Previous systematic reviews have concluded that lumbar traction is not effective for patients with low back pain (LBP), yet many clinicians continue to assert its clinical effectiveness. To systematically identify randomized controlled trials (RCTs) of traction and explore the variability of traction interventions used in each RCT. A literature search started in September 2016 to retrieve systematic reviews and individual RCTs of lumbar traction. The term “lumbar traction” and other key words were used in the following databases: Cochrane Registry, MEDLINE, EMBASE, and CINAHL. The retrieved systematic reviews were used to extract individual RCTs. The most current systematic review included RCTs from inception until August 2012. We performed an additional literature search to update this systematic review with newer RCTs published between September 2012 and December 2016. All of the identified RCTs were combined and summarized into a single evidence table. We identified a total of 37 traction RCTs that varied greatly in their method of traction intervention. The RCTs included several types of traction: mechanical (57%), auto-traction (16%), manual (10.8%), gravitational (8.1%) and aquatic (5.4%). There was also great variability in the types of traction force, rhythm, session duration and treatment frequency used in the RCTs. Patient characteristics were a mixture of acute, subacute and chronic LBP; with or without sciatica. There is wide variability in the type of traction, traction parameters and patient characteristics found among the RCTs of lumbar traction. The variability may call into question the conclusion that lumbar traction has little no or value on clinical outcomes. Also, this variability emphasizes the need for targeted delivery methods of traction that match appropriate dosages with specific subgroups of patients with LBP.

We present the movement control approach as part of the treatment-based classification system. This approach proposes a movement control schema that clarifies that movement control is a product of the interplay among multiple biopsychosocial components. The schema illustrates that for movement to occur in a dynamically controlled fashion, the lumbar spine requires both local mobility and global stability. Local mobility means that the lumbar spine and its adjacent regions possess adequate nerve and joint(s) mobility and soft tissue compliance (ie, the malleability of tissue to undergo elastic deformation). Global stability means that the muscles of the lumbar spine and its adjacent regions can generate activation that is coordinated with various joint movements and incorporated into activities of daily living. Local mobility and global stability are housed within the bio-behavioral and socio-occupational factors that should be addressed during movement rehabilitation. This schema is converted into a practical physical examination to help the rehabilitation provider to construct a clinical rationale as to why the movement impairment(s) exist. The examination findings are used to guide treatment. We suggest a treatment prioritization that aims to consecutively address neural sensitivity, joint(s) and soft tissue mobility, motor control, and endurance. This prioritization enables rehabilitation providers to better plan the intervention according to each patient's needs. We emphasize that treatment for patients with low back pain is not a static process. Rather, the treatment is a fluid process that changes as the clinical status of the patient changes. This movement control approach is based on clinical experience and indirect evidence; further research is needed to support its clinical utility.

Background: Musculoskeletal disorders (MSDs) are rapidly rising in Saudi Arabia and considered the 3rd reason for hospital visits across the country. Despite their prevalence, the adequacy of knowledge in diagnosing and treating MSDs has not been assessed. The purpose of this study is to assess MSD knowledge amongst healthcare providers (orthopedists, physicians, and physical therapists) and medical and physical therapy students and interns. Methods: In this cross-sectional study, a web-based 25-question MSD test was given to licensed physical therapists, primary care physicians and orthopedists, as well as final-year physical therapy and medical students and interns in Saudi Arabia. Two multivariable linear regression analysis models were used to determine MSD test score differences amongst (1) orthopedists, primary care physicians, and physical therapists and (2) amongst medical and physical therapy students and interns. Results: A total of 680 participants were included (response rate is 22.7%). The overall MSD test score was 48.2%, and the passing rate was 14%. Model 1 showed that orthopedist’s group had a significantly higher mean score on MSD test than physical therapists (t₄₈₂= 8.12, p < 0.001) and primary care physician (t₄₈₂= 6.00, p < 0.05). However, primary care physician scores did not significantly differ from physical therapy group (t₄₈₂= 6.47, p = 0.07). Model 2 showed that medical interns had significantly higher mean score on MSD test than physical therapy students (t₂₄₀=4.46, p < 0.001), physical therapy interns (t₂₄₀= 4.7, p < 0.05), and medical students (t₂₄₀= 2.79, p < 0.05). There was also a significant difference between medical students and physical therapy interns (t₂₄₀= 2.5, p < 0.05). However, there was no significant difference between medical students and physical therapy students. Conclusion: Except for orthopedists, the MSD knowledge appears inadequate amongst healthcare providers, medical and physical therapy students and interns in Saudi Arabia. To improve knowledge in MSDs, increasing content of MSDs in undergraduate education and postgraduate training is necessary.