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J Int Acad Phys Ther Res 2017; 8(1): 1071-1076ISSN 2092-8475

www.iaptr.orghttps://doi.org/10.20540/JIAPTR.2017.8.1.1071

Low back pain (LBP) is the most common mus-culoskeletal complaint of the adult population 1).The prevalence of back pain and the number ofpatients seeking care in the US has increased overthe last two decades 1). It is estimated that 60% to80% of people will have it during their lifetime and2-5% will have it at any given time 2, 3). Lumbartraction, lumbar mobilization, and lumbar manip-ulation are common forms of conservative careintervention for LBP 4). All three of these inter-ventions have all demonstrated positive immediateeffects for lumbar pain and motion impairments 4).Lumbar traction involves the application of a low-velocity passive motion to distract or separate thelumbar segments in a straight sagittal plane 4).Spinal mobilization involves the use of a low-velocity passive motion applied either directly to aportion of the vertebrae or more generally thepelvis or lower extremity (LE) 5). Spinal mobiliza-

tion is typically applied in a graded or oscillatoryfashion 5-7). Spinal manipulation involves theapplication a high-velocity (HV) passive motion 8).This passive movement is typically applied to thelumbar segments in an indirect fashion using thepatient’s pelvis, trunk, or shoulder region as alever to deliver what is typically a rotatory motioninto the lumbar segments 9). Spinal manipulation,when applied in this fashion, is controversial ifnot potentially dangerous if applied to patientswith LDD and associated segmental instability 10).In a comprehensive review of the literature pub-

lished in 1996, Stevinson identified 295 cases ofcomplications following HV spinal manipulation.Sixty-one of these cases noted disk herniation,worsening of radicular symptoms, or developmentof cauda equina syndrome. Fifty-six reports ofother types of complications, including disloca-tions and fractures that were often accompaniedby spinal cord compression 11). In a case study byMorandi, neurological symptoms including worsened

Immediate Effects of Side Lying Manual Lumbar Tractionin Patients with Painful Active Lumbar Motion

INTRODUCTION

The purpose of this study was to determine if a gentle form of manuallumbar traction could reduce painful lumbar motions associated withlumbar disc degeneration (LDD). This clinical trial incorporated 134 par-ticipants with painful active lumbar motion. Participants were randomlyassigned to an experimental treatment or sham group. 67 participantsreceived sidelying manual lumbar traction while the other 67 partici-pants received a sham treatment. Pre and post treatment NPRS valuesfor the painful active lumbar motion were recorded for each group.There was a statistically significant improvement (P=0.00) for decreasedpain intensity during active lumbar motion in the experimental group ascompared to the sham treatment group. The average percent decreasein numeric pain rating scale (NPRS) values was 52.1% for the experi-mental treatment group and 8.1% for the sham group. The results of thestudy suggest that side-lying manual lumbar traction can improvepainful lumbar motion in patients with LDD.

Key words: Low back pain; Lumbar disc degeneration; Lumbar manual trac-tion

Doug Creighton, Alexa Schweiger,Sarah Cubr

Team Rehabilitation Farmington Hills,Michigan, USA

Received : 5 January 2017Revised : 10 February 2017Accepted : 21 February 2017

Address for correspondenceDoug Creighton, MS, DPT, Prof. Oakland University 3077 Human Health Building Rochester Michigan 48309Ph# 248-364-8696creighto@oakland.edu

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low back pain, paresthesia in bilateral lowerextremities, loss of sensation, urinary inconti-nence, and absence of deep tendon reflexes inboth lower extremities followed a spinal manipu-lation in a patient with low back pain. These find-ings were strongly associated with HV manipula-tion of the lumbar spine 12).

The use of HV spinal manipulation in cases ofsymptomatic LDD may be further called intoquestion when one considers the associationbetween intervertebral disc (IVD) degenerationand spinal instability. Miyazaki has shown that anincrease in lumbar segmental translation accom-panies grade II (mild) disc degeneration and gradeIII (moderate) disc degeneration 13). Lumbar seg-mental stiffness, a principal indication for lumbarmobilization and HV lumbar manipulation, did notuntil a grade V level of disc degeneration wasreached 13). Miyazaki concluded, similar toKirkaldy-Willis that the changes in segmentalmotion occur with disc degeneration and progressfrom a normal state to an unstable phase withgreater mobility and subsequently to an ankylosedstage 13, 14). Tanaka also demonstrated that thekinematic properties of the lumbar spine arerelated to disc degeneration. Greater lumbar seg-mental motion was generally found with discdegeneration, particularly in grades III and IV.Disc space collapse and osteophyte formation isassociated with grade V IVD degeneration and thisresulted in stabilization of the motion segments 15).Finally, Murata et al completed a study in 1993that demonstrated similar segmental motion find-ings in relation to the five grades of disc degener-ation 16).

In a study of adults of ages 50-59 years old,fifty-three percent of patients with confirmedlumbar IVD degeneration demonstrated symptomsof low back pain. Degeneration of the lumbar IVDhas the potential to be a source of low back paindue to excessive mechanical deformation of dam-aged or sensitized disc tissue 17). In a study bySchepper, the presence of disc space narrowing atthe grade I and II levels were strongly associatedwith low back pain 18). Luoma found that theprevalence of sciatic pain increased with increas-ing numbers of degenerated lumbar discs 19). Theliterature demonstrates an association betweenlumbar disc degeneration, lumbar pain, and thedevelopment of lumbar instability. Given this, andthe potential association between HV rotatorylumbar manipulation and injury to the lumbarIVD, we hypothesize that a more gentle and

translatory form of manual intervention should beapplied to patients demonstrating disc degenera-tion with painful lumbar motion. Madson and Hollman demonstrated that the use

of manual lumbar traction has been shown to sig-nificantly reduce pain in patients with LBP. Thisstudy sampled 4000 Orthopedic Section membersof the American Physical Therapy Association anddetermined that 76.6% (767) of respondentsreported using some form of traction, with manualtraction being the most common form of delivery(68.3%) 20). In a study by Scand et al, forty-ninepatients with LBP, sciatica, and prolapsed lumbarintervertebral discs were randomized and givenauto-traction and manual traction with strict bedrest for one week. The two traction treatmentswere found equally effective and about one fourthof patients avoided surgical intervention. Aftertwo years, there was no recurrence of symptoms21). Presently, there is still a lack of high qualitystudies on manual traction. Many studies areunderpowered, and in most studies, traction isoften supplied in combination with other treat-ment modalities making the true effect of thisintervention difficult to determine 22). Given this,we believe an additional study which examines theeffect of manual traction in isolation of otherinterventions is warranted. Therefore, the purposeof this study is to evaluate the immediate effectsof lumbar manual traction in patients with painfulactive lumbar motion in isolation of other treat-ment modalities.

Following approval from the Institutional ReviewBoards at Oakland University and Team RehabIncorporated, participants with radiographically orclinically confirmed cases (Physical Therapistdiagnosis) of one or more degenerated lumbar discs,were at 18 years of age, and who were referred toTeam Rehab, in Farmington Hills, Michigan wererecruited into this study if they reported provoca-tion of low back pain at an intensity of two orgreater on the numeric pain rating scale (NPRS)during the performance of active lumbar move-ment in the standing position. Participants wereexcluded if they had any contraindications tolumbar traction. Contraindications for spinal trac-tion include disease processes and other conditions

Participants

METHODS

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Immediate effects of side lying manual lumbar traction in patients with painful active lumbar motion

for which movement is contraindicated 23). A totalof 67 participants, 25 male and 42 female, with amean age of 51.6 years received side lying lumbarmanual traction (experimental treatment tech-nique), and 67 subjects, 29 males and 38 females,with a mean age of 49.7 years received a shammanual intervention.

Pain intensity data was collected by having theparticipants perform active lumbar flexion, exten-sion, side bending, or rotation of his/her lumbarspine to a point where pain was perceived. Theparticipants maintained that position and reportedhis/her low back pain intensity using the 11-pointNPRS scale (0=no pain, 10=worst possible pain).This painful point in the range of lumbar move-ment was marked with a black marking pen usingthe participant’s finger tips touching his/her lowerextremity. The NPRS scale has been found to havehigh test-retest reliability and high constructvalidity compared to the visual analog scale 24).The NPRS is shown to have a standard error ofmeasurement of a 1.02 when used to assess lowback pain 24). The standard error of measurementestimates how repeated measures of a person onthe same instrument tend to be distributed aroundhis or her “true” score. The minimal detectablechange for low back pain is 2 points based on a95% confidence interval (24). The self-report of lowback pain intensity using the NPRS was recordeda second time immediately after provision ofeither the manual traction intervention or thesham intervention by having the participant per-form the same active lumbar motion to the pointpreviously marked on his/her lower extremity.This ended the participant’s involvement in thestudy.

The manual traction technique was applied inthe side lying position on a standard tractiontable. Lumbar traction was achieved by position-

ing the lateral aspect of the participant’s pelvis onthe moveable section of the traction table, releas-ing the lock on the table, pulling the entire pelvisin a caudal direction through a manual contact onthe participant’s sacrum. (Figure 1) Treatmentdosage was three sessions of manual traction,holding each session for 10 seconds. A 10 secondpause was given in between each session. Thesame procedure was followed for the sham groupwith regards to testing active lumbar motion andrecording NPRS values for a painful lumbarmovement both immediately before and after thesham treatment. The sham treatment consisted ofhaving the participant lie on the same tractiontable and in the same side lying position as the

Outcomes

Interventions

Age (years)

Body Weight (lb)

Gender

51.6

177.7

25 male, 42 female

49.7

176.7

29 males, 38 females

Manual Traction Group Sham Group

Table 1. Mean of patient demographics

Fig. 1. Manual lumbar traction treatment techniquedelivered to a patient in the side lying position.The clinician stabilizes the rib cage and pullsthe pelvis in a caudal direction while the trac-tion table separates and facilitates the tractionprocedure.

Fig. 2.The Sham technique delivered to a patient.The patient’s rib cage is manually stabilizedwhile an anteriorly directed pressure is appliedto the posterior surface of the sacrum.

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Creighton D, Schweiger A, Cubr S.

experimental treatment group. For 30 seconds,the participant received an anteriorly directedpressure onto his/her sacrum through contactwith the clinician’s hand (Figure 2). The shamgroup participants received what was described tothem as a deep pressure manual therapy tech-nique. No caudally directed manual traction wasperformed during the sham technique.

The effect of the side lying manual tractiontechnique of pain level was analyzed using infer-ential statistics. The P-value was set at P=0.05.Data analysis was performed using a statistician,not involved with data collection.

Group assignment in the traction group or thesham group was initially determined by a coin tossand altered thereafter. There were 67 participantsin each group. All of the 134 participants complet-ed the study, and no participants reported anydiscomfort from either the manual traction inter-vention or the sham intervention. Table 1describes the demographics for the participants inboth groups. Table 2 describes the average percentimprovement in NPRS after the provision of theexperimental treatment or sham intervention. A Wilcoxon signed-rank test was used to analyze

within group and age range comparisons forchanges in participants NPRS before and aftertreatment. Based on the analysis, the p-valueexceeded 0.005 which indicates there was a sta-

tistically significant improvement (decreased painintensity) with active lumbar motion. In the shamgroup, the p-value was 0.25 indicating aninsignificant value. The authors note that participants receiving the

sham intervention did demonstrate a small per-cent improvement (reduced lumbar pain duringactive motion), but these NPRS values fell belowthe minimal detectable difference of less than twopoints. A total of 21 participants in the shamgroup had a change of less than two points intheir post sham intervention NPRS score, com-pared to only five in the treatment group.Additionally, there were only two participants inthe manual traction group that had no change intheir pain intensity value post intervention, ascompared to 35 in the sham group.

The purposes of this study were to determine ifthere was immediate post- intervention effect onpainful active lumbar motion after the applicationof manual lumbar traction performed in the side-lying position, compare this to a sham interven-tion, to document the effect of side lying manuallumbar traction on participants both genders anddifferent age groups (Table 2). The participantstreated in this trial were representative of patientscommonly referred to outpatient physical therapypractices. The percent decrease in pain intensitylevel for the entire manual traction group was52.1% after side lying manual traction was provid-ed. Both genders receiving manual traction showed

DISCUSSION

18-29:

30-39:

40-49:

50-59:

50-69:

70-79:

80-94:

P value

6

13

10

17

10

6

5

65.5%

47.6%

59.6%

47.1%

53.6%

41.9%

64%

P=0.005

17

4

11

11

8

10

6

3.9%

3%

6.8%

6.2%

16.7%

5.76%

3.1%

P=0.25

Number of Participantsin ExperimentalTreatment Group

Percent Improvement inExperimental Treatment

Group

Number of Participantsin Sham Treatment

Group

Percent Improvement inSham Group

Table 2. Average improvement in NPRS scores following treatment or sham

Data Analysis

RESULTS

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Immediate effects of side lying manual lumbar traction in patients with painful active lumbar motion

percent improvement in NPRS values with anaverage decrease in NPRS for males at 57.3% andfemales at 49.4%. When broken down into agecategories, two groups showed the greatestdecrease in pain, 80-92 year old group demon-strated a 64% in NPRS and 18-29 year old groupdemonstrated a 62.5% decrease. The sham treat-ment group demonstrated an 8.1% decrease inactive lumbar motion pain. This may haveoccurred due to the manual contact on the partic-ipant’s sacrum, or perhaps due to lying on his/herside in a comfortable position the treatment tablefor just over 30 seconds.

The side-lying position is unique to this studyand is beneficial for many reasons. The position iseasy for the participants to transition into and outof and manual contact on portion of the patient’spelvis easily facilitates the delivery of manualtraction to the lumbar segments (25). The side-lyingposition eliminates the uncomfortable pressure inthe abdominal region and passive pelvis position-ing (tilting) can be performed to find the partici-pant’s most comfortable sagittal plane position forhis/her lumbar segments. The side lying positionalso allows the clinician easily deliver manualtraction while maintaining safe body mechanics.

Clinical ImplicationsEarly grade lumbar disc degeneration is associ-

ated with pain and segmental instability (13-16, 26)

High-velocity rotatory lumbar manipulations haspotentially been associated with the possibility ofinjuring the lumbar IVD (10-11). This manual tractionintervention likely provides a gentle, safe, andeffective treatment option of patient’s with painfulmovement impairments secondary to lumbar discdegeneration. Currently there is minimal researchon the effects of manual lumbar traction as apotential conservative care intervention option forpatients with LBP. This study provided evidencefor the immediate effects of manual traction whenprovided as a sole treatment.

There were several limitations to this study.Despite random allocation to group assignment,the same clinician performed both the manualtraction and placebo treatment to all participantsand was not blinded to group assignment.Secondly, the participants who received either thetraction treatment or the sham treatment arepotentially at risk for the placebo effect as both

groups thought they were receiving treatment.So, there may have a psychological implication ontheir symptoms, resulting in the improvement inthe NPRS value, regardless of the treatmentreceived. Finally, since the pre- and post- NPRSvalues were self-reported, the participants couldhave response bias, and exaggerated the effects oftreatment. Further research still needs to be con-ducted regarding the potential long term benefitsof manual lumbar traction on low back pain, andpainful active lumbar movement.

This study assists in demonstrating that a gentleform of translatory passive motion (manual trac-tion) was effective in reducing lumbar pain expe-rienced during active motion in patient with LDD.No participants reported any increase in pain dur-ing active lumbar motion after the technique. Themanual treatment technique used in this studyoffers clinicians a safe way to treat patients whopresent with LBP.

CONCLUSIONS

Limitations and Suggestions for Future Research

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