On last week’s ‘We Can Do Better’ blog series, I discussed the lack of evidence to support VMO isolation. This week I’ll be discussing lumbar traction.
I don’t like lumbar traction. I’ve seen several physical therapists utilize it as a mainstay treatment with anyone who has radicular symptoms affected the lower extremities. Sometimes even after patients have reported negative effects following 2-3 trials of it.
Based on my own opinions, and allusions to other bodies of research, I don’t like lumbar traction because:
- It’s a passive modality. Generally, movement and exercise (any kind of exercise) are helpful in the treatment of LBP. Why treat a patient with a passive modality if active interventions, which can positively influence other areas of a patient’s life, generally yield superior results?
- It promotes patient dependence. I believe promoting patient’s self-efficacy and an internal locus of control (belief that the patient can influence their own outcomes) should be a fundamental component of any rehab or exercise program.
- Negative side-effects are common. Anecdotally, I have seen lots of reports of increased stiffness, increased radicular symptoms, unsteadiness, etc following lumbar traction.
Additionally, I wanted to focus on one specific randomized control trial and a semi-recent Cochrane review (basically a big review of multiple randomized control trials) to further substantiate why I believe lumbar mechanical traction is an unwise choice in the treatment of individuals with low back pain and/or radicular symptoms
This Cochrane review, which was published in 2013, included 32 randomized control trials which consisted of over 2700 participants (Wegner, 2013)
The authors concluded that: “These findings indicate that traction, either alone or in combination with other treatments, has little or no impact on pain intensity, functional status, global improvement and return to work among people with LBP. There is only limited-quality evidence from studies with small sample sizes and moderate to high risk of bias. The effects shown by these studies are small and are not clinically relevant.”
2016 Randomized Control Trial
This RCT sought to distinguish outcomes between an extension-based exercise group and an extension-based exercise group combined with mechanical lumbar traction. (Thackeray, 2016)
I’ve provided a screen shot of the abstract below.
In this RCT, it was concluded that:
- Of 120 patients randomized to receive either extension-based exercises or extension-based exercises in combination with lumbar traction, there were no differences in disability or pain outcomes at 6-weeks, 6-months, or 12-months.
- Matching participants to previously established guidelines (Fritz, 2008) for those who would benefit from lumbar traction (peripheralization of symptoms when moving into lumbar extension and a + crossed SLR) did not result in any greater improvement in pain or disability.
- Negative side-effects of treatment affected 35 individuals receiving traction but only 25 of those receiving extension-based exercises only
- Those in the group receiving lumbar traction and extension-based exercises also reported a greater proportion of negative side-effects that lasted over 24 hours and/or was rated as severe.
Based on the evidence from the 2013 Cochrane review and 2016 RCT, along with my own clinical experience, I do not find lumbar traction a viable option for the treatment of LBP with or without radicular symptoms.
There may be instances where lumbar traction could potentially be performed. The author of the 2016 RCT, Anne Thackeray, also wrote a Perspective for Practice piece, where certain scenarios were described where lumbar traction may be useful.
However, I do not believe traction should simply be used based on the invalidated clinical prediction rule of peripheralization with lumbar extension and a + crossed SLR. Nor should lumbar traction be used indefinitely, as a primary focus, or if any negative side-effects occur from it.
Disagree? I’d love to hear your perspective.
Wegner, I., Widyahening, I. S., van Tulder, M. W., Blomberg, S. E., de Vet, H. C., Brønfort, G., … & van der Heijden, G. J. (2013). Traction for low‐back pain with or without sciatica. The Cochrane Library.
Fritz, J., Lindsay, W., Matheson, J. W., Brennan, G., Hunter, S., Moffit, S., … & Rodriquez, B. (2007). Is there a subgroup of patients with low back pain likely to benefit from mechanical traction. Spine, 32(26), E793-E800.
Thackeray, A., Fritz, J. M., Childs, J. D., & Brennan, G. P. (2016). The effectiveness of mechanical traction among subgroups of patients with low back pain and leg pain: a randomized trial. journal of orthopaedic & sports physical therapy, 46(3), 144-154.