Traction is an old school treatment for back pain, but does it work?
Pain in the lower back, as seen most frequently by a physiotherapist, affects around 60-80% of people during their lifetime. A small percentage of these people will develop lumbar radiculopathy, a pain syndrome caused by compression and / or irritation of the roots of the lumbar nerve.
Deep immersion in back pain with Physioplus
A typical first-line therapy for lumbar radiculopathy is a conservative treatment that can take many forms. Traction has been used for decades and is still used to treat radiculopathy, although there is a lack of evidence to support its use. Even so, in clinical practice it is still used in place of treatments that have been shown to be more effective.
A new systematic review was published to re-examine whether or not traction is effective in treating lumbar radiculopathy.
Methods
This systematic review has been registered with PROSPERO, follows the recommendations of PRISMA and uses the GRADE and RoB tools to assess bias and research quality. The databases used for this systematic review were Cochrane, PubMed, CINAHL, Scopus, WoS and PEDro. The addition of the latter is easy to see as many reviews examining physiotherapy interventions choose not to include PEDro in favor of known databases, but doing so can result in certain evidence being overlooked in the data analysis.
The search terms used for the review, which we have customized for each database and search string, are available for download. The string for PubMed is below so you can see an example of one of the searches. The research appears thorough and systematic.
("Traction" [MeSH Terms] OR "Physiotherapy modalities" [MeSH Terms]) AND ("Lower back pain" [MeSH Terms] OR "Sciatica" [MeSH Terms] OR "Radiculopathy" [MeSH Terms] OR "Radicular" Syndrome "[All Fields] OR" Nerve root pain "[All Fields] OR" Leg pain "[All Fields]) AND ((randomized controlled studies as topic [MeSH Terms]) OR (randomized controlled study [All Fields] OR controlled clinical study [All Fields] OR random * ))
The databases were searched from each date through March 31, 2019. Additional records were collected through reference list mining. Two independent blinded reviewers performed the elements of study selection, and then the authors systematically compared their results with a third person who was available for consensus in the event of disagreement.
Studies were included in the review if they were RCTs published in English in which participants 18 years of age and older with lumbar radiculopathy were confirmed by the presence of at least 2 of the following cases:
radicular symptoms (LBP with pain and / or numbness below the knee
1 or more radicular sign: (sensory loss / paresthesia in an L4-S1 dermatome, reduced patellar or Achilles tendon reflex or L4-S1 weakness)
Positive CT / MRI
Studies with any form of traction (if described in detail) were included when used alone or in combination with other conservative or medicinal treatments.
Primary endpoints were perceived pain in the lumbar and / or sciatic region, which was measured using a numerical rating scale. Secondary results include the Oswestry Disability Index, the Roland & Morris Disability Questionnaire, mobility, and psychological parameters. QoL measures and compliance with treatment.
These are many secondary outcome measures that are often found in systematic reviews. However, if you expand your network enough, you will catch something. The research question the authors are trying to answer is: What effects does traction have on lumbar radiculopathy? Perhaps this number of secondary measures is okay
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Results & clinical take-away
A total of three studies were included in the analysis, this was from an initial total of 3,673 identified studies. In total, these 3 studies comprised a total of 85 patients. They were two different types of traction (vertical and inverse), two using intermittent traction and one continuous duration.
The duration of the course of treatment was between 1 week and 2 months and the duration of the tractions between 10 and 45 minutes. The force applied ranged from the top half of the patient's body weight to the patient's full body weight. Traction was compared to physical therapy, medication, and bed rest (this is not even a control!).
Overall, the included studies had a moderate to high risk of bias which was mainly due to the inability of blind participants and therapists. However, there were also concerns about selection, attrition, and performance bias.
Brief summary of the systematic review of the traction of lumbar radiculopathy
There is no support for the use of lumbar traction in the treatment of lumbar radiculopathy
Lumbar traction is more effective than bed rest alone
Lumbar traction is no more effective than any other physiotherapeutic treatment modality for radiculopathy and offers no added benefit when added to combination treatments
The results of the systematic review show that the intermittent traction was ineffective compared to the usual physiotherapy, even in combination with another treatment. In addition, there was no positive effect on increasing physical activity. Even when traction was added to standard medical management, it had no additional effect on treatment. The only thing that traction was more effective than bed rest, but that is clearly obvious and not relevant to clinical practice.
In summary, traction does not appear to have any beneficial effects when used to treat a proven lumbar radiculopathy. Furthermore, the existing evidence is of poor quality, and until larger-scale studies of higher quality are performed, traction should not be part of treatment plans for lumbar radiculopathy. Even if these studies take place, is this the direction the profession should go? Probably not. This systematic review is another reason why traction should be limited to the treatment modality graveyard.
