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

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Abstract

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.

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References

  1. Abdulwahab SS, Sabbahi M (2000) Neck retractions, cervical root decompression, and radicular pain. J Orthop Sports Phys Ther 30:4–9 discussion 10–12

    PubMed  CAS  Google Scholar 

  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 2418

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  4. Bovim G, Schrader H, Sand T (1994) Neck pain in the general population. Spine 19:1307–1309

    Article  PubMed  CAS  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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 34:701–712

    PubMed  Google Scholar 

  7. Childs JD, Cleland JA (2006) Development and application of clinical prediction rules to improve decision making in physical therapist practice. Phys Ther 86:122–131

    PubMed  Google Scholar 

  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 141:920–928

    PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  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 47:284–290

    Google Scholar 

  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

    Article  PubMed  Google Scholar 

  15. Crue BL, Todd EM (1965) The importance of flexion in cervical halter traction. Bull Los Angel Neuro Soc 30:95–98

    PubMed  CAS  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  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 York

  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

    Article  PubMed  CAS  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  20. Freedman D (1983) A note on screening regression equations. Am Stat 37:152–155. doi:10.2307/2685877

    Article  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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 1372

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  24. Goldie I, Landquist A (1970) Evaluation of the effects of different forms of physiotherapy in cervical pain. Scand J Rehabil Med 2:117–121

    PubMed  CAS  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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 85:1349–1355

    PubMed  Google Scholar 

  27. Harris PR (1977) Cervical traction. Review of literature and treatment guidelines. Phys Ther 57:910–914

    PubMed  CAS  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  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 136:713–722

    PubMed  Google Scholar 

  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

    Article  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  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 1843

    Article  PubMed  Google Scholar 

  39. Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G (2005) Exercises for mechanical neck disorders. Cochrane Database Syst Rev CD004250

  40. Kendall FME, Provance PG (1993) Muscles: testing and function. Williams and Wilkins, Baltimore

    Google Scholar 

  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

    Article  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  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 304:601–605

    Article  PubMed  CAS  Google Scholar 

  44. Maitland G (2001) Vertebral manipulation. Butterworth & Heinemann, Oxford

    Google Scholar 

  45. Maitland G, Hengeveld E, Banks K (2000) Maintland’s vertebral manipulation. Butterworth-Heinemann, Oxford

    Google Scholar 

  46. Manipulations Inc. (2000) Orthopaedic manual physical therapy management of the cervical-thoracic spine and ribcage. Manipulations Inc., San Antonio

    Google Scholar 

  47. McKenzie R (1990) Cervical and thoracic spine: mechanical diagnosis and therapy. Orthopaedic Physical Therapy Products, Minneapolis

    Google Scholar 

  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 31:207–213

    PubMed  CAS  Google Scholar 

  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 27:49–56

    PubMed  CAS  Google Scholar 

  50. Peake N, Harte A (2005) The effectiveness of cervical traction. Phys Ther Rev 10:217–229. doi:10.1179/108331905X68547

    Article  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  52. Sarig-Bahat H (2003) Evidence for exercise therapy in mechanical neck disorders. Man Ther 8:10–20. doi:10.1054/math.2002.0480

    Article  PubMed  CAS  Google Scholar 

  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 72:679–681

    PubMed  CAS  Google Scholar 

  54. Spurling RGSW (1944) Lateral rupture of the cervical intervertebral discs: a common cause of shoulder and arm pain. Surg Gynecol Obstet 78:350–358

    Google Scholar 

  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 75:93–104

    PubMed  Google Scholar 

  56. Vernon H, Mior S (1991) The neck disability index: a study of reliability and validity. J Manip Physiol Ther 14:409–415

    CAS  Google Scholar 

  57. Viikari-Juntura E (1987) Interexaminer reliability of observations in physical examinations of the neck. Phys Ther 67:1526–1532

    PubMed  CAS  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  60. Wainner RS, Gill H (2000) Diagnosis and nonoperative management of cervical radiculopathy. J Orthop Sports Phys Ther 30:728–744

    PubMed  CAS  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

  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 43:161–169

    PubMed  CAS  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  CAS  Google Scholar 

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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.

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Correspondence to Nicole H. Raney.

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This study was approved by the Institutional Review Board at Brooke Army Medical Center, Fort Sam Houston, Texas. The opinions and assertions contained herein are the private views of the authors and are not to be construed as official as reflecting the views of the Department of the Army, Department of the Air Force, Department of the Navy, or the Department of Defense.

Appendix A

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Table 5

Table 5 Operational definitions for special tests used in the study

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Raney, N.H., Petersen, E.J., Smith, T.A. et al. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J 18, 382–391 (2009). https://doi.org/10.1007/s00586-008-0859-7

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