Efficacy of Lumbar Traction: A Randomised Clinical Trial

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.

Mechanical effects of traction on lumbar intervertebral discs: A magnetic resonance imaging study

BACKGROUND

Although traction has long been used for treating patients with low back pain (LBP), its effects are still inconclusive mainly because of limited high-quality evidence.

OBJECTIVE

To provide evidence of the mechanism of traction on lumbar intervertebral discs.

DESIGN

A quantitative approach with a repeated measurement protocol.

METHOD

Nine participants (mean age = 22.1 ± 0.8 years) without any LBP history were recruited. Magnetic Resonance Images of the lumbar spine of each participant were recorded before and after 30 min of horizontal lying and directly after 30 min of horizontal traction of 42% body weight. The average, anterior, central, and posterior disc height and tilt angle of each lumbar disc and lumbar lordosis were measured.

RESULTS

A significant increase in the average disc height for all lumbar discs, a significant reduction of lumbar lordosis and changes in tilt angle were observed after the application of 30 min of resting followed by 30 min of traction. A significant increase in the average disc height was observed only in lower lumbar discs after 30 min of traction. The increase in the posterior disc height was more apparent than that in the anterior disc height.

CONCLUSIONS

Horizontal traction was evidently effective in increasing the disc height of lower lumbar levels, particularly in the posterior regions of the discs. Further evidence of the effects of traction of different modes, magnitudes, and durations on the change in disc height is required for proper control of traction applied to specific disc levels.

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.

Lumbar spondylosis: clinical presentation and treatment approaches

Low back pain (LBP) affects approximately 60-85% of adults during some point in their lives. Fortunately, for the large majority of individuals, symptoms are mild and transient, with 90% subsiding within 6 weeks. Chronic low back pain, defined as pain symptoms persisting beyond 3 months, affects an estimated 15-45% of the population. For the minority with intractable symptoms, the impact on quality of life and economic implications are considerable. Despite the high prevalence of low back pain within the general population, the diagnostic approach and therapeutic options are diverse and often inconsistent, resulting in rising costs and variability in management throughout the country. In part, this is due to the difficulty establishing a clear etiology for most patients, with known nociceptive pain generators identified throughout the axial spine. Back pain has been termed as "an illness in search of a disease." Indeed, once "red flag" diagnoses such as cancer and fracture have been ruled out, the differential sources of low back pain remain broad, including the extensive realm of degenerative changes within the axial spine for which radiological evaluation is nonspecific and causal relationships are tentative. We will elaborate on these degenerative processes and their clinical implications. We will further discuss diagnostic approaches and the efficacy of existing treatment options.

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.

Presurgical Behavioral Medicine Evaluation (PBME) for Implantable Devices for Pain Management: A 1-Year Prospective Study

To reduce poor surgical outcomes, presurgical psychological evaluations are used to better predict prognosis. The current study investigated the utility of a revised Presurgical Behavioral Medicine Evaluation (PBME) algorithm, developed specifically for patients who were candidates for implantable devices. Patients were categorized into a Green, Yellow I, Yellow II, or Red prognosis group, with Green having the best, and Red having the worst, prognosis for good surgical outcomes. Variables, including gender, disability payment status, and involvement in pending litigation, were found to be significantly different among the groups in a sample of 95 consecutive patients. Analysis of data at the initial evaluation indicated that patients within the Red group endorsed significantly more physical/functional limitations, depressive symptomatology, and psychosocial distress than the Green group. In a 12-month follow-up analysis, significant differences among the four groups on various psychosocial measures were found. In addition, post-hoc tests revealed specific significant differences among the groups. A repeated measures analysis of the initial evaluation, 6-month, and 12-month follow-up data revealed that these measures were also significantly affected by the prognostic group. Lastly, nonparametric analysis indicated that there were significant differences among the groups on total risk factor scores as determined by the PBME algorithm.

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.

Chronic low back pain in a working-age adult

Low back pain is an extremely common patient complaint. Most cases resolve fairly quickly after the acute episode. However, a small but significant number of patients develop chronic low back pain; a persistent disabling condition. Patients suffer from unremitting pain and often become functionally impaired. Multiple patient characteristics have been identified that place patients at risk for developing chronic low back pain. Currently, it is difficult to find clinical guidelines on how best to manage chronic low back pain, and it remains a substantial treatment challenge for both physicians and patients. The causes, risk factors, prognosis and treatment strategies for chronic low back pain will be discussed in this chapter. The evidence regarding different pharmacological and non-pharmacological treatment modalities will be reviewed and a logical, focused treatment strategy will be outlined.

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.

Outcome of non-invasive treatment modalities on back pain: an evidence-based review

At present, there is an increasing international trend towards evidence-based health care. The field of low back pain (LBP) research in primary care is an excellent example of evidence-based health care because there is a huge body of evidence from randomized trials. These trials have been summarized in a large number of systematic reviews. This paper summarizes the best available evidence from systematic reviews conducted within the framework of the Cochrane Back Review Group on non-invasive treatments for non-specific LBP. Data were gathered from the latest Cochrane Database of Systematic Reviews 2005, Issue 2. The Cochrane reviews were updated with additional trials, if available. Traditional NSAIDs, muscle relaxants, and advice to stay active are effective for short-term pain relief in acute LBP. Advice to stay active is also effective for long-term improvement of function in acute LBP. In chronic LBP, various interventions are effective for short-term pain relief, i.e. antidepressants, COX2 inhibitors, back schools, progressive relaxation, cognitive-respondent treatment, exercise therapy, and intensive multidisciplinary treatment. Several treatments are also effective for short-term improvement of function in chronic LBP, namely COX2 inhibitors, back schools, progressive relaxation, exercise therapy, and multidisciplinary treatment. There is no evidence that any of these interventions provides long-term effects on pain and function. Also, many trials showed methodological weaknesses, effects are compared to placebo, no treatment or waiting list controls, and effect sizes are small. Future trials should meet current quality standards and have adequate sample size.

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.

The pain disability questionnaire: a new psychometrically sound measure for chronic musculoskeletal disorders

STUDY DESIGN

The Pain Disability Questionnaire (PDQ) is a psychometric evaluation study of a new measure of functional status.

OBJECTIVE

To evaluate the psychometric properties of the PDQ and compare its validity and responsiveness to traditional measures of functional status, such as the Oswestry, Million (MVAS), and SF-36 instruments.

SUMMARY OF BACKGROUND DATA

Measuring clinical outcomes is an essential element of any musculoskeletal treatment. The PDQ was developed for this purpose. It yields a total functional disability score ranging from 0 to 150. The focus, much like other health inventories, is primarily on disability and function. However, unlike most other measures, this instrument is designed for the full array of chronic disabling musculoskeletal disorders (CDMDs), rather than low back pain alone. Further, psychosocial variables, which recent studies have shown to play an integral role in the development and maintenance of chronic pain disability, formed an important core of the PDQ.

METHODS

Four groups were used in this psychometric evaluation: an asymptomatic normative population (NP; n = 50), an acute musculoskeletal disorder population (AMD; n = 52), a chronic disabled musculoskeletal disorder population (CDMD; n = 230), and a heterogeneous pain population (HP; n = 114). The NP and AMD groups served as comparison samples for the CDMD and HP groups. Analyses of PDQ reliability, validity, and responsiveness were conducted.

RESULTS

Test-retest reliability coefficients (ranging from 0.94 to 0.98) and a Cronbach's alpha coefficient of 0.96 for the PDQ were found to be of excellent quality. The responsiveness of the PDQ, as measured by Cohen's effect size statistic, ranged from 0.85 to 1.07, better than the Oswestry, MVAS, and SF-36. A high level of face validity was observed for the PDQ, as the CDMD population exhibited significantly higher pretreatment PDQ scores than a group of patients suffering from acute injuries. The construct-related validity of the PDQ was also found to be of excellent quality, as it correlated well to both the MVAS (0.65-0.81) and Oswestry (0.55-0.80). The PDQ consistently demonstrated stronger correlation coefficients to a wide variety of physical and psychosocial measures of human function, such as the SF-36, Beck Depression Inventory, Hamilton-D, State-Trait Anxiety Scale, and Pain Intensity VAS, than either the Oswestry or MVAS. A factor analysis of the PDQ revealed two factors: a Functional Status Component (FSC) and a Psychosocial Component (PC). Analyses proved each of these two components to be valid in assessing their theorized constructs.

CONCLUSIONS

The present study represents a comprehensive psychometric evaluation of a new functional status measure for musculoskeletal conditions in general, and a CDMD population in particular. The psychometric properties of the PDQ are excellent, demonstrating strong reliability, responsiveness, and validity, relative to many other existing measures of functional status. The many weaknesses cited for some of the existing measures were taken into account in designing this instrument. Consequently, the characteristics commonly noted as weaknesses for these other measures (such as a restriction to only the low back pain population, and inconsistent responsiveness) can be cited as strengths of the PDQ. Its generalizability and utility for assessing orthopedic treatment progress and functional outcomes must now be evaluated in broader settings.

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

OBJECTIVE

To assess the efficacy of traction for patients with low back pain (LBP) with or without radiating pain, taking into account the clinical technique or parameters used.

DATA SOURCES

A computer-aided search of MEDLINE, CINAHL, AMED, and the Cochrane Collaboration was conducted for randomized controlled trials (RCTs) in the English language, from 1966 to December 2001.

STUDY SELECTION

RCTs were included if: participants were over the age of 18 years, with LBP with or without radiating pain; the intervention group received traction as the main or sole treatment; the comparison group received sham traction or another conservative treatment; and the study used 1 of 4 primary outcome measures.

DATA EXTRACTION

The study was conducted in 2 strands. Strand 1 assessed methodologic quality using a specific criteria list recommended by the Cochrane Back Review Group. The strength of the evidence was then rated using the Agency for Health Care Policy and Research system. Strand 2 applied further inclusion criteria based on recommended clinical parameters. One reviewer conducted the selection and data extraction.

DATA SYNTHESIS

Strand 1: 1 study scored 9 points (maximum score, 10 points); the other 12 scored between 0 and 3 points, indicating that most were of poor quality. Nine studies reported negative findings, but only 1 study was of a high quality. Three studies reported positive findings and 1 study was inconclusive. Strand 2: only 4 trials having low methodologic quality were included, 2 of which reported negative findings, and 2 positive findings.

CONCLUSION

The evidence for the use of traction in LBP remains inconclusive because of the continued lack of methodologic rigor and the limited application of clinical parameters as used in clinical practice. Further trials, which give attention to these areas, are needed before any firm conclusions and recommendations may be made.

The million visual analog scale: its utility for predicting tertiary rehabilitation outcomes

STUDY DESIGN

A longitudinal cohort study involving 1749 patients with chronically disabling spine disorder (CDSD) who underwent tertiary rehabilitation investigated the relation between the Million Visual Analog Scale (MVAS) score and treatment outcome.

OBJECTIVES

To determine whether the pretreatment MVAS rating of disability severity is associated with the ability to complete functional restoration rehabilitation, and to determine whether pre- or posttreatment MVAS disability perception is associated with 1-year posttreatment socioeconomic outcomes. The relation of the MVAS to pre- and posttreatment psychosocial measures and physical performance levels also was evaluated.

SUMMARY OF BACKGROUND DATA

The MVAS yields a total functional disability score ranging from 0 to 150. Like other "disability inventories," the MVAS differs from a "pain inventory" in that the focus is on disability and function, as opposed to self-reported pain. The MVAS may currently be the most powerful functional rating scale because all its questions relate to the patient's ability to perform activities of daily living. It also has the advantage of a visual analog format, which typically is considered more effective than other commonly used self-report formats.

METHODS

A large cohort of 1749 patients with CDSD who underwent tertiary rehabilitation was divided into groups by their severity of disability, rated on the MVAS, both at pre- and posttreatment assessment. The patients were divided into groups ranging from "no reported disability" (MVAS = 0) to "extreme disability" (MVAS = 131-150). The distribution into the six groups was assessed on both pre- and posttreatment MVAS ratings. The patients underwent a 3-week functional restoration program consisting of daily quantitatively directed exercise progression and multimodal disability management. Physical capacity and psychosocial assessments, performed before and after treatment, were correlated with the MVAS scores. A 1-year posttreatment clinical interview obtained information on socioeconomic outcomes, which also were correlated with the MVAS ratings.

RESULTS

Mantel-Haenszel linear analyses showed a number of relations between demographic variables and both pre- and posttreatment MVAS scores. Most importantly, the findings showed that severe pretreatment MVAS scores were associated with a lower program completion rate (94% vs 89%; P < 0.001) and a higher rate of postrehabilitation health care use from a new provider (12% vs 41%; P < 0.001). Prerehabilitation scores also were linearly related to lower levels of pretreatment physical performance and higher rates of pretreatment depression. More severe posttreatment MVAS scores were associated linearly with a drop in the work return rate from 93% to 63%, a drop in the work retention rate 1 year after rehabilitation from 86% to 44%, and a drop in the financial settlement rate from 94% to 79% (P < 0.001). A linear trend also was found in the rate of postrehabilitation surgeries, with the percentages rising from 0% in the group with no reported disabilities to 12% in the group with extreme disabilities (P < 0.001).

CONCLUSIONS

The current study represents the first large-scale examination of the relation between MVAS ratings and treatment outcomes in a CDSD population. These results demonstrate the effectiveness of a simple disability rating scale, such as the MVAS, for systematic disability assessment in potentially predicting treatment outcomes in patients with CDSD. Despite the popularity of other questionnaires, the MVAS is the first disability inventory with demonstrated effectiveness for this purpose in a large CDSD population.

Rasch analysis of the Roland disability questionnaire

STUDY DESIGN

A cross-sectional survey using patient questionnaires was conducted. OBJECTIVE To assess whether the Roland Disability Questionnaire satisfies the Rasch model including unidimensionality and item separation.

SUMMARY OF BACKGROUND DATA

The Roland Disability Questionnaire, the most widely used patient-assessed measure of health outcome for back pain, has undergone several evaluations for its measurement properties including reliability, validity, and responsiveness. However, there is no published work relating to the underlying dimensionality of the instrument and the extent to which individual items contribute to the construct of physical disability resulting from low back pain.

METHODS

Patients entering a randomized controlled trial of exercise, manipulation, and usual management for back pain completed a questionnaire that included the Roland Disability Questionnaire. The Winsteps program was used to assess whether the Roland Disability Questionnaire fits the Rasch model. Item fit was assessed using the Infit and Outfit statistics.

RESULTS

The Roland Disability Questionnaire was completed by 1008 (90%) of the patients taking part in the trial. Most of the items in the Roland Disability Questionnaire contribute to a single underlying construct. However, four items had poor Outfit statistics, suggesting that they do not contribute sufficiently to the scale hierarchy. Several items positioned around the middle of the hierarchy are not sufficiently distinct in terms of difficulty. There were very few items positioned at the extremes of the hierarchy.

CONCLUSIONS

The Roland Disability Questionnaire largely satisfies the Rasch model for unidimensionality. However, the instrument could be improved through the removal of poorly fitting items and the addition of items at the upper and lower points of the scale hierarchy. The distribution of Roland Disability Questionnaire scores should be carefully considered before statistical testing is undertaken. Rasch transformed scores can be used to deal with deficiencies in the scale hierarchy.

Responsiveness of generic and specific measures of health outcome in low back pain

STUDY DESIGN

A longitudinal study using patient questionnaires was performed.

OBJECTIVE

To compare the discriminatory power and responsiveness of the Aberdeen Back Pain Scale (ABPS), the Roland Disability Questionnaire (RDQ), and the EuroQol in patients with low back pain.

SUMMARY OF BACKGROUND DATA

A number instruments specific to low back pain have not been compared for measurement properties. The EuroQol is a widely used generic instrument that has not been compared with specific instruments in patients with back pain.

METHODS

A questionnaire incorporating the Aberdeen Back Pain Scale, the Roland Disability Questionnaire, and the EuroQol was completed by patients taking part in a clinical trial of exercise treatments for back pain. Patients completed follow-up questionnaires at 6 weeks, 6 months, and 1 year. The discriminatory power of these instruments was assessed against variables relating to activity limitations, medication, and comorbidity. Responsiveness was assessed using standardized response means.

RESULTS

The questionnaire was completed by 187 patients taking part in the clinical trial. The Aberdeen instrument was found to be the most powerful at discriminating between different groups of patients on variables relating to activity limitations, medication, and comorbidity. The specific instruments demonstrated good levels of responsiveness, with the Aberdeen instrument producing the largest standardized response means. The Aberdeen instrument was more responsive to the smaller changes experienced by the control group, but was less powerful than the Roland at measuring differences in the levels of change between the two groups of patients at two of the three follow-up assessments in the trial. The EuroQol demonstrated a moderate level of responsiveness.

CONCLUSIONS

The two specific instruments are capable of greater levels of discrimination between groups of patients, and are more responsive over time than the generic EuroQol. The Aberdeen instrument performed most satisfactorily in relation to these criteria, but the Roland instrument was more sensitive to differences between the two groups in the clinical trial. The measurement properties of these two instruments reflect their origin: The Aberdeen instrument is based on clinical questions, whereas the Roland instrument is based on the generic Sickness Impact Profile. Instrument content should be carefullyconsidered when selecting instruments for applications, including clinical trials.

Management of nonspecific low back pain by physiotherapists in Britain and Ireland. A descriptive questionnaire of current clinical practice

STUDY DESIGN

A descriptive questionnaire of chartered physiotherapists.

OBJECTIVE

To investigate current physiotherapeutic management of low back pain throughout Britain and Ireland.

SUMMARY OF BACKGROUND DATA

Physiotherapists play a key role in low back pain management. Although clinical guidelines for best practice have been developed recently, there has been no large-scale attempt to describe current physiotherapeutic treatment approaches within Britain or Ireland.

METHODS

After semi-structured interviews (n = 6) and two pilot studies (n = 77) were done, postal questionnaires were distributed to four regional cluster samples of the membership of two physiotherapy professional organizations (n = 2654). After two mailings, a random sample of 90 nonresponders were followed up. Data were analyzed using the Statistical Package for the Social Sciences (SPSS Ltd., Woking, Surrey, UK), and precision of the survey estimates was assessed by calculation of sampling errors and intraclass correlation coefficients for cluster sampling.

RESULTS

Results were received from 1548 therapists (total response rate, 58.3%); of these, 813 reported that they were practicing in settings in which they treated patients with low back pain. Analysis of the results indicated the overall popularity of the Maitland mobilization and McKenzie approaches among physiotherapists. Although exercise per se was mentioned frequently by respondents, a marked difference in opinion among therapists regarding the optimal type of exercise for low back pain was obvious. Little evidence was demonstrated of the use of manipulation, fitness programs, or multidisciplinary efforts involving behavioral and physical aspects of treatment. Commonly used methods of electrotherapy were interferential therapy, ultrasound, pulsed short-wave diathermy, and transcutaneous electrical nerve stimulation.

CONCLUSIONS

The results of this study emphasize the need to evaluate further and improve the dissemination of findings regarding the effectiveness of specific physiotherapy approaches for low back pain management.

Efficiency and costs of medical exercise therapy, conventional physiotherapy, and self-exercise in patients with chronic low back pain. A pragmatic, randomized, single-blinded, controlled trial with 1-year follow-up

STUDY DESIGN

A multicenter, randomized, single-blinded controlled trial with 1-year follow-up.

OBJECTIVES

To evaluate the efficiency of progressively graded medical exercise therapy, conventional physiotherapy, and self-exercise by walking in patients with chronic low back pain.

SUMMARY AND BACKGROUND DATA

Varieties of medical exercise therapy and conventional physiotherapy are considered to reduce symptoms, improve function, and decrease sickness absence, but this opinion is controversial.

METHODS

Patients with chronic low back pain or radicular pain sick-listed for more than 8 weeks and less than 52 weeks (Sickness Certificate II) were included. The treatment lasted 3 months (36 treatments). Pain intensity, functional ability, patient satisfaction, return to work, number of days on sick leave, and costs were recorded.

RESULTS

Of the 208 patients included in this study, 71 were randomly assigned to medical exercise therapy, 67 to conventional physiotherapy, and 70 to self-exercise. Thirty-three (15.8%) patients dropped out during the treatment period. No difference was observed between the medical exercise therapy and conventional physiotherapy groups, but both were significantly better than self-exercise group. Patient satisfaction was highest for medical exercise therapy. Return to work rates were equal for all 3 intervention groups at assessment 15 months after therapy was started, with 123 patients were back to work. In terms of costs for days on sick leave, the medical exercise therapy group saved 906,732 Norwegian Kroner (NOK) ($122,531.00), and the conventional physiotherapy group saved NOK 1,882,560 ($254,200.00), compared with the self-exercise group.

CONCLUSIONS

The efficiency of medical exercise therapy and conventional physiotherapy is shown. Leaving patients with chronic low back pain untampered poses a risk of worsening the disability, resulting in longer periods of sick leave.

Efficacy of traction for nonspecific low back pain. 12-week and 6-month results of a randomized clinical trial

STUDY DESIGN

A randomized clinical trial.

OBJECTIVES

To assess the efficacy of motorized continuous traction for low back pain.

SUMMARY OF BACKGROUND DATA

The available studies on the efficacy of lumbar traction do not allow clear conclusions because of severe methodologic flaws. The current trial aimed to overcome these shortcomings.

METHODS

Patients with at least 6 weeks of nonspecific low back pain were selected. High-dose traction was compared with sham (or low-dose) traction. Sham traction was given with a specially developed brace that becomes tighter in the back during traction. This was experienced as if real traction were exerted. The patients and the outcome assessor were unaware of treatment allocation. Outcome measures were: patient's global perceived effect, severity of main complaints, functional status, pain, range of motion, work absence, and medical treatment. Results for the outcome measures at 12 weeks and 6 months after randomization are presented.

RESULTS

One hundred and fifty-one patients were randomly allocated to one of the two treatment methods. Intention-to-treat analysis of the 12-week and 6-month results showed no statistically significant differences between the groups on all outcome measures: all 95% confidence intervals included the value zero. The number of patients lost to follow-up study was very low. Other analyses showed the same results.

CONCLUSIONS

Most common flaws of earlier studies on traction therapy could be overcome. This trial did not support the claim that traction is efficacious for patients with low back pain.

Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions

STUDY DESIGN

A systematic review of randomized controlled trials.

OBJECTIVES

To assess the effectiveness of the most common conservative types of treatment for patients with acute and chronic nonspecific low back pain.

SUMMARY OF BACKGROUND DATA

Many treatment options for acute and chronic low back pain are available, but little is known about the optimal treatment strategy.

METHODS

A rating system was used to assess the strength of the evidence, based on the methodologic quality of the randomized controlled trials, the relevance of the outcome measures, and the consistency of the results.

RESULTS

The number of randomized controlled trials identified varied widely with regard to the interventions involved. The scores ranged from 20 to 79 points for acute low back pain and from 19 to 79 points for chronic low back pain on a 100-point scale, indicating the overall poor quality of the trials. Overall, only 28 (35%) randomized controlled trials on acute low back pain and 20 (25%) on chronic low back pain had a methodologic score of 50 or more points, and were considered to be of high quality. Various methodologic flaws were identified. Strong evidence was found for the effectiveness of muscle relaxants and nonsteroidal anti-inflammatory drugs and the ineffectiveness of exercise therapy for acute low back pain; strong evidence also was found for the effectiveness of manipulation, back schools, and exercise therapy for chronic low back pain, especially for short-term effects.

CONCLUSIONS

The quality of the design, execution, and reporting of randomized controlled trials should be improved, to establish strong evidence for the effectiveness of the various therapeutic interventions for acute and chronic low back pain.

Efficacy of traction for non-specific low back pain: a randomised clinical trial

Previous trials to assess the efficacy of lumbar traction for back pain have been methodologically flawed. To avoid these shortcomings, we conducted a randomised controlled trial in which high-dose traction was compared with sham traction. The sham traction was given with a specially developed brace that tightens in the back during traction. To the patient, the experience is that of traction. The patients and outcome assessor were blinded for the assigned treatment. 151 patients with at least six weeks of non-specific low back pain were randomised. Intention to treat analysis showed no differences between the groups on all outcome measures (patients' global perceived effect, severity of main complaints, functional status and pain); all 95% confidence intervals included the value zero. The number of withdrawals from treatment, loss to follow-up, and protocol deviations was low. Consequently, the per-protocol analysis showed results similar to the intention to treat analysis. Subgroup analyses did not show any group for which traction might seem promising. Our data do not support the claim that traction is effective for patients with low back pain.