Original Article

https://doi.org/10.14474/ptrs.2020.9.3.149 Phys Ther Rehabil Sci

pISSN 2287-7576 2020, 9 (3), 149-154
eISSN 2287-7584 www.jptrs.org

Effect of nerve mobilization with intermittent cervical http://crossmark.crossref.org/dialog/?doi=10.14474/ptrs.2020.9.3.149&domain=pdf&date_stamp=2020-9-25

segment traction on pain, range of motion, endurance, and

disability of cervical radiculopathy
Young-Ho Yuna , Byoung-Kwon Leea , Jae-Hoon Yib , Dong-Kwon Seoa
a
Department of Physical Therapy, College of Medical Science, Konyang University, Daejeon, Republic of Korea
b
Department of Smart Rehabilitation Care, Pyeongtaek University, Pyeongtaek, Republic of Korea

Objective: This study aimed to evaluate the effects of the Kaltenborn-Evjenth concept of nerve mobilization combined with in-
termittent cervical segment traction (ICST) on pain, Neck Disability Index (NDI) scores, range of motion (ROM) and endurance
in persons with cervical radiculopathy (CR).
Design: Two-group pretest-posttest design.
Methods: Thirty subjects participated in this study and were randomly assigned to two groups. The ICST group (n=15) was per-
formed simultaneously with nerve mobilization and cervical traction for the segment with cervical pain at the same time. The inter-
mittent cervical total traction (ICTT) group (n=15) performed nerve mobilization and cervical traction for the whole cervical area
at the same time. In this study, outcome measures such as the Visual Analog Scale (VAS), NDI, ROM, endurance (cranio-cervical
flexion test), and passive intervertebral motion performed before and 4 weeks after the experiment were compared to investigate
the effects of each intervention.
Results: In both groups, there were significant differences in the VAS, NDI scores, and endurance, and there were significant dif-
ferences between the two groups except for endurance (p<0.05). In the ICST group, significant differences were found in all ROM,
and in the ICTT group, significant differences were found in only extension, and there were significant differences between the
two groups (p<0.05).
Conclusions: The ICST group showed more improvement than the ICTT group in pain, NDI scores and ROM. Moreover, our
findings show that the ICST could be used as a new strategy for manual therapy in persons with CR.
Key Words: Cervical radiculopathy, Neural mobilization, Traction

Introduction root, and it reportedly has 83.2 cases per 100,000 people cas-
es per year [2].
In the modern age of fast information, many people devel- Common causes include herniation of the intervertebral
op musculoskeletal system diseases that cause cervical disc, spondylosis, cervical spine instability, trauma, osteo-
problems due to prolonged computer use, assumption of in- phytosis, and, rarely, oncological problems, resulting in nar-
appropriate working postures, and the performance of repet- rowing of space in the vertebral foramen where the cervical
itive tasks [1]. Cervical radiculopathy (CR), the most com- nerve root emerges or direct compression of the cervical
mon problem of the cervical spine, is a degenerative disease nerve root where mechanical and chemical irritation is ap-
of the cervical spine caused by a space-occupying lesion re- plied around the root to leading to inflammation of the nerve
sulting from pathological problems in the cervical nerve root, and other causes such as neuritis, edema, hypoxia, is-

Received: 2 September, 2020 Revised: 24 September, 2020 Accepted: 25 September, 2020

Corresponding author: Dong-Kwon Seo (ORCID https://orcid.org/0000-0002-3328-4922)
Department of Physical Therapy, College of Medical Science, Konyang University, 158 Gwanjeodong-ro, Daejeon 35365, Republic of Korea
Tel: 82-42-600-8457 Fax: 82-42-600-8408 E-mail: dkseo77@konyang.ac.kr
This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/
by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © 2020 Korean Academy of Physical Therapy Rehabilitation Science
150 Phys Ther Rehabil Sci 9(3)

chemia, fibrosis, and decrease in nerve mobility [3]. study. Of these 35 patients, 30 had satisfied with the se-
Manual therapy applied to patients with CR includes cer- lection conditions, understood the purpose of the study, and
vical traction. Cervical traction increases the vertebral body voluntarily signed the consent form.
gap, increases the vertebral foramen, reduces nerve root Prior to the experiment, all subjects received the full ex-
compression, increases blood circulation, and relaxes the planation of the experiment and provided voluntary consent.
surrounding muscles to restore vertebral mobility. Cervical This study was approved by the Institutional Review Board
traction is reportedly effective in that it alleviates pain, and of Konyang University (IRB No. KYU-2020-046-01) based
in a previous study, the group of patients with CR who re- on the Helsinki Declaration.
ceived manual traction or mechanical traction showed im-
Intervention
proved pain and functionality compared to the group with
only general rehabilitation [4]. The treatment for those in the ICST group was performed
Nerve mobilization is presented as an assessment of CR in supine position, which did not cause the subjects to expe-
and a therapeutic intervention method. This increases the rience any neck pain. In addition, the neck position was set
flexibility of the nerve to decrease the dynamic sensitivity of so that there was 0 degrees of flexion, lateral flexion, and
the nervous system and increases blood flow to indicate pain rotation. The therapist stood on the cranial side, placing the
relief. Moreover, the increased joint mobility of the pain in- radial side of both index fingers from the posterior arch of
creases the dynamic range of motion (ROM) and increases the vertebra to the left and right surfaces of the spinous proc-
the dynamic adaptability of the nervous system without ess, and the index finger formed an angle of 45 degrees from
resistance. It has been reported to help move the body [5,6]. the treatment table. The therapist’s index finger held the pos-
In previous studies, opinions have been divided on cer- terior arch of the vertebra, below which the traction
vical traction with nerve mobilization applied to patients occurred. By moving the pelvis backward, the tension of the
with CR. The effectiveness of simultaneously applying belt was transmitted to the vertebra. The belt around the
these techniques in people with CR has been investigated hand helped to hold the vertebral arch firmly and pull in the
previously, but the study methods comparing cervical seg- direction perpendicular to the treatment plane. When the
ment traction and cervical total traction are inadequate [7]. starting position was achieved, ICST was performed, and
This study aimed to investigate the effects of the nerve mobilization of the upper extremity was conducted by
Kaltenborn-Evjenth (K-E) concept of nerve mobilization the patients themselves. Cervical spine traction was classi-
combined with intermittent cervical segment traction fied into three grades, and cervical spine traction was ap-
(ICST) on pain, joint ROM, neck disability index (NDI) plied using grade II. The ICST was maintained for 1 minute,
scores, and craniocervical flexion test (CCFT) in patients starting from the glenohumeral joint external rotation,
with CR. When nerve root compression and inflammation 90-degrees of abduction, elbow flexion, wrist and finger ex-
occur by applying mechanical and chemical irritation to the tension, and elbow extension, wrist and finger extension.
vertebral foramen where the cervical nerve root exits, it The treatment provider performed painless cervical traction
causes neuritis, edema, fibrosis, and reduces nerve mobility and started cervical traction at grade II. Regarding the appli-
[5]. Therefore, this study intended to identify the effects of cation of nerve mobilization, the glenohumeral joint was ini-
ICST on pain, NDI scores, ROM, CCFT, and passive inter-
vertebral motion, in order to provide patients with CR with
the appropriate treatment methods, as well as to investigate
for the difference between the K-E ICST group and the inter-
mittent cervical total traction with nerve mobilization
(ICTT) group.

Methods
Participants

Thirty-five patients who were treated for CR at the Madu Figure 1. Intermittent cervical segment traction with nerve mobili-
Orthopedic hospital in Gyeonggi-do were recruited for this zation.
Yun, et al: Nerve mobilization with intermittent cervical segment traction 151

tially placed in the neutral position and slowly moved to was created based on the Oswestry index’s 10-question
90-degrees of abduction and maximal external rotation, de- questionnaire, which evaluates daily life limitations related
pending on the degree of apparent neuromechanical sensi- to back pain, pain intensity, daily life, lifting, reading, head-
tivity. The glenohumeral joint was initially at 0 degrees of ache, concentration, work, driving, sleep, and leisure, se-
abduction and external rotation for participants with high lected from one of six items for each of the 10 items (0-5).
neuromechanical sensitivity, whereas the glenohumeral The NDI score is the sum total of the items, and the higher
joint was positioned at 90-degrees of abduction and max- the score, the greater the disability associated with cervical
imal external rotation for participants with low neurome- abnormalities. The internal concordance is 0.82, and in-
chanical sensitivity. The treatment in the ICTT group was ter-rater confidence is 0.93 [10]. To measure the ROM of the
performed in entire cervical spine as a whole, and the other neck, a joint ROM instrument was used, and the parameters
process is the same as ICST group. were measured in degrees of ervical flexion and extension,
left and right lateral flexion, and left and right rotation.
Assessment tools and experimental methods
Subjects were comfortably seated in a chair and started at the
The study variables were the participants’ pain index front for measurement. The intra-measurement reliability
(assessed using the visual analog scale, VAS), NDI, ROM, was 0.89-0.98 and the inter-measurement reliability was
and deep flexor muscle CCFT was tested before the 0.76-0.98 [11]. The deep neck flexor test was used to se-
treatment. Using the Internet program (Research random- lectively test the deep muscles of the neck and the muscular
izer; Geoffrey C. Urbaniak and Scott Plous, Lancaster, PA, dndurance of the muscle group. The time to maintain 60% of
USA), two random groups were formed, and 15 people in the maximal voluntary contractile force (MVC) of the deep
the ICST group were randomly assigned to experimental neck flexors was measured, and a pressure biofeedback de-
group 1, while 15 people in the ICTT group were randomly vice (Chattanooga stabilizer pressure biofeedback;
assigned to experimental group 2. The arbitration time of Chattanooga Group Inc., Chattanooga, TN, USA) was used
each group was conducted three times a week for a total of to measure the MVC of the neck flexors. After all measure-
50 minutes/day, and the ICST and ICTT groups were com- ments were performed three times, the average value of each
posed of seven sets (1-minute treatment, 1-minute rest) and measurement was used in this study, and a 2-minute break
35 minutes of conservative physical therapy were applied. was provided between each execution, and the measurement
All subjects underwent conservative physical therapy three unit was mmHg. The intra-measurer reliability was
times a week for 4 weeks, which included superficial heat 0.82-0.89, and the inter-measurer reliability was 0.71-0.75
treatment for 20 minutes followed by transcutaneous elec- [12].
trical nerve stimulation. The frequency was set at 60 HZ ap-
Data analysis
plied for 15 minutes. After treatment, the subjects were div-
ided into the ICST and ICTT groups. Afterwards, VAS, neck For statistical analysis in this study, IBM SPSS Statistics
disability, joint ROM and deep flexor muscle endurance for Windows, Version 22.0 (IBM Co., Armonk, NY, USA)
tests were assessed after 4 weeks. Each group was treated for was used. The Shapiro-Wilk test was used to test the normal-
4 weeks by a physical therapist with a musculoskeletal K-E ity of every group variable, and the normal distribution was
orthopaedic manual therapy qualification and more than 10 confirmed. The Chi-squared test and independent t-test were
years of treatment and evaluation experience before the used to compare the general characteristics of the subjects,
experiment. Each examination was conducted by a physical and there was no significant difference as a result of using
therapist with more than 7 years of experience in muscu- the independent sample t-test to test the homogeneity of the
loskeletal treatment and evaluation who did not participate pre-dependent variables of each group. The data appeared to
in the experiment. be homogeneous. Paired t-tests were used to compare differ-
Pain was assessed using a numerical pain scale, which is ences before and after training within groups, while in-
a ‘pain graph’ with numbers from 0 to 10, with zero repre- dependent sample t-tests were used to compare the differ-
senting no pain at all, and 10 representing the highest possi- ences between groups. All statistical significance levels
ble pain intensity [8]. The test-retest reliability is 0.57-0.83 were set to p<0.05.
[9]. The Korean-language version of the NDI (K-NDI) was
used to measure the neck-pain intensity and disabilty [10]. It
152 Phys Ther Rehabil Sci 9(3)

Results Discussion

The general characteristics are shown in Table 1. In this study, cervical traction was applied to increase the
Participant characteristics across groups were relatively spacing of the vertebral body that can directly apply me-
similar. In both groups, the paired t-test revealed significant chanical pressure to the nerve when the nerve is moving in
differences in VAS, NDI, and endurance and there were sig- patients with chronic CR, while simultaneously improving
nificant differences between the two groups except for en- the nutrient supply and normal length and mobility of the
durance (p<0.05; Table 2). In ICST group, the paired t-test nervous system. The effect of applying a slider technique
revealed significant differences in all ROM, and in ICTT that does not cause stress due to stretching of the nerve dur-
group, the paired t-test revealed significant differences only ing nerve mobilization has been confirmed [13].
in extension, and there were significant differences between In the study by Savva and Giakas [14], pain was decreased
the two groups (p<0.05; Table 3). by simultaneously applying cervical manual traction and
nerve mobilization to patients with CR, reducing com-
pression of the cervical nerve root, and restoring nervous
system mobility, resulting in CR pain. It was able to confirm

Table 1. General characteristics of the subjects (N=30)

2
Variable ICST (n=15) ICTT (n=15) χ /t (p)
Sex 0.682 (0.682)
Male 3 (20.0) 5 (33.3)
Female 12 (80.0) 10 (66.7)
Age (y) 47.07 (2.99) 46.80 (3.80) 0.214 (0.832)
Height 161.53 (7.30) 165.60 (9.64) −1.302 (0.203)
Weight 61.73 (14.04) 59.93 (11.44) 0.385 (0.703)
Level 0.248 (0.884)
C4 3 (20.0) 2 (13.3)
C5 10 (66.7) 11 (73.4)
C6 2 (13.3) 2 (13.3)
Values are presented as n (%) or mean (SD).
ICST: intermittent cervical segment traction, ICTT: intermittent cervical total traction.

Table 2. Comparison of pain, NDI, and endurance between two groups (N=30)
Variable ICST (n=15) ICTT (n=15) t (p)
VAS (score)
Pre-test 7.00 (1.36) 6.73 (1.53) 0.503 (0.619)
Post-test 4.00 (1.36)* 5.80 (1.32)* −3.674 (0.001)
Change value −3.00 (1.77) −0.93 (1.28) −3.661 (0.001)
NDI (score)
Pre-test 28.20 (4.38) 27.60 (4.32) 0.378 (0.709)
Post-test 17.93 (4.33)* 24.00 (5.45)* −3.374 (0.002)
Change value −10.27 (5.39) −3.60 (3.58) −3.989 (<0.001)
Endurance (score)
Pre-test 8.33 (0.82) 8.38 (0.72) −0.603 (0.552)
Post-test 9.20 (1.17) 9.09 (1.27) 1.886 (0.070)
Change value 0.86 (0.82) 0.71 (0.89) 2.493 (0.019)
Values are presented as mean (SD).
ICST: intermittent cervical segment traction, ICTT: intermittent cervical total traction, VAS: visual analog scale, NDI: neck disability index.
*Statistical difference within group (p<0.05).
Yun, et al: Nerve mobilization with intermittent cervical segment traction 153

Table 3. Comparison of range of motion between two groups (N=30)

Range of motion ICST (n=15) ICTT (n=15) t (p)
Flex (score)
Pre-test 43.47 (4.29) 44.38 (6.35) −0.603 (0.552)
Post-test 50.22 (3.67)* 47.65 (3.81)* 1.886 (0.070)
Change value 6.75 (4.33) 3.27 (3.95) 2.493 (0.019)
EXT (score)
Pre-test 56.01 (3.21) 54.58 (3.13) 1.239 (0.226)
Post-test 65.80 (3.34)* 60.43 (5.89)* 3.070 (0.005)
Change value 9.79 (3.22) 5.85 (4.80) 2.637 (0.013)
Rt. SB (score)
Pre-test 36.55 (2.68) 35.29 (2.66) 1.291 (0.226)
Post-test 40.47 (2.88)* 36.41 (2.35)* 4.336 (<0.001)
Change value 4.02 (3.10) 1.12 (1.29) 3.347 (0.003)
Lt. SB (score)
Pre-test 31.62 (2.53) 31.43 (3.33) 0.0185 (0.854)
Post-test 38.12 (1.74)* 33.28 (2.71)* 5.826 (<0.001)
Change value 6.49 (3.11) 1.85 (2.71) 4.361 (<0.001)
Rt. Rot (score)
Pre-test 57.81 (3.93) 59.91 (5.40) −1.222 (0.232)
Post-test 64.15 (3.38)* 61.85 (4.67)* 1.544 (0.134)
Change value 6.38 (3.72) 1.94 (2.95) 3.595 (0.001)
Lt. Rot (score)
Pre-test 61.45 (1.73) 62.08 (1.55) −1.045 (0.305)
Post-test 66.67 (2.36)* 63.26 (1.51)* 4.700 (<0.001)
Change value 5.21 (3.12) 1.18 (1.60) 4.454 (<0.001)
Values are presented as mean (SD).
ICST: intermittent cervical segment traction, ICTT: intermittent cervical total traction, Flex: flexion, EXT: extention, Rt. SB: right side bending,
Lt. SB:left side bending, Rt. Rot: right rotation, Lt. Rot: left rotation.
*Statistical difference within group (p<0.05).

the analgesic effect obtained by preventing factors that ROM and decrease pain [16].
could exacerbate and stimulate the mechanoreceptors. In In this study, it was confirmed that the ICST group that in-
this study, subjects in the cervical segment traction with cluded the combination of the two treatment methods
nerve mobilization group showed greater reduction of pain showed a significant increase in cervical flexion and ex-
than the subjects in the total traction with nerve mobilization tension ROM, left and right side-bending, and left and right
group (p<0.05). rotation than the ICTT group (p<0.05). Nee and Butler [17]
In a previous study, Cleland, et al. [15] showed an im- suggested that nerve mobilization stimulates mechanor-
provement in the function disability index of patients with eceptors to increase nerve sliding and nerve root distance,
an intervention method combining cervical traction and thereby improving nerve mobility.
muscle strengthening exercises for CR. This is a study of a Compared to healthy individuals, in patients with neck
complex treatment method along with cervical traction. It pain, cervical spine control capabilities decrease due to
was confirmed that the disability index was significantly re- weakness of the longus colli and longus capitis, which are
duced in the group with nerve mobilization with cervical the deep muscles. Moreover, activity is limited due to pain
traction. In this study, there was a greater significant de- and exercise capacity decreases, resulting in loss of deep
crease in NDI scores in the ICST group than the ICTT group muscle control [18]. In this study, both groups showed an in-
(p<0.05). crease in deep flexor endurance, but there was no significant
Several previous studies reported that cervical joint ROM difference when comparing the changes between the two
was significantly decreased in people with cervical spine groups (p<0.05).
pain, and manual therapy was mainly used to increase joint This seems to be the result of recovery of the deep muscle
154 Phys Ther Rehabil Sci 9(3)

power control ability and cervical spine movement that was of neck pain and radicular symptoms. Am Fam Physician 2010;
previously lost or limited due to pain and decrease in the 81:33-40.
3. Thoomes EJ. Effectiveness of manual therapy for cervical radi-
amount of exercise rather than due to the increase in actual culopathy, a review. Chiropr Man Therap 2016;24:45.
muscle power increase. 4. Jellad A, Ben Salah Z, Boudokhane S, Migaou H, Bahri I, Rejeb
In this study, the joints with dysfunction of more than one N. The value of intermittent cervical traction in recent cervical
segment in cervical motion were selected based on this theo- radiculopathy. Ann Phys Rehabil Med 2009;52:638-52.
5. Shacklock M. Neural mobilization: a systematic review of
retical background.
randomized controlled trials with an analysis of therapeutic
It has been reported that general traction can increase efficacy. J Man Manip Ther 2008;16:23-4.
stress placed onto the posterior fiber of the ring fiber and 6. Neto T, Freitas SR, Marques M, Gomes L, Andrade R, Oliveira
cause fiber rupture if the traction load exceeds the optimal R. Effects of lower body quadrant neural mobilization in healthy
and low back pain populations: a systematic review and
amount. Conversely, segmental traction decreases the stress
meta-analysis. Musculoskelet Sci Pract 2017;27:14-22.
placed onto the posterior fiber of the ring fiber and decreases 7. Hassan F, Osama M, Ghafoor A, Yaqoob MF. Effects of oscil-
the pressure placed on the disc. Therefore, it is recom- latory mobilization as compared to sustained stretch mobi-
mended to carefully apply general traction to patients with lization in the management of cervical radiculopathy: a random-
ized controlled trial. J Back Musculoskelet Rehabil 2020;33:
intervertebral pathology [19].
153-8.
As the results of this study suggested, the ICST group 8. McCaffery M, Pasero C. Teaching patients to use a numerical
showed more improvement than the ICTT group in pain, pain-rating scale. Am J Nurs 1999;99:22.
NDI scores and ROM. Moreover, our findings show that 9. Herr KA, Spratt K, Mobily PR, Richardson G. Pain intensity as-
sessment in older adults: use of experimental pain to compare
ICST could be used as a new strategy for manual therapy in
psychometric properties and usability of selected pain scales
patients with CR. with younger adults. Clin J Pain 2004;20:207-19.
In this study, it was found that ICST was effective for 10. Song KJ, Choi BW, Choi BR, Seo GB. Cross-cultural adaptation
pain, neck disability, ROM and CCFT in patients with CR. and validation of the Korean version of the neck disability index.
However, due to the short duration of the experiment, there Spine 2010;35:E1045-9.
11. Audette I, Dumas JP, Côté JN, De Serres SJ. Validity and be-
were limitations in generalizing the results of the study. tween-day reliability of the cervical range of motion (CROM)
Moreover, the patient’s age range was narrow and the num- device. J Orthop Sports Phys Ther 2010;40:318-23.
ber of participants was small. In addition, objective meas- 12. Falla DL, Campbell CD, Fagan AE, Thompson DC, Jull GA.
ures were not made to determine whether it is applicable to Relationship between cranio-cervical flexion range of motion
and pressure change during the cranio-cervical flexion test. Man
patients with acute and bilateral CR, muscle weakness, dys- Ther 2003;8:92-6.
esthesia, and radiation pain of the upper extremity. 13. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A,
Objective measurement of the instability segment of the cer- Allison S. Reliability and diagnostic accuracy of the clinical ex-
vical spine was not possible, and muscle power for the deep amination and patient self-report measures for cervical
radiculopathy. Spine 2003;28:52-62.
flexors was not measured. In subsequent studies, continuous
14. Savva C, Giakas G. The effect of cervical traction combined with
research should be done by supplementing the above neural mobilization on pain and disability in cervical
limitations. radiculopathy. A case report. Man Ther 2013;18:443-6.
15. Cleland JA, Whitman JM, Fritz JM, Palmer JA. Manual physical
therapy, cervical traction, and strengthening exercises in patients
Conflict of Interest with cervical radiculopathy: a case series. J Orthop Sports Phys
Ther 2005;35:802-11.
The authors declared no potential conflicts of interest 16. Boyles R, Toy P, Mellon J Jr, Hayes M, Hammer B. Effectiveness
with respect to the authorship and/or publication of this of manual physical therapy in the treatment of cervical radicul-
opathy: a systematic review. J Man Manip Ther 2011;19:135-42.
article.
17. Nee RJ, Butler D. Management of peripheral neuropathic pain:
integrating neurobiology, neurodynamics, and clinical evidence.
References Phys Ther Sport 2006;7:36-49.
18. Jull GA, O’Leary SP, Falla DL. Clinical assessment of the deep
1. Larsson B, Søgaard K, Rosendal L. Work related neck-shoulder cervical flexor muscles: the craniocervical flexion test. J
pain: a review on magnitude, risk factors, biochemical character- Manipulative Physiol Ther 2008;31:525-33.
istics, clinical picture and preventive interventions. Best Pract 19. Park WM, Kim K, Kim YH. Biomechanical analysis of two-step
Res Clin Rheumatol 2007;21:447-63. traction therapy in the lumbar spine. Man Ther 2014;19:527-33.
2. Eubanks JD. Cervical radiculopathy: nonoperative management