Research Report

Manual Therapy, Exercise, and

Traction for Patients With Cervical
Radiculopathy: A Randomized
Clinical Trial
Ian A. Young, Lori A. Michener, Joshua A. Cleland, Arnold J. Aguilera,
Alison R. Snyder

I.A. Young, PT, MS, OCS, SCS,

Cert MDT, is Physical Therapist,
Spine and Sport, Savannah, Georgia, and Affiliate-Associate Professor, Department of Physical Therapy, Virginia Commonwealth
UniversityMedical College of Virginia Campus, Richmond, Virginia. Mailing address: Box 961,
Tybee Island, GA 31328 (USA).
Address all correspondence to Mr
Young at: youngian@spinesport.
org.

Background. To date, optimal strategies for the management of patients with

cervical radiculopathy remain elusive. Preliminary evidence suggests that a multimodal treatment program consisting of manual therapy, exercise, and cervical traction may result in positive outcomes for patients with cervical radiculopathy. However, limited evidence exists to support the use of mechanical cervical traction in
patients with cervical radiculopathy.

L.A. Michener, PT, PhD, ATC SCS,

is Associate Professor, Department
of Physical Therapy, Virginia Commonwealth
UniversityMedical
College of Virginia Campus.

Design. This study was a multicenter randomized clinical trial.

J.A. Cleland, PT, PhD, OCS,

FAAOMPT, is Associate Professor,
Department of Physical Therapy,
Franklin Pierce University, Concord, New Hampshire; Physical
Therapist, Rehabilitation Services,
Concord Hospital, Concord, New
Hampshire; and Faculty, Regis
University Manual Therapy Fellowship Program, Denver, Colorado.
A.J. Aguilera, MD, is Neurologist,
Neurology Associates, Fredericksburg, Virginia.
A.R. Snyder, PhD, ATC, is Assistant
Professor, Athletic Training Program, A. T. Still University, Mesa,
Arizona.
[Young IA, Michener LA, Cleland
JA, et al. Manual therapy, exercise,
and traction for patients with cervical radiculopathy: a randomized
clinical trial. Phys Ther. 2009;
89:632 642.]
2009 American Physical Therapy
Association
Post a Rapid Response or
find The Bottom Line:
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Objective. The purpose of this study was to examine the effects of manual
therapy and exercise, with or without the addition of cervical traction, on pain,
function, and disability in patients with cervical radiculopathy.

Setting. The study was conducted in orthopedic physical therapy clinics.

Patients. Patients diagnosed with cervical radiculopathy (N81) were randomly
assigned to 1 of 2 groups: a group that received manual therapy, exercise, and
intermittent cervical traction (MTEXTraction group) and a group that received manual therapy, exercise, and sham intermittent cervical traction (MTEX group).
Intervention. Patients were treated, on average, 2 times per week for an average
of 4.2 weeks.

Measurements. Outcome measurements were collected at baseline and at 2

weeks and 4 weeks using the Numeric Pain Rating Scale (NPRS), the Patient-Specific
Functional Scale (PSFS), and the Neck Disability Index (NDI).
Results. There were no significant differences between the groups for any of the
primary or secondary outcome measures at 2 weeks or 4 weeks. The effect size
between groups for each of the primary outcomes was small (NDI1.5, 95% confidence interval [CI]6.8 to 3.8; PSFS0.29, 95% CI1.8 to 1.2; and NPRS0.52,
95% CI1.8 to 1.2).

Limitations. The use of a nonvalidated clinical prediction rule to diagnose cervical radiculopathy and the lack of a control group without treatment were limitations of this study.
Conclusions. The results suggest that the addition of mechanical cervical traction
to a multimodal treatment program of manual therapy and exercise yields no significant additional benefit to pain, function, or disability in patients with cervical
radiculopathy.

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Manual Therapy, Exercise, and Traction for Cervical Radiculopathy

he annual incidence of cervical

radiculopathy (CR) has been
reported to be 83 cases per
100,000 people in the population,
with an increased prevalence noted
in the fifth decade of life.1 This disorder is most commonly associated
with a cervical disk derangement
or other space-occupying lesion, resulting in nerve root inflammation,
impingement, or both.1,2 Common
signs and symptoms of CR include
upper-extremity pain, paresthesia or
numbness, weakness, or a combination of these signs and symptoms.
Patients also may have scapular
pain,3,4 headaches,5 and neck pain.6
Patients with both neck and upperextremity symptoms have been reported to have greater functional
limitation and disability than patients
with neck pain alone.7
Diagnostic imaging (magnetic resonance imaging) and electrophysiological tests (nerve conduction
velocity, electromyography) are
commonly used to confirm a diagnosis of CR.8 11 Using nerve conduction velocity and electromyographic
data as a gold standard, a clinical
prediction rule (CPR) was derived
to identify the presence of CR using
a limited subset of variables from the
clinical examination.12 The CPR for
identifying CR includes the Spurling
test, the distraction test, the UpperLimb Tension Test 1 (ULLT1) (median nerve bias), and ipsilateral cervical rotation of less than 60 degrees.
The CPR exhibited a specificity of
94% (positive likelihood ratio6.1,
95% confidence interval [CI]2.0 to
18.6) when 3 of 4 criteria were
satisfied.
Physical therapy interventions often
used for the management of CR include cervical traction, postural education, exercise, and manual therapy
applied to the cervical spine and thoracic spine.13 Studies indicate that
some combination of these interventions may result in improved outJuly 2009

comes for patients with CR.14 23

Previous controlled clinical trials investigating the treatment of patients
with CR have not used the CPR as
an inclusion criteria.14,15,17,23,24 To
date, only 2 case series18,21 and a
cohort study22 have examined standardized treatment programs in patients diagnosed with CR, using the
previously defined CPR. The prospective cohort study identified predictor variables that can identify
which patients with CR are likely
to have short-term successful outcomes.22 A multimodal approach to
management including manual therapy, cervical traction, and deep neck
flexor strengthening was identified
as the set of predictors; however, the
study design does not allow for identification of a cause-and-effect relationship. Moreover, the treatment
protocol in that study was not standardized. A randomized clinical trial
is needed to compare the effectiveness of standardized treatment approaches in a homogenous sample of
patients with CR.
The clinical use of intermittent cervical traction for CR is common, but
its effectiveness has been examined
in only one clinical trial.17 Joghataei
et al17 found that exercise and intermittent cervical traction were
superior to exercise and ultrasound
in improving grip strength (forcegenerating capacity) following 5 visits in patients with C7 radiculopathy.
However, the lack of a measure of
pain or disability limits application of
these results. There remains a paucity of quality outcome studies investigating commonly used interventions in a homogenous population of
patients with CR. Thus, the purpose
of this study was to examine the effects of manual therapy and exercise, with or without the addition of
intermittent cervical traction, in patients with CR, as identified by the
previously described CPR.

Materials and Method

A multicenter randomized clinical
trial involving orthopedic physical
therapy clinics in Virginia, Georgia,
Alabama, and West Virginia (N7
clinics) was conducted between October 2006 and December 2007. A
total of 10 physical therapists (9
male, 1 female) with an average of
7 years (range0.512) of experience treating patients with spinal
conditions participated in data collection. In order maximize standardization, all clinicians were given
on-site training by the primary investigator (I.A.Y.) and provided with
an instruction manual and video on
all examination, treatment, and data
collection procedures.
Our original sample size estimate for
data analysis was 80 subjects. Because the outcome measures used in
this study have not been used in previous clinical trials for this patient
population, an accurate power analysis based on effect size could not be
calculated. With an estimated small
effect size ( f0.25), a sample size of
80 would have given the study a
power of 94%.
Consecutive patients with reports
of unilateral upper-extremity pain,
paresthesia, or numbness, with or
without neck pain, were screened
by a physical therapist for study eli-

Available With
This Article at
www.ptjournal.org
eAppendix: Description of
Manual Therapy and Exercise
Procedures
The Bottom Line clinical
summary
The Bottom Line Podcast
Audio Abstracts Podcast
This article was published ahead of
print on May 21, 2009, at
www.ptjournal.org.

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Manual Therapy, Exercise, and Traction for Cervical Radiculopathy

Figure 1.
CONSORT flow diagram of participants through the trial. CPRclinical prediction rule.

gibility. Of the patients screened for

participation (N121), 40 were excluded or refused to participate for
variety of reasons. A flow diagram
of patient recruitment and retention
is presented in Figure 1. Patients
who satisfied the eligibility criteria
(Tab. 1) were invited to participate
in the study. All enrolled patients
(n81) provided informed consent
for participation in the study. Following consent, each patient underwent a standardized history and
physical examination, as well as
collection of data for all outcome
measures.

The physical examination included

the items in the CPR, repetitive
motion testing (cervical protraction
and retraction),25 deep tendon reflexes (biceps, brachioradialis, triceps), myotomal assessment (C5
C8, T1), and grip strength bilaterally.
Primary outcome measures were
the Numeric Pain Rating Scale
(NPRS),26,27 the Neck Disability Index (NDI),28,29 and the PatientSpecific Functional Scale (PSFS).29,30
Secondary outcome measures were
the Fear-Avoidance Beliefs Questionnaire (FABQ),31,32 a pain diagram,33
the Global Rating of Change Scale

(GROC),34 patient satisfaction,35 and

grip strength.36,37 Each outcome
measure and its psychometric properties are described in the Appendix.
Data for the outcome measures were
collected at baseline and at 2-week
and 4-week follow-ups.
After the examination, patients were
randomly assigned to 1 of 2 treatment groups: a group that received
manual therapy, exercise, and intermittent cervical traction (MTEXTraction group) and a group that received manual therapy, exercise, and
sham intermittent cervical traction

Table 1.
Inclusion and Exclusion Criteria
Inclusion Criteria

634

Exclusion Criteria

Age 1870 y
Unilateral upper-extremity pain, paresthesia, or numbness
3 of 4 tests of clinical prediction rule positive:
- Spurling test
- Distraction test
- Upper-Limb Tension Test 1
- Ipsilateral cervical rotation 60

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History of previous cervical or thoracic spine surgery

Bilateral upper-extremity symptoms
Signs or symptoms of upper motor neuron disease
Medical red flags (eg, tumor, fracture, rheumatoid arthritis, osteoporosis,
prolonged steroid use)
Cervical spine injections (steroidal) in the past 2 wk
Current use of steroidal medication prescribed for radiculopathy symptoms

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Manual Therapy, Exercise, and Traction for Cervical Radiculopathy

(MTEX group). In order to decrease
the potential effect of the clinic
on treatment outcomes, concealed
randomization, stratified by clinic,
was used to place patients into treatment groups. Numbered, sequential,
sealed envelopes containing group
allocation for each clinic were
opened by the evaluating therapist
after the baseline examination. Support staff, who were unaware of
group assignment, administered all
patient self-report measures and grip
strength testing as instructed by the
therapist.
Treatment
Patients were treated for an average
of 7 visits (SD2.08), over an average of 4.2 weeks, with a standardized treatment protocol. Treatments
were performed sequentially to include postural education, manual
therapy, and exercise and ended
with traction or sham traction. All
patients received a home exercise
program on their first visit, including
one or more of the available exercises used in the standardized treatment protocol. The home exercise
program was updated, as needed, on
each visit by the physical therapist.
Posture education. On the initial
treatment visit, patients were educated on importance of correct postural alignment of the spine during
sitting and standing activities. Posture was addressed on subsequent
visits only if the physical therapist
deemed it necessary.
Manual therapy. Manual therapy
was defined as either high-velocity,
low-amplitude thrust manipulation
or nonthrust manipulation. Initial
treatment included manipulation
procedures directed at the upperand mid-thoracic spines of spinal
segments identified as hypomobile
during segmental mobility testing.38
Thrust manipulation of the thoracic
spine could include techniques in a
prone, supine, or sitting position
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based on therapist preference. Nonthrust

manipulation
included
posterior-anterior (P-A) glides in the
prone position. Therapists were required to perform at least one technique targeting the upper thoracic
spine and one technique targeting
the mid thoracic spine during each
visit. Following treatment directed at
the thoracic spine, at least one set
(30 seconds or 1520 repetitions) of
a nonthrust manipulation was directed at each desired level of the
cervical spine. The cervical spine
techniques could include retractions, rotations, lateral glides in the
ULTT1 position, and P-A glides. The
therapists chose the techniques
based on patient response and centralization or reduction of symptoms.
Exercise. After completing the
manual therapy procedures, the
therapist instructed the patient on
specific exercises to complement
the manual procedures performed.
Exercises included cervical retraction, cervical extension, deep cervical flexor strengthening, and scapular strengthening. At least one
exercise was used during each treatment visit. All manual therapy and
exercise procedures are described in
the eAppendix (available online at
www.ptjournal.org).
Traction and sham traction. After exercise, patients received either
mechanical intermittent cervical
traction or sham traction for 15 minutes according to their random assignment. Each patient was positioned supine, with the cervical
spine placed at an angle of approximately 15 degrees of flexion. The
traction force was started at 9.1 kg
(20 lb) or 10% of the patients body
weight (whichever was less) and increased approximately 0.91 to 2.27
kg (25 lb) every visit, depending on
centralization or reduction of symptoms. The maximum force used was
15.91 kg (35 lb). The on/off cycle
was set at 50/10. The sham traction

protocol included the identical setup; however, only 2.27 kg (5 lb) or

less of force was applied. All other
traction parameters were the same
as for the group that received intermittent cervical traction.
Data Analysis
A separate repeated-measures, mixedmodel analysis was performed for
each of the primary and secondary
outcomes, with alpha set at .05.
Treatment group (MTEX versus
MTEXTraction) was the betweenpatient factor, and time (baseline,
2-week follow-up, 4-week follow-up)
was defined as the repeated factor.
The primary and secondary outcomes were used as the dependent
variables. To allow for correlations
within participants and of participants within clinics, we modeled patient and clinic as random effects
without interactions. The main hypothesis of interest was the group
time interaction. Linear contrasts
were constructed to determine the
between-group differences at each
time point. The main effects of the
interventions were obtained by constructing linear contrasts to compare
the mean change in outcome from
baseline to each time point. The
effect size was calculated from the
between-group differences in change
score from baseline to the 4-week
follow-up in all of the primary outcome measures. Analyses followed
intention-to-treat principles. All analyses were performed using SAS statistical software (JMP version 8.0*).
Role of the Funding Source
This study was funded by a grant
from the Saunders Group.

Results
Patients (N121) were screened for
eligibility, and 81 patients were eligible and agreed to participate
(Fig. 1). Twelve patients (n6 in
* SAS Institute Inc, PO Box 8000, Cary, NC
27513.

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Table 2.
Baseline Variables and Treatment Visitsa
Variable
Age (y)

MTEXTraction Group
(n45)

MTEX Group
(n36)

47.8 (9.9)

46.2 (9.4)

Sex, n (%)
Male

14 (31.1)

12 (33.3)

Female

31 (68.9)

24 (66.7)

8 (18.2)

4 (11.8)

Work-related injury, n (%)

Duration of symptoms, n (%)
3 mo

27 (60)

15 (42)

3 mo

18 (40)

21 (58)

Neck movement alters symptoms, n (%)

35 (85.3)

30 (85.7)

Previous symptoms, n (%)

13 (28)

12 (33)

33 (75)

26 (74.3)

Most bothersome symptom, n (%)

Pain
Numbness/tingling

8 (18.2)

5 (14.3)

Both pain and numbness/tingling

3 (6.8)

4 (11.4)

19.8 (8.7)

17.1 (7.4)

3.5 (1.8)

3.3 (1.8)

Neck Disability Indexb

Patient-Specific Functional Scalec
Numeric Pain Rating Scale

Body diagram (symptom distribution)e

6.3 (1.9)

6.5 (1.7)

22.5 (10.6)

20.7 (9.6)

17.7 (7.4)

18.3 (5.7)

24.1 (17.2)

18.7 (16.2)

7.0 (2.1)

6.9 (2.1)

Fear-Avoidance Beliefs Questionnaire

Physical activity subscalef
Work subscale

No. of treatment visits

Neurological examination,h n (%)

Normal
Positive Test
Positive Test
Normal
Positive Test
Positive Test
Examination Either Category Both Categories Examination Either Category Both Categories
9 (20)

22 (48.9)

14 (31.1)

8 (22.2)

16 (44.4)

12 (33.3)

Values are mean (SD) unless otherwise stated. MTEXTraction grouppatients who received manual therapy, exercise, and intermittent cervical traction;
MTEX grouppatients who received manual therapy, exercise, and sham intermittent cervical traction.
b
Range of scores0 50; higher scores represent higher levels of disability.
c
Range of scores0 10; higher scores represent greater levels of function.
d
Range of scores0 10, where 0no pain.
e
Range of scores0 44; higher scores represent greater area of symptom distribution.
f
Range of scores0 30; higher scores represent higher levels of fear avoidance.
g
Range of scores0 66; higher scores represent higher levels of fear avoidance.
h
2 categories: deep tendon reflexes and myotome assessment.

each group) were lost to follow-up

between baseline (pretreatment)
measures and the 4-week follow-up.
Baseline demographics and data
for outcome measures are listed in
Table 2.
No significant interaction or main
effects of group were found for
the primary or secondary outcome
measures (Tab. 3). There was a significant main effect (P.05) of time
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for the NPRS, PSFS, NDI, and body

diagram, indicating there were
significant improvements in pain,
function, disability, and symptom
distribution regardless of group assignment (MTEX versus MTEXTraction) from baseline to the 4-week
follow-up. The adjusted effect size
from the mixed-models analysis for
each of the primary outcomes was
small (NDI1.5, 95% confidence interval [CI]6.8 to 3.8; PSFS0.29,

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95% CI1.8 to 1.2; and NPRS

0.52, 95% CI1.8 to 1.2).

Discussion
This randomized clinical trial investigated the effects of a multimodal
treatment approach including manual therapy and exercise, with and
without the addition of intermittent
cervical traction, in patients with
CR. The results indicate that the addition of supine intermittent cervical
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Manual Therapy, Exercise, and Traction for Cervical Radiculopathy

Table 3.
Results of Analysis Comparing Outcomes Between Treatment Groupsa
Unadjusted Mean (SD)
for Each Group

Adjusted Mean (SD)

for Each Groupb

Adjusted
Mean Difference
Between Groupsb
(95% CI)

MTEXTraction
Group

MTEX
Group

Unadjusted
Mean Difference
Between Groups
(95% CI)

2 wk

15.0 (8.2)

13.1 (7.1)

1.9 (1.8 to 5.6)

.31

14.0 (12.3)

12.2 (11.8)

1.8 (7.0 to 3.5)

.34

4 wk

12.1 (9.0)

10.9 (7.8)

1.2 (2.9 to 5.3)

.56

11.1 (12.3)

9.6 (14.1)

1.5 (6.8 to 3.8)

.42

Outcome Measure
Neck Disability Index

MTEXTraction
Group

MTEX
Group

Patient-Specific Functional
Scaled
2 wk

5.1 (2.5)

5.2 (2.4)

0.06 (1.2 to 1.1)

.91

5.3 (3.8)

5.6 (3.8)

0.22 (1.2 to 1.7)

.66

4 wk

6.6 (2.4)

6.3 (2.5)

0.27 (0.91 to 1.5)

.66

7.0 (3.8)

6.7 (4.3)

0.29 (1.8 to 1.2)

.57

2 wk

4.5 (2.3)

5.1 (2.4)

0.65 (1.7 to 0.4)

.24

4.2 (3.0)

5.2 (3.0)

0.61 (0.90 to 2.1)

.25

4 wk

3.7 (2.7)

3.2 (2.5)

0.55 (0.68 to 1.7)

.38

3.4 (3.1)

3.2 (3.4)

0.52 (1.8 to 1.2)

.33

2 wk

17.8 (12.5)

16.4 (12.2)

1.5 (4.2 to 7.0)

.60

16.5 (31.4)

16.6 (30.7)

0.04 (8.0 to 8.1)

.98

4 wk

15.2 (13.8)

12.8 (13.5)

2.3 (3.8 to 8.4)

.46

13.1 (31.7)

12.7 (34.7)

0.45 (8.6 to 7.7)

.87

16.4 (7.5)

18.1 (6.0)

1.6 (0.48 to 1.6)

.31

15.5 (10.4)

17.0 (10.5)

1.5 (3.3 to 6.2)

.37

21.9 (18.4)

20.3 (17.2)

1.5 (6.8 to 9.8)

.71

16.8 (28.3)

15.1 (28.2)

1.7 (12.6 to 9.2)

.65

Physical activity subscale

14.0 (7.8)

15.3 (7.9)

1.7 (5.5 to 2.1)

.38

12.4 (10.5)

14.2 (11.9)

1.8 (6.6 to 3.0)

.29

Work subscale

18.5 (16.9)

17.8 (16.8)

0.68 (7.4 to 8.8)

.87

14.5 (28.3)

11.6 (31.7)

2.9 (8.1 to 13.9)

.44

2 wk

5.5 (3.0)

5.6 (2.5)

0.14 (1.4 to 1.2)

.83

6.1 (4.5)

6.2 (4.6)

0.12 (1.5 to 1.2)

.85

4 wk

6.8 (3.0)

6.9 (3.0)

0.30 (1.7 to 1.3)

.83

7.1 (4.6)

7.5 (5.2)

0.44 (1.8 to 0.9)

.52

2 wk

9.7 (2.2)

9.6 (1.9)

0.12 (0.81 to 1.1)

.76

10.1 (3.4)

10.0 (3.4)

0.16 (1.13 to 0.79)

.74

4 wk

10.8 (2.0)

10.5 (2.4)

0.25 (0.81 to 1.3)

.65

11.1 (3.3)

10.8 (3.9)

0.27 (0.70 to 1.2)

.58

68

69

Numeric Pain Rating Scale

Body diagram (symptom

distribution)f

Fear-Avoidance Beliefs
Questionnaireg
2 wk
Physical activity subscaleh
Work subscale

4 wk

Satisfaction ratingj

Global Rating of Change

Scalek

Improved at 4 wk (%)

a
Values are mean (SD) unless otherwise stated. MTEXTraction grouppatients who received manual therapy, exercise, and intermittent cervical traction;
MTEX grouppatients who received manual therapy, exercise, and sham intermittent cervical traction; CIconfidence interval.
b
Adjusted values from mixed-models analysis.
c
Range of scores0 50; higher scores represent higher levels of disability.
d
Range of scores0 10; higher scores represent greater levels of function.
e
Range of scores0 10, where 0no pain.
f
Range of scores0 44; higher scores represent greater area of symptom distribution.
g
Range of scores0 30; higher scores represent higher levels of fear avoidance.
h
Range of scores0 66; higher scores represent higher levels of fear avoidance.
i
2 categories: deep tendon reflexes and myotome assessment.
j
Range of scores0 10, where 10completely satisfied.
k
Range of scores0 13; scores 10 signify clinically meaningful improvement.

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traction yielded no additional benefit
to a program of manual therapy and
exercise. Regardless of group assignment (MTEX versus MTEXTraction),
patients with CR experienced significant improvements in both primary
and secondary outcomes following 4
weeks of standardized physical therapy intervention.
Although there were no significant
differences between groups with
any of the outcome measures, the
precision of the point estimates of
the treatment effects must be considered. At the 2-week follow-up,
the lower boundary of the 95% CI
for the NDI was 7.0 (Tab. 3). This
value meets the threshold for meaningful clinically important change of
the NDI (7.0). Furthermore, at the
4-week follow-up, the lower boundary of the 95% CI for the NPRS was
1.8 (Tab. 3). This value exceeds
the threshold for meaningful clinically important change of the NPRS
(1.3) adopted for this study. Thus,
we cannot confidently exclude a
treatment effect for these variables at
these specific time points.
Although statistically significant
changes over time were found in
both groups with all of the primary
outcome measures, the threshold
for minimum clinically important
change was surpassed with the NPRS
(n47 [67%]) and the PSFS (n44
[64%]) for those patients who completed the 4-week follow-up. A total
of 2 points of change on the PSFS
has been found to exceed the threshold for minimal clinically important
change in patients with CR.29 A
change of 1.3 points on the NPRS
recently was found to meet the
threshold for minimal clinically important change in patients with neck
pain.27 As no study has identified a
minimal clinically important change
value in patients with CR, this
change score (1.3 points) on the
NPRS was adopted for this study. Of
the patients who completed the
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4-week follow-up, only 32 (46%) surpassed the minimal clinically important change of at least 7 points on
the NDI.29 A recent study27 suggests
that the minimal clinically important
change on the NDI may be more
than twice as high as the original
reported threshold of 7 points in patients with mechanical neck pain.
With these inconsistencies regarding
the appropriate threshold for clinically important difference, perhaps
the responsiveness to change of the
NDI may not be sufficient in this patient population. As the NDI is a
commonly used self-report measure
in patients with all neck-related disorders, future studies with larger
sample sizes should investigate to detect change in patient status in conjunction with the NPRS, PSFS, and
GROC in patients with CR.
The present study used a CPR to
identify the presence of CR.12 The
CPR has a sensitivity of 0.39 (95%
CI0.16 to 0.61), a specificity of
0.99 (95% CI0.97 to 1.00), and a
positive likelihood ratio of 30.3 (95%
CI1.7 to 538.2) when all 4 test
items are positive. The CPR has a
sensitivity of 0.24 (95% CI0.05 to
0.43), a specificity of 0.94 (95%
CI0.88 to 1.00), and a positive likelihood ratio of 6.1 (95% CI2.0 to
18.6)] when 3 of 4 tests are positive.
We used 3 of 4 criteria that are positive for eligibility despite other studies using 4 of 4 criteria, due to the
narrower CI and the lower-bound estimate for 3 of 4 criteria. To date, the
CPR used in the present study has
not been validated.
The protocol for the intermittent
cervical traction may have been the
reason a treatment effect was not
identified. Although a multitude of
traction parameters are used in the
clinical setting, there is no convincing evidence to suggest which
parameters are most effective in the
management of CR. Cleland et al21
used an on/off cycle of 30/10 and a

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traction angle of approximately 25

degrees, increasing force by 0.45 to
0.91 kg (12 lb) per visit, whereas
Waldrop et al18 used an on/off cycle
of 20/10 and a 15- to 24-degree angle
of traction. Each of these case studies started with a traction force
of 8.18 kg (18 lb) and monitored
the centralization and reduction of
symptoms to determine progression
of force. Furthermore, both studies
performed traction for 15 minutes
and used a minimum traction force
during the off cycle.
In the clinical trial by Joghataei et
al,17 a 13.64-kg (30-lb) traction force
at a 24-degree angle of pull was used
for a period of 20 minutes, with an
on/off cycle of 7/5. In the present
study, we used a longer duration of
pull (on/off cycle of 50/10), a 15degree flexion angle, and no traction
force during the off cycle. In this
study, the average traction force was
11.64 kg (SD2.8, range9.09
14.09) (25.6 lb, SD2.8, range20
31) for the MTEXTraction group and
an average of 1.65 kg (SD0.70,
range0.90 4.52) (3.5 lb, SD1.1,
range2.0 5.0) for the MTEX
group. Interestingly, Zybergold and
Piper24 found no significant difference in pain reduction among
groups of patients with CR who received static traction, intermittent
traction, manual traction, and treatment without traction. Possibly,
more-aggressive traction protocols
(more force or greater frequency)
may have had a greater effect on the
patient sample in the present study.
Moreover, we are unable to determine whether the sham traction
force of no greater than 2.3 kg (5 lb)
had a treatment effect on the patients in this study. Although a control group receiving a subtherapeutic traction force has its limitations,
we feel this was the best control
choice to address the setup, subsequent force production, and treatment time involved with this modality. In this study, there appeared to
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Manual Therapy, Exercise, and Traction for Cervical Radiculopathy

be no relationship between the
amount of traction force used and
perceived recovery (Fig. 2).
The manual therapy procedures
used in this study were a combination of thrust and nonthrust manipulation techniques designed to centralize and reduce the cervical and
upper-extremity symptoms. In order
to simulate clinical practice, the therapist was allowed to select individual
techniques based on centralization
or reduction of symptoms and the
patients response to treatment. If a
manual therapy procedure centralized or reduced the patients symptoms, this procedure continued to
be used until there was no further
benefit. Conversely, if a manual procedure worsened or peripheralized
the patients symptoms, this procedure was abandoned and another
technique was selected. The procedures are modifications of techniques first described by McKenzie,25 Maitland,38 Greenman,39 and
Vicenzino et al.40 An average of 2
manual procedures were performed
on both the thoracic and cervical
spines during each visit. Supine thoracic thrust manipulation, cervical
retraction nonthrust manipulation,
and cervical retraction exercise were
the most commonly used procedures in the study (Fig. 3). Although
thoracic manipulation procedures
have been shown to have a significant short-term treatment effect on
patients with mechanical neck
pain,41,42 these techniques have not
been studied in patients with CR.
Restoration of normal biomechanics
to the thoracic spine may have a role
in lowering mechanical stresses and
improving distribution of joint forces
in the cervical spine.41,43,44 Manipulations directed at the cervical spine
were not performed in this study, as
supporting evidence is sparse in patients with CR45 and considerable attention has been devoted to the risk
of serious complications.46 48

July 2009

Figure 2.
Average force of traction (per subject) versus Global Rating of Change Scale (GROC)
scores (range0 13; scores 10 signify clinically meaningful improvement). There
appears to be no relationship between the amount of traction force used and perceived
recovery. MTEXTraction grouppatients who received manual therapy, exercise, and
intermittent cervical traction; MTEX grouppatients who received manual therapy,
exercise, and sham intermittent cervical traction.

The exercises used in this study

included strengthening of the scapulothoracic and deep neck flexors,
as well as cervical retraction and extension exercises. Scapular strengthening and deep neck flexor exercises
have provided some benefit in previous studies.21,22 Cervical retraction
is thought to improve resting neck
posture, relieve neck pain or radicular or referred pain,25 and possibly
decompress neural elements in patients with CR.49 An average of 2
exercises per visit were used in the
present study.
This clinical trial supports previous
randomized clinical trials demonstrating effective conservative man-

agement of CR17,23,24 and cervicobrachial pain14,15,24 Prior to the present

study, only one randomized clinical
trial isolated the effect of intermittent cervical traction, finding that
exercise and intermittent cervical
traction were superior to exercise
(cervical isometrics) and ultrasound
on the outcome of grip strength after
5 visits in patients with C7 radiculopathy.17 However, there were no significant differences between groups
at 10 visits (discharge from physical
therapy).17
We acknowledge several limitations
of this study. First, we used a CPR to
identify the presence of cervical radiculopathy that has yet to be vali-

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Manual Therapy, Exercise, and Traction for Cervical Radiculopathy

A

Figure 3.
(A) Supine thoracic thrust manipulation, (B) cervical retraction mobilization, (C) cervical retraction exercise.

dated, which may imply less-thanoptimal diagnostic accuracy of this

condition. Second, we are unsure of
how effective the blinding was during the course of treatment, as the
patients were not asked whether
they could identify which group
they were in at the 4-week followup. If the patients thought they were
receiving the sham treatment, this
may have had an influence on their
outcome. Third, the lack of a strictly
recorded, dose-specific home exercise program maintained during the
course of treatment was a limitation.
Fourth, without a control group (a
group not receiving treatment), we
are unsure whether there was a
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spontaneous resolution of symptoms

over the course of this 4-week
treatment.

Conclusion
The addition of mechanical intermittent traction does not appear to improve outcomes for patients with CR
who are already receiving manual
therapy and exercise. Although traction provided no additional benefit
in this study, subsequent investigations examining traction at different
dosages may be of interest in this
patient population. The effect of CR
can be disabling, and continued research in the areas of diagnosis and

Number 7

treatment of this condition is of paramount importance.

Mr Young, Dr Michener, Dr Cleland, and Dr
Aguilera provided concept/idea/research design. Mr Young, Dr Michener, Dr Cleland,
and Dr Snyder provided writing. Mr Young,
Dr Michener, Dr Aguilera, and Dr Snyder
provided data analysis. Mr Young and Dr
Michener provided project management
and fund procurement. Dr Michener, Dr Cleland, Dr Aguilera, and Dr Snyder provided
consultation (including review of manuscript
before submission).
The authors thank Advance Rehabilitation
and Fredericksburg Orthopaedics for their
support of this study; physical therapists
Chris Brown, Dan Walker, Jon Lamb, and
Richard Linkonis for their patient recruiting

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Manual Therapy, Exercise, and Traction for Cervical Radiculopathy

and treatment efforts; Amee Seitz for her
help with data analysis; and Jennifer
Chastain for her help with study/data management. A final thanks to Robin Saunders
for her support of this study.
The study was approved by the Rocky Mountain University of Health Professions Internal
Review Board.
Platform presentations of this research were
given at the Combined Section Meetings
of the American Physical Therapy Association; February 6 9, 2008; Nashville, Tennessee; and February 9 12, 2009; Las Vegas,
Nevada.
This study was funded by a grant from the
Saunders Group.
This article was received September 13, 2008,
and was accepted March 25, 2009.
DOI: 10.2522/ptj.20080283

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41 Cleland JA, Childs JD, McRae M, et al. Immediate effects of thoracic manipulation
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47 Haldeman S, Kohlbeck FJ, McGregor M.

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Appendix.
Primary and Secondary Outcome Measuresa
Measure

a
b

Scale and Scoring

Reliability
(95% CI)

MCIC
Value

Neck Disability Index28,29

Self-report measure containing 10 items (scored

05). Total score out of 50 possible points
(0no disability, 50severe disability).

ICC.68
(.03 to .90)

7 points

Patient-Specific
Functional Scale29,30

Self-report activity limitations rated from 0

(inability to perform activity) to 10 (able to
perform activity as well as prior to onset of
symptoms). Activity scores averaged (higher
scoreless disability)

ICC.82
(.54 to .93)

2 points

Numeric Pain Rating

Scale26,27

Self-report measure with scores ranging from

0 (no pain) to 10 (worst pain imaginable).

ICC.63
(.28 to .96)

1.3 points

Global Rating of Change

Scale34

Self-report Likert scale with scores ranging from

0 (a very great deal worse) to 7 (about the
same) to 13 (a very great deal better). A
score of 10 signifies improvement.

Pain diagram33

Self-report measure indicating type and location

of symptoms on a standardized body chart.
Total score is out of 44 points (higher scores
indicate greater symptom distribution).

Fear-Avoidance Beliefs
Questionnaire31,32

Self-report measure that quantifies fear and

avoidance beliefs in patients with low back
pain and neck pain. Physical activity subscale:
range of scores030; Work subscale: range of
scores066; higher scores represent higher
levels of fear avoidance.

Satisfaction rating35

Self-report measure with scores ranging from

0 (not satisfied) to 10 (very satisfied) with
the use of the neck and arm.

ICC.93

Not reported

Grip strength36,37

Average of 2 trials measured with a Jamar hand

dynamometerb

ICC.87.97

Not reported

10 points

kappa.92

Not reported

Not reported

CIconfidence interval, MCICminimal clinically important change, ICCintraclass correlation coefficient.

Sammons Preston, PO Box 5071, Bolingbrook, IL 60440-5071.

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