The effects of weightbath traction hydrotherapy as a component of complex physical therapy in disorders of the cervical and lumbar spine: a controlled pilot study with follow-up

A multicentre randomized controlled follow-up study of the effects of the underwater traction therapy in chronic low back pain

Low back pain (LBP) is one of the most costly diseases in the developed world. This study aimed to investigate the effects of underwater traction therapy on chronic low back pain. The primary objective was to prove that underwater traction therapy has favorable effects on LBP. Our secondary objective was to evaluate whether it also leads to improvement in the quality of life. This is a prospective, multicenter, follow-up study. A total of 176 patients with more than 3 months of low back pain enrolled from outpatient clinics were randomized into three groups: underwater weight bath traction therapy and non-steroidal anti-inflammatory drugs (NSAIDs); weight bath; and only NSAIDs. The following parameters were measured before, right after, and 9 weeks after the 3-week therapy: levels of low back pain in rest and during activity were tested using the visual analogue scale (VAS), the Oswestry Low Back Disability Questionnaire, and the EuroQol-5D-5L Questionnaire.The VAS levels improved significantly (p < 0.05) in both underwater weight bath traction therapy groups by the end of the treatment, whereas the improvement in the third group was not statistically significant. Furthermore, the improvements measured in the groups receiving traction therapy were persistent during the follow-up period. There were no significant changes in the Oswestry Index or the EuroQol-5D-5L without VAS parameters in any of the groups.Based on our results, for patients suffering from LBP pain who underwent underwater weight bath traction therapy, there were favorable impacts on the pain levels at rest or during activity. Clinical trial registration ID: NCT03488498, April 5, 2018.

Efficacy of aquatic therapy for neck pain: a systematic review

This study systematically reviews the current state of aquatic treatment of neck pain and assesses the scientific evidence of its benefits. The databases PubMed, Scopus, Web of Science and PEDro were searched for relevant reports published from January 1, 2008, to November 7, 2017, using the keywords "neck pain" in addition to "balneotherapy", "spa treatment", "spa", "thalassotherapy", "hydrotherapy", "aquatic therapy" or "aquatic". Inclusion criteria were full-text articles published in journals included in Journal Citation Reports in English and Spanish describing human studies. Case studies, letters to the editor and meeting presentations or other contributions were excluded. Of 367 articles identified, only 13 fulfilled the inclusion criteria: 5 randomized trials, 1 single blind controlled study, 2 pilot studies, 2 observational retrospective studies, 1 prospective study, 1 clinical study and 1 not specified. Participants were 658 subjects with chronic neck pain. Main symptoms and signs treated were neck pain, disability, cervical disc herniation and compromised quality of life. Evidence that aquatic treatment improves quality of life in affected individuals was good in four studies, fair in eight and weak in one. Treatment of neck pain using different waters and techniques reduced pain and disability, and improved functional capacity, quality of life, joint mobility, balance, relaxation and mood.

Human bone morphogenetic protein 7 transfected nucleus pulposus cells delay the degeneration of intervertebral disc in dogs

The main reason for intervertebral disc (IVD) degeneration is the decrease in the quantity and activity of IVD cells with subsequent reduction of the extracellular matrix (ECM). In this study, we investigated a cell-based repair strategy by injecting nucleus pulposus cells (NPCs) transduced with human bone morphogenetic protein (hBMP7) by adeno-associated virus-2 into the canine degenerative IVD to determine whether NPCs expressing hBMP7 could delay the degeneration of the IVD. Fourteen canines received annular punctures to induce disc degeneration. Eight weeks later, saline (group A), allogeneic NPCs (group B), or allogeneic NPCs transduced with hBMP7 (group C) were injected into the degenerative discs. Twelve weeks after the injection, MRI scan showed that the degeneration process of groups C was slower and less severe compared with that of groups B and C. The IVD stability in group C was superior to that in groups A and B in left-right bending and rotation. HE, safranin-O staining, and ELISA indicated that the degenerative degree of the IVD in group C was significantly milder than that in groups A and B. The study demonstrated that the implantation of NPCs-hBMP7 could effectively maintained the structural integrity, ECM, and biomechanical properties of the canine degenerated discs. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1311-1322, 2017.

Treatment of degenerative cervical spondylosis with radiculopathy. Clinical practice guidelines endorsed by The Polish Society of Spinal Surgery

INTRODUCTION

Degenerative cervical spondylosis (DCS) with radiculopathy is the most common indication for cervical spine surgery despite favorable natural history. Advances in spinal surgery in conjunction with difficulties in measuring the outcomes caused the paucity of uniform guidelines for the surgical management of DCS.

AIMS

The aim of this paper is to develop guidelines for surgical treatment of DCS. For this purpose the available up-to-date literature relevant on the topic was critically reviewed.

METHODS AND RESULTS

Six questions regarding most important clinical questions encountered in the daily practice were formulated. They were answered based upon the systematic literature review, thus creating a set of guidelines. The guidelines were categorized into four tiers based on the level of evidence (I-III and X). They were designed to assist in the selection of optimal and effective treatment leading to the most successful outcome.

CONCLUSIONS

The evidence based medicine (EBM) is increasingly popular among spinal surgeons. It allows making unbiased, optimal clinical decisions, eliminating the detrimental effect of numerous conflicts of interest. The key role of opinion leaders as well as professional societies is to provide guidelines for practice based on available clinical evidence. The present work contains a set of guidelines for surgical treatment of DCS officially endorsed by the Polish Spine Surgery Society.

The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature

BACKGROUND CONTEXT

Cervical spine disc herniation is a disabling source of cervical radiculopathy. However, little is known about its course and prognosis. Understanding the course and prognosis of symptomatic cervical disc herniation is necessary to guide patients' expectations and assist clinicians in managing patients.

PURPOSE

To describe the natural history, clinical course, and prognostic factors of symptomatic cervical disc herniations with radiculopathy.

STUDY DESIGN

Systematic review of the literature and best evidence synthesis.

METHODS

A systematic search of MEDLINE, EMBASE, CINAHL, SportsDiscus, and the Cochrane Central Register of Controlled Trials from inception to 2013 was conducted to retrieve eligible articles. Eligible articles were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. The results from articles with low risk of bias were analyzed using best evidence synthesis principles.

RESULTS

We identified 1,221 articles. Of those, eight articles were eligible and three were accepted as having a low risk of bias. Two studies pertained to course and one study pertained to prognosis. Most patients with symptomatic cervical disc herniations with radiculopathy initially present with intense pain and moderate levels of disability. However, substantial improvements tend to occur within the first 4 to 6 months post-onset. Time to complete recovery ranged from 24 to 36 months in, approximately, 83% of patients. Patients with a workers' compensation claim appeared to have a poorer prognosis.

CONCLUSIONS

Our best evidence synthesis describes the best available evidence on the course and prognosis of cervical disc herniations with radiculopathy. Most patients with symptomatic cervical spine disc herniation with radiculopathy recover. Possible recurrences and time to complete recovery need to be further studied. More studies are also needed to understand the prognostic factors for this condition.

Evidence-based hydro- and balneotherapy in Hungary--a systematic review and meta-analysis

Balneotherapy is appreciated as a traditional treatment modality in medicine. Hungary is rich in thermal mineral waters. Balneotherapy has been in extensive use for centuries and its effects have been studied in detail. Here, we present a systematic review and meta-analysis of clinical trials conducted with Hungarian thermal mineral waters, the findings of which have been published by Hungarian authors in English. The 122 studies identified in different databases include 18 clinical trials. Five of these evaluated the effect of hydro- and balneotherapy on chronic low back pain, four on osteoarthritis of the knee, and two on osteoarthritis of the hand. One of the remaining seven trials evaluated balneotherapy in chronic inflammatory pelvic diseases, while six studies explored its effect on various laboratory parameters. Out of the 18 studies, 9 met the predefined criteria for meta-analysis. The results confirmed the beneficial effect of balneotherapy on pain with weight bearing and at rest in patients with degenerative joint and spinal diseases. A similar effect has been found in chronic pelvic inflammatory disease. The review also revealed that balneotherapy has some beneficial effects on antioxidant status, and on metabolic and inflammatory parameters. Based on the results, we conclude that balneotherapy with Hungarian thermal-mineral waters is an effective remedy for lower back pain, as well as for knee and hand osteoarthritis.

Effects of releasing recombinant human growth and differentiation factor-5 from poly(lactic-co-glycolic acid) microspheres for repair of the rat degenerated intervertebral disc

Purpose:

The objective of this study was to investigate the therapeutic potential of poly(lactic- co-glycolic acid) (PLGA) microspheres loaded with recombinant human growth and differentiation factor-5 (rhGDF-5) on the disc degeneration induced by needle puncture in a rat caudal disc model.

Methods:

The rhGDF-5-loaded PLGA microspheres were prepared by the water-oil-water double-emulsion solvent evaporation method, and release kinetics was determined over 42 days. Rats that underwent 21-G needle puncture at rat tail discs were injected with rhGDF-5/PLGA microspheres at four weeks after needle injury. At eight weeks after the injection, disc height, glycosaminoglycans content, and DNA content of the discs were evaluated. In addition, gene expression analysis of aggrecan, collagen type I, and collagen type II in the rat nucleus pulposus was measured by real-time polymerase chain reaction. Rat discs were also assessed by histology using hematoxylin and eosin stain.

Results:

Encapsulation of rhGDF-5 in PLGA microspheres guaranteed a sustained release of active rhGDF-5 for more than 42 days. The injection of GDF-5/PLGA microspheres resulted in a statistically significant restoration of disc height ( p < 0.01), improvement of sulfated glycosaminoglycan ( p < 0.05), DNA content ( p < 0.05), and significantly increased mRNA levels of collagen type II ( p < 0.01), and the differentiation index (the ratio of collagen type II to collagen type I, p < 0.01). In addition, rhGDF-5/PLGA microspheres treatment also improved histological changes induced by needle puncture.

Conclusions:

The results of this study suggest that injection of rhGDF-5 loaded in PLGA microspheres into rat tail discs may be as a promising therapy strategy to regenerate or repair the degenerative disc.

[Evidence-based physiotherapy]

This article on physiotherapy presents some current evidence stating the strengths and weaknesses of the physiotherapeutic procedures. In the area of physiotherapy empirical data obtained during decades were overtaken by evidence from current studies. The author points out the great problem of physiotherapy, namely the heterogeneity of the applied parameters. Knowledge of current evidence may be very important and helpful for the physicians, but the author proposes, from the practical point of view, that physiotherapeutical procedures based on exprience and used for many years should not be entirely neglected. Nowadays physiotherapy plays an important role in the treament of locomotor diseases but its use is increasing in other fields of medicine, as well.

[The changing position of balneo- and hydrotherapy in medicine]

Therapy with water has been known for thousands of years. Hot water bath was always pleasant for people. During the 19th century it was applied for the treatment of several diseases and modern medicine should not miss it. Today balneotherapy may help gymnastic procedures and it is commonly used in combination with other types of physiotherapy, too.

Traction for low-back pain with or without sciatica

BACKGROUND

Traction has been used to treat low-back pain (LBP), often in combination with other treatments. We included both manual and machine-delivered traction in this review. This is an update of a Cochrane review first published in 1995, and previously updated in 2006.

OBJECTIVES

To assess the effects of traction compared to placebo, sham traction, reference treatments and no treatment in people with LBP.

SEARCH METHODS

We searched the Cochrane Back Review Group Specialized Register, the Cochrane Central Register of Controlled Trials (2012, Issue 8), MEDLINE (January 2006 to August 2012), EMBASE (January 2006 to August 2012), CINAHL (January 2006 to August 2012), and reference lists of articles and personal files. The review authors are not aware of any important new randomized controlled trial (RCTs) on this topic since the date of the last search.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction. As there were insufficient data for statistical pooling, we performed a descriptive analysis. We did not find any case series that identified adverse effects, therefore we evaluated adverse effects that were reported in the included studies.

MAIN RESULTS

We included 32 RCTs involving 2762 participants in this review. We considered 16 trials, representing 57% of all participants, to have a low risk of bias based on the Cochrane Back Review Group's 'Risk of bias' tool.For people with mixed symptom patterns (acute, subacute and chronic LBP with and without sciatica), there was low- to moderate-quality evidence that traction may make little or no difference in pain intensity, functional status, global improvement or return to work when compared to placebo, sham traction or no treatment. Similarly, when comparing the combination of physiotherapy plus traction with physiotherapy alone or when comparing traction with other treatments, there was very-low- to moderate-quality evidence that traction may make little or no difference in pain intensity, functional status or global improvement.For people with LBP with sciatica and acute, subacute or chronic pain, there was low- to moderate-quality evidence that traction probably has no impact on pain intensity, functional status or global improvement. This was true when traction was compared with controls and other treatments, as well as when the combination of traction plus physiotherapy was compared with physiotherapy alone. No studies reported the effect of traction on return to work.For chronic LBP without sciatica, there was moderate-quality evidence that traction probably makes little or no difference in pain intensity when compared with sham treatment. No studies reported on the effect of traction on functional status, global improvement or return to work.Adverse effects were reported in seven of the 32 studies. These included increased pain, aggravation of neurological signs and subsequent surgery. Four studies reported that there were no adverse effects. The remaining studies did not mention adverse effects.

AUTHORS' CONCLUSIONS

These findings indicate that traction, either alone or in combination with other treatments, has little or no impact on pain intensity, functional status, global improvement and return to work among people with LBP. There is only limited-quality evidence from studies with small sample sizes and moderate to high risk of bias. The effects shown by these studies are small and are not clinically relevant. Implications for practice To date, the use of traction as treatment for non-specific LBP cannot be motivated by the best available evidence. These conclusions are applicable to both manual and mechanical traction. Implications for research Only new, large, high-quality studies may change the point estimate and its accuracy, but it should be noted that such change may not necessarily favour traction. Therefore, little priority should be given to new studies on the effect of traction treatment alone or as part of a package.

Immediate changes in spinal height and pain after aquatic vertical traction in patients with persistent low back symptoms: a crossover clinical trial

OBJECTIVE

To investigate the effect of aquatic vertical traction on spinal height, pain intensity, and centralization response compared with a land-based supine flexion position for patients with low back pain and signs of nerve root compression.

DESIGN

Single-blind, repeated-measures crossover design.

SETTING

Outpatient physical therapy clinic.

SUBJECTS

Ninety-eight subjects were recruited using consecutive sampling, with 28 men and 32 women of a mean ± standard deviation (SD) age of 59.6 ± 11.6 years completing testing.

INTERVENTION

Each subject participated in 2 sessions that consisted of loaded walking for 15 minutes, followed by either 15 minutes of land-based supine position or 15 minutes of aquatic vertical traction.

MEASUREMENTS

Spinal height change, measured using a commercial stadiometer, was determined after completing loaded walking and after each intervention.

RESULTS

The mean ± SD height change of 4.99 ± 2.88 mm after aquatic vertical traction was similar to that of 4.21 ± 2.53 mm after the land-based supine flexion (P = .0969). Paired t-test indicated that both interventions resulted in significant increased height (P < .0001). Decreases in pain after aquatic intervention (2.7 ± 2.1 cm) were significantly greater than decreases after land intervention (1.7 ± 1.7 cm; P = .0034), and centralization of symptoms was more pronounced after aquatic vertical suspension compared with the supine land-based flexion condition (P < .0001). A significant correlation between height change and both pain reduction (r = 0.39; P = .001) and centralization (r = 0.29; P = .013) was observed for the aquatic intervention only.

CONCLUSION

Although both the aquatic and land interventions produced significant increases in overall spinal height, the aquatic intervention produced greater pain relief and centralization response in subjects with low back pain and signs of nerve root compression.

Weightbath hydrotraction treatment: application, biomechanics, and clinical effects

BACKGROUND AND PURPOSE

Weightbath hydrotraction treatment (WHT) is a simple noninvasive effective method of hydro- or balneotherapy to stretch the spine or lower limbs, applied successfully in hospitals and health resort sanitaria in Hungary for more than fifty years. This study aims to introduce WHT with its biomechanical and clinical effects. History, development, equipment, modes of application, biomechanics, spinal traction forces and elongations, indications and contraindications of WHT are precented.

SUBJECTS AND METHODS

The calculation of traction forces acting along the spinal column during the treatment is described together with the mode of suspension and the position of extra weight loads applied. The biomechanics of the treatment are completed by in vivo measured elongations of lumbar segments using a special underwater ultrasound measuring method. The clinical effects, indications, and contraindications of the treatment are also presented.

RESULTS

In the underwater cervical suspension of a human body, approximately 25 N stretching load occurs in the cervical spine, and about 11 N occurs in the lumbar spine. By applying extra weights, the above tensile forces along the spinal column can be increased. Thus, the traction effect can be controlled by applying such loads during the treatment. Elongations of segments L3-L4, L4-L5, and L5-S1 were measured during the usual WHT of patients suspended cervically in water for 20 minutes, loaded by 20-20 N lead weights on the ankles. The mean initial elastic elongations of spinal segments were about 0.8 mm for patients aged under 40 years, 0.5 mm between 40-60 years, and 0.2 mm for patients over 60 years. The mean final viscoelastic elongations were 1.5 mm, 1.2 mm, and 0.6 mm for the same age classes, respectively. No significant difference was found between the sexes regarding age-dependence in tension. WHT for discopathy showed significant improvement of clinical parameters, which was still evident three months later, as demonstrated by using a controlled pilot study.

CONCLUSION AND DISCUSSION

WHT effectively mitigates pain, enhances joint flexibility, and improves the quality of life of patients. The WHT equipment is easy to install and the treatment technique is simple. The authors are the first to determine the biomechanical effects of WHT using an in vivo-measuring method and biomechanical calculations; and verifying the beneficial clinical effects by a controlled pilot study. Approximate values of tensile forces occurring along different points of the spinal column have been calculated, depending on the mode of the suspension, and the value and position of the applied extra weight loads. Time-related viscoelastic elongations of lumbar segments and discs have been measured in vivo, in terms of sex, age, body weight and height and the position of the segment. Several clinical parameters were analyzed by a controlled pilot study to verify the beneficial effects of WHT for cervical and lumbar discopathy. Based on these results, advice can be given to therapists to obtain the optimal traction effects of the treatment.

Intradiscal injection of simvastatin retards progression of intervertebral disc degeneration induced by stab injury

INTRODUCTION

Earlier work indicates that the cholesterol-lowering drug, simvastatin, is anabolic to chondrogenic expression of rat intervertebral disc (IVD) cells, which suggests a potential role for simvastatin in IVD regeneration. In this study, we expand on our earlier work to test the effectiveness of simvastatin on disc degeneration utilizing a rat tail disc degeneration model.

METHODS

30 rats that underwent 21 G needle-puncture at rat tail discs were injected with simvastatin-loaded poly(ethylene glycol)-poly(lactic acid-co-glycolic acid)-poly(ethylene glycol) (PEG-PLGA-PEG) gel (5 mg/ml) or vehicle control at 4 weeks after needle injury. All animals were sacrificed 2 weeks after simvastatin injection. Bone morphogenetic protein-2 (BMP-2), aggrecan, collagen type II, and collagen type I messenger ribonucleic acid (mRNA) expression in the rat nucleus pulposus (NP) were measured by real-time polymerase chain reaction (PCR). In vivo magnetic resonance imaging (MRI) was performed to monitor changes in disc degeneration. Rat discs were also assessed by histology using hematoxylin and eosin (H&E) and safranin O staining. In addition, the NP weight, glycosaminoglycan (sGAG) and DNA content were also measured.

RESULTS

A single dose of simvastatin loaded in thermo-sensitive PEG-PLGA-PEG gel injected into the NP had the trend to increase aggrecan expression and sGAG content, and significantly increased mRNA levels of BMP-2, collagen type II, and the differentiation index (the ratio of collagen type II to collagen type I). The decreased NP weight, T2 intensity, as well as MRI index in the rat tail discs induced by needle puncture were significantly reversed after 2 weeks of simvastatin treatment. In addition, simvastatin treatment also improved histological changes induced by needle puncture.

CONCLUSIONS

A single injection of simvastatin loaded in PEG-PLGA-PEG gel into rat tail discs had the potential to retard or regenerate the degenerative disc.

The value of intermittent cervical traction in recent cervical radiculopathy

OBJECTIVE

Our objective is to assess the effect of mechanical and manual intermittent cervical traction on pain, use of analgesics and disability during the recent cervical radiculopathy (CR).

METHODS

We made a prospective randomized study including patients sent for rehabilitation between April 2005 and October 2006. Thirty-nine patients were divided into three groups of 13 patients each. A group (A) treated by conventional rehabilitation with manual traction, a group (B) treated with conventional rehabilitation with intermittent mechanical traction and a third group (C) treated with conventional rehabilitation alone. We evaluated cervical pain, radicular pain, disability and the use of analgesics at baseline, at the end and at 1, 3 and 6 months after treatment.

RESULTS

At the end of treatment improving of cervical pain, radicular pain and disability is significantly better in groups A and B compared to group C. The decrease in consumption of analgesics is comparable in the three groups. At 6 months improving of cervical and radicular pain and disability is still significant compared to baseline in both groups A and B. The gain in consumption of analgesics is significant in the three groups: A, B and C.

CONCLUSION

Manual or mechanical cervical traction appears to be a major contribution in the rehabilitation of CR particularly if it is included in a multimodal approach of rehabilitation.