Intervention Review

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Traction for low-back pain with or without sciatica

  1. Inge Wegner1,*,
  2. Indah S Widyahening2,
  3. Maurits W van Tulder3,
  4. Stefan EI Blomberg4,
  5. Henrica CW de Vet5,
  6. Gert Brønfort6,
  7. Lex M Bouter7,
  8. Geert J van der Heijden8

Editorial Group: Cochrane Back Group

Published Online: 19 AUG 2013

Assessed as up-to-date: 13 MAY 2013

DOI: 10.1002/14651858.CD003010.pub5


How to Cite

Wegner I, Widyahening IS, van Tulder MW, Blomberg SEI, de Vet HCW, Brønfort G, Bouter LM, van der Heijden GJ. Traction for low-back pain with or without sciatica. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD003010. DOI: 10.1002/14651858.CD003010.pub5.

Author Information

  1. 1

    University Medical Center Utrecht, Department of Otorhinolaryngology - Head and Neck Surgery; G05.129, Utrecht, Netherlands

  2. 2

    Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Hospital, Centre for Clinical Epidemiology & Evidence-Based Medicine, Jakarta, Indonesia

  3. 3

    VU University, Department of Health Sciences, Faculty of Earth and Life Sciences, Amsterdam, Netherlands

  4. 4

    Department of Public Health and Caring Sciences, Family Medicine Section, Uppsala, Sweden

  5. 5

    VU University Medical Center, Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, Amsterdam, Netherlands

  6. 6

    Northwestern Health Sciences University, Wolfe-Harris Center for Clinical Studies, Bloomington, MN, USA

  7. 7

    VU University, Amsterdam, Netherlands

  8. 8

    Academic Center for Dentistry Amsterdam (ACTA), Department of Social Dentistry, Amsterdam, Netherlands

*Inge Wegner, Department of Otorhinolaryngology - Head and Neck Surgery; G05.129, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, Netherlands. i.wegner@umcutrecht.nl.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 19 AUG 2013

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Characteristics of included studies [ordered by study ID]
Beurskens 1997

MethodsRCT; participants randomly allocated by computer, sealed envelopes prepared by independent person, containing treatment code. Stratified on duration of complaints (< 6 or > 6 months), and according to PT practices.


Participants151 participants (85 male and 66 female, > 18 years old) recruited by physiotherapists and general practitioners in the Netherlands, with at least 6 wk of subacute and chronic non-specific LBP, having never had any form of lumbar traction treatment. 150 completed 12-wk follow-up and 148 completed 6-month follow-up.


InterventionsT) Traction: continuous mechanical traction with Eltrac, DIMEC Delft Instruments, the Netherlands. Traction force increased until participant indicated tolerance for pulling was reached, with minimum force of 35% and maximum of 50% of body weight.
C) Comparison intervention: sham traction. Same as above except traction force was slowly increased until participant indicated feeling little pulling with maximum force of 20% body weight. Special brace worn around iliac crest, which became tighter in the back during treatment.
Both groups treated 12 times in 5 wk for 20 min per session.


OutcomesAt 5 wk: global perceived effect (number and %): T) 34 (44%), C) 37 (51%); first main complain (mean): T) 28.5, C) 28.4; second main complaint (mean): T) 27, C) 24.6; RMDQ (mean): T) 3.5, C) 4.8; pain at the moment (mean): T) 21.2, C) 22.5; pain last wk (mean): T) 20.6, C) 23.7; severity of LBP (mean): T) 1.6, C)1.8; ROM (mean): T) -2.1, C) 0.1; ADL disability (mean): T) 26.7, C) 33.8; work absence (days) (mean): T) 21, C) 22.8. No significant differences on any outcome measures.
At 12 wk: global perceived effect-recovery (number and %): T) 38 (50%), C) 35 (48%); first main complaint (mean): T) 33.7, C) 31.5; second main complaint (mean): T) 35.4, C) 30.7; RMDQ (mean): T) 4.4, C) 4.3; pain at the moment (mean): T) 28.5, C) 22.8; severity of LBP (mean): T) 2.3, C) 2.2; ROM: T) -1.1, C) 1.2; ADL disability (mean): T) 27.1, C) 29.4; work absence (days) (mean): T) 23.5, C) 27.8.
At 6 months: global perceived effect (number and %): T) 35 (47%), C) 32 (44%); first main complain (mean): T) 36.7, C) 36.0; second main complaint (mean): T) 35.8, C) 32.8; RMDQ (mean): T) 4.7, C) 4.0; pain at the moment (mean): T) 23.8, C) 20.1; ADL disability (mean): T) 25.7, C) 25.8; work absence (days) (mean): T) 35.7, C) 43.7
No significant differences on any outcome measures.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskAllocation with the help of a random numbered list generated by computer.

Allocation concealment (selection bias)Low riskSealed envelopes prepared by an independent person containing the treatment code.

Blinding (performance bias and detection bias)
All outcomes - participants
Low riskParticipants were blinded to treatment allocation.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskAfter admission of a participant into the trial, the treating physiotherapist received a sealed envelope that contained the treatment code. The envelope was opened at the first treatment session and, therefore, the care provider was not blinded for the assigned treatment.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskOutcome assessors were blinded to treatment allocation.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low riskOf the 151 participants, only 1 was lost to follow-up.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Low riskIntention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Low riskThe 2 treatment groups had similar demographic and clinical baseline characteristics.

Influence of co-interventions (performance bias)Low riskCo-interventions, other than pain medication, were not allowed during the treatment period.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Bihaug 1978

MethodsRCT; method of randomization not described.


Participants42 participants (23 male, 19 female, aged 19-71 years (mean 44.1 years) referred from secondary care setting. All had radicular pain; in 32 radiating pain was below the knee. Pain duration was 3-52 wk (mean 9.7 wk). 25 participants were on sick leave at baseline (1-24 wk, mean 5.1 wk). 18 had severe pain, the remainder had moderate pain. 27 had neurological deficits (figures not given for the 2 different groups).


InterventionsT) Traction: auto-traction, using a combination of Lind's method and Myrin's method. Instead of pulling with the arms (as in Lind), participants pushed with 1 or both arms (according to Myrin/Spina-Trac). 4-12 sessions (mean 8.2), with interval of 3.1 days between sessions. (Force 70 kiloponds according to Lind.) All participants also received education in LBP/ biomechanics).
C) Comparison intervention: exercise. Isometric exercises of the abdominal and pelvic floor muscles, to increase abdominal pressure (and, in turn, to increase intrinsic lumbar support) (Hume, Kendall and Jenkins; Fysioterapeuten number 3, Norway). 4-12 sessions (mean 10.6) with interval of 4.1 days between sessions).


OutcomesGlobal improvement (symptom-free; mild symptoms with ability to work; some or no improvement; deterioration) (n).
At end of treatment series: T) 5, 12, 3, 1; C) 2, 9, 10, 0.
At 1 month AT: T) 12, 7, 2, 0; C) 5, 11, 5, 0.
At 3 months AT: T) 16, 4, 1, 0; C) 12, 7, 2, 0.


NotesOutcomes inappropriately dichotomized by authors, leading to P value < 0.05 at end of treatment series (ns at other follow-up points). Without this dichotomization, group differences are not statistically significant at any follow-up point.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskTransformed from old format to new format.

Allocation concealment (selection bias)Unclear riskTransformed from old format to new format.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskTransformed from old format to new format.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskTransformed from old format to new format.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskTransformed from old format to new format.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low riskTransformed from old format to new format.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Low riskTransformed from old format to new format.

Selective reporting (reporting bias)Unclear riskTransformed from old format to new format.

Group similarity at baseline (selection bias)Unclear riskTransformed from old format to new format.

Influence of co-interventions (performance bias)Unclear riskTransformed from old format to new format.

Compliance with interventions (performance bias)Low riskTransformed from old format to new format.

Timing of outcome assessments (detection bias)Unclear riskTransformed from old format to new format.

Borman 2003

MethodsRCT; method of randomization not described.


Participants42 participants (14 male, 28 female; age: T) 38.5 ± 8.4 years, C) 42.8 ± 10.5 years) with persistent (> 6 months) or recurring, non-specific LBP, or both; outpatients in physical medicine and rehabilitation department of large hospital. Duration of pain (months): T) 27 ± 19.5, C) 34.09 ± 14.1.
Ratio of participants with/without radiation: T) 14:7, C) 13:8.
Excluded those with neurological deficits.


InterventionsT) Traction and standard PT. Motorized traction (Eltrac 439, Enraf, the Netherlands), 10 x 20-min sessions, participants lying on traction table in semi-fowler position. Canvas braces attached around iliac crest and lower thoracic region, with force increased to maximum of 50% body weight. Traction applied between ultrasound therapy and exercise sessions in standard PT programme (as below).
C) Comparison intervention: standard PT. Included hot packs (10 min), ultrasound (10 min), exercise (20 min).


OutcomesPain (VAS) (mean, SD (range)): before: T) 5.7, 1.1 (3-8); C) 5.6, 1.7 (2-9); immediately after: T) 3.8, 1.1 (1-6); C) 3.8, 1.4 (1-7). Within-group difference P value < 0.01; between-group difference ns.
3 months. Follow-up: T) 4.1, 1.7 (0-7); C) 3.6, 1.7 (0-6).
ODI: (mean, SD (range)): before: T) 32.3, 9.6 (12-44); C) 25.2, 10.4 (3-41); immediately after: T) 26.8, 9.1 (4-41); C) 22.9, 10.1 (3-43). Within-group differences P value < 0.01.
3 months. Follow-up: T) 23.7, 10.8 (6-38); C) 19.7, 10.8 (0-32). Within-group difference P value < 0.05; between-group difference ns.
Global improvement (complete/mild improvement, no change, no improvement and worse) (n): immediately after: T) 11, 6, 5; C) 10, 6, 5. 3 months follow-up: T) 8, 7, 5; C) 7, 5, 7. Between-group difference ns.
Global satisfaction (n (%) of participants completely/somewhat satisfied; not satisfied): immediately after: T) 17 (80.9%), 4 (19%); C) 15 (71.4%), 6 (28.6%); 3 months' follow-up: T) 12 (60%), 8 (40%); C) 11 (57.8%), 8 (42.1%).
No differences were observed in outcomes for participants with and without radiation (P value > 0.05).


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskNo mention of attempts to blind the participants. It is unlikely that the participants were blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskNo mention of attempts to blind the care providers. It is unlikely that the care providers were blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Unclear riskNo mention of attempts to blind the outcome assessors.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low risk4 participants were lost to follow-up (9.5%): 2 in each group.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Unclear riskIt is not clear whether an intention-to-treat analysis was used or not.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Low riskThere were no differences between groups in terms of age, sex, duration of pain, VAS and ODI scores at entry.

Influence of co-interventions (performance bias)Low riskNo co-interventions were allowed during the treatment period.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Coxhead 1981

MethodsRCT; randomly allocated treatment (method of randomization not described). The design was factorial - there were 16 treatment groups, enabling a comparison of combinations of methods as well as of individual methods.


Participants334 participants (185 men, 149 women, mean age 41.9 years) referred to the outpatient department with sciatic pain at least as far as the buttock crease, with/without back pain. Pain not due to malignant or infective disease, gynaecological disorders, sacroiliac disease, vertebral collapse or gross structural abnormality. Mean duration of symptoms 14.3 wk.


InterventionsT) Traction: Tru-Trac apparatus, giving intermittent traction at pre-set forces and time intervals. Duration and intensity at the discretion of the physiotherapist.
Comparison interventions:
C1) Exercises based on a catalogue of exercises that brought in all ROM and muscle groups;
C2) Manipulation by Maitland technique;
C3) Corset - a ready-made fabric lumbar support available in 3 sizes.
All participants received short-wave diathermy and a standardized 30-min "back school" lecture. For all interventions, participants treated daily for first wk, with decreasing frequency in the following 3 wk.


OutcomesParticipant assessments at 4 wk, 16 wk (better): T) 82%, 72%; C1) 82%, 75%; C2) 80%, 69%; C3) 81%, 71%.
Pain (-100 to +100 VAS) at 4 wk: T) 50.1 (37.9); C1) 52.6 (36.9); C2) 49.0 (40.0); C3) 49.8 (37.9). Statistical significance in C1 only.
ROW at 4 wk: T) 36%; C1) 36%; C2) 33%; C3) 33%.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskParticipants were not blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskCare providers were not blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
High riskOutcome assessors were not blinded.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
High riskAt 4 months follow-up only 78% of the included participants were assessed.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Low riskIntention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Unclear riskNo information provided on demographic characteristics at baseline.

Influence of co-interventions (performance bias)Unclear riskUnclear whether co-interventions were allowed during the treatment period.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Fritz 2007

MethodsRCT; computer-generated random number lists and concealment of allocation by means of randomization envelopes.


Participants64 participants (33 in the extension group, 31 in the traction plus extension group) with symptoms of pain or numbness (or both) extending distal to the buttocks and signs of nerve root compression in the past 24 hours. All had LBP, 76.5% sciatica. Exclusion criteria included non-mechanical LBP and previous spinal fusion or spine surgery in the past 6 months. Mean age T) 41.7 years, C) 40.7 years. Duration of complaints: 47.5 days.


InterventionsT) Traction: extension-oriented treatment and mechanical traction using an adjustable table. Traction during first 2 wk of treatment, 4 sessions per wk, 12 min per session, with a traction force of 40-60% of body weight. Extension-oriented treatment included 9 sessions of exercise, mobilization and education during a 6-wk treatment period.

C) Comparison intervention: extension-oriented treatment.


OutcomesAssessment at 2 and 6 wk' post-treatment. ODI (all measurements: MD): 2 wk 7.2 (95% CI 0.13 to 14.3), 6 wk 1.8 (95% CI -6.4 to 10.1). Pain rating: 2 wk 0.23 (95% CI -1.4 to 1.9), 6 wk -0.17 (95% CI -1.4 to 1.1). FABQ - physical activity subscale: 2 wk 2.7 (95% CI 0.66 to 4.6), 6 wk 0.50 (95% CI -2.4 to 3.4). FABQ - work subscale: 2 wk -1.1 (95% CI -4.2 to 1.9), 6 wk -3.1 (95% CI -6.5 to 0.36).


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated random number list.

Allocation concealment (selection bias)Low riskRandomization envelopes.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskParticipants were not blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskCare providers were not blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
High riskOutcome assessors did not participate in the subject's treatment and were blinded to the treatment allocation. However, blinding was lost for 15 subjects (20%).

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low risk8 participants were lost to follow-up (12.5%).

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Low riskIntention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Low riskThere were no between-group differences at baseline, other than a higher percentage of participants using prescription pain medication in the TRACT group.

Influence of co-interventions (performance bias)Low riskNo co-interventions, other than analgesics, were allowed during the treatment period.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Gudavalli 2006

MethodsRCT; random number tables and concealment of allocation by means of randomization envelopes.


Participants235 participants (123 in the flexion-distraction group, 112 in the active trunk exercise programme) with LBP with a duration of at least 3 months. All had LBP, 22.8% sciatica. Mean age: T) 42.2 years, C) 40.9 years.


InterventionsT) Traction: flexion-distraction technique during 4 wk, 2-4 sessions per wk, 9-18 min of traction per session.

C) Comparison intervention: active trunk exercise programme. Treatment duration of 4 wk, 2-4 sessions per wk, 30-45 min per session.


OutcomesAssessment at 4 wk, 3 months and 12 months from baseline. VAS (mean change from baseline to time period indicated in MD (SE)): 4 wk: T) 20.57 (2.00), C) 12.34 (1.80); 3 months: T) 16.52 (2.95), C) 12.04 (2.53); 6 month: T) 18.26 (2.64), C) 8.92 (2.89); 12 months: T) 17.10 (2.55), C) 12.36 (2.43).

RMDI: 4 wk: T) 2.81 (0.38), C) 2.30 (0.33); 3 months: T) 3.50 (0.50), C) 3.75 (0.51); 6 months: T) 3.89 (0.46), C) 3.42 (0.50); 12 months: T) 3.90 (0.53), C) 3.77 (0.44).


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number tables.

Allocation concealment (selection bias)Low riskSequentially numbered, sealed, manila envelopes.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskParticipants were not blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskCare providers were not blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskOutcome assessors were blinded and all remained blinded for the entire study period. No incidents of unblinding were reported.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
High riskAlthough total loss to follow-up was only 16.6%, significantly more subjects in the active trunk exercise programme group dropped out of the study (T) 13, C) 25).

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Low riskIntention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Low riskNo significant differences were found at baseline.

Influence of co-interventions (performance bias)Low riskCo-interventions were not allowed during the treatment period. Analgesics were not allowed 24 hours prior to measurements.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Güvenol 2000

MethodsRCT; method of randomization not described.


Participants29 participants (mean age: T1) 33.8 years, T2) 39.6 years) with LBP and lower extremity pain of not less than 1 month, and lumbar disc herniation diagnosed by CT. Mean duration of pain (months): T1) 28.5 ± 26.5 months, T2) 39.3 ± 39.2 months). None had history of spinal surgery. Pain not due to disease such as malignant, inflammatory, infectious, metabolic, congenital or developmental disorders. Disc pathology at 2 levels was present in 10 subjects, 5 from each treatment group.


InterventionsTraction:

T1) Inversion spinal traction. Traction used a modified tilt table (Sheffield 1996). With participant lying supine, ankle straps mounted to the foot of the table; lumbar strap allowed vertical slide only. Table rotated until participant was upside down (inverted). Inverted for 5 min on 1st day, 8 min on 2nd, 10 min on 3rd and onwards through 7 days (10 days total).
T2) Conventional static traction. Initial force 30 kg, gradually increased up to 45 kg with 3-kg increments daily, according to participant's tolerance.
Both T1) and T2) also received 15 min of infrared radiation, with abdominal and gluteal isometric exercises. Participants were not allowed to take NSAIDS; bed rest was required of all participants.


OutcomesClinical parameters examined before, immediately after and 3 months after last treatment session. Pain cluster 1 - combination of: morning pain; pain throughout the day; night pain; pain with Valsalva manoeuvre; radicular pain. Pain cluster 2 - combination of: straight leg raising test pain onset; finger-to-floor distance; deep tendon reflex, sensory impairment, and motor strength; CT investigation.
Results presented as P values only.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskNo mention of attempts to blind the participants. It is unlikely that the participants were blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskNo mention of attempts to blind the care providers. It is unlikely that the care providers were blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Unclear riskNo mention of attempts to blind the outcome assessors.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low risk4 participants were lost to follow-up (14%): 2 from each group.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
High riskNo intention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Low riskThere was no significant difference between groups regarding any of the baseline characteristics.

Influence of co-interventions (performance bias)Low riskNo co-interventions, other than analgesics, were allowed during the study period.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Harte 2007

MethodsRCT; predetermined randomization table, concealment of allocation through sealed, opaque and sequentially numbered envelopes.


Participants30 participants (16 in the traction group and 14 in the manual therapy group) with acute or subacute LBP accompanied with radiculopathy. Exclusion in case of previous spinal surgery, co-existing conditions interventions within the last 3 months. Mean age T) 45.25 years, C) 42.79 years. Duration of complaints: T) 6.5 wk, C) 6 wk.


InterventionsT) Traction: manual therapy (techniques described by Maitland or Cyriax), exercises, advice and motorized lumbar traction for 4-6 wk, 2-3 times per wk, 10-20 min per session, traction force 5-60 kg.

C) Comparison intervention: manual therapy, exercises and advice.


OutcomesAssessment at discharge, 3 months and 6 months post-treatment (all measures median (IQR), T vs. C). RMDQ: at discharge: 4 (5.8) vs. 4 (10.3), 3 months: 4.5 (10.8) vs. 1 (10.5), 6 months: 4.5 (15.3) vs. 2.5 (14). MPQ-PRI: at discharge: 4 (15.3) vs. 12 (16.5), 3 months: 6 (16.5) vs. 6 (21), 6 months: 10 (20.5) vs. 6.5 (21). SF36 PCS: at discharge: 38.5 (16.2) vs. 41.1 (21.1), 3 months: 41.6 (18.6) vs. 43.2 (24), 6 months: 40 (15) vs. 46 (22). SF36 MCS: at discharge: 52 (26.1) vs. 48.3 (25.6), 3 months: 49.5 (25.8) vs. 47.3 (21.3), 6 months: 51.8 (23) vs. 49.8 (19.8).


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskPredetermined randomization table.

Allocation concealment (selection bias)Low riskSealed, opaque and sequentially numbered envelopes.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskParticipants were not blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskCare providers were not blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskOutcome assessors were blinded to treatment group allocation.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
High risk7 participants were lost to follow-up (23%).

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Unclear riskIntention-to-treat analysis was used.

Selective reporting (reporting bias)High riskPublished results did not include all prespecified outcomes: VAS score, improvement and straight leg raising test.

Group similarity at baseline (selection bias)High riskBaseline characteristics varied between groups: off work due to LBP, history of episodes, participation in physical activity and presence of neurological signs.

Influence of co-interventions (performance bias)Low riskParticipants were not permitted to receive any other type of manual therapy or any additional interventions during the treatment period.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Konrad 1992

MethodsRCT; participants were randomly allocated to 1 of 4 groups in each factory. Method of randomization not described.


Participants170 participants (95 female, 75 male, mean age of 41.5 years) from 3 factories in Budapest, with non-specific back pain localized to the lumbosacral region, with or without radiation to the thigh. Duration of pain at least 1 month, but no longer than 3 months. A pain-free year before onset of the current episode.
Exclusion criteria: participants with pregnancy, back surgery, spondylolisthesis, infections, tumours, fractures, ankylosing spondylitis, osteoporosis and structural scoliosis.
12 participants dropped out (3 from the balneotherapy group and 9 from the underwater massage group) and were analyzed separately.


InterventionsT) Traction: underwater traction. Participant fixed perpendicularly in special deep pool, bar grasped under the arms and traction applied. 1st treatment - participant's own weight used. Then, in addition to traction due to gravity, traction belt applied to the pelvis with 3-kg weight on both sides.
Comparison interventions:
C1) Balneotherapy. Participants immersed in thermal water with minerals.
C2) Underwater massage. Same water, with massage and movement while a stream of hot water (37 °C, 1 atm, 10 cm) played on the affected part.
C3) Control group (no treatment).
All treatments done for 15 min, 3 times per wk, for 4 wk. All participants taught how to use their back correctly. Only NSAIDs were offered to participants in the control group.


OutcomesNumber of analgesics taken on admission, at 4 wk, at 1 year: T) 5.1 (2.9), 2.2 (0.9), 2.1 (1.2); C1) 4.8 (3.2), 2.3 (1.3), 1.9 (1.8); C2) 4.9 (3.4), 1.8 (0.7), 2.3 (1.7); C3) 5.1 (2.8), 3.9 (2.7), 3.7 (1.9). At 1 month, statistically significant difference in all treatment groups compared to control (P value < 0.01). No significant difference in analgesic consumption between the treatment groups.
Pain intensity (100 mm VAS) on admission, at 4 wk, at 1 year: T) 56.7 (28.2), 24.6 (11.9), 45.8 (26.2); C1) 63.4 (24.1), 31.7 (16.2), 49.5 (25.7); C2) 68.4 (31.8), 33.5 (19.1), 54.7 (33.7); C3) 61.5 (32.88), 53.7 (23.8), 54.9 (24.8).
At 1 month, statistically significant pain reduction in all treatment groups (P value < 0.01). No significant difference in control group
At 1 year, no difference between groups. Reduction in analgesic consumption well maintained in treatment groups.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskNo mention of attempts to blind the participants. It is unlikely that the participants were blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskNo mention of attempts to blind the care providers. It is unlikely that the care providers were blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskThe investigator assessing the outcome was not aware of the treatment given.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low risk12 participants were lost to follow-up (7%).

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
High riskNo intention-to-treat analysis was used.

Selective reporting (reporting bias)Unclear riskPublished results did not include all prespecified outcomes: spinal ROM and straight leg raising.

Group similarity at baseline (selection bias)Low riskGroups were comparable at baseline regarding age, sex and medical history.

Influence of co-interventions (performance bias)Low riskNo co-interventions, other than analgesics, were allowed during the study period.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Larsson 1980

MethodsRCT; method of randomization not described.


Participants82 participants (51 males and 31 female, age 20-55 years) in 6 departments of orthopaedic surgery in Sweden, with lumbago-sciatica with or without symptoms of neurological deficit. Duration of current episode at least 2 wk and not more than 3.5 months, positive straight leg raise test.


InterventionsT) Traction: auto-traction: up to 3 treatments within 1 wk as per Lind (1974). Pelvis fixed to the foot end of bench, participant grasps bars at end and performs traction himself by pulling his arms. Participant supplied with reinforced, high, fabric corset and special pillow. Sessions < 1 hour. Participants treated as outpatients were usually taken home by ambulance. Participants confined to bed for first few days, then mobilized gradually in corset.
C) Comparison intervention: corset of same type as traction group and same instructions with respect to rest.
Standard analgesics (paracetamol) prescribed when required for both groups.


OutcomesComplete recoveries 1 wk, 3 wk: T) 15%, 17% C) 0%, 7%. Partial recoveries 1 wk, 3 wk: T) 27%, 32% C) 4%, 12%.
Statistically significant between group differences in participant's recovery at 1 wk. At 3 wk, ns for those "completely recovered" but significant for those "completely recovered or free from pain in the leg" and "completely recovered or free from pain in the leg or the back", with traction group having better results.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskNo mention of attempts to blind the participants. It is unlikely that the participants were blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskNo mention of attempts to blind the care providers. It is unlikely that the care providers were blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskOutcome assessors were blinded.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Unclear riskIt is unclear how many participants were lost to follow-up.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Unclear riskIt is unclear whether intention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Low riskClinical characteristics were evenly distributed between the 2 groups at baseline.

Influence of co-interventions (performance bias)Low riskNo co-interventions, other than analgesics, were allowed during the treatment period.

Compliance with interventions (performance bias)Low riskParticipants were hospitalized, therefore, compliance with the given treatment was high.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Letchuman 1993

MethodsRCT, cross-over. Subjects randomly assigned to 1 of the 2 experimental groups, with each subject serving as his/her own control in the control group (method of randomization not described).


Participants26 subjects (16 male, 10 female, aged 26-65 years) referred from physicians. Participants with LBP with/without lower extremity pain and neurological signs. Cough, sneeze or deep breaths did not cause severe pain, x-rays, MRI or CT scan of lumbar spine taken within past 6 months


InterventionsTraction:
T1) Static (mechanical traction), continuous traction force (after sham treatment) for a 6-min period at magnitude of 50% bodyweight.
T2) Intermittent traction, for a 6-min period (after sham treatment), with a 10-sec hold period at a magnitude of 50% body weight, followed by a 10-second rest period.
C) Comparison intervention: sham treatment. 6 min of 'sham traction', using only 10 lb (4.5 kg) for a 10-sec hold, and 0 lb for a 10-sec rest.


OutcomesPain intensity (0-10 VAS). Decreased pain: T1) 53.9% (7 of 13 participants), T2) 61.5% (8 of 13 participants). Increased pain: T1) 30.8% (4 of 13 participants), T2) 15.4% (2 of 13 participants).


NotesMajor thrust of study was to look at myoelectric activity for static or intermittent traction. Pain measures were recorded immediately after traction. Just 1 session of traction appears to have been given. Small sample size, frequency data only reported for pain measures.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
Low riskNo mention of attempts to blind the participants. It is unlikely that the participants were aware of group assignment.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskNo mention of attempts to blind the care providers. It is unlikely that the care providers were blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
High riskNo mention of attempts to blind the outcome assessors.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low risk4 participants were lost to follow-up (13%): 2 in each group.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
High riskNo intention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Low riskGroups were similar at baseline with respect to age, sex and symptoms.

Influence of co-interventions (performance bias)Low riskNo co-interventions were used.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Lidström 1970

MethodsRCT, subjects were placed by a physiotherapist in 1 of 3 groups according to a randomization procedure decided before the experiment (method of randomization not described).


Participants62 participants (29 male, 33 female, aged 21-61 years) selected from an orthopaedic outpatient clinic. Participants had LBP and sciatic pain radiating down 1 leg for more than 1 month' duration. 32 participants had a history of pain > 1 year. Participants strongly suspicious of the presence of a disc prolapse were not accepted.


InterventionsT) Traction: intermittent pelvic traction with a Tru-Trac traction table for 20 min with 4-sec hold intervals and a 2-sec rest. Traction force was correlated to the participant's weight according to the given figures. Instruction on Fowler position, strengthening exercises, regimental dispositions, every day at home.
Comparison interventions:
C1) Conventional treatment, hot packs for 15 min, massage and mobilizing exercises.
C2) Control, hot packs for a length of time corresponding with the mean for the other methods of treatment.


OutcomesGlobal measure - participants opinion of noticeable improvement: T) 90% (18 of 20 participants), C1) 48% (10 of 21 participants), C2) 67% (14 of 21 participants).
Need for analgesics before, after the treatments (of the 30 that were taking pills before the treatment): T) 9, 0; C1) 12, 7; C2) 9, 4.
Traction appears to have reduced the subjective symptoms of the participants to a higher degree than the other methods.


NotesAuthors stress the need for sufficient pull and duration of traction in order to influence the mechanical conditions of the spine effectively.
No apparent follow-up after the treatment had finished (i.e. other than post-treatment).


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskNo mention of attempts to blind the participants. It is unlikely that the participants were blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskNo mention of attempts to blind the care providers. It is unlikely that the care providers were blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
High riskBoth the care provider and a blinded outcome assessor took part in the assessment of the outcome measures.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low risk4 participants (6.5%) did not complete follow-up evaluation.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Low riskIntention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Low riskAll 3 groups were similar at baseline.

Influence of co-interventions (performance bias)High riskThe traction group received isometrical training in conjunction with traction. The comparison group was not treated with isometrical training.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Lind 1974

MethodsRCT, method of randomization not reported.


Participants45 participants (29 male, 16 female; aged 30-50 years, mean 34.0 years) from waiting list of orthopaedic surgery department. All had several periods of attack, mean number 3.5. Participants with serious disorders (e.g. arteriosclerosis, hypertension) excluded. All had had some previous non-surgical therapy. Included participants with or without neurological signs.


InterventionsT) Traction: auto-traction treatment followed initially by bed rest, correction of statico-dynamic disorders and advice on spinal hygiene. No PT or medicine. 1 participant given cotton corset. Mean number of treatments, approximately 1 hour long, over 1-3 wk: 3.7.
Comparison interventions:
C1) PT, with physiotherapist choosing individual treatment, including drugs. 12 of 15 participants received Tru-Trac traction; other treatments included isometric muscle training (n = 14), ergonomic instruction (n = 11), shortwave therapy (n = 7), heat (n = 7), cycle machine (n = 10), bath (n = 4) and manipulation (n = 1).
C2) Bed rest and analgesics (Paraflex comp, 3-6 tablets/day), sham shortwave therapy.


OutcomesDisappearance of pain in lower back/legs without coughing/sneezing: T) 100%, C1) 53%, C2) 43%.
Disappearance of pain in lower back/legs on coughing sneezing: T) 100%, C1) 50%, C2) 0%.
Pain, mean distance radiated (initial radiation mean; at 3 wk; mean change score): T) 60 cm, 0 cm, 100%; C1) 66 cm; 23 cm, 65%; C2) 65 cm, 28 cm, 57%.
Participant's own evaluation at 3 wk (1, 2, 3, 4, 0, -1 where 1 = highest improvement, 4 = unchanged, -1 = worse)
T) 11, 2, 2, 0, 0, 0; C1) 0, 0, 6, 3, 5, 1; C2) 0, 2, 7, 3, 2, 0. (T vs. C1, P value < 0.000001; T vs. C2, P value < 0.0001)
Recovery: T) 87%, C1) 0%, C2) 0%. P value < 0.00001 at 3 wk.
Straight leg raising (% recovered) T) 100%, C1) 0%, C2) 0% (P value < 0.001).
Regression of neurological deficits: auto-traction more effective in effecting a regression of neurological deficits.


NotesAlthough no final conclusions were made by the authors, we can assume it had a positive conclusion considering the P values reported. This is an underpowered study that would need replication.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskTransformed from old format to new format.

Allocation concealment (selection bias)Unclear riskTransformed from old format to new format.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskTransformed from old format to new format.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskTransformed from old format to new format.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
High riskTransformed from old format to new format.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Unclear riskTransformed from old format to new format.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Low riskTransformed from old format to new format.

Selective reporting (reporting bias)Unclear riskTransformed from old format to new format.

Group similarity at baseline (selection bias)Low riskTransformed from old format to new format.

Influence of co-interventions (performance bias)Low riskTransformed from old format to new format.

Compliance with interventions (performance bias)Low riskTransformed from old format to new format.

Timing of outcome assessments (detection bias)Unclear riskTransformed from old format to new format.

Ljunggren 1984

MethodsRCT (method of randomization not described)


Participants52 hospitalized participants with lumbago-sciatica and prolapsed lumbar intervertebral discs, admitted to neurological department, and considered for operation. Inclusion criteria: radicular signs L5 or S1 (or both) nerve root; symptoms aggravated or unchanged in last 2-4 wk.


InterventionsT1) Auto-traction and modified Gertrud Lind: traction force between 33% and 100% of participant's body weight; each pull for some seconds and sometimes up to 2 min. Every treatment lasted about 1 hour.

T2) Manual traction and modified manual therapy. Traction force scarcely reached 300 N. Static traction given twice, each pull lasting for 5 min.


OutcomesImmediately AT: overall assessment: no effect (number) T1) 21, T2) 15. Moderate effect (number): T1) 2, T2) 4. Good effect (number) T1) 3, T2) 4. At 2 wk: overall assessment: no effect (number) T1) 21, T2) 16. Moderate effect (number): T1) 1, T2) 4. Good effect (number) T1) 4, T2) 3. At 3 months: identical to results at 2 wk.
Pain intensity (VAS) median (SD): BT: T1) 1.3 (0.3-3.5), T2) 3.5 (0.9-6.0). AT: T1) 0.8 (0-1.8), T2) 1.6 (0.2-3.0).


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
Low riskParticipants were not informed about their participation in a randomized investigation with 2 treatment modalities.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskThere is no mention of blinding of the care providers, but it is unlikely that they were.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskThe outcome assessor was blinded to the treatment allocation.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low risk3 participants (5.8%) were lost to follow-up.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
High riskNo intention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)High riskGroups were not similar at baseline with regards to level of herniation, duration since first symptoms of sciatica and pain intensity in the lower back.

Influence of co-interventions (performance bias)Low riskParticipants were deprived of long-term working analgesics later than hours prior to the traction session.

Compliance with interventions (performance bias)Low riskAll participants were hospitalized, therefore, the compliance with the given treatment was high.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Ljunggren 1992

MethodsRCT (method of randomization not described)


Participants50 participants (27 males, 23 females, aged 16-62 years) admitted to the department of neurology were included. Inclusion criteria: radiating pain, neurological symptoms and signs confirmed by a myelogram. Participants with previous spinal surgery, spondylolisthesis and root entrapment were excluded. The males had a mean duration of symptoms for 4.8 months, and the females for 5.3 months.


InterventionsT) Traction: continuous manual (static) traction. The therapist exerted traction by gently leaning backwards against a belt placed around the back or hips, and attached below the knees of the participant. The traction force reached approximately 300 N. Repeated relief of pain was guiding factor; once per day for 10 min (in a few cases twice per day for 5 min).
C) Comparison intervention: isometric exercises for the abdominal, back, hip and thigh muscles. Education about importance of these muscles was given. Contractions 6-8 sec, repeated 5-10 times, daily session approximately 20 min.
Following treatment, all participants were instructed to lie in the most comfortable positions for 2 hours. Treatment for all participants lasted 5-7 days.


OutcomesPain alleviation (1-10 VAS): pain-free or improved: T) 10 of 24 participants (41.6%), C) 10 of 26 participants (38.5%). Pain unchanged or worse: T) 14 of 24 participants (58.3%), C) 16 of 26 participants (61.5%).
No significant difference between the 2 treatment groups found.
4 participants of each group deteriorated temporarily in connection with the treatment given.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskParticipants were not blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskCare providers were not blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskOutcome assessors were blinded.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Unclear riskIt is not clear how many participants were lost to follow-up.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Unclear riskIt is not clear whether an intention-to-treat analysis was used.

Selective reporting (reporting bias)High riskPublished results did not include all prespecified outcomes: straight leg raising, mobility and ADL.

Group similarity at baseline (selection bias)Low riskGroups were similar at baseline with respect to age, sex, habits of physical therapy and symptoms.

Influence of co-interventions (performance bias)Low riskNo co-interventions were used, except for analgesics.

Compliance with interventions (performance bias)Low riskAll participants were hospitalized.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Mathews 1975

MethodsRCT, participants were allocated at random to either control or treatment groups (method of randomization not described).


Participants27 participants (9 female and 18 male, aged 20-60 years). Participants had sciatica or cruralgia of at least 3 wk' duration with or without back pain. Back movement was required to be limited in at least 1 direction and either the sciatic or femoral nerve stretch test positive. All had root pain. Exclusion criteria: a recently acquired neurological deficit, psychological disturbance, were pregnant, a radiological evidence of sacro-iliitis or osteoporosis, previous traction.


InterventionsT) Traction: traction on a plain couch using a force of at least 36.3 kg applied through a pelvic harness, the trunk being restrained by a thoracic harness; 30 min per day, 5 days per wk, 3 wk.
C) Comparison intervention: sham traction; same routine as above except the traction did not exceed 9.1 kg.


OutcomesMean improvement in pain (VAS): T) 28.8%, C)18.9%. Not statistically significant.


NotesControl group was low force traction.
Small sample.
Authors cited an improvement but it was not statistically significant. Questioned whether larger trial would have shown significance.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
Low riskParticipants were blinded. A sham condition was used.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskNo mention of attempts to blind the care providers. It is unlikely that the care providers were blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
High riskNo mention of attempts to blind the outcome assessors. It is unlikely that the outcome assessors were blinded.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Unclear riskIt is not clear how many participants were lost to follow-up.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Unclear riskIt is not clear whether an intention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)High riskGroups were not similar at baseline with regards to age and heavy work.

Influence of co-interventions (performance bias)Low riskNo co-interventions were used.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Mathews 1988

MethodsRCT, participants were allocated to treatment or control by the study methodologist, using a predetermined randomization system.


Participants143 participants (63 females, 80 males, aged 20-60 years), referred from a rheumatology clinic or general practitioner were included. Participants had low backache or pain, local tenderness, asymmetrical restriction of movement, limited straight leg raise and root pain with in the past 3 months.


InterventionsT) Traction: continuous auto-traction at level required to relieve pain (usually approximately 45 kg), for 30 min, 5 days per wk, until pain was relieved, but for a maximum of 3 wk.
C) Comparison intervention: 3 times per wk infrared heat treatment to the low back area at 60 cm for 15 min.


OutcomesParticipant's assessment of pain (6-point scale). Number recovered (10-18 days, 1 year): T) 40/77 (52%), 30/83 (36%); C) 27/54 (50%), 11/60 (18%). The 10-18 day and 1 year outcomes are based on different numbers of participants in each group. On 8th day, more than twice the number treated people as controls were recovered (statistically significant)


NotesData inconsistent between text and graph.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskParticipants were not blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskCare providers were not blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskOutcome assessors were blinded.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Unclear riskIt is not clear how many participants were lost to follow-up.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Unclear riskIt is not clear whether an intention-to-treat analysis was used or not.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Unclear riskNo description of baseline characteristics given. No baseline table was added to the article.

Influence of co-interventions (performance bias)Unclear riskIt is not clear whether co-interventions were part of treatment protocol or whether co-interventions were allowed besides the treatment that was part of the protocol.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Ozturk 2006

MethodsRCT; method unknown.


Participants46 participants (24 in the traction group, 22 in the control group) hospitalized with the diagnosis of lumbar disc herniation. Participants had LBP or sciatica, pain duration < 6 months and lumbar disc herniation verified by CT scan. People with LBP due to neoplastic, inflammatory, infectious or metabolic causes were excluded. Mean age: T) 40.2 years, C) 52.7 years.


InterventionsT) Traction: physiotherapy programme, including hot pack, ultrasound and diadynamic current, and traction: continuous lumbar traction with Enraf Nonius Traction Eltrac 439. In total, 15 sessions, 5 sessions per wk, 15 min per session, traction force 255-0% of body weight.

C) Comparison intervention: physiotherapy programme without traction.


OutcomesAssessment before and immediately AT. VAS for pain (mean (SD)) AT: T) 2.4 (1.7), C) 3.6 (2.7).


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskNo mention of attempts to blind the participants. It is unlikely that the participants were blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskNo mention of attempts to blind the care providers. It is unlikely that the care providers were blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
High riskNo mention of attempts to blind the outcome assessors.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Unclear riskIt is not clear how many participants were lost to follow-up.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Unclear riskIt is not clear whether an intention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Unclear riskNo mention of group characteristics at baseline.

Influence of co-interventions (performance bias)Low riskNo co-interventions were used during the treatment period.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Unclear riskUnclear at what time outcome assessments (for all intervention groups) were measured.

Pal 1986

MethodsRCT, participants were randomly allocated to groups A and B (method of randomization not described).


Participants39 participants (23 male (mean age 38 years) and 16 female (mean age 39 years) were admitted to hospital for back pain and sciatica. Mean duration of pain: T) 42 days, C) 56 days. Neurological deficits at baseline: T) 50% of participants, 73% of participants.


InterventionsT) Traction: continuous mechanical traction of 5.5-8.2 kg according to body weight, 2-6 wk (n = 25).
C) Comparison intervention: sham traction (continuous mechanical) of 1.4-1.8 kg, 2-6 wk (n = 14).
Both methods were applied with the participant supine on a tilted bed by means of a pelvic harness pulled by metal weights over a pulley.


OutcomesPain score (0-100 VAS) baseline, 1 wk, 2 wk, 3 wk: T) 50, 25, 6, 5; C) 50, 15, 9, 3.
No significant differences between groups. Number of participants returned to work, < 3 months, 3-6 months, > 6 months: T) 7, 6, 5; C) 3, 4, 2.


NotesUsed median scores.
Timing or RTW measures not clear.
Conclusion is that all recovered, may be due to enforces immobilization. Suggest that "minimal wt traction at home as compliment to complete bed rest may have important place".
Data inconsistent between text and graph.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
Low riskThe participants were not aware of the amount of traction and, therefore, were blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
Low riskThe ward sister was responsible for allocation. All other care providers were blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskThe outcome assessors were not aware of the amount of traction and, therefore, were blinded.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low risk2 participants (4.9%) did not complete the trial: 1 participant in each group withdrew after a few days because of home circumstances.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
High riskNo intention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)High riskGroups were not similar at baseline. 24 participants were allocated to T and 15 participants were allocated to C.

Influence of co-interventions (performance bias)Low riskNo co-interventions were used.

Compliance with interventions (performance bias)Low riskTreatment was well tolerated by both groups. Participants were hospitalized.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Reust 1988

MethodsRCT, participants were randomized to 1 of 3 groups by a table of randomization.


Participants60 participants (35 male, 25 female, mean age 50.8 years) hospitalized for back pain, with or without neurological deficits, were included. Exclusion criteria: previous traction, fast progressing neurological deficit, behavioural problems, or bone aliments that may have caused the back pain. Duration of back pain unknown.


InterventionsTraction:
T1) Continuous mechanical traction on an Eltrac 439. 5-kg force on day 1, 10 kg on day 2, 15 kg on day 3, increasing 5 kg each day up to a maximum of 50 kg. 10 min per day, 12 sessions, 12 days. Participants also received medication, 20 min lumbar 'parafango' per day, 20 min massage per day and strict bed rest.
T2) Same as above, except traction force of up to maximum of 15 kg.
C) Comparison intervention: same as above, except traction force to maximum of 5 kg.


OutcomesPain (100-mm VAS): T1) 33.61 (29.55), T2) 30.68 (26.83), C) 30.25 (26.23).
No significant difference between groups.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskTransformed from old format to new format.

Allocation concealment (selection bias)Unclear riskTransformed from old format to new format.

Blinding (performance bias and detection bias)
All outcomes - participants
Low riskTransformed from old format to new format.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskTransformed from old format to new format.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskTransformed from old format to new format.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Unclear riskTransformed from old format to new format.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Low riskTransformed from old format to new format.

Selective reporting (reporting bias)Unclear riskTransformed from old format to new format.

Group similarity at baseline (selection bias)High riskTransformed from old format to new format.

Influence of co-interventions (performance bias)Low riskTransformed from old format to new format.

Compliance with interventions (performance bias)High riskTransformed from old format to new format.

Timing of outcome assessments (detection bias)Unclear riskTransformed from old format to new format.

Schimmel 2009

MethodsRCT; computer-generated random block lists and adequate allocation procedure.


Participants60 participants randomly allocated to 2 treatment groups (31 to the traction group, 29 to the sham group). All participants had LBP for > 3 months. Exclusion criteria were previous surgical treatment and radicular leg pain. Mean age: T) 42 years, C) 46 years.


InterventionsT) Traction: intervertebral differential dynamics therapy: 20 sessions during 6 wk, 25-30 min per session, traction force 50% of body weight. After 2 wk a standard graded activity programme was added to the traction sessions, which consisted of 1-hour training for 2 days per wk during a total of 12 wk.

C) Comparison intervention: same as traction group, except for traction force of < 10% of body weight.


OutcomesAssessment at 2, 6 and 14 wk. VAS LBP (mean change (SD)) at 14 wk: 32 (26.8) in the intervertebral differential dynamics group vs. 36 (27.1) in the sham group. Significant improvement during the treatment period in both intervertebral differential dynamics and sham group for the ODI, SF-36 and VAS leg pain.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandomization through computer-generated random block lists.

Allocation concealment (selection bias)Low riskNumbered, sealed envelopes.

Blinding (performance bias and detection bias)
All outcomes - participants
Low riskThe participant was not informed about the intervention received until after the 14 wk' follow-up.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskThe care provider was not blinded for the assigned treatment.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskFollow-up evaluation was carried out by an independent assessor, who was blinded to the treatment.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low risk4 participants were lost to follow-up (7%): 1 from the T group, 3 from the C group.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
High riskNo intention-to-treat analysis was used.

Selective reporting (reporting bias)High riskPublished results did not include all prespecified outcomes: outcome assessments at 2 and 6 wk were not included or could not be extracted from the graphs.

Group similarity at baseline (selection bias)Low riskNo significant between-group differences at baseline.

Influence of co-interventions (performance bias)Unclear riskIt is not clear whether co-interventions were allowed during the treatment period or whether co-interventions were part of treatment protocol.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Sherry 2001

MethodsRCT; participants randomized in sequential order and treatments determined by predefined central randomization list.


Participants44 participants recruited through advertisements in local newspapers. Inclusion criteria: pain of > 3 months' duration, associated leg pain and confirmed disc protrusion or herniation on CT scan or MRI. (T) 11 male, 11 female; C) 12 male, 10 female; age (mean/range) T) 41/27-57, C) 43/27-55; chronicity (mean/range years) T) 8.4/0.25-30, C) 6.2/0.5-28.


InterventionsT) Traction: VAX-D: participant grasps handgrips with arms extended above head; pelvic harness connected to tensionometer, which provides feedback to programmed logic control and operating system; tension applied from baseline tension to therapeutic range of 50-95 lbs, with sessions 30 min long, comprising 15 cycles of decompression and relaxation. 5 sessions/wk over 4 wk, then once/week for 4 wk.
C) Comparison intervention: transcutaneous electrical nerve stimulation treatment 30 min per day for 20 days, then once per wk for 4 wk.


OutcomesPost-treatment (8 wk): pain (10-cm VAS: pre/post): T) 5.99/1.85, C) 5.44/5.97. Disability (4-point self rating scale where 1 = cannot to, 4 = can do without limitation) (pre/post): T) 2.2/2.9, C) 2.2/2.2.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskParticipants were not blinded to treatment allocation.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskNo mention of attempts to blind the care providers. It is unlikely that the care providers were blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
High riskNo mention of attempts to blind the outcome assessors.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low risk2 participants (4.5%) did not complete the study: 1 participant from each group.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
High riskNo intention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Low riskGroups were similar at baseline.

Influence of co-interventions (performance bias)Low riskNeither group received any physiotherapy modalities, epidural steroid injections or other treatments during the trial. Both groups were allowed to take non-narcotic analgesics and anti-inflammatory medication if necessary.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for both groups were measured at the same time.

Simmerman 2011

MethodsRCT; flip of a coin followed by an inadequate allocation procedure.


Participants61 participants randomly allocated to 2 treatment groups (31 in the land-based supine flexion first group, 30 to the aquatic vertical traction first group). All participants had LBP and sciatica. Participants with neurological disorders or vertebral fractures were excluded. Mean age: T) 59.9 years, C) 59.3 years. Mean duration of pain complaints: T) 1.7 years, C) 8.9 years.


InterventionsT) Traction: 1 session of aquatic vertical traction for 15 min with the use of 2 x 2-3 kg ankle weights, followed by 1 session of land-based supine flexion.

C) Comparison intervention: flexion group; 1 session of land-based supine flexion, followed by 1 session of aquatic vertical traction.


OutcomesAssessment at 2-7 days following treatment. Decrease in pain (mean (SD)) on a numerical rating scale (0-10 cm) after the first intervention: T) 2.7 (2.1), C) 1.7 (1.7).


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskFlip of a coin.

Allocation concealment (selection bias)Unclear riskFlip of a coin for the first subject, followed by assignment of all uneven-numbered subjects to the land-based supine flexion position as their first intervention and all even-numbered subjects to the aquatic vertical traction position.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskParticipants were not blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskCare providers were not blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
High riskOutcome assessors were not blinded.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low riskNo participants were lost to follow-up.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Low riskIntention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Low riskThere were no statistical differences between groups in terms of age, sex, body mass index, clinical signs and symptoms.

Influence of co-interventions (performance bias)Unclear riskIt is not clear whether co-interventions were allowed during the treatment period or whether they were part of the treatment protocol.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Sweetman 1993

MethodsRCT, randomization was organized by placing the sequentially numbered treatment folders in a random order according to Documenta Geigy random number tables.


Participants400 participants (200 males and 200 females, aged 14-78 years) referred from general practice. Inclusion criteria: LBP of sufficient severity to warrant PT, pain for > 1 wk. Exclusion criteria: serious causes for back pain including fractures, infection and malignancy, pregnancy, inflammatory arthritis, bone diseases, where physician suspected that treatments may precipitate or exacerbate spinal cord or nerve root compromise, when other therapy was specifically indicated, recent steroid injections, intercurrent treatment other than routine oral medication.


InterventionsT) Traction: continuous mechanical traction, constant pull (10 min), 1st wk 33% body weight, 2nd wk 50% body weight, 3 times per wk.
Comparison interventions:
C1) Shortwave diathermy: 20 min, 3 times per wk, 2 wk.
C2) Sham shortwave diathermy: once participant felt heat, output was turned down to minimum, 20 min, 3 times per wk, 2 wk.
C3) Extension exercises: hump and hollow, alternate leg raise, alternate arm raise, opposite leg and arm raise (prone kneeling). Bridging (crouch lying), alternate leg raise, clasp hands behind head and shoulder, and both leg raise, head and shoulder raise (prone lying), 3 times per wk, 2 wk.


OutcomesParticipant opinion of overall effect (better) at 2 wk: T) 49, C1) 39, C2) 37, C3) 45. Not statistically significant.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number tables.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskNo mention of attempts to blind the participants. It is unlikely that the participants were blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskNo mention of attempts to blind the care providers. It is unlikely that the care providers were blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Unclear riskNo mention of attempts to blind the outcome assessors.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low risk51 participants (12.8%) failed to attend for follow-up.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Low riskIntention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Low riskGroups were similar at baseline.

Influence of co-interventions (performance bias)Unclear riskIt is not clear whether co-interventions were allowed during the treatment period or whether they were part of the treatment protocol.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Tesio 1993

MethodsRCT, participants allocated at random (method of randomization not described).


Participants44 participants (25 males, 19 females, aged 23-63 years), referred from an outpatient service of a rehabilitation unit in a large teaching hospital.
Inclusion criteria: LBP with or without radiation, duration > 1 month, herniation or protrusion, failure of 1 or more conservative approaches. Exclusion criteria: neoplastic, inflammatory or metabolic causes of back pain, or indication for urgent surgery.


InterventionsTraction:
T1) Intermittent auto-traction, participant provides traction force by pulling vigorously on the bar at the head of the table for a period of 3-6 sec, 1 min rest, 30-60 min session, every 2nd or 3rd day, total 3-10 sessions. If the participant reported benefit, the treatment was continued for 3-6 more sessions until no further improvement.
T2) Passive traction. Traction force was adjusted approximately every 10 min, 35% of body weight, 45 min, daily bases for 5-10 sessions.


OutcomesImmediate outcomes (improved): T1) 17 of 22 participants, T2) 4 of 22 participants (statistically significant).

Cross-over: non-responders to either treatment were crossed over to the other modality after a delay of 4-5 days.


NotesMost results given for only auto-traction responses (they openly favoured the treatment of the researchers).


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
Low riskNo mention of attempts to blind the participants. It is likely that the participants were blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskNo mention of attempts to blind the care providers. It is unlikely that the care providers were blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Unclear riskNo mention of attempts to blind the outcome assessors.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Unclear riskIt is not clear how many participants were lost to follow-up.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
High riskNo intention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Low riskNo significant differences were found between groups with respect to sex, age, pain duration and score, presence of positive straight leg raise test or neural deficits, presence of more than 1 disc affected, presence of spinal stenosis, history of previous episodes and possible psychological bias.

Influence of co-interventions (performance bias)High riskCo-interventions were allowed.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)High riskAll important outcome assessments for all intervention groups were not measured at the same time. The auto-traction group was evaluated after 3 sessions, whereas the passive traction group was assessed after 5 treatment sessions.

Unlu 2008

MethodsRCT; method of randomization unclear.


Participants60 participants (20 in the traction group, 20 in the ultrasound group and 20 in the low power laser group) with acute LBP and leg pain that was definitely being caused by lumbar disc herniation. All participants had complaints of sciatica. Mean age: T) 42.5 years, C1) 48.2 years, C2) 42.8 years. Symptom duration: T) 47.9 days, C1) 36.8 days, C2) 49 days.


InterventionsT) Traction: standard motorized traction therapy system (Tru-Trac 401) for 15 min per session, traction force 35-50% of total body weight.

Comparison interventions:

C1) Ultrasound treatment, using 1 MHz at an intensity of 1.5 W/cm2, at the right and left sides of the lumbar region. The ultrasound head was moved using small, continuous, circular movements for 8 min.

C2) Laser: a Gal-Al-As diode laser device (Endolaser 476) at power input of 50 mV and wavelength of 830 nm. Diameter of the laser beam was 1 mm. Stimulation time of 4 min at each point (both sides of the herniated disc).


OutcomesAssessment BT, AT and at 1 and 3 months.

VAS for LBP (mean (SD)): T) BT 58.2 (18.1), AT 29.5 (16.4), 1 month 25.5 (13.3), 3 months 31.3 (16.4); C1) BT 51.7 (18.7), AT 29.7 (17.9), 1 month 27.2 (18.6), 3 months 26.9 (15.2); C2) BT 54.0 (17.0), AT 34.4 (18.9), 1 month 30.7 (19.1), 3 months 30.0 (16.9).

VAS for radicular pain (mean (SD)): T) BT 59.6 (15.4), AT 27.7 (15.4), 1 month 21.8 (15.4), 3 months 29.5 (16.7); C1) BT 56.0 (15.3), AT 29.1 (14.4), 1 month 26.8 (18.6), 3 months 25.2 (13.9); C2) BT 53.1 (25.9), AT 32.9 (23.6), 1 month 25.6 (21.1), 3 months 23.6 (17.7).

RMDQ (mean (SD)): T) BT 14.2 (4.3), AT 9.8 (3.9), 1 month 8.5 (3.5), 3 month 8.9 (4.0); C1) BT 13.4 (4.5), AT 9.3 (5.7), 1 month 8.2 (6.0), 3 month 8.6 (6.0); C2) BT 12.5 (5.0), AT 9.9 (4.1), 1 month 7.3 (4.3), 3 months 6.7 (4.5).

MODQ (mean (SD)): T) BT 19.3 (5.3), AT 14.6 (4.7), 1 month 13.5 (5.0), 3 months 14.9 (4.9); C1) BT 19.6 (6.4), AT 14.4 (5.0), 1 month 14.3 (5.5), 3 months 14.4 (5.9); C2) BT 18.4 (7.1), AT 14.7 (6.0), 1 months 13.5 (5.9), 3 months 13.6 (6.2).


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskNo mention of attempts to blind the participants. It is unlikely that the participants were blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskNo mention of attempts to blind the care providers. It is unlikely that the care providers were blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskOutcome assessor was blinded to treatment allocation during the assessments.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low riskNo loss to follow-up.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Low riskIntention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Low riskNo statistically significant differences between groups.

Influence of co-interventions (performance bias)Low riskCo-interventions were not allowed during the treatment period. After the treatment period, participants were asked to restrict further treatment as much as possible.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Van der Heijden 1995

MethodsRCT (using sealed envelopes allocated from a list of random numbers)


Participants25 participants (13 men, 12 women) recruited from hospital setting. Mean (SD) age: T) 46(8); C) 47(8). At baseline: mean duration: T) 18% < 6 months, 82% > 24 months; C) 17% < 6 months, 83% > 24 months. Severity: mean (SD) on pain VAS: T) 47 (27), C) 37 (23). Radiation: T) 73%, C) 58%.


InterventionsT) Continuous traction: force slowly increased from 30% of body weight until participant indicated a distinct but tolerable pulling; maximum force 30-50% of body weight.
C) Comparison intervention: force slowly increased from zero until participant indicated a little pulling. Maximal force 25% of body weight.
For both groups: 10-12 sessions during 4 consecutive wk; also received leaflet about LBP and ADL.


OutcomesVAS at 5 wk (median improvement): T) 14, C) 16. Difference (95% CI): 2 (-29 to 14).
VAS at 9 wk (median improvement): T) 14, C) 4. Difference (95% CI): -10 (-31 to 17).
Global improvement/recovery at 5 wk (% recovered): T) 54, C) 34. Difference (95% CI): 20% (-18% to 58%).
Global improvement/recovery at 9 wk (% recovered): T) 38, C) 25. Difference (95% CI): 13% (-25% to 51%).


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number list.

Allocation concealment (selection bias)Low riskTreatment allocation with sealed envelopes with a code for either treatment group. Envelopes were prepared by an independent person.

Blinding (performance bias and detection bias)
All outcomes - participants
Low riskParticipants were blinded to treatment allocation.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskCare providers were not blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
High riskOutcome assessors were not blinded.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low risk4 participants (16%) were lost to follow-up: 3 from the traction group and 1 from the comparison group.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Low riskIntention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Low riskBoth groups were comparable with respect to age, sex and back pain history.

Influence of co-interventions (performance bias)Low riskNo co-interventions were allowed for the duration of the treatment period.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Walker 1982

MethodsRCT, methods of randomization judged adequate.


Participants29 participants (18 male, 11 female, mean age: T) 37.8 years, C) 37.3) chosen by a specialist in neurology at the department of neurology in a hospital in Oslo, Norway. Non-specific LBP and radiating pain, of mixed duration (18 subjects with pain > 12 wk; 11 with < 12 wk).


InterventionsT) Traction: Spina-Trac according to Myrin; 20 min daily with 2 hours rest afterwards, for 4-8 days. 40-70 kiloponds force. Other: "traditional regimen for sciatica: 1 wk of strict bed-rest, back school, unspecified analgesics when needed (but never in morning BT sessions).
C) Comparison intervention: sham traction. Same as (T) except that forces greater than 10 kiloponds not possible.


OutcomesPain (number improved, unchanged or worse). T) 4, 13. C) 2, 10 (not statistically significant).
Lasègue (number improved, unchanged or worse). T) 7, 10. C) 2, 10 (not statistically significant).
Mobility (number improved, unchanged or worse). T) 4, 13. C) 2, 10 (not statistically significant).


NotesUnderpowered study with invalid pain outcome measure.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskTransformed from old format to new format.

Allocation concealment (selection bias)Unclear riskTransformed from old format to new format.

Blinding (performance bias and detection bias)
All outcomes - participants
Low riskTransformed from old format to new format.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskTransformed from old format to new format.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskTransformed from old format to new format.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Unclear riskTransformed from old format to new format.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Unclear riskTransformed from old format to new format.

Selective reporting (reporting bias)Unclear riskTransformed from old format to new format.

Group similarity at baseline (selection bias)High riskTransformed from old format to new format.

Influence of co-interventions (performance bias)Low riskTransformed from old format to new format.

Compliance with interventions (performance bias)Low riskTransformed from old format to new format.

Timing of outcome assessments (detection bias)Unclear riskTransformed from old format to new format.

Weber 1973

MethodsNo randomization methods mentioned.


Participants72 participants (42 men, 32 women, 85% aged 30-60 years), admitted to neurology department. All had radiating pains and neurological signs corresponding to a lesion in the L5 or S1 root (or both), positive radiculogram. Exclusion criteria: people with bladder paresis, strong persistent pains, acutely occurring pareses or considerable constraint of the spinal column (or both). Duration unknown.


InterventionsT) Traction: intermittent mechanical traction, 33% of body weight, Tru-Trac motor, 5-sec pauses, 20 min once per day for 5-7 days.
C) Comparison intervention: sham traction with a force of up to 7 kg, 20 min once per day for 5-7 days.


OutcomesBack pain (improved): T) 14 of 37 participants, C) 15 of 35 participants. Leg pain (improved): T) 19 of 37, C) 16 of 35.
No difference between the groups.


NotesDid not test for statistical significance.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
Low riskParticipants were not informed as to the amount of traction applied, therefore, they were blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskNo mention of attempts to blind the care providers. It is unlikely that the care providers were blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskThe investigator was not informed as to which participant belonged to which group, therefore, the outcome assessor was blinded.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low risk14 participants were lost to follow-up: 6 in the traction group and 8 in the comparison group.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
High riskNo intention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Unclear riskNo description of baseline characteristics, no baseline table included.

Influence of co-interventions (performance bias)Low riskNo co-interventions were allowed/administered during the treatment period.

Compliance with interventions (performance bias)Low riskParticipants were hospitalized during the course of treatment.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Weber 1984

MethodsRCT, allocation to the treatment groups was done by randomization (method of randomization not described).


Participants94 participants (54 males, 40 females). All had sciatica, radiating pain, neurological symptoms and signs corresponding to a lesion of the L5 or S1 root and positive radiculogram. Exclusion criteria: spondylolisthesis or previous operations of the spine, root entrapment caused mainly by hypertrophic facet joints or a narrow bony canal in the last 3 studies. Duration unknown.


InterventionsTraction:
T1) Spina-Trac, intermittent manual traction, force 40-70 Kp for 10-12 sec followed by rest. 20 min once per day.
T2) Continuous manual traction, therapist exerted traction by gently leaning back against a belt placed below the knees of participant, force < 30 Kp.
Comparison intervention:
C1) Simulated traction (for comparison against Spina-Trac).
C2) Isometric exercises (for comparison against continuous manual traction).

Duration of treatment unknown.


OutcomesImproved (overall assessment): T1) 5 of 21 participants, T2) 10 of 24 participants, C1) 5 of 23 participants, C2) 10 of 26 participants.
No significant difference between T1 and C1. No significant difference between T2 and C2. Temporary, immediate relief of pain obtained in the manual traction group, but not in the exercise group.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo mention of randomization procedure.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
Low riskStudy 1: participants were blinded for treatment allocation.

Study 2: no mention of attempts to blind the participants, but it is unlikely that the participants were blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskNo mention of attempts to blind the care providers, but it is unlikely that the care providers were blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
Low riskStudy 1: without knowledge of the method used, a neurologist recorded the results.

Study 2: without knowledge of the method used, a physiotherapist recorded the results.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low riskStudy 1: 4 participants (9.1%) were lost to follow-up: 6 from the treatment group and 8 from the control group.

Study 2: 1 participant (2%) was lost to follow-up.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
High riskNo intention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Unclear riskNo description of baseline characteristics, no baseline table provided.

Influence of co-interventions (performance bias)Low riskExcept for analgesics, no co-interventions were allowed during the treatment period.

Compliance with interventions (performance bias)Low riskParticipants were hospitalized.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

Werners 1999

MethodsRCT, randomization was done by the orthopaedic practitioner using a minimization computer program.


Participants147 participants (79 males, 68 females, mean age 38.75 years). Entry criterion was LBP severe enough to warrant seeking the help of an orthopaedic general practitioner. Participants with sciatica not excluded. No participant had objective neurology Exclusion: age < 20, > 60 years, previous surgery, significant medical condition and spinal disorder demonstrable on plain x-ray.


InterventionsT) Traction: motorized, intermittent lumbar traction, with simultaneous massage applied by 2 motorized, mechanical wheels moving up and down the spine while the participant is lying on their back, 10-20 kg, 6 sessions, 2-3 wk.
C) Comparison intervention: interferential therapy, standard Galva electrotherapy system, 6 sessions, 2-3 wk.


OutcomesODI 1st, 2nd, 3rd visit: T) 29.5 (14.8), 24.5 (15.0), 21.7 (14.7); C) 29.7 (15.1), 25.4 (14.0), 21.1 (14.6).
Pain (VAS 1-100) 1st, 2nd, 3rd visit: T) 50.6 (15.1), 44.3 (14.7), 39.2 (13.5); C) 49.7 (13.3), 45.5 (13.7), 42.0 (12.8).
No differences between groups.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskMinimization computer program with stratification.

Allocation concealment (selection bias)Unclear riskNo information provided on allocation concealment.

Blinding (performance bias and detection bias)
All outcomes - participants
High riskParticipants were not blinded.

Blinding (performance bias and detection bias)
All outcomes - providers
High riskCare providers were not blinded.

Blinding (performance bias and detection bias)
All outcomes - outcome assessors
High riskOutcome assessors were not blinded.

Incomplete outcome data (attrition bias)
All outcomes - loss to follow-up
Low risk24 participants (16%) were lost to follow-up.

Incomplete outcome data (attrition bias)
All outcomes - intention to treat analysis
Low riskIntention-to-treat analysis was used.

Selective reporting (reporting bias)Low riskPublished results included all prespecified outcomes.

Group similarity at baseline (selection bias)Low riskThe demographics of the participants entering were similar for both groups with respect to age, sex, type of work, sick leave, weight, height and previous treatment for back pain.

Influence of co-interventions (performance bias)Unclear riskIt is not clear whether co-interventions were allowed during the treatment period or whether they were part of the treatment protocol.

Compliance with interventions (performance bias)Unclear riskNot mentioned.

Timing of outcome assessments (detection bias)Low riskAll important outcome assessments for all intervention groups were measured at the same time.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Cevik 2007Study was not randomized.

Gose 1998Study was not an RCT.

Hansen 1993Used low-force traction as a sham treatment and included regular traction as 1 component of a physiotherapy programme.

Moret 1998Article described a feasibility study, not a full trial.

Olah 2008Study was not randomized.

Ramos 1994Study is not an RCT; outcome is intradiscal pressure.

Van der Heijden 1991Pilot study only, in preparation for Van der Heijden 1995.

 
Comparison 1. Low-back pain with/without radiation, traction versus placebo, sham or no treatment

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain intensity2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    1.1 3-5 weeks
2247Mean Difference (IV, Fixed, 95% CI)-18.49 [-24.12, -12.87]

    1.2 6-12 weeks
1150Mean Difference (IV, Fixed, 95% CI)0.30 [-9.91, 10.51]

    1.3 6 months
1150Mean Difference (IV, Fixed, 95% CI)-0.5 [-11.55, 10.55]

    1.4 1 year
197Mean Difference (IV, Fixed, 95% CI)-9.10 [-19.32, 1.12]

 2 Functional status1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    2.1 3-5 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.2 6-12 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.3 6 months
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Global improvement2Risk Difference (M-H, Fixed, 95% CI)Subtotals only

    3.1 3-5 weeks
2175Risk Difference (M-H, Fixed, 95% CI)-0.03 [-0.17, 0.12]

    3.2 6-12 weeks
2175Risk Difference (M-H, Fixed, 95% CI)0.03 [-0.12, 0.18]

    3.3 6 months
1150Risk Difference (M-H, Fixed, 95% CI)0.02 [-0.14, 0.18]

 4 Return to work (days)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    4.1 3-5 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.2 6-12 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    4.3 6 months
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 2. Low-back pain with/without radiation, physiotherapy with traction versus physiotherapy without traction

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain intensity1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 1-2 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 12-16 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Functional status1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    2.1 1-2 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.2 12-16 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Global improvement1Risk Difference (M-H, Fixed, 95% CI)Totals not selected

    3.1 1-2 weeks
1Risk Difference (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 12-16 weeks
1Risk Difference (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 3. Low-back pain with/without radiation, two types of traction

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Global improvement2Risk Difference (M-H, Fixed, 95% CI)Subtotals only

    1.1 1-2 weeks
293Risk Difference (M-H, Fixed, 95% CI)0.35 [0.17, 0.54]

 
Comparison 4. Low-back pain with/without radiation, traction versus other treatment

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain intensity4Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 1-2 weeks
2Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 3-5 weeks
2Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.3 12-16 weeks
2Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.4 6 months
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.5 1 year
2Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Functional status2Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only

    2.1 1-2 weeks
1138Std. Mean Difference (IV, Fixed, 95% CI)-0.06 [-0.40, 0.27]

    2.2 3-5 weeks
1235Std. Mean Difference (IV, Fixed, 95% CI)0.20 [-0.05, 0.46]

    2.3 12-16 weeks
2290Std. Mean Difference (IV, Fixed, 95% CI)-0.03 [-0.26, 0.21]

    2.4 6 months
1168Std. Mean Difference (IV, Fixed, 95% CI)0.15 [-0.16, 0.45]

    2.5 1 year
1173Std. Mean Difference (IV, Fixed, 95% CI)0.04 [-0.25, 0.34]

 3 Global improvement3Risk Difference (M-H, Fixed, 95% CI)Totals not selected

    3.1 1-2 weeks
2Risk Difference (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 3-5 weeks
2Risk Difference (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.3 12-16 weeks
1Risk Difference (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 5. Low-back pain with radiation, traction versus placebo, sham or no treatment

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain intensity2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    1.1 1-2 weeks
279Mean Difference (IV, Fixed, 95% CI)2.93 [-14.73, 20.59]

    1.2 3-5 weeks
139Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Global improvement5Risk Difference (M-H, Fixed, 95% CI)Subtotals only

    2.1 1-2 weeks
4398Risk Difference (M-H, Fixed, 95% CI)0.13 [0.04, 0.22]

    2.2 3-5 weeks
2123Risk Difference (M-H, Fixed, 95% CI)0.27 [0.12, 0.43]

    2.3 12-16 weeks
181Risk Difference (M-H, Fixed, 95% CI)0.06 [-0.16, 0.28]

 3 Return to work1Risk Difference (M-H, Fixed, 95% CI)Subtotals only

    3.1 2 years
139Risk Difference (M-H, Fixed, 95% CI)0.15 [-0.15, 0.45]

 
Comparison 6. Low-back with radiation, physiotherapy with traction versus physiotherapy without traction

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain intensity2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    1.1 1-2 weeks
2110Mean Difference (IV, Fixed, 95% CI)-7.96 [-16.53, 0.61]

    1.2 6 weeks
164Mean Difference (IV, Fixed, 95% CI)2.0 [-10.02, 14.02]

 2 Functional status2Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only

    2.1 1-2 weeks
294Std. Mean Difference (IV, Fixed, 95% CI)-0.08 [-0.49, 0.32]

    2.2 6-12 weeks
164Std. Mean Difference (IV, Fixed, 95% CI)0.14 [-0.35, 0.63]

    2.3 12-16 weeks
130Std. Mean Difference (IV, Fixed, 95% CI)0.43 [-0.30, 1.16]

    2.4 6 months
130Std. Mean Difference (IV, Fixed, 95% CI)0.18 [-0.54, 0.90]

 3 Global improvement3Risk Difference (M-H, Fixed, 95% CI)Totals not selected

    3.1 1-2 weeks
1Risk Difference (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 3-5 weeks
1Risk Difference (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.3 6 weeks
1Risk Difference (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.4 12-16 weeks
1Risk Difference (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 4 Return to work1Odds Ratio (M-H, Fixed, 95% CI)Totals not selected

    4.1 3-5 weeks
1Odds Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 7. Low-back pain with radiation, traction versus other treatment

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain intensity2Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 1-2 weeks
2Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.2 3-5 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    1.3 12-16 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 2 Functional status2Std. Mean Difference (IV, Fixed, 95% CI)Totals not selected

    2.1 1-2 weeks
2Std. Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.2 3-5 weeks
1Std. Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

    2.3 12-16 weeks
1Std. Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 3 Global improvement2Risk Difference (M-H, Fixed, 95% CI)Totals not selected

    3.1 1-2 weeks
1Risk Difference (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

    3.2 3-5 weeks
1Risk Difference (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 8. Low-back pain with radiation, two types of traction

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain intensity3Mean Difference (IV, Fixed, 95% CI)Subtotals only

    1.1 1-2 weeks
3149Mean Difference (IV, Fixed, 95% CI)6.58 [-2.77, 15.93]

 2 Global improvement1Risk Difference (M-H, Fixed, 95% CI)Totals not selected

    2.1 1-2 weeks
1Risk Difference (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Comparison 9. Low-back pain without radiation, traction versus sham

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Pain intensity1Mean Difference (IV, Fixed, 95% CI)Totals not selected

    1.1 12-16 weeks
1Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 
Summary of findings for the main comparison. Traction compared with placebo, sham or no treatment for people with low-back pain with and without sciatica

Traction compared with placebo, sham or no treatment for people with low-back pain with and without sciatica

Patient or population: people with low-back pain with and without sciatica

Settings: diverse

Intervention: traction

Comparison: placebo, sham or no treatment

OutcomesEffectsNo of Participants
(studies)
Quality of the evidence
(GRADE)

Pain intensity

VAS (0-100 mm).

Follow-up 12-16 weeks.
1 trial showed that there was no difference in pain intensity between the 2 groups (MD -4, 95% CI -17.7 to 9.7).60

(1)
⊕⊕⊕⊝
moderate

 

Imprecision (< 400 participants)

Functional status

Oswestry Disability Index or Roland Morris Disability Questionnaire.

Follow-up 12-16 weeks.
Not measured.  

Global improvement

Follow-up 12-16 weeks.
1 trial showed that there was no difference in global improvement between the 2 groups (RD 0.06, 95% CI -0.16 to 0.28).81

(1)
⊕⊕⊕⊝
moderate

 

Imprecision (< 300 participants)

Return to work

Follow-up 12-16 weeks.
Not measured.

Adverse effects1 trial reported aggravation of neurological signs in 28% of the traction group, 20% of the light traction group and 20% of the placebo group.

CI: confidence interval; MD: mean difference; RD: risk difference; VAS: visual analogue scale.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 Note. Each 'Summary of findings' table presents evidence for a specific comparison and a set of prespecified outcomes. Therefore, the information presented in the tables is limited by the comparisons and outcomes reported in the included studies.
 
Summary of findings 2. Physiotherapy with traction compared with physiotherapy without traction for people with low-back pain with and without sciatica

Physiotherapy with traction compared with physiotherapy without traction for people with low-back pain with and without sciatica

Patient or population: people with low-back pain with and without sciatica

Settings: physical medicine and rehabilitation outpatient clinic of a larger hospital

Intervention: physiotherapy with traction

Comparison: physiotherapy without traction

OutcomesEffectsNo of Participants
(studies)
Quality of the evidence
(GRADE)

Pain intensity

VAS (0-100 mm).

Follow-up 12-16 weeks.
1 trial showed that there was no difference in pain intensity between the 2 groups (MD 5, 95% CI -5.7 to 15.7) in favour of the control group.39

(1)
⊕⊕⊝⊝
low

 

Study design (high risk of bias)

Imprecision (< 400 participants)

Functional status

Oswestry Disability Index or Roland Morris Disability Questionnaire.

Follow-up 12-16 weeks.
2 trials showed that there was no difference in functional status between the 2 groups (SMD from 0.36 (95% CI -0.27 to 1.00) to 0.43 (95% CI -0.30 to 1.16)).69

(2)
⊕⊕⊝⊝
low

 

Study design (high risk of bias)

Imprecision (< 400 participants)

Global improvement

Follow-up 12-16 weeks.
1 trial showed no difference in global improvement, another trial did show a clinically significant difference in global improvement (RD 0.53, 95% CI 0.28 to 0.79).220

(2)
⊕⊕⊝⊝
low

 

Study design (high risk of bias)

Imprecision (< 300 participants)

Return to work

Follow-up 12-16 weeks.
Not measured.  

Adverse effects1 study reported that 25% of the physiotherapy with traction group and 37% of the physiotherapy without traction group felt worse at 3 months' follow-up.  

CI: confidence interval; MD: mean difference; RD: risk difference.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 
Summary of findings 3. Traction compared with another type of traction for people with low-back pain with and without sciatica

Traction compared with another type of traction for people with low-back pain with and without sciatica

Patient or population: people with low-back pain with and without sciatica

Settings: diverse

Intervention: traction

Comparison: another type of traction

OutcomesEffectsNo of Participants
(studies)
Quality of the evidence
(GRADE)

Pain intensity

VAS (0-100 mm).

Follow-up 12-16 weeks.
Not measured.

Functional status

Oswestry Disability Index or Roland Morris Disability Questionnaire.

Follow-up 12-16 weeks.
Not measured.  

Global improvement

Follow-up 12-16 weeks.
Not measured.  

Return to work

Follow-up 12-16 weeks.
Not measured.  

Adverse effects1 trial reported increased pain in 31% of the static traction group and 15% of the intermittent traction group.  

VAS: visual analogue scale.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 
Summary of findings 4. Traction compared with any other treatment for people with low-back pain with and without sciatica

Traction compared with any other treatment for people with low-back pain with and without sciatica

Patient or population: people with low-back pain with and without sciatica

Settings: diverse

Intervention: traction

Comparison: other treatment

OutcomesEffectsNo of participants
(studies)
Quality of the evidence
(GRADE)

Pain intensity

VAS (0-100 mm).

Follow-up 12-16 weeks.
3 trials, of which 1 compared traction with 2 other types of treatment, showed no difference greater than 5 points on the VAS scale between the 2 groups (MD -2.90 (95% CI -8.53 to 2.93) to 4.50 (95% CI -0.45 to 9.45).304

(3)
⊕⊕⊕⊝
moderate

 

Imprecision (< 400 participants)

Functional status

Oswestry Disability Index or Roland Morris Disability Questionnaire.

Follow-up 12-16 weeks.
3 trials, of which 1 compared traction to 2 other types of treatment and used 2 types of questionnaires to assess functional status, showed no difference between the 2 groups (SMD -0.08 (95% CI -0.39 to 0.23) to 0.51 (95% CI -0.12 to 1.14)).350

(3)
⊕⊕⊕⊝
moderate

 

Imprecision (< 400 participants)

Global improvement

Follow-up 12-16 weeks.
1 trial showed no difference in global improvement (RD 0.05, 95% CI -0.1 to 0.2).42

(1)
⊕⊕⊝⊝
low

 

Study design (high risk of bias)

Imprecision (< 300 participants)

Return to work

Follow-up 12-16 weeks.
Not measured.

Adverse effects1 trial reported temporary deterioration of low-back pain in 17% of the traction group and 15% of the exercise group.

MD: mean difference; RD: risk difference; SMD: standardized mean difference.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 
Table 1. Clinical relevance

AuthorParticipantsInterventionsOutcomesEffect sizeBenefits/harms

Beurskens 1997+++--

Bihaug 1978+++--

Borman 2003+++--

Coxhead 1981+-+--

Fritz 2007+++--

Gudavalli 2006+++--

Güvenol 2000+++?-

Harte 2007+++--

Konrad 1992+?+--

Larsson 1980+++--

Letchuman 1993-++--

Lidström 1970+++?-

Lind 1974+++++

Ljunggren 1984+++--

Ljunggren 1992+++--

Mathews 1975+++--

Mathews 1988+++--

Ozturk 2006+++--

Pal 1986+++--

Reust 1988-++--

Schimmel 2009+++--

Sherry 2001++++?

Simmerman 2011+++--

Sweetman 1993+++--

Tesio 1993+++?-

Unlu 2008+++--

Van der Heijden 1995+++--

Walker 1982+++--

Weber 1973-++--

Weber 1984 (1)-++--

Weber 1984 (2)-++--

Werners 1999+++--

 +: yes; -: no; ?: unknown.