The efficacy of traction for back pain: a systematic review of randomized controlled trials

Manual traction is effective in alleviating lumbosacral spine pain: Evidence from a randomized controlled trial

Background

Manual traction, a therapeutic technique frequently employed in healthcare, involves applying controlled pulling force by hand, usually to the spine, to stretch muscles and decompress joints, thereby alleviating pain. This method can be particularly beneficial for addressing lumbosacral spine pain exacerbated by radicular symptoms, characterized by pain radiating from the lower back due to compression or irritation of spinal nerves.

Purpose

This study aimed to compare the effects of manual traction against control group in alleviating the lumbosacral spine pain caused by radicular symptoms.

Methods

A randomized controlled study design was utilized with a sample of 60 patients experiencing lumbosacral spine pain, evenly distributed between an experimental group (n = 30; receiving manual traction) and a control group (n = 30). Patients underwent assessments before and after six treatment sessions, which included the Straight Leg Raise test, modified Bragard's test, Kernig's test, and the visual analogue scale for pain perception.

Results

Between-group significant differences were found at post-intervention, favoring the experimental group on SLR - Left (°) (p = 0.004; medium effect size), SLR - Right (°) (p = 0.004; medium effect size), Modified Bragard test - Left (°) (p = 0.024; small effect size), Modified Bragard test - Right (°) (p = 0.003; medium effect size), Kernig's Test - Left (°) (p = 0.013; medium effect size) and Kernig's Test - Right (°) (p = 0.010; medium effect size). Additionally, between-group significant differences were found at post-intervention, favoring the experimental group on VAS scores at SLR left (p < 0.001; medium effect size), and right (p < 0.001); medium effect size, Modified Bragard test left (p < 0.001; medium effect size) and right (p < 0.001; medium effect size) and at Kernig's Test left (p < 0.001; medium effect size) and right (p < 0.001; medium effect size).

Conclusions

In conclusion, manual traction is recommended as an effective approach for alleviating lumbosacral spine pain in patients experiencing symptoms resulting from irritation or compression of a spinal nerve root.

Evolving Spinal Treatment Modalities: A Review of the Literature on Non-surgical Interferential Differential Dynamics (IDD) Therapy

Low back pain is one of the most common ailments encountered by physicians and orthopedic surgeons. There are various modalities used to treat low back pain, including conservative management, and a few of them involve rest, medications, massage, bracing, acupuncture, and physical therapy. Though most of the patients improve with conservative management, the burden of this disease has been very high and caused a significant amount of economic loss. Therefore, in-depth knowledge of all conservative methods is essential for physicians managing low back pain. Furthermore, there can be many causes of low back pain. Some of the more common ones are mechanical back pain due to paraspinal muscles or facetal in origin, discogenic back pain, and sacroiliac joint dysfunction. Many patients, especially the older population, have the discogenic origin as the more common cause of back pain, and traction therapy has been used for its treatment for ages. In this review, we discuss non-surgical spinal decompression/traction therapy popularly known as interferential differential dynamics (IDD) therapy with its current standing and recent advancement.

Effects of non-surgical decompression therapy in addition to routine physical therapy on pain, range of motion, endurance, functional disability and quality of life versus routine physical therapy alone in patients with lumbar radiculopathy; a randomized controlled trial

Background

Lumbar radiculopathy is an extensively common complaint reported by patients of low back pain (LBP), resulting in several impairments. A comparatively novel technique, non-surgical spinal decompression (NSD), is introduced, which uses a sensitive computerized feedback mechanism and decompresses the spinal nerve roots through segmental distraction. The objective of this study was to determine the effects of NSD therapy in addition to routine physical therapy on pain, lumbar range of motion (ROM), functional disability, back muscle endurance (BME), and quality of life (QOL) in patients with lumbar radiculopathy.

Methods

A total of sixty patients with lumbar radiculopathy were randomly allocated into two groups, an experimental (n = 30) and a control (n = 30) group, through a computer-generated random number table. Baseline values were recorded before providing any treatment by using a visual analogue scale (VAS), Urdu version of Oswestry disability index (ODI-U), modified-modified Schober’s test (MMST), prone isometric chest raise test, and Short Form 36-Item Survey (SF-36) for measuring the pain at rest, functional disability, lumbar ROM, BME, and QOL, respectively. All patients received twelve treatment sessions over 4 weeks, and then all outcome measures were again recorded.

Results

By using the ANCOVA test, a statistically significant (p < 0.05) between-group improvement was observed in VAS, ODI-U, BME, lumbar ROM, role physical (RP), and bodily pain (BP) domains of SF-36, which was in favour of NSD therapy group. The between-group difference was 1.07 ± 0.32 cm (p < .001) for VAS, 5.65 ± 1.48 points (p < .001) for ODI-U, 13.93 ± 5.85 s (p = 0.002) for BME, 2.62 ± 0.27 cm (p < .001) for lumbar flexion, 0.96 ± 0.28 (p < .001) for lumbar extension, 5.77 ± 2.39 (p = 0.019) for RP and 6.33 ± 2.52 (p = 0.016) for BP domain of SF-36. For these outcomes, a medium to large effect size (d = 0.61–2.47, 95% CI: 0.09–3.14) was observed.

Conclusion

It was concluded that a combination of non-surgical spinal decompression therapy with routine physical therapy is more effective, statistically and clinically, than routine physical therapy alone in terms of improving pain, lumbar range of motion, back muscle endurance, functional disability, and physical role domain of quality of life, in patients with lumbar radiculopathy, following 4 weeks of treatment.

Trial registration

WHO Iranian registry of clinical trials (IRCT20190717044238N1) Dated: 23.12.2019.

Inversion Table Fall Injury, the Phantom Menace: Three Case Reports on Cervical Spinal Cord Injury

Background: An inversion device, which is used to suspend one’s body and perform traction therapy, was introduced as an inversion table under the name of “Geokkuri” in South Korea. Fall injuries while hanging on inversion tables are among the most devastating spine injuries, as the likelihood of severe neurological sequelae such as tetraplegia increases. However, its enormous danger has been overlooked and this devastating injury has become a common clinical entity over time. The limited number of studies reported imply the lack of interest of researchers in these injuries. We reviewed three cases of spinal cord injury sustained on inversion tables in different environments and report the potential danger associated with the use of inversion tables to facilitate a safer exercise environment.

Effect of Caudal Traction on Mechanical Nociceptive Thresholds of Epaxial and Pelvic Musculature on a Group of Horses With Signs of Back Pain

Direct muscular attachment from lumbar vertebrae to the caudal vertebrae of the tail suggests that caudal traction, also described as a tail pull, may affect lumbar vertebral segments and/or associated soft tissues in horses. Traction is a commonly used human manual therapy technique used for pain relief and anecdotally observed to relieve pain in horses. However, research is lacking validating the efficacy of manual caudal traction on the horse. The objective of this study was to determine if caudal traction has an effect on mechanical nociceptive thresholds (MNTs) in a group of horses with clinical signs of back pain. Pressure algometry was used to measure MNTs of five bilateral anatomical sites in the epaxial and pelvic musculature of 11 horses referred to physiotherapy because of clinical signs of back pain. Measurements were recorded both before and immediately after traction. A significant difference (P ≤ .05) was identified between mean before and after caudal traction algometry measurements in all described sites. The percentage of MNT increase was highest in the thoracic region (83%) compared with the lumbar (50%) and the pelvic (52.4%) regions. These results support an effect of caudal traction in increasing MNTs in the thoracolumbar and pelvic regions in horses. Further research to determine the clinical effect of this technique is warranted.

Spinal manipulation in the treatment of patients with MRI-confirmed lumbar disc herniation and sacroiliac joint hypomobility: a quasi-experimental study

Background

To investigate the effect of lumbar and sacroiliac joint (SIJ) manipulation on pain and functional disability in patients with lumbar disc herniation (LDH) concomitant with SIJ hypomobility.

Methods

Twenty patients aged between 20 and 50 years with MRI-confirmed LDH who also had SIJ hypomobility participated in the trial in 2010. Patients who had sequestrated disc herniation were excluded. All patients received five sessions of spinal manipulative therapy (SMT) for the SIJ and lumbar spine during a 2-week period. Back and leg pain intensity and functional disability level were measured with a numerical rating scale (NRS) and the Oswestry Disability Index (ODI) at baseline, immediately after the 5th session, and 1 month after baseline.

Results

A significantly greater mean improvement in back and leg pain was observed in the 5th sessions and 1 month after SMT. Mean changes in ODI in the 5th session and 1 month after treatment also showed significant improvement. The MCIC for NRS and ODI scores in the present study were considered 20 and 6 points, respectively. Therefore, the mentioned improvements were not clinically significant in the 5th session or at 1-month follow-up.

Conclusion

Five sessions of lumbar and SIJ manipulation can potentially improve pain and functional disability in patients with MRI-confirmed LDH and concomitant SIJ hypomobility.

Trial registration

Irct.ir (Identifier: IRCT2017011924149N33), registered 19 February 2017 (retrospectively registered).

Age-related differences in the response of the L5-S1 intervertebral disc to spinal traction

BACKGROUND

Lumbar traction is a common treatment for low back pain; however its mechanisms of action are poorly understood. It has been hypothesized that a key effect of lumbar traction is its capacity to influence fluid movement within the intervertebral disc (IVD).

OBJECTIVES

To determine differences in the apparent diffusion coefficient (ADC) obtained with lumbar diffusion-weighted imaging (DWI) of the L5-S1 IVD before, and during, the application of lumbar traction.

DESIGN

Case series, repeated measures.

METHODS

A static traction load of ∼50% of body-weight was applied to the low back using a novel "MRI-safe" apparatus. DWI of the lumbar spine was performed prior to, and during the application of the traction load.

RESULTS

Participants were currently asymptomatic and included a young adult group (n = 18) and a middle-aged group (n = 15). The young adult group had a non-significant 2.2% increase in ADC (mean change = 0.03 × 10^-3 mm²/s, SD = 0.24, 95% CI = -0.09, 0.15). The ADC for the middle-aged group significantly increased by 20% (mean change of 0.18 × 10^-3 mm²/s, SD = 0.19; 95% CI = 0.07, 0.28; p = 0.003; effect size = 0.95). There was an inverse relationship between the ADC obtained before traction and the percent increase in ADC that was measured during traction.

CONCLUSION

Static traction was associated with an increase in diffusion of water within the L5-S1 IVDs of middle-age individuals, but not in young adults, suggesting age-related differences in the diffusion response. Further study is needed to assess the relationship between these findings and the symptoms of back pain.

LEVEL OF EVIDENCE

4.

Effects of segmental traction therapy on lumbar disc herniation in patients with acute low back pain measured by magnetic resonance imaging: A single arm clinical trial

BACKGROUND

Low Back Pain (LBP) is considered as one of the most frequent disorders, which about 80% of adults experience in their lives. Lumbar disc herniation (LDH) is a cause for acute LBP. Among conservative treatments, traction is frequently used by clinicians to manage LBP resulting from LDH. However, there is still a lack of consensus about its efficacy.

OBJECTIVE

The purpose of this study was to evaluate the effects of segmental traction therapy on lumbar discs herniation, pain, lumbar range of motion (ROM), and back extensor muscles endurance in patients with acute LBP induced by LDH.

METHODS

Fifteen patients with acute LBP diagnosed by LDH participated in the present study. Participants undertook 15 sessions of segmental traction therapy along with conventional physiotherapy, 5 times a week for 3 weeks. Lumbar herniated mass size was measured before and after the treatment protocol using magnetic resonance imaging. Furthermore, pain, lumbar ROM and back muscle endurance were evaluated before and after the procedure using clinical outcome measures.

RESULTS

Following the treatment protocol, herniated mass size and patients' pain were reduced significantly. In addition, lumbar flexion ROM showed a significant improvement. However, no significant change was observed for back extensor muscle endurance after the treatment procedure.

CONCLUSION

The result of the present study showed segmental traction therapy might play an important role in the treatment of acute LBP stimulated by LDH.

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.

Clinical examination procedures to determine the effect of axial decompression on low back pain symptoms in people with chronic low back pain

STUDY DESIGN

Observational.

OBJECTIVE

To assess the effects of spinal decompression procedures performed during a clinical exam on low back pain (LBP) symptoms.

BACKGROUND

Not all patients report an immediate or complete improvement in symptoms when the direction of lumbar motion or alignment is corrected according to principles of the movement system impairment (MSI) model. Axial compression of the spine may be responsible for the remaining symptoms.

METHODS

Seventy subjects (mean ± SD age, 41.9 ± 11.5 years; 38 females, 32 males) with chronic LBP were evaluated using a standardized MSI exam. Seven tests assessing the effects of spinal decompression on LBP were added to the exam if the subjects' symptoms were not alleviated with typical standardized corrections of movement and alignment. For each test of decompression, subjects reported their symptoms compared to a reference movement or position.

RESULTS

When decompression was performed during lateral bending to the right and left, 21 of 21 (100%) and 16 of 20 (80%) subjects, respectively, reported an improvement. When traction was applied to subjects in right and left sidelying, 6 of 11 (55%) and 7 of 9 (78%), respectively, reported an improvement. When patients performed a push-up in sitting, 36 of 51 (71%) reported an improvement. In subjects who had symptoms in unsupported sitting, 41 of 57 (72%) reported an improvement in supported sitting. In subjects who reported symptoms in standing, 33 of 47 (70%) reported an improvement in hook-lying.

CONCLUSION

Patients with chronic LBP consistently reported an improvement in symptoms with tests proposed to decrease the axial load on the spine. These tests are a quick and effective way to assess the contribution of axial decompression to LBP symptoms and potentially could be used as part of the plan of care.

Trunk muscle response to various protocols of lumbar traction

The purpose of this study was to compare trunk muscle activity, spinal decompression force, and trunk flexibility resulting from various protocols of spinal traction. Four experiments explored the effects of (1) sinusoidal, triangular, square, and continuous distraction-force waveforms, (2) 0, 10, 20, and 30 degrees of pull angle, (3) superimposed low, medium and high frequency force oscillations, and (4) sham traction. Nineteen healthy subjects volunteered for this study. Surface EMG was recorded during traction and later used in a biomechanical model to estimate spine decompression force. Trunk flexibility was measured before and after each treatment. There were no differences in muscle activity between any of the experimental conditions except the thoracic erector spinae muscle, which had lower EMG during continuous compared to sinusoidal distraction-force waveform (p=0.02). Thoracic and lumbar erector spinae muscles were significantly less active during sham than real traction (p=0.01 and p=0.04, respectively). The estimated L4-L5 spine compression force was 25N. Trunk flexibility decreased after each experimental session (p=0.01), and there were no differences between sessions. Our results suggest that the trunk muscle activity is minimal and point toward fluid exchange in the disc as one of the key biomechanical effects of spinal traction.

Current understanding of lumbar intervertebral disc degeneration: a review with emphasis upon etiology, pathophysiology, and lumbar magnetic resonance imaging findings

Degeneration of the lumbar intervertebral discs (IVDs) is highly prevalent in adults and is nearly universal in the elderly population. Degenerative changes within, and adjacent to, the IVDs are likely to contribute to a variety of pain syndromes; however, the exact association between these findings and symptoms remains speculative. Recent research has provided new information regarding the etiology, pathophysiology, and clinical relevance of degeneration of the IVD. This information will assist clinicians and researchers in understanding the development and clinical course of lumbar disc degeneration, as well as its potential impact upon patients seeking physical therapy care for back pain. The purposes of this clinical commentary are to review the structure and metabolic capacity of the normal and degenerative lumbar IVD, and to discuss factors that influence the onset and progression of disc degeneration. Lumbar magnetic resonance images will be used to illustrate the common findings associated with this condition.

An interdisciplinary clinical practice model for the management of low-back pain in primary care: the CLIP project

BACKGROUND

Low-back pain is responsible for significant disability and costs in industrialized countries. Only a minority of subjects suffering from low-back pain will develop persistent disability. However, this minority is responsible for the majority of costs and has the poorest health outcomes. The objective of the Clinic on Low-back pain in Interdisciplinary Practice (CLIP) project was to develop a primary care interdisciplinary practice model for the clinical management of low-back pain and the prevention of persistent disability.

METHODS

Using previously published guidelines, systematic reviews and meta-analyses, a clinical management model for low-back pain was developed by the project team. A structured process facilitating discussions on this model among researchers, stakeholders and clinicians was created. The model was revised following these exchanges, without deviating from the evidence.

RESULTS

A model consisting of nine elements on clinical management of low-back pain and prevention of persistent disability was developed. The model's two core elements for the prevention of persistent disability are the following: 1) the evaluation of the prognosis at the fourth week of disability, and of key modifiable barriers to return to usual activities if the prognosis is unfavourable; 2) the evaluation of the patient's perceived disability every four weeks, with the evaluation and management of barriers to return to usual activities if perceived disability has not sufficiently improved.

CONCLUSION

A primary care interdisciplinary model aimed at improving quality and continuity of care for patients with low-back pain was developed. The effectiveness, efficiency and applicability of the CLIP model in preventing persistent disability in patients suffering from low-back pain should be assessed.

Outcomes after a prone lumbar traction protocol for patients with activity-limiting low back pain: a prospective case series study

OBJECTIVE

To determine outcomes after administration of a prone lumbar traction protocol.

DESIGN

Prospective, longitudinal, case series.

SETTING

Suburban, chiropractic practice.

PARTICIPANTS

A total of 296 subjects with low back pain (LBP) and evidence of a degenerative and/or herniated intervertebral disk at 1 or more levels of the lumbar spine. We excluded patients involved in litigation and those receiving workers' compensation.

INTERVENTION

An 8-week course of prone lumbar traction, using the vertebral axial decompression (VAX-D) system, consisting of five 30-minute sessions a week for 4 weeks, followed by one 30-minute session a week for 4 additional weeks.

MAIN OUTCOME MEASURES

The numeric pain rating scale and the Roland-Morris Disability Questionnaire (RMDQ) were completed at preintervention, discharge (within 2 weeks of the last visit), and at 30 days and 180 days after discharge. Intention-to-treat strategies were used to account for those subjects lost to follow-up.

RESULTS

A total of 250 (84.4%) subjects completed the treatment protocol. On the 30-day follow-up, 247 (83.4%) subjects were available; on the 180-day follow-up, data were available for 241 (81.4%) subjects. We noted significant improvements for all postintervention outcome scores when compared with preintervention scores (P<.01).

CONCLUSIONS

Traction applied in the prone position using the VAX-D for 8 weeks was associated with improvements in pain intensity and RMDQ scores at discharge, and at 30 and 180 days after discharge in a sample of patients with activity-limiting LBP. Causal relationships between these outcomes and the intervention should not be made until further study is performed using randomized comparison groups.

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.

Is there a subgroup of patients with low back pain likely to benefit from mechanical traction? Results of a randomized clinical trial and subgrouping analysis

STUDY DESIGN

Randomized Clinical Trial.

OBJECTIVE

To identify a subgroup of patients with low back pain who are likely to respond favorably to an intervention including mechanical traction.

SUMMARY OF BACKGROUND DATA

Previous research has failed to find evidence supporting traction for patients with low back pain. Previous studies have used heterogeneous samples, although clinical experts tend to recommend traction for a more limited subgroup of patients with low back pain.

METHODS

Sixty-four subjects (mean age 41.1 year, 56.3% female) with low back and leg pain and signs of nerve root compression were randomized to receive a 6-week extension-oriented intervention with or without mechanical traction during the first 2 weeks. Between-group comparisons were conducted for changes in pain, disability, and fear-avoidance beliefs. Baseline variables were explored for potential as subgrouping criteria defining a subgroup of subjects likely to benefit from traction.

RESULTS

The group receiving traction showed greater improvements in disability (adjusted mean difference in Oswestry change 7.2 points) and fear-avoidance beliefs (adjusted mean difference in FABQPA change 2.6 points) after 2 weeks. There were no between-group differences after 6 weeks. Two baseline variables were associated with greater improvements with traction treatment; peripheralization with extension movements and a crossed straight leg raise.

CONCLUSION

A subgroup of patients likely to benefit from mechanical traction may exist. The results of this study suggest this subgroup is characterized by the presence of leg symptoms, signs of nerve root compression, and either peripheralization with extension movements or a crossed straight leg raise. Further research is needed to validate this finding.

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.

Practice patterns of physiotherapists in the treatment of work-related back pain

RATIONALE AND OBJECTIVES

Although physiotherapists (PTs) are one of the health professionals most involved in the treatment of back pain, their practice patterns have not been well studied. The study objectives were to identify the practice patterns of PTs treating workers suffering from acute/subacute back pain, with and without radiating pain below the knee, and to assess the relationship between these patterns and characteristics of PTs.

METHODS

PTs working in private clinics in the province of Quebec, Canada were invited to participate. Each PT used a self-administered questionnaire to record, for each treatment session, treatment objectives, interventions used and education given to two workers with back pain, one without radiating pain (n = 189 PTs) and one with radiating pain (n = 136 PTs). Multiple correspondence analysis with hierarchical classification was used to identify practice patterns of PTs. Multinomial logistic regressions were used to assess the relationship between practice patterns and PTs characteristics.

RESULTS

For workers without radiating pain, 51.9% of PTs focused their treatment on soft tissue mobilizations/massage and heat, 24.3% focused on the McKenzie approach and related interventions, and 23.8% focused on exercises and function. Similar results were found for workers with radiating pain. Most of the PT characteristics were not related to practice patterns.

CONCLUSIONS

The practices of PTs appeared to be separated into three distinct patterns. These practice variations suggest that there may be disagreement or uncertainty among PTs in the management of work-related back pain. The lack of evidence for the majority of interventions used by PTs and the difficulties of integrating evidence into clinical practice may be possible explanations.

Subgrouping patients with low back pain: evolution of a classification approach to physical therapy

The development of valid classification methods to assist the physical therapy management of patients with low back pain has been recognized as a research priority. There is also growing evidence that the use of a classification approach to physical therapy results in better clinical outcomes than the use of alternative management approaches. In 1995 Delitto and colleagues proposed a classification system intended to inform and direct the physical therapy management of patients with low back pain. The system described 4 classifications of patients with low back pain (manipulation, stabilization, specific exercise, and traction). Each classification could be identified by a unique set of examination criteria, and was associated with an intervention strategy believed to result in the best outcomes for the patient. The system was based on expert opinion and research evidence available at the time. A substantial amount of research has emerged in the years since the introduction of this classification system, including the development of clinical prediction rules, providing new evidence for the examination criteria used to place a patient into a classification and for the optimal intervention strategies for each classification. New evidence should continually be incorporated into existing classification systems. The purpose of this clinical commentary is to review this classification system, its evolution and current status, and to discuss its implications for the classification of patients with low back pain.

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.

Systematic Literature Review of Spinal Decompression Via Motorized Traction for Chronic Discogenic Low Back Pain

OBJECTIVE

The objective of this study was to systematically review the literature to assess the efficacy of nonsurgical spinal decompression achieved with motorized traction for chronic discogenic lumbosacral back pain.

DESIGN

Computer-aided systematic literature search of MEDLINE and the Cochrane collaboration for prospective clinical trials on adults with low back pain in the English literature from 1975 to October 2005. Methodologic quality for each study was assessed. Studies were included if the intervention group received motorized spinal decompression and the comparison group received sham or another type of nonsurgical treatment.

RESULTS

Data from 10 studies were fully analyzed. Seven studies were randomized controlled trials using various apparatus types. Because of this low number, we also analyzed three nonrandomized case series studies of spinal decompression systems. As the overall quality of studies was low and the patient groups heterogeneous, a meta-analysis was not appropriate and a qualitative review was undertaken. Sample sizes averaged 121 patients (range 27-292), with six of the seven randomized studies reporting no difference with motorized spinal decompression and one study reporting reduced pain but not disability. The three unrandomized studies (no control group) of motorized spinal decompression found a 77% to 86% reduction in pain.

CONCLUSIONS

These data suggest that the efficacy of spinal decompression achieved with motorized traction for chronic discogenic low back pain remains unproved. This may be, in part, due to heterogeneous patient groups and the difficulties involved in properly blinding patients to the mechanical pulling mechanism. Scientifically more rigorous studies with better randomization, control groups, and standardized outcome measures are needed to overcome the limitations of past studies.

Nonsurgical management of acute and chronic low back pain

A variety of nonsurgical treatment alternatives exists for acute and chronic low back pain. Patients should receive appropriate education about the favorable natural history of low back pain, basic body mechanics, and methods (eg, exercises, activity modification, behavioral modification) that can reduce symptoms. Nonprescription medication is efficacious for mild to moderate pain. Nonsteroidal anti-inflammatory drugs, alone or in combination with muscle relaxants, relieve pain and improve overall symptoms of acute low back pain. Exercise therapy has limited value for acute low back pain, but strong evidence supports exercise therapy in the management of chronic low back pain. Moderately strong evidence supports the use of manipulation in acute back pain. Evidence is weak for the use of epidural corticosteroid injections in patients with acute low back pain, strong for short-term relief of chronic low back pain, and limited for long-term relief of chronic low back pain. The use of facet injections in the management of acute low back pain is not supported by evidence, nor is the effectiveness of orthoses, traction, magnets, or acupuncture. Trigger point injections are not indicated for nonspecific acute or chronic low back pain, and sacroiliac joint injections are not indicated in the routine management of low back pain. Conflicting evidence exists regarding the use of transcutaneous electrical nerve stimulation.

Traction for low back pain with or without sciatica: an updated systematic review within the framework of the Cochrane collaboration

STUDY DESIGN

Systematic review.

OBJECTIVE

To determine if traction is more effective than reference treatments, placebo/sham traction, or no treatment for low back pain (LBP).

SUMMARY OF BACKGROUND DATA

Various types of traction are used in the treatment of LBP, often in conjunction with other treatments.

METHODS

We searched MEDLINE, EMBASE, and CINAHL to November 2004, and screened the latest issue of the Cochrane Library (2004, issue 4) and references in relevant reviews and our personal files. We selected randomized controlled trials (RCTs) involving any type of traction for the treatment of acute (less than 4 weeks duration), subacute (4-12 weeks), or chronic (more than 12 weeks) nonspecific LBP with or without sciatica. Sets of 2 reviewers independently performed study selection, methodological quality assessment, and data extraction. Because available studies did not provide sufficient data for statistical pooling, we performed a qualitative "levels of evidence" analysis, systematically estimating the strength of the cumulative evidence on the difference/lack of difference observed in trial outcomes.

RESULTS

A total of 24 RCTs (2177 patients) were included. There were 5 trials considered high quality. For mixed groups of patients with LBP with and without sciatica, we found: (1) strong evidence that there is no statistically significant difference in short or long-term outcomes between traction as a single treatment, (continuous or intermittent) and placebo, sham, or no treatment; (2) moderate evidence that traction as a single treatment is no more effective than other treatments; and (3) limited evidence that adding traction to a standard physiotherapy program does not result in significantly different outcomes. For LBP with sciatica, we found conflicting evidence in several of the comparisons: autotraction compared to placebo, sham, or no treatment; other forms of traction compared to other treatments; and different forms of traction. In the remaining comparisons, there were no statistically significant differences; level of evidence is moderate regarding continuous or intermittent traction compared to placebo, sham, or no treatment, and is limited regarding different forms of traction.

CONCLUSION

Based on the current evidence, intermittent or continuous traction as a single treatment for LBP cannot be recommended for mixed groups of patients with LBP with and without sciatica. Neither can traction be recommended for patients with sciatica because of inconsistent results and methodological problems in most of the studies involved. However, because high-quality studies within the field are scarce, because many are underpowered, and because traction often is supplied in combination with other treatment modalities, the literature allows no firm negative conclusion that traction, in a generalized sense, is not an effective treatment for patients with LBP.

The McKenzie method for low back pain: a systematic review of the literature with a meta-analysis approach

STUDY DESIGN AND OBJECTIVES

Meta-analysis of randomized controlled trials to evaluate the effectiveness of the McKenzie method for low back pain (LBP).

SUMMARY OF BACKGROUND DATA

The McKenzie method is a popular classification-based treatment for LBP. The faulty equation of McKenzie to extension exercises (generic McKenzie) is common in randomized trials.

METHODS

MEDLINE, EMBASE, PEDro, and LILACS were searched up to August 2003. Two independent reviewers extracted the data and assessed methodologic quality. Pooled effects were calculated among homogeneous trials using the random effects model. A sensitivity analysis excluded trials reporting on generic McKenzie.

RESULTS

Eleven trials of mostly high quality were included. McKenzie reduced pain (weighted mean difference [WMD] on a 0- to 100-point scale, -4.16 points; 95% confidence interval, -7.12 to -1.20) and disability (WMD on a 0- to 100-point scale, -5.22 points; 95% confidence interval, -8.28 to -2.16) at 1 week follow-up when compared with passive therapy for acute LBP. When McKenzie was compared with advice to stay active, a reduction in disability favored advice (WMD on a 0- to 100-point scale, 3.85 points; 95% confidence interval, 0.30 to 7.39) at 12 weeks of follow-up. Heterogeneity prevented pooling of studies on chronic LBP as well as pooling of studies included in the sensitivity analysis.

CONCLUSIONS

There is some evidence that the McKenzie method is more effective than passive therapy for acute LBP; however, the magnitude of the difference suggests the absence of clinically worthwhile effects. There is limited evidence for the use of McKenzie method in chronic LBP. The effectiveness of classification-based McKenzie is yet to be established.

A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

To compare the long-term effectiveness of medical and chiropractic care for low back pain in managed care and to assess the effectiveness of physical therapy and modalities among patients receiving medical or chiropractic care.

SUMMARY OF BACKGROUND DATA

Evidence comparing the long-term relative effectiveness of common treatment strategies offered to low back pain patients in managed care is lacking.

METHODS

A total of 681 low back pain patients presenting to a managed-care facility were randomized to chiropractic with or without physical modalities, or medical care with or without physical therapy, and followed for 18 months. The primary outcome variables are low back pain intensity, disability, and complete remission. The secondary outcome is participants' perception of improvement in low back symptoms.

RESULTS

Of the 681 patients, 610 (89.6%) were followed through 18 months. Among participants not assigned to receive physical therapy or modalities, the estimated improvements in pain and disability and 18-month risk of complete remission were a little greater in the chiropractic group than in the medical group (adjusted RR of remission = 1.29; 95% CI = 0.80-2.07). Among participants assigned to medical care, mean changes in pain and disability and risk of remission were larger in patients assigned to receive physical therapy (adjusted RR = 1.69; 95% CI = 1.08-2.66). Among those assigned to chiropractic care, however, assignment to methods was not associated with improvement or remission (adjusted RR = 0.98; 95% CI = 0.62-1.55). Compared with medical care only patients, chiropractic and physical therapy patients were much more likely to perceive improvement in their low back symptoms. However, less than 20% of all patients were pain-free at 18 months.

CONCLUSIONS

Differences in outcomes between medical and chiropractic care without physical therapy or modalities are not clinically meaningful, although chiropractic may result in a greater likelihood of perceived improvement, perhaps reflecting satisfaction or lack of blinding. Physical therapy may be more effective than medical care alone for some patients, while physical modalities appear to have no benefit in chiropractic care.

The State of Rehabilitation Research: Art or Science?

Rehabilitation research has been criticized as not standing up enough to the rigors of scientific method to be called "science." The field has been portrayed as slow to promote its scientific achievements and to include them under the rubric of evidence-based rehabilitation. Following in the footsteps of psychology, rehabilitation as a broad-based discipline has faced many similar obstacles in achieving scientific status. Controversy exists about what exactly constitutes rehabilitation science versus its art and its respective multidisciplinary domains. The conception of these domains is directly related to current methods available to assess the state of the discipline and its research accomplishments. I used quantitative methods, such as randomized clinical and/or controlled trials (RCTs) and systematic reviews, to assess the status of rehabilitation research. Findings suggest that, as a field, rehabilitation makes significant contributions to science, measurable by the number and quality of RCTs and systematic reviews conducted so far on topics of critical importance for clinical care. In "artful" complement, qualitative approaches can be used as research tools to aid investigators in seeking knowledge beyond that obtained by quantitative methods, assessing many complexities associated with the various contexts of rehabilitation research. Other requirements to develop a common vision of rehabilitation science are also discussed.

Physiotherapy management of low back pain in Thailand: a study of practice

BACKGROUND AND PURPOSE

Low back pain (LBP) is one of the most common musculoskeletal disorders in both developed and developing countries. Whilst there have been a number of studies investigating the current physiotherapy management of LBP in the former, little is known about such management in developing countries. The objectives of the present study were to investigate the physiotherapy management of LBP in Thailand and to compare the results with those of developed countries where applicable.

METHOD

A cross-sectional survey was undertaken to collect information on physiotherapists, LBP patients and treatment interventions used, using a Thai version of an available (English) questionnaire. Subsequent to a pilot study with 32 Thai therapists, minor revisions were made and the final questionnaires were mailed to all 776 physiotherapists currently working throughout Thailand.

RESULTS

Responses were received from 559 therapists (a 77.2% response rate), and 502 of these were currently involved in LBP management. Results indicated that LBP patients made up, on average, 37.5% of their patient caseloads. Electrophysical modalities, especially hot packs (64%), ultrasound (61%) and mechanical traction (61%), were reported to be the most commonly used treatments, particularly by hospital-based therapists, whereas those working in university-based hospitals and private clinics were more likely to use manual therapy.

CONCLUSIONS

This study provides descriptive data from the therapists' perspective about LBP management and shows that the treatments most commonly used are different from those treatments commonly used in developed countries. The potential reasons for this are explored in this paper and recommendations are made for further research.

Management of Work-Related Low Back Pain: A Population-Based Survey of Physical Therapists

Background and Purpose. Physical therapy often is used in the management of work-related low back pain (LBP). Little information, however, is known about the types of interventions used by physical therapists in the management of this condition. The objective of this study was to describe the interventions used by physical therapists in the treatment of workers with acute or subacute LBP, with or without radiating pain below the knee. Subjects. Clinical management questionnaires for workers without and with radiating pain were returned by 190 and 139 physical therapists, respectively. Methods. For each treatment session, therapists recorded treatment objectives, interventions, and education provided to 2 workers with LBP, 1 with radiating pain and 1 without radiating pain. Results. The majority of physical therapists used stretching and strengthening exercises, spinal mobilizations, soft tissue mobilizations and massage, manual traction, posture correction, interferential current, ultrasound, heat, and functional activities education. With radiating pain, the majority of the therapists also used cold and the McKenzie approach. Treatment objectives pursued by the majority of the therapists were decrease of pain, increase of range of motion, increase of muscle strength (force-generating capacity of muscle), decrease of muscle tension, and worker education. Discussion and Conclusion. Physical therapists use an array of interventions with workers with LBP. The effectiveness of most interventions reported has not been well studied.

Traction for low-back pain with or without sciatica

BACKGROUND

Various types of traction are used in the treatment of low-back pain (LBP), often in conjunction with other treatments.

OBJECTIVES

To determine the effectiveness of traction in the management of LBP.

SEARCH STRATEGY

We searched The Cochrane Library 2004, Issue 4, MEDLINE, EMBASE, and CINAHL to November 2004, references in relevant reviews, and our personal files.

SELECTION CRITERIA

Randomized controlled trials (RCTs) examining any type of traction for the treatment of 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 sets of two reviewers. As available studies did not provide sufficient data for statistical pooling, a qualitative analysis was performed.

MAIN RESULTS

Twenty-four RCTs, involving 2177 patients (1016 receiving traction) were included in the review. Five trials were considered high quality. There is strong evidence that there is no significant difference in short or long-term outcomes between either continuous or intermittent traction and placebo, sham, or other treatments for patients with a mixed duration of LBP, with or without sciatica. There is moderate evidence that: autotraction is more effective other forms of traction are no more effective than placebo, sham or no treatment for patients with a mixed duration of LBP with sciatica. There is limited evidence that: there is no significant difference in outcomes between a standard physical therapy program with continuous traction and the same program without traction, for patients with a mixed duration of LBP, with or without sciatica autotraction on its own is more effective than a physical therapy program that includes Tru-Trac traction for patients with a mixed duration of LBP with sciatica. There is conflicting evidence regarding the short-term effectiveness of either continuous or intermittent traction compared to placebo, sham or other treatments, in the management of patients who have either chronic LBP or a mixed duration of LBP with sciatica.

AUTHORS' CONCLUSIONS

The evidence suggests that traction is probably not effective. Neither continuous nor intermittent traction by itself was more effective in improving pain, disability or work absence than placebo, sham or other treatments for patients with a mixed duration of LBP, with or without sciatica. Although trials studying patients with sciatica had methodological limitations and inconsistent results, there was moderate evidence that autotraction was more effective than mechanical traction for global improvement in this population.

Current use of lumbar traction in the management of low back pain: results of a survey of physiotherapists in the United Kingdom

OBJECTIVE

To identify the current use of traction and the types of patients, treatment parameters, and treatment modalities used in conjunction with traction.

DESIGN

Postal survey, with 4 sections: professional characteristics of respondent, current use of traction, patient selection, and treatment parameters.

SETTING

Musculoskeletal outpatient departments (private and nonprivate practitioners).

PARTICIPANTS

Random sample (N=1491) of chartered physiotherapists in the UK who work in the management of low back pain (LBP).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Descriptive analysis of information on current use and practice in applying traction.

RESULTS

A response rate of 83% (n=1239) was achieved; 41% (n=507) use lumbar traction, which is most commonly used in the management of subacute LBP patients presenting with nerve root symptoms. Treatment parameters were established for weights (5-60 kg), frequency (2-3 times weekly), and length of treatment (4 wk). In addition, traction is commonly used with other modalities (87%): mobilizations, advice, and exercise.

CONCLUSIONS

Survey results show the continued use of lumbar traction despite the recommendations of numerous guidelines. Results also clarify the types of patients and the parameters used in the application of traction.

Intraligamentous injection of sclerosing solutions (prolotherapy) for spinal pain: a critical review of the literature

BACKGROUND CONTEXT

The injection of various solutions aimed at producing a sclerosing effect has been used to treat soft tissues injuries (eg, inguinal hernia) for more than 100 years. In the 1930s, this treatment approach was applied to injured joints in an attempt to stimulate connective tissue repair. Although several studies have been published about this method of treatment for various orthopedic and spinal indications (termed prolotherapy), its use remains controversial.

PURPOSE

To conduct a critical review of the literature on prolotherapy for spinal pain.

STUDY DESIGN/SETTING

Critical review of the literature.

METHODS

Computerized medical literature databases (Medline, CINAHL, Mantis, Cochrane Central Register of Controlled Trials) were searched to uncover all published information about the use of sclerosing injections in humans with spinal pain disorders. Search results were reviewed for relevance, and information was abstracted from full-text articles.

RESULTS

Our search uncovered almost 200 reference materials in various media related to prolotherapy, including 31 clinical studies related to spinal pain. There were 26 observational cohorts and 5 randomized clinical trials (RCTs). Indications in these studies were low back pain (22), neck pain (3), cervical headaches (3) and dorsal or thoracic pain (3). A total of 20 sclerosing solutions were used in these studies; the most common was a mixture of dextrose 12.5%, glycerin 12.5%, phenol 1.25% and lidocaine 0.25%. Wide variations were found in treatment protocols, such as dose, number of treatments and use of adjunct therapies. Most cohort studies were only of moderate quality and varied greatly in the substances injected and the use of co-interventions. Most clinical studies reported positive results such as decreased pain or disability, although differences between treatment and control groups did not always reach statistical significance. Commonly reported adverse reactions to this treatment include temporary postinjection pain and stiffness. A handful of more serious adverse events were reported in the 1950s and 1960s with stronger or unknown solutions.

CONCLUSION

Prolotherapy describes a variety of treatment approaches rather than a specific protocol. Results from clinical studies published to date indicate that it may be effective at reducing spinal pain. Great variation was found in the injection and treatment protocols used in these studies that preclude definite conclusions. Future research should focus on those solutions and protocols that are most commonly used in clinical practice and have been used in trials reporting effectiveness to help determine which patients, if any, are most likely to benefit from this treatment.