Brandon Nguyen
PTDP-6108
Annotated Bibliography
Mechanical Traction for Lumbar Pain. Supine or Prone? A Randomized Controlled Trial
In this article, the authors engage in a study in order to examine the correlation between difference in positioning and effectiveness for mechanical lumbar traction.Prior to this study’s publishing in 2018, no studies had compared the effects of lumbar traction in the supine position and prone position for patients with chronic lower back pain. The authors argued that mechanical traction performed in the prone position could be even more successful than when performed in the supine position for these patients, due to less muscle activation in the position. Thus, the purpose of this study was to compare the effects of mechanical lumbar traction either in the supine or in the prone position with conventional physical therapy in patients with chronic low back pain and lumbosacral nerve root involvement in terms of disability, pain, and mobility.¹
The experimental paradigm of this study is an investigator-blinded randomized clinical trial. 125 patients from two outpatient clinics in Turkey were selected for this study. In regards to the inclusion criteria, participants had to be within the age range of 18-65 years old and have chronic lower back pain with accompanying radiculopathy of L4-L5, L5-S1, or L4-S1, for more than 3 months. For the exclusion criteria, patients with previous history of spinal surgery, a current pregnancy or postpartum period, co-existing medical conditions (such as severe spinal stenosis, osteoporosis, spondylolisthesis, scoliosis, ankylosing spondylitis, spinal fracture, spinal tumor), and lower back pain due to neoplastic, inflammatory, or infectious causes, were excluded from the study.¹ Patients were randomly allocated into three groups; these included a supine traction group, a prone traction group, and a physical therapy only group- functioning as a control group. All groups received a conventional PT program 5 sessions per week for a total of 15 sessions. In addition, members of the two traction groups were positioned accordingly while receiving intermittent traction (30 sec-hold, 10 sec-rest pattern) for 15 minutes per session. Traction was started with 25% of the patient’s body weight was increased until the patient indicated that the tolerance for pulling was reached, with a maximum of 50% of total body weight in both groups.¹ Measurements of disability due to lower back pain, pain, and lumbar flexion range of motion were taken at baseline evaluation and then repeated after the final session of PT. Disability due to lower back pain was measured via the Oswestry Disability Index. Pain was measured with a visual analog scale, numbered from 0 to 10. Lumbar flexion range of motion was measured with a modified lumbar Schober test.
The data was then compared among the three groups. Overall, the results demonstrated that greatest improvements in the three outcome measures occurred in the prone traction group. Conversely, the control group demonstrated the least improvement in the outcome measures. Optimal muscle relaxation occurred earlier in the prone traction group than in the supine traction group. Muscle relaxation was also much more significant in comparison to the supine traction group. These results were consistent with the authors’ opening arguments. Thus, the authors agree that when using traction as a modality, prone traction might be the optimal choice.¹
This study has some considerable strengths. By randomly allocating participants into groups, potential sources of bias were removed. In regards to participants in these groups, there were no statistical significant differences in age, sex, BMI, symptom duration, symptomatic side, working status, or affected root.¹ There was also a large sample size with an initial participant pool of 125, which eventually dropped to 118. Both treating physical therapists in the study also had over ten years of experience, reducing the risk of making errors during treatment. Patients also received the same sets of exercises regardless of group allocation.
The study also has some limitations, however. A major one is that patients were not blinded during the study. The authors remark that the placebo effect of traction and the lack of a sham treatment for the PT-only group may have interfered with results accordingly. There was also no follow-up evaluation after the final PT session; therefore, only short-term results could be measured. Having two different physical therapists work with patients may have created potential variation in results. Home exercise programs and compliance also could not be supervised; this may have created variation in values such as lumbar flexion range of motion. The authors also mention that their scales of measurement may have been inadequate in the initial evaluation stage of the study. Future research can look into repeating a similar study, but with a sham traction treatment incorporated in order to offset placebo effects, or investigate them further.
References
Filiz MB, Kiliç Z, Uçkun A, Çakir T, Doğan ŞK, Toraman NF. Mechanical Traction for Lumbar Radicular Pain. American Journal of Physical Medicine & Rehabilitation. 2018;97(6):433-439. doi:10.1097/phm.0000000000000892.