CERVICAL RADICULOPATHY TREATED WITH

CHIROPRACTIC FLEXION DISTRACTION MANIPULATION: A

RETROSPECTIVE STUDY IN A PRIVATE PRACTICE SETTING
Jason S. Schliesser, DC, MPH,a Ralph Kruse, DC,b and L. Fleming Fallon, MD, DrPHc

ABSTRACT

Background: Although flexion distraction performed to the lumbar spine is commonly utilized and documented as
effective, flexion distraction manipulation performed to the cervical spine has not been adequately studied.
Objective: To objectively quantify data from the Visual Analogue Scale (VAS) to support the clinical judgment
exercised for the use of flexion distraction manipulation to treat cervical radiculopathy.
Design and Setting: A retrospective analysis of the files of 39 patients from a private chiropractic clinic that met
diagnostic criteria for inclusion. All patients were diagnosed with cervical radiculopathy and treated by a single
practitioner with flexion distraction manipulation and some form of adjunctive physical medicine modality.
Main Outcome Measures: The VAS was used to objectively quantify pain. Of the 39 files reviewed, 22
contained an initial and posttreatment VAS score and were therefore utilized in this study.
Results: This study revealed a statistically significant reduction in pain as quantified by visual analogue scores. The
mean number of treatments required was 13.2 8.2, with a range of 6 to 37. Only 3 persons required more
treatments than the mean plus 1 standard deviation.
Conclusion: The results of this study show promise for chiropractic and manual therapy techniques such as flexion
distraction, as well as demonstrating that other, larger research studies must be performed for cervical radiculopathy.
(J Manipulative Physiol Ther 2003;26:e19)
Key Indexing Terms: Cervical Spine; Radiculopathy; Chiropractic Manipulation

INTRODUCTION
adiculopathy is defined as a clinical syndrome re- distal in the extremity, and to eventually obtain complete

R sulting from damage to either the dorsal or ventral

nerve root or both. These lesions may affect sensory
and/or motor fibers.1 Thus, patients may have radicular
pain, paresthesia, or motor symptoms, such as painless
weakness. Patients more commonly present with pain or a
combination of symptoms. In this retrospective study, pa-
tients were clinically diagnosed with cervical radiculopathy
based on this definition. When treating patients with radic-
ulopathy, the primary goal is to centralize the pain toward
the spine, ie, to have the pain move more proximal from
a
Private practice of chiropractic, Holland, Ohio, and Northwest
Ohio Consortium for Public Health, Toledo, Ohio.
b
Private practice of chiropractic, Olympia Fields, Ill.
c
Professor, Director of Master of Public Health Program, Bowl-
ing Green State University, Bowling Green, Ohio.
Submit requests for reprints to: Jason S. Schliesser, DC, PO Box
1284, Holland, OH 43528 (e-mail: drschliesser@aol.com).
Paper submitted February 12, 2002; in revised form June 25,
2002.
Copyright 2003 by National University of Health Sciences.
0161-4754/2003/$30.00 0
doi:10.1016/j.jmpt.2003.08.009
relief of symptoms. This process is called the centralization
phenomenon2 and was first described by McKenzie3; it has
been studied for the lumbar spine.4
Outcome assessment procedures, which document the
effectiveness of care, are an important aspect of clinical
practice. This is due, in part, to the necessity of determining
and documenting whether a patients condition has changed
during the course of therapy. Proper documentation helps to
justify the type, duration, and frequency of care and may
help determine a point of maximum improvement.
Cervical pain is becoming a large medical problem. The
incidence of cervical radiculopathy has been estimated to be
approximately 85 per 100,000 people. Chronic neck syn-
drome was identified in 9.5% of the men and 13.5% of the
women. However, Bovim et al5 reported that 34.4% of a
random sample of 10,000 people in Norway experienced
neck symptoms that lasted for more than 1 month. Other
research data reported from Minnesota found 561 patients
with radiculopathy from 1976 to 1990.6
Patients presenting with pain radiating distally from the
spine are a concern among practitioners of manual medi-
cine, as well as other health care practitioners and spine
Schliesser, Kruse, and Fallon Journal of Manipulative and Physiological Therapeutics
Cervical Radiculopathy November/December 2003

specialists. The primary modalities that have been used for Table 1. Visual Analogue Scale scores
treatment are manual manipulation and surgery.
Statistical
Many conditions are showing promising results with ma- Gender Initial score Final score Change significance
nipulation. Flexion distraction, primarily for the lumbar
spine, is one of the most commonly utilized forms of Male 40.2 14.3* 3.5 4.0 36.7 16.5 U 9.34; P .05
treatment among chiropractic physicians.7 However, studies Female 53.8 19.8 10.6 16.5 43.2 18.6 t 6.70; P .05
on cervical flexion distraction are lacking. Therefore, we Total 50.1 19.2 8.7 14.4 41.4 17.9 t 8.09; P .05
felt that it was important to document the results that were *Mean SD.
found by this practitioner.

The pretreatment and posttreatment Visual Analogue

METHODS Scale scores were analyzed using paired t tests for females
In this retrospective study, the files of 1 private chiro- and the total sample. A U score was calculated for males
practic office were reviewed to identify patients who were using a Mann-Whitney test. This test was selected due to the
diagnosed with cervical radiculopathy. The files of patients small number of males in the sample group.
who presented from 1998 through 2001 with neck pain and
radiating pain into 1 or both upper extremities and who were RESULTS
treated with flexion distraction manipulation were analyzed.
In this study, the symptoms of the 22 patients who
Patient files meeting these criteria, independent of the type
provided an initial and final estimate of their pain with the
of condition that produced the radiating pain, (ie, disk,
VAS diminished in correlation to treatment. The reductions
radiculopathy, or sclerotogenous referral pattern) formed
in pain perception in this specific patient population were
the cohort analyzed in this study. Initially, 39 patients
statistically significant. The mean change in VAS score was
meeting these criteria were identified. Of these, 22 had
41.4 17.9. These results can be used to statistically
completed initial and posttreatment pain drawings and Vi-
estimate an optimal number of treatments. Dividing the
sual Analogue Scale (VAS) recording for pain within a
average difference in VAS score (41.4) by the average
given 6-month time frame. The first VAS was obtained on
change per treatment (3.9) yields an estimate of the number
the initial office visit. The second VAS was completed at the
of treatments needed to reduce an average patients pain by
end of their prescribed treatment schedule. In this manner, a
the average amount for the group: 10.6 or 11 treatments.
subjective assessment of pain was obtained, yielding a
This is reasonably congruent with the actual average num-
quantitative measurement of individual patient discomfort.
ber of treatments (13.2). These data are presented in Table
Cervical flexion distraction treatment was administered
1.
on all of the patients in this clinical series. This is a type of
The number of treatments provided is based on a profes-
manual manipulation that primarily uses traction as the
sional evaluation of a given patients clinical condition. In
mode of delivery for the adjustment.8 The cervical head-
this series, only 3 patients (13.6%) required more treatments
piece of the flexion-distraction instrument was utilized.
than the average plus 1 standard deviation above the mean.
During the flexion distraction procedure, the contact hand
This is consistent with a theoretical normal distribution in
was placed at the T1 level in an attempt to essentially treat
which approximately 16% of the area under the curve is
the entire cervical spine. The treating physician then applied
more than 1 standard deviation above the mean. Further
a gentle and steady force through the contact hand in the
supporting the clinical judgments applied to the 3 patients
caudal and posterior-to-anterior direction. The physician
receiving the most treatments, they had an average initial
uses the noncontact hand on the handle of the headpiece to
VAS score of 65.2 22.2 and a mean final VAS score of
cause the desired movement. Most of the patients in this
3.3 2.3. Stated in other terms, these patients started with
study were treated in straight flexion. However, if lateral
higher than average levels of pain and achieved greater than
flexion of the cervical headpiece affected a significant de-
average reductions in their pain. Additional details concern-
crease in radicular symptoms (centralization), the headpiece
ing treatments are provided in Table 2.
was place in lateral flexion, usually contralateral to the side
of radiculopathy, prior to administering flexion.
All the patients also received some form of adjunctive DISCUSSION
physical medicine modality, eg, low-volt galvanic stimula- Defining radiculopathy is important to having a clear
tion, ultrasound, and hot/cold packs. All patients were understanding of the clinical phenomenon. According to
treated by the same clinician (RK) in the same private Cramer and Darby,9 radicular pain is caused by activation of
practice clinical setting. Many patients had confirmatory sensory fibers at the level of the dorsal root. It is described
electromyography studies, magnetic resonance imaging, or as a thin band of sharp shooting pain along the distribution
radiological reports that documented radicular conditions or of the nerve(s) supplied by the affected dorsal root. This is
anatomic reasons for the condition of radiating pain. also termed the dermatomal pattern. Other descriptions can
Journal of Manipulative and Physiological Therapeutics
Volume 26, Number 9
Table 2. Treatment data
Change
Number of per
Gender treatments Range treatment
Male 16.0 10.0* 7 to 31 2.6 0.6
Female 12.2 7.5 6 to 37 12.2 7.5
Total 13.2 8.2 6 to 37 3.9 2.4
*Mean SD.
include long tract radiation into the upper or lower extrem-
ity. It may be accompanied by paresthesia, hypesthesia, or
decreased reflexes, as well as being coupled with motor
weakness secondary to compromise of the ventral roots.9
There are several possible causes of radicular pain, such
as disk lesion, abscess, tumor, spondylolisthesis, malforma-
tion of the vertebral canal, malformation of the spinal nerve
root and/or sheath, diseases of surrounding bone, and chem-
ical inflammation due to degeneration of the intervertebral
disk. Disk herniation is the most common cause of radicu-
lopathy. However, other nonmechanical causes of radicu-
lopathy include the following: leptomeningitis, meningeal
carcinomatosis, and herpes zoster.10
One common cause of cervical radiculopathy is due to
encroachment of the cervical intervertebral foramen. The
anatomy of a cervical foramen has been described as an
hourglass with a narrowing at the center. Foraminal cross-
sectional area of the cervical spine may be one of the causes
of radiculopathy.11 Humphreys et al12 studied symptomatic
and asymptomatic patients with cervical radiculopathy.
They found that the inferior foraminal width, but not the
height, tends to decrease with age.
The primary diagnosis of cervical radiculopathy is based
on a patients subjective symptoms.13 Patients commonly
report neck pain and pain that radiates along specific der-
matomes. Many patients also commonly present with a
positive Bakodys sign (holding ones hand on ones own
head to relieve the pain on the affected side).14 Bakodys
sign has also been described as the shoulder abduction relief
test.15 Other orthopedic testing that decreases the size of the
cervical intervertebral foramina will increase the radicular
symptoms. Conversely, tests that increase the cervical in-
tervertebral foramina usually decrease the radicular find-
ings.
The prognosis varies for cervical radiculopathy. In cases
of radiculopathy, the first changes of denervation are found
in the paraspinal muscles within 7 to 10 days.16 Within 2 to
3 weeks, deficits in the limb muscles of the affected myo-
tome become evident. Healing and reinnervation can be
seen at 3 to 6 months after the original injury.
Magnetic resonance imaging (MRI) is the primary imag-
ing modality when radiculopathy is suspected.16 Needle
electromyography (EMG) is the gold standard for an elec-
trodiagnostic evaluation.17 However, both tests have their
Schliesser, Kruse, and Fallon
Cervical Radiculopathy
disadvantages. EMG will not display radiculopathies if they
are mild or primarily sensory. MRI may show structural
changes that are not clinically significant. The timing of the
study may also influence MRI results. According to Nardin
et al,16 some studies have shown that large disk herniations
regress with time. Therefore, radiculopathy that is due to a
disk herniation may show differing disk appearances de-
pending on the time that the diagnostic study was performed
relative to the time of injury.
Dynamic motion is also an important factor in the cervi-
cal spine. Researchers have studied the intervertebral fora-
men sizes with different motions. Extension combined with
axial rotation has been shown to decrease the foraminal
size.18 Muhle et al18 also reported that, among symptomatic
patients, the foraminal size increased with flexion and axial
rotation to the side opposite to the pain. Biomechanical
studies have shown that extension reduces the size of the
spinal canal compared with neutral, with extension decreas-
ing the canal size and area of the intervertebral foramen.19,20
These motions may also increase the symptoms that many
patients experience.
Chronic neck pain has been effectively treated by several
different approaches.21-24 Some studies show support of
manual manipulation for neck pain,25 but others show that
the data are inconclusive.21,26,27 Traction has also been
shown to be effective.28 In one study of 503 patients, 246
were found to have cervical radiculopathy without myelop-
athy. After evaluation, only 86 were recommended for
surgery.28 According to these researchers, surgical patients
improved significantly in regards to pain and functional
status. Heller15 reported that surgical intervention for neck
pain without neurological deficit had no benefits.
Studies of conservatively treated patients who were
treated without surgery reported larger improvements in
many areas, including reflexes, motor weakness, and pain,
than those treated with surgery.24 Skargren and Oberg22
showed that 5 different variables were involved when re-
viewing individuals responses to treatment. The factors
were duration of current episode, Oswestry score29 at entry
into the study, number of areas involved or number of
localizations, expectations of treatment, and patient well-
being. In a 12-month study,22 patients that had a poorer
prognosis had a longer duration of pain (1 month), more
than 1 localization, and fewer positive expectations. How-
ever, Skargren and Oberg22 reported that age, gender, smok-
ing, previous history of a similar problem, neck or low back
pain, pain intensity and frequency, and general health did
not contribute significantly to the prediction of outcome.
However, the incidence of neck pain in general has been
found to be greater in women than men.30
The VAS is a form of patient perception outcome assess-
ment that has been described as generally relevant, valid,
reliable, responsive, and safe.31,32 With the VAS, patients
are asked to place a mark on a horizontal line, 10 cm in
length, to indicate the severity of their pain. The left end of
Schliesser, Kruse, and Fallon
Cervical Radiculopathy
Table 3. Comparison of initial VAS scores for two groups of
patients
Initial and final Only initial
VAS scores VAS score Statistical
Attribute available available significance
Minimum 26 5 other forms of treatment. While the results of this study
Maximum 91 100
Male 40.2 14.3* 51.0 24.7 U 1.07; P .05
Female 53.8 19.8 40.4 27.4 t 1.23; P .05
Total 50.1 19.2 49.1 21.8 t 0.15; P .05
*Mean SD.
the line represents no pain, and the right end represents
severe, or unbearable, pain. A clinician can then measure
the distance from the left end of the line to the patients
mark and give it a numeric value. In this way, future
assessments can be measured and compared, thereby docu-
menting progress.
One concern of the present study was not having final
VAS recordings for all patients. This occurred because they
did not return for scheduled additional treatments or were
not officially dismissed from care. A total of 17 individuals
never completed a second VAS form and were therefore not
included in the study. Neither the mean initial score for
these patients nor the range of scores was significantly
different from those for whom 2 VAS scores were available.
Complete details can be found in Table 3.
CONCLUSION
All patients utilized in this study were diagnosed clini-
cally with cervical radiculopathy, independent of results
from supportive diagnostic testing such as MRI or EMG.
Studies of individuals with cervical radiculopathy demon-
strate that not all patients are candidates for surgery. This
leaves a significant portion that can benefit from other
means of treatment. Many conditions are showing promis-
ing results with manipulation. Flexion distraction, primarily
for the lumbar spine, is one of the most commonly utilized
forms of treatment among chiropractic physicians.7 How-
ever, studies on cervical flexion distraction are lacking.
Within this private practice setting, the ability to perform
preexaminations and postexaminations was sometimes
hampered. We found that patients may not be willing to
spend extra time to complete research instruments. Contin-
ued pain or other personal agendas may bias research re-
sults. Patients may also not return for follow-up care or a
release examination when they believe (erroneously) that
maximum improvement has occurred or they may not be
satisfied with the progress of their treatments. Because
patients in a private practice setting have to bear the finan-
cial costs for their treatment, they may not be fully compli-
ant with suggestions concerning care and follow-up treat-
ment.
Journal of Manipulative and Physiological Therapeutics
November/December 2003
This study objectively demonstrates that in this patient
population, there was a significant decrease in pain levels
and provides the basis for further research. This study also
did not include all clinic patients, as they may have been
treated with other forms of chiropractic care that did not use
flexion distraction or were referred to other providers for
show promise for chiropractic and manual therapy tech-
niques, specifically cervical flexion distraction, it demon-
strates that other, larger research studies must be performed.
ACKNOWLEDGMENTS
The authors would like to thank Gregory Cramer, DC,
PhD and Jerrilyn Cambron, DC, MPH of the National
University of Health Sciences for assistance with this study.
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