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

Taylor & Francis
Disability and Rehabilitation
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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.]
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
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)
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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
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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
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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.
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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.
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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
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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.
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... De la búsqueda bibliográfica realizada se identificó un total de 2196 publicaciones. Después de aplicar los criterios de inclusión y exclusión, se seleccionaron 12 publicaciones para incluirlos en la realización del metaanálisis (39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50). El proceso de selección de los artículos se resume en la Figura 1. Además, se proporciona información básica de cada estudio y se presenta la evaluación metodológica utilizando la escala PEDro en la Tabla 1. Los resultados de promedios y desviaciones estándar antes y después del tratamiento de los estudios se presentan en la Tabla 2. ...
... Este estudio tuvo como objetivo principal investigar la efectividad de la tracción mecánica en el tratamiento del dolor lumbar en personas con hernia de disco, mientras que el objetivo secundario fue determinar su efecto sobre la discapacidad funcional de estos pacientes. La eficacia clínica de la tracción lumbar ha sido controvertida y objeto de debate durante mucho tiempo, con estudios que arrojan resultados contradictorios, inconsistentes y no concluyentes, incluso en términos de eficacia a corto, mediano y largo plazo (39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50). Sin embargo, los resultados de este metaanálisis sugieren que la tracción lumbar es efectiva para reducir el dolor lumbar y miembros inferiores y mejorar las funciones físicas relacionadas con este dolor en pacientes con hernia de disco lumbar (39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50). ...
... La eficacia clínica de la tracción lumbar ha sido controvertida y objeto de debate durante mucho tiempo, con estudios que arrojan resultados contradictorios, inconsistentes y no concluyentes, incluso en términos de eficacia a corto, mediano y largo plazo (39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50). Sin embargo, los resultados de este metaanálisis sugieren que la tracción lumbar es efectiva para reducir el dolor lumbar y miembros inferiores y mejorar las funciones físicas relacionadas con este dolor en pacientes con hernia de disco lumbar (39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50). De acuerdo con el análisis de este estudio, la tracción mecánica influye de manera positiva en la reducción del dolor lumbar, la disminución de la discapacidad asociada al dolor y la mejora de los síntomas en pacientes con hernia de disco lumbar. ...
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El presente estudio tiene como objetivo determinar el efecto clínico de la tracción mecánica lumbar sobre el dolor y la funcionalidad en pacientes con hernia discal. La metodología consistió en una revisión de la literatura relacionada con las bases de datos PubMed, Medline, ScienceDirect, Cochrane Library, SciELO y PEDro. Se incluyeron ensayos controlados aleatorizados que compararon la terapia de tracción lumbar contra la terapia convencional en personas con hernias discales. Para la prueba de heterogeneidad, se utilizó la prueba de Chi2 y se utilizó un modelo de efectos aleatorios. Si no había heterogeneidad, se utilizó el modelo de efectos fijos y se utilizaron gráficos en embudo para probar el sesgo de publicación. Se obtuvieron resultados que, en la escala analógica visual del grupo de tracción mecánica, fue menor que en el grupo de fisioterapia convencional (DM = -0.61 (IC del 95 % (-1.96, -0.25)), Z = -3.32 y P < 0.001). Hubo heterogeneidad moderada entre los estudios (Chi2 = 3.47, P < 0.001 e I2 = 71%) y no hubo sesgo de publicación. El índice de discapacidad de Oswestry también fue menor en el grupo de tracción mecánica (DM = -0.57 (IC del 95 % (-0.92, -0.22)), Z = -3.18 y P = 0.001). Hubo heterogeneidad moderada entre los estudios (Chi2 = 3.15, P = 0.003 e I2 = 68%) y no hubo sesgo de publicación. Se concluyó que la tracción mecánica puede reducir el dolor lumbar y mejorar la funcionalidad en pacientes con hernia discal a corto y mediano plazo.
... 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. ...
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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 I 2 = 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 I 2 = 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 I 2 = 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.
... Probability of remaining surgery free in the inversion registry (red) vs. Matched controls (green) from a UK NHS neurosurgery clinic list (Logrank test p < 0.001). Backswing I Inversion cases (yellow) and controls (purple) were from the previous Prospective Randomized Controlled Trial (14). Hospital discectomy NHS waiting list controls (blue) were from the Neurosurgery lumbar spine operative waiting list in 2014, followed through to 2015. ...
... Pozitivni učinci trakcije kralježnice navode se i u istraživanju koje su proveli Presad i suradnici, a koji su istraživali učinkovitost intermitentne trakcije s inverzijom u kombinaciji s fizioterapijom (terapijske vježbe i edukacija) u populacije u dobi od 18. do 65. godine života koja je čekala na operativne zahvate hernije diska (unilateralna lumbalna disk protruzija), a u kojem se navodi da je u skupini s inverzijskom intermitentnom mehaničkom trakcijom u 76,9 % izbjegnuta operacija, te u skupini s terapijskim vježbama i edukacijom u 22,2 % ispitanika (33). Međutim, ovi nalazi su dobiveni na malom uzorku i trebalo bi ih dodatno utvrditi. ...
... Physical and behavioral therapy, medication, and interventional therapy are noninvasive or minimally invasive methods used for the treatment of LDH (4). Physical and behavioral therapy techniques used in the management of LDH consist of exercise (5), traction (6), manual therapy (7), electrotherapy (8), and heat interventions (9), from a high to a low evidence level, respectively. ...
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Introduction: Decreased or delayed multifidus and transversus abdominis (TrA) activity, transition of the TrA from tonic to phasic activity, and increased activity in the more superficial erector spinae muscles are behaviors unique to people with lumbar radiculopathy. The aim of this study was to investigate whether the isolated AHM could compensate for functional impairments caused by tibialis anterior (TA) muscle weakness due to unilateral L4-L5 radiculopathy. Material and Method: The healthy and affected lower extremities of seventeen patients with unilateral lumbar disc herniation were analyzed. The ratio of TA and medial gastrocnemius (MGC) values that emerged during the activities to the maximum voluntary isometric contraction (MVIC) values of these muscles was called MVIC%. Then the MVIC% values of the TA and MGC were matched and the muscle reciprocal activation ratio was determined ("MVIC%"-TA/"MVIC%"-MGC). While the activities were being performed, the MVIC% values of both muscles were measured separately without performing the AHM and during the AHM. Results: During the tandem walking activity performed with the AHM, the reciprocal activation rates of TA:MGC on the affected and healthy legs converged (p=0.010,d=0.71). Conclusion: According to the results of the study, integration of the AHM into tandem walking activity brought the reciprocal activation rates of both legs closer to each other and enabled them to exhibit similar behaviors, even without adherence to any exercise protocol. Therefore, tandem walking can be selected as an appropriate activity to combine with spinal stabilization exercises performed by unilateral L4-L5 radiculopathy patients using the AHM along with the task.
... Traction is a broad term that includes mechanical traction, automatic traction, manual traction, gravity traction, and water traction, et cetera. [15][16][17][18] And, these traction treatment method varies in their traction force, traction frequency, treatment time, and duration of treatment. Apart from this, the therapeutic effectiveness of traction is not been recognized by everyone. ...
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Background: Self-gravitation traction is 1 of the most popular treatments for lumbar disc herniation (LDH). This study aims to evaluate the effectiveness and safety of the self-gravitation traction device in the treatment of LDH and to confirm its positive treatment effect. Methodology: This trial is designed as a pragmatic double-center, single-blind, and 3-arm (1:1:1 ratio) randomized controlled trial. The recruited patients with LDH will be randomly allocated to the intervention (traction weight is 40% or 60% of its body weight) or control (traction weight is 20% of its body weight) group. Traction will be completed within 6 consecutive weeks (3 times a week), with 10 minutes of traction for the first 3 weeks, 20 minutes of traction for the next 3 weeks. After the experiment is completed, we will establish an experiment-related database. The software of SPSS, version 21 (SPSS Inc. Chicago, IL) will be used for statistical analysis, and measurement data will be expressed via mean and standard deviation (mean ± SD). Discussion: Once the trial is completed, we will publish the study in journals in both Chinese and English to promote the dissemination and use of the results. In addition, we also plan to promote the research results at various academic conferences both domestically and internationally.
... Traction when performed intelligently under the supervision of clinical experts can be used in rehabilitating patient who suffer from conditions related to the spine, the upper and lower extremities [6]. Using the straight leg raise test as the endpoint, static traction between 30% and 60% of body weight has been reported to improve leg mobility in patients with low back pain and radicular symptoms [7]. ...
Article
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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.
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Introduction . This study aimed to assess blood microcirculation changes in the skin of the forehead, cheeks and lower extremities before, during and after performing a yoga inverted pose, using wearable laser Doppler flowmetry analyzers in healthy volunteers. Materials and methods . The study involved 25 volunteers, with an average age of 37 [35–44] years. Blood microcirculation changes were evaluated by laser Doppler flowmetry using six LAZMA PF wireless wearable devices, placed in pairs on the supraorbital artery regions of the forehead, cheeks and on the first toes of the feet, symmetrically on the right and left. A three-phase study protocol included a supine position before the inverted pose (6 minutes), the inverted pose (3 minutes), and a supine position after the inverted pose (6 minutes). Measurements included the index of microcirculation (Im), nutritive blood flow (Imn), the amplitude of endothelial (Ae), neurogenic (An), myogenic (Am), respiratory (Ar) and cardiac (Ac) oscillations for each investigated area. Results . Transitioning from the supine position to the inverted pose increases the forehead Im by 21.7 %; when returning to the supine position, Im decreases but remains significantly above the baseline. Imn in the forehead area remains stable. Ae, An, Am and Ac before and after the inversion show no significant changes. Ar shows a statistically significant change while maintaining the median values. In the cheek area, when transitioning from the supine position to the inverted pose, there is a 35.6 % increase in Im, and upon returning to the supine position, Im continues to rise while Imn tends to increase. There is a significant increase in Ar (by 50 %) and Ac (by 42.9 %), as well as a tendency to increase Ae, An, Am. Im in the feet area decreases by 55.6 %, but after returning to the horizontal position, compared to the initial state, it increases by 27.4 % and Imn increases by 42.9 %. There is a statistically significant increase in Ae (by 28.6 %), Am (by 40 %), Ar (by 50 %) and Ac (by 50 %). Conclusion . Findings revealed significant impacts of the inversion position on the blood microcirculation in all investigated areas. The index of microcirculation significantly increases after performing the inverted pose both in the skin of the forehead and cheeks. However, the respiratory and cardiac oscillation amplitudes increases only in the skin of the cheeks, without changing significantly or with a median shift in the forehead skin, which confirms the peculiarities of microcirculatory regulation in the supraorbital artery area. In the toe skin after performing the inverted position, the index of microcirculation and nutritive blood flow, as well as the amplitudes of myogenic, respiratory and cardiac oscillations of tissue perfusion increase significantly. We can assume that inverted yoga poses may be beneficial in clinical practice for rehabilitating individuals with lower extremity circulatory disorders.
Article
In the USA, low back pain related illness accounts for approximately 149 million workdays lost each year. Initial management of back pain typically involves allied healthcare professionals who implement various treatments, such as chiropractic manipulation, physiotherapy, and acupuncture which have varying outcomes and levels of supporting evidence. Another passive treatment for back pain is inversion table therapy (ITT). It is a form of spinal traction which is thought to have a role in relieving low back pain due to the gravity-facilitated traction of the spine which distracts the lumbar vertebrae. However, ITT is not without risk. According to the Food and Drug Administration (FDA) Medical Device Reporting Events Database, ITT has resulted in serious injuries including spinal cord injury, fractures, lacerations, and death. The FDA has regulated ITT for only manufacturers that indicated medical use; however, most manufacturers have not made such medical claims and were exempt from FDA regulation. This article discusses the risks of ITT, the current regulatory process for ITT, and the need for a better understanding of the role of ITT in the treatment of spinal pain while optimizing consumer safety.Implications for rehabilitationInversion table therapy (ITT) is a form of spinal traction which is thought to have a role in relieving low back pain due to the gravity-facilitated traction of the spine which distracts the lumbar vertebrae.According to the Food and Drug Administration (FDA) statistics, injuries due to non-powered traction from various medical devices have been rising since 2011.The FDA has regulated ITT for only manufacturers that indicated medical use; however, most manufacturers have not made such medical claims and were exempt from FDA regulation.This article discusses the risks of ITT, the current regulatory process for ITT, and the need for a better understanding of the role of ITT in the treatment of spinal pain while optimizing consumer safety.
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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.
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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.
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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
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