The efficacy of lumbar traction in the management of patients with low back pain. A controlled trial of continuous lumbar traction in the treatment of back pain and sciatica. Auto-traction for treatment of lumbago-sciatica. A multicentre controlled investigation. [Treatment of lumbar sciatica with or without neurological deficit using mechanical traction. A double-blind study]. Lumbar traction: a double-blind controlled study for sciatica. Autotraction versus manual traction in patients with prolapsed lumbar intervertebral discs. The efficacy of traction for lumbar back pain: design of a randomized clinical trial. Cervical spine disorders. A comparison of three types of traction. Efficacy of transcutaneous electrical nerve stimulation (tens) for chronic low-back pain in a multiple sclerosis population: a randomized, placebo-controlled clinical trial. Back pain and sciatica: controlled trials of manipulation, traction, sclerosant and epidural injections. Stabilizing training compared with manual treatment in sub-acute and chronic low-back pain. Long-term effects of specific stabilizing exercises for first-episode low back pain. Conservative treatment in patients sick-listed for acute low-back pain: a prospective randomised study with 12 months' follow-up. Physiotherapy-based rehabilitation following disc herniation operation: results of a randomized clinical trial. Physical performance, pain, pain behavior and subjective disability in patients with subacute low back pain.
The literature on the efficacy of traction in the treatment of low back pain (LBP) is conflicting. The aim of this study was to examine its efficacy in this disorder. Forty-two patients with at least 6 weeks of nonspecific LBP were selected. Demographic data were obtained. All patients completed the Oswestry disability index (ODI) to assess disability and the 10-cm visual analog scale (VAS) for evaluation of pain. Subjects were randomly assigned into group 1, receiving only standard physical therapy, or group 2, receiving standard physical therapy with conventional lumbar traction. Standard physical therapy consisted of local heat, ultrasound for the lumbar region, and an active exercise program, given for ten sessions in all. The subjects received instruction on correct posture and recommended therapeutic exercises. They were reevaluated at the end of treatment and at 3-month follow-up. The mean outcome measures were global improvement and satisfaction with the therapy, as well as disability by ODI and pain by VAS. There were no group differences in terms of demographic and baseline clinical characteristics. There was a significant reduction in pain intensity and disability at the end of treatment in both groups. There was complete or mild improvement in 47.6% of group 1 and 40% of group 2. The satisfaction rate with both treatments was more than 70% immediately after the therapies. During the 3-month period, the outcome measures except disability remained statistically stable, with no difference amongst groups. Disability was significantly reduced at follow-up in both groups. Of the patients, 51% continued with the recommended exercises and had significantly lower disability scores than those who did not continue with the exercises. Pain and global improvement were also better in this group, but the difference was not statistically significant. In conclusion, no specific effect of traction on standard physical therapy was observed in our study group. We suggest focusing on back education and exercise therapy in the management of patients suffering from this chronic condition. A controlled trial of continuous lumbar traction in the treatment of back pain and sciatica showed similar improvements in both the treated group (weighted traction) and the control group (simulated traction). The findings of this study question the justification of admitting patients with back pain into hospitals for purposes of traction alone. In this controlled prospective study of the Auto-traction method for the treatment of lumbago-sciatica, 82 patients were randomly allocated to either treatment with Auto-traction for up to three 1-hour sessions in 1 week, or they were given a corset and advised to rest. The orthopaedic surgeons participating in the study worked at six different hospitals and all had limited experience of the Auto-traction method obtained during a 1-week course. All patients were clinically evaluated by an independent observer who also performed the follow-up examinations 1 and 3 weeks after the treatment sessions. In addition a 3-month follow-up was performed by letter. The Auto-traction method gave prompt relief of pain and a normalizing of the SLR test more often than treatment with only a corset and rest. The difference between the two treatment groups was statistically significant. The immediate difference noted between the treatment groups had decreased slightly at 3 weeks but was still statistically significant at this time. Traction therapy for low back pain with sciatica has been evaluated in a double blind study. 60 patients hospitalized for sciatica with or without signs of sensory or motor deficiency were randomized to 3 treatment groups: "placebo traction" (5 kg), "light traction" (15 kg) and "normal traction" (50 kg). Clinical evaluation after 4, 8 and 12 traction sessions showed no difference between the three groups. A double-blind control study of lumbar traction for sciatica has been carried out. Although there is a tendency for traction to produce improvement in pain and straight-leg raise the extent does not achieve statistical significance. Changing 'control' patients to 'treatment' seemed to produce worthwhile relief of pain for all who were not already improving. It is suggested that a large trial using more discriminating criteria might delineate a group of patients susceptible to help by traction. Forty-nine patients with lumbago-sciatica and prolapsed lumbar intervertebral discs, comparable concerning anamnestical and clinical data were randomized for autotraction and manual traction given by the same therapist for a period of one week while strict bed rest was prescribed. A blind overall assessment performed immediately after the traction period, after two weeks follow-up training and three months after hospitalization showed that the two traction modalities are equally efficient. As treatment for hospitalized patients with lumbar intervertebral disc prolapses the relatively simple manual traction variety should be preferred, if any. Traction is suggested to be used as a prognostical aid. Pain intensity was significantly reduced in all body parts. About one fourth of patients avoided operation. After two years there was no recurrence of symptoms. To present the design of a trial on the efficacy of lumbar traction.
                Randomized clinical trial.
                Patients with a minimum of 6 wk, nonspecific low back pain.
                High-dose, motorized, continuous traction with a force between 35% and 50% of the total body weight was compared with sham or low-dose traction with a force between 0 and 20% of body weight. The sham traction was given with a specially developed brace that becomes tighter in the back during traction. This is experienced by patients as if traction were exerted.
                Primary measures were the patient's global impression of the effect and the severity of three main complaints. Secondary effect measures were functional status, pain, range of motion, work absence and recurrences. The effect measures were rated before randomization and 4 wk, 12 wk and 6 months later.
                There have been a number of earlier trials on the efficacy of lumbar traction; they suffer, however, from severe methodological flaws. This trial aimed to avoid these shortcomings. A randomized clinical trial was conducted to evaluate the efficacy of three commonly employed forms of traction in the treatment of cervical spine disorders. One hundred consenting men and women with disorders of the cervical spine were randomly assigned to one of four treatment groups, static traction, intermittent traction, manual traction, or no traction. All patients, regardless of group assignment, were seen twice weekly. The four groups were shown to be similar with regard to age, sex, diagnosis, chronicity, and prescores on the seven outcome measures. Although the entire cohort of neck patients, regardless of group assignment, improved significantly on all the outcome variables over the 6-week period, patients receiving intermittent traction performed significantly better than those assigned to the no traction group in terms of pain (P = 0.03), forward flexion (P = 0.01), right rotation (P = 0.004) and left rotation (P = 0.05). This study was designed to investigate the hypoalgesic effects of self-applied transcutaneous electrical nerve stimulation (TENS) on chronic low-back pain (LBP) in a multiple sclerosis (MS) population.
                Ninety participants with probable or definite MS (aged 21 to 78 y) presenting with chronic LBP were recruited and randomized into 3 groups (n=30 per group): (1) low-frequency TENS group (4 Hz, 200 micros); (2) high-frequency TENS group (110 Hz, 200 micros); and (3) placebo TENS. Participants self-applied TENS for 45 minutes, a minimum of twice daily, for 6 weeks. Outcome measures were recorded at weeks 1, 6, 10, and 32. Primary outcome measures included: Visual Analog Scale for average LBP and the McGill Pain Questionnaire. Secondary outcome measures included: Visual Analog Scale for worst and weekly LBP, back and leg spasm; Roland Morris Disability Questionnaire; Barthel Index; Rivermead Mobility Index; Multiple Sclerosis Quality of Life-54 Instrument, and a daily logbook. Data were analyzed blind using parametric and nonparametric tests, as appropriate.
                Results indicated a statistically significant interactive effect between groups for average LBP (P=0.008); 1-way analysis of covariance did not show any significant effects at any time point once a Bonferonni correction was applied (P>0.05). However, clinically important differences were observed in some of the outcome measures in both active treatment groups during the treatment and follow-up periods.
                Although not statistically significant, the observed effects may have implications for the clinical prescription and the use of TENS within this population. Four treatment regimens for patients with specified combinations of low back pain and sciatica were evaluated. The largest group studied had low back pain with limited straight-leg raising (SLR) and in them the beneficial effect of manipulation in hastening pain relief was highly significant. In similar patients without limitation of SLR, the effect was of borderline significance. In all the other groups, treated patients also recovered more quickly than their controls. Traction, for patients with low back pain and sciatica, and epidural injections when a root palsy was present also produced some significant pain relief. The effect of sclerosants for back pain was less clear. The present aim was to compare the effects of stabilizing training with those of manual treatment in patients with sub-acute or chronic low-back pain (LBP). Forty-seven patients were randomized to a stabilizing training group (ST group) or a manual treatment group (MT group). The patients underwent a 6-week treatment programme on a weekly basis. Pain, health and functional disability level at the start of treatment, after treatment, and at 3- and 12-month follow-ups were assessed. In the ST group all assessed variables improved significantly (P<0.05) after the treatment period and were maintained long term. After the treatment period there was a significant difference between the groups in assessed function (P<0.05). More individuals in the ST group had improved than in the MT group. At the 3-month follow-up significantly more improved individuals were evident in the ST group regarding pain, general health and functional disability levels. In the long term, significantly more (P<0.05) patients in the MT group reported recurrent treatment periods. The study did not indicate any clear short-term differences between the groups in the accessed outcome measures. In the long term, however, stabilizing training seemed to be more effective than manual treatment in terms of improvement of individuals and the reduced need for recurrent treatment periods. A randomized clinical trial with 1-year and 3-year telephone questionnaire follow-ups.
                To report a specific exercise intervention's long-term effects on recurrence rates in acute, first-episode low back pain patients.
                The pain and disability associated with an initial episode of acute low back pain (LBP) is known to resolve spontaneously in the short-term in the majority of cases. However, the recurrence rate is high, and recurrent disabling episodes remain one of the most costly problems in LBP. A deficit in the multifidus muscle has been identified in acute LBP patients, and does not resolve spontaneously on resolution of painful symptoms and resumption of normal activity. Any relation between this deficit and recurrence rate was investigated in the long-term.
                Thirty-nine patients with acute, first-episode LBP were medically managed and randomly allocated to either a control group or specific exercise group. Medical management included advice and use of medications. Intervention consisted of exercises aimed at rehabilitating the multifidus in cocontraction with the transversus abdominis muscle. One year and three years after treatment, telephone questionnaires were conducted with patients.
                Questionnaire results revealed that patients from the specific exercise group experienced fewer recurrences of LBP than patients from the control group. One year after treatment, specific exercise group recurrence was 30%, and control group recurrence was 84% (P < 0.001). Two to three years after treatment, specific exercise group recurrence was 35%, and control group recurrence was 75% (P < 0.01).
                Long-term results suggest that specific exercise therapy in addition to medical management and resumption of normal activity may be more effective in reducing low back pain recurrences than medical management and normal activity alone. We evaluated three different conservative treatment methods for acute low-back pain patients in groups following a manual therapy programme, an intensive training programme, or a general practitioner programme, the latter serving as the control group. Patients aged 19-64 years on sick leave for low-back pain with or without sciatica were included in a prospective randomised study evaluating outcomes such as impairment, pain, functional disability, socio-economic disability and satisfaction with the treatment or explanations. Evaluation by unbiased observers was performed at 1, 3 and 12 months. The three treatment groups were comparable at baseline. With regard to satisfaction, the patients in the manual therapy programme and those in the intensive training programme were more satisfied with the treatment than those in the general practitioner programme at all follow-ups. With regard to the explanations of current low-back pain episodes, the patients in the manual therapy programme were more satisfied than those in the general practitioner programme at all follow-ups. The manual therapy programme group were also more satisfied with the explanations than those in the intensive training programme at the 1-month follow-up. However, no differences were revealed between the groups with respect to outcomes on measures of impairment, pain, functional disability or socioeconomic disability. All three study groups showed rapid improvement. After 1 month a significant improvement was noted in all outcome values compared with the values on entry to the study. Within the limitations discussed in our study, it is concluded that (1) patients sick listed with acute low-back pain, with or without sciatica, will be significantly improved after 1 month regardless of conservative treatment programme; (2) they will be more satisfied with the treatment if they are referred to a manual treatment programme or a training treatment programme; (3) they will be more satisfied with the explanations of the acute low-back problem if they are referred to one of the above groups, especially the manual treatment group; (4) they will not show any other differences with respect to subjective and objective variables, either at short-term or at long-term follow-ups. Three-group, randomized, single blinded, controlled trial.
                To test the effectiveness of physiotherapy-based rehabilitation starting 1 week after lumbar disc surgery. In addition, we tried to estimate the contribution of specific effects to the observed outcome (efficacy).
                Physiotherapy-based rehabilitation is usually recommended for patients following lumbar disc surgery. Few and conflicting data exist for the relative effectiveness of this intervention.
                A total of 120 patients following first-time, uncomplicated lumbar disc surgery were randomly assigned to "comprehensive" physiotherapy, "sham" neck massage, or no therapy. Before enrollment, all subjects completed a minimal physiotherapeutic intervention. Physiotherapy was administered by experienced physiotherapists and consisted of 20 sessions per patient over 12 weeks. Masseurs administered "sham massage" to the neck. The amount of treatment time was equal to that of physiotherapy. The main outcome measure was the Low Back Pain Rating Score (LBPRS) at 6 and 12 weeks, and 1.5 years after randomization. Secondary parameters were patients' overall satisfaction with treatment outcome and socioeconomic and psychologic measures.
                At the end of therapy (12 weeks), the LBPRS revealed a significantly better improvement in the physiotherapy group than in the untreated group. LBPRS outcome, however, did not significantly differ between physiotherapy and "sham" therapy. There was a tendency toward significance between the sham therapy and no therapy. Within the 1.5-year follow-up, LBP rating scales remained significantly improved compared with baseline, but there were no significant outcome differences. No statistically significant between-group differences were found for the secondary outcome parameters.
                As compared with no therapy, physiotherapy following first-time disc herniation operation is effective in the short-term. Because of the limited benefits of physiotherapy relative to "sham" therapy, it is open to question whether this treatment acts primarily physiologically in patients following first-time lumbar disc surgery, but psychological factors may contribute substantially to the benefits observed. The aim of this paper was to study the physical performance, pain, pain behavior and disability in patients with subacute low back pain (LBP). The patients were blue-collar workers and had been sick-listed for 8 weeks due to subacute low back pain. A total of 103 patients were randomized, 51 of them to the intervention group and the other to a control group. Recordings of physical performance and complaints of LBP were done before and after treatment in the intervention group. The proportion of patients with no complaints of LBP was significantly greater in the intervention group than in the control group at the one-year follow-up. The patients who intra-individually improved their physical performance also intra-individually decreased their complaints of LBP. The intra-individual improvements were suggested to be important for the individual return to work.
Implications for practice
The results of the available studies involving mixed groups of acute, sub-acute and chronic patients with LBP with and without sciatica were quite consistent, indicating that continuous or intermittent traction as a single treatment for LBP is not likely effective for this group. Traction for patients with sciatica cannot be judged effective at present either, due to inconsistent results and methodological problems in most studies. We conclude that traction as a single treatment for LBP is probably not effective. 

Implications for research
Any future research on traction for patients with LBP should distinguish between symptom pattern and duration, and should be carried out according to the highest methodological standards.