Research Report
Manual Therapy, Exercise, and
I.A. Young, PT, MS, OCS, SCS,
Cert MDT, is Physical Therapist,
Spine and Sport, Savannah, Geor-
gia, and Affiliate-Associate Profes-
sor, Department of Physical Ther-
apy, Virginia Commonwealth
University–Medical College of Vir-
ginia Campus, Richmond, Vir-
ginia. Mailing address: Box 961,
Tybee Island, GA 31328 (USA).
Address all correspondence to Mr
Young at: youngian@spinesport.
org.
L.A. Michener, PT, PhD, ATC SCS,
is Associate Professor, Department
of Physical Therapy, Virginia Com-
monwealth University–Medical
College of Virginia Campus.
J.A. Cleland, PT, PhD, OCS,
FAAOMPT, is Associate Professor,
Department of Physical Therapy,
Franklin Pierce University, Con-
cord, New Hampshire; Physical
Therapist, Rehabilitation Services,
Concord Hospital, Concord, New
Hampshire; and Faculty, Regis
University Manual Therapy Fellow-
ship Program, Denver, Colorado.
A.J. Aguilera, MD, is Neurologist,
Neurology Associates, Fredericks-
burg, Virginia.
A.R. Snyder, PhD, ATC, is Assistant
Professor, Athletic Training Pro-
gram, A. T. Still University, Mesa,
Arizona.
[Young IA, Michener LA, Cleland
JA, et al. Manual therapy, exercise,
and traction for patients with cer-
vical 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:
www.ptjournal.org
632 f Physical Therapy Volume 89
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
Background. To date, optimal strategies for the management of patients with
cervical radiculopathy remain elusive. Preliminary evidence suggests that a multi-
modal treatment program consisting of manual therapy, exercise, and cervical trac-
tion may result in positive outcomes for patients with cervical radiculopathy. How-
ever, limited evidence exists to support the use of mechanical cervical traction in
patients with cervical radiculopathy.
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.
Design. This study was a multicenter randomized clinical trial.
Setting. The study was conducted in orthopedic physical therapy clinics.
Patients. Patients diagnosed with cervical radiculopathy (N⫽81) 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 man-
ual 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 (NDI⫽1.5, 95% confi-
dence interval [CI]⫽⫺6.8 to 3.8; PSFS⫽0.29, 95% CI⫽⫺1.8 to 1.2; and NPRS⫽0.52,
95% CI⫽⫺1.8 to 1.2).
Limitations. The use of a nonvalidated clinical prediction rule to diagnose cer-
vical radiculopathy and the lack of a control group without treatment were limita-
tions 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 sig-
nificant additional benefit to pain, function, or disability in patients with cervical
radiculopathy.
Number 7 July 2009

T
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 dis-
order is most commonly associated
with a cervical disk derangement
or other space-occupying lesion, re-
sulting 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 combina-
tion of these signs and symptoms.
Patients also may have scapular
pain,3,4 headaches,5 and neck pain.6
Patients with both neck and upper-
extremity symptoms have been re-
ported to have greater functional
limitation and disability than patients
with neck pain alone.7
Diagnostic imaging (magnetic reso-
nance imaging) and electrophysio-
logical tests (nerve conduction
velocity, electromyography) are
commonly used to confirm a diag-
nosis of CR.8 –11 Using nerve conduc-
tion 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 Upper-
Limb Tension Test 1 (ULLT1) (me-
dian nerve bias), and ipsilateral cer-
vical rotation of less than 60 degrees.
The CPR exhibited a specificity of
94% (positive likelihood ratio⫽6.1,
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 in-
clude cervical traction, postural edu-
cation, exercise, and manual therapy
applied to the cervical spine and tho-
racic spine.13 Studies indicate that
some combination of these inter-
ventions may result in improved out-
July 2009
Manual Therapy, Exercise, and Traction for Cervical Radiculopathy
comes for patients with CR.14 –23
Previous controlled clinical trials in-
vestigating 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 stan-
dardized treatment programs in pa-
tients diagnosed with CR, using the
previously defined CPR. The pro-
spective cohort study identified pre-
dictor variables that can identify
which patients with CR are likely
to have short-term successful out-
comes.22 A multimodal approach to
management including manual ther-
apy, cervical traction, and deep neck
flexor strengthening was identified
as the set of predictors; however, the
study design does not allow for iden-
tification of a cause-and-effect rela-
tionship. Moreover, the treatment
protocol in that study was not stan-
dardized. A randomized clinical trial
is needed to compare the effective-
ness of standardized treatment ap-
proaches in a homogenous sample of
patients with CR.
The clinical use of intermittent cer-
vical traction for CR is common, but
its effectiveness has been examined
in only one clinical trial.17 Joghataei
et al17 found that exercise and in-
termittent cervical traction were
superior to exercise and ultrasound
in improving grip strength (force-
generating capacity) following 5 vis-
its in patients with C7 radiculopathy.
However, the lack of a measure of
pain or disability limits application of
these results. There remains a pau-
city of quality outcome studies inves-
tigating commonly used interven-
tions in a homogenous population of
patients with CR. Thus, the purpose
of this study was to examine the ef-
fects of manual therapy and exer-
cise, with or without the addition of
intermittent cervical traction, in pa-
tients with CR, as identified by the
previously described CPR.
Volume 89
Materials and Method
A multicenter randomized clinical
trial involving orthopedic physical
therapy clinics in Virginia, Georgia,
Alabama, and West Virginia (N⫽7
clinics) was conducted between Oc-
tober 2006 and December 2007. A
total of 10 physical therapists (9
male, 1 female) with an average of
7 years (range⫽0.5–12) of experi-
ence treating patients with spinal
conditions participated in data col-
lection. In order maximize stan-
dardization, all clinicians were given
on-site training by the primary in-
vestigator (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. Be-
cause the outcome measures used in
this study have not been used in pre-
vious clinical trials for this patient
population, an accurate power anal-
ysis based on effect size could not be
calculated. With an estimated small
effect size ( f⫽0.25), 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.
Number 7 Physical Therapy f 633
Manual Therapy, Exercise, and Traction for Cervical Radiculopathy

Figure 1.
CONSORT flow diagram of participants through the trial. CPR⫽clinical prediction rule.

gibility. Of the patients screened for
participation (N⫽121), 40 were ex-
cluded 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
(n⫽81) provided informed consent
for participation in the study. Fol-
lowing consent, each patient under-
went 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 re-
flexes (biceps, brachioradialis, tri-
ceps), myotomal assessment (C5–
C8, T1), and grip strength bilaterally.
Primary outcome measures were
the Numeric Pain Rating Scale
(NPRS),26,27 the Neck Disability In-
dex (NDI),28,29 and the Patient-
Specific Functional Scale (PSFS).29,30
Secondary outcome measures were
the Fear-Avoidance Beliefs Question-
naire (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 prop-
erties 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 treat-
ment groups: a group that received
manual therapy, exercise, and inter-
mittent cervical traction (MTEXTrac-
tion group) and a group that re-
ceived manual therapy, exercise, and
sham intermittent cervical traction

Table 1.
Inclusion and Exclusion Criteria

Inclusion Criteria Exclusion Criteria

● Age 18–70 y ● History of previous cervical or thoracic spine surgery

● 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°
● 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

634 f Physical Therapy Volume 89 Number 7 July 2009


(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 treat-
ment groups. Numbered, sequential,
sealed envelopes containing group
allocation for each clinic were
opened by the evaluating therapist
after the baseline examination. Sup-
port 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 (SD⫽2.08), over an aver-
age of 4.2 weeks, with a standard-
ized treatment protocol. Treatments
were performed sequentially to in-
clude 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 exer-
cises used in the standardized treat-
ment 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 edu-
cated on importance of correct pos-
tural alignment of the spine during
sitting and standing activities. Pos-
ture 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 upper-
and 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
July 2009
Manual Therapy, Exercise, and Traction for Cervical Radiculopathy
based on therapist preference. Non-
thrust manipulation included
posterior-anterior (P-A) glides in the
prone position. Therapists were re-
quired to perform at least one tech-
nique 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 15–20 repetitions) of
a nonthrust manipulation was di-
rected at each desired level of the
cervical spine. The cervical spine
techniques could include retrac-
tions, rotations, lateral glides in the
ULTT1 position, and P-A glides. The
therapists chose the techniques
based on patient response and cen-
tralization 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 retrac-
tion, cervical extension, deep cervi-
cal flexor strengthening, and scap-
ular strengthening. At least one
exercise was used during each treat-
ment visit. All manual therapy and
exercise procedures are described in
the eAppendix (available online at
www.ptjournal.org).
Traction and sham traction. Af-
ter exercise, patients received either
mechanical intermittent cervical
traction or sham traction for 15 min-
utes according to their random as-
signment. Each patient was posi-
tioned supine, with the cervical
spine placed at an angle of approxi-
mately 15 degrees of flexion. The
traction force was started at 9.1 kg
(20 lb) or 10% of the patient’s body
weight (whichever was less) and in-
creased approximately 0.91 to 2.27
kg (2–5 lb) every visit, depending on
centralization or reduction of symp-
toms. The maximum force used was
15.91 kg (35 lb). The on/off cycle
was set at 50/10. The sham traction
Volume 89
protocol included the identical set-
up; 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 inter-
mittent cervical traction.
Data Analysis
A separate repeated-measures, mixed-
model analysis was performed for
each of the primary and secondary
outcomes, with alpha set at .05.
Treatment group (MTEX versus
MTEXTraction) was the between-
patient factor, and time (baseline,
2-week follow-up, 4-week follow-up)
was defined as the repeated factor.
The primary and secondary out-
comes were used as the dependent
variables. To allow for correlations
within participants and of partici-
pants within clinics, we modeled pa-
tient and clinic as random effects
without interactions. The main hy-
pothesis 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 con-
structing 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 out-
come measures. Analyses followed
intention-to-treat principles. All anal-
yses were performed using SAS sta-
tistical software (JMP version 8.0*).
Role of the Funding Source
This study was funded by a grant
from the Saunders Group.
Results
Patients (N⫽121) were screened for
eligibility, and 81 patients were eli-
gible and agreed to participate
(Fig. 1). Twelve patients (n⫽6 in
* SAS Institute Inc, PO Box 8000, Cary, NC
27513.
Number 7 Physical Therapy f 635
Manual Therapy, Exercise, and Traction for Cervical Radiculopathy

Table 2.
Baseline Variables and Treatment Visitsa

MTEXTraction Group MTEX Group

Variable (nⴝ45) (nⴝ36)

Age (y) 47.8 (9.9) 46.2 (9.4)

Sex, n (%)

Male 14 (31.1) 12 (33.3)

Female 31 (68.9) 24 (66.7)

Work-related injury, n (%) 8 (18.2) 4 (11.8)

Duration of symptoms, n (%)

ⱕ3 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)

Most bothersome symptom, n (%)

Pain 33 (75) 26 (74.3)

Numbness/tingling 8 (18.2) 5 (14.3)

Both pain and numbness/tingling 3 (6.8) 4 (11.4)

Neck Disability Indexb 19.8 (8.7) 17.1 (7.4)

Patient-Specific Functional Scalec 3.5 (1.8) 3.3 (1.8)

d
Numeric Pain Rating Scale 6.3 (1.9) 6.5 (1.7)

Body diagram (symptom distribution)e 22.5 (10.6) 20.7 (9.6)

Fear-Avoidance Beliefs Questionnaire

Physical activity subscalef 17.7 (7.4) 18.3 (5.7)

g
Work subscale 24.1 (17.2) 18.7 (16.2)

No. of treatment visits 7.0 (2.1) 6.9 (2.1)

Normal Positive Test Positive Test Normal Positive Test Positive Test
Neurological examination,h n (%) 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)

a
Values are mean (SD) unless otherwise stated. MTEXTraction group⫽patients who received manual therapy, exercise, and intermittent cervical traction;
MTEX group⫽patients who received manual therapy, exercise, and sham intermittent cervical traction.
b
Range of scores⫽0 –50; higher scores represent higher levels of disability.
c
Range of scores⫽0 –10; higher scores represent greater levels of function.
d
Range of scores⫽0 –10, where 0⫽“no pain.”
e
Range of scores⫽0 – 44; higher scores represent greater area of symptom distribution.
f
Range of scores⫽0 –30; higher scores represent higher levels of fear avoidance.
g
Range of scores⫽0 – 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 sig-
nificant main effect (P⬍.05) of time
for the NPRS, PSFS, NDI, and body
diagram, indicating there were
significant improvements in pain,
function, disability, and symptom
distribution regardless of group as-
signment (MTEX versus MTEXTrac-
tion) 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 (NDI⫽1.5, 95% confidence in-
terval [CI]⫽⫺6.8 to 3.8; PSFS⫽0.29,
95% CI⫽⫺1.8 to 1.2; and NPRS⫽
0.52, 95% CI⫽⫺1.8 to 1.2).
Discussion
This randomized clinical trial investi-
gated the effects of a multimodal
treatment approach including man-
ual therapy and exercise, with and
without the addition of intermittent
cervical traction, in patients with
CR. The results indicate that the ad-
dition of supine intermittent cervical

636 f Physical Therapy Volume 89 Number 7 July 2009

 Manual Therapy, Exercise, and Traction for Cervical Radiculopathy

Table 3.
Results of Analysis Comparing Outcomes Between Treatment Groupsa

Unadjusted Mean (SD) Adjusted Mean (SD)

Unadjusted Adjusted
for Each Group for Each Groupb
Mean Difference Mean Difference
MTEXTraction MTEX Between Groups MTEXTraction MTEX Between Groupsb
Outcome Measure Group Group (95% CI) P Group Group (95% CI) P
c
Neck Disability Index

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

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
e
Numeric Pain Rating Scale

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

Body diagram (symptom

distribution)f

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

Fear-Avoidance Beliefs
Questionnaireg

2 wk

Physical activity subscaleh 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
i
Work subscale 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

4 wk

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

Satisfaction ratingj

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

Global Rating of Change

Scalek
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

Improved at 4 wk (%) 68 69
a
Values are mean (SD) unless otherwise stated. MTEXTraction group⫽patients who received manual therapy, exercise, and intermittent cervical traction;
MTEX group⫽patients who received manual therapy, exercise, and sham intermittent cervical traction; CI⫽confidence interval.
b
Adjusted values from mixed-models analysis.
c
Range of scores⫽0 –50; higher scores represent higher levels of disability.
d
Range of scores⫽0 –10; higher scores represent greater levels of function.
e
Range of scores⫽0 –10, where 0⫽“no pain.”
f
Range of scores⫽0 – 44; higher scores represent greater area of symptom distribution.
g
Range of scores⫽0 –30; higher scores represent higher levels of fear avoidance.
h
Range of scores⫽0 – 66; higher scores represent higher levels of fear avoidance.
i
2 categories: deep tendon reflexes and myotome assessment.
j
Range of scores⫽0 –10, where 10⫽“completely satisfied.”
k
Range of scores⫽0 –13; scores ⱖ10 signify clinically meaningful improvement.

July 2009 Volume 89 Number 7 Physical Therapy f 637

Manual Therapy, Exercise, and Traction for Cervical Radiculopathy
traction yielded no additional benefit
to a program of manual therapy and
exercise. Regardless of group assign-
ment (MTEX versus MTEXTraction),
patients with CR experienced signif-
icant improvements in both primary
and secondary outcomes following 4
weeks of standardized physical ther-
apy 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 con-
sidered. 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 mean-
ingful clinically important change of
the NDI (7.0). Furthermore, at the
4-week follow-up, the lower bound-
ary of the 95% CI for the NPRS was
⫺1.8 (Tab. 3). This value exceeds
the threshold for meaningful clini-
cally 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
(n⫽47 [67%]) and the PSFS (n⫽44
[64%]) for those patients who com-
pleted the 4-week follow-up. A total
of 2 points of change on the PSFS
has been found to exceed the thresh-
old 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 im-
portant 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
638 f Physical Therapy Volume 89
4-week follow-up, only 32 (46%) sur-
passed the minimal clinically impor-
tant 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 pa-
tients with mechanical neck pain.
With these inconsistencies regarding
the appropriate threshold for clini-
cally important difference, perhaps
the responsiveness to change of the
NDI may not be sufficient in this pa-
tient population. As the NDI is a
commonly used self-report measure
in patients with all neck-related dis-
orders, future studies with larger
sample sizes should investigate to de-
tect change in patient status in con-
junction 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%
CI⫽0.16 to 0.61), a specificity of
0.99 (95% CI⫽0.97 to 1.00), and a
positive likelihood ratio of 30.3 (95%
CI⫽1.7 to 538.2) when all 4 test
items are positive. The CPR has a
sensitivity of 0.24 (95% CI⫽0.05 to
0.43), a specificity of 0.94 (95%
CI⫽0.88 to 1.00), and a positive like-
lihood ratio of 6.1 (95% CI⫽2.0 to
18.6)] when 3 of 4 tests are positive.
We used 3 of 4 criteria that are pos-
itive for eligibility despite other stud-
ies using 4 of 4 criteria, due to the
narrower CI and the lower-bound es-
timate 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 con-
vincing 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
Number 7
traction angle of approximately 25
degrees, increasing force by 0.45 to
0.91 kg (1–2 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 stud-
ies 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 15-
degree flexion angle, and no traction
force during the off cycle. In this
study, the average traction force was
11.64 kg (SD⫽2.8, range⫽9.09 –
14.09) (25.6 lb, SD⫽2.8, range⫽20 –
31) for the MTEXTraction group and
an average of 1.65 kg (SD⫽0.70,
range⫽0.90 – 4.52) (3.5 lb, SD⫽1.1,
range⫽2.0 –5.0) for the MTEX
group. Interestingly, Zybergold and
Piper24 found no significant differ-
ence in pain reduction among
groups of patients with CR who re-
ceived static traction, intermittent
traction, manual traction, and treat-
ment 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 deter-
mine whether the sham traction
force of no greater than 2.3 kg (5 lb)
had a treatment effect on the pa-
tients in this study. Although a con-
trol group receiving a “subtherapeu-
tic” traction force has its limitations,
we feel this was the best control
choice to address the setup, subse-
quent force production, and treat-
ment time involved with this modal-
ity. In this study, there appeared to
July 2009
 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 combina-
tion of thrust and nonthrust manip-
ulation techniques designed to cen-
tralize and reduce the cervical and
upper-extremity symptoms. In order
to simulate clinical practice, the ther-
apist was allowed to select individual
techniques based on centralization
or reduction of symptoms and the
patient’s response to treatment. If a
manual therapy procedure central-
ized or reduced the patient’s symp-
toms, this procedure continued to
be used until there was no further
benefit. Conversely, if a manual pro-
cedure worsened or peripheralized
the patient’s symptoms, this proce-
dure was abandoned and another
technique was selected. The proce-
dures are modifications of tech-
niques first described by McKen-
zie,25 Maitland,38 Greenman,39 and Figure 2.
Vicenzino et al.40 An average of 2 Average force of traction (per subject) versus Global Rating of Change Scale (GROC)
scores (range⫽0 –13; scores ⱖ10 signify clinically meaningful improvement). There
manual procedures were performed appears to be no relationship between the amount of traction force used and perceived
on both the thoracic and cervical recovery. MTEXTraction group⫽patients who received manual therapy, exercise, and
spines during each visit. Supine tho- intermittent cervical traction; MTEX group⫽patients who received manual therapy,
racic thrust manipulation, cervical exercise, and sham intermittent cervical traction.
retraction nonthrust manipulation,
and cervical retraction exercise were
the most commonly used proce- The exercises used in this study agement of CR17,23,24 and cervicobra-
dures in the study (Fig. 3). Although included strengthening of the scapu- chial pain14,15,24 Prior to the present
thoracic manipulation procedures lothoracic and deep neck flexors, study, only one randomized clinical
have been shown to have a signifi- as well as cervical retraction and ex- trial isolated the effect of intermit-
cant short-term treatment effect on
tension exercises. Scapular strength- tent cervical traction, finding that
patients with mechanical neck
ening and deep neck flexor exercises exercise and intermittent cervical
pain,41,42 these techniques have not
have provided some benefit in previ- traction were superior to exercise
been studied in patients with CR.
ous studies.21,22 Cervical retraction (cervical isometrics) and ultrasound
Restoration of normal biomechanics
is thought to improve resting neck on the outcome of grip strength after
to the thoracic spine may have a role
posture, relieve neck pain or radicu- 5 visits in patients with C7 radiculop-
in lowering mechanical stresses and
lar or referred pain,25 and possibly athy.17 However, there were no sig-
improving distribution of joint forces
decompress neural elements in pa- nificant differences between groups
in the cervical spine.41,43,44 Manipu-
tients with CR.49 An average of 2 at 10 visits (discharge from physical
lations directed at the cervical spine
exercises per visit were used in the therapy).17
were not performed in this study, as
present study.
supporting evidence is sparse in pa-
We acknowledge several limitations
tients with CR45 and considerable at-
This clinical trial supports previous of this study. First, we used a CPR to
tention has been devoted to the risk
randomized clinical trials demon- identify the presence of cervical ra-
of serious complications.46 – 48
strating effective conservative man- diculopathy that has yet to be vali-

July 2009 Volume 89 Number 7 Physical Therapy f 639

Manual Therapy, Exercise, and Traction for Cervical Radiculopathy

B C

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

dated, which may imply less-than-
optimal diagnostic accuracy of this
condition. Second, we are unsure of
how effective the blinding was dur-
ing the course of treatment, as the
patients were not asked whether
they could identify which group
they were in at the 4-week follow-
up. 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 exer-
cise 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
spontaneous resolution of symptoms
over the course of this 4-week
treatment.
Conclusion
The addition of mechanical intermit-
tent traction does not appear to im-
prove outcomes for patients with CR
who are already receiving manual
therapy and exercise. Although trac-
tion provided no additional benefit
in this study, subsequent investiga-
tions examining traction at different
dosages may be of interest in this
patient population. The effect of CR
can be disabling, and continued re-
search in the areas of diagnosis and
treatment of this condition is of par-
amount importance.
Mr Young, Dr Michener, Dr Cleland, and Dr
Aguilera provided concept/idea/research de-
sign. 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 Cle-
land, 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

640 f Physical Therapy Volume 89 Number 7 July 2009


and treatment efforts; Amee Seitz for her
help with data analysis; and Jennifer
Chastain for her help with study/data man-
agement. A final thanks to Robin Saunders
for her support of this study.
The study was approved by the Rocky Moun-
tain University of Health Professions Internal
Review Board.
Platform presentations of this research were
given at the Combined Section Meetings
of the American Physical Therapy Associa-
tion; February 6 –9, 2008; Nashville, Tennes-
see; 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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Appendix.
Primary and Secondary Outcome Measuresa

Reliability MCIC
Measure Scale and Scoring (95% CI) Value

Neck Disability Index28,29 Self-report measure containing 10 items (scored ICC⫽.68 ⱖ7 points
0–5). Total score out of 50 possible points (.03 to .90)
(0⫽“no disability,” 50⫽“severe disability”).

Patient-Specific Self-report activity limitations rated from 0 ICC⫽.82 ⱖ2 points

Functional Scale29,30 (“inability to perform activity”) to 10 (“able to (.54 to .93)
perform activity as well as prior to onset of
symptoms”). Activity scores averaged (higher
score⫽less disability)

Numeric Pain Rating Self-report measure with scores ranging from ICC⫽.63 ⱖ1.3 points
Scale26,27 0 (“no pain”) to 10 (“worst pain imaginable”). (.28 to .96)

Global Rating of Change Self-report Likert scale with scores ranging from ⱖ10 points
Scale34 0 (“a very great deal worse”) to 7 (“about the
same”) to 13 (“a very great deal better”). A
score of ⱖ10 signifies improvement.

Pain diagram33 Self-report measure indicating type and location kappa⫽.92 Not reported
of symptoms on a standardized body chart.
Total score is out of 44 points (higher scores
indicate greater symptom distribution).
Fear-Avoidance Beliefs Self-report measure that quantifies fear and Not reported
Questionnaire31,32 avoidance beliefs in patients with low back
pain and neck pain. Physical activity subscale:
range of scores⫽0–30; Work subscale: range of
scores⫽0–66; higher scores represent higher
levels of fear avoidance.

Satisfaction rating35 Self-report measure with scores ranging from ICC⫽.93 Not reported
0 (“not satisfied”) to 10 (“very satisfied”) with
the use of the neck and arm.

Grip strength36,37 Average of 2 trials measured with a Jamar hand ICC⫽.87–.97 Not reported
dynamometerb
a
CI⫽confidence interval, MCIC⫽minimal clinically important change, ICC⫽intraclass correlation coefficient.
b
Sammons Preston, PO Box 5071, Bolingbrook, IL 60440-5071.

642 f Physical Therapy Volume 89 Number 7 July 2009