sexta-feira, 24 de abril de 2015


Non-Pharmacological Management of Hand Osteoarthritis: From A Perspective of Physiatry
Nihan Cuzdan Coskun1 and Ilke Coskun Benlidayi2*
1Faculty of Medicine, Department of Physical Medicine and Rehabilitation, Division of Rheumatology, Cukurova University, Adana, Turkey

Keywords
Hand osteoarthritis; Non-pharmacological management; Physical therapy; Rehabilitation
Introduction
Hand Osteoarthritis (OA) is a common OA phenotype, which particularly affects females. According to the results from Rotterdam study, radiographic hand OA is present in 67% of women and 54.8% of men at the age of 55 or above [1]. Although radiographic hand OA is almost universally present in elderly, symptomatic hand OA is less common, with a percentage of 8.2% and 15.9%, in males and females, respectively [2,3]. On the other hand erosive hand OA was reported as, 2.8%, 5.0% and 10.2%, in the general, radiographic and symptomatic hand OA population, respectively [4].
Patients with hand OA usually present with pain and enlargement of the finger joints, particularly in the dominant hand [5]. Hand pain was reported by 16% of the general population and 19% of the radiographic hand OA population. Besides, in patients with erosive hand OA, the percentage of pain was 40%. Hand disability is another consequence of hand OA. In patients with radiographic hand OA, the hand disability rate is 2.3%, whilst it is 7.3% in erosive OA patients [4]. Since it includes several disorders including thumb base hand OA, nodal interphalangeal OA and erosive OA, the presentation of the disease varies among sufferers of hand OA. Nevertheless, the clinical hallmarks of hand OA are the bony enlargements of the joints, along with Heberden and Bouchard nodes [6].
Management of hand OA is a complex issue that includes the pharmacological, surgical and mainly, the non-pharmacological interventions [7]. Non-pharmacological modalities recommended for hand OA are instruction in joint protection techniques, use of splints in trapeziometacarpal (TMC) joint OA and thermal agents for relief of pain and stiffness [8]. Besides, exercise therapy is widely prescribed to patients with hand OA, in order to improve joint range of motion, as well as muscle strength and tendon lengthening [7,9].
Since the treatment of hand OA is based particularly on the nonpharmacological methods, herein, we aimed to review the current literature on the non-pharmacological management of hand OA, by means of using evidence based approach (Table 1). This review article was conducted at the department of Physical Medicine and Rehabilitation, Cukurova University Faculty of Medicine between June-September 2014. For this purpose, the MEDLINE database between 1975-2014 was searched by using the primary search terms or their synonyms, individually or in combination, including ‘hand osteoarthritis’, ‘non-pharmacological management’, ‘physical modalities’ and ‘rehabilitation’. A total of 3733 articles were found. Single case reports, non-randomized studies without any control group were excluded (n=2915). Meta-analysis, systematic reviews, review articles and randomized controlled trials were included (n=818). The titles and abstracts of the included articles were reviewed by two independent reviewers. Articles on surgical modalities, with nonspecified patient groups and/or non-specified modalities and/or nonvalidated outcomes and duplicates were excluded (n=766).
Joint Protection Education
Joint protection education (JPE) is recommended by international guidelines, as the first line management of hand OA [7,8,10]. According to the systematic review of Valdes et al., there is moderate evidence to support JPE and provision of adaptive equipment for improvement in pain and hand function [11].
Joint Protection Education is instructed to patients either alone or together with exercise and splinting in randomized controlled trials (RCTs) [12-16] The two RCTs investigating the effect of JPE pointed that the intervention of JPE along with exercise could improve hand function, with the improvement in grip strength, without any change regarding pain [12,13].
It should be noted that JPE instruction is not a time-consuming intervention, with several benefits and no expenses.
Exercise Therapy
As for many chronic conditions, exercise therapy also has several beneficial effects on OA [17,18]. In clinical practice, exercise therapy is generally included in physiotherapy programs, by physicians and physical therapists.
According to the European League against Rheumatism (EULAR) recommendations for the management of hand OA, bothrange of motion (ROM) and strengthening exercise regimens are recommended in the treatment program [7]. However, due to the lack of direct evidence of benefit, the recommendation remains at the level of expert opinion. In the American College of Rheumatology (ACR) recommendations, exercise therapy is not included as a non-pharmacologic therapeutic option; since there is no strong evidence supporting its beneficial effect [8]. Osteoarthritis Research Society International (OARSI) 2009 recommendations report the pain relief effect of exercise for knee and hip OA; however, there was no comment on the effect of hand OA in this updated guideline [19].
There are four major purposes of exercise therapy for hand OA; decreasing stiffness, decreasing pain, improving ROM and increasing grip strength. In the RCTs, various combinations of therapeutic exercise programs are instructed to patients. Among these, ROM exercises together with strengthening exercises are the common prescribed exercise regimens for hand OA. According to a systematic review which included 21 articles of therapy-spesific interventions for hand OA, strengthening exercises alone or in combination with ROM exercises are found to be effective in increasing grip strength and decreasing stiffness, with a weak to moderate evidence [11,15,16,20]. The only study which investigated the effectiveness of strengthening exercise therapy with a sham control group, showed modestly improved hand strength in the exercise group, while there was no change in the sham group [15]. In this study, exercise protocol including 9 exercises with 10 to 20 repetitions was given to hand OA patients daily for 16 weeks [15]. Pain is frequently used as an outcome measure in these studies because of its direct relation with hand function. Exercise intervention, particularly in combination with hand splints seems to relieve night and motion pain as shown in a study which the Carpometacarpal (CMC) splint was prescribed to patients together with ROM and strengthening exercise program [14]. However, the strength of evidence regarding the effectiveness of strengthening exercises alone, on pain, remains low.
Aquatic exercises and balneotherapy are popular therapeutic options in many painful musculoskeletal conditions [21]. According to the systematic review conducted by Kamioka et al., aquatic exercises are effective, as well as land exercises, in various joint involvements of OA in short term; while the evidence in balneotherapy remains unclear [22]. Currently, there is no study designed to investigate the effect of aquatic exercise in hand OA. Still, it is important to keep in mind that aquatic exercises are safe, cheap and easy to perform. Additionally, less strain on the joints and optional therapeutic thermal effect can be considered as the advantages of the therapy. Two recent studies on balneotherapy showed the beneficial overall effects of therapy on symptomatic hand OA in short term, especially in pain scores; albeit the long-term effectiveness was similar to controls in both studies [23,24]. Both studies have the intervention of thermal water bath with similar temperature (37-38°C) for 15 to 20 minutes. However, the mineral ingredients of thermal water, intervals and the duration of the therapy were different.
The effectiveness of yoga is investigated in one study performed by Garfinkel et al. [20]. An exercise program with 60 minutes of supervised yoga and relaxation techniques was performed by patients once weekly for 8 times. According to the results of this study, that yoga therapy is effective in increasing grip strength, as well as decreasing pain and joint tenderness [20]. Similarly, acupuncture therapy is also beneficial in decreasing pain and disability, in accordance with a RCT by Dickens et al [25]. Despite high methodological quality and clearly described intervention (6 sessions, 2 week duration, TMC joint), the low number of patients reduces the validity of results [25]. Further research is needed to support these results, since these are the unique studies on yoga and acupuncture therapy, with low level of evidence.
Massage therapy was also found to be effective in hand OA patients with pain. Patients who received massage therapy by a therapist once a week for 4 weeks period, showed more improvement in depression and anxiety scores, when compared with controls. Although the study is in low quality, the ease of self-administration and the mood-improvement effect makes the therapy method considerable [26].
Occupational Therapy (OT) is consisted of JPE and exercise therapy for hand OA. Even though EULAR recommendations included OT for hand OA management, systematic reviews on this issue revealed that there is lack of evidence to reach a definitive conclusion [27-29]. One trial with 77 patients aimed to evaluate the effectiveness of OT in hand OA, revealed the improvement in hand function, by means of an exercise regimen held by an occupational therapist (every two weeks for 12 weeks), in combination with JPE [13]. Likewise, the results of a recently published multicentre RCT support the superiority of JPE together with hand exercises given by occupational therapists, on written advice alone [30]. However, there is an urgent need for RCTs with high methodological quality to provide stronger evidence on this subject.
In conclusion, RCTs performed to investigate the effect of exercise therapy in hand OA are at low quality and the clinical outcome measures are not standardized [11,28,31]. In addition, different intensities and durations of exercise programs do not allow authors to obtain a consensus on an effective standardized exercise regimen.
Physical Modalities
Heat and cold
Applying heat is known to be a good therapeutic choice for many chronic conditions. However, in acute inflammation or edema, thermotherapy is not recommended as a therapeutic option [32]. Apart from aforementioned conditions, local heat applications can be used safely in OA.
According to EULAR recommendations, thermotherapyincluding local hot pack and ultrasound (US) therapy is proposed as an expert opinion in hand OA [7]. Also, ACR recommendations support the instruction of thermal modalities in the non-pharmacological management of hand OA [8].
There is limited number of RCTs evaluating the effectiveness of heat application, specifically for hand OA. Infrared radiation, which is a superficial heat modality, was used for hand OA, in a crossover study. Both groups received the infrared radiation of a tiled stove therapy 3 hours for 3 times a week during 3 weeks and treatment free periods alternately. After 6 weeks, the groups showed no difference in terms of pain and function scores [33].
One of the most commonly used heat modalities in the trials is paraffin [14,34,35]. Studies demonstrated relief of pain in short and long term, following the treatment with paraffin. The only singleblind controlled trial on this issue belongs to Dilek et al. [34]. The intervention group was treated for both hands, with 15 minutes of deep-wrap paraffin bath therapy (50°C) for 5 days per week during 3 weeks. Accordingly, although no improvement was achieved in hand function, there was improvement both in pain and stiffness. Consequently, paraffin bath can be considered as a good local thermal therapeutic approach for symptomatic hand OA.
Diathermy is recommended in knee OA by international guidelines [7,8]. Nevertheless, to our knowledge, there is no trial concerning the effect of US, short wave diathermy or microwave diathermy, specifically on hand OA. Considering the effects of thermotherapy on pain relief and muscle relaxing, ultrasound therapy is worth to investigate in hand OA.
No controlled trials were encountered following our literature search regarding cold application for hand OA. Still, cold application is a frequently used method for acute inflammation of joints in rheumatic diseases [36]. Hence, cold application might be considered for acute exacerbations of inflammation in involved joints of hand OA.
Electrotherapy
There are a number of trials that investigated the role of electrotherapy on the treatment of hand OA [37,38].Transcutaneous electrical nerve stimulation (TENS) with glove electrode is more effective than that with carbon electrode, in individuals with hand OA. Besides, low laser therapy was shown to be an effective method for increasing ROM, in hand OA. However, it has no effect on hand pain, function and stiffness according to a study where 3W/cm2 modulated mode Gallium Aluminium Arsenide (GaAlAs) was applied to finger joints and 3 superficial nerves for 3 weeks [38]. Magnetotherapy is an alternative physical therapy agent used for many diseases such as rheumatologic diseases, ischemic disorders in lower extremity and intracranial pathologies [39,40]. The magnetic induction is believed to cause a flow of ionic current through the cell, with a result of a healing effect, by the cytoprotection of cells and stimulation of growth factor synthesis [41]. Magneototherapy was found effective in improving pain and hand function by single-blind pilot trial of Dilek et al., in which the patients were allocated to exercise and exercise+magnetotherapy groups [42]. In the trial of Horváth et al., the effect of magnetotherapy together with balneotherapy versus magnetotherapy alone was investigated; and the results showed superiority of combination therapy in terms of pain reduction [43]. Accordingly, both trials have shown the effect of magnetotherapy on pain in different regimens. While the aforementioned study of Dilek et al. used pulse magnetotherapy at 25 Hz, 450 pulse/s, 20 minutes a day for 10 days; in the study of Horváth et al. pulse magnetic field therapy was used at 60 Hz, 20J of 15 minutes for 3 times weekly during 3 weeks.
Although there are limited trials on electrotherapy, TENS, low laser therapy and magnetotherapy are known to be reliable therapeutic agents, in painful conditions [44-47]. More trials should be carried out in order to reach a definite conclusion on their beneficial effect in patients with hand OA.
Orthoses
According to the EULAR management strategies for hand OA, splints for thumb base OA and orthoses for angular deformities are recommended [7]. Systematic reviews show low to moderate evidence to support this proposal [11,48]. A meta-analysis investigating the design and effect of splints in hand OA, demonstrates the significant pain relief effect of splints, by short and long-term usage [49]. Longterm use of carpometacarpal and inter-phalangeal joint splints at night, establishes pain relief, improvement in hand function, hand strength and ROM, while the short-term night use of splints improves hand strength and function [50,51]. Besides, splinting of carpometacarpal joint continuously for 3-4 weeks, is shown to be well-tolerated by the patients in every stage of hand OA [52].
Although the materials can differ (elastic, elastic with semi-rigid thumb, semi-rigid material), the diversity in the orthotics’ material, does not change the pain reduction effect [53]. Howbeit, depending on the two RCTs with high quality, EULAR recommendations support thumb base splint with an inclusion of wrist component, in order to increase the effect of stabilization [7,54,55].
Taken as whole, assistive devices are claimed as the most effective self-management methods by patients with OA, splinting might be included in the non-pharmacological management of hand OA, as a core component [56].
Taking into account that no strong evidence stands for any of the therapy methods above, there is an urgent requirement for comparative studies including sham control groups. Besides, even though there are moderate evidence for exercise and splinting, information about the intensity, interval and duration of regimen is lacking. So, it might be the concern of researchers to build a common consensus for an optimum exercise regimen. Additionally, weak evidence regarding the beneficial effect of aquatherapy, balneotherapy and electrotherapy must be fortified.
Conclusion
In the present paper, up-to-date information about the nonpharmacological and non-surgical treatment modalities for hand OA was reviewed. Limited numbers of high quality RCTs on nonpharmacological treatment modalities restrict international guidelines from providing recommendations with strong evidence on this subject. According to our present knowledge based on literature, there is moderate to high evidence supporting JPE, exercise, local application of heat therapy and splinting in hand OA, whilst there is low evidence regarding balneotherapy, magnetotherapy, electrotherapy and acupuncture. Additionally, consensus on the optimum intensity and duration of exercise therapy regimen is lacking. Since the conservative therapy methods are commonly preferred in hand OA, further research with high methodological quality is mandatory, in order to achieve a consensus on this issue.
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Lumbar Traction in the Management of Low Back Pain: A Survey of Latest Results
Luca Cavagnaro*, Marco Basso, Mattia Alessio Mazzola and Matteo Formica
Orthopedic Clinic - University Hospital IRCCS San Martino - IST, National Institute for Cancer Research, Italy
Corresponding Author :Luca Cavagnaro
Orthopedic Clinic - University Hospital IRCCS San Martino - IST
National Institute for Cancer Research, Largo Rosanna Benzi, 10 16132 Genoa, Italy
Tel: 393333011814
E-mail: cavagnaro.luca@libero.it

Introduction : Low back pain (LBP) is one of the most common complaints in the general population, affecting about 70-80% of the population at some point in life. LBP management comprises a wide range of different intervention strategies. One of the treatment options is traction therapy. The aim of our short review is to summarize and analyze the latest result reporting the use of lumbar traction in LBP treatment in order to evaluate the real effectiveness and indications of this specific physical therapy.

Materials and methods: A comprehensive search of PubMed, Medline, Cochrane, Embase, and Google Scholar databases was performed, covering the period between 2006 and 2013. 54 citations were obtained. Relevant data from each included study were extracted and recorded.

Results: A total of 14 studies were included in the review. Among these 14 studies, 11 were randomized clinical trials, 1 was a retrospective cohort study and 2 were case series. The majority of included studies used traction on patients that suffered nerve root compression symptoms. The mean number of traction sessions was 19. At most, the duration of each session was 30 min (range 3-30 min). The mean period of traction treatment was 6 weeks (range 3-12 weeks). 11 studies coupled with traction other therapies. Only 3 studies used traction as a single treatment. The mean follow up period was 16,5 weeks from the end of treatment.

Conclusion: Several biases can be introduced by limited quality evidence from the included studies. Lumbar traction seems to produce positive results in nerve root compression symptoms. Data in degenerative and discogenic pain are debatable. To date, the use of lumbar traction therapy alone in LBP management is not recommended by the best available evidence.
Keywords 

Lumbar traction; Low back pain; Lumbar disc herniation; Lumbar disc disease; LBP; Physical therapy.
Introduction

Low back pain (LBP) is one of the most common complaints in the general population, affecting about 70-80% of the population at some point in life [1,2]. Moreover, LBP is a common cause of disability and work loss in developed countries, creating a large social and economic burden on society [3]. When we talk about low back pain, we have to deal with a great variety of clinical situations including acute, subacute(4 to 12 weeks) or chronic LBP. Furthermore, LBP can be due to several spine or “extra-spinal” diseases as nerve root compression, discogenic pain, rheumatologic or hip-related problems. The management of these conditions, that have to be clearly distinguished, comprises a wide range of different intervention strategies including surgery, drug therapy (NSAID’s, corticosteroids, opioid) and non-medical interventions (rest, physical therapy, ozone therapy). There are numerous clinical guidelines on LBP produced worldwide, yet lack of consensus about effectiveness [4,5]. Physiotherapy (PT) interventions for the management of LBP are wide and variable, but the efficacy of many is still questionable [6,7]. One of the treatment options is traction, which may be applied in many forms: motorized lumbar traction (traction applied by a motorized pulley), autotraction (the patient exerts the traction force through a pulling or pushing action), gravitational traction (traction through a suspension device), or manual traction (forces exerted by the therapist). The supposed mechanical effects of traction are vertebral separation and widening of intervertebral foramen in order to relieve pain and recover joint function by reducing pressure on discs or nerves [8-11]. Despite a huge number of systematic reviews regarding its efficacy in lumbar pain management [11-19], the evidence of traction use is still unclear. On the contrary, many surveys have shown its continued use: with 7% of the LBP patients in the Republic of Ireland and the UK [20], with 13.7% in Northern Ireland [21], 7% in the Netherlands[5,22] 21% in the United States [23], and up to 30% of patients with acute LBP and sciatica in Canada [24]. The aim of our short review is to summarize and analyze the latest result reporting the use of lumbar traction in LBP treatment in order to evaluate the real effectiveness and indications of this specific physical therapy.
Materials and Methods

A comprehensive search of PubMed, Medline, Cochrane, Embase, and Google Scholar databases was performed, covering the period between 2006 and 2013. We used various combinations of the following keywords: ‘‘lumbar traction,’’ ‘‘ low back pain,’’ ‘‘lumbar disc herniation,’’ “lumbar disc disease,” ‘‘LBP,’’ and ‘‘physical therapy.’’ Each reference list from the identified articles was manually checked to verify that relevant articles were not missed. A total of 54 citations were obtained. The non–English-language studies were excluded. Biomechanical, cadaveric and preclinical studies were excluded as well. Reviews, case reports or case series reporting less than 20 cases were excluded. Flow diagram illustrates the number of studies that have been identified, included, and excluded and the reasons for exclusion (Figure 1). Further, each included study was evaluated for the following variables: study type, number of patients, type of LBP, traction mode, duration and frequency of sessions, traction position, weight applied, associated therapy and duration of follow up after treatment. Relevant data from each included study were extracted and recorded.
Results

A total of 14 studies published from 2006 to 2013 that reported clinical or radiological outcomes of lumbar traction treatment in LBP were finally included in the review. Among these 14 studies, 11 were randomized clinical trials [11,24-33], 1 was a retrospective cohort study [34] and 2 were case series [35,36]. The total number of patients included in our review is 1104. 12 studies were related specifically to nerve root compression symptoms [24-28,30,31,33-36], 6 took into account degenerative disc disease, mechanic pain, hypolordosis or generic “chronic low back pain” alone or in association with nerve root compression symptoms [11,25,29,32,33,35]. In 12 studies, motorized traction was used [11,24,26-30,32-36] when in 1 RTC manual traction was the declared physical therapy [25]. Inversion therapy was used only in one study [31]. In 8 studies, the preferred traction position was supine [11,27-29,32-34,36]. Patients were treated prone in 3 studies [26,30,35]. 1 prone vs supine position study was found in literature [25]. 1 RCT don’t declare the traction position [24]. The mean number of traction sessions was 19. At most, the duration of each session was 30 min (range 3-30 min). In almost all studies the duration of each session increased along with the number of session. The mean period of traction treatment was 6 weeks (range 3-12 weeks). The weight applied for traction was in a range between 5 kg and 60% of the body weight. Only 1 study increased the traction weight till patient’s tolerance [36]. Normally, traction weight increased along with the number of traction session. 11 studies coupled with traction other therapies (physiotherapy, manual therapy, US, hotpack, TENS, massage) [11,24-27,29-33,36]. Only 3 studies used traction as a single therapy [28,34,35]. The mean follow up period was 16,5 weeks from the end of treatment. Only 1 work evaluated patients at the end of treatment [34]. All included studies and their main features are resumed in Table 1.
Discussion

Acute and chronic LBP are complex disorders that must be managed with a multidisciplinary approach addressing physical and socioeconomic aspects of the illness. Medication and physical therapy methods including traction have proven to be useful adjuncts to an active program of exercise and education that promotes functional restoration [37].

Traction mechanism to relieve pain seems to separate the vertebrae, remove pressure or contact forces from injured tissue, increase peripheral circulation by a massage effect, and reduce muscle spasm [38]. The results of previous studies examining the efficacy of lumbar traction yielded conflicting results [6,39-41]. The aim of this short review is to discuss and analyze the latest result regarding lumbar traction in order to clarify some aspects of this specific and useful physical therapy.

The majority of included studies employed traction on patients that suffered nerve root compression symptoms (radiculopathy, sciatica, discogenic pain). Mustafa, in his randomized clinical trial, aims to investigate the effects of lumbar extension traction in patients with unilateral lumbosacral radiculopathy due to L5-S1 disc herniation. All patients has also hypolordotic lumbar spine (<39°). The control group received hot packs and interferential therapy, whereas the traction group received lumbar extension traction in addition to hot packs and interferential therapy. He concluded that traction group had better effects than the control one with regard to pain, disability, H-reflex parameters and segmental intervertebral movements [33]. Fritz et al. performed a RCT in order to identify a subgroup of patients with low back pain who are likely to respond favorably to an intervention including mechanical traction. The results of this study suggest this subgroup is characterized by the presence of leg symptoms, signs of nerve root compression, and either peripheralization with extension movements or a crossed straight leg raise [26]. Some years later, the same author conducted a preliminary study on 120 patients examining the effectiveness of a treatment protocol of mechanical traction with extension-oriented activities for patients with low back pain and signs of nerve root irritation. The authors proved that add traction to extension-oriented activities lead to a better clinical outcome. Moreover, they examine a validity of a subgrouping method based on the presence peripheralization of symptoms with extension movement and/or a positive crossed straight leg raise test. This screening will allows the identification of patients who could take advantage from traction therapy [30].

The use of mechanical traction in the management of patients with chronic low back pain/degenerative spine disorders has generally not been endorsed by evidence-based practice guidelines. Diab et al. aim to investigate the effects of lumbar extension traction with stretching and infrared radiation compared with stretching and infrared radiation alone on the lumbar curve, pain, and intervertebral movements of 80 patients with chronic mechanical low back pain (CMLBP). They stated that lumbar extension traction with stretching exercises and infrared radiation was statistically superior to stretching exercises and infrared radiation alone for improving the sagittal lumbar curve, pain, and intervertebral movement in CMLBP [11]. Beyki et al. compared the outcomes of prone and supine lumbar traction in patients with chronic discogenic low back pain. They noted that prone traction was associated with improvements in pain intensity and ODI scores at discharge but they cannot imply a long lasting relationship between the traction and outcomes [25].

Some studies tried to investigate the radiological (MRI or CT) outcome of lumbar traction therapy along with clinical ones. Unlu et al. compared the outcome of traction, ultrasound, and low-power laser (LPL) therapies by using magnetic resonance imaging and clinical parameters in patients with nerve root compression symptoms. 60 patients were randomly assigned into 1 of 3 groups equally according to the therapies applied. There were significant reductions in pain and disability scores between baseline and follow-up periods, but there was not a significant difference between the 3 treatment groups at any of the 4 interview times. There were significant reductions of size of the herniated mass on magnetic resonance imaging immediately after treatment, but no differences between groups [28]. Kamanli et al. measured the outcome of conservative physical therapy with traction, by using magnetic resonance imaging and clinical parameters in patients presenting with low back pain caused by lumbar disc herniation. Magnetic resonance imaging examinations were carried out before and 4-6 weeks after the treatment. There were significant improvement in clinical outcomes and significant increases in lumbar movements between baseline and follow-up periods. There were significant reductions of size of the herniated mass in five patients, and significant increase in 3 patients on magnetic resonance imaging after treatment, but no differences in other patients. These results suggest that clinical improvement is not correlated with the finding of MRI. Patients with lumbar disc herniation should be monitored clinically [36]. In 2006, Ozturk et al. investigated the effects of continuous lumbar traction in patients with lumbar disc herniation on clinical findings, and size of the herniated disc measured by computed tomography (CT). 46 patients with lumbar disc herniation were included, and randomized into two groups as the traction group (24 patients), and the control group (22 patients). The traction group was given a physical therapy program and continuous lumbar traction. The control group was given the same physical therapy program without traction, for the same duration of time. They achieved statistically relevant improvement in their reults concluding that lumbar traction is both effective in improving symptoms and clinical findings in patients with lumbar disc herniation and also in decreasing the size of the herniated disc material as measured by CT [24]. The goal of the study carried out by Apfel et al. was to determine if changes in LBP, as measured on a verbal rating scale, before and after a 6-week treatment period with non-surgical spinal decompression, correlate with changes in lumbar disc height, as measured on computed tomography (CT) scans. 30 patients were enrolled for this study. The concluded that non-surgical spinal decompression was associated with a reduction in pain and an increase in disc height. The correlation of these variables suggests that pain reduction may be mediated, at least in part, through a restoration of disc height. Nevertheless, authors stated that randomized controlled trials is needed to confirm these promising results [34].

The possibility of lumbar sagittal curve correction with 2 way lumbar traction has been described in literature [12]. In 2013, Diab et al. conducted an RCT to investigate the effect of extension on the , function and whole spine sagittal balance as represented in curvature, thoracic curvature, C7 plumb line, and sacral slope. Eighty patients with chronic mechanical (CMLBP) and definite hypolordosis were randomly assigned to or a control group. The control group (n=40) received stretching exercises and infrared radiation, whereas the traction group (n=40) received lumbar extension traction in addition to stretching exercises and infrared radiation three times a week for 10 weeks. They stated l extension in addition to stretching exercises and infrared radiation improved the spine sagittal balance parameters and decreased the and disability in chronic mechanical LBP.

In lumbar traction therapy, several factors has to be considered [32]. Among other (weight, number and duration of sessions, duration of treatment) the position of traction is of a paramount importance. No univocal results can be drawn from literature. 8 studies included in our review used supine traction position. According to these findings, the majority of studies found in literature employed supine position for traction therapy. Beattie et al. aim to determine outcomes after administration of a prone lumbar traction protocol in 296 consecutive patients with LBP and evidence of a degenerative and/or herniated intervertebral disk. Traction applied in the prone position for 8 weeks was associated with clinical improvements till the end of follow up (180 days after discharge). Obviously, causal relationships between these outcomes and the intervention should not be made until further study is performed using randomized comparison groups [35]. Only 1 study compared the efficacy of prone and supine lumbar traction. Beyki et al. performed a 4-week course of lumbar traction, prone or supine, in 124 patients randomly divided in case and control groups. Case group (prone traction) had statistically better clinical results compared to control group (supine traction) [25].

Separate mention has to be done for inversion therapy. 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 [42]. The traction forces here are likely to be more consistent and tailored to each patient than conventional traction. In our review, we detected only 1 study concerning inversion therapy. It was a prospective randomized controlled trial. 24 patients awaiting surgery for pure lumbar discogenic disease were allocated to either physiotherapy or physiotherapy and intermittent traction with an inversion device. Authors concluded that the association of inversion traction and physiotherapy resulted in a significant reduction in the need for surgery. Along with several supposed benefits, traction therapy has some adverse effects. These effects were in the main not of a serious nature (short-term exacerbation of symptoms, pain on release of traction, headache, difficulty relaxing). In contrast, episodes of cauda equina symptoms and hospitalization because of acute onset of pain are rare but possible complications [43,44].

This short review has several limitations. First of all, we included only English-language studies. Several biases can be introduced by quality of studies. Most of them were RCTs but in many cases authors don’t cleared the randomization protocol. Most of these studies enrolled few patients. In consequence, clear statistical results cannot be drawn. Follow up periods were too short. Lastly, the majority of included papers associated other therapies (physiotherapy, TENS, massage, US) to lumbar traction. This consideration created an heavy bias on the evaluation of traction benefits.
Conclusion

To conclude, we identified 14 studies (11 RCTs, 1 retrospective cohort study and 2 were case series) that evaluated lumbar traction effects for patients with acute or chronic non-specific LBP. Lumbar traction seems to produce positive results in nerve root compression symptoms. Data in degenerative and discogenic pain are debatable. A subgroup of patients with low back pain (peripheralization of symptoms with extension movement and/or a positive crossed straight leg raise test) may exist for whom mechanical traction is an effective treatment. Nevertheless, the limited quality evidence from the included studies show very small effects that are not clinically relevant. The majority of included studies applied lumbar traction in association with other therapies. Therefore, authors cannot draw definite clinical result. In summary, to date the use of lumbar traction therapy alone in LBP management is not recommended by the best available evidence. For future research the focus should be on high-quality RCTs with sufficient sample size to be able to draw firm conclusions.
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