Zahra Masood  ( Department of Physical Medicine and Rehabilitation, Combined Military Hospital, Okara, Pakistan. )
Atif Ahmed Khan  ( Department of Physical Medicine and Rehabilitation, Combined Military Hospital, Okara, Pakistan. )
Aisha Ayyub  ( Department of Chemical Pathology, Bakhtawar Amin Medical and Dental College, Multan, Pakistan. )
Rida Shakeel  ( Department of Physical Medicine and Rehabilitation, Combined Military Hospital, Okara, Pakistan. )

Introduction

 

Low back pain (LBP) is one of the most widespread disorders in society, with 80% people having back pain at some point in their lifespan.¹ Back pain is a multifactorial disorder, and in roughly 45% of the patients, it is disc- mediated in origin.² It affects 40.6% of elderly people in Pakistan.³ Discogenic LBP (DLBP) is non-radicular and appears without signs of neural strain, instability and spinal malformation.⁴ Degenerative changes initiate inflammatory repair mechanisms which sensitise nociceptors in the disc and lead to DLBP. In combination, mechanical and neural elements add to DLBP.^2,5 Risk factors for DLBP are obesity, smoking, frequent weight-lifting, psychological distress and postural stress.⁶ LBP negatively affects the performance of tasks in daily life, in employment days and output.⁷ LBP influences the quality of life (QOL), causes insomnia and functional disabilities.^8,9

In clinical practice, in addition to the pharmacological option, multiple non-pharmacological options are available, including paraspinal strengthening and stretching exercises, manipulation, lumbar traction, epidural injection and electrotherapy.¹⁰ DLBP may react positively to traction therapy. Lumbar traction (LT) can cause the distraction of facet joints and vertebral bodies, widening of inter-vertebral foramen and straightening and stretching of spinal curvature and spinal muscles respectively. LT can be applied in intermittent or sustained mode. Intermittent LT includes a mechanical device with traction applied and withdrawn alternatively every few seconds.¹¹

Some studies have shown that high-force LT (HFLT) was more effective compared to low-force LT (LFLT) in LBP management.¹² In contrast, some studies showed no significant difference between the two different forces in LBP with or without sciatica.¹³

A lot of studies have been conducted on LBP in Pakistan,^9,14,15 but limited work has been done on LT. The current study was planned to see LT effect on DLBP using variable forces.

 

Patients and Methods

 

The experimental study was conducted at the Department of Physical Medicine and Rehabilitation at the Combined Military Hospital, Okara, Pakistan, from July to December 2018. After approval from the institutional ethics review committee, the sample size was calculated using 95% confidence level and 5% confidence interval on basis of a previous study.¹⁶ The sample was raised using non-purposive consecutive sampling technique. Those included were LBP of either gender aged 25-50 years having history of non-traumatic pain at lumbar region for >6 weeks who had never been treated with LT. Patients with history of lumbar surgery, recent epidural injection for LBP <2 weeks, those who had rheumatoid arthritis, tumour, previous fracture in thoracic, pelvic, groin and lumbar regions, respiratory disorder, cardiovascular disorder, inguinal hernia, osteoporosis, local acute infection, spondylolysis, spondylolisthesis, pelvic pain, inflammatory disease, spondyloarthropathies and pregnancy were excluded. Data was collected after taking informed consent from all the patients.

Demographic characteristics were noted using a performa. Body mass index (BMI) was also calculated; those having BMI <18.5 kgm2 were considered underweight, BMI in between 18.5-22.9 kgm2 as normal weight, 23-24.9 kgm2 as overweight, >25kgm2 as obese.¹⁷ The patients were randomised using the lottery method into group 1 treated with HFLT, hot pack and lumbar stabilisation exercises, and group 2 treated with LFLT, hot pack and lumbar stabilisation exercises. Both the groups underwent 3 sessions per week for 3 weeks for a total of 9 sessions which were conducted by trained and qualified physiotherapists. During each session patients in both groups were given 15 minutes of heat therapy with hydro collator pack in the lumbar region, followed by lumbar stabilisation exercises, and intermittent HFLT and LFLT depending upon the group.

A digital traction unit (Auto Trac 460) was used. LT was applied in supine position by two-canvas saddles; one at the region of the lower ribcage and the other at iliac crest. In group 1, traction force was approximately 44% of bodyweight (hold: 20 sec and rest: 5 sec) for 10 minute. In group 2, the traction force was 19% of bodyweight (hold: 20 sec and rest: 5 sec) for 10 minute. The force was increased by 1kg after every three sessions and the traction time was increased by 1 minute for each session so that in session 9 it amounted to 19 minutes.

Pain was measured using the visual analogue scale (VAS)¹⁸ and the Modified Oswestry Disability Index (m-ODI) questionnaire¹⁹ was filled up under supervision by the patients at baseline and at the end of session 9. Data was analysed using SPSS 20. Paired and independent t tests were used as appropriate. P<0.05 was considered significant.

 

Result

 

Of the 30 patients, there were 15(50%) in each of the two groups. There were 18(60%) females and 12(40%) males, with an overall mean age of 30±5.5 years. Of the total, 18(60%) patients were obese(Table 1).

 

 

Intra-group comparison showed no significant difference at baseline (p>0.05). With respect to m-ODI score, group 1 showed significant improvement compared to group 2 (Table 2).

 

 

Also, there was significant improvement in both pain and disability in both the groups (Table 3).

 

 

 

Young age was significantly associated with better results (p<0.05) (Table 4).Pain and disability values for those having normal weights showed significantly more improvement as compared to overweight and obese subjects.(Table 4).

 

 

 

Discussion

 

The current study showed that LBP prevalence was higher among the females and this was consistent with a systematic review.¹⁶ Previous studies had demonstrated association between obesity and LBP.^20,21 The current results were consistent with such findings.

The age group with the highest prevalence in the current study was 25-37 years, while a previous study reported it to be 21-40 years.²² Another study, however, showed  the  most affected to be aged 56-64 years.²³

The finding that LT had positive effect on pain and disability for LBW patients and that the addition of hot pack further relieved pain and improved functional status was supported by a randomised control trial.²⁴ The intra-group results showed that HFLT was more effective in reducing disability compared to LFLT, because high force is required to separate the vertebras.²⁵

Pain improvement occurred in both the groups, which is line with a study.²⁶ Another study conducted showed that most of the physiotherapists used traction at high force of 30-50% of the bodyweight to get beneficial effects which was consistent with the present study.¹² Another  study’s  outcome measures showed that therapeutic traction and sham traction showed the same improvement for non-specific LBP as the cause of the pain was unknown.²⁷

In the current study, lumbar stabilisation exercises were used along with traction in line with a study which showed that pain and disability improved with lumbar stabilisation exercises.²⁸

In terms of limitations, the results of the current study cannot be generalised because of a small sample size and the lack of long-term follow-up. Further studies taking into consideration these limitations are recommended.

 

Conclusion

 

Use of variable force lumbar traction improved pain in DLBP, while HFLT also reduced the functional disability score.

 

Disclaimer: None.

Conflict of interest: None.

Source of Funding: None.

 

References

 

1.       Lehmann TR, Russell DW, Spratt KF, Colby H, Liu YK, Fairchild ML, et al. Efficacy of electroacupuncture and TENS in the rehabilitation of chronic low back pain patients. Pain 1986; 26: 277-90.

2.       Kallewaard JW, Terheggen MA, Groen GJ, Sluijter ME, Derby R, Kapural L, et al. 15. Discogenic low back pain. Pain Practice 2010; 10: 560-79.

3.       Bishwajit G, Tang S, Yaya S, Feng Z. Participation in physical activity and back pain among an elderly population in South Asia. J Pain Res 2017; 10: 905-13.

4.       Peng B, Wu W, Hou S, Li P, Zhang C, Yang Y. The pathogenesis of discogenic low back pain.  J Bone Joint Surg Br 2005; 87: 62-7.

5.       Saal JS, Saal JA. Management of chronic discogenic low back pain with a thermal intradiscal catheter: A preliminary report. Spine (Phila Pa 1976) 2000; 25: 382-8.

6.       Heliövaara M. Risk factors for low back pain and sciatica. Ann Med 1989; 21: 257-64.

7.       Hong  JH, Kim HD, Shin HH, Huh B. Assessment of depression, anxiety, sleep disturbance, and quality of life in patients with chronic low back pain in Korea. Korean J Anesthesiol 2014; 66: 444-50.

8.       Kose G, Hatipoglu S. The effect of low back pain on the daily activities of patients with lumbar disc herniation: a Turkish military hospital experience. J Neurosci Nurs 2012; 44: 98-104.

9.       Bahouq H, Allali F, Rkain H, Hmamouchi I, Hajjaj-Hassouni N. Prevalence and severity of insomnia in chronic low back pain patients. Rheumatol Int 2013; 33:1277-81.

10.     Shipton EA. Physical Therapy Approaches in the Treatment of Low Back Pain. Pain Ther 2018;7:127-37.

11.     Saunders HD. Lumbar traction.* J Orthop Sports Phys Ther 1979; 1: 36-45.

12.     Madson TJ, Hollman JH. Lumbar traction for managing low back pain: A survey of physical therapists in the United States. J Orthop Sports Phys Ther 2015; 45: 586-95.

13.     Krause M, Refshauge KM, Dessen M, Boland R. Lumbar spine traction: evaluation of effects and recommended application for treatment. Man Ther 2000; 5: 72-81.

14.     Tauqeer S, Amjad F, Ahmed A, Gillani SA. PREVALENCE OF LOW BACK PAIN AMONG BANKERS OF LAHORE, PAKISTAN. Khyber Med Uni J 2018; 10: 101-4.

15.     Sagheer MA, Khan MF, Sharif S. Association between chronic low back pain, anxiety and depression in patients at a tertiary care centre. J Pak Med Assoc 2013; 63: 688-90.

16.     Isner-HorobetiME, Dufour SP, Schaeffer M, Sauleau E, Vautravers P, Lecocq J, et al. High-Force Versus Low-Force Lumbar Traction in Acute Lumbar Sciatica Due to Disc Herniation: A Preliminary Randomized Trial. J Manipulative Physiol Ther 2016; 39: 645-54.

17.     WHO Expert Consultation.Asian populations and its implications for policy and intervention strategies. Available at: 0957708211_eng.pdf - WHO | World Health Organization cited on 20. Jan. 2022.

18.     Beurskens AJ, de Vet HC, Köke AJ, Lindeman E, Regtop W, van der Heijden GJ, et al. Efficacy of traction for non-specific low back pain: a randomised clinical trial. Lancet 1995; 346: 1596-600.

19.     Moon HJ, Choi KH, Kim DH, Kim HJ, Cho YK, Lee KH, et al. Effect of lumbar stabilization and dynamic lumbar strengthening exercises in patients with chronic low back pain. Ann Rehabil Med 2013; 37: 110-7.

20.  Shafshak TS, Elnemr R. The Visual Analogue Scale Versus Numerical Rating Scale in Measuring Pain Severity and Predicting Disability in Low Back Pain. J Clin Rheumatol 2020;  27: 282-5.

21.  Isner-Horobeti ME, Dufour SP, Schaeffer M, Sauleau E, Vautravers P, Lecocq J, et al.  High-Force Versus Low-Force Lumbar Traction in Acute Lumbar Sciatica Due to Disc Herniation: A Preliminary Randomized Trial. J Manipulative Physiol Ther 2016; 39: 645-54.

22.     Yang H, Haldeman S. Behavior-Related Factors Associated With Low Back Pain in the US Adult Population. Spine (Phalia Pa 1976) 2018; 43: 28-34.

23.  Fairbank JC, Pynsent PB.  The Oswestry Disability Index.  Spine (Phila Pa 1976) 2000; 15: 2940-52.

24.     Zhang TT, Liu Z, Liu YL, Zhao JJ, Liu DW, Tian QB. Obesity as a Risk Factor for Low Back Pain: A Meta-Analysis. Clin Spine Surg 2018; 31: 22-7.

25.     Peng T, Pérez A, Gabriel K. The Association AmongOverweight, Obesity, and Low Back Pain in U.S.Adults: ACross-Sectional Study of the 2015 National Health Interview Survey. J Manipulative Physiol Ther 2018; 41: 294-303.

26.     Zafar F, Qasim YF, Farooq MU, Shamael I, Khan IU, Khan DH. The Frequency of Different Risk Factors for Lower Back Pain in a Tertiary Care Hospital. Cureus 2018; 10: e3183.

27.     Bilgilisoy Filiz M, Kiliç Z, Uçkun A, Çakir T, Koldaş Doğan Ş, Toraman NF. Mechanical Traction for Lumbar Radicular Pain: Supine or Prone? A Randomized Controlled Trial. Am J Phys Med Rehabil 2018; 97: 433- 9.

28.     Van der Heijden G, Beurskens A, Dirx M, Bouter L, Lindeman E. Efficacy of lumbar traction: a randomised clinical trial. Physiotherapy 1995; 81: 29-35.