1. Introduction. Keywords: Traction, prone position, low back pain, distraction, heating

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1 Journal of Back and Musculoskeletal Rehabilitation 20 (2007) IOS Press Effect of new traction technique of prone position on distraction of lumbar vertebrae and its relation with different application of heating therapy in low back pain Remzi Cevik a,, Aslan Bilici b, Ali Gur a, Aysegül Jale Sarac a, Hidir Yildiz b, Kemal Nas a, Adnan Ceviz c and Yasar Bukte b a Department of Physical Medicine and Rehabilitation, University of Dicle, Faculty of Medicine, Diyarbakir, Turkey b Department Radiology, University of Dicle, Faculty of Medicine, Diyarbakir, Turkey c Department of Neurosurgery, University of Dicle, Faculty of Medicine, Diyarbakir, Turkey Abstract. Objective: In medicine, traction is used for act of pulling force for producing distraction or separation between two or more parts of body. However, it is limited to the cervical or lumbar spine in physiotherapic application. We aimed to investigate effect of new traction technique on anatomic structures of lumbar vertebrae, and its relation to different application of heating therapy. Method: Ninety five consecutive patients with persistent low back pain participated in this study. Traction applied on 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. Results: Significant distraction in each disc space; decreasing in both lumbosacral angles and increasing in L1-S1 total distance were found with lying on new table without traction in three groups. Significant widening of all disc spaces and L1-S1 total distances were also obtained during traction in group I, while there were significant widening in L1-L2 anterior, L3-L4 anterior and posterior, L5-S1 posterior disc spaces, and L1-S1 anterior and posterior total distances during traction in group II and in posterior disc space of L5-S1 during sham traction in group III as compared to lying on table without traction. Conclusion: This is a preliminary study to investigate efficacy of new traction technique in prone position. Significant increasing in lumbar intervertebral disc spaces and changes in other anatomic structures were obtained on new table. Efficacy of traction application seemed to be increased by synchronized heating therapy. Creation of negative intradiscal pressure is important to suck back herniated disc material with distraction of lumbar vertebrae in prone position. Future clinical studies should be carried out to investigate efficacy of this traction technique in treatment of low back pain. Keywords: Traction, prone position, low back pain, distraction, heating 1. Introduction Address for correspondence: Remzi Cevik, MD, Physical Medicine and Rehabilitation, Dicle University School of Medicine, Diyarbakir, Turkey. Tel.: ; Fax: ; ftremzi@dicle.edu.tr. Traction is used for act of pulling force for producing distraction or separation between two or more parts of body. However, it is limited to the cervical or lumbar spine in physiotherapic application. Traction is most commonly used for normalization neurological deficits ISSN /07/$ IOS Press and the authors. All rights reserved

2 72 R. Cevik et al. / Lumbar distraction of new traction or painfully restricted neuromeningeal tension sign, the relief of the pain and for improving joint mobility [13]. Although traction is widely used for the treatment of lumbar spine [23], efficacy and application method of it remain unresolved [13]. Vertebral separation and widening of intervertebral foramen are supposed to be mechanical effects of traction [4,17,21]. Part of the applied traction force is needed to overcome opposing forces, namely friction of the body on table-top, muscle contraction, spinal curvatures (e.g. flattening lumbar lordosis), ligamentous resistance and friction of the machinery [11,12,16]. Lumbar interverteral separation has been demonstrated when isolated lumbar spine specimens are subjected to sustained traction loads. Most intervertebral separation occurred when the specimens positioned to flatten the lordosis, a position that simulates the typical traction position when the hips are flexed to approximately 90 to place the legs on stool [14,22]. Despite the lack of conclusive information on both lumbar traction efficacy and application method, there exist to be different traction tables. Supine position is, though, more commonly employed method in practice, application of prone position is also seen to be used to a lesser extent. Flattening of lumbar lordosis can well be achieved when hips are flexed to approximately 90 with the legs on stool, whilst this flattening may be of problem when in prone position. A traction table which is suitable for hips and knees to be flexed to approximately 90 in prone position was, therefore, developed. Paravertebral muscle contraction is important condition that needed to be relaxed for better traction efficacy [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. The primary aim of this study is to investigate the effect of new developed lumbar traction table on intervertebral disc spaces and other anatomic structures of lumbar vertebral column and relationship with different heating application. 2. Material and methods We investigated effect of new traction technique on the distraction of lumbar vertebrae and other structures of lumbar column by using this technique with and without pulling as synchronized with heating and after heating therapy. All patients were pulled one time on new traction table, and their lateral lumbosacral radiographs were obtained before and during traction. All patients gave informed consent for participating. Patients who had suffered for at least six weeks from persistent low back pain resulting from factors such as lumbar disc bulging, disc degeneration, facet syndrome, mild spodylosis, segmental instability and nonspecific causes, were participated in this study. Patients, who were at least 18 years old, were recruited from outpatient clinic of the physical medicine and rehabilitation department of Dicle University Hospital in Diyarbakir. 114 consecutive patients were seen by Physical Medicine and Rehabilitation specialist and 19 of them were excluded. The reason for the exclusion was mainly due to patients have pain for less than six weeks, inflammatory, infectious, malign or metabolic disease of spine, those with trauma/fracture, severe degenerative changes, osteoporosis, spinal operations, neurological defects, serious cardiopulmonary, vascular or other internal medical conditions and no consent of participating. Ninety five patients (55 men and 40 women) gave consent and were assigned to three traction groups. Synchronized heating applied with traction in group I that composed of 32 patients were pulled by new traction, and group III that composed of 31 patients were pulled by sham traction. Group II, composed of 32 patients and pulled by new traction after heating. Group I was composed of 20 men and 12 women. They were a mean of ± 7.51 years of age, weighted ± kg and heighted 1.68 ± 0.09 m. Group II was composed of 18 men and 14 women. They were a mean of ± 9.82 years of age, weighted ± kg and heighted 1.69 ± 0.09 m. Group III was composed of 17 men and 14 women. They were a mean of ± 8.97 years of age, weighted ± kg and heighted 1.68 ± 9.10 m (Table 1). There are this type of studies carried out and published which combine men and women [19,21]. Traction was applied on newly developed table that the patient lies down in prone position. The table was composed of two moveable parts; the first part consists of two split elements which serves for upper body, while the second part provides hips and knees with flexed position for lower body (Fig. 1). For the sake of comfort of the patient, a mobile rest to support the patient s head and a couple of hand-grip were provided on the first part of the device. Furthermore, two couples of attachable and removable side packs were added to split parts to support upper body for comfortable traction. Wheels were also fixed to the table to carry the patient to bed after traction (Fig. 2).

3 R. Cevik et al. / Lumbar distraction of new traction 73 Table 1 Baseline values of study groups Group I Group II Group III (n =32) (n =32) (n =31) Male/Female 20/12 18/14 17/14 Age (mean ± SD) (years) ± ± ± 8.97 Weight (mean ± SD) (kg) ± ± ± Height (mean ± SD) (m) 1.68 ± ± ± 9.10 A G C D F H B E Fig. 1. Technical drawing of traction table. A. Pulling source, B. Second movable part for lower body. C. and D. First split parts for upper body. E. and F. Movable part for head. G. To attaching canvas braces of upper body. H. Handle. Hot packs were applied to low back of all patients for 20 min as local superficial heat. Traction force was applied at 20 th min concomitantly with hot pack in group I and group III, while pulling force was applied after implementing of heating that patients were moved from hot pack table to traction table in group II. Before lying the patients on traction table in prone position, the canvas braces were attached, one around the iliac crest and the other around the lower thoracic cage. After lying on traction table, sliding table top was unlocked and the traction force was increased. The traction force was applied 50% of body weight in both traction groups. In sham traction group, traction force slowly increased until the patient indicated that he felt little pulling from braces, with a maximum force of 20% of the body weight. Nobody felt any discomfort for this pulling. These traction forces were studied in some other studies that examine the efficacy of traction in low back pain [2,3,10]. First lateral lumbosacral radiographs were obtained in standing position. The other two lateral lumbosacral radiographs were obtained before traction and during traction on traction table. Radiographs were obtained by digital Philips Diagnost 93 in standing position and by Philips V 3000 Entegris DSA on traction table in prone position. Utmost care was paid to keep fixed tube-imaging intensifier distance for all patients in an effort to obtain conventional imagines. Lateral lumbosacral radiographs were evaluated by two different experienced radiologists. Widening of the intervertebral space, changes in sacral inclination and lumbar lordosis angles were measured by these two radiologists in different time. Lateral lumbosacral radiographs of standing position were compared to prone position before and during traction for changes in sacral inclination and lumbar lordosis angles, and widening of intervertebral spaces. Total distances of L1-S1 were also measured. Kappa statistics was used for interrater reliability. Kappa values higher than 0,75 may be regarded as excellent interrater agreement, and those below 0,40 as poor agreement. Widening of the intervertebral disc space, changes in sacral inclination and lumbar lordosis angles were analyzed by using student s t test. The level of statistical significance was set at a two-tailed p-value of 0.05.

4 74 R. Cevik et al. / Lumbar distraction of new traction Fig. 2. Figure of traction table with patient. 3. Results In this study, anterior and posterior disc spaces were significantly widened in three groups by lying on traction table, without applying of the traction force as compared to standing position. These widening were generally more than 4 mm, and more than 5 mm below L3 disc spaces (Tables 2,3,4). Significant widening was found in all disc spaces by applying traction and heating therapy concomitantly as compared to before traction and standing position in group I (Table 2). There were significant widening only in L1-L2 anterior, L3-L4 anterior and posterior, L5-S1 posterior intervertebral disc spaces by applying traction after heating therapy as compared to lying on table without traction in group II (Table 3). There was significant widening only in posterior disc space of L5- S1 by sham traction as compared lying on table without traction in group III (Table 4). Anterior and posterior heights of L1-S1 were significantly increased in lumbar column in three groups by lying on table without applying pulling force. These elongations were approximately more than 70 mm. There were also significant increasing in anterior and posterior heights of L1-S1 in lumbar column during traction as compared to lying on table without traction in group I and group II. Sacral inclination and lumbar lordosis angles were decreased significantly in three groups (Tables 2,3). The excellent interrater reliability between two radiologists in lateral lumbosacral radiographs measurements were found (kappa = 0, 76). 4. Discussion Although traction is widely used for lumbar spine disease, there is lack of consensus about lumbar traction efficacy and application method. In spite of several types of traction applications, prone position has not been studied more in literature. Distraction of lumbar vertebrae and subsequent widening of disc space reflect a stretching of anterior and posterior vertebral ligaments. Although there are some advantages of traction in prone position, this aspect was not greatly considered in clinical application. Application of synchronized heating therapy with traction is possible and creation of negative intradiscal pressure with distraction of lumbar vertebrae may have additive contribution to suck back herniated disc material with in this position. Distraction of the spinal vertebrae either creates a suction force that reduced disc prolapse, or tightens the posterior longitudinal ligament suck that the disc is forced back to its original location [1,19,20]. In this study we found significant decreases in sacral inclination and lumbar lordosis angles in three groups. In addition, significant widening of disc space were defined in three groups by lying on traction table without applying traction force. These results indicate that our new traction table design and patient positioning most suitable for traction application. We also detected significant increasing in all intervertebral disc spaces by synchronized heating and traction application. However, there were significant widening only in a few intervertebral disc spaces by applying traction force and heating therapy separately, and also significant widen-

5 R. Cevik et al. / Lumbar distraction of new traction 75 Table 2 Findings of lumbosacral radiographs before and during traction in Group I (n =32; mean ± SD) In standing Before traction During traction L1-L2 distance anterior (mm) 6.28 ± ± 1.48 a ± 1.86.a.b L1-L2 distance posterior (mm) 3.14 ± ± 1.82 a 7.35 ± 1.90 a.b L2-L3 distance anterior (mm) 7.84 ± ± 1.67 a ± 1.89 a.b L2-L3 distance posterior (mm) 3.48 ± ± 1.78 a 9.32 ± 1.84 a.b L3-L4 distance anterior (mm) 8.70 ± ± 2.22 a ± 2.27 a.b L3-L4 distance posterior (mm) 4.20 ± ± 1.60 a ± 1.88 a.b L4-L5 distance anterior (mm) 9.95 ± ± 3.29 a ± 3.39 a.c L4-L5 distance posterior (mm) 4.32 ± ± 2.10 a ± 2.16 a.b L5-S1 distance anterior (mm) ± ± 3.89 a ± 3.68 a.c L5-S1 distance posterior (mm) 3.39 ± ± 2.31 a 8.30 ± 3.05 a.b L1-S1 distance anterior (mm) ± ± a ± a.b L1-S1 distance posterior (mm) ± ± a ± a.b Sacral inclination angle ± ± a ± a Lumbar lordosis angle ± ± a ± a.c a : p<0.001 compare to standing. b : P<0.001 compare to before traction. c : p<0.01 compare to before traction. d : p<0.05 compare to before traction. Table 3 Findings of lumbosacral radiographs before and during traction in Group II (n =32; mean ± SD) In standing Before traction During traction L1-L2 distance anterior (mm) 5.63 ± ± 2.07 a ± 2.09 a.b L1-L2 distance posterior (mm) 3.17 ± ± 1.70 a 7.50 ± 1.65 a L2-L3 distance anterior (mm) 7.29 ± ± 2.34 a ± 2.32 a L2-L3 distance posterior (mm) 3.85 ± ± 1.90 a 8.74 ± 1.77 a L3-L4 distance anterior (mm) 7.91 ± ± 2.90 a ± 2.79 a.c L3-L4 distance posterior (mm) 4.24 ± ± 2.16 a 9.99 ± 2.37 a.d L4-L5 distance anterior (mm) 8.50 ± ± 3.68 a ± 3.64 a L4-L5 distance posterior (mm) 3.83 ± ± 2.54 a ± 2.55 a L5-S1 distance anterior (mm) 8.84 ± ± 5.68 a ± 5.10 a L5-S1 distance posterior (mm) 3.25 ± ± 2.38 a 7.05 ± 2.52 a.d L1-S1 distance anterior (mm) ± ± a ± a.d L1-S1 distance posterior (mm) ± ± a ± a.d Sacral inclination angle ± ± a ± 9.93 a Lumbar lordosis angle ± ± a ± a a : p<0.001 compare to standing, b : p<0.01 compare to before traction, c : p<0.05 compare to before traction, d : p<0.001 compare to before traction. ing only in one disc space by applying sham traction and heating therapy simultaneously. Our study indicates that synchronized heating and traction application seems to be more effective than applying separately. Different values of intervertebral disc space widening may be related to muscle spasm which can be relaxed by applying heating and traction concomitantly and increased traction effect in group I [15]. Stimulating of the reactive reflexes of lumbar musculature with pulling force may be prevented by heating therapy. This avoidance of paravertebral muscle contraction allows distraction of intervertebral disc space [7]. Otherwise, muscular spasm may be occurred during moving from heating table to traction table, and also may be reactivated by traction force when applied after heating therapy. The patients standing by isometric muscle contractions which stimulated by proprioceptors and axon reflex mechanisms between two tables [8,13]. This may be the cause of fewer effect of traction force in group II. Hypertonic multifidi muscles have been theorized to play a major role in the maintenance of dysfunction and pain associated with disc and facet injury [6]. Hypertonicity of multifidi and other low back muscles may not be completely reduced only by stretching, and heating therapy is frequently needed to achieve better muscular relaxing. Andersson et al. reported increased L3 intradiscal pressure in healthy subjects during both passive traction and active traction compared to resting pressure while lying. Reflex muscle spasm secondary

6 76 R. Cevik et al. / Lumbar distraction of new traction Table 4 Findings of lumbosacral radiographs before and during traction in Group III (n =31; mean ± SD) In standing Before traction During traction L1-L2 distance anterior (mm) 6.67 ± ± 2.24 a ± 1.85 a L1-L2 distance posterior (mm) 3.41 ± ± 1.97 a 7.20 ± 1.92 a L2-L3 distance anterior (mm) 8.16 ± ± 2.24 a ± 1.85 a L2-L3 distance posterior (mm) 4.25 ± ± 1.82 a 9.21 ± 1.62 a L3-L4 distance anterior (mm) 8.11 ± ± 2.53 a ± 2.39 a L3-L4 distance posterior (mm) 4.41 ± ± 1.78 a 9.99 ± 1.85 a L4-L5 distance anterior (mm) 8.95 ± ± 3.26 a ± 2.89 a L4-L5 distance posterior (mm) 3.75 ± ± 2.19 a ± 2.23 a L5-S1 distance anterior (mm) 8.92 ± ± 4.70 a ± 3.88 a L5-S1 distance posterior (mm) 2.91 ± ± 2.73 a 7.23 ± 2.74 a.b L1-S1 distance anterior (mm) ± ± a ± a L1-S1 distance posterior (mm) ± ± a ± a Sacral inclination angle ± ± 7.86 a ± 7.34 a Lumbar lordosis angle ± ± 9.17 a ± 8.86 a.b a : p<0.001 compare to standing, b : p<0.05 compare to before traction. to stretching by pulling force was offered as possible explanation for this finding [1]. Synchronized heating with traction application seems to be accomplished better muscle relaxation and intervertebral distraction than separately applying. Studies indicate that intervertebral greatest separation does occur during the application of traction when the patient is positioned in supine with the hips flexed, and immediately after the distraction force is applied [13]. This hips and knees flexing were provided in new table at prone position and significant flattening of lumbar lordosis and distraction in intervertebral disc spaces were obtained by lying on table without applying traction force. Vertebral separation measured in vivo using plain radiography was shown to occur with a traction force of 50 lb (approximately 20 kg) applied either as a static or intermittent force in normal subject [4,5]. This separation was demonstrated by isolated lumbar specimens [14,22]. Sari et al. [19] studied effect of static lumbar traction on lumbar disc herniation and other anatomic structures. They found significant expanding in posterior intervertebral disc height, while anterior intervertebral disc height remained unchanged with traction. Colachis and Strohm [5] used kg and 45.4 kg for lumbar traction with a split table and measured statistically significant vertebral separation in both weights. Tekeoglu et al. [21] reported statistically significant widening of intervertebral disc space with gravitational traction by lateral lumbosacral radiographs. There is no more traction table which applied in prone position. It was reported that vertebral axial decompression therapy (VAX-D) table which applied in prone position [18] reduced intradiscal pressure. However, flattening of lumbar lordosis was not considered in VAX-D therapy. This study carried out with new table that developed by department of physical medicine and rehabilitation of Dicle University Hospital. We tried to make perfect device as far as possible inspite of inadequate opportunity. Therefore we can not eliminate the lower body segment friction inspite of using split table. For this reason, we used 50% of body weight as traction force which used as maximum pulling force in lumbar traction application [2,3,10]. On the other hand, traction force was applied one time for short period which normally should have been applied approximately 20 min in treatment of low back pain. These are limitations of our study. In conclusion, this is a preliminary study to investigate efficacy of new traction technique in prone position. 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. Future clinical studies should to be carried out to define the efficacy of this traction equipment in treatment of low back pain. References [1] G.B.J. Andersson, A.B. Schultz and A.L. Nachemson, Intervertebral disc pressures during traction, Scandinavian Journal of Rehabilitation Medicine 9 (1983),

7 R. Cevik et al. / Lumbar distraction of new traction 77 [2] A.J. Beurskens, H.C. de Vet, A.J. Köke, E. Lindeman, W. Regtop, G.J. van der and P.G. Knipschild, Efficacy of traction for non-specific low back pain: a randomized clinical trial, The Lancet 346 (1995), [3] P. Borman, D. Keskin and H. Bodur, The efficacy of lumbar traction in the management of patients with low back pain, Rheumatology International 23(2) (2003), [4] R.S. Bridger, S. Ossey and G. Fourie, Effect of lumbar traction on stature, Spine 156 (1990), [5] S.C. Colachis and B.R. Strohm, Effects of intermittent traction on separation of lumbar vertebrae, Archives of Physical Medicine and Rehabilitation 44 (1969), [6] R.E. Gay, G. Bronfort and R.L. Evans, Distraction manipulation of the lumbar spine: a review of the literature, Journal of Manipulative and Physiological Therapeutics (2005), [7] E.E. Gose, W.K. Naguszewski and R.K. Naguszewski, Vertebral axial decompression therapy for pain associated with herniated or degenerated or facet syndrome: An outcome study, Neurol Res 20 (1998), [8] E.E. Gose, W.K. Naguszewski and R.K. Naguszewski, Vertebral axial decompression therapy for pain associated with herniated or degenerated or facet syndrome: An outcome study, Neurol Res 20 (1998), [9] E.E. Gose, W.K. Naguszewski and R.K. Naguszewski, Vertebral axial decompression therapy for pain associated with herniated or degenerated or facet syndrome: An outcome study, Neurol Res 20 (1998), [10] G.J.M.G. Heijden van der, A.J.H.M. Beurskens, M.J.M. Dirx, L.M. Bouter and E. Lindeman, Efficacy of traction: a randomized clinical trial, Physiotherapy 81 (1995), [11] B. Judovich and G.R. Nobel, Traction therapy, a study of resistance forces, Am J Surg 93 (1957), [12] B.D. Judovich, Lumbar traction therapy-elimination of physical factors that prevent lumbar stretch, JAMA 1596 (1955), [13] M. Krause, K.M. Refshauge, M. Dessen and R. Boland, Lumbar spine traction: evaluation of effects and recommended application for treatment, Manual Therapy 5(2) (2000), [14] R.Y.W. Lee and J. Ewans, The biomechanics of spinal traction therapy, Annual meeting of the International Society for the Study of the Lumbar Spine Marseilles 118 (1993). [15] J.F. Lehmann and B.J. De Lateur, Therapeutic Heat, in: Therapeutic Heat and Cold, J.F. Lehmann, ed., Baldimore, Williams and Wilkins, 1990, pp [16] J.A. Mathews, The effects of spinal traction, Physiotherapy 58 (1972), [17] D. Onel, M. Tuzlaci, H. Sari and K. Demir, Computed tomographic investigation of the effect of traction on lumbar disc herniations, Spine 141 (1989), [18] G. Ramos and W. Martin, Effect of vertebral axial decompression on intradiscal pressure, J Neurosurg 81 (1994), [19] H. Sari, U. Akarirmak, I. Karacan and H. Akman, Computed tomographic evaluation of lumbar spinal structures during traction, Physiother Theory Pract 21(1) (2005), 3-1. [20] H.D. Saunders, Lumbar traction, in: Modern Manual Therapy of the Vertebral Column, G.P. Grieve, ed., Churchill Livingstone 1986, pp [21] I. Tekeoglu, B. Adak, M. Bozkurt and N. Gurbuzoglu, Distraction of lumbar vertebrae in gravitational traction, Spine 23 (1998), [22] L.T. Twomey, Sustained lumbar traction. An experimental study of long spine segments, Spine 10 (1985), [23] G.J.M.G. van der Heijden, A.J.H.M. Beurskens, B.W. Koes, W.J.J. Assendelft, H.C.W. de Vet and L.M. Bouter, The efficacy of traction for back and neck pain: a systematic, blinded review of randomized clinical trial methods, Physical Therapy 75 (1995),

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