The Effect of Traction on Pain, Neurological Signs, and Function in Patients with Cervical Radiculopathy

Andrzej Slugocki

May 3, 2005

University of Medicine and Dentistry of New Jersey

Critical Literature Review and Scientific Writing

IDST 6400

Dr. Craig Scanlan

Cervical radiculopathy is defined as dysfunction of a cervical nerve root resulting in symptoms of pain in the neck and upper extremity (radicular pattern), as well as neurological signs such as dermatomal paraesthesia, myotomal weakness, and diminished deep tendon reflexes. It is usually caused by herniated disks or spondylotic changes (Ellenberg, Honet & Treanor, 1994). It most frequently afflicts adults in their fourth and fifth decades of life (Wainner & Gill, 2000). The most commonly affected nerve roots are C7 and C6 (Radhakrishnan, Litchy, O’Fallon & Kurland, 1994).

Cervical radiculopathy can be successfully treated conservatively (Saal, Saal & Yurth, 1996)). Saal et al state that their conservative outcome matched that in several surgical outcome studies. Several studies also point to no difference in the long term between surgical and conservative outcomes (Persson, Carlsson & Carlsson, 1997; Persson, Moritz, Brandt & Carlsson, 1997; Persson & Moritz, 1998). Because conservative treatment is often prescribed for this diagnosis, physical therapists are frequently utilized as practitioners of choice for such treatment. Thus the burden of proving the effectiveness of conservative interventions is upon them, as they encounter patients with cervical radiculopathy in their daily practice. This burden is even made greater by the fact that cervical radiculopathy frequently results in disablement from work, so pressure to return a patient to the productive status is exerted by the employers, worker’s compensation insurance administrators, and also patients’ expectations as well.

Traction is commonly employed in physical therapy to treat cervical radiculopathy. It is believed that it can reduce disk herniations, decompress the nerve root, or stretch ligaments and dural sheaths, thus reducing symptomatology (Moeti & Marchetti, 2001). Conclusive scientific evidence proving its efficacy is lacking, however. In this day and age of continual scrutiny of utilization and HMO's aiming to save money by denying treatments, it is necessary to seek the best available evidence to support interventions used. An additional impetus to search for such evidence is given by the evident success of conservative treatment in obviating surgery (Saal et al., 1996).

Reviews pertaining to traction for neck pain do exist, but they conclude that, based on the available evidence, it can be neither recommended nor declared ineffective (van der Heijden et al., 1995). As stated before, no evidence-based reviews exist as to the specific use of traction for cervical radiculopathy. In view of this fact, and in view of the urgent need to seek the best available evidence to support physiotherapeutic interventions, this review of effectiveness of traction has been undertaken. Since generally the field of physical therapy interventions lacks conclusive evidence of randomized controlled trials, one can expect to find low to mid-level evidence establishing observations about effectiveness of traction for cervical radiculopathy. The evolving trend is to use evidence derived from case series and cohort studies to design RCT studies.

Since cervical radiculopathy causes pain and neurological consequences, which in turn lead to dysfunction and disablement; pain, weakness, sensory changes and reflexes as well as function must be considered when researching efficacy of traction for cervical radiculopathy. These factors are also chief reasons for referral for physical therapy, and the referring physicians judge therapeutic effectiveness by improvement in those areas. Specifically this review is to answer the following clinical question: In adults with cervical radiculopathy, is cervical traction effective against pain and neurological signs such as numbness, weakness, or diminished deep tendon reflexes. Also is it effective in improving functional outcomes in this population.

To find relevant original research literature, the CINAHL and PUBMED Medline unfiltered databases were searched. Also a prominent filtered database for physical therapists, Hooked on Evidence (available to APTA members) was searched. To find relevant secondary research, the following databases were searched via OVID: Cochrane Database of Systematic Reviews, ACP Journal Club, Database of Abstracts of Reviews of Effectiveness, and Central Controlled Trial Register. Bibliographies and reference lists of all articles used for background information as well as of the articles to be reviewed were also screened for relevant references.

The following keywords were used to search the secondary databases listed above (also see Appendix 1 for search history): traction, cervical pain or neck pain, radiculopathy, herniated nucleus pulposus, neurological signs, nerve compression or pinched nerve, weakness, numbness or paraesthesia or anesthesia, physical therapy or physiotherapy. The following keywords were used to search the CINAHL: radiculopathy, neck pain, pain, cervical radiculopathy, cervical traction, traction, physical therapy. The same search as for the secondary databases was rerun for OVID Medline 1996-present turning up no new articles. Pubmed was searched using the keywords: cervical radiculopathy and traction. The keywords cervical radiculopathy and traction were also used to search the Hooked on Evidence filtered database.

The majority of articles were case series. Others were cohort studies. There was only one probability-tested randomized controlled trial (RCT) with a small sample. This reflects the state of evidence regarding many physical therapy interventions including traction, and therefore points to the need for RCT’s built on lesser evidence (grades 5 through 2). The one RCT that was extracted is a harbinger of future level 1 studies on traction.

In order to be included in the review, the study had to be an original research paper of any design and level of evidence concerned with the effect of traction in adult patients with cervical radiculopathy with regard to all or any of the following outcomes: change in pain, neurological signs (dermatomal numbness, myotomal weakness, deep tendon reflexes), and functional status. Since majority of clinical research about traction does not isolate it as a sole intervention, articles that made traction the main and consistent intervention in all subjects were accepted for the purpose of this review. For example, studies were not excluded if patients were also given soft cervical collar for home use or moist heat prior to traction. Also studies identifying patients with cervical radiculopathy as a subgroup of patients receiving traction were accepted. Studies were excluded if traction was used inconsistently or only in some patients, and if the outcome studied differed from the outcomes specified in the above inclusion criteria. Also if patients studied were not explicitly described as having a firmly established diagnosis of cervical radiculopathy, such studies were also excluded. Since articles older than 1982 were difficult to obtain (the interlibrary loan service failed to deliver them), they were also excluded.

16 studies were originally selected for screening. 9 met the inclusion criteria, and 7 were excluded. Among the rejected articles, 4 used traction as part of physical therapy, but inconsistently (at the discretion of the physical therapist) thus leaving some subjects in the physical therapy group not having received traction (Persson et al., 1997; Persson & Lilja, 2001; Persson & Moritz, 1998; Persson, Moritz, et al., 1997). Two research articles studied patients without cervical radiculopathy (Baker & Marcoux, 1999; Hiraoka & Nagata, 1998). Finally, one article presented the effect of traction on cervical muscle relaxation, which is not an outcome with which this review is concerned (Wong, Lee, Chang & Tang , 1997).

The articles to be reviewed comprise 1 randomized controlled trial, 1 prospective cohort study, 1 repeated measures within subject design, 4 case series, and 2 case reports. The chosen articles will be discussed in an ascending order of evidence level. There will be presented specific findings and evaluation of a study’s quality especially as to validity of the findings. A grade of evidence will be assigned. Validity-based weight of the study in answering the main clinical question asked in this review will also be presented.

Corso and Brosky (1999) present a case of 42-year-old woman with a left C7 radiculopathy present for 9 months. The initial presentation included constant radicular pain rated 6-7/10 and numbness in digits 2-4. The C7 myotome weakness showed in the left wrist flex 4/5 and triceps 4-/5. A sensory deficit was present in the left third digit (light touch and sharp/dull incorrectly identified 50% of time). The left triceps reflex was diminished to 1+. The intervention consisted of in-clinic mechanical cervical traction (12 minutes;20 lb.; 30 sec. On/ 10 sec. Off; in supine) and home cervical traction (2-3 x/a day for 12 minutes at 16 lb.) Additional treatments (confounding factors) included electric stimulation, ultrasound; ROM, postural and strengthening exercises. Traction appears, however, to be the only consistent and most time intensive treatment applied.

At the conclusion of the treatment at six weeks, the patient's pain decreased to 4/10. The patient reported no numbness in the upper extremity and sensory testing was normal. The C7 myotome retest indicated improvement to "4/5 for the left triceps and 4+/5 for the left wrist flexors." The left triceps reflex remained at 1+. In terms of function, the patient increased her work hours from 4 to 6 hours a day.

This case report contains evidence at Oxford level 5 for effectiveness of traction in improving cervical radiculopathy related pain, sensory and myotomal deficits and function, but not reflex status, complemented with other physiotherapeutic treatments. The findings are encouraging for the role of traction in managing cervical radiculopathy, but as level 5 evidence with poor validity, this case report does not prove causality. Moreover, the use of other treatments though considered accessory provides for confounding factors, which may be responsible for a degree of improvement. Considering the condition’s duration of 9 months prior to the treatment, however, it seems that the 6 weeks of treatment are responsible for the change.

Piva, Erhard, and Al_Hugail (2000) report on a 51-year-old woman with a C7 cervical radiculopathy present for 5 weeks. The initial presentation included radicular pain rated 10/10. The C7 myotome weakness showed in the left wrist flexors and triceps at 4/5. Moderate self-reported functional disability showed in the Neck Disability Index score of 42%. The intervention consisted of intermittent mechanical supine traction and spinal manipulations (a confounding factor). However, only cervical traction was used consistently during all eight visits over a period of 6 weeks. No specific parameters are provided. At the conclusion of the treatment, pain decreased to 0/10. A C7 myotome retest indicated improvement to "4+/5 for the left triceps and 5/5 for the left wrist flexors." In terms of function the patient’s NDI score improved to 0%.

This case report indicates effectiveness in resolving cervical radiculopathy related pain, dysfunction and myotomal deficits (level of evidence 5) for consistent clinical use of traction with spinal manipulation (confounding factor). The findings are encouraging for the role of traction in managing cervical radiculopathy, but as level 5 evidence with poor validity, this case report does not prove causality. Moreover, the use of other treatments provides for confounding factors, which may be responsible for a degree of improvement.

Constantoyannis, Konstantinou, Kourtopoulos, and Papadakis (2002) present a case series of 4 adults (31-41 y/o; two males, two females) with C6 and C7 radiculopathy present for up to two weeks. The initial presentation included radicular pain, dermatomal hypoesthesia, diminished DTR, but no myotomal weakness. The intervention consisted of home cervical traction performed daily for up to one month (45 minutes on/15 minutes off for 6-8 hours at 5 lb.; seated halter type). Additional treatments (confounding factors) included muscle relaxants and anti-inflammatory medication. The outcome was a resolution of radicular pain, of dermatomal hypoesthesia, and of deep tendon hyporeflexia. The outcome follow-up was 2-3 years.

This small case series indicates effectiveness in resolving cervical radiculopathy related pain, dermatomal hypoesthesia, and diminished DTR (level of evidence 4) for extensive daily use of home cervical traction and accessory use of muscle relaxants and anti-inflammatory medication (a confounding factor). The findings are encouraging for the role of traction in managing cervical radiculopathy, especially in view of the long follow-up. However, as level 4 evidence with marginal validity, this case series does not prove causality. Moreover this is a small case series that appears to highlight excellent results.

Swezey, Swezey, and Warner (1999) present a case series of 58 adults with Grade 1-3 Whiplash-Associated Disorders (WAD’s). Of interest to this review is the identified subgroup of 10 cervical radiculopathy patients (WAD grade 3). The initial presentation is described as radicular pain and neurological signs. The intervention consisted of home over-the-door cervical traction repeated twice a day for 5 minutes, performed for more than 3-4 weeks. The outcome is described as 90% (9 out of 10 cervical radiculopathy patients) improved in pain and neurological signs (p<.01). 50% (5 patients) experienced a full resolution of the radicular pain and neurological signs ( p<.01).

This case series with a small subgroup of cervical radiculopathy patients indicates effectiveness in improving cervical radiculopathy related pain and neurological signs (level of evidence 4) for minimal daily use of home cervical traction. The findings are encouraging for the role of home cervical traction in managing cervical radiculopathy, especially in view of no other confounding therapeutic factors, medium series size, and, importantly, statistically significant improvement. However, as level 4 evidence with marginal validity, this case series does not prove causality. Moreover, no numeric data on improved deficits, nor information on the length of follow-up are provided.

Moeti and Marchetti (2000) present a case series of 15 adults with cervical radiculopathy of highly variable duration (4 to 520 weeks). The initial presentation is described as radicular pain and at least one neurological sign. The Neck Disability Index is used to measure self-reported disability. The intervention included varied protocols of in-clinic intermittent mechanical cervical traction administered for up to 2 months (15 - 20 minutes; 18 - 35lb.; 10 to 30 sec. on/ 6 to 15 sec. off; supine). Additional treatments were manipulations for hypomobile segments as needed, as well as postural exercises and conditioning. The outcome is presented as 8 patients (53%) with complete pain resolution (symptom duration 12 weeks or less) and near-normal function (47% NDI score decreased to 10% or less); 3 patients (20%) overall improved, but not resolved; 1 patient (7%) with significant improvement in pain (40%), but no change in perceived disability; and 3 patients (20%) with no improvement (symptom duration >12 weeks). In total, 73% patients were improved, or resolved their complaints of pain and disability.

This relatively small case series indicates effectiveness in improving cervical radiculopathy related pain and functional deficits (level of evidence 4) for consistent clinical use of intermittent mechanical cervical traction, complemented with other physiotherapeutic treatments. The findings are encouraging for the role of clinical cervical traction in managing cervical radiculopathy, especially in view of the medium series size and use of a valid and reliable function-measuring tool (NDI). However, as level 4 evidence with marginal validity, this case series does not prove causality. Moreover, no statistical analysis has been performed, the data are presented in an unclear and convoluted manner, and a short follow-up was conducted.

Oliviero and Dulebohn (2002) present a retrospective chart review case series consisting of 81 adults with cervical radiculopathy; 55 patients with C7; 37 with C6; 2 with C5, and 2 patients with C8 radiculopathy present for 6 weeks. The initial presentation included a neck and arm pain and one of these: reflex loss, dermatomal numbness, and/or myotomal weakness. The intervention consisted of halter cervical traction at home for 2- 6 weeks (3x/a day x 15 minutes 8 - 12 lb.) and a cervical collar as passive support (a confounding factor). The outcome was described as 60 patients (74%) having achieved "good relief of arm pain."

This large case series indicates effectiveness in improving cervical radiculopathy related pain (level of evidence 4) for daily use of home cervical traction, complemented with the use of cervical collar (a confounding factor). The findings are encouraging for the role of home cervical traction in managing cervical radiculopathy, especially in view of the large series size; the patients’ representing a spectrum of cervical radiculopathy types; and the fact that all patients had been unimproved with prior other conservative measures for 3-6 weeks (a degree of control rarely seen in a case series). Another strength is its 3-month follow-up. However, as level 4 evidence with relatively low validity, this case series does not prove causality. Moreover, no statistical analysis has been performed and no numeric data on pain improvement were provided. Nonetheless, this large case series provides the best observational evidence of all cited case reports and series studies.

Saal et al. (1996) published a longitudinal cohort study of 26 adults with cervical radiculopathy characterized by radicular pain and "neurologic loss" for up to 3 months. They were also disabled from work. The intervention "consisted of traction, specific physical therapeutic exercise, oral anti-inflammatory medication, and patient education." All patients received manual and mechanical traction as well as home traction for up to 3 months. The outcome was measured via pain, level of activities, patient satisfaction, and return to full work duties. In terms of pain and function 20 of 24 (83%) had good or excellent outcome defined as: Excellent - no pain, no limitation in activity; Good - minor neck pain only, minimal limitation of activity. In terms of work-related function: 22 of 24 (92%) patients returned to full work duties. Neurologically, all patients with motor deficit resolved 100%.

This cohort study indicates effectiveness in improving cervical radiculopathy related pain, myotomal weakness, and disability (level of evidence 4 - a cohort study with no controls) for the use of home and in-clinic cervical traction, complemented with therapeutic exercise, oral anti-inflammatory medication, and patient education (confounding factors). The findings are encouraging for the role of cervical traction in managing cervical radiculopathy, especially in view of the long mean follow-up of 2.3 years. However, as level 4 evidence with relatively low validity, this uncontrolled cohort study does not prove causality. As purported controls the authors consider surgical case series and cohorts cited by them with results comparable to their result of 83% success rate. Their findings are also juxtaposed against natural history reported to be 60% of patients recovering spontaneously.

Abdulwahab (1999) presents a repeated-measures within-subject design study of a sample of convenience comprising 10 patients with a C7 radiculopathy. The initial presentation was that of a flexor carpii radialis weakness and radicular pain for the past 6 months. The intervention consisted of manual traction. The outcome was measured via EMG and was reported as an increase in H reflex amplitude (Repeated measure ANOVA: p<. 001) indicating immediate improvement in the affected muscle performance. A decrease in radicular pain was also noted.

This study indicates effectiveness in immediately improving cervical radiculopathy (C7) related pain and myotomal weakness (level of evidence 2b) for the use of manual traction. The study shows a relatively high level of evidence and validity for an immediate in-session improvement in pain and objective motor performance in patients with C7 radiculopathy especially in view of the findings’ statistical significance and the control provided by the repeated within-subject measurements. The findings are encouraging for the role of manual cervical traction in managing cervical radiculopathy. Nonetheless, despite a relatively sound internal validity, the results cannot be generalized to the population in which long-term results are sought.

Joghatei, Arab, and Khaksar (2004) have conducted the only RCT on the effect of traction. The sample of convenience consisted of 30 adult men and women with a unilateral C7 radiculopathy for over one month. The initial presentation is described as C7 dermatomal numbness, and grip weakness (control mean 17.64 =/- 6.74, and experimental mean 14.17+/- 6.9 kPa). There is no mention of pain or functional status. The intervention consisted of clinic-based: "electrotherapy/exercise treatment for control group and combined cervical traction [20 minute duration; 30 lb.; 7 sec. on/ 5 sec. off; supine] and electrotherapy/exercise for experimental group" over ten physical therapy sessions, three times a week. The only reported outcome was grip strength measured before treatment and after 5 and 10 treatment sessions (total duration of treatment = about 3.5 weeks). After 5 sessions the grip was stronger in traction patients 20.33+/-8.35 (p=.04) versus the control mean 20.36 +/- 5.57 kPa. After 10 sessions both groups were equally stronger.

This study indicates effectiveness in improving cervical radiculopathy (C7) related myotomal weakness (grip) (level of evidence 2b - probability tested imperfect RCT) for the use of in-clinic intermittent mechanical cervical traction. The findings demonstrate at level 2b that traction is effective for short-term accelerated increase in grip strength related to C7 myotomal weakness. The study is overall rigorously designed and executed (randomization, similar controls, double blinding, and intention-to-treat). Its main flaw, however, is a small sample, likely rendering it underpowered. Despite a relatively sound internal validity, the results may not be very significant clinically because the short term increase in grip is small. This RCT study is an excellent and rare attempt in the field of physical therapy to study treatment effects of traction at this level of evidence. The need for this type of studies is acute.

The studies concerned with effects of traction on cervical radiculopathy are mainly case series and case reports Level 4-5. Those low level reports show traction as effective in improving rather than resolving cervical radiculopathy. Natural history reported in literature (Olivero & Dulebohn, 2002; Saal et al., 1996) indicates that 43-60% cervical radiculopathy patients will improve or resolve without treatment, while the low level studies adduced in this review show overall improvement 73% or up. The one uncontrolled cohort study cited shows improvement at 83 %. Thus basic observational studies indicate a better than natural history course for cervical radiculopathy when receiving traction. Unfortunately most studies are obviously contaminated by additional treatments, so that dilutes evidence for specific use of traction. Nonetheless traction was the most consistent and time intensive treatment used. While validity of level 5 and 4 studies is highly questionable, higher- level evidence shows similar promise for traction in treating cervical radiculopathy . Abdulwahab (1999) and Joghatei et al. (2004) (both at level 2b) show immediate effects measured objectively and subjectively. These studies are controlled, and present high internal validity. They show short-term effectiveness of cervical traction on motor function, and Abdulwahab presents evidence for immediate improvement in pain.

Since cervical radiculopathy results in pain, neurological signs, and associated disablement, a discussion of evidence for each outcome category (improvement due to traction) is warranted. The best evidence exists for the role of traction in rapidly improving muscle performance. The Joghatei et al. RCT (2004) shows this effect with high internal validity, and Abdelwahab’s experimental controlled study (1999) shows traction-induced EMG changes indicative of improved motor performance in the affected muscle. Lower level evidence from an uncontrolled cohort study (Saal et al, 1996) supports traction as having a long-term effect (mean follow-up of 2.3 years) in restoring muscle strength. Eight out of nine studies reviewed demonstrate improvement in radicular pain due to traction treatments (one study, Joghatei’s RCT, simply omits pain level as an outcome). The highest 2b evidence comes from Abdelwahab, but it is only for a pain relief effect immediately after the treatment. Of interest to this review is a long term effect, and such an effect is demonstrated only at level 4. Since the total number of subjects studied in the four case series is 110, and satisfactory pain relief is achieved in 85 (77%), it is a somewhat compelling evidence. Thus level 4 observational evidence appears to indicate that traction helps accelerate pain relief, exceeding natural history which is reported as 43-60% of patients spontaneously recovering (Olivero & Dulebohn, 2002; Saal et al., 1996).

Level 4 evidence (Moeti & Marchetti, 2001; Saal et al, 1996) supports the use of traction to improve function. In Saal et al.’s uncontrolled cohort, all subjects returned to full duty employment. In Moeti and Marchetti’s case series, 11 out of 15 patients studied (73%) experienced significant to nearly complete restoration of function based on the Neck Disability Index. As for sensory deficits, traction is shown to help restore sensation at only evidence level 4. Constantoyannis et al.’s case series (2002) demonstrating such an effect features only four cases, however. This same case series also demonstrates improvement in deep tendon reflexes. Interestingly, Corso and Brosky (1999) in their case report show no improvement in the patient’s reflex status.

Overall, literature indicates that in adults with cervical radiculopathy traction is effective at level of evidence 2b for short-term improvement in motor deficits. Traction can also help decrease radicular pain and improve function as evidenced by observational studies at level 4. There is paucity of literature on the role of traction in improving sensation and reflexes. Minimal observational evidence at level 4 does support its use to improve sensory and reflex deficits. Anecdotal level 5 evidence, however, shows a lack of improvement in a deep tendon reflex status upon traction. Thus the answer to the clinical question that inspired this review suggests that physical therapists should provide clinical and home traction to help their patients with cervical radiculopathy, as the best available evidence, despite its limitations, supports its use. The cited evidence does not favor any particular traction protocol, and the success of home and clinic-based traction is equally represented.

This review also shows that the basic observational evidence about effectiveness of traction for cervical radiculopathy has been established, and a foray into the highest levels of evidence has been executed with promising results. Conclusive evidence at Oxford level of evidence 1 is lacking, however. The paucity of high quality evidence underscores the need for well-designed RCT’s making it possible in the future to conduct a meta-analysis. That in turn would lead to guidelines for the use of traction in conservative treatment of cervical radiculopathy.

It is concluded here also that, in order to better answer the clinical question asked in this review, the subsequent study ought to be a multi-center study (to maximize sample size) of the effects of traction on all aspects of cervical radiculopathy in patients with various nerve root level involvement. The study should be at level 1b of evidence (RCT) with traction possibly both clinical and home based as the only difference between the experimental and control groups.

Appendix 1

The Search History for databases: CDSR, ACP Journal Club, DARE, CCTR
--------------------------------------------------------------------------------
1 traction.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw] (461)
2 (cervical pain or neck pain).mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw] (346)
3 radiculopathy.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw] (93)
4 herniated nucleus pulposus.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw] (16)
5 neurological signs.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw] (102)
6 (nerve compression or pinched nerve).mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw] (95)
7 weakness.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw] (1088)
8 (numbness or paresthesia).mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw] (662)
9 anesthesia.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw] (15688)
10 (paraesthesia or paraesthesiae).mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw] (143)
11 anaesthesia.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw] (7847)
12 (physical therapy or physiotherapy).mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw] (2561)
13 8 or 10 (762)
14 9 or 11 (18975)
15 1 and 2 (26)
16 cervical traction.mp. [mp=ti, ot, ab, tx, kw, ct, sh, hw] (13)
17 1 and 3 (3)
18 1 and 4 (1)
19 1 and 5 (5)
20 1 and 6 (8)
21 1 and 7 (12)
22 1 and 13 (19)
23 1 and 14 (59)
24 1 and 12 (57)
25 2 or 3 or 4 (439)
26 12 and 25 (100)
27 15 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 26 (201)
28 from 27 keep 17,40 (2)
29 from 27 keep 40,67,74,78,84,87,91,101,105,115-116,119,129-130,135,138,140,144-148,150-151,153,158-159,177,181,183,198,200 (32)
30 from 27 keep 201 (1)
31 from 27 keep 201 (1)
32 from 27 keep 201 (1)
33 28 or 29 (33)
34 from 33 keep 1-33 (33)

Appendix 2

The Search History for CINAHL - Cumulative Index to Nursing & Allied Health Literature <1982 to February Week 4 2005>
Search Strategy:
--------------------------------------------------------------------------------
1 exp Radiculopathy/ (233)
2 exp Neck Pain/ (673)
3 exp Pain/ (30535)
4 cervical radiculopathy.mp. (70)
5 cervical traction.mp. (41)
6 exp Traction/ (336)
7 exp Physical Therapy/ (25653)
8 4 and 5 (6)
9 4 and 6 (9)
10 4 and 7 (13)
11 5 and 1 (7)
12 5 and 2 (7)
13 5 and 3 (14)
14 5 and 7 (11)
15 8 or 9 or 10 or 11 or 12 or 13 or 14 (35)
16 1 and 6 (11)
17 1 and 7 (32)
18 2 and 6 (11)
19 2 and 7 (170)
20 3 and 6 (74)
21 16 or 17 or 18 or 19 or 20 (270)
22 15 or 21 (283)
23 from 15 keep 5-7,10,15-19,21,23-25,27,29-30 (16)
24 16 or 17 or 18 (49)
25 from 24 keep 7,10-12,18,24,26-28,34,37-38,40,43-45 (16)
26 23 or 25 (18)
27 from 26 keep 1-2,5-7,9-17 (14)
28 from 27 keep 1-14 (14)

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Baker, P., Marcoux, B.C. (1999). The effectiveness of home cervical traction on relief of neck pain and impaired cervical range of motion. Physical Therapy Case Reports, 2, 145-151.

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van der Heijden, G.J.M.G., Beurskens, A.J.H.M., Koes, B.W., Assendelft, W.J.J., de Vet, H.C.W., Bouter, L.M. (1995). The efficacy of traction for back and neck pain: a systematic, blinded review of randomized clinical trial methods. Physical Therapy, 75, 93-104.

Wainner, R.S., Gill, H. (2000). Diagnosis and nonoperative management of cervical radiculopathy. Journal of Orthopedic and Sports Physical Therapy, 30, 728-744.

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