ArticlePDF Available

Inversion therapy in patients with pure single level lumbar discogenic disease: A pilot randomized trial

Authors:

Abstract and Figures

Backache and sciatica due to protuberant disc disease is a major cause of lost working days and health expenditure. Surgery is a well-established option in the management flowchart. There is no strong evidence proving that traction for sciatica is effective. We report a pilot prospective randomized controlled trial comparing inversion traction and physiotherapy with standard physiotherapy alone in patients awaiting lumbar disc surgery. This study sought to study the feasibility of a randomized controlled trial on the effect of inversion therapy in patients with single level lumbar discogenic disease, who had been listed for surgery. This was a single centre prospective randomized controlled trial undertaken at the Regional Neurosciences Centre, Newcastle Upon Tyne, UK. It was a prospective randomized controlled trial where patients awaiting surgery for pure lumbar discogenic disease within the ambit of the prestated inclusion/exclusion criteria were allocated to either physiotherapy or physiotherapy and intermittent traction with an inversion device. Post-treatment assessment made by blinded observers at 6 weeks for various outcome measures included the Roland Morris Disability Questionnaire (RMDQ) Score, Short Form 36 (SF 36), Oswestry Disability Index (ODI), Visual Analogue Pain Score (VAS), magnetic resonance imaging (MRI) appearance and the need for surgery. Avoidance of surgery was considered a treatment success. Twenty-six patients were enrolled and 24 were randomized [13 to inversion + physiotherapy and 11 to physiotherapy alone (control)]. Surgery was avoided in 10 patients (76.9%) in the inversion group, whereas it was averted in only two patients (22.2%) in the control group. Cancellation of the proposed operation was a clinical decision based on the same criteria by which the patient was listed for surgery initially. There were no significant differences in the RMDQ, SF 36, ODI, VAS or MRI results between the two groups. Intermittent traction with an inversion device resulted in a significant reduction in the need for surgery. A larger multicentre prospective randomized controlled trial is justified in patients with sciatica due to single level lumbar disc protrusions. [IMPLICATIONS FOR REHABILITATION:• Resolution of impairment and diasability due to radiculopathy is the aim of any intervention.• Avoidance of surgery meant satisfactory resolution of impairment and disability due to radiculopathy. This happened more often in the inversion group to the extent of reaching statistical significance.• The 12-point improvement in disability by the Oswestry Disability Index in the inversion group suggests a role for this intervention in disability reduction.• Inversion may form part of the conservative rehabilitation of patients with single level unilateral lumbar disc protrusion alongside other forms of physiotherapy.• There is a potential secondary impact in the reduction of rehabilitation following surgery.]
Content may be subject to copyright.

Disability & Rehabilitation
2012
34
17
1473
1480
© 2012 Informa UK, Ltd.
10.3109/09638288.2011.647231
0963-8288
1464-5165
Disability & Rehabilitation, 2012; 34(17): 1473–1480
© 2012 Informa UK, Ltd.
ISSN 0963-8288 print/ISSN 1464-5165 online
DOI: 10.3109/09638288.2011.647231
16 March 2011
26 November 2011
December 2011
Purpose: Backache and sciatica due to protuberant disc disease
is a major cause of lost working days and health expenditure.
Surgery is a well-established option in the management
flowchart. There is no strong evidence proving that traction for
sciatica is effective. We report a pilot prospective randomized
controlled trial comparing inversion traction and physiotherapy
with standard physiotherapy alone in patients awaiting
lumbar disc surgery. This study sought to study the feasibility
of a randomized controlled trial on the effect of inversion
therapy in patients with single level lumbar discogenic disease,
who had been listed for surgery. Methods: This was a single
centre prospective randomized controlled trial undertaken
at the Regional Neurosciences Centre, Newcastle Upon Tyne,
UK. It was a prospective randomized controlled trial where
patients awaiting surgery for pure lumbar discogenic disease
within the ambit of the prestated inclusion/exclusion criteria
were allocated to either physiotherapy or physiotherapy
and intermittent traction with an inversion device. Post-
treatment assessment made by blinded observers at 6 weeks
for various outcome measures included the Roland Morris
Disability Questionnaire (RMDQ) Score, Short Form 36 (SF 36),
Oswestry Disability Index (ODI), Visual Analogue Pain Score
(VAS), magnetic resonance imaging (MRI) appearance and
the need for surgery. Avoidance of surgery was considered a
treatment success. Results: Twenty-six patients were enrolled
and 24 were randomized [13 to inversion + physiotherapy and
11 to physiotherapy alone (control)]. Surgery was avoided
in 10 patients (76.9%) in the inversion group, whereas it was
averted in only two patients (22.2%) in the control group.
Cancellation of the proposed operation was a clinical decision
based on the same criteria by which the patient was listed for
surgery initially. There were no significant differences in the
RMDQ, SF 36, ODI, VAS or MRI results between the two groups.
Conclusion: Intermittent traction with an inversion device
resulted in a significant reduction in the need for surgery. A
larger multicentre prospective randomized controlled trial is
justified in patients with sciatica due to single level lumbar disc
protrusions.
Keywords: Avoidance of surgery, inversion therapy, single
level lumbar discogenic disease, traction
Introduction
Degenerative lumbar disease is a major cause of disability
and health expenditure, especially in the industrialized world
[1,2]. Compression of the nerve roots is oen the cause of
sciatica and, if sustained or severe, can result in neurological
decits. is can be caused by a degenerative disc protrusion
RESEARCH PAPER
Inversion therapy in patients with pure single level lumbar discogenic
disease: a pilot randomized trial
K. S. Manjunath Prasad1, Barbara A. Gregson2, Gerard Hargreaves3, Tiernan Byrnes2, Philip Winburn2 &
A. David Mendelow2
1Department of Neurosurgery, James Cook University Hospital, Middlesbrough, United Kingdom, 2Department of Neurosurgery,
Regional Neurosciences Centre, Newcastle upon Tyne, United Kingdom, and 3Department of Physiotherapy, University of
Northumbria, Newcastle upon Tyne, United Kingdom
Correspondence: Dr. K.S. Manjunath Prasad, Department of Neurosurgery, James Cook University Hospital, Middlesbrough TS4 3BW,
United Kingdom. Tel: +44 1642 835717. Fax: +44 1642 282770. E-mail: manjunath.prasad@doctors.org.uk
Resolution of impairment and diasability due to radic-•
ulopathy is the aim of any intervention.
Avoidance of surgery meant satisfactory resolution of •
impairment and disability due to radiculopathy. is
happened more oen in the inversion group to the
extent of reaching statistical signicance.
e 12-point improvement in disability by the Oswestry •
Disability Index in the inversion group suggests a role
for this intervention in disability reduction.
Inversion may form part of the conservative rehabilita-•
tion of patients with single level unilateral lumbar disc
protrusion alongside other forms of physiotherapy.
ere is a potential secondary impact in the reduction •
of rehabilitation following surgery.
Implications for Rehabilitation
(Accepted December 2011)
Disabil Rehabil Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 07/20/12
For personal use only.
1474 K.S.M. Prasad et al.
Disability & Rehabilitation
or by other processes like spondylolisthesis, spinal stenosis
and arthritis of the spinal joints. Sciatica can be described as
pain radiating down the leg(s) along the distribution of the
sciatic nerve and is usually a sequel to mechanical compres-
sion or inammation of the lumbosacral nerve roots [1].
e natural history of lumbar discogenic disease is well
known. It is usually a benign self-limiting condition. Sciatica
due to disc disease resolves without surgery in 1–12 months
in the majority of patients [3]. Over a period of time, the
protruded disc fragment decreases in size as the normal route
of nutrition is impeded and the hydration is reduced. e
relationship between the bulging disc and the adjacent nerve
is not only very close, but the inammatory changes in the
root cause further reduction in the space for the nerve. With
restriction of movement and activity coupled with reduction
in disc size, the inammation is also reduced and symptoms
are sometimes alleviated. If this does not happen, a variety of
interventions are available [4].
General Practitioners in Maastricht have reported that
there was no dierence in the outcomes when patients with
lumbar discogenic backache were managed either with bed
rest or no bed rest [5]. ese results were conrmed in a later
Cochrane review [6]. ere is no evidence that one or the
other type of conservative therapy is superior, including no
treatment for patients with lumbosacral radicular syndrome
[7]. ere is no evidence for optimal sequencing of therapies
or their ecacy in the treatment of sciatica [8].
Surgery for sciatica due to disc herniation is well estab-
lished [9], but costs more than a hundred million pounds per
year in the United Kingdom alone. Surgery has been shown
to reduce the time to recovery by about 50% but is associated
with a complication rate of 1–3% [3]. e biggest challenge
faced by clinicians in the management of these patients there-
fore is to optimize the use and timing of surgical intervention.
Avoiding surgery (and that too within a reasonable waiting
period as a signicant outcome measure) has not been clearly
addressed by earlier trials. e SPORT trial failed to show a
benet from surgery perhaps because of a high cross-over rate
(30%) from conservative treatment to surgery [10].
Traction is a well-known treatment for lumbar discogenic
disease used commonly in North America [11] and to a lesser
extent in parts of Europe [12]. Traction may work by separa-
tion of vertebral bodies, distraction and gliding of facet joints,
widening of the intervertebral foramen, straightening of the
spinal curves and stretching of the spinal musculature [13].
By distracting the vertebral bodies, negative pressure could
probably withdraw the protruding fragment back into the disc
space. e futility of traction (continuous or intermittent) as
a single treatment for low back pain [14] or radiculopathy [7]
is highlighted in some systematic reviews while research is
not infallible in denitively proving that there is “no eect”
or “no dierence” between two treatments [15]. Traction is
more likely to work if there is radicular involvement [16–19]
manifesting as sciatica [16,17].
Type of traction and traction dosage could inuence eec-
tiveness in sciatica. Traction can be continuous or intermittent
and can be manual, mechanical or motorized. Traction forces
of less than 20% of the body weight have been described as
placebo [20], whereas others claim that this can also be useful
[16,21]. e importance of intradiscal pressure especially in
relation to posture is well known [22]. Nachemson et al. [22]
showed that a traction load of 60% of the body weight is suf-
cient to reduce the residual pressure of 25% caused by stand-
ing to zero. In Inversion” or “Backswing”, a tilt table is used
and the weight of the entire upper half of the patient’s body
assisted by gravity acts as the traction. e traction forces here
are likely to be more consistent and tailored to each patient
than conventional traction.
e primary aim of the present study was to assess the e-
cacy of traction using an inversion device in alleviating symp-
toms due to lumbar disc protrusion and avoiding the need for
surgery in patients with acute disc prorusions that had been
oered microdiscectomy.
Methods
Patients
Recruitment and randomization were undertaken at the
Regional Neurosciences Unit, Newcastle upon Tyne between
February 2003 and September 2006. Approval from the
Newcastle Local Research ethics committee was obtained in
2003. Patients eligible for inclusion were aged between 18 and
45 years (both inclusive), within 6 months of the rst episode
of symptoms caused by a single level unilateral lumbar disc
protrusion causing the appropriate nerve root impingement
and in whom a decision to operate was made. Patients were
not considered eligible if there were any red ag features,
increasing neurological decits, signicant cardio-respiratory
disorder, pregnancy, weight more than 20% of ideal norms
for height and age or more than 140 kg. Magnetic resonance
imaging (MRI) evidence of a large sequestrated disc fragment
was also an exclusion criterion.
Written informed consent according to the prescription
of the local research ethics committee was obtained in every
patient.
Procedures
Sealed serially marked envelopes were used for randomiza-
tion by the treating physiotherapist. All patients were given a
standard regime of physiotherapy. One group had traction with
standardized access and time on the inversion table for a period
of 4 weeks whereas the other group did not have this. All patients
were assessed by blinded observers aer 6 weeks. e outcome
measures used were Roland Morris Disability Questionnaire
(RMDQ), Short Form 36 (SF 36), Oswestry Disability Index
(ODI), Visual Analogue Pain Score (VAS), MRI appearance
and need for surgery. An MRI done 6 weeks aer the random-
ized treatment was commenced and the pre randomization
and post-treatment MRI scans were compared. If the second
MRI was worse, a score of −1 was given while it was 0 for an
unchanged appearance. If the second MRI was better, but com-
pression persisted, a score of +1 was given while total relief of
compression earned +2. Patients who went on to have surgery
were considered as treatment failures. In all patients, surgery
Disabil Rehabil Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 07/20/12
For personal use only.
Inversion therapy in lumbar discogenic disease 1475
©  Informa UK, Ltd.
was initially considered the best option; but because of the wait-
ing lists in the unit, a nal decision about surgery was made by
the treating surgeon preoperatively. e treating neurosurgeon
was blinded to the allocation to inversion or not.
e treatment protocol for both groups of patients
included physiotherapy. Best practice physiotherapy remains
to be established for radiculopathy [23–25]. Each patient was
assessed for impairment and clinical ndings and treated with
a combination of education and advice [26], specic exercise
for movement control [27] exercises for reduction of derange-
ment [23] and manual therapy techniques [24,25]. Distraction
techniques were not used with this group. In addition to phys-
iotherapy, the inversion therapy group received mechanical
inversion three times a week for 4 weeks. Each session com-
prised up to six 2-minute inversions within the tolerance of
the patient. Guvenol et al. [28] inverted patients 10 minutes
daily for 10 days, however poor tolerance due to anxiety was
reported with this dose. Static inversion is reported to pro-
duce feelings of congestion and to avoid this Goldman et al.
[29] suggest short periods within patient tolerance.
e patient completed outcome measures used in the
study were SF 36, RMDQ, ODI and VAS. All four question-
naires have been used in the low back pain population. e
RMDQ and ODI are recognized disease-specic measures
of patient perception of disability [30]. e RMDQ [31] is a
patient completed questionnaire developed from the Sickness
Impact Prole. e 24-item scale covers a range of functional
activities with higher scores representing worse dysfunction.
e ODI [32] measures perceived disability in 10 activities
of daily living. e scale produces a score out of 100% with
a higher score representing increasing disability. e SF 36
[33] is a generic measure of eight dimensions of health status
divided between physical and mental health. A score of 100%
denotes the best health status possible. A VAS is a measure-
ment instrument that measures a characteristic or attitude
across a continuum of values.
Statistical analysis
Statistical analyses were conducted using SPSS 140 and
WinPepi 6.3. Data were compared using Fisher Exact test,
t-tests and Mann–Whitney U tests as appropriate.
Results
Twenty-six patients were recruited but two patients did not
attend the physiotherapy department, and so 24 patients were
randomized. Of these, all baseline and follow-up data were
missing for one patient and one patient did not fulll the inclu-
sion criteria. us 22 patients were eligible for assessment. Of
these, 13 patients were randomized to inversion while 11 were
allocated to the group without inversion. e trial prole is
shown as a ow chart in Figure 1 and details of all patients’
age, sex and level of disc involved is given in Table I.
Surgery
Surgical intervention was avoided in 10 patients (76.9%)
among the inversion group, while it was avoided in only two
patients (22.2%) among the no inversion group. Cancellation
of the proposed operation was a clinical decision-based on
the same criteria by which the patient was listed for surgery
initially. is is statistically signicant (Figures 2 and 3).
Avoidance of surgery thus has to be considered as a treatment
success.
MRI
Post-treatment MRI scans were available for 21 patients. One
patient who had surgery before the treatment was completed
because of worsening symptoms. e majority of the patients
in both groups (53.8% for the inversion group and 54.5% for
the control group) had unchanged images. e number of
patients in whom a change was seen either for the better or
worse was not statistically signicantly dierent and the same
was true when the two groups were compared (Figure 4).
Roland Morris Disability Questionnaire
is was available for 12 subjects in the inversion group and
7 patients in the other group. Table II displays the median
and range of Roland Morris scores at baseline and follow-up
for each group and change over time. A higher score implies
the disability is greater and a negative change score implies
improvement over time. ere are no statistically signicant
dierences between the two treatments.
SF 36
is was available for 12 subjects in the inversion group and
7 patients in the other group. Table III displays the mean and
standard deviation of each component of SF 36 at baseline
and the change over time between baseline and follow-up.
e higher the score at baseline, the better the health status
and the more positive the change over time the greater the
improvement. e change in health measure ranges from 1
to 5 and a score of 1 indicates that the patient feels they are
much better now than they were a year ago whereas a score
of 5 indicates that they are much worse now. A negative
value for change in health status implies improvement and
a positive value implies the patient is reporting being worse.
Comparisons between the two treatment groups have been
made using the t-test.
Patients in both groups show a poor health status on most
components at baseline. ese values are similar to those
reported in other studies. ere is little dierence between
the two groups. On average, the patients improve over time
but again there is no dierence between the two groups in
the degree by which they improve although this study is not
powered to be able to show a dierence.
Oswestry Disability Index
is was available for eight subjects in the inversion group and
three patients in the other group. Table IV displays the median
and range of Oswestry scores at baseline and follow-up for
each group and the change in score. A higher score at baseline
or follow-up implies a greater disability. A negative change in
score implies an improvement over time. ere is no dier-
ence in score at baseline but patients in the inversion therapy
Disabil Rehabil Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 07/20/12
For personal use only.
1476 K.S.M. Prasad et al.
Disability & Rehabilitation
group tend to have less disability at follow-up and the change
in score between baseline and follow-up almost reaches sta-
tistical signicance (using Mann–Whitney U test). Patients in
the inversion therapy group have a median improvement of
12 percentage points while those in the physiotherapy group
have a median improvement of 0 percentage points.
Visual Analogue Pain Score (VAS)
ough the VAS was available for 12 patients in the inversion
group before and aer treatment, one in each of the before
and aer cohort groups was not available at the other time
point and therefore the mean and median was calculated for
11 subjects. In the control group, data were available for seven
patients, before and aer treatment. A negative change over a
period of time indicates improvement. Figure 5 gives details
of the VAS before and aer treatment in the two groups. e
change was not statistically signicant in either group. In the
control group, the median VAS changed from 2.8 to 3.0 (t-test
p = 0.697) and for the inversion group it changed from 3.2 to
0.9 (t-test p = 0.078).
Discussion
Our pilot trial has shown that intermittent extreme traction
with an inversion device has resulted in a signicant reduc-
tion in the number of patients requiring surgery for radicular
symptoms due to lumbar disc protrusion.
Traction for sciatica
Some systematic reviews have highlighted the ineective-
ness of traction in low back pain [14] and radiculopathic
pain like sciatica [7], whereas a number of other reports have
Figure 1. Trial prole.
Disabil Rehabil Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 07/20/12
For personal use only.
Inversion therapy in lumbar discogenic disease 1477
©  Informa UK, Ltd.
contradicted this, especially when used for disability and pain
due to radiculopathy [16–19].
is study was therefore undertaken in patients listed and
waiting for an operation to relieve root compression due to
lumbar disc disease.
Type of traction
Inversion or Backswing is a form of traction where the patient
is strapped at the ankles in a tilt table. e patient is then
gradually tilted to a head down position. is results in a
form of extreme traction where the traction force is created
by the weight of the upper half of the patients’ body and grav-
ity. is brings in a sort of standardization as the traction is
dependent on the patient’s own body weight. Inversion is used
as intermittent traction with each patient having standardized
access and time with the device spread over a specied period
of time. Our study looked at the specic subset of patients
with radicular symptoms with the traction group receiving
intermittent inversion.
Sheeld [34] surmised that the benecial eects from
adapting the tilt table for traction resulted from stretching
of paraspinal muscles, ligaments and intervertebral discs.
Another study showed that gravity assisted traction was more
eective than other forms of traction [35]. Studying the eects
of gravity assisted traction on intervertebral dimensions of
the lumbar spine, it has been shown that this form of traction
produced signicant intervertebral separation between the
lumbar vertebrae [36,37].
Decline in electromyographic (EMG) activity (which is
thought to be an indicator of muscle pain) was consistently
demonstrated with the use of the inversion device [37,38].
Traction dosage
Using gravity and the weight of the patients own body, a con-
sistent and reproducible traction can be administered. ese
factors inuence the traction dosage as well.
Traction of less than 25% of body weight has been
described as low dose or sham traction [39]. A traction
load of 60% body weight was found to cause a reduction
of the residual intradiscal pressure of 25% standing body
weight to zero [22]. Inversion devices can easily achieve this.
Table I. Patient details.
SINo Age Sex Level Treatment Scan outcome Surgery
1 33 M L5-S1 Inversion 1 0
2 40 M L4-5 Control 0 1
3 29 M L5-S1 Inversion 1 0
4 28 M L4-5 Inversion 0 1
5 34 M L4-5 Control 2 1
6 25 M L5-S1 Inversion 1 1
7 38 F L4-5 Control 0 0
8 36 F L4-5 Inversion 0 0
9 34 M L5-S1 Inversion 0 1
10 38 F L4-5 Inversion 0 0
11 38 F L5-S1 Control 0 1
12 43 M L4-5 Inversion −1 0
13 41 F L5-S1 Control 1 0
14 44 F L5-S1 Inversion 2 0
15 28 F L5-S1 Control 0 0
16 43 F L5-S1 Control 0 1
17 31 M L5-S1 Control OPERATED 1
18 35 F L5-S1 Control 0 1
19 31 F L5-S1 Inversion −1 0
20 40 F L4-5 Inversion 0 0
21 32 M L5-S1 Inversion 0 0
22 43 M L5-S1 Control 0 1
23 35 F L5-S1 Inversion 0 0
24 31 F L5-S1 Control 0 1
Figure 2. Avoidance of surgery.
Figure 3. Duration of Avoidance of surgery.
Figure 4. MRI scan outcome.
Disabil Rehabil Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 07/20/12
For personal use only.
1478 K.S.M. Prasad et al.
Disability & Rehabilitation
Administration of consistent and eective traction dosage
could thus be achieved by using inversion as an intervention
in this study.
Possible effects
e most striking feature in this study was the statistically
signicant higher rate of avoidance of surgery in the inversion
group. e other domain where the change due to inversion
was noteworthy was in the ODI. A 12 point improvement
was seen in this scale, suggesting a useful role for inversion in
reducing disability. is almost reached statistical signicance
when compared with the “no inversion” group. Fritz and
Irrgang [40] used a modied ODI and found that an improve-
ment of 6 points or more made a clinical dierence.
Surgery only addresses neural compression by disc
material, but this is seen in a number of asymptomatic
individuals as well. Pain and disability in lumbar disco-
genic disease might be due to mechanical, inammatory
and immunological causes and not just due to compression
[41]. Sheeld [34] surmised that the benecial eects due to
inversion resulted from stretching of paraspinal muscles, lig-
aments and intervertebral discs whereas other studies have
demonstrated decline in EMG activity (which is thought to
be an indicator of muscle pain) with the use of the inver-
sion device [37,38]. ese observations might explain the
signicant benets due to inversion as assessed by ODI and
avoidance of surgery even though the appearance on MRI
was not congruent.
Changes in practice
Some surgeons in this centre now oer inversion therapy as
standard initial treatment to patients awaiting surgery for
pure single level lumbar discogenic sciatica within the ambit
of the inclusion/exclusion criteria used in this trial.
Adverse effects
No serious adverse eect was noted in either group in this
trial. is was noted from a process of reporting adverse
events by exception. e available literature shows that there
is no clear reporting of adverse events with traction in general
and inversion in particular [14].
Economic impact
Again, the costs of treatment with traction or the price of any
adverse event thereof is not clearly seen in the available lit-
erature. Looking at costs for intermittent inversion, costs for
lumbar disc surgery and the demonstrated reduction in the
number of operations from our own data, savings in excess
of a hundred million pounds per year can be expected if we
assume that around 15,000 operations are done in the UK
every year for lumbar discogenic disease.
Further research
e available literature does not provide evidence of e-
cacy from traction. However, traction as a single treatment
Table IV. Oswestry disability index.
Inversion +
physiotherapy
N = S
Physiotherapy
N = 3 Signicance
Baseline oswestry 50 (22–78) 48 (38–56) 0.644
Follow-up oswestry 31 (14–74) 54 (32–56) 0.298
Change in oswestry −12 (−26 to 0) 0 (−6 to 6) 0.064
Figure 5. Visual analogue score.
Table III. SF 36 scores.
Inversion +
physiotherapy
N = 12
Physiotherapy
N = 7 Signicance
Baseline
SF 36 physical function 43.5 (27.5) 35.7 (20.1) 0.521
SF 36 role − physical 17.3 (37.3) 32.1 (47.2) 0.449
SF 36 bodily pain 29.8 (23.7) 26.3 (9.3) 0.710
SF 36 general health 59.0 (13.2) 71.7 (12.4) 0.065
SF 36 vitality 39.2 (12.7) 44.3 (6.7) 0.344
SF 36 social function 44.2 (22.0) 53.6 (25.7) 0.404
SF 36 role − emotional 46.2 (46.2) 42.9 (53.5) 0.887
SF 36 mental health 54.1 (19.3) 61.7 (22.0) 0.436
SF 36 change in health 4.3 (0.8) 3.3 (1.0) 0.032
Change
SF 36 physical function 9.2 (15.3) 8.2 (18.3) 0.901
SF 36 role − physical 10.4 (24.9) 7.1 (31.3) 0.804
SF 36 bodily pain 12.5 (24.6) 15.6 (15.5) 0.771
SF 36 general health 2.8 (15.1) 0.0 (13.4) 0.705
SF 36 vitality 11.3 (16.0) 0.5 (12.9) 0.148
SF 36 social function 15.6 (28.3) 2.5 (30.6) 0.824
SF 36 role − emotional 13.9 (54.0) 23.8 (41.8) 0.682
SF 36 mental health 10.0 (14.6) −2.3 (14.2) 0.092
SF 36 change in health −0.7 (0.9) 0.2 (1.3) 0.151
Table II. Roland Morris disability questionnaire assessment.
Inversion +
physiotherapy
N = 12
Physiotherapy
N = 7 Signicance
Baseline Roland Morris 12.5 (1–20) 10 (1–19) 0.475
Follow-up Roland Morris 7.5 (0–20) 11 (2–21) 0.552
Change ill Roland Morris −1 (−13 to 4) −1 (−5 to 8) 0.441
Disabil Rehabil Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 07/20/12
For personal use only.
Inversion therapy in lumbar discogenic disease 1479
©  Informa UK, Ltd.
for low back pain also cannot be recommended at present
[7,14]. Heterogeneity of patient populations in terms of type
and duration of symptoms, non standardization of traction,
variations in duration of follow-up and outcome measures
used and lack of power are all contributory factors for lack
of strong evidence regarding the use of traction [42,43]. is
should encourage researchers to organize trials of high quality
incorporating these points.
Conclusion
Our hypothesis was that inversion therapy would reduce the
need for a surgical procedure in subjects with sciatica due to
single level disc protrusion. e results of this study do sup-
port this; surgery was avoided in 77% in the inversion group
while it was averted in only 22% in the non inversion group.
Avoidance of surgery did not prejudice other outcome mea-
sures and vice versa. e study demonstrated the feasibility
of a randomized controlled trial of the impact of an inversion
device on various outcome measures in single level disco-
genic disease. Previous trials of traction have not reported on
avoidance of surgery as an outcome measure and this trial has
addressed that issue. e economic impact is very signicant
and a larger multicentre prospective randomized control trial
is justied.
Declaration of Interest: e work was partially supported by
a grant from the Jacobson Charitable Trust.
References
1. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults:
Clinical Practice Guideline. No. 14. Rockville, MD: Agency for Health
Care Policy and Research, Public Health Service, US Department of
Health and Human Services; 1994.
2. van Tulder MW, Koes BW, Bouter LM. A cost-of-illness study of back
pain in e Netherlands. Pain 1995;62:233–240.
3. Legrand E, Bouvard B, Audran M, Fournier D, Valat JP; Spine
Section of the French Society for Rheumatology. Sciatica from
disk herniation: medical treatment or surgery? Joint Bone Spine
2007;74:530–535.
4. van Tulder MW, Koes BW, Bouter LM. Conservative treatment of
acute and chronic nonspecic low back pain. A systematic review
of randomized controlled trials of the most common interventions.
Spine 1997;22:2128–2156.
5. Vroomen PC, de Krom MC, Wilmink JT, Kester AD, Knottnerus
JA. Lack of eectiveness of bed rest for sciatica. N Engl J Med
1999;340:418–423.
6. Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute
low-back pain and sciatica. Cochrane Database Syst Rev. 2004
18;(4):CD001254.
7. Luijsterburg PA, Verhagen AP, Ostelo RW, van Os TA, Peul WC,
Koes BW. Eectiveness of conservative treatments for the lum-
bosacral radicular syndrome: a systematic review. Eur Spine J
2007;16:881–899.
8. Chou R, Human LH; American Pain Society; American College of
Physicians. Nonpharmacologic therapies for acute and chronic low
back pain: a review of the evidence for an American Pain Society/
American College of Physicians clinical practice guideline. Ann Intern
Med 2007;147:492–504.
9. Gibson JNA, Waddell G. Surgical interventions for lumbar disc pro-
lapse. Cochrane Database Syst Rev 2007, Issue 2. Art.No.: CD001350.
DOI: 10.1002/14651858.CD001350.pub4.
10. Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B,
Skinner JS, Abdu WA, et al. Surgical vs nonoperative treatment for
lumbar disk herniation: the Spine Patient Outcomes Research Trial
(SPORT): a randomized trial. JAMA 2006;296:2441–2450.
11. Li LC, Bombardier C. Physical therapy management of low back
pain: an exploratory survey of therapist approaches. Phys er
2001;81:1018–1028.
12. Harte AA, Gracey JH, Baxter GD. Current use of lumbar traction in the
management of low back pain: results of a survey of physiotherapists
in the United Kingdom. Arch Phys Med Rehabil 2005;86:1164–1169.
13. Kisner C and Colby LA. e spine: traction procedures. In: erapeutic
exercise: foundations and techniques. Philadelphia: FA Davis Co;
1996. pp 575–591.
14. Clarke JA, van Tulder MW, Blomberg SEI, de Vet HCW, van der
Heijden GJMG, Bronfort G, Bouter LM. Traction for low-back pain
with or without sciatica. Cochrane Database Syst Rev 2007, Issue 2.
Art. No.: CD003010DOI:10.1002/14651858.CD003010.pub4.
15. Alderson P. Absence of evidence is not evidence of absence. BMJ
2004;328:476–477.
16. Krause M, Refshauge KM, Dessen M, Boland R. Lumbar spine trac-
tion: evaluation of eects and recommended application for treat-
ment. Man er 2000;5:72–81.
17. Sherry E, Kitchener P, Smart R. A prospective randomized controlled
study of VAX-D and TENS for the treatment of chronic low back pain.
Neurol Res 2001;23:780–784.
18. Lind G. Auto-Traction. Treatment of Low Back Pain and Sciatica. An
Electromyographic, Radiographic and Clinical Study. Linko¨ ping:
University of Linko¨ ping, 1974.
19. Graham N, Gross AR, Goldsmith C; Cervical Overview Group.
Mechanical traction for mechanical neck disorders: a systematic
review. J Rehabil Med 2006;38:145–152.
20. Beurskens AJ, van der Heijden GJ, de Vet HC, Köke AJ, Lindeman E,
Regtop W, Knipschild PG. e ecacy of traction for lumbar back
pain: design of a randomized clinical trial. J Manipulative Physiol
er 1995;18:141–147.
21. Harte AA, Baxter GD, Gracey JH. e ecacy of traction for back
pain: a systematic review of randomized controlled trials. Arch Phys
Med Rehabil 2003;84:1542–1553.
22. Nachemson A, Elfström G. Intravital dynamic pressure measure-
ments in lumbar discs. A study of common movements, maneuvers
and exercises. Scand J Rehabil Med Suppl 1970;1:1–40.
23. van Tulder M, Koes B. Low back pain and sciatica: chronic. Clin Evid
2002;7:1032–1048.
24. Valat JP, Genevay S, Marty M, Rozenberg S, Koes B. Sciatica. Best
Pract Res Clin Rheumatol 2010;24:241–252.
25. Clinical Knowledge Summaries (2010) Sciatica Lumbar Radiculopathy.
Available at: @ http://www.cks.nhs.uk//sciatica_lumbar_radiculopa-
thy. Accessed on 14 September 2011.
26. Hofstee DJ, Gijtenbeek JM, Hoogland PH, van Houwelingen HC, Kloet
A, Lötters F, Tans JT. Westeinde sciatica trial: randomized controlled
study of bed rest and physiotherapy for acute sciatica. J Neurosurg
2002;96:45–49.
27. Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Hodges PW,
Jennings MD, Maher CG, Refshauge KM. Comparison of general
exercise, motor control exercise and spinal manipulative therapy for
chronic low back pain: a randomized trial. Pain 2007;131:31–37.
28. Guvenol K, Tuzun C, Peker, Goktay Y. A comparison of inverted spi-
nal traction and conventional traction in the treatment of lumbar disc
herniations. Physiother eor Pract 2000;16:151–160.
29. Goldman RM, Tarr RS, Pinchuk BG, Kappler RE, Slick G, Nelson K.
More on gravity inversion. West J Med 1984;141:247.
30. Liebenson C, Yeomans S. Outcomes assessment in musculoskeletal
medicine. Man er 1997;2:67–74.
31. Roland M, Morris R. A study of the natural history of back pain. Part
I: development of a reliable and sensitive measure of disability in low-
back pain. Spine 1983;8:141–144.
32. Fairbank JC, Couper J, Davies JB, O’Brien JP. e Oswestry low back
pain disability questionnaire. Physiotherapy 1980;66:271–273.
33. Ware JE Jr, Sherbourne CD. e MOS 36-item short-form health sur-
vey (SF-36). I. Conceptual framework and item selection. Med Care
1992;30:473–483.
34. Sheeld FJ. Adaptation of tilt table for lumbar traction. Arch Phys
Med Rehabil 1964;45:469–472.
35. Gianakopoulos G, Waylonis GW, Grant PA, Tottle DO, Blazek JV.
Inversion devices: their role in producing lumbar distraction. Arch
Phys Med Rehabil 1985;66:100–102.
36. Kane MD, Karl RD, Swain JH. Eects of Gravity-Facilitated Traction
on lntervertebral Dimensions of the Lumbar Spine*. J Orthop Sports
Phys er 1985;6:281–288.
37. Vernon H. Inversion therapy: a study of physiological eects. e
Journal of CCA 1985;29:138–140.
Disabil Rehabil Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 07/20/12
For personal use only.
1480 K.S.M. Prasad et al.
Disability & Rehabilitation
38. Nosse LJ. Inverted spinal traction. Arch Phys Med Rehabil
1978;59:367–370.
39. Beurskens AJ, de Vet HC, Köke AJ, Regtop W, van der Heijden GJ,
Lindeman E, Knipschild PG. Ecacy of traction for nonspecic low
back pain. 12-week and 6-month results of a randomized clinical trial.
Spine 1997;22:2756–2762.
40. Fritz JM, Irrgang JJ. A comparison of a modied Oswestry Low Back
Pain Disability Questionnaire and the Quebec Back Pain Disability Scale.
Phys er 2001;81:776–788. Erratum in: Phys er 2008;88:138–139.
41. Staord MA, Peng P, Hill DA. Sciatica: a review of history, epidemiol-
ogy, pathogenesis, and the role of epidural steroid injection in man-
agement. Br J Anaesth 2007;99:461–473.
42. Pellecchia GL. Lumbar traction: a review of the literature. J Orthop
Sports Phys er 1994;20:262–267.
43. van der Heijden GJ, Beurskens AJ, Koes BW, Assendel WJ, de Vet
HC, Bouter LM. e ecacy of traction for back and neck pain: a
systematic, blinded review of randomized clinical trial methods. Phys
er 1995;75:93–104.
Disabil Rehabil Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 07/20/12
For personal use only.
... The function of spinal traction is to generate a vertical stretch in the spine, relax the back muscles, and increase disc height [23,24]. Traction may work by separation of vertebral bodies, distraction, and gliding of facet joints, widening of the intervertebral foramen, straightening of the spinal curves, and stretching of the spinal musculature [24][25][26]. ...
... The function of spinal traction is to generate a vertical stretch in the spine, relax the back muscles, and increase disc height [23,24]. Traction may work by separation of vertebral bodies, distraction, and gliding of facet joints, widening of the intervertebral foramen, straightening of the spinal curves, and stretching of the spinal musculature [24][25][26]. Spine traction and inversion traction devices seem to be effective in the reduction of low back pain and discomfort, [12,13] but the effects of their use in the prevention of back pain are not clear due to the variability of the studies carried out [22]. Therefore, further studies are needed to clarify its effect on low back pain and loss of height during the working hours of workers [3]. ...
... Traction interventions such as treatment of low back pain seem to have limited or no impact on these clinical outcomes studied in previous studies [22]. Prasad et al. observed that intervention with inversion traction used intermittently with a physiotherapist significantly showed no differences in the self-perception of low back pain, but it reduced the need for surgery in people with hernia and low back pain [24]. Despite this finding, the effectiveness of this treatment is unclear, and more studies are needed. ...
Article
Increasing back discomfort and spinal shrinkage during the workday is a problem that affects assembly line workers. The aim of this research was to analyze the effect of a spinal traction system on discomfort, spinal shrinkage, and spinal sagittal alignment in assembly line workers, who are in prolonged standing conditions during a workday. A total of 16 asymptomatic males were recruited to assess spinal shrinkage, spinal sagittal alignment, and back discomfort during the workday. The measurement was carried out in two days of work, a normal day, and the other using a spinal traction device utilized in two breaks during the workday. Assembly line workers lost height significantly on both control and intervention days. No differences were found between days. No changes were found in spinal sagittal alignment on the control day. Lumbar lordosis angle increased significantly at the end of the intervention day. The use of a spinal traction device during the workday in two breaks time did not significantly reduce the spinal shrinkage of healthy workers. Lumbar lordosis angle increased significantly at the end of the spinal traction intervention day. Prospective studies would be necessary to clarify the possible benefits of the traction device.
... 6 Lumbar traction is effective for treating discogenic sciatica. [168][169][170][171] Traction is one of the oldest treatments for spinal problems. The first known mention of its use is the Indian epic Srimad Bhagwat Mahapuranam written circa 3500-1800 BCE. ...
... One theory is that traction lowers the intra-discal pressure and creates a suction force that draws displaced disc material inwards. 170 It has been suggested that traction works best for disc bulges and protrusions, which are best able to retract into their parent disc. 62 Traction also can reduce the appearance of high-intensity zones, 176 which are thought to represent annular tears. ...
... 169 One randomized trial examined the effect on discogenic sciatica of six two-minute inversion table sessions three times per week for four weeks on discogenic sciatica and found a significant reduction in the need for discectomy compared to patients that did not receive this therapy. 170 ...
Chapter
• The treatment of sciatica differs according to its cause • Most cases warrant a trial of conservative treatment • Integrated programs including manual therapies and exercise may be superior to any single therapy • Surgery is indicated in the presence of red flags and/or a lack of response to conservative treatment
... The three included studies were published from 1998 to 2015 and conducted in Iran [33], Nederland [34], and United Kingdom [35]. The total number of patients enrolled in the studies was 90; the total number of patients who completed the assessments was 85 (range , with a mean of 28.3 participants. ...
... The different types of traction used were VT [33,34] and inversion traction [35], which was considered a different type of VT for statistical analysis purposes. Two studies used intermittent traction [33,35] and one study [34] used continuous traction. ...
... The different types of traction used were VT [33,34] and inversion traction [35], which was considered a different type of VT for statistical analysis purposes. Two studies used intermittent traction [33,35] and one study [34] used continuous traction. The duration of the treatments ranged from 1 week to 2 months and the duration of each treatment ranged from 10 to 45 min. ...
Article
Full-text available
Background Only low-quality evidence is currently available to support the effectiveness of different traction modalities in the treatment of lumbar radiculopathy (LR). Yet, traction is still very commonly used in clinical practice. Some authors have suggested that the subgroup of patients presenting signs and symptoms of nerve root compression and unresponsive to movements centralizing symptoms may benefit from lumbar traction. The aim of this study is to conduct a systematic review of randomized controlled trials (RCTs) on the effects of vertical traction (VT) on pain and activity limitation in patients affected by LR. Methods We searched the Cochrane Controlled Trials Register, PubMed, CINAHL, Scopus, ISI Web of Science and PEDro from their inception to March 31, 2019 to retrieve RCTs on adults with LR using VT to reduce pain and activity limitation. We considered only trials reporting complete data on outcomes. Two reviewers selected the studies, extracted the results, and performed the quality assessment using the Risk of Bias and GRADE tools. Results Three studies met the inclusion criteria. Meta-analysis was not possible due to the heterogeneity of the included studies. We found very low quality evidence for a large effect of VT added to bed rest when compared to bed rest alone (g = − 1.01; 95% CI = -2.00 to − 0.02). Similarly, VT added to medication may have a large effect on pain relief when compared to medication alone (g = − 1.13; 95% CI = -1.72 to − 0.54, low quality evidence). Effects of VT added to physical therapy on pain relief were very small when compared to physical therapy without VT (g = − 0.14; 95% CI = -1.03 to 0.76, low quality evidence). All reported effects concerned short-term effect up to 3 months post-intervention. Conclusions With respect to short-term effects, VT may have a positive effect on pain relief if added to medication or bed rest. Long-term effects of VT are currently unknown. Future higher quality research is very likely to have an important impact on our confidence in the estimate of effect and may change these conclusions.
... A total of 1436 literatures were retrieved as described above. Screening through all literatures with defined criteria, there were 1430 literatures excluded and a total of 6 literatures included in this meta-analysis [15][16][17][18][19][20]. The working flow for screening is summarized in Figure 1. ...
... Lumbar traction can not only effectively improve the clinical manifestations of patients with lumbar disc herniation but also reduce the degree of lumbar disc herniation. Prasad et al. [17] also concluded that intermittent traction combined with physical therapy could improve the clinical symptoms and function of lumbar disc herniation and improve the life treatment of patients. Intermittent traction could significantly reduce the need for surgery. ...
Article
Full-text available
Objective. This study is aimed at exploring the clinical effect of mechanical traction on lumbar disc herniation (LDH). Methods. Related literatures were retrieved from PubMed, Medline, Embase, CENTRAL, and CNKI databases. Inclusion of literature topic was comparison of mechanical traction and conventional physical therapy for lumbar disc herniation. Jadad scale was used to evaluate the quality of the included RCT studies. The Chi-square test was used for the heterogeneity test, and a random effect model was used with heterogeneity. Subgroup analysis and sensitivity analysis were used to explore the causes of heterogeneity. If there was no heterogeneity, the fixed effect model was used, and funnel plots were used to test publication bias. Results. Visual analog scale (VAS) in the mechanical traction group was lower than that in the conventional physical therapy group (MD=−1.39 (95% CI (-1.81, -0.98)), Z=6.56, and P<0.00001). There was no heterogeneity among studies (Chi2=6.62, P=0.25, and I2=24%) and no publication bias. Oswestry disability index (ODI) in the mechanical traction group was lower than that in the conventional physical therapy group (MD=−6.34 (95% CI (-10.28, -2.39)), Z=3.15, and P=0.002). There was no heterogeneity between studies (Chi2=6.27, P=0.18, and I2=36%) and no publication bias. There was no significant difference in Schober test scores between the mechanical traction group and the conventional physical therapy group (MD=−0.40 (95% CI (-1.07, 0.28)), Z=1.16, and P=0.25). There was no heterogeneity among studies (Chi2=1.61, P=0.66, and I2=0%) and no publication bias. Conclusion. Mechanical traction can effectively relieve lumbar and leg pain and improve ODI in patients with lumbar disc herniation but has no significant effect on spinal motion. The therapeutic effect of mechanical traction was significantly better than that of conventional physical therapy. Lumbar traction can be used in conjunction with other traditional physical therapy.
... We have previously shown that inversion therapy reduced the need for surgery in patients with lumbar disc protrusions 1) . Low back pain is now the 4th most common cause of Disability Associated Life Years (DALYs) in the 25 to 49 year old age group 2) and it has become even more common over the last decade 3) . ...
... In a prospective randomised controlled trial (PRCT), we showed that inversion therapy reduced the need for surgery in three out of four patients that had been added to a surgical discectomy waiting list in our UK NHS Hospital 1) . The purpose of the current study was to evaluate the efficacy of inversion therapy in a larger cohort. ...
Article
Full-text available
[Purpose] We have previously shown inversion therapy to be effective in a small prospective randomised controlled trial of patients with lumbar disc protrusions. Our purpose now was to measure symptoms and to compare the surgery rate following inversion for 85 participants with the surgery rate in 3 control groups. [Participants and Methods] Each of the 85 inverted participants acted as their own control for the “symptomatic” part of the study. In the “Need for surgery” part of the study, one control group was made up of similar patients with leg pain and sciatica who were referred to the same clinic in the same year. Two additional control groups were examined: the original control group from the pilot trial and the lumbar disc surgery waiting list patients. [Results] Inversion therapy relieved symptoms: there were improvements in the Visual Analogue Score, Roland Morris and Oswestry Disease indices and Health Utility Score compared with their pre-treatment status. Also, the 2 year surgery rate in the inversion participants in the registry (21%) was significantly lower than in the matched control group (39% at two years and 43% at four years). It was also lower than the surgery rate in the other 2 control groups. [Conclusion] Inversion therapy relieved symptoms and avoided surgery.
... There is one moderate-quality RCT incorporated into this analysis. 564 Inversion therapy has been used for treatment of patients with herniated discs 564 and LBP, but as there is no quality evidence of efficacy, there is No Recommendation (I), Low Confidence. ...
... There is one moderate-quality RCT incorporated into this analysis. 564 Inversion therapy has been used for treatment of patients with herniated discs 564 and LBP, but as there is no quality evidence of efficacy, there is No Recommendation (I), Low Confidence. ...
... In 2012, Dr. Prasad and his colleagues proved that in a small number of those patients on waiting lists for discus hernia surgery, 77% of them who received combined traction and physical therapy did not require surgery (Prasad et al. 2012). ...
Article
Full-text available
Low back pain (LBP) is one of the most costly diseases in the developed world. This study aimed to investigate the effects of underwater traction therapy on chronic low back pain. The primary objective was to prove that underwater traction therapy has favorable effects on LBP. Our secondary objective was to evaluate whether it also leads to improvement in the quality of life. This is a prospective, multicenter, follow-up study. A total of 176 patients with more than 3 months of low back pain enrolled from outpatient clinics were randomized into three groups: underwater weight bath traction therapy and non-steroidal anti-inflammatory drugs (NSAIDs); weight bath; and only NSAIDs. The following parameters were measured before, right after, and 9 weeks after the 3-week therapy: levels of low back pain in rest and during activity were tested using the visual analogue scale (VAS), the Oswestry Low Back Disability Questionnaire, and the EuroQol-5D-5L Questionnaire. The VAS levels improved significantly ( p < 0.05) in both underwater weight bath traction therapy groups by the end of the treatment, whereas the improvement in the third group was not statistically significant. Furthermore, the improvements measured in the groups receiving traction therapy were persistent during the follow-up period. There were no significant changes in the Oswestry Index or the EuroQol-5D-5L without VAS parameters in any of the groups. Based on our results, for patients suffering from LBP pain who underwent underwater weight bath traction therapy, there were favorable impacts on the pain levels at rest or during activity. Clinical trial registration ID: NCT03488498, April 5, 2018
Article
Background: Orthopedic tractions can be employed in the rehabilitation of patients suffering from problems affecting the spine, as well as the upper and lower extremities but the high costs of using tractions due to prolonged hospital stays is a major disadvantage particularly in low-income economies. Objective: The objective of this study was to design and develop a two-way adjustable traction system that accommodates both cervical and lower limb rehabilitation and improves limb and neck positioning. Method: The production process involved the use of computer-aided design (CAD) as well as other manufacturing procedures like material selection, welding, and drilling. The system was tested for stability to be sure it does not fail under large loads. Result: A functional and easy-to-install two-way orthopedic traction system for both hospital and home use was developed, installed and tested. The dimensions and adjustability would ensure that it can be used for children and adults. Conclusion: This study describes a device that can be used in hospitals. When used at homes, it can reduce the cost of medical bills, and provide patients with the emotional/psychological benefits of being cared for in a familiar environment.
Article
Full-text available
Objective To evaluate the effectiveness of traction in improving low back pain, functional outcome, and disk morphology in patients with herniated intervertebral disks. Data Source PubMed, Scopus, Embase, and the Cochrane Library were searched from the earliest record to July 2019. Review methods We included randomized control trials which (1) involved adult patients with low back pain associated with herniated disk confirmed by magnetic resonance imaging or computed tomography, (2) compared lumbar traction to sham or no traction, and (3) provided quantitative measurements of pain and function before and after intervention. Methodological quality was assessed using the physiotherapy evidence database (PEDro) scale and Cochrane risk of bias assessment. Results Initial searches for literature yielded 3015 non-duplicated records. After exclusion based on the title, abstract, and full-text review, 7 articles involving 403 participants were included for quantitative analysis. Compared with the control group, the participants in the traction group showed significantly greater improvements in pain and function in the short term, with standard mean differences of 0.44 (95% confidence interval (CI): 0.11–0.77) and 0.42 (95% CI: 0.08–0.76), respectively. The standard mean differences were not significant to support the long-term effects on pain and function, nor the effects on herniated disk size. Conclusion Compared with sham or no traction, lumbar traction exhibited significantly more pain reduction and functional improvements in the short term, but not in the long term. There is insufficient evidence to support the effect of lumbar traction on herniated disk size reduction.
Article
Full-text available
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.
Article
Full-text available
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.
Article
Full-text available
Context Lumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients, but the efficacy of the procedure relative to nonoperative care remains controversial.Objective To assess the efficacy of surgery for lumbar intervertebral disk herniation.Design, Setting, and Patients The Spine Patient Outcomes Research Trial, a randomized clinical trial enrolling patients between March 2000 and November 2004 from 13 multidisciplinary spine clinics in 11 US states. Patients were 501 surgical candidates (mean age, 42 years; 42% women) with imaging-confirmed lumbar intervertebral disk herniation and persistent signs and symptoms of radiculopathy for at least 6 weeks.Interventions Standard open diskectomy vs nonoperative treatment individualized to the patient.Main Outcome Measures Primary outcomes were changes from baseline for the Medical Outcomes Study 36-item Short-Form Health Survey bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons MODEMS version) at 6 weeks, 3 months, 6 months, and 1 and 2 years from enrollment. Secondary outcomes included sciatica severity as measured by the Sciatica Bothersomeness Index, satisfaction with symptoms, self-reported improvement, and employment status.Results Adherence to assigned treatment was limited: 50% of patients assigned to surgery received surgery within 3 months of enrollment, while 30% of those assigned to nonoperative treatment received surgery in the same period. Intent-to-treat analyses demonstrated substantial improvements for all primary and secondary outcomes in both treatment groups. Between-group differences in improvements were consistently in favor of surgery for all periods but were small and not statistically significant for the primary outcomes.Conclusions Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period. Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis.Trial Registration clinicaltrials.gov Identifier: NCT00000410
Article
Full-text available
A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.
Article
Full-text available
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.
Article
The purpose of this investigation of lumbar disc herniation patients was to compare the effi cacy of the inversion spinal traction and the conventional mechanical spinal traction on several clinical parameters and computed tomography. This investigation consisted of 29 patients with low back pain and sciatica due to lumbar disc herniation. Patients were randomly assigned into two groups: an inversion spinal traction that was applied to 15 patients, and a conventional traction that was applied to 14 patients for ten sessions. The efficacy of the treatments was evaluated based upon clinical parameters before, immediately after, and three months after the treatment. Computed tomographic (CT) investigation was done before and immediately after the treatment. Both methods of traction were found to be clinically effective. Although there was no statistically significant difference between the two groups based upon the clinical parameters, CT fi ndings of the conventional traction group tended to show more improved parameters than the inverted spinal traction group. Reasons for better results of the conventional traction are discussed and the necessity for further investigations on this topic is emphasized.
Article
Sciatica is a symptom rather than a specific diagnosis. Available evidence from basic science and clinical research indicates that both inflammation and compression are important in order for the nerve root to be symptomatic. Tumour necrosis factor-alpha (TNF-alpha) is a key mediator in animal models, but its exact contribution in human radiculopathy is still a matter of debate. Sciatica is mainly diagnosed by history taking and physical examination. In general, the clinical course of acute sciatica is considered to be favourable. In the first 6-8 weeks, there is consensus that treatment of sciatica should be conservative. We review and comment on the levels of evidence of the efficacy of patient information, advice to stay active, physical therapy analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), epidural corticosteroid injections and transforaminal peri-radicular injections of corticosteroid. There is good evidence that discectomy is effective in the short term. but, in the long term, it is not more effective than prolonged conservative care. Shared decision making with regard to surgery is necessary in the absence of severe progressive neurological symptoms. Although the term sciatica is simple and easy to use, it is, in fact, an archaic and confusing term. For most researchers and clinicians, it refers to a radiculopathy, involving one of the lower extremities, and related to disc herniation (DH). As such, the term 'sciatica' is too restrictive as nerve roots from L1 to L4 may also be involved in the same process. However, even more confusing is the fact that patients, and many clinicians alike, use sciatica to describe any pain arising from the lower back and radiating down to the leg. The majority of the time, this painful sensation is referred pain from the lower back and is neither related to DH nor does it result from nerve-root compression. Although differentiating the radicular pain from the referred pain may be challenging for the clinician, it is of primary importance. This is because the epidemiology, clinical course and, most importantly, therapeutic interventions are different for these two conditions. It should, however, be emphasised that the quality of the available evidence is rather limited due to a considerable heterogeneity in the study populations included in the trials. This makes generalisation of findings across studies, and to routine clinical practice, a challenge. Prevalence estimates of radicular pain related to DH also vary considerably between studies, which is, in part, due to differences in the definitions used. A recent review showed that the prevalence of sciatic symptoms is rather variable, with values ranging from 1.6% to 43%. If stricter definitions of sciatica were used, for example, in terms of pain distribution and/or pain duration, lower prevalence rates were reported. Studies in working populations with physically demanding jobs consistently report higher rates of sciatica compared with studies in the general population.