J. Phys. Ther. Sci.

24: 1127–1131, 2012

Stretching Versus Mechanical Traction of the Spine

in Treatment of Idiopathic Scoliosis

Abdulrahim Zakaria, BSc, MSc, PhD1), Ashraf R amadan Hafez, BSc, MSc, PhD1),
Syamala Buragadda, BPT, MPT1), Ganeswara R ao Melam, MPT1)
1) Departmentof Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University:
Riyadh 11433, Saudi Arabia, PO box 10219, TEL: +966 531262956, E-mail: syamala3110@yahoo.co.in

Abstract. [Purpose] Traction-based therapies are non-invasive and probably cost-effective and have received in-
terest recently. This study was conducted to compare two training programs, traction and stretching exercises,
in rehabilitation of moderate scoliotic patients. [Subjects] Forty patients who were 15 to 25 years of age and had
moderate scoliosis (Cobb’s angle of 20 to 40 degrees) were randomized to either a stretching exercises group (n=20)
or mechanical traction group (n=20). [Methods] All the patients were informed about the testing and training proce-
dure and were allocated randomly into two groups. Both the groups received a common physical therapy program
of 3 sessions a week for 3 months. In addition, the stretching exercises group received stretching of muscles on the
concave side with postural instructions for activities of daily living. The mechanical traction group received me-
chanical traction of the lumbar spine with postural instructions for activities of daily living. The outcome measures
used were anteroposterior view of loading X-ray to detect any change in the Cobb’s angle of the lower spine, tape
measurement to detect forward flexion of the trunk by using fingertip-to-floor test (FFT), and the visual analogue
scale (VAS) for pain measurement. [Results] There was more significant improvement of the Cobb’s angle in the
stretching exercises group than in the mechanical traction group. There was no significant difference in VAS and
FFT values between the groups. [Conclusion] Stretching exercises led to significant improvement in the Cobb’s
angle and resulted in improvement of scoliotic curves in moderate scoliotic patients.
Key words: Stretching exercises, Idiopathic scoliosis, Spinal deformity
(This article was submitted May 15, 2012, and was accepted Jun. 20, 2012)

INTRODUCTION most cases of scoliosis are classified as idiopathic, a minority

Idiopathic scoliosis is a multifactorial, three-dimensional
deformity of the spine and trunk that can appear and
sometimes progress during any rapid growth period in appar-
ently healthy children1). Adolescent idiopathic scoliosis
(AIS) is the most common form and affects children.
Although its ultimate cause is unknown, there is evidence to
support that there are two types of pathogenic factors called
initiating factors and progression factors for AIS2). There
is consensus that curve progression involves a mechanical
process called torsion with eccentric loading of the spine and
vertebral growth modulation (vicious cycle model)3).
AIS is defined by the Scoliosis Research Society as
scoliosis whose onset occurs after ten years of age and whose
cause is essentially unknown. It is a relatively common
condition among adolescents. AIS has been described as
having a prevalence of about 0.35 to 13%, depending on the
defined Cobb’s angles, screening age and sex. Idiopathic
scoliosis is estimated to affect about 2–3% of 10–16-
year-old adolescent females. The prevalence rate is slightly
higher in girls, and it more rapidly increases with age4, 5).
Scoliosis is a spinal deformity characterized as a lateral
curvature of the spine greater than 10°, as measured by the
Cobb method on standing upright spine radiographs. While
of scoliosis cases are traced to structural anomalies, such as
wedged vertebrae or abnormal soft tissue development. In
addition to lateral curvature, scoliosis is also recognized in
the sagittal plane. Although a distinct cause is unknown, it
is postulated to arise from an injury to the vertebral growth
plate during the adolescent period, causing cessation of
further development6, 7).
Curve progression is related to both changes in the
morphology of the spine and the trunk, as well as changes
in the geometry of the spine8). Curves that affect both the
upper and lower spine are called double major curves–S-
shaped curves. Single curves are C shaped. In some cases,
a curve in the lower spine may be compensatory (the body’s
way of balancing the curve in the upper spine) rather than
structural9, 10). A structural curve of the upper spine with a
compensatory curve of the lower spine is not considered a
double curve11, 12).
It has been recognized that low back pain (LBP) is a
common condition, with a high rate of occurrence not only
in adults, but also in children and adolescents. However,
there have been a few studies regarding the details of back
pain in adolescents with idiopathic scoliosis, with regard to
the prevalence, severity, and location of back pain. Some
studies have indicated that the prevalence of back pain in
1128 J. Phys. Ther. Sci. Vol. 24, No. 11, 2012
adolescents with idiopathic scoliosis is similar to that of
the general adolescent population, while other studies have
concluded that adolescents with scoliosis experience more
back pain than their peers13).
The Cobb angle is the angle formed at the intersection of
these lines or the angle formed at the intersection of lines
perpendicular to these lines (lines are drawn tangential to the
superior endplate of the superior end vertebra and the inferior
endplate of the inferior vertebra). A Cobb angle of at least
10° is essential for diagnosing scoliosis. The Cobb technique
uses the position of the spinous process for assessing the
degree of vertebral rotation. The vertebra is divided into
6 equal segments by drawing 5 vertical lines. The spinous
process is normally situated in the middle part of the vertebra
overlying the third line. With increasing rotation, the spinous
process is rotated toward the convex side of the curve and is
the most reliable method of measuring Cobb’s angle14).
Scoliosis rehabilitation including physiotherapy
methods and bracing can alter the natural evolution of this
condition15). The importance of multidisciplinary teamwork
in scoliosis rehabilitation has been recently pointed out, and
physiotherapists are an essential part of such a team16). As
part of the rehabilitation team, the role of the physiotherapist
is to teach the patient to correctly perform specific exercises
and to inform and educate the patient and patient’s family
about activities of daily living8).
Traction-based therapies are non-invasive and probably
cost-effective and have received interest recently17). For
example, studies that have been reported that lacked a
randomized comparison group1, 18), had a retrospective
design19–22), had sample that were small19, 20), studied
heterogeneous patient groups31) or had authors who
were commercially related to the evaluated therapy20, 21).
Moreover, there is still controversy within this particular
field because various different traction techniques and corre-
sponding protocols exists23).
The aim of the current study was to compare stretching
exercises and mechanical traction in treatment of idiopathic
scoliosis.
SUBJECTS AND METHODS
Subjects
Forty female volunteer patients with idiopathic scoliosis
(Cobb’s angle ranged from 20 to 40 degrees) from 15 to
25 years were included in this study. The subjects were
recruited from outpatient orthopedic departments of Cairo
university hospitals. Patients with moderate idiopathic
scoliosis suffering from pain and limitations of trunk forward
flexion and ADL were included.
Methods
All the patients were evaluated by a therapist. After eligi-
bility for this study was established and approval from an
ethics committee was obtained, the subjects were randomly
assigned to the stretching exercises or manual traction group.
All the patients participated in 3 sessions per week for
three months.
The stretching exercises group had a mean age of
18.21±2.34 years and followed a physical therapy program
of exercises, which included the following:
1) Strengthening exercises for the muscles of the convex
side by instructing the patients to get into a side- lying
position on the concave side and raise their upper trunk up as
much as possible (10 repetitions with 3 sets, 6 seconds rest
between each repetition, and 1 minute rest between the sets;
the resistance progressed according to repetitions).
2) Abdominal strengthening exercises from the crock
lying position in which the patient was asked to touch their
knees with their hands (10 repetitions with 3 sets, 6 seconds
rest between each repetition, and 1 minute rest between the
sets; the resistance progressed according to repetitions).
3) Stretching of back muscles from the crock lying
position in which the therapist moved both lower limbs
toward the chest (5 repetitions, 30 seconds in position of
stretching, 30 seconds in position of relaxation).
4) Stretching of concave side tight muscles in a side lying
position on the convex side and upper trunk at the edge of
the bed (5 repetitions, 30 seconds in position of stretching,
30 seconds in position of relaxation). Postural instructions
for ADL were also given.
The program was carried out in 3 sessions per week
for three months and was supervised by the same physical
therapist.
The mechanical traction group had a mean age of
17.88±2.39 years and received a physical therapy program
consisting of the following:
1) Strengthening exercises for the muscles of the convex
side by instructing the patients to get into side- lying position
on the concave side and try to raise their upper trunk up as
much as possible (10 repetitions with 3 sets, 6 seconds rest
between each repetition, and 1 minute rest between the sets;
the resistance is progressed according to the number of
repetitions).
2) Abdominal strengthening exercises from the crock
lying position in which the patients were asked to touch their
knees by their hands (10 repetitions with 3 sets, 6 seconds
rest between each repetition, and 1 minute rest between the
sets; the resistance is progressed according to the number of
repetitions).
3) Stretching of back muscles from the crock lying
position in which the therapist moved both lower limbs
toward the chest (5 repetitions, 30 seconds in position of
stretching, 30 seconds in position of relaxation).
4) Mechanical traction of the spine in a supine lying
position on a bed designed for mechanical lumbar traction
by fixing the upper trunk and pulling on the lower trunk by
separating the middle of the bed by mechanical force for 15
minutes. Postural instructions for ADL were also given.
The program continued 3 sessions per week for three
months.
The pre- and post-assessments of the patients were
performed with the following:
1- Anteroposterior view of loading X-ray to detect
any change in scoliotic curve by measuring Cobb’s angle
(meeting of two lines, a horizontal line from the superior
surface of the first vertebrae of the curve and a horizontal
 1129

Table 1. The pre & post test measures of pain, FFT, Cobb’s angle of spine scores in stretching exercises group

Pain FFT Cobb’s angle of the spine

  (VAS) (cm) (degrees)
Pre Post Pre Post Pre Post
Mean 6.5 1.975 19.3 3.35 28 18.85
SD 0.945 0.525 2.735 1.225 2.973 2.134
Significance, p≤0.05. There was significant improvement in pain (6.5±0.945 to 1.975±0.525), FFT (19.3±2.735 to
3.35±1.225), Cobb’s angle of spine (28±2.973 to 18.85±2.134). FFT-fingertip to floor test measured in centimeters.
VAS-visual analogue scale measured on 10 point scale

Table 2. The pre & post test measures of pain, FFT, Cobb’s angle of spine scores in mechanical traction group

Pain FFT Cobb’s angle of the

  (VAS) (cm) spine(degrees)
Pre Post Pre Post Pre Post
Mean 6.45 2.25 19.2 4.25 27.2 24.8
SD 0.887 0.55 2.706 1.77 2.6 2.68
Significance, p≤0.05. There was significant improvement in pain (6.45±0.887 to 2.25±0.55), FFT (19.2±2.706 to
4.25±1.77), Cobb’s angle of spine(27.2±2.6 to 24.8±2.68). FFT-fingertip to floor test measured in centimeters. VAS-visual
analogue scale measured on 10 point scale

Table 3. Comparison of post test scores of stretching and mechanical traction groups

Pain FFT Cobb’s angle of lower spine

(VAS) (cm) (degrees)
SE gr. MT gr. SE gr. MT gr. SE gr. MT gr.
Mean 1.975 2.25 3.35 4.25 18.85 24.8
SD 0.525 0.55 1.225 1.773 2.134 2.687
Significance p≤0.05. There was significant improvement in SE group when compared to MT group in Cobb’s angle of spine
parameters but, there was no significant improvement in pain and FFT values. SE gr –stretching exercises group, MT
gr –mechanical traction group, FFT-fingertip to floor test measured in centimeters, VAS-visual analogue scale measured
on 10 point scale

line from the superior surface of last vertebrae of the curve)
for the lower trunk.
2- Visual analogue scale to measure the pain, which was
graded from 0 to 10. Zero represents no pain, whereas grade
10 represents unbearable pain. The subjects were asked to
indicate the intensity of pain by placing a dash at the appro-
priate level on a 10 cm horizontal line.
3- Tape measurement to detect forward trunk flexion
(fingertip-floor test) for both groups as follows: the patients
were instructed to bend forward as far as they could with
their knees straight and asked to touch their toes, and then
the distance from their middle fingertip to the floor was
measured.
RESULTS
The collected data were statistically analyzed by using a
one sample paired t-test to compare pre- and post-test values
within the group and two-sample unpaired t-test to compare
post values between the groups at a confidence level of
p≤0.05.
In the stretching exercises group, the results of the paired
t-test between pre- and post-test values showed significant
improvement in the Cobb’s angle, pain and forward flexion
of the trunk at p=0.0001 (as shown in Table 1).
In the mechanical traction group, there were improve-
ments in pain and forward flexion of the trunk at p=0.0001
and Cobb’s angle at p= 0.001 (as shown in Table 2).
The results of the unpaired t-test showed that Cobb’s
angle improved significantly in the stretching exercises
group compared with the mechanical traction group (at
p=0.0001), whereas no significant improvement was found in
pain scores and forward flexion of the trunk between groups
(as shown in Table 3). The mean difference of Cobb’s angle
was 9 degrees in the stretching exercises group, where as the
difference was only 2.4 degrees in the mechanical traction
group.
The results of this study showed that stretching exercises
are more effective than mechanical traction of the lower
spine in treatment of idiopathic scoliosis.
DISCUSSION
The goal of nonoperative treatment of patients with
1130 J. Phys. Ther. Sci. Vol. 24, No. 11, 2012
scoliosis in our study was to correct and maintain the spine
in a balanced position in the coronal and sagittal planes over
a level pelvis. This goal was achieved through traction or
stretching to correct the spinal deformity24).
We were unsure which intervention would be more
effective. Both protocols showed improvement in all the
outcome variables, but we found a significant decrease in the
scoliotic curve in the stretching exercises group compared
with the other group.
Stretching exercise for tight concave muscles was
applied to decrease spasm and hyperactivity of concave
side musculature and lengthening of the shortened muscles
and to correct the scoliotic curvature of the lumbar region.
Strengthening of the weak convex side muscles creates
a muscle balance and normal path for the body’s line of
gravity. The abdominal muscles, which are considered to
form the anterior wall of the spine, must be strong enough to
protect the spine from anterior aspect25, 26).
Back muscles stretching decreases spasms in the muscles
and improves the circulation, which in turn decreases the
concentration of metabolites, hypertonicity, and hyperac-
tivity of the lumbar erector spinae. This increase in elasticity
of the back muscles results in improvement of forward
flexion25, 27).
A recent focus in the physiotherapy management of
patients with back pain has been the specific training of
muscles surrounding the spine (deep abdominal muscles and
lumbar multifidus), which is considered to provide dynamic
stability and fine control to the lumbar spine28).
In the mechanical traction group, significant improvement
in pain, forward flexion of the trunk, and Cobb’s angle of the
lower spine was reported.
Traction of the spine was used in stretching of tight
muscles by using the patient’s body weight which is giving
equal stretching force on both sides of the spine which effects
the whole length of the spine (longitudinal stretching).
The use of exercise alone for the treatment of idiopathic
scoliosis has been suggested for many years. Although
exercise has traditionally been used to stretch tight trunk
musculature and strengthen muscles of the trunk, it has been
shown that exercise alone will not halt the progression of
or correct an existing moderate or severe scoliosis. Exercise
alone may be beneficial as a treatment for patients with very
mild idiopathic scoliosis. Exercise used in conjunction with
other methods of correction such as traction which has been
shown to be beneficial26, 29).
The abdominal muscles, which are considered to form the
anterior wall of the spine, must be strong enough to protect
the spine from the anterior aspect.
The program of traction and strengthening of the
abdominal muscles was created a controlling and balancing
effect between agonist and antagonist muscles of the spine.
In comparison the results of both groups, there was more
significant improvement in the stretching exercises group
than in the mechanical traction group in the Cobb’s angle of
lower spine but no significant improvement in pain and the
FFT of the trunk flexion. This is explained by the assumption
that the power of traction is less than the power of stretching
exercises and equally applied to both sides of the spine.
Addition of mechanical traction therapy to a standard graded
activity program has been shown not to be effective. Never-
theless, the results of the current study seem to support the
conclusions of recent reviews17, 30, 31) in which no uniform
evidence of the efficacy of traction therapy as a treatment for
LBP was reported23). A limitation of our study is the lack of
follow-up concerning the effects for at least after 3 months.
Future research should be focused on putting emphasis on
a follow-up period to determine the long- lasting effects of
various techniques.
The results of this study showed that stretching exercises
are more effective than traction of the spine in treatment of
idiopathic scoliosis.
From all of the above, we found that the stretching
program, strengthening of the convex side and abdominal
muscles, and following instructions concerning the correct
manner of performing ADL make up the appropriate regimen
for treatment of idiopathic scoliosis.
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