International Journal of Osteopathic Medicine (2016) 21, 19e28

www.elsevier.com/ijos

ORIGINAL ARTICLE

Effectiveness of neural mobilization with

intermittent cervical traction in the
management of cervical radiculopathy: A
randomized controlled trial
Christos Savva a,b,*, Giannis Giakas b,c,
Michalis Efstathiou a,b, Christos Karagiannis a,
Ioannis Mamais a

a
Department of Health Science, Diogenous 6, Engomi, European University, Nicosia,
Cyprus
b
Department of Physical Education and Sport Science, University of Thessaly, Karyes,
Trikala 42100, Greece
c
Department of Kinesiology, CERETETH, Karyes, Trikala, 42100, Greece

Received 1 November 2013; revised 15 March 2016; accepted 27 April 2016

KEYWORDS Abstract Background: The effectiveness of both neural mobilization and intermit-
Cervical tent cervical traction (ICT) has been previously explored in some studies of gener-
radiculopathy; ally low methodological quality. However, the effect of simultaneous application of
Neck pain; these techniques in people with cervical radiculopathy (CR) has not been previously
Spinal manipulative investigated.
therapy; Aim: To investigate the effect of neural mobilization with simultaneously applied
Neurodynamics ICT on pain, disability, function, grip strength and cervical range of motion in pa-
tients with CR.
Design: Randomized, controlled, assessor-blinded, clinical trial.
Methods: Participants (n ¼ 42) diagnosed with unilateral CR were randomly allo-
cated to intervention (neural mobilization combined with ICT, n ¼ 21) or control
(n ¼ 21) groups. Participants in the intervention group were asked to attend for
12 treatment sessions to receive 6 sets of 60s grade IIeIV ICT with simultaneously
applied ‘slider’ neural mobilizations with median nerve bias. Participants random-
ized to the control group did not receive any type of treatment and were asked to
avoid prescription or over-the-counter analgesia or anti-inflammatory medication.

* Corresponding author. Argolidos 25 Panthea, Limassol, Cyprus. Tel.: þ357 99666124.

E-mail address: savva.christos@hotmail.com (C. Savva).

http://dx.doi.org/10.1016/j.ijosm.2016.04.002
1746-0689/ª 2016 Elsevier Ltd. All rights reserved.
20 C. Savva et al.

The Neck Disability Index (NDI), the Patient-Specific Functional Scale (PSFS), the
Numeric Pain Rating Scale (NPRS), and measures of grip strength (GS) and cervical
spine active range of motion (CSAROM) were administered at baseline and at
4-weeks.
Results: The intervention group demonstrated significant improvements in NDI
scores (mean difference ¼ 16.95; 95% CI ¼ 22.47 to 11.43, ES ¼ 0.42), PSFS
scores (mean difference ¼ 2.88; 95% CI ¼ 2.33 to 3.43, ES ¼ 0.66), NPRS scores
(mean difference ¼ 3.74; 95% CI ¼ 4.92 to 2.96, ES ¼ 0.37), GS (mean
difference ¼ 1.87 kg; 95% CI ¼ 0.51 to 3.23; ES ¼ 0.07), and CSAROM (except for
lateral flexion), compared to the control group where significant changes were
not detected.
Conclusion: Neural mobilization with simultaneous ICT can improve, pain, func-
tion, disability, grip strength and cervical range of motion in people with CR.
Further clinical trials comparing neural mobilization with cervical traction to other
standard interventions are justified.
ª 2016 Elsevier Ltd. All rights reserved.

movement) signs in the upper-limb.1,6,10e12 In

Implications for practice
 Neural mobilization combined with intermit-
tent cervical traction can produce clinically
meaningful improvements in pain and
disability.
 The combination of these techniques could
improve neck function.
 Cervical spine range of motion could
improved significantly with this practice in
cervical radiculopathy patients.
Introduction
Cervical radiculopathy (CR) is a peripheral nervous
system disorder affecting the normal function of
cervical nerve roots (CNRs) and is often associated
with chronic pain and functional limitations in
daily life.1e5 The annual incidence of CR has been
reported to be 83 cases per 100,000 people in the
population, with an increased prevalence in the
fourth to sixth decade of life.6e8
CR is associated with mechanical and/or in-
flammatory stimuli around the CNRs and several
imaging studies have demonstrated cervical disc
herniation and osteophytic encroachment to be
the most common lesions that lead to nerve root
compression, inflammation, or both.3,5,9 These
lesions may affect sensory and motor fibers of
CNRs, producing neuropathic symptoms described
as ‘burning’, ‘shooting’, ‘sharp’ pain or ‘electric-
shock-like’, sensory (numbness or paraesthesia)
and motor (muscle weakness or loss of active
order to identify CR, these signs and symptoms
may be further investigated using magnetic reso-
nance imaging (MRI) and electrodiagnostic studies,
although these are not always feasible in clinical
practice.4,7,13
A variety of manual therapy techniques including
intermittent cervical traction (ICT) and neural
mobilization have been proposed to reduce pain
and functional limitations in CR.7,14e20 Using MRI
and CT scans, a small number of imaging studies
indicate that ICT can modify mechanical stimuli
compressing the involved CNR by increasing inter-
vertebral space, widening the cervical neural
foramina, and reducing intradiscal pressure.8,15,21 It
has been also suggested that application of ICT can
disperse inflammation at CNRs,22 however the
mechanism behind this action remains poorly un-
derstood. The therapeutic value of ICT for CR is not
clear, as studies of its effectiveness have generally
been of poor methodological quality due to inap-
propriate use of homogenous participants, short-
term follow-ups and small sample sizes.5,23,24
Neural mobilization was introduced as an
intervention for pain relief more than 25 years ago
and is advocated in CR to facilitate nerve ‘sliding’
(also described as ‘gliding’) and normalization of
mechanosensitivity at involved CNRs.16,19,25 There
is some evidence demonstrating the benefits of
neural mobilization in the management of pe-
ripheral neuropathies including carpal tunnel syn-
drome26 lumbar radiculopathy20 and CR.18,19
Neural mobilization in patients with CR is com-
mon, although previous studies of neural mobili-
zation in CR have been compromised by several
methodological weaknesses, including the lack of
randomization, absence of an adequate control
Neural mobilization with cervical traction for cervical radiculopathy
group, and poor participant and assessor
blinding.2,16,20,27
A clinically positive effect of neural mobiliza-
tion and ICT applied simultaneously has been
previously reported in a case study.24 However, a
randomized controlled trial has not been reported
to date. Therefore, the purpose of this study was
to investigate the effect of neural mobilization
with simultaneous ICT on pain, disability, function,
grip strength and cervical range of motion in pa-
tients with CR.
Methods
Study design
A randomized, controlled, assessor-blinded, clinical
trial was designed to investigate changes in pain,
function and disability of participants with CR
receiving ICT with neural mobilization (Fig. 1).
Participants were assessed by two data collectors
who were blinded to group allocation to prevent
potential recorder and ascertainment bias.28 Par-
ticipants were blinded to their measurement scores
to address potential expectation bias.29,30 Knowl-
edge of the existence of two groups and group
allocation may also affect participant behavior and
responses to outcome measures and participants
were therefore blind to group assignment.
Fig. 1 CONSORT flow diagram of patients through the
trial.
21
Participants were randomly allocated using
block randomization to an intervention group
receiving neural mobilization with concurrent ICT
(n ¼ 21), or a wait-list control group (n ¼ 21) who
did not receive any type of treatment (Fig. 1).
Participants in both groups were asked to avoid
prescription or over-the-counter analgesia or anti-
inflammatory medication and were assessed on all
outcome measures, applied at baseline (week 0)
and at the end of the 4-week program (week 4).
Participants randomized to the intervention group
received the final assessment one day after their
last treatment session.
The study was approved by the Cyprus National
Bioethics Committee and all participants gave
written informed consent prior to participation.
Sample size calculation
In order to identify potential clinically significant
differences between the two groups, power
calculation was performed to detect the required
sample size per group. The Minitab statistics
package version 16 (Minitab Inc., State College,
PA, USA) was used to conduct sample size calcu-
lation,31 based on the primary outcome measure,
the Neck Disability Index (NDI). The minimum
clinically important difference for the NDI and its
standard deviation have been reported to be 14/
100 and 15, respectively.32 In order to detect the
size of the minimum difference between the two
groups (5% two-sided significance level) with an
80% power, the minimum size of each group was
estimated at 21 participants.
Participants and setting
Data collection was conducted between
September 2012 and July 2013, in the outpatient
physiotherapy department of Nicosia General
Hospital. Consecutive patients diagnosed by or-
thopedic surgeons using MRI or CT scans as having
unilateral CR who were referred to the outpatient
physiotherapy department were initially recruited.
A physiotherapist not involved in delivering treat-
ment or outcome assessment undertook clinical
evaluation to screen all referred patients and
determined eligibility for participation (n ¼ 58).
Participants were eligible if they (1) reported uni-
lateral sensory and motor deficits including sharp
pain, muscle weakness and numbness in the upper
arm,33 and (2) if a positive result was found in a
minimum three of four tests (Spurling’s test,
Distraction test, Upper Limb Neurodynamic Test 1
and ipsilateral cervical rotation of less than 60 ) of
22
a clinical prediction rule.27,33e35 This clinical pre-
diction rule has demonstrated 94% specificity (95%
CI ¼ 0.88 to 1.00), 24% sensitivity (95% CI ¼ 0.05 to
0.43) and a positive likelihood ratio of 6.1 (95%
CI ¼ 2.0 to 18.6) when 3 of 4 items were pos-
itive.27,33e35 Participants were not eligible if they
had a current history of cervical myelopathy or
signs of upper motor neuron disease, bilateral CR
or other musculoskeletal conditions in the affected
limb.33 Participants were excluded if they had
been receiving any prescription or over-the-
counter analgesia or anti-inflammatory medica-
tion during the prior two weeks.33
Randomization
Blocked randomization was used in order to mini-
mize potential selection and accidental bias, as
well as to achieve a balance in sample size be-
tween groups.29,36 A block size of 4 was used and
therefore 6 possible ways to equally assign par-
ticipants to a block were created.36 More specif-
ically, 6 different envelopes were created with all
possible allocation combinations of 4 consecutive
enrolled patients (e.g. AABB, ABAB, BABA, etc).
One envelope was randomly selected by the first
participant of each group of 4 participants and
then each of these 4 participants were allocated
according to the ordering of the selected enve-
lope, until the required number in each group was
reached. The research assistant responsible for the
participant allocation was blinded to the block size
to prevent guessing group allocation in trial.37 The
principal investigator guided and coordinated the
process of patient allocation and was blinded to
group allocation.
Treatment providers
Two treatment providers were recruited to
perform neural mobilization and ICT. The treat-
ment providers were qualified physiotherapists
with 5-years post-qualification clinical experience
in the field of neuro-musculoskeletal physio-
therapy. Due to the nature of the techniques, it
was impossible to blind providers to the interven-
tion given.
Intervention
Participants were scheduled to attend 12 treat-
ment sessions (3 sessions every week for 4 weeks;
15 min each session). At the beginning of each
session, participants rested in a supine position
and were advised to position their cervical spine in
C. Savva et al.
the most pain-free position. Most participants
selected cervical flexion as the least painful neck
position but in some cases the particular position
aggravated their present symptoms due to the high
mechanosensitivity of the involved CNR.38 There-
fore, these participants were positioned with the
neck rested in 0 of flexion, lateral flexion and
rotation. Once the starting neck position was
achieved, neural mobilization techniques com-
bined with ICT were performed by the two treat-
ment providers (Fig. 2).
Cervical traction has been classified into five
grades.39 In the present study, cervical traction
was applied using grades IIeIV. Grade II is
described as a large-amplitude longitudinal
movement within the available range of motion,
grade III as a large-amplitude longitudinal move-
ment that reaches the end range of motion, and
grade IV as a small amplitude longitudinal move-
ment at the very end range of motion.39 Each
session comprised of 6 sets of grade IIeIV ICT. In
every set, ICT was applied and maintained for
1 min and was followed by a rest period of
1 min.24 Maintaining ICT for 1 min, slider neural
mobilizations using a median nerve bias were
performed in slow and oscillatory fashion at the
same time.40 Specifically, ICT was maintained for
1 min and during this period the elbow joint along
with the wrist and fingers were moved in several
positions to mobilize the affected CNRs (Fig. 2).
Treatment providers were instructed to apply
pain free cervical traction. Therefore, cervical
traction was commenced at grade II. As symptoms
allowed, the traction force was progressively
increased (from grade II to grade III and IV) during
the session. The treatment providers’ target was
to apply grade IV ICT in a pain-free neck flexion
with the intention of achieving maximum
widening of the cervical neural foramina and
maximum reduction of intradiscal pressure.8,21
Regarding the application of neural mobiliza-
tion, the glenohumeral joint was initially placed
in neutral position and gradually was moved into
90 of abduction and maximum lateral rotation,
depending on the degree of apparent neural
mechanosensitivity. In participants where neural
mechanosensitivity was high, the glenohumeral
joint was initially placed at 0 of flexion, abduc-
tion and rotation, while in participants with low
mechanosensitivity, the glenohumeral joint was
positioned at 90 of abduction and maximum
lateral rotation (Fig. 2).38
Participants allocated to the control group
were assessed using all outcome measures
at baseline and were subsequently allocated to
wait list control for 1 month. During this period,
Neural mobilization with cervical traction for cervical radiculopathy 23

Fig. 2 Slider neural mobilizations of the median nerve combined with ICT were applied concurrently. ICT was
maintained for 1 min and during this period the elbow joint along with the wrist and fingers were moved in several
positions to mobilize the affected CNRs. (A), (B) Neural mobilization techniques were given in patients with high nerve
mechanosensitivity and therefore the shoulder angle was placed at 0 of flexion, abduction and rotation. The elbow
joint was moved from full flexion to full extension while the patient’s wrist and fingers were moved from full extension
to full flexion in a sliding manner. (C), (D) Neural mobilization techniques were given in patients with low mecha-
nosensitivity and therefore the shoulder angle was placed at 90 of flexion and maximum lateral rotation. Maintaining
this position, the elbow joint was moved from full flexion to full extension while the patient’s wrist and fingers were
moved from full extension to full flexion in a sliding manner.

participants did not receive any type of treat-
ment and did not take oral medicine. After 4
weeks post initial evaluation, participants were
re-assessed.
Outcome measures
The Numeric Pain Rating Scale (NPRS) was used to
estimate the intensity of ‘current’, ‘best’, and
‘worst’ pain intensity over the previous 24 h.1 The
Neck Disability Index (NDI) and the Patient-Specific
Functional Scale (PSFS) were also used to deter-
mine the disability associated with CR.5,9,10 Higher
scores on the NDI (range 0e100%) and NPRS (range
0e10) indicate greater disability and higher pain
intensity, respectively. For the PSFS (range 0e10)
lower scores indicate lower function.24,33 In addi-
tion, grip strength (GS) measurement using a grip
dynamometer (Jamar hand dynamometer, model
5030J1, Seahan Corporation, Korea) and mea-
surement of cervical spine active range of motion
(CSAROM) using a universal goniometer (model
G300, Whitehall Manufacturing, USA) was
performed to assess changes in GS and range of
movement.41 GS data were collected using the
Jamar hand dynamometer measured in kilogram
force (kg). All outcome measures were recorded at
baseline and at the end of the 4-week program to
identify differences in pain intensity, function and
disability between groups. The selected outcome
measures have been used in similar studies and
have acceptable validity and reliability.1,42,43
Statistical analysis
A two-way repeated measures ANOVA was per-
formed to identify potential statistically significant
differences between the intervention and control
groups, with alpha set at 0.05. Therefore, separate
analyses were conducted on each outcome mea-
sure (dependent variables) to evaluate the effects
of simultaneous application of neural mobilization
and ICT on pain, disability and function in patients
with CR. The group (intervention or control group)
was the between-participant factor and time
(baseline, reassessment 4 weeks post initial
24
evaluation) was defined as the repeated factor. If a
significant interaction was obtained, pairwise
comparisons were performed by using the Sidak
method. Pairwise mean differences with 95% con-
fidence interval (CIs) were calculated to detect
the effect size at the 4-week follow up in all
outcome measures. Effect size (ES) estimates were
calculated for all mean differences using Cohen’s
d.44 For descriptive purposes, Cohen’s original
scale was adopted: 0.1 for ‘small’, 0.2 for ‘mod-
erate’, and 0.4 for ‘large’ effects.44 Data analysis
was undertaken using SPSS version 20 (IBM SPSS,
Armonk, NY: IBM Corp.).
Results
Of the 58 consecutive patients, 16 were excluded
either because they did not meet the inclusion
criteria or because they declined to participate for
certain reasons (Fig. 1).
Forty-two participants (mean  SD
age ¼ 47.2  11.3 y; range 28 to 70 y) met the
inclusion criteria and agreed to participate. Spe-
cifically, 21 females (mean  SD age, 45.2  13.5
years) and 21 males (mean  SD age, 49.1  8.53
years) were included. Eight males and 13 females
(mean age  SD age, 45.2  13.5 y) were allocated
in the intervention group, and 8 females and 13
males (mean  SD age, 49.2  8.5 y) were allo-
cated to the control group. Changes in all outcome
measures are reported in Table 1.
Grip Strength Measurement
There were no significant interaction effects of
group and time for GS measurement (p > 0.05).
The intervention group demonstrated a significant
improvement in GS (p ¼ 0.009). In the control
group changes were not statistically significant.
The ES between groups for the measurement of GS
was ‘small’ (ES ¼ 0.07).
Neck Disability Index, Patient-Specific
Functional Scale, Numeric Pain Rating Scale
Post hoc pairwise comparisons demonstrated sta-
tistically significant differences between measures
for the NDI, PSFS and NPRS in the intervention
group from baseline to the 4-week follow up
(p < 0.05). This suggests that neural mobilization
applied simultaneously with cervical traction can
provide pain reduction and improvements in
function and disability (Table 1). The threshold for
the minimum clinically important difference was
C. Savva et al.
surpassed in all outcome measures demonstrating
a clinical meaningful improvement in pain, func-
tion and disability for the intervention group.
There were no improvements observed in control
group. The ES between groups for the NDI and the
PSFS was ‘large’ (ES ¼ 0.42 and ES ¼ 0.66,
respectively). For the NPRS the effect size was
‘moderate’ (ES ¼ 0.37).
Cervical spine active range of motion
Post hoc pairwise comparisons showed statistically
significant differences in the intervention group
for all movements except for ipsilateral and
contralateral lateral flexion. Specifically, partici-
pants who received neural mobilization with ICT
demonstrated a significant improvement in cervi-
cal flexion, extension, ipsilateral rotation and
contralateral rotation. The control group demon-
strated statistical significant restriction in contra-
lateral lateral flexion and contralateral rotation
(Table 1). The between-group ESs for change in
flexion, extension and lateral flexion was ‘moder-
ate’ (Flexion ES ¼ 0.40; Extension ES ¼ 0.26;
Ipsilateral lateral flexion ES ¼ 0.12; Contralateral
lateral flexion ES ¼ 0.18) compared to the ‘large’
ESs of rotations (Ipsilateral rotation ES ¼ 0.40;
Contralateral rotation ES ¼ 0.42). These changes
were in favor of the intervention group.
Discussion
Although various manual therapy techniques have
been proposed to be effective in CR, few ran-
domized clinical trials have investigated non-
operative management strategies for people with
CR. Neural mobilization and ICT are widely utilized
in clinical practice in order to reduce pain and
functional limitations in CR.6,7,24,35 Previous
studies examining the effectiveness of neural
mobilization and ICT have been found to have poor
methodological quality, mainly due to the lack of
randomization,16 the absence of wait-list control
groups,5,7 and weakness in blinding of participants
and data collectors.16
The present study demonstrated that the simul-
taneous application of neural mobilization and ICT
was associated with improvement in pain, disability,
function, grip strength, and cervical range of motion
in people with CR. Between-group comparisons
revealed that the intervention group experienced
significant improvements in all outcome measures
except for the range of lateral flexion (Table 1).
These findings suggest that over a period of 4 weeks
 Neural mobilization with cervical traction for cervical radiculopathy
Table 1 Results for intervention and control group for outcome parameters.
Baseline 4-week Mean 95%CI p-Value Effect Effect size
follow up difference mean difference size descriptor
Subjective outcome measures
PSFSa Within group Intervention 3.96  1.24 6.83  1.78 2.88 2.33, 3.43 <0.001 e e
Control group 4.58  1.43 3.86  1.82 0.71 1.36, 0.07 0.03 e e
Between group Intervention vs Control e e 2.97 0.56, 2.97 <0.001 0.66 Large
NDIb Within group Intervention 33.33  17.57 16.38  12.19 16.95 22.47, 11.43 <0.001 e e
Control group 30.19  16.44 31.71  13.98 1.52 3.03, 6.07 0.493 e e
Between group Intervention vs Control e e 15.33 23.51, 7.15 <0.001 0.42 Large
NPRSc Within group Intervention 5.62  2.52 1.88  1.88 3.74 4.92, 2.96 <0.001 e e
Control group 5.19  2.11 5.14  2.39 0.05 1.11, 1.02 0.927 e e
Between group Intervention vs Control e e 3.26 4.61, 1.92 <0.001 0.37 Moderate
Objective outcome measures
GSMd Within group Intervention 19.52  10.28 21.38  10.64 1.87 0.51, 3.23 0.009 e e
Control group 21.56  9.65 21.48  9.03 0.08 1.74, 1.58 0.920 e e
Between group Intervention vs Control e e 0.10 0.09, 3.05 0.974 0.07 Small
CSAROMe
Flexion (0e50) Within group Intervention 32.33  10.42 38.11  8.28 5.78 1.83, 9.73 0.006 e e
Control group 34.64  9.78 32.40  9.06 2.23 4.66, 0.18 0.068 e e
Between group Intervention vs Control e e 5.70 0.29, 11.12 0.039 0.25 Moderate
Extension (0e60) Within group Intervention 35.21  10.75 46.62  15.32 11.40 5.03, 17.78 0.001 e e
Control group 42.14  15.22 37.85  15.41 4.28 10.17, 1.59 0.144 e e
Between group Intervention vs Control e e 8.76 0.82, 18.34 0.072 0.26 Moderate
Ipsilateral lateral Within group Intervention 25.73  10.19 28.83  8.10 3.09 0.36, 6.55 0.077 e e
flexion (0e45) Control group 24.52  7.62 22.48  7.47 2.05 5.06, 0.97 0.172 e e
Between group Intervention vs Control e e 6.35 1.49, 11.22 0.012 0.12 Moderate
Contralateral Within group Intervention 24.93  10.34 28.57  8.38 3.64 0.18, 7.46 0.061 e e
lateral flexion (0e45) Control group 25.35  7.06 22.59  6.17 2.76 5.11, 0.40 0.024 e e
Between group Intervention vs Control e e 5.97 1.38, 10.56 0.012 0.18 Moderate
Ipsilateral Within group Intervention 45.69  11.82 57.59  10.57 11.90 7.30, 16.50 <0.001 e e
rotation (0e80) Control group 51.52  12.43 49.67  10.61 1.85 4.89, 1.18 0.217 e e
Between group Intervention vs Control e e 7.93 1.32, 14.53 0.02 0.40 Large
Contralateral Within group Intervention 47.97  12.31 60.16  9.23 12.19 6.56, 17.82 <0.001 e e
rotation (0e80) Control group 54.86  9.96 49.55  13.48 5.31 9.20, 1.42 0.01 e e
Between group Intervention vs Control e e 10.61 3.41, 17.82 0.005 0.42 Large
a
Patient-Specific Functional Scale (ranging from 0 to 10); higher scores represent greater level of function.
b
Neck Disability Index (ranging from 0 to 100); higher scores represent higher level of disability.
c
Numeric Pain Rating Scale (ranging from 0 to 10); higher scores represent higher level of pain.
d
Grip Strength Measurement (ranging from 0 to 100); higher scores represent greater level of grip strength.
e
Cervical spine active range of motion; higher range of motion represents greater level of function.

25
26
the combination of these two manual techniques can
reduce pain and disability and increase functional
status, grip strength and active range of cervical
motion. In contrast, participants in the control group
demonstrated a deterioration of symptoms between
measures, although most of these changes were not
significant.
Importantly, there were no significant differences
between the two groups at baseline. At the 4-week
follow-up, improvement on the PSFS and lower
scores on the NDI and NPRS were observed in the
intervention group compared to the control group
indicating that participants receiving the interven-
tion exhibited a higher level of function and a lower
level of pain and disability (Table 1). Regarding
cervical range of motion, at the end of treatment,
the intervention group demonstrated greater range
of flexion, lateral flexions and rotations compared to
the control group. However, changes in grip strength
and the range of neck extension were not statisti-
cally different between groups.
The minimum clinically important difference for
NPRS and PSFS in people with CR has been re-
ported as 2.2 (out of 10) and 8.5 points (out of 50)
for the NDI.1 The threshold for minimum clinically
significant difference was exceeded for each of
these outcome measures demonstrating a clinical
meaningful improvement in pain, function and
disability for the intervention group (Table 1). The
control group did not demonstrate statistically
significant changes and did not exceed the mini-
mum clinically significant change for these
particular outcome measures.
Although the pathophysiology of CR has not
been fully understood, imaging studies have shown
that certain musculoskeletal pathologies, such as
cervical disc herniation and osteophytic
encroachment, can lead to nerve root compression
(mechanical stimuli) and/or inflammation (chemi-
cal stimuli).7,45 Based on this, ICT was used to
modulate mechanical and/or chemical stimuli in
order to treat nerve root compression or inflam-
mation.8,14,21,46 Maintaining the elongation of the
cervical neural foramina and reducing intradiscal
pressure through the application of ICT, sliding
techniques were applied concurrently to improve
nerve sliding as well as to modulate mechano-
sensitivity of the affected CNR.16,17,19,25,45 A slider
neural mobilization of the median nerve was
applied to mobilize the C6eT1 nerve roots which
are most commonly involved in CR.4,6,35 Sliding
techniques were applied because they may be
more comfortable than ‘tensioning’ techniques in
patients whose irritability and severity of symp-
toms were high.17
C. Savva et al.
The findings of the present study support the use
of neural mobilization with simultaneous ICT as a
possible treatment strategy for patients with CR.
Similar results were reported by a case study,24 but
this was the first randomized controlled clinical trial
exploring the effect of simultaneous application of
these two techniques. Other studies have also rec-
ommended the application of therapeutic exercise,
such as strengthening of the scapulothoracic and
deep neck flexor muscles, as well as the application
of thoracic spine thrust manipulation in the man-
agement of CR.33,47 In a randomized clinical trial,
Fritz et al.,47 reported that cervical traction com-
bined with an exercise program can reduce pain and
disability in CR and improvements were maintained
at 6-month follow-up. Using a similar study design,
Young et al.,33 found that a multimodal treatment
approach including cervical traction, exercise and
thoracic spine thrust manipulation resulted in lower
disability, pain intensity and higher function in CR.
Interestingly, participants randomized to a group
that received thrust manipulation, exercise, and
cervical traction did not demonstrate any significant
differences in outcome measures compared to the
group that received thrust manipulation, exercise,
and sham cervical traction. This suggests that the
addition of cervical traction to Young et al.’s multi-
modal treatment program yielded no additional
benefit to pain, function, or disability in CR.33
Limitations
The improvements in outcome measures demon-
strated by participants in the intervention group
are limited to the 4-week follow-up period used in
this study. The long-term effectiveness of neural
mobilization applied simultaneously with cervical
traction must be examined in future studies. Par-
ticipants included in this study were not screened
based on the specific etiology and duration of
symptoms. It would be of interest if future studies
could compare participants with CR caused by a
mechanical versus an inflammatory stimulus.
Neural mobilization may not be effective in cases
where a nerve root is under compression due to a
disc herniation or foraminal stenosis.24 In nerve
root compression, the presence of mechanical
stimuli around the affected CNRs may not allow
their mobilization and this may aggravate CR
pain.24,48 Based on this notion, future studies
should be undertaken to explore whether the ef-
fect of the intervention used in this study varies
for different sub-groups. Furthermore, although
the duration of pain-related disability can be a
marker for poor rehabilitation outcomes in CR,39
Neural mobilization with cervical traction for cervical radiculopathy
this factor could be now investigated compared to
the effect of neural mobilization and cervical
2.
traction. Finally, the neural mobilization tech-
nique used (median nerve bias) tends to bias the
C6-T1 nerve roots.4,6 Therefore, the techniques
used in this study may not be effective in partici- 3.
pants with CR at other cervical levels.
Conclusion 4.
The findings of this study demonstrated that in a 5.
sample of people diagnosed with CR, neural
mobilization applied simultaneously with ICT pro-
duced clinically meaningful improvements over a
6.
4-week period, in terms of pain, disability, func-
tion, grip strength and cervical spine range of
motion. Future randomized controlled trials are
warranted in order to evaluate the long-term 7.
effectiveness of cervical traction with neural
mobilization in CR, as well as the effect of these
8.
two techniques in comparison with other
interventions.
9.
Conflict of interest
None declared. 10.
Ethical approval 11.
On meeting the requirements for inclusion, par-
ticipants gave informed consent prior to partici- 12.
pation. A participant information sheet detailed
the aim and the procedures of the study, and
informed participants of their right of privacy,
anonymity, and confidentially as well as their right 13.
to withdraw from the study at any time without
giving a reason. The study was approved by the
Cyprus National Bioethics Committee and all par- 14.
ticipants gave written informed consent prior to
participation.
15.
Funding
16.
None declared.
17.
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