EFFECTS OF MOBILIZATION, STRETCHING AND TRACTION IN SPORTS PROFESSIONALS WITH CERVICAL RADICULOPATHIES.

Author: 1.Dr. SARATH BABU.V. Associate Professor, MGM's institute of physiotherapy, Aurangabad. 2. Dr. RAMAKRISHNAN .K.S. Associate Professor, Department of Physiotherapy, Padmashree Dr DY Patil University, Navimumbai INTRODUCTION: Cervical radiculopathy is common in the sports population, with an annual increase in incidence.4 Cervical radiculopathy, although recognized early in the 20th century, was first associated with disc pathology in the mid-1930s. Spondylosis , disc herniation , acute wry neck, whiplash injuries, osteoarthritis are the common causes of neck pain.2 Neck pain also present posture imbalance resulting from shortening and increased activation of suboccipital, sternocledomastoid, upper trapezius, pectoralis and rotator cuff muscles.3 It is most commonly caused by disc herniation or cervical spondylosis.5 Cervical radiculopathy is a disease process marked by nerve compression from herniated disk material or arthritic bone spurs6. Disc herniation accounts for 20-25% of the cases of cervical radiculopathy. The seventh (60%) and sixth ( 25%) cervical nerve roots are the most commonly affected.8,9,10,11,12,13,14 sports professionals with cervical radiculopathy often report neck pain and radiating arm pain or numbness, sensory deficits, or motor dysfunction in the neck and upper extremities ; however, they most frequently seek treatment to address their arm pain.6,15,16,17 sports professionals with neck pain combined with upper extremity symptoms experience greater levels of disability than do people with nec Maitland technique involves the application of passive and accessory oscillatory movements to spinal and vertebral joints to treat pain and stiffness of a mechanical nature. The technique aims to restore motions of spin, glide and roll between joint surfaces and are graded according to their amplitude.21 Mulligans concept is now an integral component of many manual physiotherapists clinical practice its foundation is built on Kaltenborns principles of restoring the accessory component of physiological joint movement. His spinal mobilization with arm movements (SMWAMS) are transverse glide applied to the spinous process with active spinal movement.22 Also research suggests that manipulation (adjustments to the spine) and mobilization (movement imposed on joints and muscles) can be used alone or in combination with other physical therapies to treat neck pain.20 Mechanical traction for the cervical spine involves a pulling force applied to the neck via a mechanical system which can be applied intermittently or continuously. It is often used as an adjunct therapy in outpatient rehabilitation. The physiological effects of mechanical traction for the cervical spine may include separation of vertebral bodies, movement of facet joints, expansion of intervertebral foramen and stretching of soft tissue.1 Muscle manual therapy includes soft tissue therapy , muscle energy technique..2 Stretching is a general term to describe any therapeutic maneuver designed to lengthen(elongate) pathologically shortened soft tissue structures and thereby increase range of motion.23 Static stretching involves the maintenance of a stationary position of muscle tissue deformation over a period of time, usually at the end of the range of motion or the muscles ability to deform.24Jaenson et al said that stretching is a regular item in training program and it is increasing the flexibility and preventing muscle tenderness and strains.25Osternig et al said when a muscle is stretched motor neuron
1

supplying that receive both excitatory and inhibitory impulses from the receptors. If the stretch is continued for a slightly extended period of tie the inhibitory signals from the golgi tendon organs eventually override the excitatory impulses and therefore cause relaxation.26However, there is little evidence to suggest which non-operative interventions are the most effective.8,9 In the sports sector, where resources are more limited, advice on ergonomics, posture and self administered stretching is more commonly the sole intervention by physiotherapists. However, there is insufficient evidence to allow conclusions to be drawn about the effectiveness of passive manual therapy compared with stretching exercises. Thus, the aim of the present study was to compare the effectiveness of passive manual therapy, consisting of mobilization and stretching techniques, with traction on pain and disability in Sports Professionals with neck pain. Aim of the study: To find out the effect of mobilization, stretching and traction in sports professionals with cervical radiculopathies. Purpose of the study: To compare between manual therapy techniques for decreasing pain. Need of the study:The conceptualization of joint and muscle manual therapy techniques to be used for reducing pain . Studies have already been done on mobilization, traction and stretching in cervical radiculopathy. This study has been done to compare between these three techniques and to find out which one has a better emphasis. Hypothesis Experimental Hypothesis Manual therapy will be more effective in reducing neck pain. Null Hypothesis There is no relationship between these three variables. OPERATIONAL DEFINITIONS Cervical radiculopathy Cervical radiculopathy is a disease process marked by nerve compression from herniated disk material or bone spurs which causes neck pain and radiating arm pain or numbness, sensory deficits, or motor dysfunction in the neck and upper extremities.6 Manual therapy Manual therapy is a broad group of treatments in which a clinician applies forces directly to musculoskeletal system to restore painfree full ROM and can be applied to joints, muscles and neural structures. Maitland mobilization

Maitland technique involves the application of passive and accessory oscillatory movements to spinal and vertebral joints to treat pain and stiffness of a mechanical nature. Mulligan mobilization Mulligans technique is built on Kaltenborns principles of restoring the accessory component of physiological joint movement.22 Spinal mobilization with arm movements (SMWAMS) Mulligans spinal mobilization with arm movements are transverse glide applied to the spinous process with active arm movement.22 Mechanical Traction Mechanical traction involves a pulling force applied to the body via a mechanical system which can be applied intermittently or continuously.1 Stretching Stretching is a general term to describe any therapeutic maneuver designed to lengthen (elongate) pathologically shortened soft tissue structures and thereby increase range of motion.23 Static stretching Static stretching involves the maintenance of a stationary position of muscle tissue deformation over a period of time, usually at the end of the range of motion or the muscles ability to deform.24

RESEARCH DESIGN AND METHODOLOGY

Sample Subject of cervical radiculopathy playing sports (n = 45), the sample studied include 9 males and 36 females 15 each in group A, in group B and in group C . Twenty two Sports Professionals had right side and twenty three Sports Professionals and left side neck and radiating pain. Sampling Total sampling was 45 and subject were selected through random sampling. Design Experimental design was chosen and subjects were grouped according to convenience. The treatment methods used were maitland and mulligan mobilization, traction and stretching. Treatment schedule consist of five consecutive sessions. Selection criteria Once the subject registered as positive spurling and distraction test, they were clinically assessed according to the format which is mentioned in appendix B. If the subjects were found to have positive spurling and distraction test, all inclusion and exclusion criteria were checked. The procedure for spurling and distraction test is explained in appendix D. The subjects were told about all the interventions and procedure in detail to be followed in the study and thereafter consent was obtained. Inclusion criteria

Positive spurling test Unilateral radiating pain Positive Distraction test Positive upperlimb tension test (Median nerve)

Exclusion criteria 1. Any medical red flags ( Tumor, Fracture, Metabolic disease, RA, Osteoporosis, prolong history of steroid use). 2. Bilateral upper extremity symptoms.
4

3. Evidence of CNS involvement.

Dependent variable Visual Analogue Scale (VAS) for Pain Assessment

Independent Variable 1. Cervical Traction 2. Maitland mobilization 3. Mulligan mobilization 4. Upper trapezius, levator scapulae, and sub-occipital stretching. Instruments for data collection 1. Standardized stop watch It is used to note the duration of stretching. 2. Protocol Group A - Maitland mobilization and cervical traction Group B - Mulligan mobilzation and cervical traction Group C - Upper trapezius, levator scapule, sub-occipital stretching and cervical traction. Mechanical cervical traction

Procedure 45 Sports Professional with informed consent were participated in the pre assessment session to confirm the inclusion criteria. Sampling was conveniently done and groups were allotted as A, B, C and procedure was thoroughly explained and VAS was measured before the treatment sessions. The procedure to measure VAS is explained in appendix E. Subjects under group A, maitland mobilization and cervical traction was given. The procedure is explained in appendix F. Subjects under group B, mulligan mobilization and cervical traction was given. The procedure is explained in appendix G. Subjects under group C, neck muscle stretching and cervical traction was given. The procedure is explained in appendix H
5

The procedure for cervical traction is explained in appendix I.

DATA ANALYSIS: t test was used to compare the difference between pre-VAS and post-VAS within the group. One way ANOVA has been done to compare all the three groups. Difference between post sessions were also compared using post hoc scheffe.. The significant (probability- P) has been selected as 0.01 and 0.05 for t test and for one way ANOVA respectively. RESULTS Subject information: There are three groups, Group A (n=15) (maitland mobilization and cervical traction),Group B (n=15) (mulligan mobilization and cervical traction) and Group C (n=15) (stretching and cervical traction) were taken. Statistical tests: The mean and Standard deviation of pre-VAS and Post- VAS was done for group A, B and C. The values of pre-VAS for group A are 6.622.12 with 5.42 to 7.77 of CI 95%. The values of post-VAS for group A are 3.812.29 with 2.57 to 5.1 of CI 95%. The values of pre-VAS for group B are 7.601.21 with 6.95 to 8.31 of CI 95%. The values of post-VAS for group B are 2.331.49 with 1.50 to 3.16 of CI 95%. The values of pre-VAS for group C are 6.851.67 with 5.92 to 7.78 of CI 95%.The values of post-VAS for group C are 1.901.58 with 1.02 to 2.77 of CI 95%. (Table 4) t test: Comparison between pre-VAS and post-VAS has been done for group A, B and C by using t test. The result were highly significant for all three groups.(Table 5) One way ANOVA and Sheffe test: When the comparison of mean between the groups A, B C were done for post values there were significant (p<0.05) results (Table 6). Comparison of mean difference between groups A, B and C was done using Post hoc scheffe test. The mean difference for A Vs B were not significant (p>0.05). The mean difference for B Vs C also shown non significant result (p>0.05). But when the mean difference for A Vs C was done the result were significant (p<0.05).(Table 7) Table 1. Distribution of Sports Professionals according to sex in Group A, Group B and Group C: GROUP GROUP A GROUP B GROUP C MALE 04 03 02 FEMALE 11 12 13 TOTAL 15 15 15

Table 1.A. Homogenity N A 1 5 B 1 5 C 1 5 GROUP GROUP A GROUP B GROUP C Alpha 3.83 2.33 1.90 Table 2. Distribution of Sports Professionals according to affected side in Group A, Group B and Group C. LEFT 07 07 09 TOTAL 15 15 15

RIGHT 08 08 06

Table 3. Mean and standard deviation of pre- VAS and post- VAS in group A, group B and group C GROUP Pre-VAS GROUP A Post-VAS GROUP A Pre-VAS GROUP B Post-VAS GROUP B Pre-VAS GROUP C Post-VAS GROUP C MEAN and SD 6.622.12 3.812.29 7.601.21 2.331.49 6.851.87 1.901.58 CONFIDENCE INTERVAL 95% 5.42 to 7.77 2.57 to 5.1 6.95 to 8.81 1.50 to 3.16 5.92 to 7.78 1.02 to 2.77

Table 4. Comparison between Pre-VAS and Post-VAS in group A, group B and group C using t test. Comparison Pre-VAS in GROUP A VS Post-VAS in GROUP A Pre-VAS in GROUP B VS Post-VAS in GROUP B Pre-VAS in GROUP C VS Post-VAS in GROUP C Table.5. ANOVA for Group A, Group B, and Group C. Betwee n groups Sum of square 30.87 d.f 2 Mean square F-value significant 15.439 4.639 0.015 (S) t-value 5.70 11.27 9.20 p-value 0.000 0.000 0.000 Significant/not significant Significant Significant Significant

Within groups Total

139.76

42

3.32

170.64

44

Table 6. Post Hoc Sheffe test Mean difference Scheffe value Significant A Vs B 1.5 0.091 Non-significant B Vs C 0.433 0.81 Non-significant A Vs C 1.93 0.22 significant

Graph .1

Graph 2

10

Graph 3

11

DISCUSSION The result of this study suggest that neck muscle stretching along with traction in Sports Professionals with cervical radiculopathy results in immediate improvements in their neck pain. patient received stretching and traction demonstrated a mean of 1.90 cm (95% CI:1.02-2.77) on VAS, compared to 2.33 cm (95% CI:1.503.16) and 3.81 cm (95%:2.57-5.1) change on VAS among mulligan and maitland mobilization respectively. While recent research has identified the accurate methods for clinical diagnosis of cervical radiculopathy , identification of appropriate conservative management stratergies appears to remain a clinical enigma.35, 39Hoving et al (2002) found that manual therapy including massage, specific mobilization techniques involving lowvelocity passive movements within the limit of joint range of motion and coordination or stabilization techniques, reduced neck pain significantly more effectively than treatment by a general practitioner, which included medication, information and a booklet containing ergonomic advice and home exercises and encouragement to await further recovery. The effect of cervical traction were reported by Moeti and marchetti (2001), who measured the outcomes in a group of Sports Professionals with cervical radiculoapathy treated with cervical traction, neck retraction exercises, scapula muscle strengthening and mobilization and reported full resolution of pain in 8 of 15 (53%) Sports Professionals at the time of discharge. Also similar positive results were observed with cervical traction by constantoyannis et al (2002), and olivero et al (2002). The physiological effects of mechanical traction for the cervical spine may include separation of vertebral bodies, movement of facet joints, expansion of intervertebral foramen and stretching of soft tissue which was already reported by graham and goldsmith (2010) which would be the rationale for relieving the nerve compression. But a study of Graham et al (2010) suggests that there is very little efficacy of cervical traction in cervical radiculopathy. Also in a study conducted by Murphy (1991) on effects of cervical traction on muscle activity concludes no significant difference between at rest and with 10 mins of traction. According to chris ferrigno scapula stabilization muscles ( upper trapezius, levator scapulae) provide a solid base for cervical spine. In an abnormal posture due to improper muscle stabilizers disc herniation occur due to pressure difference and cause cervical radiculpathy. Also he reported cervical retraction decrease cervical flexion and upper cervical extension and results decrease pressure on anterior aspect of lower cervical disc and reduces Sports Professionals neck pain. So when stretching of neck extensors creats pressure placed on posterior aspect of cervical disc; with repeated movements at end range , the disc has the potential to creep anteriorly and take pressure off the irritated nerve. Osternig et al said when a muscle is stretched motor neuron supplying that receive both excitatory and inhibitory impulses from the receptors. If the stretch is continued for a slightly extended period of tie the inhibitory signals from the golgi tendon organs eventually override the excitatory impulses and therefore cause relaxation.26 This rationale would made stretching was very effective than mobilization in this study. The effect of stretching has been documented by several studies. In a study conducted by Hakkienen et al (2008) and Jari ylinen et al (2007) showed both manual
12

therapy and stretching were significant effective short term treatment for reducing neck pain. Though statistical analysis in this study showed stretching clearly favouring to reduce neck pain, several studies have already shown manual therapy with respective of mobilization to be effective treatment in neck pain. A substantial amount of literature concerning the rationale for the use of manual therapy highlights the value of movement in maintaining health and strength of collagenous, muscular and bony tissues (Smith 1995 a and b; Twomey 1992, Threlkeld 1992, Evans 1980).Maitland and Mulligan present different but not mutually exclusive sets of widely employed manual therapy techniques for treating pain and stiffness in human joints. Whilst the literature reports extensively on the efficacy of their respective techniques (Rothstein: Exelby 1995, 1996; Wilson).Maitlands techniques involve the application of passive and accessory oscillatory movements to spinal and vertebral joints to treat pain and stiffness of a mechanical nature. The techniques aim to restore motions of spin, glide and roll between joint surfaces and are graded according to their amplitude (maitland 2002, 1998).However, in treating the spine Maitland will follow the planes of the intervertebral body joints. whilst Mulligan techniques follow the plane of the zygapophyseal joints. Exelby (1995) argues that the zygapopheseal joints guide the spine and so improving their glide will improve the range of spinal movement. Applying treatment on the plane of the intervertebral body joints results in compression on the zygapopheseal joints and will not promote glide. The concept of mulligan has its foundation built on kaltenborns principles of restoring the accessory movement. one of his techniques of spinal mobilizations with arm movements (SMWAMS) gave new dimension to spinal mobilization. He found spinal movement had an important role to play in the peripheral joint by combining extremity joint mobilizations with extremity joint movement. This new mobilization with movement developed because of the fact that when the shoulder girdle is moved spinal movement also takes place because of the muscle attachments from the scapula to the cervical and upper thoracic vertebra. The rationale for relieving the symptom according to mulligan , when movements of spinous process of above the affected vertebra to one side results rotation on opposite direction on below vertebra. This causes the facets to separate on opposite side and relieving the symptoms.72, 77 So mulligans mobilization not only relieving the symptoms by abovementiond physiological perspective but also improving the spinal movement by gliding the zygopopheseal joints which would be the clear clinical rationle to made mulligans mobilization beter than of maitland mobilization.

13

Relevance to clinical practice 1. In general practice traction and electrical modalities are the commonest method of treating radiculopathy. But this study will prove manual therapy techniques and stretching can also be useful for reducing the symptoms. 2. The effect produce by both mobilization provides opening of intervertebral foramina there by relieve the compressed nerve root. 3. Simple stretching techniques also lengthen the soft tissues thereby relieving the nerve compression.

Future research 1. Future research should examine the long term effects of manual therapy. 2. More number of sample size. 3. Future research should examine less variations in age groups.

CONCLUSION The result of the study concluded that manual therapy shown significant improvement in reducing neck pain. Among that, stretching shown more effective than mulligan and maitland mobilization. When comparing both mobilizations, mulligan shown much effective than maitland. However treatment to be more effective low-cost stretching exercises can be recommended along with mobilization.

14

CHAPTER - 8 REFERENCES

1. Graham N, Gross A, Goldsmith CH, Klaber Moffett J, Haines T, Burnie SJ, Peloso. Mechanical traction for the neck pain with or without radiculopathy.PMJ. The Cochrane Library 2010, Issue 2. 2. Peter Brukner and Karim khan Clinical sports medicine third edition 230,241. 3. Wang WTJ, Olson SL. Effectiveness of physical therapy for Sports Professionals with neck pain.Am J Phys Med Rehab.2003;82: 203-18. 4. Radhakrishnan K, Litchy WJ, OFallon WM, Kurland LT. Epidemiology of cervical radiculopathy: A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994;117:325335. 5. Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopathy. Arch phys rehab1994Mar;75(3):34252. med

1. Eubanks JD. Cervical radiculopathy: nonoperative management of neck pain and radicular symptoms. Am Fam physician 2010 Jan 1;81(1):33-40. 7. Murphey F, Simmons JC, Brunson B. Chapter 2. Ruptured cervical discs, 1939 to 1972. Clin Neurosurg. 1973;20:9-17. 8. Bogduk N, Twomey LT. Clinical Anatomy of the Lumbar Spine. 2nd ed. Edinburgh, UK: Churchill Livingstone Inc; 1991.

9. Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil. Mar 1994;75(3):342-52. 10. Malanga GA. The diagnosis and treatment of cervical radiculopathy. Med Sci Sports Exerc. Jul 1997;29(7 suppl):S236-45. 11. Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. Apr 1994;117(pt 2):325-35.
15

12. Van Gijn J, Reiners K, Toyka KV, Braakman R. Management of cervical radiculopathy. Eur Neurol. 1995;35(6):309-20. 13. White AA, Panjabi MM. Clinical Biomechanics of the Spine. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1990:102. 14. Parminder SP. Management of cervical pain. In: Delisa JA, Gans BM, eds. Rehabilitation Medicine: Principles and Practice. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1988:753.

15. Wainner RS, Gill H. Diagnosis and nonoperative management of cervical radiculopathy. J Ortho Sports Phys Ther. 2000;30:728744. 16. Cleland JA, Whitman JM, Fritz JM, Palmer JA. Manual physical therapy, cervical traction, and strengthening exercises in Sports Professionals with cervical radiculopathy: A case series. J Orthop Sports Phys Ther. 2005;35:802811. 17. Daffner SD, Hilibrand AS, Hanscom BS, et al. Impact of neck and arm pain on overall health status. Spine. 2003;28:20302035. 18. Jeffrey Boyling , Gwendolen Jull. Greives Modern Manual Therapy. 3rd edition 453. 19. Young IA, Michener LA, Cleland JA, Aguilera AJ, Snyder AR. Manual therapy, exercise, and traction for Sports Professionals with cervical radiculopathy: a randomized clinical trial.Phys therapy.2009 Jul;89(7):632-42. 20. Gross A, Miller J, DSylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brnfort G,Hoving JL. Manipulation or Mobilization for Neck pain. The Cochrane Library 2010, Issue 5. 21. L. Exelby. Manual therapy- spinal vertebral mobilization. The health care journal of the core concepts group for musculoskeletal health. Feb 2008. 22. L.Exelby. The Mulligan concept: Its application in the management of spinal conditions . Manual therapy 2002; 7(2), 64-70. 23. Carolyn kisner, Lynn Allen Colby. Therapeutic exercise. 4th ed;172. 24. David Magee. Atheletic injuries and rehabilitation. 25. Jaenson et al 1989 stretching in relation to sports and prevention of injuries. Ugeskraeger mar 13:151(11):672-3. 26. Osernig et al(1990) differential responses to pnf stretch technique cause relaxation. Med.sci.sports excerc.:22:106-111. 27. Nyaard P, Andersen TI, Zwart JA. Neck pain with and without affection of nerve roots. Tidskr Nor Laegeforen 2010 Nov 18; 130(22): 2252-5. 28. Rhee JM, Yoon T, Riew KD.Cervical radiculopathy. J Am Acad ortho surg. 2007Aug; 15(8):486-94. 29. Abbed KM, Coumans JV. Cervical radiculopathy: pathophysiology, presentation and clinical evaluation. Neurosurgery. 2007 Jan;60(1 SUPP 1 1): S28-34. 30. Shedid D, Benzel EC. Cervical spondylosis anatomy: pathophysiology and biomechanics. Neurosurgery. 2007 Jan; 60: S7-13. 31. L.C.G.Persson, U.Moritz, L.Brandt. Pain, muscle weakness and sensory loss in Sports Professionals with cervical radiculpathy treated with surgery, physiotherapy and color.Eur Spine J. 1997;6:256-266.

16

32. Rubinstein SM, Pool JJ, Van Tulder MW. Diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy: A systematic review. Eur spine J. 2007Mar;16(3):307-19. 33. Malanga GA, Landes P Nadier SF. Provocative tests in cervical spine examination: Historical basis and scientific analyses. Pain Physician. 2003April;6(2):199-205. 34. Tong HC, Haig AJ, Yamakawa K. The Spurling test and cervical radiculopathy. Spine(phila pa 1a76). 2002Jan15;27(2):156-59. 35. Moeti P, Marchetti G. Clinical outcome from mechanical intermittent cervical traction for the treatment of the cervical radiculopathy: A case series. J ortho sports phys therapy. 2001 April;31(4):207-13. 36. Waldrop MA. Diagnosis and treatment of cervical radiculopathy using a clinical prediction rule and multimodal intervention approach. A case series. J ortho sports phys ther. 2006 March;36(3):152-9. 37. Constantoyannis, Konstantinou, Kourtopoulous. Intermittent cervical traction for cervical radiculopathy caused by large volume herniated discs. J manipulative physio ther. 2002March,april;25(3):188-92. Olivero, Dulebohn. Results of cervical traction for the treatment of cervical radiculopathy: Retrospective review of 81 Sports Professionals. Neuro surg focus.2002Feb15;12(2):ECPI.

38.

39. Joghataei MT, Arab AM, Khaksar H. The effect of cervical traction combined with conventional therapy on grip strength on Sports Professionals with cervical radiculopahty. Clin rehab.2004Dec;18(8):879-87. 40. Graham N, Gross A, Goldsmith CH, Klaber. Mechanical traction for neck pain with or without radiculopathy. Cochrane database of systematic review. Issue 2, 2010. 41. Ian A, Young, Lori A, Joshua A, Arnold Aguilera. Manual therapy exercise and traction for Sports Professionals with cervical radiculopathy: A randomized clinical trial. Clin rehab 2008Jan;20(4):294-99. 42. Diane Jette, Jeffrey Fallkel, Catherine Trombly et al. effect of intermittent, supine cervical traction on myoelectric activity of upper trapezius muscle in subjects with neck pain. Phys Ther.1985Aug;65(8);1173-6. 43. Zyloborgold RS, Piper MC. Cervical spine disorder. A comparison of three types of traction. Spine.1985Dec;10(10):867-71. 44. Murphy MJ. Effects of cervical traction on muscle activity. J Ortho sports Phys Ther .1991;13(5):220-5. 45. Nanno M. Effects of intermittent cervical traction on muscle pain. Flowmetric and electromyographic studies of cervical paraspinal muscles. Nippon Ika Daigaku Zasshi.1994April;61(2):137-47. 46. Deets D, Hands KL, Hopp S. cervical traction. A comparison of sitting and supine positions. Phys Ther.1977Mar;57(3);55-61.

17

47. Raney NH, Petersen EJ, Smith TA, Cowan JE . Development of a clinical prediction rule to identiy Sports Professionals with neck pain likely to benefit from cervical traction and exercises. Eur spine J .2009 Mar;18(3):382-91. 48. Jerrad A , Ben Salah Z, Rejeb N. The value of ICT in recent cervical radiculopathy. Am Phys Rehab Med. 2009 Nov;52(9):638-52. 49. Hseuh TC, Chou YL. Evaluation of the effects of pulling angle and force on ICT with the sounders halter. J Formos Med Assoc.1991 Dec;90(12):1234-9. 50. Wong AM, leong CP, Chen CM. The traction angle and cervical intervertebral separation. Spine. 1992 Feb;17(2):136-38. 51. Eubanks JD. Cervical radiculopathy: non operative management of neck pain and radicular symtoms. Am Fam Physician. 2010 Jan 1; 81(1):33-40. 52. Bronfort G, Hass M, Evans RL, Boutir LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: A systematic review and best evidence synthesis. Spine J.2004 may-june;4(3):335-56. 53. Cleland JA, Whitman JM, Fritz JM, Palmer JA. Manual physical therapy, cervical traction and strengthening exercises in Sports Professionals with cervical radiculopathy: a case series. J ortho sports Phys Ther. 2005 dec;35(12):802-811. 54. Classidy JD, Lopes AA, Yong-Hing K. The immediate effect of manipulation versus mobilization on pain and range of motionin cervical spine: a randomized controlled trial. J Manipulative Physical ther.1992nov-dec;15(9):570-5. 55. Michael Costello, MTS. Treatment of a patient with cervical radiculopathy using thoracic spine thrust manipulation, soft tissue mobilization and exercise. J Man Manip Ther.2008;16(3):129-35. 56. Gross A, Miller J, Dsylva J, Burnie SJ, Goldsmith CH. Mobilization or manipulation for neck pain. Cochrane database of systematic review issue5, 2010. 57. Kay TM, Gross A, Goldsmith CH, Hoving JL. Exercises for mechanical neck disorders. Cochrane database of systematic review, issue 4, 2009. 58. Leanne Apfelbeck MS. An ntegrative treatment approach of a patient with cervical radiculitis. J Chiropr Med.2005;4:97-102. 59. Vernon H , Humphreys K, Hagino C.Chronic mechanical neck pain in adults treated by manual therapy. J. Manip Phy Ther. 2007 Mar-Apr;30(3):215-27. 60. Pickar JG. Neurophysiological effects of spinal manipulation.Spine J.2002 Sepoct;2(5):357-71. 61. Ana Claudia Biolino Cunha, Thomas Nogueira Burke, Fabio Jorge. Effect of global posture re- education of static stretching on pain range of motion and quality of life in women with chronic neck pain. Pasqual@usbr. Tel 55113091 8423. 62. Hseuh TC, Ju MS, Chor YL. Evaluation of the effecys of pulling angle and force on intermittent cervical traction with the saunders Halter. J Formos Med Assoc.1991Dec;90(12):1234-9.
18

63. Hakkinen A, Salo P, Tarvaenen U, Wiren. Effect of manual thrapy and stretching on neck muscle strength and mobility in chronic neck pain. J Rehabil Med.2007Sep;39(7):575-9. 64. Hakkinen A, Kautlainon H, Hannaoen P, Ylinen J.Strength training and stretching versus stretching only in the treatment of Sports Professionals with chronic neck pain. Clin Rehab 2008 July;22(7):592-600. 65. Ylinen J, Kautiainen H .Stretching exercises Vs manual therapy in treatment of chronic neck pain. J Rehab Med. 2007 Mar;19(2):126-32. 66. Taylor Dalton et al . Viscoelastic properties of muscle tendon units. Am J Sports Med. 1990 May- Jun;18(3):300-9. 67. Shellock et al. Physiological benefits of warm up. Phy Sports Med.1983;11(10):134-39. 68. Bandy , Iron . The effect of time of stretch on the flexibility of hamstring muscles. Phy Ther .1995 Mar;75(3):238-9. 69. Cipriani, Abel . A comparison of two stretching protocols .J Strength Cond res. 2003 May;17(2):274-8. 70. Maitland GD, Banks K, English K, Hengeveld, E: Vertebral Manipulation. Butterworth Heinemann, Oxford. 2002. 71. Maitland GD: Peripheral Manipulation . Butterworth Heinemann, Oxford 1998 Mulligan BM: NAGS, SNAGS and MWM etc. Plane View Services. 1993. 72. Mulligan B: Mobilisations with movement (MWMS) for the hip joint to restore internal rotation and flexion. Journal of Manual and Manipulative Therapy Vol 4 No.1 1996.35-36. 73. Exelby L:: Mobilisations with movement a personal view. Physiotherapy, Dec 1995, vol 81, No.12. 74. Smith, N: Connective Tissue: its molecular structure and responses to movement and manual therapy. Journal of Therapy and Rehabilitation (1995a) Vol. 2, no. 12, 659-662. 75. Threlkeld AJ: The effects of manual therapy on connective tissue. Physical Therapy, Vol 72, No.12, Dec 1992. 893-902. 76. Twomey LT: A rationale for the treatment of back pain and joint pain by manual therapy. Physical Therapy, Vol 72, No.12, Dec 1992 885-892. 77. Wilson E: The Mulligan Concept: NAGS, SNAGS and mobilizations with movement. Clinical Methods, Apr 2001 UK. 78. Hoving JL, Koes BW, De Vet HC, Assendelft WJ, Van der Windt DA, Van Mameren H, et al. Manual therapy, physical therapy or continued care by the general practitioner for Sports Professionals with neck pain: short-term results from a pragmatic randomized trial. Ann Intern Med 2002; 136: 713722.
19

79. Nicola J Petty, Ann P Moore. Neuromusculoskeletal examination and assessment. 2nd edition . Pg13. 80. Maitland. Vertebral Manipulation. 7th edition. Pg 281. 81. Brian Mulligan. Manual Therapy, NAGS, SNAGS, MWMS. 4th edition. Pg 29- 30. 82. Nicola J Petty, Ann P Moore. Neuromusculoskeletal examination and assessment. 2nd edition . Pg 60. 83.Michelle H Cameron. Physical agents in rehabilitation. 3rd edition. Pg 304.

20