Comparison of the Effectiveness of Traditional Motorized Traction and Non-surgical Spinal Decompression Therapy Added to Conventional Physiotherapy in Low Back Pain

doi:10.21203/rs.3.rs-2643155/v1

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Comparison of the Effectiveness of Traditional Motorized Traction and Non-surgical Spinal Decompression Therapy Added to Conventional Physiotherapy in Low Back Pain

https://doi.org/10.21203/rs.3.rs-2643155/v1

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Abstract Background: There are limited number of studies comparing non-surgical spinal decompression with other treatment options such as conventional motor traction in the treatment of low back pain caused by lumbar discopathy. This retrospective study aimed to compare the effectiveness of these treatments. Methods: Retrospective data of patients who had physical therapy in our clinic with the diagnosis of lumbar dyscopathy were reviewed. Demographic datas, duration of their symptoms, physical examination findings, lumbosacral magnetic resonance imaging (MRI) reports, method and duration of treatment and Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) results were recorded. Results: A total of 160 patients met the inclusion criteria. Their mean age was 44.6±12.4 (range 21-65) years, 57.5% (n=92) was female, and 42.5% (n=68) was male. There were no differences between the conventional physiotherapy, motorized traction, and spinal decompression groups in terms of age, duration of symptoms, and the number of sessions (p>0.05). In both three groups, the mean scores of VAS and ODI were significantly decreased in the pre-and post-treatment comparisons (p<0.005). The rates of change in VAS and ODI were higher in the traction group and spinal decompression group compared to the conventional treatment (p<0.005). Conclusion: In patients with subacute and chronic lumbar dyscopathies, motorized traction and spinal decompression treatments added to conventional treatment were found to be more effective than conventional treatment alone. The results of spinal decompression and conventional motorized traction treatments appear to be similar. Trial registration: ClinicalTrials.gov identifier number of the study is NCT05617924. Keywords: Low back pain, intervertebral disc, traction, decompression

Low back pain

intervertebral disc

traction

decompression

Chronic low back pain is found in approximately 20% of individuals worldwide and it is a leading cause of disability (1). Physically heavy workers, those with physical and mental comorbidities, smokers, and obese individuals are at greater risk for low back pain (2). Anatomical structures that have a potentially nociceptive contribution to low back pain are intervertebral discs, facet joints, and vertebral endplates (2).

Treatment modalities such as superficial and deep heaters, massage, electrotherapy, and traction are used in the physical therapy of low back pain (3). It has been determined that these treatments are effective in reducing pain and improving function in patients with lumbar disc herniation. However, the level of evidence was not evaluated as high in general. Despite the moderate level of evidence, exercise and traction are recommended (4).

Different traction types have been reported in the literature. These are manual traction, mechanical or motorized traction, auto traction, and underwater traction. Manual traction is most commonly used in clinical practice, followed by motorized traction. Traction can be continuous (continues up to 20 minutes or longer) or intermittent (alternating traction and cyclic relaxation with several minutes) depending on the application, also, strength, rhythm, and patient positioning can vary (5). It has been suggested that traction reduces the compressive forces on the discs by separating the vertebral bodies, reduces nerve root compression by expanding the intervertebral foramen, and helps restore herniated discs by creating tension in the spinal ligaments (6). Horizontal traction has been shown to be significantly effective in increasing the disc height at the lower lumbar levels, especially in the posterior regions of the discs (7).

A relatively new technique, non-surgical spinal decompression, uses a sensitive computerized mechanism and expands spinal nerve roots by segmental distraction (8). The basis of the mechanism of action of spinal decompression is the reduction of intradiscal pressure. This facilitates oxygen and nutrient uptake and increases the metabolism and healing of the disc (9). Although spinal decompression devices theoretically allow the distraction of the spine without reactive muscle contraction and allow the vertebrae to separate better, there is little evidence that they differ from simple traction (10).

There are limited number of studies comparing non-surgical spinal decompression with other treatment options such as conventional motor traction in the literatute (11). In this retrospective study, we aimed to compare the effectiveness of these treatments, which are in our routine practice in our clinic.

Participants

The records of patients aged 20–65 years, who had physical therapy with the diagnosis of lumbar intervertebral disc disorders (with ICD codes M51 and its lower codes) in XXXXXXXX, Department of Physical Medicine and Rehabilitation, between 01.01.2019 and 10.11.2022, were reviewed. The records of routine anamnesis, examination, treatment card, and control evaluation records of the patients in the outpatient clinic were examined from our hospital’s electronic database. Patients with acute low back pain (< 6 weeks), history of lumbar surgery, spondylolisthesis or spinal stenosis, inflammatory rheumatic disease, sequestered hernia, patients receiving treatment other than the defined standard conventional physiotherapy (eg, massage therapy, balneotherapy, hydrotherapy, etc.), patients with less than 10 sessions of treatment, and those for whom sufficient data could not be obtained in the records were excluded.

The patients were divided into 3 groups according to the treatments they received. The first group consisted of patients who received conventional therapy alone, the second group consisted of patients who received motorized traction therapy in addition to conventional physiotherapy, and the third group consisted of patients who received non-surgical spinal decompression therapy in addition to conventional therapy.

Conventional Physiotherapy Group

In conventional physiotherapy, lumbar joint range of motion and core stabilization exercises, transcutaneous electrical nerve stimulation (TENS) as an analgesic electrotherapy method (with ChattanogaIntelect Advanced 2773MS device), ultrasound as a deep heater (with ChattanogaIntelect mobile model 2776 device) and 20 minutes hot pack as superficial heater were applied. TENS was applied in conventional mode for 20 minutes with two sets of 40 x 40 mm electrodes placed in the lumbar region. Ultrasound was applied to the lumbar region paravertebral muscles for 10 minutes with 1.5 W/cm² intensity and 1 MHZ frequency in continuous mode. Superficial hot pack treatment was applied for 20 minutes with a towel covered around, in a way that would not disturb the patient. Patients performed lumbar range of motion and core stabilization exercises for 20 minutes with the supervision of physiotherapists who were trained and experienced for at least 5 years. Data from patients who underwent different physiotherapy protocols other than this combination were excluded from the study.

Motorized Traction Group

Patients who received motorized traction treatment with the Chattanooga Triton Traction Machine 4798 for 3 days a week in addition to conventional physiotherapy were included in this group. The patient is positioned on the traction bed in the supine position with the hips and knees flexed. The traction belt is attached around the pelvis (Fig. 1). Traction is applied for 20 minutes. Intermittent traction is applied in three steps: a 10-second (sec) pull and 10-sec release in the first step, 60 sec pull 20-sec release in the second step, and 10 sec pull and 10-sec release in the third step. The traction force is adjusted as half of the patient's body weight and the release force as 1/4. The patient is given a safety switch button, so when the switch button is pressed (if the patient feels any discomfort or unusual pain) the device stops traction.

Spinal Decompression Group

Patients who received spinal decompression therapy with the DRX9000 Integrity Spinal Care System device, 3 days a week in addition to conventional physiotherapy were included in this group. The patients are positioned in the supine position supported by the table with their knees in flexion. They are fastened to the table with three belts, the first on the chest, the second under the rib cage, and the third on the iliac wing (Fig. 2). Decompression starts with 10 lbs (4.54 kg) less than half of the patients' weight and increases to half of their weight in the second session. Further sessions are applied with 10 lbs more than half of the patient’s weight. Each session lasts approximately 20 minutes. The relaxation is continued until the pulling force reached half of the patient's weight, when it reaches this level, traction is applied by the device again. The relaxation time is 30 seconds and the withdrawal time is 60 seconds. In this process, the traction angle is set to 30 degrees. The patient is given a safety switch button, so when the switch button is pressed (if the patient feels any discomfort or unusual pain) the device stops traction.

Evaluation Parameters

Demographic data of the patients, symptom durations, medical treatments, examination findings, lumbosacral MRI findings, method and duration of the treatment given, and the results of VAS and ODI before/after the treatment were recorded.

Visual Analogue Scale

The pain VAS is a scale consisting of a horizontal or vertical line, usually 10 centimeters (100 mm) long. For pain intensity, the scale is fixed at "no pain" (0 points) and "worst possible pain" or "worst pain imaginable" (100 points [10 cm scale]) (12).

Oswestry Disability Index

ODI has 10 questions about activities of daily life that are affected by low back pain, such as standing, walking, weightlifting, sitting, dressing, traveling, sleeping, and self-care. Each item is scored from 0 to 5, with higher values representing greater disability. The total score is multiplied by 2 and expressed as a percentage. Its reliability and validity have also been demonstrated in Turkish people (13).

Statistical Analysis

The statistical analysis was performed using IBM SPSS ver. 20.0 (IBM Corp., Armonk, NY, USA). The distribution of continuous variables was evaluated using the Shapiro-Wilk test. For descriptive statistics, the number of units (n), percentage (%), and median (range) values were given. For comparisons of two independent groups using non-parametric data, the Mann-Whitney U-test was performed. For comparisons of three independent groups using non-parametric data, the Kruskall-Wallis test was used. P values < 0.05 were considered significant.

A total of 160 patients were evaluated. The mean age of the patients was 44.6 ± 12.4 years (range 21–65), 57.5% (n = 92) were female and 42.5% (n = 68) were male. Of the patients, 87.5% (n = 140) were using nonsteroidal anti-inflammatory drugs, 11.9% (n = 19) were using gabapentin/pregabalin and 0.6% (n = 1) were using opiate analgesics. The rate of patients who received conventional physiotherapy alone was 49.4% (n = 79), for those who received motorized traction was 22.5% (n = 36), and who received spinal decompression was 28.1% (n = 45).

The findings of mean values and comparisons of demographic data, duration of symptoms, and the number of sessions, examination, and imaging findings according to the groups are given in Table 1. The decompression level of 62.2% of patients who underwent spinal decompression was L5-S1, 35.6% was L4-L5 and 2.2% was L3-4.

Table 1

Comparison of demographic data and percentage statistics of clinical characteristics of the groups
Variable (%)	Conventional Physiotherapy n = 79	Conventional Motorized Traction n = 36	Non-surgical Spinal Decompression n = 45	p
Sex Male/Female	41.8/58.2	41.7/58.3	44.4/55.6	p^a= 0.992
				p^b= 0.772
				p^c = 0.802
Hard work Yes/No	35.4/64.6	19.4/80.6	51.1/48.9	p^a= 0.084
				p^b= 0.088
				p^c= 0.003
Straight leg raise test +/-	62/38	36.1/63.9	57.8/42.2	p^a= 0.010
				p^b=0.642
				p^c = 0.052
Neurological deficit Yes/No	7.6/92.4	11.1/88.9	6.7/93.3	p^a= 0.535
				p^b= 0.848
				p^c =0.479
Single/Multilevel hernia	20.3/79.7	5.6/94.4	48.9/51.1	p^a= 0.044
				p^b= 0.001
				p^c<0.001
MRI bulging/hernia	54.4/45.6	50/50	15.6/84.4	p^a= 0.659
				p^b<0.001
				p^c<0.001

p^a = Statistical significance level of the difference between conventional physiotherapy and traction groups

p^b = Statistical significance level of the difference between conventional physiotherapy and spinal decompression groups

p^c = Statistical significance level of the difference between traction and spinal decompression groups

MRI: Magnetic resonance imaging

There was no difference between the conventional physiotherapy, motorized traction, and spinal decompression groups in terms of age, duration of symptoms, and the number of sessions (p > 0.05). In both three groups, the mean VAS and ODI scores were significantly decreased in the pre-and post-treatment comparisons (p < 0.005) (Tablw 2).

The initial VAS and ODI values of the groups were not similar; therefore the changes in percentage rates of VAS and ODI were compared. Change rates in VAS scores were higher in the traction group and spinal decompression group than in the conventional treatment group (p < 0.001, p = 0.019, respectively). There was no difference between the traction and spinal decompression groups in terms of VAS change rates (p = 0.081). ODI change rates were higher in the traction group and spinal decompression group than in the conventional treatment group (p = 0.001, p = 0.025, respectively). There was no difference between the traction and spinal decompression groups in terms of ODI change rates (p = 0.291) (Table 2).

Table 2

Comparison of age, symptom duration, number of sessions, and VAS, ODI values of the groups
Variable Mean ± SD	Conventional Physiotherapy n = 79	Conventional Motorized Traction n = 36	Non-surgical Spinal Decompression n = 45	p
Age (years)	46.45 ± 12.25	43.08 ± 12.55	42.44 ± 12.31	0.144
Symptom duration (months)	19.27 ± 27.66	13.00 ± 22.46	19.21 ± 29.41	0.088
Number of sessions	15.54 ± 1.54	16.20 ± 2	16.17 ± 2.79	0.330
VAS BT	6.01 ± 1.66^a	7.08 ± 1.61^b	6.2 ± 1.58^a	0.004
VAS AT	4.98 ± 1.69	4.94 ± 1.63	4.66 ± 1.93	0.622
VAS BT-AT p*	< 0.001	< 0.001	< 0.001
VAS improvement (%)	16.63 ± 18.38^a	26.80 ± 13.57^b	22.44 ± 19.81^b	0.001
ODI BT	37.24 ± 17.22	41.72 ± 15.09	40.02 ± 15.25	0.128
ODI AT	27.18 ± 16.19	22.83 ± 11.06	25.44 ± 17.55	0.603
ODI BT-AT p*	< 0.001	< 0.001	< 0.001
ODI İmprovement (%)	19.73 ± 66.94^a	47.47 ± 20.24^b	37.28 ± 45.52^b	0.002

p : Statistical significance level of the difference between three groups.

a-b: There is no difference between groups with the same letter for each row.

p*: Intra-group comparisons of values before and after treatment

VAS BT: Visual Analogue Scale mean values before treatment

VAS AT: Visual Analogue Scale mean values after treatment

VAS improvement: Percentage change rate of VAS after treatment

ODI BT: Oswestry Disability Index Mean values before treatment

ODI AT: Oswestry Disability Index Mean values after treatment

ODI İmprovement: Percentage change rate of ODI after treatment

Mean ± SD: Mean ± Standard deviation

In the subgroup analyses of SLR positive patients change rates in VAS scores were higher in the traction group and spinal decompression group than in the conventional treatment group (p = 0.004, p = 0.006 respectively). There was no difference between the traction and spinal decompression groups in terms of VAS change rates (p = 0.648). ODI change rates were higher in the traction group and spinal decompression group than in the conventional treatment group (p = 0.036, p < 0.023, respectively). There was no difference between the traction and spinal decompression groups in terms of ODI change rates (p = 0.553) (Table 3).

Table 3

Comparisons of groups in patients with positive Straight Leg Raise Test
Variable Mean ± SD	Conventional Physiotherapy n = 49	Conventional Motorized Traction n = 13	Non-surgical Spinal Decompression n = 26	p
Age (years)	45.36 ± 11.60	45.61 ± 12.08	42.80 ± 12.22	0.602
Symptom duration (months)	23.24 ± 32.53	4.69 ± 3.37	24.57 ± 36.03	0.176
Number of sessions	15.57 ± 1.56	15.38 ± 1.38	16.19 ± 3.05	0.534
VAS BT	5.91 ± 1.61	6.84 ± 1.99	6.38 ± 1.94	0.085
VAS AT	5.1 ± 1.68	5.07 ± 1.89	4.61 ± 2.28	0.687
VAS improvement (%)	13.25 ± 16.01^a	27.21 ± 15.33^b	30.11 ± 27.3^b	0.002
ODI BT	39.16 ± 19.01	38.46 ± 17.81	40.88 ± 16.02	0.887
ODI AT	30.46 ± 17.44	23.69 ± 13.63	26.5 ± 18.08	0.552
ODI İmprovement (%)	10.75 ± 80.41^a	45.84 ± 24.86^b	33.58 ± 57.14^b	0.023

p : Statistical significance level of the difference between three groups

a-b: There is no difference between groups with the same letter for each row.

VAS BT: Visual Analogue Scale mean values before treatment

VAS AT: Visual Analogue Scale mean values after treatment

VAS improvement: Percentage change rate of VAS after treatment

ODI BT: Oswestry Disability Index Mean values before treatment

ODI AT: Oswestry Disability Index Mean values after treatment

ODI İmprovement: Percentage change rate of ODI after treatment

Mean ± SD: Mean ± Standard deviation

In the current study, aimed to compare the effectiveness of conventional physiotherapy, and motorized traction and spinal decompression treatments added to conventional physiotherapy in patients with low back pain, it was found that motorized traction and spinal decompression treatments added to conventional physiotherapy were more effective on pain and disability compared to conventional physiotherapy alone.

Lumbar traction therapy refers to any method of distracting the lumbar vertebrae with force directed along the lower-upper axis of the spine to treat chronic low back pain. It became a common alternative for the treatment of chronic low back pain in the early 20th century, and views were developed on how traction should be applied, including discussions about the ideal amount of force, duration of traction, and timing of force intervals (10). Cyriax stated that traction could be used not only for chronic low back pain, but also for lumbar disc lesions, and he theorized that traction would create negative pressure on the disc and thus reduce disc herniations (10). In recent years, several imaging studies have been conducted, that prove this theory. Liu et al. evaluated the water content in the intervertebral disc after traction by MRI in patients with chronic low back pain and investigated the relationship between MRI changes and the ODI and VAS score. In each patient, the mean MRI changes in the nucleus pulposus of the 5 discs and the changes in the ODI/VAS scores showed a strong correlation. While this study showed the clinical and anatomical effects of traction, it also provided evidence about the traction mechanism of action (14).

Although motorized traction devices are capable of producing specific measurable forces and rhythms, most studies do not have any standardized traction protocols (15). Especially the number of sessions and traction force differ in protocols. In a study in which traction forces of one-fifth, one-third, and half their body weight were applied, all three forces were equally effective in immediately improving the straight leg raise test (SLR) angle in patients with lumbar protruded intervertebral discs; however, improvement in low back pain was observed only in the group that traction was with half the body weight (16). Traction therapy with both 30% and 60% of body weight has been shown to be effective in improving the angle of the SLR test (17). As a result, the recommended amount of force for traction varies, however, it is considered that traction performed with 30–50% of body weight is the most effective (10). In light of this data, a traction protocol with half of the body weight is generally applied in our clinic. In our study, we evaluated the results of patients who underwent intermittent traction with half of their body weight for 20 minutes. According to the results of our study, we can say that similar to the literature, traction with half of the body weight is effective on pain and disability.

According to the results of systematic reviews, there is low to moderate quality of evidence that for people with mixed symptom patterns (18). The systematic reviews and guidelines are mostly based on research using heterogeneous subjects with nonspecific low back pain. Clinical experts advocate the use of mechanical traction for more specific patient sub-groups with low back pain, particularly with sciatic and nerve root compression symptoms (19). In a study performed with 64 patients with low back and leg pain and symptoms of nerve root compression, two groups were compared to receive a exercise intervention with or without mechanical traction and the results of this study suggested that traction may be more effective in the presence of leg symptoms, signs of nerve root compression and in patients characterized by crossed straight leg raising (19). In our study, in the subgroup analysis formed of SLR test positive patients, we found the effects of motorized traction and spinal decompression added to conventional physiotherapy to be superior to conventional physiotherapy alone, regarding pain and disability.

In our study, it was observed that the rates of working in a heavy job were higher in the patient group with spinal decompression. We thought that it could be related to the fact that physicians prefer treatments that they think are more effective considering the patient's social history. Besides, it was seen that single-level hernia rates were higher in the spinal decompression group. In this method, an effective traction force can be applied on a specific disc without leading to paraspinal muscle spasm reflexes (9). Therefore, spinal decompression therapy could have been preferred more in patients with a significant single-level hernia. There are a limited number of studies showing that spinal decompression treatment provides an improvement in MRI findings in addition to its clinical effect in patients with subacute and chronic low back pain (20) (21). Apfel et al. stated that there is a relationship between the restoration of disc height and pain relief (20).

Besides the studies examining the effect of spinal decompression alone, the effectiveness of treatments in which spinal decompression combined with conventional methods was also evaluated. As an example, Demirel et al. stated that both combination treatment and conventional treatment alone had positive effects on pain relief, functional restoration, and reduction of hernia thickness. In addition, they reported that although the reduction in hernia size was more in the group in which spinal decompression was added compared to the conventional treatment, they did not find a difference between the groups (22). However, in our study, we found that combined therapy was more effective on pain and disability. This difference in results may be due to the difference in the conventional treatment methods applied in each study, as well as the difference in the patient groups. For example, in the study of Demirel et al., deep friction massage was used as a conventional method in addition to exercise (22). In our study, different from Demirel et al.'s study, hot pack, TENS, Ultrasound and exercise protocols were used. Also, different from this study, we also evaluated patients with multiple hernias. Concurrent with our study, Amjad et al. reported that in patients with subacute lumbar radiculopathy, combination treatment was more effective in relieving pain than conventional physical therapy alone, in which they applied spinal decompression therapy in addition to routine conventional physical therapy (8).

There are a limited number of studies in the literature comparing non-surgical spinal decompression with conventional motorized traction. The study of Koçak et al. showed that both conventional motorized traction and spinal decompression are effective methods in pain management and improvement of functional status and depressive mood in patients with chronic lumbar disc herniation, and that non-surgical spinal decompression was not superior to conventional motorized traction in terms of pain, functionality, depression, and quality of life (11). In a review evaluating the effectiveness of motorized traction and nonsurgical spinal decompression for chronic discogenic lumbosacral pain, six of seven randomized studies reported no difference between motorized traction and spinal decompression (9). In our study, we also found the two groups were similar. The strength of our study is that it is the first study to compare spinal decompression and traction added to conventional treatment, both with each other and with conventional treatment alone. Also, the evaluation of patients with heterogeneous examination and MRI findings and the subgroup with positive SLR strengthens the results of our study.

The heterogeneity of patient groups due to the retrospective nature of our study is one of our limitations. In addition, the fact that factors such as body mass index, accompanying fibromyalgia, and exercise compliance, which have the potential to affect the effectiveness of treatments, were not evaluated may also have affected our results.

According to the results of our study, in patients with subacute and chronic lumbar dyscopathies, motorized traction and spinal decompression treatments added to conventional treatment seem to be effective; however, there is not enough data on their superiority over each other. Further prospective randomized controlled studies comparing the relatively new spinal decompression therapy with conventional traction, are needed.

MRI: Magnetic resonance imaging

VAS: Visual Analogue Scale

ODI: Oswestry Disability Index

TENS: Transcutaneous electrical nerve stimulation

Sec: Second

SLR: Straight leg raise test

Ethical Approval and Consent to participate

Approval was obtained for this study on 04.11.2022 and with the number 2022/539, from the Afyonkarahisar University of Health Sciences Clinical Research Ethics Committee. ClinicalTrials.gov identifier number of the study is NCT05617924.

Consent for publication

Not applicable.

Availability of Data and Material

The datasets are not publicly available but are available from the corresponding author upon reasonable request.

Competing Interest

The authors declare that they have no competing interests.

Funding

Not applicable.

Authors’ Contributions

Conceptualization: all authors; Data curation: OA; Formal analysis: SA; Investigation: All authors; Methodology: SA, ÜD, HT; Project administration: SA, OA; Resources: All authors; Software: OA; Supervision: ÜD, HT; Validation: SA,; Visualization: SA, OA; Writing-original draft: SA; Writing-review & editing: All authors.

All authors approved the last article.

Acknowledgments

The authors wish to acknowledge all the participating physiotherapists and physical therapy technicians in their clinic.

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Comparison of the Effectiveness of Traditional Motorized Traction and Non-surgical Spinal Decompression Therapy Added to Conventional Physiotherapy in Low Back Pain

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