Manual Traction Versus Isometric Exercises in Patients with Herniated Intervertebral Lumbar Discs

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.

Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses

BACKGROUND

There are numerous treatment approaches for sciatica. Previous systematic reviews have not compared all these strategies together.

PURPOSE

To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously.

STUDY DESIGN

Systematic review and network meta-analysis.

METHODS

We searched 28 electronic databases and online trial registries, along with bibliographies of previous reviews for comparative studies evaluating any intervention to treat sciatica in adults, with outcome data on global effect or pain intensity. Network meta-analysis methods were used to simultaneously compare all treatment strategies and allow indirect comparisons of treatments between studies. The study was funded by the UK National Institute for Health Research Health Technology Assessment program; there are no potential conflict of interests.

RESULTS

We identified 122 relevant studies; 90 were randomized controlled trials (RCTs) or quasi-RCTs. Interventions were grouped into 21 treatment strategies. Internal and external validity of included studies was very low. For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy, and exercise therapy were significantly inferior to epidural injections or surgery. For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, nonopioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were inferior to most other treatment strategies; although these findings represented large effects, they were statistically equivocal.

CONCLUSIONS

For the first time, many different treatment strategies for sciatica have been compared in the same systematic review and meta-analysis. This approach has provided new data to assist shared decision-making. The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction. The issue of how best to estimate the effectiveness of treatment approaches according to their order within a sequential treatment pathway remains an important challenge.

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.

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.

Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review

Patients with a lumbosacral radicular syndrome are mostly treated conservatively first. The effect of the conservative treatments remains controversial. To assess the effectiveness of conservative treatments of the lumbosacral radicular syndrome (sciatica). Relevant electronic databases and the reference lists of articles up to May 2004 were searched. Randomised clinical trials of all types of conservative treatments for patients with the lumbosacral radicular syndrome selected by two reviewers. Two reviewers independently assessed the methodological quality and the clinical relevance. Because the trials were considered heterogeneous we decided not to perform a meta-analysis but to summarise the results using the rating system of levels of evidence. Thirty trials were included that evaluated injections, traction, physical therapy, bed rest, manipulation, medication, and acupuncture as treatment for the lumbosacral radicular syndrome. Because several trials indicated no evidence of an effect it is not recommended to use corticosteroid injections and traction as treatment option. Whether clinicians should prescribe physical therapy, bed rest, manipulation or medication could not be concluded from this review. At present there is no evidence that one type of treatment is clearly superior to others, including no treatment, for patients with a lumbosacral radicular syndrome.

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.

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.

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.

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.

Conservative treatment of sciatica: a systematic review

Most patients with sciatica (often caused by disc herniations) are managed conservatively at first. The natural course seems to be favorable. The additional value of many conservative therapies remains controversial. Because a systematic review of the conservative treatment of sciatica is lacking, such a review was carried out. After a standardized literature search and selection procedure, methodology and outcome of randomized controlled trials (RCTs) were assessed by three observers. If possible, trial results were statistically pooled (= metaanalysis). The 19 RCTs that were selected showed greatly varying methodologic quality. Pooled odds ratios were calculated for several treatment types. Neither traction, exercise therapy, nor drug therapy was unequivocally effective. Epidural steroids may be beneficial for subgroups of nerve root compression. The literature suggests possible effectiveness of epidural steroids for sciatica. The authors recommend trials to investigate this treatment option further, especially with regard to patient subgroups (e.g., acute sciatica). The effects of clinical heterogeneity and methodology on review results are illustrated.

The effects of common medical interventions on pain, back function, and work resumption in patients with chronic low back pain: A prospective 2-year cohort study in six countries

STUDY DESIGN

A prospective cohort study with identical questionnaires and inclusion criteria was performed.

OBJECTIVES

To compare in six different countries the frequencies and effects of the common medical interventions used for patients with low back pain who are work incapacitated.

SUMMARY OF BACKGROUND DATA

Low back pain is a huge problem with increasing costs for health care, industry, and society.

METHODS

Cohorts of employed men and women ages 18 to 59 years who had been sick-listed (100%) for a minimum of 90 days because of low back pain were recruited in Denmark, Germany, Israel, Sweden, the Netherlands, and the United States. The subjects received three separate questionnaires with identical questions after 90 days, 1 year, and 2 years. The questionnaires included separate questions about background factors, treatment, and the like, as well as validated scales such as the Hannover Activities of Daily Living, von Korff pain score, Short Form-36, and Karasek-Theorell. Working status was obtained from registers. Main outcome measures were working/not working, back function, and pain.

RESULTS

All three questionnaires were completed by 2080 subjects in the six countries. With few exceptions, there were great similarities in the appointments, examinations, and treatments in the different countries. Considerable differences were found between the back surgery rates, which ranged from 6% in Sweden to 32% in the United States during the first 90 days of the study. Very few of the interventions had any noticeable positive effects on work resumption, pain, or back function. Back surgery in Sweden was a striking exception, positively affecting all three outcome measures. The frequencies of work resumption within the first year ranged from 73% in the Netherlands to 32% in Denmark.

CONCLUSIONS

Almost none of the commonly occurring and frequently practiced medical interventions for patients who are sick-listed because of low back pain had any positive effects on either the recorded health measures or work resumption.

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.