EFFECTS OF PRONE LUMBAR TRACTION COMPARED WITH SUPINE LUMBAR TRACTION IN CONJUNCTION WITH EXTENSION ORIENTED TREATMENT APPROACH (EOTA) RESPECTIVELY FOR CHRONIC LOW

BACK PAIN AND DISABILITY

PROJECT WORK MAY 2014

SUBMITTED BY PRABHAKARAN NATRAJ

A Project Work Submitted to the Pondicherry University in Partial Fulfillment of the requirements for the degree of BACHELOR OF PHYSIOTHERAPY.

SRI VENKATESWARAACOLLEGE OF PARAMEDICAL SCIENCES,

COLLEGE OF PHYSIOTHERAPY,ARIYUR, PUDUCHERRY-605102

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SRI VENKATESWARAA COLLEGE OF PARAMEDICAL SCIENCES, COLLEGE OF PHYSIOTHERAPY

MAY 2014

CERTIFICATEREGISTER NO: 10BPOO57

This is to certify that this project work entitled “EFFECTS OF PRONE LUMBAR TRACTION COMPARED WITH SUPINE LUMBAR TRACTION IN CONJUNCTION WITH EXTENSION ORIENTED TREATMENT APPROACH (EOTA) RESPECTIVELY FOR CHRONIC LOW BACK PAIN AND DISABILITY” is done by PRABHAKARAN NATRAJ in partial fulfillment of the requirements for the award of the Degree of Physiotherapy, Pondicherry University.

PROJECT GUIDE

Mr.C.Rathinasabapathy, M.P.T. (CARDIO-RESP.)Asst. Professor,

SVCPMS,College of Physiotherapy.

INTERNAL EXAMINER EXTERNAL EXAMINAR

HEAD OF THE INSTITUTION

Pace:

Date:

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ACKNOWLEDGEMENT

First and foremost I would like to thank the almighty, who showed his blessings in all walls of my life.

I gratefully acknowledge my indebtedness to our respected Principal Prof. A. Pahinian.,M.P.T., P.G.D. Fit.M., for granting me permission to do this project.

I am extremely thankful to my respectful project guideMr.C.Rathinasabapathy.,M.P.T.,Asst.Prof.,for his helpful suggestions and guidance which has led to the completion of this project.

I own my sincere thanks to all staffs work in Sri Venkateshwaraa College of Paramedical Sciences, College of Physiotherapy, for their encouragement and moral support throughout my study, special mention during the course of the project.

I am thankful to Dr. E .Susiganesh Kumar, M. Sc., M. Phil.,Ph.D., Asst. Prof., Dept. of Community medicine, SVMCH&RC for his valuable assistance in statistical analysis.

My grateful thanks to all the participants, who contributed their time and energy in this project as subjects.

I am whole heartedly thankful to my friends who have been with me throughout this project advising, encouraging and providing materials for this project.

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DEDICATED TO MY MOTHER AND FRIENDS

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CONTENTS

S.No. TABLE OF CONTENTS Page No.

I INTRODUCTIONTractionExtension oriented treatment approach (EOTA)

II REVIEW OF LITRATURE

III MATERIALS AND METHODOLOGYStudy designSelection criteriaMaterials requiredProcedure

IV OUTCOME MEASURES

V STATISTICAL TOOLS

VI DATA ANALYSIS AND PRESENTATION

VII RESULTS

VIII DISCUSSION

IX CONCLUSION

X RECOMMENDATIONS AND LIMITATIONS

XII REFERENCES

XIII APPENDIX –I

APPENDIX – II

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LIST OF TABLES

Table No. Titles Page No.

1 Exercise progression within the extension-oriented treatment approach.

2 Subject characteristics

3 Group A data of NPRS and ODQ

4 Group B data of NPRS and ODQ

5 Statistical presentation

LIST OF FIGURESFigure No. Title Page No.

1 Participant flow through the study

2 Patient in prone lumbar traction

3 Patient in fowler’s position for traction

4 Prone on elbows

5 Prone press up

INTRODUCTION

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70–85% of all people have back pain at some time in life. The annual prevalence of back pain ranges from 15% to 45%, with point prevalence averaging 30 %.( 1)

Low back pain chronicity implies that those affected suffer more or less continuous pain, and have few if any, pain-free periods.Definition of chronic (>12 weeks) low back pain should specifically excludethose patients who experience recurrent episodic low back pain. (2)

Chronic low back pain is generally considered a result of mechanical causes and is not related to an underlying condition such as infection, neoplasm, or fracture. Chronic low back pain is often thought to be the result of disc degeneration, musculoskeletal sprain or strain, or of disorders associated with the movement or position of the spine. The causes of chronic low back pain may stem from nociceptive, neuropathic, or psychological processes, or a combination of these. (3)

Mechanical or Activity-related Causes of low back pain (4):Segmental and discal degenerationMyofascial or soft tissue injury/disorder/strainDisc herniation with possible radiculopathySpinal instability with possible spondylolisthesis or fractureVertebral body fractureSpinal canal or lateral recess stenosisArachnoiditis, including postoperative scarringSpondylosisFacet joint dysfunctionDegenerative joint disease of spine

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Red Flags (4): Presentation age <20 yrs. or onset >55 yrs. (tumor?). Violent trauma, e.g. fall from a height, MVA (tumor?). Constant, progressive, non-mechanical pain. Thoracic pain. Previous history

Carcinoma. Systemic steroids. Drug abuse, HIV.

Systemically unwell Weight loss.

Persisting severe restriction of lumbar flexion. Widespread neurologic symptoms. Structural deformity. Caudaequina syndrome. Inflammatory disorder (ankylosing spondylitis and other related disorders) Positive studies

ESR > 25. Plain x-ray: vertebral collapse or bone destruction.

The management of chronic LBP begins usually with a conservative approach because surgery is expensive and not always effective. One such conservative approach is mechanical spinal traction which relies on the application of a continuous or intermittent distraction-force between the pelvis and ribcage. (5)

TRACTION

The word traction is a derivative of the Latin "tractico", which means "a process of drawing or pulling." As traction is applied, the movement produced at the segment is a combination of distraction and gliding. (6) Systematic reviews of literature (7-10) and evidence- based guidelines (9, 10) have concluded that there is not enough evidence to support the conventional supine lumbar traction as an effective treatment for patients with LBP. Epidurography and CT investigations have shown that high-force traction can reduce disk protrusions and relieve spinal nerve root compression symptoms. Some of the studies that showed lumbar traction was ineffective were performed with low forces. In many of the studies, patient selection criteria were poorly defined. (11)

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Variables for lumbar tractionPosition:Lumbar traction can be administered in the prone position or supine, with the traction belts exerting a pull to the anterior or posterior aspect of the joint. (11) The Fowler’s position (i.e. supine with the hips and knees flexed, and the lower legs supported on a stool) is clinically important in that it reduces the traction force required to stretch posterior tissues as compared to traditional supine position. The Fowler’s position imposes a significant flexion moment on the lumbar spine. (12)

Advantage of prone traction is that the therapist can palpate the interspinous spaces to ascertain the amount of movement that is taking place during the treatment. (9)It is possible to apply heating therapy synchronized with traction application and relaxing muscular spasm in prone position that impossible to be applied in supine position.(13)

Prone position may reduce a patient’s reflex spinal muscle contraction and allows distraction of the vertebrae, causing a subsequent symptom reduction.(14-17)

Force:There is consensus in the literature that a force of 40% to 50% of the patient’s body weight is necessary to cause vertebral separation. Judovich advocated a force equal to one half the patient’s body weight on a friction-free surface as the minimum force necessary to cause therapeutic effects in the lumbar spine. (11)

Mode:Some conditions, such as herniated disc seem to respond better to sustained traction, while conditions such as joint hypomobility and muscle guarding are usually treated more effectively with intermittent traction(6). Herniated disk is usually treated more effectively in static mode or with longer hold-rest periods (3- to 5-minute hold, 1-minute rest) in intermittent mode. Joint dysfunction and degenerative disk disease usually respond to shorter hold-rest periods (1 to 2 minute hold, 30-second rest) in intermittent mode. (11)

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Time:As the disk space widens, the intradiskal pressure decreases, causing the herniated disk material to be retracted into the disk space. The decrease in pressure is temporary, however, because eventually the decreased intradiskal pressure will cause fluid to be imbibed into the disk. When pressure equalization occurs, the suction effect on the disk protrusion is lost, and it is possible for patients to experience a sudden increase in pain when traction is released. If the traction time is 8 to 10 minutes, this effect is minimized. For other conditions, a treatment time of up to 20 minutes is often used. As a general rule, the higher the force, the shorter the treatment time. (11)

EXTENSION ORIENTED TREATMENT APPROACH (EOTA)

This approach typically involves some combination of active or passive activities to promote extension in the lumbar spine (18, 19).Several studies have examined the effectiveness of an EOTA for subjects with LBP, with most finding no benefit compared with other treatments. The key criterion for inclusion in the EOTA subgroup is the presence of the centralization phenomenon with extension movement testing during the physical examination. Extension exercises are progressed as tolerated starting with static prone positioning and progressing to sustained and repeated end range prone and standing extension. (20) The centralization phenomenon occurs when a movement or position results in the migration of symptoms from an area more distal or lateral in the buttocks or lower extremity to a location more proximal or closer to the midline of the lumbar spine. (19)

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NEEDS OF THE STUDY:

1) Although traction is widely used for the treatment of lumbar spine, efficacy and application method of it remain unresolved. There is not enough evidence of the effects of prone traction.

2) Systematic reviews of literature and evidence- based guidelines have concluded that there is not enough evidence to support the conventional supine lumbar traction as aneffective treatment for patients with chronic LBP.

3) To study the effectiveness of adding a conventional protocol of lumbar mechanical traction to an extension-oriented treatment approach for individuals with chronic LBP

OBJECTIVES OF THE STUDY:

1) To compare the outcomes of prone traction and supine lumbar traction in conjunction with extension-oriented treatment approach (EOTA) in subjects with chronic LBP

2) To evaluate the effectiveness of prone traction along with extension-oriented treatment approach (EOTA) for chronic LBP.

HYPOTHESIS:

1) Research hypothesis:

There will be significant difference between prone traction with EOTA and supine traction with EOTA for chronic LBA in decreasing pain and back disability.

2) Null hypothesis:

There will be no significant difference between prone traction with EOTA and supine traction with EOTA for chronic LBA in decreasing pain and back disability.

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REVIEW OF LITERATURE

1. Mahmoud Beyki et al. (2007) compared the outcomes of prone and supine lumbar traction in patients with chronic discogenic low back pain. A 4-week course of lumbar traction, prone or supine in case and control groups consecutively, consisting of six 30-minute sessions every other days, followed by four 30-minute sessions every 3 days was carried out. The study concluded that Traction applied in the prone position was associated with improvements in pain intensity and ODI scores at discharge, in a sample of 124 patients with activity limiting LBP. Prone traction has some superiority on traditional supine traction at least in early stages after treatment.

2. RemziCevik et al (2007) Aimed to investigate effect of new traction technique on anatomic structures of lumbar vertebrae, and its’ relation to different application of heating therapy. Ninety five consecutive patients with persistent low back pain were applied traction on a new table in prone position. Heating therapy applied concomitantly with traction (group I, n: 32) and sham traction (group III, n: 31), and before traction (group II, n: 32). Lateral lumbosacral radiographs were obtained before and during traction. They concluded that Significant widening in lumbar intervertebral disc spaces and flattening in lumbar lordosis were accomplished by new table. Synchronized heating therapy with traction has more effect on distracion of disc spaces than separately applying. Furthermore, creation of negative intradiscal pressure with this distraction is important to suck back herniated disc material in prone position.

3. Lee RYW and Evans JH (2001) Studied to determine the loads acting on the lumbar spine when traction therapy was given in the Fowler’s position. The study had two parts: a theoretical analysis which showed that traction produced a flexion moment on the spine as well as axial distraction; and an experimental study which measured the flexion moment induced by the adoption of the Fowler’s position. The Fowler’s position is clinically essential in that it flexes the spine and takes up the slack of the posterior tissues before the traction force is applied. Hence the axial tension and flexion moment generated by the traction force are more effective in stretching the posterior tissues.

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4. Morton C. R.(1957) the purpose of this article was to report the results obtained in the first hundred cases in which they used cyriax traction device for the relief of disc syndrome. The patient was positioned either prone or supine, according to comfort, usually the former. The traction force was of 80 to 200 lb. for about half an hour. Mechanical traction in this series of cases was proved to be a marked advance.

5. Paul F Beattie et al. (2008) studied to determine outcomes after administration of a prone lumbar traction protocol. The numeric pain rating scale and the Roland-Morris Disability Questionnaire (RMDQ) were completed at preintervention, discharge (within 2 weeks of the last visit), and at 30 days and 180 days after discharge. Intention-to-treat strategies were used to account for those subjects lost to follow-up. Traction applied in the prone position using the VAX-D for 8 weeks was associated with improvements in pain intensity and RMDQ scores.

6. Hebert et al. (2011) studied to identify subgroups of patients with LBP and match them with targeted therapies. Sub-grouping patients with LBP using the treatment-based classification criteria allows for improved identification of those who are most likely to experience clinical success with spinal manipulation, stabilization exercise, end-range loading exercise, and traction therapies.

7. David A Browder et al. (2007) Studied to examine the effectiveness of an extension-oriented treatment approach (EOTA) in a subgroup of subjects with low back pain (LBP) who were hypothesized to benefit from the treatment compared with similar subjects who received a lumbar spine strengthening exercise program.Forty-eight subjects were randomly assigned to groups that received an EOTA (n=26) or a strengthening exercise program (n=22). Subjects attended 8 physical therapy sessions and completed a home exercise program. Follow-up data were obtained at 1 week, 4 weeks, and 6 months after randomization. They concluded that EOTA was more effective than trunk strengthening exercise in a subgroup of subjects hypothesized to benefit from this treatment approach. Additional research is needed to explore whether an EOTA may benefit other subgroups of patients.

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8. Julie M Fritz et al. (2010) studied 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 within the pre-defined sub-group.120 patients with low back pain and signs of nerve root irritation were randomized based on the presence of the pre-defined sub-grouping criteria. Patients received 12 physical therapy treatment sessions over 6 weeks. Follow-up assessments after 6 weeks, 6 months, and 1 year were taken. The primary outcome measures were modified Oswestry questionnaire. Secondary outcomes included self-reports of low back and leg pain intensity, quality of life, global rating of improvement, additional healthcare utilization, and work absence. They concluded that this approach may be effective, particularly in a more specific sub-group of patients.

9. H. Duane Saunders (1979) studied various reviews and came with standardized variations and application procedures for lumbar traction.

10.Geraldine L. Pellecchia (1994)reviewed various literature evidences and concluded that clinical effects of lumbar traction are conflicting, many aspects have not been systematically investigated and classification system that identify patients likely to benefit from traction must be developed and validated.

11.Davidson M and Keating J (2002) studied 5 commonly used questionnaires for assessing disability in people with low back pain. Patients with low back pain completed the questionnaires during initial consultation with a physical therapist and again 6 weeks later (n_106). Test-retest reliability was examined for a group of 47 subjects who were classified as “unchanged” and a subgroup of 16 subjects who were self-rated as “about the same”. They concluded that the Oswestry Disability Questionnaire, the SF-36 Physical Functioning scale, and the Quebec Back Pain Disability Scale have sufficient reliability and scale width to be applied in an ambulatory clinical population with low back problems. The Waddell Disability Index has insufficient scale width for clinical utility. The Roland-Morris Disability Questionnaire and the SF-36 Role Limitations–Physical and Bodily Pain scales did not have sufficient reliability to be recommended as clinical outcome measures for individual patients.

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MATETRIALS AND METHODOLOGY

STUDY DESIGN:

Comparative study.

SETTING:

Sri Venkateshwaraa Medical College Hospital And Research Centre, Department Of Physiotherapy, Ariyur, Pondicherry-605 102

SOURCE OF DATA:

Subjects diagnosed with chronic LBA with radicular symptoms from hospitals and clinics in and around Pondicherry and referred to SVMCH&RC, Department of Physiotherapy.

METHOD OF COLLECTION OF DATA:

Male and female subjects with chronic LBP and radicular symptoms who satisfy the selection criteria.

SELECTION CRITERIA:

INCLUSION CRITERIA:

Chronic (> 3 months) low back pain. Age 30-65 years. LBP with the presence of associated lower extremity pain. Pain that had an average intensity greater than or equal to 4/10 on an 11 point

numeric pain rating scale (NPRS). Subjects who have imaging evidence of a degenerative and / or herniated

intervertebral disk at one or more levels of the lumbar spine. LBA resulting from factors such as lumbar disc bulging, facet syndrome,

spondylosis. Presence of signs of nerve root compression, centralization with extension

movement, positive crossed SLR test or reduction of symptoms by manual lumbar traction.

All subjects must have reported a lack of favorable outcomes after at least 1 previous, non-operative interventions (e.g., Joint manipulation, TENS, or oral medications) for their current symptoms.

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EXCLUSION CRITERIA:

Unstable spine (bilateral pars defect or spondylolisthesis). Spinal surgical implants, recent spinal surgery. Spinal pain due to tumor. Infection. Inflammatory diseases or metabolic diseases. Pregnancy. Osteoporosis. Formal therapeutic or medical intervention within the last three months (e.g.

epidural injection, facet joint block etc.) or the use of prescription anticoagulants, corticosteroids, or opiate-based pain medications.

Concomitant severe medical problem preventing participation in the trial (cardiac conditions, respiratory conditions, neurological disorder or organ disease).

Subjects were also excluded if there were radiographic or physical examination evidence of conditions that would represent precautions or contraindications for traction.

History of major psychiatric illness. History of trauma / fracture.

SAMPLE METHOD AND SAMPLE SIZE:

Sample method: Simple non-consecutive convienent sampling.

Sample size: 52 subjects with 26 in each group.

MATERIALS REQUIRED:

Mechanical lumbar traction unit Oswestry disability questionnaire Numeric pain rating scale

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PROCEDURE:

After fulfilling the inclusion criteria and obtained an informed consent subjects were recruited for this study. Subjects were divided into 2 groups based on patient preference and condition specific.

Group A: subjects received prone traction and extension oriented treatment approach (EOTA).

Group B: Subjects received supine lumbar traction in fowler’s position and extension oriented treatment approach (EOTA).

Figure 1: Participant flow through the study

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Admission of subjects who met the inclusion criteria and assessed for symptoms extending distal to buttocks, NPRS (≥ 4), symptom centralization with lumbar extension & orthopedic diagnosis initiallyBaseline measurement using NPRS and

ODI

Assignment of subjects into groups based on patients ability lie relax in prone or

supine position & preliminary diagnosis

Group A – Prone traction + EOTA

5 Sessions over 3 weeks

Group B – Spine traction + EOTA

5 Sessions over 3 weeks

3 week (post treatment) assessment NPRS & ODI

At baseline, subjects completed self-report measures and then received a standardized history and physical examination. Self-report measures included the ODQ and Numeric Pain Rating Scale (NPRS).

Manual lumbar traction was used to test the patient’s tolerance of traction and to find most comfortable direction in which to administer the treatment. (6)

A single movement of lumbar extension was assessed first, followed by repeated extension movements consisting of 10 repetitions performed with the subject standing. Repeated extension movements also were performed with the subject positioned prone. Centralization was judged to be present when extension movementabolished symptoms or caused symptoms to move proximally toward themidline of the lumbar spine in at least one of these positions. The interraterreliability of determining the presence of centralization using thisdefinition has been reported to be high. (21)

The electromechanical system used was cervical cum lumbar traction with molded aluminium gearbox and metal gear by technomed consisting of friction less split table for lumbar traction.

The traction force was applied for 20 min in prone / supine position to the grouped subjects respectively. The effective range of force used was 30% to 50% of body weight. The setting of traction was intermittent hold for 30 seconds, then rest for 10 seconds.

The position for traction is decided by patient comfort and the ability of the patient to remain relaxed during treatment. For subjects in prone traction, the amount of lumbar flexion was controlled by pillows under the pelvis (10° of hip flexion).

Intensity of the treatment was set initially to 30% of the weight of the subject and then increased to 40 - 50% gradually according to patient tolerance up to third week.

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Figure 2: patient in prone lumbar traction

Figure 3:Patient in fowler’s position for traction

The EOTA intervention involved two components. The goals of each component were to promote centralization of symptoms of the lumbar spine. The first component was a series of active extension-oriented exercises (table 1). These exercises consisted of sustained and repeated extension movements performed with the subject prone or standing.

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Figure 4: Prone on elbows

Figure 5: Prone press up

Table 1: Exercise progression within the extension-oriented treatment approach. (22)

Extension-Oriented Exercises Goal Options for Progression

1) Prone Lying 5 minutes May use pillow to allow lumbar flexion initially if needed

May shift pelvis laterally if needed

Progress to full lumbar extension without pillows or lateral shift of pelvis

Progress time up to 5 minutes

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2) Prone Lying on Elbows 5 minutes May use partial range of extension motion initially if needed

May shift pelvis laterally if needed

Progress to full lumbar extension with-out lateral shift of pelvis

Progress time up to 5 minutes

3) Prone Press-Ups 30repetitions

May use partial range of extension motion initially if needed

May shift pelvis laterally if needed

Progress to full lumbar extension with-out lateral shift of pelvis

Progress to exhalation during the last repetition to promote increased extension

Progress up to 30 repetitions

4) Extension in Standing 30repetitions

May use partial range of extension motion initially if needed

May shift pelvis laterally if needed

Progress to full lumbar extension with-out lateral shift of pelvis

Progress up to 30 repetitions

The exercises may be performed with a lateral component (i.e. shifting of the pelvis in the frontal plane) if this facilitates centralization. Not all exercises will be used for every subject, only those which promote centralization. Exercise progression will be accomplished by increasing the exercise time (up to 5 minutes for sustained exercises) or repetitions (up to 30 repetitions per session) motion is obtained. Subjects will be instructed to perform all assigned exercise activities once after each traction session and at home, every 8 hours throughout the day, on days when they do not have a treatment session. Subject compliance with their home exercise program will be recorded at each treatment session. The second component of the EOTA will be subject education. Subjects will be educated to maintain the natural lordosis of the lumbar spine while sitting, and will be instructed to avoid prolonged sitting. Each subject would be scheduled for 5 days/ week each for 3 weeks.

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OUTCOME MEASURES:

1) Pain intensity: 11 point NPRS (23-25)Anchor points are defined as 0 (none) and 10 (worst imaginable).

2) Oswestry Disability Questionnaire (26, 27): Back pain related activity limitation is assessed by using 10 items. Each item is measured on a 6 point scale.

STATISTICAL TOOLS:

All data analyses were done with SPSS statistical software (SPSS) and presented as mean value ± SD. For using the above said outcome measures, data were collected regarding the pretest and posttest values. The related paired “t” test was performed to find the significant changes after treatment using the formula.

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S.D. = √∑ (d−d )2

n−1

S.D. =standard deviation

d = mean value of the difference between pretest and posttest

n = no of observations

t= dS . D√n

DATA ANALYSIS AND PRESENTATION

Table 2: subject characteristics

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Characteristic Group A Group B

Age(mean±SD)(years) 43.84 45.80

Male/Female 10/16 23/3

Weight(mean±SD)(kg) 56 61

Table 3: Group A

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Table 4: Group B

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sr no.,

NPRS ODQ

Pre test

Post test

Pre test

Post test

1) 8 4 47 35.5

2) 6 3 44.4 24.4

3) 7 5 52 40

4) 5 0 24.4 17.7

5) 7 4 42.2 33.3

6) 7 4 48.8 33.3

7) 5 0 28.8 17.7

8) 7 2 62.2 37.7

9) 6 1 33.3 24.4

10) 6 1 42.2 28.8

11) 6 3 40 24.4

12) 7 3 64.4 28.8

13) 6 1 44.4 17.7

Sr. no,.

NPRS ODQ

Pre test

Post test

Pre test

Post test

14) 5 1 68.8 35.5

15) 7 4 53.3 33.3

16) 8 3 64.4 28.8

17) 6 3 52 24.4

18) 5 1 37.7 17.7

19) 7 2 40 24.4

20) 7 2 53.3 17.7

21) 8 4 57.7 28.8

22) 6 2 37.7 28.8

23) 7 2 44.4 28.8

24) 6 1 40 17.7

25) 6 2 44.4 24.4

26) 5 1 37.7 17.7

Table 4: statistical presentation of mean

Mean (x) Mean() S.D T value P value

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Sr.no.

NPRS ODQ

Pre test

Post test

Pre test

Post test

1) 5 4 51 40

2) 5 4 57.7 35.5

3) 6 5 48.8 35.5

4) 6 1 42.2 24.4

5) 7 2 53.3 35.5

6) 5 2 51.1 28.8

7) 7 2 60 40

8) 6 1 48.8 37.7

9) 7 3 71 42.2

10) 6 2 60 35.5

11) 7 4 57.7 40

12) 7 2 51.1 33.3

13) 6 2 40 35.5

Sr. no

NPRS ODQ

Pre test

Post test

Pre test

Post test

14) 6 1 37.7 24.4

15) 8 3 71.1 40

16) 6 3 52 28.8

17) 5 2 42.2 24.4

18) 6 3 33.3 17.7

19) 7 4 68.8 35.5

20) 5 3 37.7 17.7

21) 7 3 64.4 28.8

22) 6 4 53.3 33.3

23) 5 2 42.2 28.8

24) 7 3 57.7 33.3

25) 6 2 40 17.7

26) 5 3 33.3 24.4

Group A

NPRS 6.38 2.26 0.90

1.658 0.110ODQ 46.36 26.6 8.90

Group B

NPRS 6.11 2.69 8.90

3.023 0.006ODQ 51.01 31.48 7.4

Group A Group B0

1

2

3

4

5

6

7 6.38 6.11

2.262.69

NPRS

Pre testPost test

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Group A Group B0

10

20

30

40

50

60

46.3651.01

26.631.48

ODQ

Pre testPost test

RESULTS

After confirming the statistical significance between two groups, NPRS decrement (after intervention) in prone and supine groups, has no meaningful difference (P = 0.110). After confirming the statistical significance between two groups, ODQ decrement (after intervention) has meaningful difference (p = 0.05) prominent in prone group.

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DISCUSSION

This study will examine the effectiveness of adding a standardized protocol of lumbar mechanical traction to an extension-oriented treatment approach for individuals with LBP and nerve root irritation.

The study used patients who are likely to respond to the intervention on the basis of treatment-based classification subgroups with identification criteria and treatment approaches for patients with low back Pain. (28)

Traction has the advantage of being non-invasive with a relatively low risk of injury to the patient. Traction can affect metabolism of disc, facilitate the transfer of oxygen and nutrient into the disc, relieving irritation and compression on pain sensitive structures enhancing healing and repair. (29)

Synchronized heating therapy with traction has more effect on distracion of disc spaces than separately applying. Furthermore, creation of negative intradiscal pressure with this distraction is important to suck back herniated disc material in prone position. (13)

EOTA is a more effective treatment than a strengthening approach for patients with symptoms extending to the buttocks or more peripherally who demonstrate centralization with extension movements. (20) EOTA is a stage I exercise protocol for chronic LBP.

Mckenzie proposed that spinal extension pushes the nucleus pulposus anterior and away from the spinal nerve roots and other pain producing structures. (30) Although the magnitude and clinical relevance of nuclear movement with extension is Controversial. (31, 32)

As extension exercises are contraindicated in patients with spondylolisthesis hence these patients were not included in the study.

Since the study lacked a randomized control group it is difficult to imply a causal relationship between the traction applied and outcome.

CONCLUSION

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In conclusion, this is a preliminary study to investigate efficacy of prone lumbar traction in comparison with supine lumbar traction in fowler’s position in conjunction with EOTA. Mechanical lumbar traction along with EOTA in both the groups proved to be effective and showed significant improvement of ODQ in prone lumbar traction group. Further study is needed using randomized controlled comparison groups of large population and with longer study duration.

RECOMMENDATIONS

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1) Heat therapy like hot packs can be synchronized with traction application and relaxing muscular spasm in prone position that is impossible to be applied in supine position.

2) Similar studies could be attempted by other direction specific exercises like flexion and lateral shift.

3) It is recommended that more advanced traction units like vertical axial decompression (VAX –D) and other decompression therapy units may be used for better analysis however they are more expensive to administer than most conventional traction protocols.

4) It is also recommended that the third component of the EOTA that is mobilization (application of a posterior- to-anterior mobilization force directed over the spinous process, or laterally over the transverse process using a grade I - IV mobilization of the lumbar spine) based on the consideration of promoting centralization and lumbar extension range of motion may be useful in this type of study method.(22)

5) It is further recommended that to use the low back pain rating scale that was developed by manniche to address three separate dimensions of LBP, namely pain, disability and physical impairment. The measures used to evaluate physical impairment included a back extensor endurance test, a modified schober test, and a functional mobility test. (33, 34)

LIMITATIONS

1) There was lack of long time reasonable follow-up, we cannot imply a long lasting relationship between the traction and outcome, and a long time follow-up is suggested.

2) This study did not include patients whowere not expected to respond to an EOTA.

REFERENCES:

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6) H. Duane Saunders. Lumbar traction, Journal of Orthopaedic& Sports Physical Therapy, 1979

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APPENDIX - I

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NAME :

AGE :

SEX :

PATIENT NO. (OP/IP No.) :

ADDRESS :

OCCUPATION :

WEIGHT :

GROUP :

INCLUSION CRITERIAS :

GROUP INTERVENTION :

EXTENSION ORIENTED EXERCISE PROGRESSION :

OUTCOME MEASURES :

MEASUREMENT TOOLS NUMERIC PAIN RATING

SCALE

OSWESTRY DISABILITY

QUESTIONNAIRE

PRE-TEST

POST-TEST

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APPENDIX – II

36

37

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