|Year : 2020 | Volume
| Issue : 4 | Page : 498-502
Effects of patient-specific three-dimensional lumbar traction on pain and functional disability in patients with lumbar intervertebral disc prolapse
F Asiri, JS Tedla, MS D Alshahrani, I Ahmed, RS Reddy, K Gular
Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Kingdom of Saudi Arabia
|Date of Submission||25-May-2019|
|Date of Acceptance||26-Dec-2019|
|Date of Web Publication||4-Apr-2020|
Dr. J S Tedla
C/3/108, Gate-2, Building C, Assistant Professor, Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Abha
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Prolapsed lumbar intervertebral disc is one of the most prevalent causes of low back pain and traction is one of the most common physical therapy treatments offered to affected patients. Advancements in traction equipment are needed to ensure their effectiveness in clinical situations. Aims: The objective of the study was to find out the effect of patient-specific three-dimensional lumbar traction on pain and functional disability in individuals with lumbar intervertebral disc prolapse. Subjects and Methods: Original article and Experimental design. Twenty-five participants (age range: 34–67 years) diagnosed with lumbar intervertebral disc prolapse were included in this study. Patient-specific three-dimensional lumbar traction was given as three sessions per week for the duration of one month. All participants completed a 10-cm visual analog pain scale and pain pressure threshold to assess pain and the Oswestry disability index to assess the functional disability. Results: On pre to post interventions, a significant change in mean values were found for visual analog scale pain score, pain pressure threshold, and Oswestry disability index (P < 0.001). The pain intensity was reduced from 8.5 to 3.2, pain pressure threshold increased from 0.7 to 1.6 kg/cm2, and functional disability was reduced from 53.5% to 31.3%. Conclusion: Twelve sessions of patient-specific three-dimensional lumbar traction promoted a reduction in pain and improvement in functional disability among subjects with lumbar intervertebral disc prolapse.
Keywords: Intervertebral disc prolapse, lumbar spine, traction
|How to cite this article:|
Asiri F, Tedla J S, D Alshahrani M S, Ahmed I, Reddy R S, Gular K. Effects of patient-specific three-dimensional lumbar traction on pain and functional disability in patients with lumbar intervertebral disc prolapse. Niger J Clin Pract 2020;23:498-502
|How to cite this URL:|
Asiri F, Tedla J S, D Alshahrani M S, Ahmed I, Reddy R S, Gular K. Effects of patient-specific three-dimensional lumbar traction on pain and functional disability in patients with lumbar intervertebral disc prolapse. Niger J Clin Pract [serial online] 2020 [cited 2020 Nov 24];23:498-502. Available from: https://www.njcponline.com/text.asp?2020/23/4/498/281916
| Introduction|| |
Low back pain (LBP) is one of the leading causes of disability in developing countries. The incidence of LBP is higher in aging people, and the prevalence of LBP is more in Saudi females as compared with in males. LBP is considered to be an occupational hazard, as it is highly prevalent among employees working in public and private sectors., As LBP is more prone to present among working people, it can lead to a reduction in working hours and production efficiency, which affects the socioeconomic status of the country.,
Lumbar intervertebral disc prolapse (LIVDP) is a common cause of LBP. The most frequent lumbar segments prone to suffer LIVDP are L4/5 followed by L5/S1. LIVDP is most common among middle-aged females., Spinal decompression therapy has shown the propensity to promote a significant reduction in pain and improvement in functional outcome. It presents a strong correlation between mobility and activities of daily living in the chronic LBP population.
The previous studies have suggested an intermittent or continuous lumbar traction effect of improving symptoms and reducing the size of a herniated disc in patients with LIVDP., However, the efficacy of physical therapy treatment in LIVDP is questionable, and the optional treatments remain unclear. The most common treatment option for LIVDP is traction, which can be combined with other physical therapy modalities. However, the literature on the efficacy of lumbar traction as a part of conservative treatment is conflicting.,
A recent systematic review showed a wide variability in the type of traction, traction parameters, and patient characteristics among the randomized controlled trials of lumbar traction. It concluded that lumbar traction has little or no impact on clinical outcomes. In addition, this variability emphasizes the need for targeted delivery methods of traction that match appropriate dosages with specific subgroups of patients with LBP. The ambiguity in traction effects may be attributed to a lack of traction force specific to the level of the lesion and the side of involvement. Patient-specific three-dimensional lumbar traction (PS3DLT) provides level and side-specific adjustments in the patient positioning, which yields better results. Three-dimensional computerized cervical traction showed phenomenal results in reducing pain and improving the range of motion at the cervical region. Still, even though it is proven that three-dimensional spinal traction approaches are effective in the cervical spine, we cannot generalize the effect to LIVDP and currently there is a dearth of literature related to this topic. Therefore, the aim of the present study was to elucidate the effect of PS3DLT according to a visual analog scale (VAS), pain pressure threshold (PPT) scale, and the Oswestry disability index (ODI), in LIVDP.
| Subjects and Methods|| |
Twenty-five patients (11 males and 14 females) with LIVDP aged between 34 and 67 years referred by an orthopedician or general physician were recruited. Participants with chronic, one level in LIVDP were included in the study. Participants with involvement at the cervical or thoracic region along with LIVDP and patients with severe osteoporosis were excluded from the study. The research ethics committee of the university approved this study (REC#2016-08-30). Study duration was one year from January 2017 to January 2018. All participants signed a written informed consent document. A brief explanation of the procedure was given to the participants. The details of the collected demographic characters along with number of patients in each level of involvement are provided in [Table 1]. The level of lumbar disc involvement was decided as per the MRI scan report.
|Table 1: Mean and standard deviation of the subjects' demographic characteristics|
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We used the Spine MT machine (Sinhwa Medical Co. Ltd. Korea) to provide PS3DLT to the subjects [Figure 1]. First, the patient details like weight and lesion level were entered into the machine. The machine adjusted the amount of load for traction (one-third of the bodyweight) and the angle of sacral elevation by inflations and deflations into the sacral block as per the level of disc prolapse. The therapist adjusted the lower-extremity positions, the tilt of the bed, and the lateral tilt angles to the right or left depending on the side of involvement. More details about patient-specific adjustments are described in [Table 2].
Data on the outcome measures of pain and functional disability were collected at 0 week, after 2 weeks, and after 4 weeks of treatment by an independent investigator. The pain was investigated by VAS and PPT and the functional disability was elucidated by ODI. Twelve treatment sessions (three sessions per week for 4 weeks) was delivered to the patients. The total duration of traction treatment was 30 min. Along with the traction, home advice of extension exercises and positioning was also given to all the patients.
Data analysis was completed using the Statistical Package for the Social Sciences version 21 software program (IBM Corp., Armonk, NY, USA). Univariate analysis for mean, standard deviation, minimum, maximum, and range was done by descriptive statistics. The outcome measures were analyzed for normality by using the Shapiro–Wilk test and all variables were normally distributed. Parametric repeated measures of analysis of variance was done for analyzing changes between 0, 2 weeks, and 4 weeks for all outcome measures. A Bonferroni post-hoc test was performed to assess differences between the sessions for all outcome measures.
| Results|| |
In this experimental study, we included 25 patients with lumbar IVDP. In total, 11 were males and 14 were females. The age of the included patients ranged from 34 to 67 years. Further details of their demographic characteristics were presented in [Table 1]. The VAS, PPT, and ODI scores were the outcome measures for this study. We collected these three measures in three time periods, that is, before the treatment at 0 week (pre), 2 weeks after the treatment (mid), and 4 weeks after the treatment (post).
The mean and standard deviations of VAS, PPT, and ODI along with their significance values are revealed in [Table 3]. We found that VAS, PPT, and ODI had significant differences between the three time periods (0, 2nd, and 4th weeks) with a P value of less than 0.001. The baseline VAS score changed from 8.56 ± 1.32 to 3.22 ± 2.29 at 4 weeks after the intervention, while the mean baseline PPT score changed from 0.70 ± 0.19 kg/cm2 to 1.64 ± 0.36 kg/cm2 at the same point. The mean baseline ODI score changed from 53.55 ± 15.26 to 31.36 ± 10.14 also at 4 weeks post intervention [Table 3]. Post-hoc analysis revealed significant differences between pre-mid-post of all three outcome measures, except for ODI differences between the pre- and mid-measurements with a P value of 0.198 [Table 4]. Short-lived adverse effects of mild pain and numbness in the lower limbs during the traction session were noted in four patients. When we readjusted the patients' positions, the pain and numbness disappeared.
|Table 3: Mean, standard deviation, and significance values for VAS, PPT, and ODI|
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| Discussion|| |
To our knowledge, this is a unique first-of-its-kind study used patient-specific three-dimensional lumbar traction in patients with LIVDP. In comparison with conventional traction method, the Spine MT has more patient-specific options like sacral inclination, 3-dimensional decompression pressure adjustment, lumbar lateral bending, leg rest position, and rotation adjustments, etc., These effected level and sidewise adjustments in PS3DLT made it an effective tool for decreasing pain and improving functional disability in patients with LIVDP. The use of lumbar traction and its effectiveness on LIVDP remains a subject of controversy but, still, it is the most common therapeutic modality used for LIVDP in day-to-day physical therapy clinical practice.
Improvements following traction in subjects with LIVDP were reported by several authors., Filiz et al. conducted a study on the use of mechanical traction for radicular pain subjects. Their 15 intervention sessions reduced the mean pain intensity (VAS) from 8 to 4.3 and the functional disability (ODI) from 50.4% to 33.2%. These results are in accordance with our study results, where 12 sessions of PS3DLT reduced the mean pain intensity (VAS) from 8.56 to 3.22 and the functional disability (ODI) from 53.5% to 31%.
Importantly, even though individual RCTs showed a positive effect of traction, the recent systematic reviews say that traction had limited and low effectiveness in decreasing pain and disability., However, these reviews suggest that having a targeted delivery method of traction with matching appropriate dosages specific to a subgroup of patients with LBP may have a better outcome. This was the reason for why we used PS3DLT confining to LIVDP, which showed a positive effect of decreasing pain and improving functional disability.
As per the Lee et al. study, the VAS has 30 mm minimal clinically important difference (MCID). In the study by Emshoff et al., the clinically important difference threshold for MCID was ranged from 20.9 to 57.5 mm. In our study, we obtained a mean difference of 53.40 mm after 12 sessions of intervention which was similar to MCID indicated in the previous studies. Mutlu and Ozdincler in osteoarthritis gave a MCID for PPT: they quoted a value of 1.53 to 1.62 pounds/cm2, which is equal to 0.69 to 0.73 kg/cm2. In our study, we obtained a mean difference of 0.94 kg/cm2, which is well beyond the MCID, indicating better improvements in pain perception.
The MCID for ODI was calculated by points or by percentages. By points, researchers say a 10-, or 17-point difference as a MCID, while, per the percentage calculation, 30%, is a relevant value. In our study, we secured a 22-point difference or 41.43% for the MCID. This indicates that we obtained a very good MCID for ODI.
The improvements in this study may be attributed to the lumbar traction mechanism on the LIVDP by separating vertebra, removing of nerve root pressure, decreasing direct contact force on injured tissue, increasing blood flow to the distal area, and reducing muscle spasm. PS3DLT includes multiple adjustments like traction load, split bed, sacral inclination, three-dimensional decompression pressure, lumbar lateral bending, adjustable leg rest position, and left/right rotation stop decompression based on patient requirements. Due to all these adjustments, we could change the traction angle of pull to the specific segments, which might have provided decompression to the targeted segments and showed improvements in pain and functional disability.
The common position of traction is supine, but many studies have failed to show significant improvements in this position. Some of the more recent studies conducted traction experiments in the prone position and found that prone is better than supine., However, in our opinion, if there is the availability of patient-specific options, then we could provide traction in a comfortable and easy position like supine rather than going for uncomfortable and less clinically possible positions like prone.
Limitations of the study
The current study was an experimental study without a comparable control group to see the magnitude of improvements. In addition, the study did not include follow-up after 4 weeks of intervention to determine the long-term benefits. Future studies with randomized controlled trials with longer follow-up will provide more evidence that is concrete.
| Conclusion|| |
The current experimental study involving 25 patients with LIVDP suggests the effectiveness of PS3DLT. Twelve weeks of intervention significantly decreased the pain and improved the functional disability in patients with LIVDP. Future randomized controlled studies are needed to further support our evidence.
Financial support and sponsorship
This project was supported by the Deanship of Scientific Research, King Khalid University, Abha, Kingdom of Saudi Arabia [G.R.P – 135 – 39]
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol 2010;24:769-81.
Cross M, Smith E, Hoy D, Carmona L, Wolfe F, Vos T, et al
. The global burden of rheumatoid arthritis: Estimates from the global burden of disease 2010 study. Ann Rheum Dis 2014;73:1316-22.
Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, et al
. A systematic review of the global prevalence of low back pain. Arthritis Rheum 2012;64:2028-37.
Awaji M. Epidemiology of low back pain in Saudi Arabia. J Adv Med Pharm Sci 2016;6:1-9.
Homaid MB, Abdelmoety D, Alshareef W, Alghamdi A, Alhozali F, Alfahmi N, Hafiz W, Alzahrani A. and Elmorsy, S. Prevalence and risk factors of low back pain among operation room staff at a Tertiary Care Center, Makkah, Saudi Arabia: A cross-sectional study. Ann Occup Environ Med 2016;28:1.
Abduljabbar TA. Musculoskeletal disorders among dentists in Saudi Arabia. Pak Oral Dent J 2008;28:134-44.
Petit A, Roquelaure Y. Low back pain, intervertebral disc and occupational diseases. Int J Occup Saf Ergon 2015;21:15-9.
Seidler A, Bergmann A, Jäger M, Ellegast R, Ditchen D, Elsner G, et al
. Cumulative occupational lumbar load and lumbar disc disease-results of a German multi-center case-control study (EPILIFT). BMC Musculoskelet Disord 2009;10:48.
Sahrah H, Alzahrani A, Mansour M, Elhussein N, Ahmed R. Disc prolapse awareness among population in Taif- Saudi Arabia. Int J Adv Res 2016;4:188-97.
Ongeti KW, Ogeng'o J, Gakuu LN, Saidi H, Pulei A. Prolapsed intervertebral disc in an African population: Kenyan experience. East Afr Orthop J 2012;6:12-5.
Choi J, Lee S, Hwangbo G. Influences of spinal decompression therapy and general traction therapy on the pain, disability, and straight leg raising of patients with intervertebral disc herniation. J Phys Ther Sci 2015;27:481-3.
Ozturk B, Gunduz OH, Ozoran K, Bostanoglu S. Effect of continuous lumbar traction on the size of herniated disc material in lumbar disc herniation. Rheumatol Int 2006;26:622-6.
Gagne AR, Hasson SM. Lumbar extension exercises in conjunction with mechanical traction for the management of a patient with a lumbar herniated disc. Physiother Theory Pract 2010;26:256-66.
Van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: A systematic review of randomized controlled trials of the most common interventions. Spine 1997;22:2128-56.
Kanji G, Menhinick P. Efficacy of traction for non-specific low back pain: A randomised clinical trial. Australas Musculoskelet Med 2017;21:43.
Revel M. Does traction still have a role in nonspecific low back disorders? Joint Bone Spine 2000;67:146-9.
Alrwaily M, Almutiri M, Schneider M. Assessment of variability in traction interventions for patients with low back pain: A systematic review. Chiropr Man Ther 2018;26:35.
River Y, Aharony S, Bracha J, Levital T, Gerwin R. Three-dimensional computerized mobilization of the cervical spine for the treatment of chronic neck pain: A pilot study. Pain Med 2014;15:1091-9.
Nyiendo J, Haas M, Goldberg B, Sexton G. Pain, disability, and satisfation outcomes and predictors of outcomes: A practice-based study of chronic low back pain patients attending primary care and chiropractic physicians. J Manipulative Physiol Ther 2001;24:433-9.
Vianin M. Psychometric properties and clinical usefulness of the Oswestry Disability Index. J Chiropr Med 2008;7:161-3.
Algarni AS, Ghorbel S, Jones JG, Guermazi M. Validation of an Arabic version of the Oswestry index in Saudi Arabia. Ann Phys Rehabil Med 2014;57:653-63.
Boyd BS, Wanek L, Gray AT, Topp KS. Mechanosensitivity of the lower extremity nervous system during straight-leg raise neurodynamic testing in healthy individuals. J Orthop Sports Phys Ther 2009;39:780-90.
Diab AAM, Moustafa IM. The efficacy of lumbar extension traction for sagittal alignment in mechanical low back pain: A randomized trial. J Back Musculoskelet Rehabil 2013;26:213-20.
Moustafa IM, Diab AA. Extension traction treatment for patients with discogenic lumbosacral radiculopathy: A randomized controlled trial. Clin Rehabil 2013;27:51-62.
Filiz MB, Kiliç Z, Uçkun A, Çakir T, Doǧan ŞK, Toraman NF. Mechanical traction for lumbar radicular pain: Supine or prone? A Randomized Controlled Trial. Am J Phys Med Rehabil 2018;97:433-9.
Wegner I, Widyahening IS, van Tulder MW, Blomberg SE, de Vet HC, Brønfort G, et al
. Traction for low-back pain with or without sciatica. Cochrane Database Syst Rev 2013:8.
Lee JS, Hobden E, Stiell IG, Wells GA. Clinically important change in the visual analog scale after adequate pain control. Acad Emerg Med 2003;10:1128-30.
Emshoff R, Bertram S, Emshoff I. Clinically important difference thresholds of the visual analog scale: A conceptual model for identifying meaningful intraindividual changes for pain intensity. Pain 2011;152:2277-82.
Mutlu EK, Ozdincler AR. Reliability and responsiveness of algometry for measuring pressure pain threshold in patients with knee osteoarthritis. J Phys Ther Sci 2015;27:1961-5.
Hägg O, Fritzell P, Nordwall A. The clinical importance of changes in outcome scores after treatment for chronic low back pain. Eur Spine J 2003;12:12-20.
Ostelo RW, de Vet HC. Clinically important outcomes in low back pain. Best Pract Res Clin Rheumatol 2005;19:593-607.
Maughan EF, Lewis JS. Outcome measures in chronic low back pain. Eur Spine J 2010;19:1484-94.
Gatchel RJ, Mayer TG. Testing minimal clinically important difference: Consensus or conundrum? Spine J 2010;10:321-7.
Ostelo RW, Deyo RA, Stratford P, Waddell G, Croft P, Von Korff M, et al
. Interpreting change scores for pain and functional status in low back pain: Towards international consensus regarding minimal important change. Spine 2008;33:90-4.
Krause M, Refshauge KM, Dessen M, Boland R. Lumbar spine traction: Evaluation of effects and recommended application for treatment. Manual Therapy 2000;5:72-81.
[Table 1], [Table 2], [Table 3], [Table 4]