Traction for low-back pain with or without sciatica

An Updated Overview of Low Back Pain Management

We aimed to determine the recommendation level for the treatment of acute and chronic low back pain (LBP). A systematic review (SR) of the literature was performed and all English-language articles that discuss acute and chronic LBP, including MEDLINE and the Cochrane Database of Systematic Reviews, were searched. Of the 873 searched literature reports, 259 articles, including 131 clinical trials, 115 SRs, nine meta-analyses, and four clinical guidelines were analyzed. In these articles, high-quality randomized controlled trials, SRs, and used well-written clinical guidelines were reviewed. The results indicated multiple acute and chronic LBP treatment methods in the literature, and these reports when reviewed included general behavior, pharmacological therapy, psychological therapy, specific exercise, active rehabilitation and educational interventions, manual therapy, physical modalities, and invasive procedures. The Trial conclusions and SRs were classified into four categories of A, B, C, and D. If there were not enough high-quality articles, it was designated as "I" (insufficient). This review and summary of guidelines may be beneficial for physicians to better understand and make recommendations in primary care.

Traction Therapy for Cervical Radicular Syndrome is Statistically Significant but not Clinically Relevant for Pain Relief. A Systematic Literature Review with Meta-Analysis and Trial Sequential Analysis

Aim: We aimed to investigate the effectiveness of traction therapy in reducing pain by performing a systematic review with meta-analysis. We also explore the best modality for administering traction to patients with cervical radicular syndrome (CRS). Methods: We searched the Medline, Physiotherapy Evidence Database (PEDro), Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) electronic databases. Two reviewers independently selected randomized controlled trials (RCTs) that compared traction in addition to other treatments versus the effectiveness of other treatments alone for pain outcome. We calculated the mean differences (MDs) and 95% confidence intervals (CIs). We used Cochrane’s tool to assess risk of bias and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to evaluate the quality of evidence and summarize the study conclusions. Results: A total of seven studies (589 patients), one with low risk of bias, were evaluated. An overall estimate of treatment modalities showed low evidence that adding traction to other treatments is statistically significant (MD −5.93 [95% CI, −11.81 to −0.04] P = 0.05 and I² = 57%) compared to other treatments alone. The subgroup analyses were still statistically significant only for mechanical and continuous modalities. Conclusions: Overall analysis showed that, compared to controls, reduction in pain intensity after traction therapy was achieved in patients with cervical radiculopathy. However, the quality of evidence was generally low and none of these effects were clinically meaningful.

Functional Changes in Patients and Morphological Changes in the Lumbar Intervertebral Disc after Applying Lordotic Curve-Controlled Traction: A Double-Blind Randomized Controlled Study

Background and Objectives: Lumbar traction is widely used as a non-operative treatment for lumbar intervertebral disc disease. The effect of traditional traction (TT) using linear-type traction devices remains controversial for various reasons, including technical limitations. Thus, the purpose of this study was to compare the effects of the newly developed lumbar lordotic curve-controlled traction (L-LCCT) and TT on functional changes in patients and morphological changes in the vertebral disc. Materials and Methods: A total of 40 patients with lumbar intervertebral disc disease at the L4/5 or L5/S1 level as confirmed by magnetic resonance imaging were recruited and divided into two groups (L-LCCT or TT). The comprehensive health status changes of the patients were recorded using pain and functional scores (the visual analogue scale, the Oswestry Disability Index, and the Roland–Morris Disability Questionnaire) and morphological changes (in the lumbar central canal area) before and after traction treatment. Results: Pain scores were significantly decreased after traction in both groups (p < 0.05). However, functional scores and morphological changes improved significantly after treatment in the L-LCCT group only (p < 0.05). Conclusions: We suggest that L-LCCT is a viable option for resolving the technical limitations of TT by maintaining the lumbar lordotic curve in patients with lumbar intervertebral disc disease.

Assessment of variability in traction interventions for patients with low back pain: a systematic review

Background

Previous systematic reviews have concluded that lumbar traction is not effective for patients with low back pain (LBP), yet many clinicians continue to assert its clinical effectiveness.

Objective

To systematically identify randomized controlled trials (RCTs) of traction and explore the variability of traction interventions used in each RCT.

Method

A literature search started in September 2016 to retrieve systematic reviews and individual RCTs of lumbar traction. The term “lumbar traction” and other key words were used in the following databases: Cochrane Registry, MEDLINE, EMBASE, and CINAHL. The retrieved systematic reviews were used to extract individual RCTs. The most current systematic review included RCTs from inception until August 2012. We performed an additional literature search to update this systematic review with newer RCTs published between September 2012 and December 2016. All of the identified RCTs were combined and summarized into a single evidence table.

Results

We identified a total of 37 traction RCTs that varied greatly in their method of traction intervention. The RCTs included several types of traction: mechanical (57%), auto-traction (16%), manual (10.8%), gravitational (8.1%) and aquatic (5.4%). There was also great variability in the types of traction force, rhythm, session duration and treatment frequency used in the RCTs. Patient characteristics were a mixture of acute, subacute and chronic LBP; with or without sciatica.

Conclusion

There is wide variability in the type of traction, traction parameters and patient characteristics found among the RCTs of lumbar traction. The variability may call into question the conclusion that lumbar traction has little no or value on clinical outcomes. Also, this variability emphasizes the need for targeted delivery methods of traction that match appropriate dosages with specific subgroups of patients with LBP.

Epidural steroid injection in patients with lumbosacral radiculopathy in Abuja, Nigeria

Objective:

This prospective-controlled observational study looked at well-matched patients with spinal pain and radicular symptoms, caused by lumbar intervertebral disc herniation to compare the short-term clinical outcome of transforaminal and interlaminar epidural steroid injection (ESI) in a resource challenged tertiary institution in Nigeria.

Materials and Methods:

49 patients with radicular symptoms who were matched for age, symptom duration, magnetic resonance imaging findings, and pre-injection revised Oswentry Disability Index (ODI) score and Visual Analogue Scale (VAS) were assigned into ESI technique. The ODI and VAS score were analyzed immediately after an injection and upon follow-up (average 178.5 days), also with the need for repeated injections and surgical interventions over a 1-year follow-up interval.

Result:

In the transforaminal group (25 patients), there was a statistically significant improvement in the ODI scores from before the injection (ODI mean 62.4) to immediately after the injection (ODI mean 24.4, P < 0.01), and upon follow-up (ODI mean 20.8, P < 0.01). 9 patients (18.4%) required 1 or 2 repeated injections, 3 (6.1%) patients underwent surgery and 2 (4%) patients lost to follow-up. In the interlaminar group (24 patients), there was a statistically significant improvement in the ODI scores from before the injection (ODI mean 60.7) to immediately after the injection (ODI mean 30.1, P < 0.01), but not upon follow-up (ODI mean 43.2, P = 0.09). 11 (22.4%) patients required 1 or 2 repeated injection, 4 (8%) patients underwent surgery and 3 (6.1%) patients were lost to follow-up. There is an average of 2 fold improvement of transforaminal ESI over interlaminar ESI in a 40 point scale of ODI score on follow-up, which was statistically significant (P < 0.01). The VAS showed similar pattern with the ODI scores in the study.

Conclusion:

Transforaminal ESI to treat symptomatic lumbar disc herniation resulted in better short-term pain improvement and fewer long-term surgical interventions compared to interlaminar ESI.

Management of radicular pain in rheumatic disease: insight for the physician

Rheumatologists are still relatively unaware of the causes, presentation, diagnosis and management of radicular pain. This is against a background of increasing evidence of the presence and importance of radicular problems in patients with rheumatological disorders. When they coexist in patients, differentiating between nociceptive and neuropathic pain is clinically important because these components require different pain management strategies. Consequently, it is essential that rheumatologists become skilled in identifying as well as managing both forms of pain. This review will serve to further increase awareness among rheumatologists of this important issue as well as discuss the practical aspects of managing these conditions. The evaluation of patients requires very careful history taking and full thorough neurological examination. Diagnostic testing is suggested mainly to confirm the diagnosis and aetiology in patients with persistent symptoms despite conservative treatment. Neuroimaging is recommended for patients with acute radicular pain with progressive neurological deficits or those with high suspicion of neoplasm or epidural abscess. If neuroimaging does not confirm diagnosis, electrophysiology studies may be helpful. The management of this condition is multifaceted and involves physicians and allied healthcare professionals as well as the patients who should be encouraged to participate in self-management programmes. Nociceptive and neuropathic pain often coexists in patients with rheumatic disease. There are challenges to making the diagnosis of radicular pain in these patients. The diagnosis is primarily clinical but pathophysiological issues, diversity in symptoms, the multiple mechanisms of action and difficulties in communication between patients and their doctors as well as variable response to therapy pose challenges to the effective management of these patients. Despite these difficulties and challenges, it is essential that rheumatologists familiarize themselves with the management of radicular pain in rheumatic diseases. The evaluation of patients requires very careful history taking, aided by the use of an appropriate screening tool and full, thorough neurological examination. In addition, investigations such as the use of imaging or electrophysiology studies when required may help to differentiate between the pain phenotypes.

A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with mechanical lumbar traction

The objective of the study was to develop a clinical prediction rule for identifying patients with low back pain, who improved with mechanical lumbar traction. A prospective, cohort study was conducted in a physiotherapy clinic at a local hospital. Patients with low back pain, referred to physiotherapy were included in the study. The intervention was a standardized mechanical lumbar traction program, which comprised three sessions provided within 9 days. Patient demographic information, standard physical examination, numeric pain scale, fear-avoidance beliefs questionnaire and Oswestry low back pain disability index (pre- and post-intervention) were recorded. A total of 129 patients participated in the study and 25 had positive response to the mechanical lumbar traction. A clinical prediction rule with four variables (non-involvement of manual work, low level fear-avoidance beliefs, no neurological deficit and age above 30 years) was identified. The presence of all four variables (positive likelihood ratio = 9.36) increased the probability of response rate with mechanical lumbar traction from 19.4 to 69.2%. It appears that patients with low back pain who were likely to respond to mechanical lumbar traction may be identified.

Low back pain

General internists and family practitioners play an important role in the initial evaluation and treatment of acute low back pain and chronic low back pain. Given the usual time constraints placed on the primary care physician for evaluation of a patient with back pain, it is imperative that the generalist be acquainted and comfortable with the salient points in the history, the essentials of the examination, the appropriate use of diagnostic tests, and the effectiveness (or lack thereof) of available treatments.

Fusion and nonsurgical treatment for symptomatic lumbar degenerative disease: a systematic review of Oswestry Disability Index and MOS Short Form-36 outcomes

BACKGROUND CONTEXT

Although numerous studies have been published, controversy still exists regarding fusion and nonsurgical treatment for symptomatic degenerative lumbar spine conditions. Definite conclusions are difficult to draw because of differences in patient inclusion criteria, fusion technique, nonoperative treatment regimen, and clinical outcome measures used to determine success.

PURPOSE

The objective of this study was to evaluate lumbar fusion and nonsurgical interventions for various degenerative spine disorders using the Oswestry Disability Index (ODI) as a primary outcome measure in a systematic review. A secondary objective was to determine whether there is a difference in clinical outcomes based on the specific diagnosis.

STUDY DESIGN/SETTING

Systematic review.

PATIENT SAMPLE

Patients with low back pain of at least 12 weeks duration and older than 18 years, with prospectively collected ODI scores and at least a 12-month follow-up.

OUTCOME MEASURES

ODI and Short Form-36 (SF-36).

METHODS

A MEDLINE, HealthSTAR, CINAHL, and Cochrane database search was done using the search strategy recommended by the Cochrane Back Review Group. Proceedings from annual meetings of various spine societies and reference lists from review articles and retrieved articles were evaluated for possible inclusion. Criteria for inclusion were prospective randomized clinical trials in patients with low back pain of at least 12 weeks duration and older than 18 years; with prospectively collected ODI scores and at least a 12-month follow-up. The methodological quality of the studies was assessed using the van Tulder criteria. Data extracted from each study included demographics, study design, diagnosis, baseline and change in ODI, and baseline and change in SF-36 Physical Composite Score (PCS). The data were pooled and analyzed based on the primary reported inclusion diagnosis: degenerative disc disease (DDD), chronic low back pain (CLBP), and spondylolisthesis; and treatment: fusion (unspecified, posterior, anterior, combined) and nonsurgical.

RESULTS

Twenty-five studies met the inclusion criteria. The distribution of sex and smokers was similar across diagnoses and treatments. Patients with spondylolisthesis were older than patients with DDD and CLBP. Patients with spondylolisthesis had the greatest ODI improvement followed by patients with DDD and CLBP. The three fusion types produced similar amounts of improvement in ODI. Nonsurgical patients did not improve as much but had a lower baseline ODI. Improvements in the SF-36 PCS were fairly consistent across diagnostic groups and treatment types.

CONCLUSIONS

Substantial improvement can be expected in patients treated with fusion, regardless of technique, when an established indication such as spondylolisthesis or DDD exists. CLBP patients are less disabled and experience less improvement.

Stress in lumbar intervertebral discs during distraction: a cadaveric study

BACKGROUND CONTEXT

The intervertebral disc is a common source of low back pain (LBP). Prospective studies suggest that treatments that intermittently distract the disc might be beneficial for chronic LBP. Although the potential exists for distraction therapies to affect the disc biomechanically, their effect on intradiscal stress is debated.

PURPOSE

To determine if distraction alone, distraction combined with flexion, or distraction combined with extension can reduce nucleus pulposus pressure and posterior annulus compressive stress in cadaveric lumbar discs compared with simulated standing or lying.

STUDY DESIGN

Laboratory study using single cadaveric motion segments.

OUTCOME MEASURES

Strain gauge measures of nucleus pulposus pressure and compressive stress in the anterior and posterior annulus fibrosus.

METHODS

Intradiscal stress profilometry was performed on 15 motion segments during 5 simulated conditions: standing, lying, and 3 distracted conditions. Disc degeneration was graded by inspection from 1 (normal) to 4 (severe degeneration).

RESULTS

All distraction conditions markedly reduced nucleus pressure compared with either simulated standing or lying. There was no difference between distraction with flexion and distraction with extension in regard to posterior annulus compressive stress. Discs with little or no degeneration appeared to distribute compressive stress differently than those with moderate or severe degeneration.

CONCLUSIONS

Distraction appears to predictably reduce nucleus pulposus pressure. The effect of distraction therapy on the distribution of compressive stress may be dependent in part on the health of the disc.

Evidence-informed management of chronic low back pain with traction therapy

The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Use of complementary alternative medicine for low back pain consulting in general practice: a cohort study

Background

Although back pain is considered one of the most frequent reasons why patients seek complementary and alternative medical (CAM) therapies little is known on the extent patients are actually using CAM for back pain.

Methods

This is a post hoc analysis of a longitudinal prospective cohort study embedded in a RCT. General practitioners (GPs) recruited consecutively adult patients presenting with LBP. Data on physical function, on subjective mood, and on utilization of health services was collected at the first consultation and at follow-up telephone interviews for a period of twelve months

Results

A total of 691 (51%) respectively 928 (69%) out of 1,342 patients received one form of CAM depending on the definition. Local heat, massage, and spinal manipulation were the forms of CAM most commonly offered. Using CAM was associated with specialist care, chronic LBP and treatment in a rehabilitation facility. Receiving spinal manipulation, acupuncture or TENS was associated with consulting a GP providing these services. Apart from chronicity disease related factors like functional capacity or pain only showed weak or no association with receiving CAM.

Conclusion

The frequent use of CAM for LBP demonstrates that CAM is popular in patients and doctors alike. The observed association with a treatment in a rehabilitation facility or with specialist consultations rather reflects professional preferences of the physicians than a clear medical indication. The observed dependence on providers and provider related services, as well as a significant proportion receiving CAM that did not meet the so far established selection criteria suggests some arbitrary use of CAM.

The effectiveness of motorised lumbar traction in the management of LBP with lumbo sacral nerve root involvement: a feasibility study

BACKGROUND

Traction is commonly used for the treatment of low back pain (LBP), predominately with nerve root involvement; however its benefits remain to be established. The aim of this study was to test the feasibility of a pragmatic randomized controlled trial to compare the difference between two treatment protocols (manual therapy, exercise and advice, with or without traction) in the management of acute/sub acute LBP with 'nerve root' involvement.

METHODS

30 LBP patients with nerve root pain were recruited and randomly assigned to one of two treatment groups. Primary outcome measures were the: McGill pain questionnaire, Roland Morris disability questionnaire, and the SF36 Questionnaire; recorded at baseline, discharge, 3 and 6 months post-discharge.

RESULTS

27 patients completed treatment with a loss of another four patients at follow up. Intention to treat analysis demonstrated an improvement in all outcomes at follow up points but there appeared to be little difference between the groups.

CONCLUSION

This study has shown that a trial recruiting patients with 'nerve root' problems is feasible. Further research based upon a fully powered trial is required to ascertain if the addition of traction has any benefit in the management of these patients.

TRIAL REGISTRATION

REGISTRATION NUMBER

ISRCTN78417198.

Physical disability due to musculoskeletal conditions

Musculoskeletal conditions (MSC) are common throughout the world and their impact on individuals is diverse and manifold. Knowledge of the determinants for disability and of strategies for prevention and rehabilitation management according to the scientific evidence is critical for reducing the burden of MSC. The first section of this chapter reviews the evidence for common determinants of functioning and disability in patients with MSC. We have focussed on environmental factors (EF) and personal factors (PF) and have structured them according to the International Classification of Functioning, Disability and Health (ICF) framework. The second section discusses prevention strategies. Generally, prevention needs to address those EF and PF that were presented in the first section. The final section describes modern principles of rehabilitation and reviews the evidence for specific rehabilitation interventions.

Traction for low-back pain with or without sciatica

BACKGROUND

Traction is used to treat low-back pain (LBP), often with other treatments.

OBJECTIVES

To determine traction's effectiveness, compared to reference treatments, placebo, sham traction or no treatment for LBP.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2006, issue 4), MEDLINE, EMBASE, and CINAHL to October 2006, references in relevant reviews and personal files.

SELECTION CRITERIA

Randomized controlled trials (RCTs) involving traction to treat acute (less than four weeks duration), sub-acute (four to 12 weeks) or chronic (more than 12 weeks) non-specific LBP with or without sciatica.

DATA COLLECTION AND ANALYSIS

Study selection, methodological quality assessment and data extraction were done independently by two authors. As there were insufficient data for statistical pooling, we performed a qualitative analysis.

MAIN RESULTS

We included 25 RCTs (2206 patients; 1045 receiving traction). Five trials were considered high quality. For patients with mixed symptom patterns (acute, sub-acute and chronic LBP with and without sciatica) there is: strong evidence of no statistically significant difference in outcomes between traction as a single treatment and placebo, sham or no treatment; moderate evidence that traction as a single treatment is no more effective than other treatments; limited evidence of no significant difference in outcomes between a standard physical therapy program with or without continuous traction. For LBP patients with sciatica (with acute, sub-acute or chronic pain), there is conflicting evidence in several comparisons: autotraction compared to placebo, sham or no treatment; other forms of traction compared to other treatments; different forms of traction. In other comparisons, there were no statistically significant differences; the evidence is moderate for continuous or intermittent traction compared to placebo, sham or no treatment, and limited for light versus normal force traction.

IMPLICATIONS FOR PRACTICE

The results of the available studies involving mixed groups of acute, sub-acute and chronic patients with LBP with and without sciatica were quite consistent, indicating that continuous or intermittent traction as a single treatment for LBP is not likely effective for this group. Traction for patients with sciatica cannot be judged effective at present either, due to inconsistent results and methodological problems in most studies. We conclude that traction as a single treatment for LBP is probably not effective.

IMPLICATIONS FOR RESEARCH

Any future research on traction for patients with LBP should distinguish between symptom pattern and duration, and should be carried out according to the highest methodological standards.

Evidence synthesis combining individual patient data and aggregate data: a systematic review identified current practice and possible methods

OBJECTIVE

Meta-analysis of individual patient data (IPD) is the "gold-standard" for synthesizing evidence across several studies. Some studies, however, may only provide aggregate data (AD). In this situation researchers might need to combine IPD with AD to utilize all the evidence available. Here, we review applied IPD meta-analysis articles to assess if and how AD is combined with IPD in practice.

STUDY DESIGN AND SETTING

A systematic review of articles identified from bibliographic databases and searches.

RESULTS

We identified 33 applied IPD articles that combined IPD and AD and 166 that did not. For each article, we recorded the proportion of total studies providing IPD, and found that articles combining IPD and AD had, on average, IPD available in only 64% of studies (compared to 90% in articles not combining IPD and AD). Two different methods were used to combine IPD and AD, the two-stage method and analysis of partially reconstructed IPD, but a review of methodological articles identified two further methods, multilevel modeling and Bayesian hierarchical related regression. We summarize each method to aid practitioners.

CONCLUSION

Combining IPD and AD is a relevant issue for evidence synthesis, and the further development and validation of suitable meta-analysis methods is needed.