2015 - Ago - Lumbar Traction For Managing LBP. A Survey of Physical Therapists in The United States PDF

1 Lumbar Traction for Managing Low Back Pain: A Survey of Physical Therapists in the United
2 States
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4 Timothy J. Madson, PT, MS
5 John H. Hollman, PT, PhD
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7 Both authors are with the Program in Physical Therapy, Mayo Clinic College of Medicine and
8 Department of Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, MN. U.S.A.
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10 The Department of Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, MN, provided
11 funding for this study.
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Downloaded from www.jospt.org at University of Otago on July 3, 2015. For personal use only. No other uses without permission.
13 Mayo Clinics Institutional Review Board approved this study.

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15 Corresponding author: Timothy J. Madson, PT, MS, Department of Physical Medicine &
16 Rehabilitation, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; email:
17 madson.timothy@mayo.edu
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Copyright ${year} Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
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Journal of Orthopaedic & Sports Physical Therapy
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21 Lumbar Traction for Managing Low Back Pain: A Survey of Physical Therapists in the United
22 States
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25 Financial Disclosure and Conflict of Interest: I affirm that I have no financial affiliation
26 (including research funding) or involvement with any commercial organization that has a direct
27 financial interest in any matter included in this manuscript, except as disclosed in an attachment
28 and cited in the manuscript. Any other conflict of interest including personal associations or
29 involvement as a director, officer, or expert witness is also disclosed in an attachment. Abstract
30 Study Design: Cross sectional survey.
31 Objectives: To examine how many physical therapists (PTs) use traction, patients for whom
32 traction is used, preferred delivery modes/parameters, supplemental interventions, and whether
33 professional characteristics influence traction usage.

34 Background: Several systematic reviews and clinical guidelines question tractions
35 effectiveness for managing low back pain (LBP), yet some patients may benefit from lumbar
36 traction. While traction usage among PTs in other countries has been described, usage among
37 PTs in the United States has not been examined.

38 Methods: We surveyed a random sample of 4000 orthopaedic section members of the American
39 Physical Therapy Association. Associations among respondents professional characteristics and
40 survey responses were explored with chi-square analyses ( = .05).
41 Results: The response rate was 25.5% (n = 1001); 76.6% (n = 767) use traction. Most (58.4%)
42 use traction for patients with signs of nerve root compression, though many (31.4%) do not.
43 Common delivery modes include manual methods (68.3%) and mechanical tables (44.9%), most
44 often supplemental to other interventions (e.g., stabilization exercises, postural education).
45 Levels of professional preparation (doctoral/masters-level versus bachelors/certificate-level) are
46 associated with many variables, as is attainment of an orthopaedic specialist certification.
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47 Conclusion: Most orthopaedic PTs in the United States use lumbar traction, though not
48 necessarily consistently with proposed criteria that identify patients most likely to benefit from
49 traction. They use various traction delivery modes/parameters and use traction within
50 comprehensive plans of care incorporating multiple interventions. Professional characteristics
51 (education levels and clinical specialist credentialing) are associated with traction usage.
52
53 Key Words: Traction, Low Back Pain, Physical Therapists, Physical Therapy Modalities, Cross-
54 Sectional Studies
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56 Low back pain (LBP) is a leading cause of disability and work loss in the United States.24
57 Physical therapists (PTs) may choose from myriad intervention options for treating LBP, but the
58 effectiveness of many is questionable.22,24,46 One option is spinal traction, in which forces
59 applied via motorized pulleys, manual methods or through autotraction are thought to distract
60 tissues and joints in the lumbar spine.6,16,33,48 Authorities have recommended traction for
61 conditions including protruded intervertebral discs,6,48 spinal muscle spasm,29,33,37,39,43,45,47,48 and
62 general pain and stiffness.39
63 Despite historical recommendations for traction, several systematic reviews and clinical
64 guidelines conclude that tractions effectiveness is limited.8,34,41,49 The United Kingdom Royal
65 College of General Practitioners concluded there was little evidence to recommend traction for
66 non-specific LBP.41 The Philadelphia Panel concluded that clinically important benefits of
67 lumbar traction were demonstrated neither for acute nor chronic LBP.34 More recently, Delitto et
68 al summarized moderate evidence that traction should not be used in patients with acute or
69 subacute non-radicular LBP or in patients with chronic LBP.8 A Cochrane review concluded
70 that traction as a sole treatment for LBP cannot be recommended.49 Nevertheless, traction has
71 commonly been used; for example, 15% of patients with LBP in Northern Ireland received
72 traction.12 Harte et al16 reported that 41% of PTs in the United Kingdom used traction, most
73 commonly for patients with subacute LBP who also presented with nerve root symptoms.
74 A reason for the discrepancy between published clinical guidelines and the use of traction
75 may be due to several factors. Trials examining tractions efficacy in LBP, for example, may
76 have been underpowered to detect clinically meaningful changes in pain or function.5,34,41,45,49
77 Traction parameters, force amplitudes and patient positioning have often been variable, not
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78 described or not well-controlled.17,34,37,39,45,47,49 Additionally, trials may not have optimized the
79 patients in whom traction was most likely to be beneficial.5,17,23,26,38,39,45 One classification
80 system, for example, espouses that lumbar traction may be useful for patients with LBP and
81 lower extremity symptoms that move distally (peripheralize) with lumbar extension or who
82 present with a positive crossed straight leg raise test.9-11,15 Nevertheless, tractions efficacy for
83 LBP has been reviewed extensively and demonstrated limited benefits.34,41,49

84 Many factors may influence whether traction is selected as an intervention and how
85 traction parameters are chosen. Understanding how clinicians make decisions about using
86 traction, how they select patients in whom traction is administered and how they make decisions
87 about traction parameters is important. While Harte et al16 described some of those
88 characteristics among PTs in the United Kingdom, it is not clear how PTs in the United States
89 useor make decisions about usingtraction. Therefore, the purpose of this study was to
90 examine how traction is used for managing LBP in the United States. Specifically, we examined
91 (1) the percentage of PTs who use traction in their practices, (2) if clinicians were using traction
92 for patients preliminarily identified as those who may benefit from lumbar traction;10 (3) the
93 delivery modes and parameters (e.g., patient positioning, load, duration) being used; (4) the
94 supplemental interventions in patients plans of care; and (5) whether professional characteristics
95 influenced clinical decisions regarding the use of traction.
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97 METHODS
98 Study Design
99 This was a cross-sectional observational study using a survey. Mayo Clinics
100 Institutional Review Board approved the study.
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101 Participants
102 We surveyed PTs from July through October of 2013 who were American Physical
103 Therapy Association (APTA) members and who designated their practice to be primarily in
104 orthopaedic and musculoskeletal practice settings. There are approximately 16,000 PT members
105 of the orthopaedic section of the APTA.1 We assumed that is the group who primarily treat
106 patients with LBP and therefore we targeted our recruitment of participants accordingly.
107 Inclusion criteria included PT licensure and membership in the APTAs orthopaedic section.
108 Survey Design
109 We designed the survey to approximate that of Harte et al.16 We conducted a pilot study
110 with 20 PTs from our institution who completed an initial draft of the survey. Final questions
111 were modified to improve clarity. The survey contained 28 open- and closed-ended questions
112 regarding professional and demographic characteristics of respondents, adherence to
113 classification criteria for lumbar traction, information regarding delivery modes and parameters
114 used during traction and additional treatment interventions used in conjunction with traction
115 (Supplement). Two specific clinical scenarios were presented to assess respondents clinical
116 decision making regarding traction: the first clinical scenario described a case presentation in
117 which the patients signs and symptoms matched the traction classification in a treatment-based
118 classification system7,10 and the second clinical scenario described a case presentation in which
119 the patients signs and symptoms departed from the classification. The mailed packet included a
120 cover letter inviting participation, an informed consent statement, instructions for online
121 completion of the survey for those who opted to respond electronically and a paper survey with a
122 prepaid, self-addressed envelope for those who opted to return the hard copy.
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123 Data for the study were collected and managed with REDCapTM (Research Electronic
124 Data Capture) tools hosted at Mayo Clinic.13 REDCapTM is a web-based application designed to
125 support data capture for survey research.
126 Data Analysis
127 In an accessible population of approximately 16,000 individuals, obtaining a margin of
128 error of 5 points at a 95% confidence level on a dichotomous variable requires a sample of 375
129 individuals, whereas obtaining a margin of error of 2 points requires a sample of approximately
130 2000 individuals.42 Since response rates for mailed, non-incentivized surveys of health care
131 professionals may be as low as 15%,19 we obtained contact information for a random sample of
132 4000 PTs who met inclusion criteria to obtain a margin of error that would not exceed 5 points.
133 Raw data in REDCapTM were exported to IBM SPSS Statistics 21.0 software (IBM
134 Corporation, Armonk, NY). Descriptive statistics including frequencies of responses were
135 calculated. Since most of the survey variables represented nominal or ordinal levels of
136 measurement, planned associations among respondents professional characteristics and

137 responses to survey questions about traction usage were explored with chi-square analyses.
138 Cases containing missing data were omitted from the computations. All testing was conducted at
139 = 0.05.
140
141 RESULTS
142 Survey Response
143 Surveys were mailed to 4000 individuals who met the inclusion criteria; 75 were returned
144 as non-deliverable. Assuming the remaining surveys reached intended participants, 3925
145 surveys were distributed. We received 1001 responses, which represents a 25.5% response rate;
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146 27.6% of those (n = 276) responded electronically and 72.4% (n = 725) returned hard copies. A
147 majority of respondents (n = 767, 76.6%) indicated they used traction in their practices.
148 Respondents Profile
149 Demographic and professional characteristics of respondents are presented in Table 1.
150 Respondents were mostly female (60%), were distributed relatively uniformly across our defined
151 age groups, and worked primarily in hospital-based or private outpatient settings (30.8% and
152 58.3%, respectively). Their entry-level degrees were uniformly distributed across bachelors,
153 masters and doctoral degrees (33.5%, 31.8% and 31.1%, respectively), whereas relatively few
154 earned post-baccalaureate certificates (3.5%). The majority practiced full-time (48.2%) or near
155 full-time (33.0%). A minority (28.8%) reported having earned a certification through the
156 American Board of Physical Therapy Specialties (ABPTS), most of which were the orthopaedic
157 (n = 229) or sports clinical specializations (n = 25).
158 While a majority (76.6%) of respondents indicated they used traction in their practice,
159 using traction was associated with having an ABPTS certification (2 = 24.046, p < 0.001). A
160 higher proportion of respondents with the orthopaedic certification reported using traction
161 (88.6%) than respondents without a certification (73.0%).
162 Adherence to Classification Profiles
163 In response to the first clinical scenario (Supplement, Questions 13-14) in which the
164 patient would presumably be classified into the traction classification, 448 traction-users (58.4%)
165 indicated they would incorporate traction into the plan of care whereas 241 (31.4%) indicated
166 they would not. Deciding to use traction was associated neither with respondents levels of
167 entry-level preparation (2 = 5.891, p = 0.317) nor with having an ABPTS specialty certification
168 (2 = 1.688, p = 0.890). Traction-users most commonly preferred intermittent traction in a
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169 neutral supine position (20.6%) or in prone with adjustments to the spines extension angle based
170 on centralization responses (16.2%) as part of a comprehensive plan of care including education,
171 exercise, manual therapy and/or modalities (56.6%).
172 In response to the second clinical scenario (Supplement, Questions 16-17) in which the
173 patient presumably would not be classified into the traction classification, 435 traction-users
174 (56.7%) indicated they would not use traction for the patient whereas 265 (34.6%) indicated they
175 would use traction in the plan of care. Similar to the first scenario, deciding to use traction was
176 associated neither with respondents entry-level preparation (2 = 6.609, p = 0.158) nor with
177 having an ABPTS specialty certification (2 = 6.365, p = 0.173).
178 Traction Delivery Modes & Parameters

179 Among traction-users, manual traction was the most common mode of delivery (68.3%).
180 A mechanical traction table permitting multiplanar angles was the second most frequently used
181 mode (44.9%), followed by home traction devices and autotraction techniques at 33.9% and
182 27.2%, respectively.

183 Professional characteristics of respondents were associated with several of the preferred
184 delivery modes. First, respondents entry-level education was associated with preference for
185 manual traction delivery (2 = 30.451, p < 0.001). Respondents educated at the masters or
186 doctoral levels of preparation (58.2% and 59.5%, respectively) more commonly use manual
187 traction than those educated at the bachelors or certificate levels (28.6% and 42.9%,
188 respectively). Second, having the ABPTS orthopaedic certification was also associated with
189 preferences for delivery modes (manual traction 2 = 6.656, p = 0.010 and mechanical traction 2
190 = 9.353, p = 0.002). Respondents with the certification reported higher preferences for manual
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191 traction and multiplanar traction tables (59.8% and 42.8%, respectively) than those without the
192 certification (50.1% and 31.9%, respectively).
193 Among traction-users, patient positioning is generally influenced by clinical exam
194 findings. While the most commonly indicated position for administering traction was supine
195 with knees and hips flexed in a moderate flexion bias (37.4%), many respondents indicated
196 patient positioning would be diagnosis-specific (34.4%). Most indicated that a clinical
197 presentation consistent with degenerative joint disease (58.0%) or a herniated disc (75.9%)
198 would influence their decision to use a flexion bias or extension bias, respectively, when
199 administering traction. Furthermore, preference for patient positioning was associated with
200 having the ABPTS orthopaedic certification (2 = 19.663, p = 0.001). Respondents with the
201 certification more commonly reported that patient positioning would be diagnosis specific
202 (48.1%) than did respondents without the certification (34.0%). In contrast, respondents without
203 the certification were more likely to default to the supine lying patient position with a moderate
204 flexion bias (44.9%) than would respondents with the certification (30.5%).
205 Responses for preferred loading and duration parameters varied. Most administered
206 traction at loads of 30-40% (33.9%) or 40-50% of body weight (31.8%) over treatment times of
207 11-20 minutes, depending on the patients condition (Table 2). Having the ABPTS orthopaedic
208 certification, however, was associated with respondents preferred treatment times in two
209 particular conditions. For general mobilization of a stiff spine, respondents without the
210 certification were more likely to administer traction for 11-15 minutes (41.8%), whereas
211 respondents with the certification were more likely not to use traction (28.2%, 2 = 13.269, p =
212 0.039). Similarly, for generalized pain relief, respondents without the certification were again
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213 more likely to use traction for 11-15 minutes (49.0%), whereas respondents with the certification
214 were more likely not to use traction (26.2%, 2 = 13.539, p = 0.035).
215 Supplemental Interventions
216 Traction-users most often implemented traction as one component of a plan of care,
217 rather than in isolation (Table 3). The most common supplemental interventions included core
218 stabilization exercises (90.5%), education regarding posture and body mechanics (86.3%),
219 mobilization techniques (85.0%), general exercise/fitness program prescriptions (70.0%) and
220 massage or soft tissue mobilization techniques (65.2%).
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222 DISCUSSION
223 Several systematic reviews and clinical practice guidelines conclude that spinal traction
224 has limited effectiveness for treating LBP.8,34,41,49 Despite those guidelines, there is evidence a
225 specific subset of patients with LBP may respond positively to traction.9-11 Furthermore, while
226 traction utilization in some European countries may be declining,27 PTs in the United Kingdom
227 have commonly used traction for patients with LBP and symptoms of nerve root
228 compression.12,15,16 We surveyed PTs in the United States about their use of spinal traction,
229 whether they use traction consistently with a classification system identifying patients for whom
230 traction may be beneficial, their preferred traction delivery modes and parameters, and examined
231 their use of supplemental interventions. Our findings suggest a majority of APTA orthopaedic
232 section members use traction and use it consistently with recommendations from a classification
233 system that preliminarily identifies a patient sub-group in whom traction may provide benefit.9-
11,15
234 In contrast, approximately one-third of respondents indicated they would use traction for
235 patients in a manner that is contrary to that classification and respondents were quite variable in
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236 their selection of traction modes and parameters. Additionally, PTs use traction as a component
237 of comprehensive plans of care that include multiple interventions.
238 A majority of respondents (76.6%) indicated they used traction in their practices. This
239 proportion is higher than that identified by Harte et al,16 who reported 41% of PTs in the United
240 Kingdom used traction. Whereas Harte et al reported an 83% response rate, our response rate
241 (25.5%) was considerably lower. While reasons for the differential response rates are not
242 entirely clear, the length of the survey (28 open- and closed-ended questions) and potentially the
243 perceived importance of the surveys topic by invited participants are factors that may have
244 contributed to the response rate.2,4 The differences in the proportions of respondents reporting
245 they use traction in their practices may reflect a response bias whereby therapists who use
246 traction were more likely to respond. Differences may also be accounted for by varying
247 sampling approaches used in the studies. Harte et al16 surveyed a random sample of chartered
248 PTs in the United Kingdom who specialized in musculoskeletal management. The manner in
249 which they determined which therapists specialized in musculoskeletal management, however,
250 was not described. We, on the other hand, exclusively surveyed PTs who were members of the
251 APTAs orthopaedic section. It is possible we administered the survey to a higher proportion of
252 PTs whose patient populations are favored toward patients with LBP. Moreover, differences
253 could also reflect changes in practice over time. Harte et al16 published their findings more than
254 a decade ago. While more recent evidence suggests traction utilization in some European
255 countries may be declining,27 it is possible that contemporary practice changes may have
256 influenced traction usage rates in the United States, particularly since much of the work
257 regarding a traction classification has occurred since that time.10,11
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258 Historically, care for LBP has revolved around the belief that patients with LBP represent
259 a homogeneous group.7,8 More recently, clinicians have theorized that patients with LBP are
260 heterogeneous, should be classified into subgroups accordingly and propose that patients in each
261 subgroup will more likely respond to distinct treatment strategies.7,9-11,30 While the evidence is
262 preliminary, the subgroup most likely to respond to traction is hypothesized to be patients with
263 signs and symptoms of nerve root irritation who do not centralize with lumbar movements.10 We
264 therefore examined whether PTs in the United States were using traction for patients identified
265 by Fritz et al10 who are most likely to benefit from traction. The first clinical scenario in the
266 survey (Supplement, Questions 13-14) specifically addressed this purpose, in which the mock
267 patient presented with peripheralization of symptoms with standing lumbar extension movements
268 and a positive crossed straight leg raise, both of which are signs by which a patient presumably
269 would be classified into the traction profile.7 We hypothesized that most respondents would opt
270 to use traction in that scenario. The results partially supported our hypothesis. While a majority
271 (58.4%) indicated they would implement traction, nearly one-third of respondents (31.4%) would
272 not use traction in that scenario. Further, we presented a second scenario (Supplement,
273 Questions 16-17) in which the patient presumably would not be classified into the traction
274 classification profile. While most respondents (56.7%) indicated they would not implement
275 traction into a plan of care, more than one-third (34.6%) indicated they would. An implication of
276 these findings is that approximately one-third of PTs may not incorporate lumbar traction in a
277 manner that is consistent with current recommendations for its use.
278 We secondarily examined preferred traction delivery modes and parameters. With regard
279 to traction delivery modes, respondents most often administered traction manually (68.3%) or
280 with a mechanical traction table permitting multiple angles of pull (44.9%). The preference for
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281 administering traction manually makes it difficult to ascertain preferred loading magnitudes.
282 The proportion of respondents using manual traction techniques, however, is comparable to the
283 proportion of PTs using manual traction in the United Kingdom (53%).16 In contrast, the
284 proportion using mechanical traction tables (44.9%) is considerably less than that reported by
285 Harte et al (79%). Per several ad hoc comments, many respondents indicated they lacked access
286 to mechanical traction tables in their particular practice settings, which may account for this
287 difference. With regard to magnitude of traction delivery, most respondents preferred to
288 administer lumbar traction at 30-50% of body weight. These magnitudes are consistent with the
289 assumptions that intervertebral separation is necessary for therapeutic efficacy and that loads of
290 20-50% of body weight are required to achieve intervertebral separation.3,20,21,40 Those
291 assumptions, however, have not been confirmed through controlled trials and our findings
292 suggest only that PTs in the United States, with lack of confirmatory evidence to guide clinical
293 decisions for loading guidelines, most often apply lumbar traction at magnitudes of 30-50% of a
294 patients body weight. As a comparison, Meszaros et al31 reported that pain-free straight leg
295 raise measurements in patients with low back and lower extremity pain improved following
296 traction application at 30% and 60% body weight but not at 10% body weight. Despite that
297 report, evidence-based recommendations for loading parameters have yet to be clearly
298 articulated.
299 Physical therapy practice for managing LBP is often characterized by a vast array of
300 intervention approaches such as stretching and strengthening exercises, direction-specific
301 exercises, manual therapy approaches to mobilize spinal segments, soft tissue
302 mobilization/massage and the use of electrical or thermal modalities.26,35 Therefore, we
303 examined supplemental interventions in patients plans of care. It was clear that respondents use
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304 traction as part of comprehensive plans of care incorporating multiple interventions. The most
305 commonly used interventions included core stabilization exercises, education regarding posture
306 and body mechanics, mobilization techniques, prescription of general exercise/fitness programs
307 and massage or soft tissue mobilization techniques. These findings are largely consistent with
308 those of Harte et al,16 who reported that advice regarding posture and management, general
309 exercise and physical activity, core stabilization exercises and mobilization techniques were
310 incorporated into the plans of care by over 50% of their respondents. One difference between
311 our findings and those of Harte et al was that they reported massage as being used by 12.1% of
312 the PTs in their study, whereas employing soft tissue mobilization or massage was identified by
313 approximately 65% of our respondents as a supplement to traction. Given limited evidence for
314 the effectiveness of massage for treating LBP when compared against other manual therapy
315 approaches or against exercise and education,18,25 the extent to which PTs in the United States
316 use soft tissue mobilizations/massage in managing LBP may be concerning.
317 Last, we examined if professional characteristics of respondents were associated with

318 clinical decisions regarding traction. Two characteristics were associated with traction
319 preferences. First, a higher proportion of PTs with the ABPTS orthopaedic certification use
320 traction (88.6%) than do PTs without the certification (73.0%) and PTs with the certification
321 more commonly reported that patient positioning would be diagnosis-specific (48.1%) than did
322 respondents without the certification (34%). Second, a higher proportion of PTs educated at the
323 masters or doctoral levels of preparation reported using manual traction techniques (58.2% and
324 59.5%, respectively) than those educated at the bachelors or certificate levels (28.6% and 42.9%,
325 respectively).
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326 Professional characteristics of respondents were also associated with many of the
327 supplemental intervention options illustrated in Figure 1. Respondents with the masters or
328 doctoral levels of preparation were more likely to include mobilization, manipulation,
329 neuromobilization, interferential current, hot packs, massage/soft tissue mobilization, education
330 of posture/body mechanics and/or prescription of general exercise/fitness programs in their plans
331 of care than PTs with certificate or bachelors levels of preparation (Figure 1A). Similarly,
332 respondents with the ABPTS orthopaedic specialty certification were more likely to include
333 mobilization, manipulation, directional preference exercises, neuromobilization, education on
334 posture/body mechanics, and prescription of general exercise/fitness programs and/or core
335 stabilization exercises than respondents without the certification (Figure 1B).
336 It is evident from these collective findings that professional preparation is associated with
337 treatment decisions regarding the use of traction. While explaining that association would be
338 speculative, the finding supports hypotheses generated by others that higher levels of
339 professional preparation may alter the way in which PTs practice. Several studies,28,32,44 for
340 example, have reported that recent graduates and clinicians with specialty certification differ in
341 terms of knowledge, skills and attitudes toward evidence-based practice than generalists or those
342 with more experience. Mikhail et al,32 using clinical vignettes similar to ours to elicit responses
343 from therapists about preferred interventions for LBP, reported that therapists who chose
344 interventions with high evidence of effectiveness were more likely to have practiced less than 15
345 years. Manns et al28 reported that recent graduates demonstrated better knowledge of evidence-
346 based practice skills than therapists with more years of experience. Last, van Bodegom-Vos et
347 al44 reported that generalists had more difficulty interpreting guidelines for rheumatoid arthritis
348 and that specialists had more knowledge and positive attitudes regarding their use. Additional
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349 studies have examined outcomes associated with training levels. Hart and Dobrzykowski,14 for
350 example, suggested that PTs with the ABPTS orthopaedic certification treated patients over
351 fewer visits and with a lower overall cost than non-certified PTs. Resnik and Hart36 reported that
352 PTs who achieved superior patient outcomes were more likely to have ABPTS orthopaedic
353 certification, training through the American Academy of Orthopaedic Manual Physical
354 Therapists, or manual therapy certification than those who achieved more moderate patient
355 outcomes. Collectively, there is a growing body of evidence that higher levels of professional
356 preparation influence clinical decision making and potentially patient outcomes. Our findings
357 suggest similarly that ones level of degree attainment and/or ABPTS certification may influence
358 how traction is administered or incorporated into plans of care for patients with LBP.
359 Several limitations may have influenced our findings. First, the survey was conducted
360 among a random sample of APTA orthopaedic section members. Findings may not generalize to
361 non-members of the section or to non-APTA members. Second, we had a 25.5% response rate.
362 Respondent characteristics (Table 1) may have differed from non-responders and therefore
363 external validity of the study may be flawed. Since the survey was administered anonymously,
364 we had no method of determining who the non-responders were. Third, the high proportion of
365 reported traction-users (76.6%) may reflect a response bias; perhaps traction-users were more
366 likely to respond than non-traction-users. Fourth, while we asked respondents to indicate their
367 most commonly used traction delivery modes and parameters, including patient positioning, we
368 acknowledge that such decisions are often dependent on the patients conditionincluding
369 symptom acuity and severityand therefore the survey had limited capacity to detect how PTs
370 make clinical decisions regarding the use of traction for managing LBP. Despite these
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371 limitations, the findings present a novel representation of lumbar traction usage among PTs in
372 the United States.
373
374 CONCLUSION
375 While systematic reviews and clinical practice guidelines generally do not provide
376 support for spinal traction in managing LBP without signs of nerve root compression, PTs in the
377 United States commonly use traction. Most employ traction consistently with a classification
378 system that preliminarily identifies a patient sub-group in whom traction may provide benefit,
379 yet approximately one-third of respondents indicated traction usage that would be contrary to
380 that classification. Additionally, our findings imply that PTs use a variety of traction delivery
381 modes and parameters, dependent on patients conditions, and use traction as part of
382 comprehensive plans of care incorporating multiple intervention modes. Last, professional
383 characteristics (professional education levels and ABPTS orthopaedic clinical specialist
384 credentialing) are associated with traction usage.

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385
386 Key Points
387 Findings: Most orthopaedic PTs in the United States use lumbar traction, though not necessarily
388 consistently with clinical guidelines. They use various traction delivery modes/parameters and
389 within comprehensive plans of care incorporating multiple interventions. Therapists
390 professional characteristics including training levels and ABPTS orthopaedic clinical specialist
391 credentialing are associated with traction usage.
392
393 Implications: Most PTs employ traction consistently with a classification system that
394 preliminarily identifies a patient sub-group in whom traction may provide benefit, yet
395 approximately one-third of respondents indicated traction usage that would be contrary to that
396 classification. Adjunctive interventions include core stabilization exercises, education regarding
397 posture and body mechanics, mobilization techniques, prescription of general exercise/fitness
398 programs and massage or soft tissue mobilization techniques which are largely consistent with
399 findings from a similar survey in the United Kingdom.
400
401 Caution: A response rate of 25.5% may not reflect how the majority of orthopaedic PTs use
402 traction. The survey was conducted among a random sample of APTA orthopaedic section
403 members. Findings may not generalize to PTs who are not section members or to non-APTA
404 members and may reflect a response bias if traction users were more likely to respond than non-
405 traction users.
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406
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25
529
530 TABLE1.RespondentDemographics
Respondents(n=1001) Frequency(n) ValidPercentage(%)
Sex
Female 598 60.0
Male 399 40.0
Agegroup(years)
2030 188 18.9
3140 286 28.7
4150 224 22.5
>50 297 29.8
Regionofresidence
SouthAtlantic(DE,DC,GA,MD,NC,PR,SC,VA,WV,FL) 170 17.2
MiddleAtlantic(NJ,NY,PA) 133 13.4
EastNorthCentral(IL,IN,MI,OH,WI) 155 15.7
WestNorthCentral(IA,KS,MN,MO,NE,ND,SD) 135 13.7
EastSouthCentral(AL,KY,MS,TN) 61 3.5
NewEngland(CT,ME,MA,NH,RI,VT) 54 6.2
Pacific(AK,CA,HI,OR,WA) 148 5.5

Mountain(AZ,CO,ID,MT,NV,NM,UT,WY) 98 15.0
Yearsofpracticeasphysicaltherapist(years)
15years 217 22.1
610years 130 13.3
1115years 162 16.5
1620years 115 11.7
>20years 356 36.3
Entrylevelphysicaltherapydegree
Certificate 35 3.5
Bachelors 333 33.5
Masters 316 31.8
Doctoral 309 31.1
Hoursofpracticeperweek(hours)
<10hours 55 5.6
1120hours 39 4.0
2130hours 89 9.1
3140hours 322 33.0
4150hours 411 42.1
>50hours 60 6.1
Primaryfacility/setting
Acutecarehospital 25 2.5
Subacuterehabilitationhospital(inpatient) 9 0.9
Healthsystemorhospitalbasedoutpatientclinic 306 30.8
Privateoutpatientpracticeorgrouppractice 580 58.3
SNF/ECF/ICF 12 1.2
Schoolsystem(preschool,primary,secondary) 7 0.7
26
Academicinstitution(postsecondary) 50 5.0
Healthandwellnessfacility 3 0.3
Researchcenter 1 0.1
Industry 2 0.2
ABPTSCertification
Orthopedic 229 22.9
Neurologic 10 1.0
Geriatric 11 1.1
Sports 25 2.5
Pediatric 10 1.0
Cardiovascular/Pulmonary 4 0.4
ClinicalElectrophysiology 4 0.4
WomensHealth 4 0.4
531 Abbreviations:ABPTS,AmericanBoardofPhysicalTherapySpecialties
532
27
533
534 TABLE2.Preferredtractionparameters.
Parameter Frequency(n) Valid%
Load(%BodyWeight)
2030% 156 20.3
3040% 260 33.9
4050% 244 31.8
>50% 34 4.4
TreatmentTime(minutes)
Nerverootwithradicularfeaturessecondarytoaherniateddisc
<5minutes 16 2.1
610minutes 93 12.1
1115minutes 261 34.0
1620minutes 261 34.0
2125minutes 51 6.6
>25minutes 25 3.3
Iwouldnotusetractionforthiscondition 33 4.3
Generalmobilizationofastiffspine
<5minutes 15 2.0
610minutes 45 5.9
1115minutes 191 24.9
1620minutes 179 23.3
2125minutes 37 4.8
>25minutes 8 1.0
Degenerativejoint/facetdisease
<5minutes 14 1.8
610minutes 53 6.9
1115minutes 219 28.6
1620minutes 213 27.8
2125minutes 47 6.1
>25minutes 12 1.6
Generalizedpainrelief
<5minutes 19 2.5
610minutes 41 5.3
1115minutes 172 22.4
1620minutes 155 20.2
2125minutes 30 3.9
>25minutes 7 0.9
535
28
536
537 TABLE3.SummaryofInterventionsUsedinConjunctionwithTraction
Intervention Frequency(n) Valid%
CoreStabilizationExercises 694 90.5
EducationRegardingPosture&BodyMechanics 667 87.0
MobilizationTechniques 652 85.0
PrescriptionofGeneralExercise/FitnessProgram 537 70.0
Massage/SoftTissueMobilizationTechniques 500 65.2
McKenzieDirectionSpecificExerciseRegimes 454 59.2
NeuromobilizationTechniques 424 55.3
HotPacks 350 45.6
InterferentialCurrent 347 45.2

ManipulationTechniques 286 37.3
OtherElectrotherapyModalities 142 18.5
Other 95 12.4
538
29
539
540
541
542 FIGURE. Associations between (A) professional education levels and (B) attainment of an
543 orthopaedic certification (OCS) through the American Board of Physical Therapy Specialties and
544 supplemental interventions in plans of care for persons with low back pain.
30

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1 Lumbar Traction for Managing Low Back Pain: A Survey of Physical Therapists in the United

13 Mayo Clinics Institutional Review Board approved this study.

30 Study Design: Cross sectional survey.

32 traction is used, preferred delivery modes/parameters, supplemental interventions, and whether

33 professional characteristics influence traction usage.

34 Background: Several systematic reviews and clinical guidelines question tractions

37 PTs in the United States has not been examined.

39 Physical Therapy Association. Associations among respondents professional characteristics and

40 survey responses were explored with chi-square analyses ( = .05).

44 often supplemental to other interventions (e.g., stabilization exercises, postural education).

45 Levels of professional preparation (doctoral/masters-level versus bachelors/certificate-level) are

46 associated with many variables, as is attainment of an orthopaedic specialist certification.

50 comprehensive plans of care incorporating multiple interventions. Professional characteristics

58 effectiveness of many is questionable.22,24,46 One option is spinal traction, in which forces

61 conditions including protruded intervertebral discs,6,48 spinal muscle spasm,29,33,37,39,43,45,47,48 and

62 general pain and stiffness.39

76 have been underpowered to detect clinically meaningful changes in pain or function.5,34,41,45,49

79 patients in whom traction was most likely to be beneficial.5,17,23,26,38,39,45 One classification

83 LBP has been reviewed extensively and demonstrated limited benefits.34,41,49

95 influenced clinical decisions regarding the use of traction.

99 This was a cross-sectional observational study using a survey. Mayo Clinics

100 Institutional Review Board approved the study.

108 Survey Design

112 regarding professional and demographic characteristics of respondents, adherence to

125 support data capture for survey research.

126 Data Analysis

127 In an accessible population of approximately 16,000 individuals, obtaining a margin of

136 measurement, planned associations among respondents professional characteristics and

142 Survey Response

148 Respondents Profile

149 Demographic and professional characteristics of respondents are presented in Table 1.

157 (n = 229) or sports clinical specializations (n = 25).

161 (88.6%) than respondents without a certification (73.0%).

162 Adherence to Classification Profiles

168 (2 = 1.688, p = 0.890). Traction-users most commonly preferred intermittent traction in a

171 exercise, manual therapy and/or modalities (56.6%).

177 having an ABPTS specialty certification (2 = 6.365, p = 0.173).

178 Traction Delivery Modes & Parameters

182 27.2%, respectively.

192 certification (50.1% and 31.9%, respectively).

193 Among traction-users, patient positioning is generally influenced by clinical exam

215 Supplemental Interventions

220 massage or soft tissue mobilization techniques (65.2%).

237 of comprehensive plans of care that include multiple interventions.

257 regarding a traction classification has occurred since that time.10,11

300 intervention approaches such as stretching and strengthening exercises, direction-specific

302 mobilization/massage and the use of electrical or thermal modalities.26,35 Therefore, we

316 use soft tissue mobilizations/massage in managing LBP may be concerning.

317 Last, we examined if professional characteristics of respondents were associated with

333 mobilization, manipulation, directional preference exercises, neuromobilization, education on

372 the United States.

384 credentialing) are associated with traction usage.

386 Key Points

389 within comprehensive plans of care incorporating multiple interventions. Therapists

391 credentialing are associated with traction usage.

399 findings from a similar survey in the United Kingdom.

405 traction users.

Pacific(AK,CA,HI,OR,WA) 148 5.5

InterferentialCurrent 347 45.2

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