervical harness)

• Severe pain or neurological worsening during application

Parameters of Traction

Let’s be clear up front, the parameters below are only for joint distraction. If you’re talking about mechanical setups or using traction for other pathologies (like disc herniation protocols or muscle spasms), the numbers and setup might shift a bit. But since the NPTE seems laser-focused on the basics, particularly distraction for cervical and lumbar segments, here’s what actually matters to know and use clinically.

Manual traction is all about feel and feedback. You’re constantly reading the patient, the goal is gentle joint distraction and symptom reduction, not turning the spine into a wishbone.

For the cervical spine, positioning is everything:

• Neutral to slight flexion (0–5°) = upper cervical (C1–C2)

• Mid flexion (~15–20°) = mid-cervical (C3–C5)

• Greater flexion (25–30°) = lower cervical (C5–C7)

Get that wrong, and you’ll either miss your target or reproduce symptoms instead of relieving them.

Parting Words

Manual traction isn’t the hero, it’s the assist. If it reduces symptoms, centralizes pain, and lets the patient move better, cool, you’ve earned yourself a window to load what matters. If there’s no change after a couple sessions (or symptoms push distal), drop it and move on. Don’t chase temporary relief just because it felt good on the table. The win is better movement and buy-in, not a stronger pull.

References

1. Cameron M. Physical Agents in Rehabilitation. From Research to Practice. 3rd edition. Saunders, 2009.

2. George SZ, Fritz JM, Silfies SP, et al. Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021. J Orthop Sports Phys Ther. 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.0304

3. Blanpied PR, Gross AR, Elliott JM, et al. Neck Pain: Revision 2017. J Orthop Sports Phys Ther. 2017;47(7):A1-A83. doi:10.2519/jospt.2017.0302

Disclaimer

I am a current Doctor of Physical Therapy (DPT) student sharing information based on my formal education and independent studies. The content presented in this newsletter is intended for informational and educational purposes only and should not be considered professional medical advice. While I strive to provide accurate and up-to-date information, my knowledge is based on my current academic and clinical rotations and ongoing learning, not extensive clinical practice.