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17ПРЕДСТАВЛЕНИЕ НАУЧНОЙ РАБОТЫ
OPPORTUNITIES OF THE TRACTION THERAPY FOR TREATMENT AND PREVENTION OF THE LUMBAR DISC DISEASE
Krasteva Mariyana Mihajlova, Department of Physiotherapy, rehabilitation, thalassotherapy and occupational diseases, Medical University of Varna
E-mail: m.mihailolova96@abv.bg
Abstract. Extension therapy has been known in the medical circles since the ages of Hippocrates. During the different eras there were periods of frequent usage regarding treatment of diseases originating from the spine, as well as times when this type of therapy had been completely forgotten. Despite many proponents of this method, it has had its opponents throughout the years. Nowadays thanks to the scientific and technological progress, we have the opportunity to utilize high-tech apparatuses for extension treatment with high level of safety.
The goal of this overview is to summarize the main methods of conducting extension therapy and its capabilities for prophylactic and treatment of the lumbar disc disease.
Key words: lumbar disc disease, extension therapy, treatment, prophylactic.
Introduction
It's knows that traction of the spine in the medical practice has been used since Ancient times. Into the treatise „guido guides (vidus vidius) h chirurgia", containing translated writings of Hippocrates and Galen from Greek to Latin, are included paintings showing methods and devices used by Hippocrates himself [13].
From the Antiquity until today the tools used for extension therapy have been improves influenced by the scientific and technological progress.
Extension therapy falls into the group of the passive kinesitherapeutic methods. It can be conducted manually or with the assistance of special tools (tables, chairs, girdles etc.). The main goal of this method is appliance of mechanical traction on the
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spine, aiming to eliminate the phenomena of compression and irritation of the nerve elements and vessels, occurring as a result of degenerative processes into the spinal segments. In the core of the healing effect of every type of traction including "the dry stretching of the spine", is the mechanism for reduction of the intraspinal pressure. According to Cyriax (1950) traction leads to two effects.
The first one is increase of the space between the vertebrae which leads to negative intraspinal pressure and conditions for sucking the hernia back. The second effect is a result of the stretching of the rear longitudinal link as a "string", which pushes the bulging part of the disc back to its place [11]. Those effects help the elimination of the disco-radicular conflict, that is in the core of the neurological display of the degenerative diseases of the spine. In 1968 Mathews JA through dynamic discography research proves that the lumbar extension can lead to sucking of the herniated nucleus pulposus back and the duration of the effect depends on the proper motor regiment after the treatment [17]. Prof. Georgi Gechev recommends as a counter relapse measure that the patient must conduct extension treatment every 1 -2 years, although the lack of pain [1].
Depending of the targeted area of the spine there are: cervical, thoracic and • lumbar extension. The extension of the lumbar region of the spine is the most common type of therapy as both direct - manual extension and indirect - mediated extension conducted through extension apparatuses. Depending of the patients position on the extension table there are: horizontal, inclined, vertical and angled extension (Pearl). Depending on the duration of the procedure there are: permanent, temporarily continuous, intermittent and progressive-successive.
Manual traction - conducted by a skilled manual therapist, who applies traction throughout the axis of the spine by hand, aiming to distancing of the joint surfaces [4].
Autotraction - conducted by the patient himself, using the gravity and his own bodyweight. Performed within 3-5 minutes and repeated 2-3 times throughout a session, at a maximum of 2 sessions daily. This methodology delivers a good result as a prophylactic mean and sometimes it's enough to suspend the morbid syndrome but it doesn't have a long enough effect [19].
Extension on an inclined surface when the patient is lying on his back is the easiest way for dry extension, using the patient's bodyweight. It's conducted on a medical bed that has the ability to adjust the inclination of the surface. In this method the traction is completed using the patient's own weight through adjusting the inclination thus the power of the traction. This method as well as the autocracy has more impact on the more cranial placed motor segments of the spine. This extension can last 4-6 hours with a 30 minute break. A grand total of 14 procedures are required. However, the procedure is not very comfortable because of the long duration and
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unnatural position of the patient [19].
Traction on an inclined surface when the patient is lying on his stomach is
another type of horizontal extension. The patient should be fixed on the level of his hip bones. A disadvantage of this type of traction is that it can be conducted only on patients with normal blood pressure and it has to be monitored throughout the whole procedure alongside the pulse [22].
The automatized extension tables, which are being used today are very diversified. They provide the opportunity to conduct traction to patients with kyphosis, lordosis, lateroflexion, laterorotation. The extension can be conducted in different starting positions - horizontal with the head downwards or upwards. Some tables have devices for roller massage during the procedure, others have two or three moving parts to avoid friction between the body of tha patient and the surface of the table. The main thing is that they are equipped with computerized system of management that makes them more precise in dosing the power of traction and help avoiding unwanted side effects [3].
Underwater extension has the advantage of being conducted at a temperature of the water 36,5°C- 37,5 °C. That leads to myorelaxation thus reduced • pain syndrome. Positive effect has the lift of the water causing the reduction of the bodyweight impact thus relaxation of the musculoskeletal apparatus as a whole. These advantages of the underwater traction provide the opportunity to apply greater power. This type of extension can be combined with hydrokinesitherapy for strengthening of the musculature of the body and specifically in the lumbar region [1].
Mechanism of appliance and effects of the extension therapy
The effectiveness of the extension therapy in cases of lumbar disc disease depends on the different types and ways of traction. The improvement of the applied methods for extension treatment is one of the most important things in the therapy of the patients with lumbar disc disease. Firstly we can highlight the improvement of the mobility and microcirculation in the affected motor segments, which is a prerequisite for a secure recovery of the spine. Secondly extension in one way or the other has an influence over all pathogenic mechanisms, which lead to neurological display of lumbar disc disease, through decompression of the nerve structures, improvement of the blood circulation conditions, decrease in the swelling, elimination of the reactive phenomena in the tissues, decrease in the muscular contractures and pathological muscle pressure.
As a result of improper static loads of the spine throughout the day, in the patients arise short mechanic pressure in the spinous joints [2]. When conducting an extension therapy a recovery of the mobility of the spinal motor segments and facet joints is achieved in a full volume. Such dosed mechanical efforts lead to relaxation of
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the periarticular muscles, eliminate the blocks of the intervertebral joints and releasing the disc [3]. An important anatomic feature of the intervertebral disc is that it doesn't have its own blood supply and its sustenance is conducted through pump mechanism [21]. Throughout the day while working, at the expense of the gravity, the distance between the vertebrae is reduced, intervertebral discs lose water and macronutrients -they dehydrate. During the night the reverse process of rehydration happens [9].
The harmonic combination between work and rest is a key factor in the proper functioning of the spine [6]. Through many radiology researches is proved that in the moment of traction the distance between the vertebrae bodies is increased with 1 -2,5 mm and the vertical size of the intervertebral hole with 0,2-0,65 mm [3,7]. In other words, the extension therapy supports improvement of the thropics of the disc and delays the aging processes. In this sense the extension therapy may be viewed as a prophylactic tool for avoidance of the progression of the degenerative processes into the intervertebral discs.
Side effects: extension therapy is a noninvasive method for treatment, thus the side effects are minimal. Such effects may happen in a case of improper of the traction power, contraindications for conducting the procedure, improper preparation • of the patient and breaking the assigned regiment after the procedure. These side effects can be: increased pain, breathing problems and precordial pain when the thoracic belt is too tight, orthostatic hypertonic reaction when standing up suddenly and rarely increase in the existing hernia because of wrong technique.
Contraindications for conducting extension therapy are: hypertonic disease, heart failure, ulcer of the stomach in active form, active infection, inguinal and scrotal hernia, active tuberculosis, bone tumors, ankylosing spondylitis, pregnancy, severe disc hernias requiring surgery, osteomalacia, osteoporosis, after surgery of the spine and psychotic diseases.
Short analysis of literature data regarding the efficiency of the extension therapy
The overview of the results of many medical researches including ours is encouraging regarding the efficiency of the method in treatment of the lumbar disc disease.
In 1998 Takeoglu I et al conduct an experimental research amongst 30 patients with diagnosis of low back pain because of lumbar disc degeneration, hernia and segment instability. The patients were treated with gravity traction in order to widen the intervertebral spaces. The derived effect is assessed by skiagraphy. The same procedure is applied to 30 healthy individuals. Before and after the traction was completed radiography for examination of the changes in the intervertebral spaces on levels L2-L3, L3-L4, L4-L5 and L5-S1. The conclusion that the researchers reach is
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that gravity traction has very prominent effect over the intervertebral spaces and it's an effective method for physiological distancing of the vertebrae [24].
Decompression of the afferent nociceptive conductors in the zone of influence helps for recovery of the mobility of the spinal motor segment that's been blocked. The tear of the "vicious circle" of the reflex periarticular muscle spasm, which is a defensive mechanism of the organism for immobilization of the motor segments, leads to recovery of the spinal mobility. The following myorelaxation causes elimination of the antalgic pose. The end results are achievement of mild and elegant relaxation of the spine and creating conditions for stimulating the thropics of the otherwise bradytrophic intervertebral disc. In our opinion this type of traction is suitable for prevention of lumbar disc disease, because of the advantages listed above.
In 1999 Warner R et al carry out a randomized controlled research aiming to compare the effect of the therapy with interference current combined with massage and traction therapy. The study was held amongst 152 patients divided in two groups in a three month period. The authors report an improvement when it comes to life quality in both groups, without any significant difference, so they couldn't conclude which therapy more effective [26]. •
In 2000 Meszaros TF et al carry out a research aiming to establish the effectiveness of extension therapy in three cases with differing applied power (10%, 30% and 60% of the bodyweight) on patients with low back pain and radicular problems. The patients who were treated with power equal to 30% and 60% of their bodyweight showed better results regarding their clinical recovery. The authors recommend future testing to be carried out using power between 30% and 60% of the bodyweight [18].
In 2003 Borman P, Keskin D and Bodur H carry out randomized, controlled research comparing the effect of the extension therapy and conventional physiotherapy. At the end of the study they conclude that both therapies have a positive influence over the overall reverse of the symptoms without any significant difference between the two [10].
In 2006 Macario A and Pergolizzi JV do a systematic overview of the English literature from 1975 to 2005 regarding clinical studies of the effect of the extension therapy compared to placebo procedures or another type of nonsurgical treatment. The data from 10 studies is completely analysed. Seven of them use different apparatuses for extension. In six of them there's no difference between the two compared groups and one finds a significant advantage in the pain reduction using extension, but no difference in the level of disability. Three of the studies have no controlled group, but report level of improvement in the pain syndrome between 77% and 86% [16].
In 2006 Ozturk B et al carry out a randomized clinical research in two groups of patients with lumbar hernia. The experimental group was treated with physiotherapy
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and constant extension and the controlled group only with physiotherapy. At the end of the study using computer tomography was reported a reduction of the hernia size and statistically significant improvement in the both objective and subjective symptomatic of the patients from the experimental group [20].
In 2008 Leslie J et al in their pilot research treat over 20 patients with low back pain with motorized spinal decompression using DRX9000 ™ apparatus. In 16 patients there were reported a significant reduction and improvement of the ability to carry out everyday tasks [15].
In 2008 Beattie PF et al, track the effect of the extension therapy in 296 patients with low back pain and proven degenerative changes and/or disc herniation in one or more levels in the lumbar region in a 8 week period. The first 4 weeks contain 5 sessions lasting 30 minutes each, and the last 4 weeks 1 session per week. The examination is conducted at the end of the first and sixth month after the treatment. The study reports significant improvement regarding the quality of life and pain reduction. In order even more explicit prove to be gathered regarding the effect of extension therapy, the authors recommend to be performed a study with randomized comparison groups [9]. •
Lai A and Chou D carry out a research in 2010 concerning the significance of the mechanical compression and extension over the rate of degeneration of intervertebral discs of rats. They reach the conclusion that traction helps slowing down the degeneration processes and is appropriate as a prophylactic, while the mechanical compression has the opposite effect. Through extension therapy is recovered the mobility of the individual spinal motor segments, which is impaired because of the damage on the fibrous ring and changed location of the mucilaginous core, shut meniscus (the end appendages of the synovial membrane), mechanical pressure over the vessel's connective tissues and nerve structures full of nociceptor, pathologically formed paravertebral muscle spasm [14].
Apfel C et al in 2010 carry out a two-year study and prove the recovery of the height intervertebral discs after the conducted 22 day's extension therapy using computer-tomography tracking. This result confirms the opportunity extension to be used as a prophylactic tool, in order to slow down the disc degeneration [8].
In 2013 Diab A and Moustafa I carry out a randomized controlled research involving 80 patients with low back pain and three month tracking. One group is treated with extension therapy, procedure with infrared light and physical exercises, the other only with infrared light and physical exercises. The group treated with extension has better results when it comes to correction of the antalgic pose, reduced pain and increased mobility in the lumbar region [12].
A lot of authors applied extension in cases of compressive syndrome, emphasizing the reduction of root syndrome and expression of the pain [1, 3,19,
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23,25]. In Bulgaria since a long time is practiced underwater extension using prof. Georgi Gechev methodology in Pavel Bayna with great results.
According to modern perceptions for proper conduction of dry extension therapy, the traction force should be 30%-50% up to 60% of the patient's bodyweight [18]. Most authors base that on the fact the muscle activation caused by their resistance to the stretching is defined not so much of the magnitude of the stretching, but from the speed that it changes with. The resistance to stretching is bigger when the change in the traction power is more rapid, thus the smoother is the conduction of the procedure the safer is the procedure itself, regarding eventual complications and exacerbation of the pain [3]. It's recommended that extension therapy should not be done as a monotherapy, but as a upgrade therapy in a complex program, because of the greater effectiveness.
In 2015 in the University Hospital "St. Marina" in Varna we conducted a randomized controlled study with three month tracking period. The experimental group (EG) was treated with intermittent extension therapy, procedure with interference current and magnetic therapy, and the control group (CG) was treated only with magnetic therapy and interference current. The results have a high statistical • significance (p<0,001) for both groups regarding suspension of the pain syndrome, the functional tests for mobility in the lumbar region, the indicators for psycho-functional testing and quality of life, while comparing EG with CG the difference is also statistically significant (p<0,01) in favor of the first one [5].
Conclusion
The lumbar disc disease is a significant part of the pathology that physiotherapists face in their daily work. The effectiveness of the conducted treatment depends of the rational choice of physical factors depending on the particular case. In this sense, the composition of a proper physiotherapeutic approach, based on a professional judgement, determined the end results of the treatment. Based on the publications in the medical literature and the results of our researches we recommend extension therapy to be included in the physiotherapeutic program in cases of lumbar disc disease. The good understanding of the advantages of the method as well as the benefits from it, gives the opportunity to be used with medical as well as with prophylactic purpose.
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