# Exercise, manipulation and traction physiotherapy in the conservative management of lumbar disc herniation: A systematic review and meta-analysis

## TL;DR

This study compares the effectiveness of exercise, manipulation, and traction therapies for treating lower back pain caused by disc herniation, finding traction to be most effective but noting significant variability in results.

## Contribution

The study provides a meta-analysis comparing three conservative physiotherapy approaches for lumbar disc herniation, identifying traction therapy as having the highest pooled effect size.

## Key findings

- Traction therapy showed the largest effect size (SMC = 2.52) compared to exercise and manipulation therapies.
- High heterogeneity (I² = 97.9%) suggests variability in study protocols and populations.
- Shorter follow-up durations were associated with larger treatment effects (p < 0.001).

## Abstract

Lumbar disc herniation (LDH) is a leading cause of global back pain with significant socioeconomic impact. Conservative physiotherapy, including exercise, manipulation, and traction therapies, is a common first-line treatment. However, their relative efficacy and applicability to specific subgroups remain unclear.

This systematic review and meta-analysis evaluated the efficacy of these three modalities, identified factors influencing variability, and explored subgroup-specific applications.

Following PRISMA guidelines, a systematic review was conducted with searches of PubMed, MEDLINE, EMBASE, OVID, Scopus, and grey literature. Forty-three studies were included in the qualitative synthesis and 20 in the meta-analysis. Random-effects models estimated pooled standardized mean changes (SMCs), and meta-regression examined covariates influencing variability.

The pooled SMC across modalities was 2.28 (95 % CI: 1.51, 3.05), indicating large treatment effects, though heterogeneity was high (I2 = 97.9 %). Traction therapy had the highest effect size (SMC = 2.52, 95 % CI: 1.57, 3.37), followed by exercise therapy (SMC = 1.97, 95 % CI: 0.46, 3.48) and manipulation therapy (SMC = 1.91, 95 % CI: 0.24, 4.04). Follow-up duration significantly influenced effect sizes (p < 0.001), with shorter durations associated with larger effects. Qualitative findings suggested potential subgroup benefits for complex or chronic pain patients, but quantitative evidence for subgroup differentiation was limited.

Conservative therapies may effectively reduce LDH-related pain and disability, with traction therapy demonstrating the largest pooled effect size. High heterogeneity and methodological inconsistencies limit subgroup-specific recommendations. Rigorous trials and standardized methodologies are essential for optimizing evidence-based care for LDH patients.

•Traction therapy demonstrated the largest effect size among modalities (SMC = 2.52, 95 % CI: 1.57–3.37).•High heterogeneity (I2 = 97.9 %) highlights variability in protocols, populations, and follow-up durations.•Follow-up duration significantly influenced outcomes, with shorter durations showing exaggerated effects (p < 0.001).•Despite strong effects, methodological inconsistencies limit subgroup-specific therapy recommendations.•Findings emphasize the need for standardized protocols and head-to-head comparisons to guide personalized LDH care.

Traction therapy demonstrated the largest effect size among modalities (SMC = 2.52, 95 % CI: 1.57–3.37).

High heterogeneity (I2 = 97.9 %) highlights variability in protocols, populations, and follow-up durations.

Follow-up duration significantly influenced outcomes, with shorter durations showing exaggerated effects (p < 0.001).

Despite strong effects, methodological inconsistencies limit subgroup-specific therapy recommendations.

Findings emphasize the need for standardized protocols and head-to-head comparisons to guide personalized LDH care.