European Spine Journal

, Volume 18, Issue 3, pp 382–391 | Cite as

Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise

  • Nicole H. RaneyEmail author
  • Evan J. Petersen
  • Tracy A. Smith
  • James E. Cowan
  • Daniel G. Rendeiro
  • Gail D. Deyle
  • John D. Childs
Original Article


The objective of the study was to develop a clinical prediction rule (CPR) to identify patients with neck pain likely to improve with cervical traction. The study design included prospective cohort of patients with neck pain referred to physical therapy. Development of a CPR will assist clinicians in classifying patients with neck pain likely to benefit from cervical traction. Eighty patients with neck pain received a standardized examination and then completed six sessions of intermittent cervical traction and cervical strengthening exercises twice weekly for 3 weeks. Patient outcome was classified at the end of treatment, based on perceived recovery according to the global rating of change. Patients who achieved a change ≥+6 (“A great deal better” or “A very great deal better”) were classified as having a successful outcome. Univariate analyses (t tests and chi-square) were conducted on historical and physical examination items to determine potential predictors of successful outcome. Variables with a significance level of P ≤ 0.15 were retained as potential prediction variables. Sensitivity, specificity and positive and negative likelihood ratios (LRs) were then calculated for all variables with a significant relationship with the reference criterion of successful outcome. Potential predictor variables were entered into a step-wise logistic regression model to determine the most accurate set of clinical examination items for prediction of treatment success. Sixty-eight patients (38 female) were included in data analysis of which 30 had a successful outcome. A CPR with five variables was identified: (1) patient reported peripheralization with lower cervical spine (C4–7) mobility testing; (2) positive shoulder abduction test; (3) age ≥55; (4) positive upper limb tension test A; and (5) positive neck distraction test. Having at least three out of five predictors present resulted in a +LR equal to 4.81 (95% CI = 2.17–11.4), increasing the likelihood of success with cervical traction from 44 to 79.2%. If at least four out of five variables were present, the +LR was equal to 23.1 (2.5–227.9), increasing the post-test probability of having improvement with cervical traction to 94.8%. This preliminary CPR provides the ability to a priori identify patients with neck pain likely to experience a dramatic response with cervical traction and exercise. Before the rule can be implemented in routine clinical practice, future studies are necessary to validate the rule. The CPR developed in this study may improve clinical decision-making by assisting clinicians in identifying patients with neck pain likely to benefit from cervical traction and exercise.


Neck pain Classification Cervical traction 


Conflict of interest statement

We affirm that we have no financial affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript, except as disclosed in an attachment and cited in the manuscript. Any other conflict of interest (i.e., personal associations or involvement as a director, officer, or expert witness) is also disclosed in an attachment. The Saunders Group, Inc. loaned the investigative team use of a 3D ActiveTrac table for this study. The company played no role in the design, conduct, or reporting of the study or in the decision to submit the manuscript for publication.


  1. 1.
    Abdulwahab SS, Sabbahi M (2000) Neck retractions, cervical root decompression, and radicular pain. J Orthop Sports Phys Ther 30:4–9 discussion 10–12PubMedGoogle Scholar
  2. 2.
    Bolton JE (2004) Sensitivity and specificity of outcome measures in patients with neck pain: detecting clinically significant improvement. Spine 29:2410–2417. doi: 10.1097/01.brs.0000143080.74061.25 discussion 2418PubMedCrossRefGoogle Scholar
  3. 3.
    Borghouts J, Janssen H, Koes B, Muris J, Metsemakers J, Bouter L (1999) The management of chronic neck pain in general practice. A retrospective study. Scand J Prim Health Care 17:215–220. doi: 10.1080/028134399750002430 PubMedCrossRefGoogle Scholar
  4. 4.
    Bovim G, Schrader H, Sand T (1994) Neck pain in the general population. Spine 19:1307–1309PubMedCrossRefGoogle Scholar
  5. 5.
    Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE (2006) Identifying subgroups of patients with acute/subacute “nonspecific” low back pain: results of a randomized clinical trial. Spine 31:623–631. doi: 10.1097/01.brs.0000202807.72292.a8 PubMedCrossRefGoogle Scholar
  6. 6.
    Browder DA, Erhard RE, Piva SR (2004) Intermittent cervical traction and thoracic manipulation for management of mild cervical compressive myelopathy attributed to cervical herniated disc: a case series. J Orthop Sports Phys Ther 34:701–712PubMedGoogle Scholar
  7. 7.
    Childs JD, Cleland JA (2006) Development and application of clinical prediction rules to improve decision making in physical therapist practice. Phys Ther 86:122–131PubMedGoogle Scholar
  8. 8.
    Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A (2004) A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 141:920–928PubMedGoogle Scholar
  9. 9.
    Cleland JA, Childs JD, Fritz JM, Whitman JM, Eberhart SL (2007) Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Phys Ther 87:9–23. doi: 10.2522/ptj.20060155 PubMedCrossRefGoogle Scholar
  10. 10.
    Cleland JA, Fritz JM, Whitman JM, Heath R (2007) Predictors of short-term outcome in people with a clinical diagnosis of cervical radiculopathy. Phys Ther 87:1619–1632. doi: 10.2522/ptj.20060155 PubMedCrossRefGoogle Scholar
  11. 11.
    Constantoyannis C, Konstantinou D, Kourtopoulos H, Papadakis N (2002) Intermittent cervical traction for cervical radiculopathy caused by large-volume herniated disks. J Manip Physiol Ther 25:188–192. doi: 10.1067/mmt.2001.123356 CrossRefGoogle Scholar
  12. 12.
    Cote P, Cassidy JD, Carroll L (2000) The factors associated with neck pain and its related disability in the Saskatchewan population. Spine 25:1109–1117. doi: 10.1097/00007632-200005010-00012 PubMedCrossRefGoogle Scholar
  13. 13.
    Cote P, Cassidy JD, Carroll L (2003) The epidemiology of neck pain: what we have learned from our population-based studies. J Can Chiropract Assoc 47:284–290Google Scholar
  14. 14.
    Cote P, Cassidy JD, Carroll LJ, Kristman V (2004) The annual incidence and course of neck pain in the general population: a population-based cohort study. Pain 112:267–273. doi: 10.1016/j.pain.2004.09.004 PubMedCrossRefGoogle Scholar
  15. 15.
    Crue BL, Todd EM (1965) The importance of flexion in cervical halter traction. Bull Los Angel Neuro Soc 30:95–98PubMedGoogle Scholar
  16. 16.
    Deyo RA, Centor RM (1986) Assessing the responsiveness of functional scales to clinical change: an analogy to diagnostic test performance. J Chronic Dis 39:897–906. doi: 10.1016/0021-9681(86)90038-X PubMedCrossRefGoogle Scholar
  17. 17.
    Elvey RL (1994) The investigation of arm pain: signs of adverse responses to the physical examination of the brachial plexus and related tissues. In: Boyling JD, Palastanga N (eds) Grieve’s modern manual therapy, 2nd edn. Churchill Livingstone, New YorkGoogle Scholar
  18. 18.
    Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole RM (2001) Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 94:149–158. doi: 10.1016/S0304-3959(01)00349-9 PubMedCrossRefGoogle Scholar
  19. 19.
    Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S (2002) A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 27:2835–2843. doi: 10.1097/00007632-200212150-00021 PubMedCrossRefGoogle Scholar
  20. 20.
    Freedman D (1983) A note on screening regression equations. Am Stat 37:152–155. doi: 10.2307/2685877 CrossRefGoogle Scholar
  21. 21.
    Fritz JM, Brennan GP (2007) Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther 87:513–524. doi: 10.2522/ptj.20060101 PubMedCrossRefGoogle Scholar
  22. 22.
    Fritz JM, Delitto A, Erhard RE (2003) Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine 28:1363–1371. doi: 10.1097/00007632-200307010-00003 discussion 1372PubMedCrossRefGoogle Scholar
  23. 23.
    George SZ, Fritz JM, Erhard RE (2001) A comparison of fear-avoidance beliefs in patients with lumbar spine pain and cervical spine pain. Spine 26:2139–2145. doi: 10.1097/00007632-200110010-00019 PubMedCrossRefGoogle Scholar
  24. 24.
    Goldie I, Landquist A (1970) Evaluation of the effects of different forms of physiotherapy in cervical pain. Scand J Rehabil Med 2:117–121PubMedGoogle Scholar
  25. 25.
    Graham N, Gross AR, Goldsmith C (2006) Mechanical traction for mechanical neck disorders: a systematic review. J Rehabil Med 38:145–152. doi: 10.1080/16501970600583029 PubMedCrossRefGoogle Scholar
  26. 26.
    Harris KD, Heer DM, Roy TC, Santos DM, Whitman JM, Wainner RS (2005) Reliability of a measurement of neck flexor muscle endurance. Phys Ther 85:1349–1355PubMedGoogle Scholar
  27. 27.
    Harris PR (1977) Cervical traction. Review of literature and treatment guidelines. Phys Ther 57:910–914PubMedGoogle Scholar
  28. 28.
    Hicks GE, Fritz JM, Delitto A, McGill SM (2005) Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil 86:1753–1762. doi: 10.1016/j.apmr.2005.03.033 PubMedCrossRefGoogle Scholar
  29. 29.
    Hoving JL, Gross AR, Gasner D, Kay T, Kennedy C, Hondras MA, Haines T, Bouter LM (2001) A critical appraisal of review articles on the effectiveness of conservative treatment for neck pain. Spine 26:196–205. doi: 10.1097/00007632-200101150-00015 PubMedCrossRefGoogle Scholar
  30. 30.
    Hoving JL, Koes BW, de Vet HC, van der Windt DA, Assendelft WJ, van Mameren H, Deville WL, Pool JJ, Scholten RJ, Bouter LM (2002) Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. A randomized, controlled trial. Ann Intern Med 136:713–722PubMedGoogle Scholar
  31. 31.
    Hurst H, Bolton J (2004) Assessing the clinical significance of change scores recorded on subjective outcome measures. J Manip Physiol Ther 27:26–35. doi: 10.1016/j.jmpt.2003.11.003 CrossRefGoogle Scholar
  32. 32.
    Jacob T, Baras M, Zeev A, Epstein L (2001) Low back pain: reliability of a set of pain measurement tools. Arch Phys Med Rehabil 82:735–742. doi: 10.1053/apmr.2001.22623 PubMedCrossRefGoogle Scholar
  33. 33.
    Jaeschke R, Guyatt GH, Sackett DL (1994) Users’ guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The evidence-based medicine working group. JAMA 271:703–707. doi: 10.1001/jama.271.9.703 PubMedCrossRefGoogle Scholar
  34. 34.
    Jaeschke R, Singer J, Guyatt GH (1989) Measurement of health status. Ascertaining the minimal clinically important difference. Control Clin Trials 10:407–415. doi: 10.1016/0197-2456(89)90005-6 PubMedCrossRefGoogle Scholar
  35. 35.
    Jensen MP, Turner JA, Romano JM (1994) What is the maximum number of levels needed in pain intensity measurement? Pain 58:387–392. doi: 10.1016/0304-3959(94)90133-3 PubMedCrossRefGoogle Scholar
  36. 36.
    Joghataei MT, Arab AM, Khaksar H (2004) The effect of cervical traction combined with conventional therapy on grip strength on patients with cervical radiculopathy. Clin Rehabil 18:879–887. doi: 10.1191/0269215504cr828oa PubMedCrossRefGoogle Scholar
  37. 37.
    Jull G, Kristjansson E, Dall’Alba P (2004) Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients. Man Ther 9:89–94. doi: 10.1016/S1356-689X(03)00086-9 PubMedCrossRefGoogle Scholar
  38. 38.
    Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C (2002) A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 27:1835–1843. doi: 10.1097/00007632-200209010-00004 discussion 1843PubMedCrossRefGoogle Scholar
  39. 39.
    Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G (2005) Exercises for mechanical neck disorders. Cochrane Database Syst Rev CD004250Google Scholar
  40. 40.
    Kendall FME, Provance PG (1993) Muscles: testing and function. Williams and Wilkins, BaltimoreGoogle Scholar
  41. 41.
    Klaber HG, Moffett JA, Hughes GI, Griffeths P (1990) An investigation of the effects of cervical traction. Part 1: clinical effectiveness. Clin Rehabil 4:205–211. doi: 10.1177/026921559000400304 CrossRefGoogle Scholar
  42. 42.
    Koes BW, Bouter LM, van Mameren H, Essers AH, Verstegen GM, Hofhuizen DM, Houben JP, Knipschild PG (1992) The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific back and neck complaints. A randomized clinical trial. Spine 17:28–35. doi: 10.1097/00007632-199201000-00005 PubMedCrossRefGoogle Scholar
  43. 43.
    Koes BW, Bouter LM, van Mameren H, Essers AH, Verstegen GM, Hofhuizen DM, Houben JP, Knipschild PG (1992) Randomised clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: results of one year follow up. BMJ 304:601–605PubMedCrossRefGoogle Scholar
  44. 44.
    Maitland G (2001) Vertebral manipulation. Butterworth & Heinemann, OxfordGoogle Scholar
  45. 45.
    Maitland G, Hengeveld E, Banks K (2000) Maintland’s vertebral manipulation. Butterworth-Heinemann, OxfordGoogle Scholar
  46. 46.
    Manipulations Inc. (2000) Orthopaedic manual physical therapy management of the cervical-thoracic spine and ribcage. Manipulations Inc., San AntonioGoogle Scholar
  47. 47.
    McKenzie R (1990) Cervical and thoracic spine: mechanical diagnosis and therapy. Orthopaedic Physical Therapy Products, MinneapolisGoogle Scholar
  48. 48.
    Moeti P, Marchetti G (2001) Clinical outcome from mechanical intermittent cervical traction for the treatment of cervical radiculopathy: a case series. J Orthop Sports Phys Ther 31:207–213PubMedGoogle Scholar
  49. 49.
    Palmer KT, Walker-Bone K, Griffin MJ, Syddall H, Pannett B, Coggon D, Cooper C (2001) Prevalence and occupational associations of neck pain in the British population. Scand J Work Environ Health 27:49–56PubMedGoogle Scholar
  50. 50.
    Peake N, Harte A (2005) The effectiveness of cervical traction. Phys Ther Rev 10:217–229. doi: 10.1179/108331905X68547 CrossRefGoogle Scholar
  51. 51.
    Saal JS, Saal JA, Yurth EF (1996) Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine 21:1877–1883. doi: 10.1097/00007632-199608150-00008 PubMedCrossRefGoogle Scholar
  52. 52.
    Sarig-Bahat H (2003) Evidence for exercise therapy in mechanical neck disorders. Man Ther 8:10–20. doi: 10.1054/math.2002.0480 PubMedCrossRefGoogle Scholar
  53. 53.
    Silverman JL, Rodriquez AA, Agre JC (1991) Quantitative cervical flexor strength in healthy subjects and in subjects with mechanical neck pain. Arch Phys Med Rehabil 72:679–681PubMedGoogle Scholar
  54. 54.
    Spurling RGSW (1944) Lateral rupture of the cervical intervertebral discs: a common cause of shoulder and arm pain. Surg Gynecol Obstet 78:350–358Google Scholar
  55. 55.
    van der Heijden GJ, Beurskens AJ, Koes BW, Assendelft WJ, de Vet HC, Bouter LM (1995) The efficacy of traction for back and neck pain: a systematic, blinded review of randomized clinical trial methods. Phys Ther 75:93–104PubMedGoogle Scholar
  56. 56.
    Vernon H, Mior S (1991) The neck disability index: a study of reliability and validity. J Manip Physiol Ther 14:409–415Google Scholar
  57. 57.
    Viikari-Juntura E (1987) Interexaminer reliability of observations in physical examinations of the neck. Phys Ther 67:1526–1532PubMedGoogle Scholar
  58. 58.
    Waddell G, Newton M, Henderson I, Somerville D, Main CJ (1993) A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 52:157–168. doi: 10.1016/0304-3959(93)90127-B PubMedCrossRefGoogle Scholar
  59. 59.
    Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S (2003) Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine 28:52–62. doi: 10.1097/00007632-200301010-00014 PubMedCrossRefGoogle Scholar
  60. 60.
    Wainner RS, Gill H (2000) Diagnosis and nonoperative management of cervical radiculopathy. J Orthop Sports Phys Ther 30:728–744PubMedGoogle Scholar
  61. 61.
    Werneke M, Hart DL, Cook D (1999) A descriptive study of the centralization phenomenon. A prospective analysis. Spine 24:676–683. doi: 10.1097/00007632-199904010-00012 PubMedCrossRefGoogle Scholar
  62. 62.
    Ylinen J, Hakkinen A, Nykanen M, Kautiainen H, Takala EP (2007) Neck muscle training in the treatment of chronic neck pain: a three-year follow-up study. Eura Medicophys 43:161–169PubMedGoogle Scholar
  63. 63.
    Ylinen J, Takala EP, Nykanen M, Hakkinen A, Malkia E, Pohjolainen T, Karppi SL, Kautiainen H, Airaksinen O (2003) Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial. JAMA 289:2509–2516. doi: 10.1001/jama.289.19.2509 PubMedCrossRefGoogle Scholar
  64. 64.
    Zylbergold RS, Piper MC (1985) Cervical spine disorders. A comparison of three types of traction. Spine 10:867–871. doi: 10.1097/00007632-198512000-00001 PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Nicole H. Raney
    • 1
    Email author
  • Evan J. Petersen
    • 2
  • Tracy A. Smith
    • 3
  • James E. Cowan
    • 4
  • Daniel G. Rendeiro
    • 5
  • Gail D. Deyle
    • 6
  • John D. Childs
    • 7
  1. 1.Department of Physical TherapyWilford Hall Medical CenterSan AntonioUSA
  2. 2.Department of Physical TherapyBrooke Army Medical CenterSan AntonioUSA
  3. 3.Army Physical Fitness Research InstituteU.S. Sergeants Major AcademyEI PasoUSA
  4. 4.Physical Therapy, BUD/SNaval Special Warfare CenterCoronadoUSA
  5. 5.Physical Therapy ServiceCarl R. Darnall Army Medical CenterFort HoodUSA
  6. 6.U.S. Army-Baylor University Post Professional Doctoral Fellowship in Orthopaedic Manual Physical TherapyBrooke Army Medical CenterFort Sam HoustonUSA
  7. 7.U.S. Army-Baylor UniversityFort Sam HoustonUSA

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