[ research report ]

PIERRE LANGEVIN, PT, FCAMPT, MClSc1,2 • FRANÇOIS DESMEULES, PT, PhD3,4 • MÉLANIE LAMOTHE, PT, MSc1
SIMON ROBITAILLE, PT1 • JEAN-SÉBASTIEN ROY, PT, PhD2,5

Comparison of 2 Manual Therapy

and Exercise Protocols for Cervical
Radiculopathy: A Randomized Clinical
Trial Evaluating Short-Term Effects
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TTSTUDY DESIGN: Participant- and assessor- (week 8). A mixed-model, 2-way analysis of vari-
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

blinded randomized clinical trial.
TTOBJECTIVES: To compare a rehabilitation
program thought to increase the size of the inter-
vertebral foramen (IVF) of the affected nerve root
ance was used to analyze treatment effects.
TTRESULTS: No significant group-by-time interac-
SUPPLEMENTAL
VIDEO ONLINE
tion or group effect was observed for Neck Dis-

C
ability Index, QuickDASH, and numeric pain-rating
to a rehabilitation program that doesn’t include scale scores (P≥.14) following the intervention.
any specific techniques thought to increase the ervical radiculopathy (CR)
However, both groups showed statistically and
size of the IVF in patients presenting with cervical
clinically significant improvement from baseline is an important subgroup
radiculopathy (CR).
to week 4 and to week 8 in Neck Disability Index, of neck disorders. Al­
TTBACKGROUND: Clinical approaches for the QuickDASH, and numeric pain-rating scale scores though less prevalent
treatment of CR commonly include exercises and (P<.05).
than mechanical neck pain, CR
Journal of Orthopaedic & Sports Physical Therapy®

manual therapy techniques thought to increase the

size of the IVF, but evidence regarding the effective-
ness of these specific manual therapy techniques
is scarce.
TTMETHODS: Thirty-six participants with CR were
randomly assigned either to a group that received
a manual therapy and exercise program aimed at
increasing the size of the IVF of the affected nerve
root (experimental group, n = 18) or to a group that
received a manual therapy and exercise program
without the specific goal of increasing the size of
the IVF of the affected level and side (comparison
group, n = 18). Primary (Neck Disability Index) and
secondary (shortened version of the Disabilities
of the Arm, Shoulder and Hand questionnaire
[QuickDASH] and numeric pain-rating scale)
outcomes were evaluated at baseline, at the end of
the 4-week program (week 4), and 4 weeks later
TTCONCLUSION: Results suggest that manual
therapy and exercises are effective in reducing
pain and functional limitations related to CR. The
addition of techniques thought to increase the
size of the IVF of the affected nerve root yielded no
significant additional benefits. Given the absence
of a “no treatment” group, a spontaneous resolu-
tion of symptoms cannot be excluded. However,
the magnitude of improvement makes spontane-
ous resolution unlikely. The trial was registered at
ClinicalTrials.gov (NCT01500044).
TTLEVEL OF EVIDENCE: Therapy, level 1b–.
J Orthop Sports Phys Ther 2015;45(1):4-17. Epub
24 Nov 2014. doi:10.2519/jospt.2015.5211
TTKEY WORDS: disability, intervertebral foramen,
neck pain, nerve root, spine
leads to more severe pain and
disability.7,27,37 In fact, individuals
with combined axial and radicular symp-
toms have been shown to present higher
functional limitations than those with
either isolated axial or radicular pain.10
Cervical radiculopathy primarily results
from an impingement and inflamma-
tion of a nerve root induced by a space-
occupying lesion that reduces the size of
the intervertebral foramen (IVF).33 This
reduction in size is most often caused by
a herniated disc or a degenerative lesion
of the zygapophyseal joints.3,6,9 Typical
symptoms of CR include neck, periscap-

1
Physio Interactive Clinics, Quebec City, Quebec, Canada. 2Department of Rehabilitation, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada. 3School of
Rehabilitation, University of Montreal, Montreal, Quebec, Canada. 4Orthopaedic Clinical Research Unit, Maisonneuve-Rosemont Hospital Research Center, Montreal, Quebec,
Canada. 5Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec Rehabilitation Institute, Quebec City, Quebec, Canada. The Institutional Review
Board of the Quebec Rehabilitation Institute approved this study. This research project was supported by the Ordre professionnel de la physiothérapie du Québec and the Réseau
provincial de recherche en adaptation-réadaptation. The funding sources were not involved in the study’s design, conduct, or reporting. Dr Roy was supported by a salary award
from the Fonds de recherche du Québec – Santé. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial
interest in the subject matter or materials discussed in the article. Address correspondence to Dr Jean-Sébastien Roy, Center for Interdisciplinary Research in Rehabilitation and
Social Integration, 525 Boulevard Wilfrid Hamel, Quebec City, Quebec, Canada G1M 2S8. E-mail: jean-sebastien.roy@rea.ulaval.ca t Copyright ©2014 Journal of Orthopaedic
& Sports Physical Therapy®

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45-01 Langevin.indd 4 12/16/2014 6:27:10 PM

 ular, and upper-limb radicular pain, as
well as neurological signs such as sen-
sory disturbance, weakness, and reduced
tendon reflexes in the affected nerve root
distribution.5 The annual incidence of CR
is 83.2 per 100 000 individuals. Cervical
radiculopathy is more prevalent in men,
and the peak incidence is in the fifth and
sixth decades.33
In rehabilitation of CR, a variety of
treatment options are available to clini-
cians, including strengthening or stretch-
ing exercises for the cervical and thoracic
spines, manual therapy techniques, cer-
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vical traction, and postural education.41
Evidence of the effectiveness of such re-
habilitation interventions for CR remains
sparse.13,16,20,21,30 In a systematic review
published in 2013 on the effectiveness
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
of nonsurgical treatment for CR,43 11
randomized clinical trials (RCTs) were
retrieved. Of these 11 RCTs, only 2 had
a low risk of methodological bias. The
conclusions of this systematic review
were that there is low-level to very low-
level evidence that no single intervention
is superior or consistently more effective
than another. The authors also concluded
Journal of Orthopaedic & Sports Physical Therapy®
that, on a short-term basis, there is low-
level evidence that active rehabilitation
interventions may be more effective than
a wait-and-see approach.
Physical therapy approaches for acute
and subacute CR commonly include
interventions thought to increase the
size of the IVF.41 It is hypothesized that
some movements that increase the size
of the IVF, such as flexion, contralateral
rotation, and contralateral sidebend-
ing, may decompress an affected nerve
root.14,15,32,46,47 Conversely, movements of
extension, ipsilateral rotation, and ipsi-
lateral sidebending may reduce the IVF
space.32,47 It would therefore be logical
that rehabilitation programs for acute
and subacute CR should include tech-
niques or exercises to increase the size of
the IVF and, based on the same rationale,
exclude movements and positions that
decrease the size of the IVF. However, to
our knowledge, the effects of such a reha-
bilitation program have never been eval-
journal of orthopaedic & sports physical therapy | volume 45 | number 1 | january 2015 | 5
45-01 Langevin.indd 5
uated in patients with symptoms related
to CR. Thus, the primary objective of this
RCT was to compare a rehabilitation pro-
gram thought to increase the size of the
IVF corresponding to the affected nerve
root to a rehabilitation program that did
not include any specific techniques to in-
crease the size of the IVF in participants
presenting with signs and symptoms con-
sistent with acute or subacute CR.
This clinical trial was registered at
ClinicalTrials.gov (NCT01500044), and
the trial protocol was published prior to
the initiation of the study.23
METHODS
Participants
P
otential participants with CR
were recruited from medical and
physical therapy clinics in the Que-
bec City area of Canada. Those included
met the following criteria: (1) between 18
and 65 years of age; (2) pain, paresthe-
sia, or numbness in 1 upper limb, with
cervical or periscapular pain of less than
3 months in duration; (3) at least 1 neu-
rological sign of a lower motor neuron
lesion in a cervical spine nerve root or
spinal nerve; and (4) positive responses
to at least 3 of the 4 following clinical
tests (positive likelihood ratio for CR of
6): Spurling A test, upper-limb tension
test A, cervical distraction test, and less
than 60° of cervical rotation to the pain-
ful side.44 The clinical neurological exam
included the evaluation of dermatomes,
myotomes, and deep tendon reflexes.
Even though the diagnostic accuracy
of the neurological exam has not been
determined with a gold standard crite-
rion,24,44 it is widely used in clinical set-
tings to identify the affected nerve root.
Therefore, the result of the clinical neu-
rological exam was used to determine the
presumed level of the radiculopathy.
Potential participants were excluded
if they had (1) prior surgery to the cer-
vicothoracic spine, (2) bilateral symp-
toms, (3) signs of upper motor neuron
impairments, (4) cervical spine injection
in the previous 4 weeks, (5) current use
of steroidal anti-inflammatory drugs, or
(6) financial compensation for the cervi-
cal condition. The Institutional Review
Board of the Quebec Rehabilitation In-
stitute approved the protocol for this
study.
Study Design
All participants took part in a baseline
evaluation, during which they completed
a questionnaire to report demograph-
ics, symptomatology, and comorbidi-
ties, and 3 self-report questionnaires on
pain and disability: the Neck Disability
Index (NDI), the shortened version of
the Disabilities of the Arm, Shoulder
and Hand questionnaire (QuickDASH),
and a numeric pain-rating scale (NPRS).
Cervicothoracic range of motion (ROM)
was measured using the CROM device
(Performance Attainment Associates,
Lindstrom, MN). Participants were ran-
domly assigned to either the comparison
(COM) group or experimental (EXP)
group. A research assistant opened a
randomization envelope containing the
participants’ assignments to the group of
clinics providing the assigned program.
The research assistant was blinded to the
baseline evaluation results, as well as to
the clinics providing the programs. Par-
ticipants were able to choose the clinic
providing their intervention from a list
of 3 different clinics for each program.
Once randomization was completed, par-
ticipants took part in the 4-week rehabili-
tation program. Any harm or unintended
effect during the rehabilitation program
was recorded by the treating physical
therapist or the assessor, as was the use
of medication.
At the end of the 4-week intervention
and 4 weeks after conclusion of the pro-
gram, participants were reassessed with
the 3 self-report questionnaires (NDI,
QuickDASH, and NPRS), a measure
of cervicothoracic ROM, and a ques-
tion pertaining to global change since
the baseline evaluation (global rating of
change [GRC]). Finally, to evaluate the
effectiveness of blinding, participants
and assessors responded to a question
12/16/2014 6:27:11 PM
 [ research report
related to their opinion of the allocation.
Independent physical therapists (asses-
sors), blinded to the group assignment,
performed all the evaluations according
to standardized procedures.
Randomization and Blinding
An independent research assistant not
involved in data collection generated a
randomization list prior to the initiation
of the study, using a random-number
generator. Group allocations were con-
cealed in sealed, opaque, sequentially
numbered envelopes, and blocked ran-
Downloaded from www.jospt.org at on January 18, 2019. For personal use only. No other uses without permission.
domization (block size of 6) was used
to make sure that 2 equal groups were
obtained. The participants and outcome
assessors were blind to treatment group
allocation. Participants were blinded by
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
being unaware of the precise type of mo-
bilizations received. To reduce potential
contamination bias, the 2 programs were
given in different clinics and the evalua-
tion sessions took place outside the treat-
ing clinics.
Outcome Measures
Neck Disability Index The NDI, the pri-
Journal of Orthopaedic & Sports Physical Therapy®
mary outcome, is a validated 10-item
questionnaire that measures a patient’s
self-reported neck pain–related disabil-
ity.25 The score ranges from 0 (no disabil-
ity) to 100 (full disability). For patients
with CR, the minimal detectable change
(MDC) is 10 points,8 and the clinically
important difference (CID) is 14 points.25
Shortened Version of the Disabilities of
the Arm, Shoulder and Hand Question-
naire The QuickDASH is a region-spe-
cific questionnaire that evaluates physical
disability and symptoms of the upper
limb in patients with upper extremity
disorders.28 The score ranges from 0 (no
disability) to 100 (most severe disability).
The QuickDASH is valid, reliable, and re-
sponsive.36 The MDC is 10.8 points and
the CID is 10.2 points.36 The QuickDASH
is also valid for the measurement of up-
per extremity disability in patients pre-
senting with neck pain.29
Numeric Pain-Rating Scale The levels
of upper-limb and neck pain were rat-
6 | january 2015 | volume 45 | number 1 | journal of orthopaedic & sports physical therapy
45-01 Langevin.indd 6
ed separately with the NPRS. Using an
11-point scale ranging from 0 (no pain)
to 10 (worst pain imaginable), partici-
pants were asked, “On a scale of 0 to
10, where 0 corresponds to no pain and
10 to the worst imaginable pain, evalu-
ate the intensity of your neck pain at
this moment.” The same question was
asked for the upper limb. The NPRS is
moderately reliable and has a CID of 1.0
point.8,11
Cervicothoracic Mobility The CROM de-
vice was used to measure active cervical
ROM in a standardized seated position.
The mean of 3 measures was used for
data analysis. The CROM device is reli-
able and has good construct validity.2
Rehabilitation Programs
Each participant took part in 8 treatment
sessions during a 4-week period and per-
formed a home exercise program. At the
beginning of each session, the treating
physical therapist conducted a standard-
ized biomechanical examination con-
sisting of an intervertebral segmental
mobility evaluation, using lateral glides
at the cervical spine and posteroanterior
glides at the thoracic spine (T1-T6). Seg-
mental mobility was rated as normal, hy-
pomobile, or hypermobile.35,38
Rehabilitation Program for the COM
Group The rehabilitation program for the
COM group consisted of cervical and tho-
racic mobilizations, as well as stabilization
and mobility exercises. This program was
based on current clinical practice7 and on
programs developed in 2 RCTs evaluating
participants with neck and upper-limb
pain that did not include any specific
techniques thought to increase the size of
the IVF.45,48 In the present study, 4 manual
therapy techniques were executed at each
treatment session. The manual therapy
techniques were chosen by the physical
therapist according to the results of the
biomechanical examination. The physi-
cal therapists were allowed to use any of
the following manual therapy techniques
applied at the spinal level of their choice:
rotations, lateral glides in neutral, pos-
teroanterior glides, posteroinferior medial
]
glides, or anterosuperior anterior glides
(APPENDIX A, ONLINE VIDEOS). However, phys-
ical therapists were not allowed to use
these techniques, or any other exercise,
to specifically increase the size of the IVF
of either the presumed affected segment
or the 2 segments above and 2 segments
below the presumed affected segment. For
example, contralateral rotation, lateral
glides in the direction of the presumed af-
fected nerve root, and anterosuperior an-
terior glides on the same side and segment
as the presumed affected nerve root were
not allowed. Each manual therapy tech-
nique was performed for 10 repetitions of
30 seconds, with a force grade of 3 to 4, as
described by Maitland et al.26 Following
the mobilization techniques, a 5-minute
global (nonspecific) static manual cervical
traction was applied. Finally, a standard-
ized home exercise program was given to
the participants. The program consisted
of 3 exercises: (1) strengthening exercises
for the deep neck flexors, (2) axial exten-
sion exercises, and (3) 1 exercise selected
by the treating physical therapist and
based on the participant’s impairments:
cervical or thoracic active ROM mobil-
ity, cervical extension strengthening, or
scapular strengthening (APPENDIX B).17
However, no exercise led specifically to
an increase in the size of the IVF ipsilat-
eral to the lesion. Standardized postural
advice was also given.
Rehabilitation Program for the EXP
Group The EXP group received the
same rehabilitation program as the COM
group, with 2 exceptions: (1) of the 4 mo-
bilization techniques executed at each
treatment session, 2 were mandatory
techniques thought to increase the size
of the IVF on the same side and at the
same presumed level as the radiculopa-
thy (global contralateral rotation mobi-
lization and ipsilateral lateral glide in a
flexed position); and (2) the third exer-
cise of the home program was a repeated
movement that is known to increase the
size of the IVF32,47 (cervical spine rotation
in the direction contralateral to the af-
fected side, performed for 10 repetitions,
10 times per day).
12/16/2014 6:27:12 PM
 egorized as success if they reported an
Assessed for eligibility, telephone improvement of 50% or higher in NDI
interview, n = 71 score and a GRC of “moderately better”
(+3) or higher42 and as failure if they re-
Excluded, n = 32
ported less than 50% improvement in
• Not meeting inclusion
criteria, n = 32 NDI score and a GRC of “somewhat bet-
ter” (+2) or lower. The proportion of suc-
Assessed for eligibility at initial cess/failure was compared across groups
Enrollment

meeting, n = 39 using chi-square tests.

Excluded, n = 3
• Not meeting inclusion
RESULTS
criteria, n = 3

F
rom February 2012 to April 2013,
Randomized, n = 36 71 potential participants contacted
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the research team for potential in-

clusion. Following a screening interview
Allocated to comparison Allocated to rehabilitation by phone, 32 potential participants were
Allocation

rehabilitation program program targeting the excluded for not meeting the eligibil-
(comparison group), n = 18 opening of intervertebral ity criteria, and 3 potential participants
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Received allocated foramen (experimental were further excluded at the initial meet-
intervention, n = 18 group), n = 18
ing (FIGURE 1). Thirty-six (51%) of the
Received allocated
initial 71 potential participants were re-
intervention, n = 18
cruited and randomly assigned to either
the COM rehabilitation program (COM
group, n = 18) or the EXP rehabilitation
Attended follow-up at 4 wk, Attended follow-up at 4 wk,
Follow-up

n = 18 n = 17 program (EXP group, n = 18), which in-

Attended follow-up at 8 wk, Attended follow-up at 8 wk, cluded manual therapy techniques and
n = 18 n = 18 exercises thought to increase the size of
Journal of Orthopaedic & Sports Physical Therapy®

the IVF. One participant from the EXP

group missed the week-4 evaluation;
Analysis

Analyzed, n = 18 Analyzed, n = 18 baseline scores were therefore imputed

FIGURE 1. Flow diagram for participant recruitment, allocation, follow-up, and analysis.
Sample-Size Calculation
The sample-size calculation was based on
the CID of the NDI (14 points), the NDI
standard deviation (18.4 points) report-
ed in the literature for this population,8
and a type I error of .05 with a power
of 0.80. For an analysis of variance, the
sample size required was 16 participants
per group. However, 18 participants per
group were recruited to compensate
for potential withdrawals and loss to
follow-up.
Statistical Analyses
All data were tested to ensure that they
met the assumptions of the inferential
statistical analyses. Baseline character-
istics that could potentially impact the
results of the study were evaluated. An
intention-to-treat analysis, in which all
participants were analyzed in the group
to which they were assigned, was con-
ducted. A mixed-model, 2-way analysis
of variance (group by time) was used to
analyze the effects of the rehabilitation
programs on the primary and secondary
outcomes. Changes in mean scores (with
95% confidence intervals) following the
programs were also calculated for all
dependent variables. Because this study
examined a new rehabilitation program,
the patient’s perceived change following
the programs was dichotomized as either
success or failure. Participants were cat-
for the week-4 outcomes. Data from
all 36 participants were considered for
analysis. All participants took part in all
4 weeks of the program, and the compli-
ance (compliance rates for the 8 treat-
ment sessions: 94.4% for the COM group
and 95.1% for the EXP group) was simi-
lar between the 2 groups (P>.05). TABLE 1
presents baseline participant characteris-
tics and baseline mean scores for all out-
comes according to group. The 2 groups
were similar for all variables at baseline.
For the primary outcome measure
(NDI), no significant group-by-time in-
teraction was observed (F2,68 = 0.84, P
= .44) (FIGURE 2). However, both groups
showed significant improvement in NDI
scores from baseline to week 4 and to
week 8 (P<.05). Mean changes over time
and their 95% confidence intervals are
presented for both time points in TABLE 2.

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 [ research report ]
50
Participant Characteristics and

Neck Disability Index (0-100)

TABLE 1
Dependent Variables at Baseline* 40

30

Variable Comparison Group (n = 18) Experimental Group (n = 18) 20

Age, y 47.8  11.3 42.8  10.4 10
Sex (female), n (%) 12 (67) 12 (67)
0
Weight, kg 76.3  22.3 80.9  24.4
Baseline 4 wk 8 wk
Height, cm 165.7  7.6 167.7  9.3
Dominant affected side, n (%) 9 (50) 14 (77) EXP group COM group
Symptom duration of current episode, wk 5.7  3.6 5.4  3.2
History of previous episode(s) of neck and 6 (33) 8 (44) FIGURE 2. Neck Disability Index scores for the COM
arm pain, n (%) group (n = 18) and the EXP group (n = 18) at baseline,
Affected myotome, n (%) end of intervention (4 weeks), and 4 weeks after end
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of intervention (8 weeks). Values are mean  SD

C5 1 (5) 2 (11)
Neck Disability Index points (0-100). Lower scores
C6 9 (50) 7 (39) indicate less disability. Values at 4 and 8 weeks were
C7 5 (28) 5 (28) significantly different from those at baseline (P<.05).
C8 3 (17) 4 (22) Abbreviations: COM, comparison; EXP, experimental.
Using medication at enrollment,† n (%) 10 (55) 13 (72)
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Job activity description, n (%)

60
Office work 9 (50) 10 (55)

QuickDASH (0-100)
Light physical work 4 (22) 2 (11)
40
Heavy physical work 1 (5) 3 (17)
Not employed or retired 4 (22) 3 (17)
20
Currently on leave of absence, n (%) 4 (22) 2 (11)
NDI (0-100)‡ 32.0  8.0 34.8  11.4
0
QuickDASH (0-100)‡ 42.3  16.5 42.8  13.6
Baseline 4 wk 8 wk
QuickDASH work module (0-100)‡§ 46.0  28.3 47.7  27.3
Journal of Orthopaedic & Sports Physical Therapy®

Cervical NPRS (0-10)‖ 4.1  2.5 4.3  1.9 EXP group COM group
Upper-limb NPRS (0-10)‖ 4.6  2.9 4.8  1.4
Cervicothoracic mobility, deg FIGURE 3. QuickDASH scores for the COM group
Flexion 40.2  11.3 42.2  12.6 (n = 18) and the EXP group (n = 18) at baseline,
end of intervention (4 weeks), and 4 weeks after
Extension 49.1  15.3 53.5  11.2
end of intervention (8 weeks). Values are mean
Rotation, affected side 55.7  15.9 54.8  10.0  SD QuickDASH points (0-100). Lower scores
Rotation, nonaffected side 54.7  11.8 56.2  12.3 indicate less disability. Values at 4 and 8 weeks were
Lateral flexion, affected side 32.1  7.5 30.6  9.7 significantly different from those at baseline (P<.05).
Lateral flexion, nonaffected side 31.7  12.8 36.3  7.3 Abbreviations: COM, comparison; EXP, experimental;
QuickDASH, shortened version of the Disabilities of
Abbreviations: NDI, Neck Disability Index; NPRS, numeric pain-rating scale; QuickDASH, shortened
the Arm, Shoulder and Hand questionnaire.
version of the Disabilities of the Arm, Shoulder and Hand questionnaire.
*Values are mean  SD unless otherwise indicated.
†
Medications reported include analgesics, nonsteroidal anti-inflammatory drugs, corticosteroids, both groups in extension and sidebend-
or antidepressants.
‡
A higher score indicates a higher level of disability.
ing (P<.05).
§
Comparison group, n = 16; experimental group, n = 17. The NDI and GRC were used to evalu-
‖
A higher score indicates greater pain. ate the proportions of success and failure
resulting from the 2 treatment programs.
Similarly, no significant group-by- and to week 8 (P<.05) (TABLE 2) for all 3 The proportion of success did not signifi-
time interaction was found for the Quick- variables. cantly differ between groups at week 4
DASH (F2,62 = 0.36, P = .70) (FIGURE 3) or Changes in ROM from baseline to (61% for the COM group versus 82% for
the cervical (F2,68 = 2.04, P = .14) (FIGURE week 4 and to week 8 are presented in the EXP group, P = .16) and at week 8
4) and upper-limb (F2,68 = 1.87, P = .16) TABLE 2. No significant group-by-time (83% for the COM group versus 77% for
(FIGURE 5) NPRS data. Both treatment interaction was found for any specific the EXP group, P = .67).
groups also showed significant improve- cervical movements (P≥.05). However, No adverse events were reported for
ments in scores from baseline to week 4 significant improvements were seen for any of the participants during the study.

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45-01 Langevin.indd 8 12/16/2014 6:27:14 PM

 8
Changes at the End of the
Cervical NPRS (0-10)

6 TABLE 2 Intervention (4 Weeks) and 4 Weeks After

4 the End of the Intervention (8 Weeks)*
2

0 Mean Change From Baseline

–2 Comparison Group Experimental Group

Baseline 4 wk 8 wk
Outcome Measure (n = 18) (n = 18) Mean Difference†
NDI (0-100) ‡

EXP group COM group 4 wk –17.8 (–23.3, –12.3)§ –20.1 (–25.6, –14.6)§ –2.3 (–10.1, 5.5)
8 wk –21.7 (–27.0, –16.4) §
–26.3 (–31.6, –21.1)§ –4.6 (–12.1, 2.8)
FIGURE 4. Cervical NPRS for the COM group QuickDASH (0-100)‡
(n = 18) and the EXP group (n = 18) at baseline, end
4 wk –20.8 (–28.0, –13.7)§ –24.8 (–31.9, –17.6)§ –3.9 (–14.0, 6.2)
of intervention (4 weeks), and 4 weeks after end of
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8 wk –28.8 (–35.9, –21.7) §

–32.5 (–39.5, –25.4)§ –3.7 (–13.7, 6.4)
intervention (8 weeks). Values are mean  SD on a
0-to-10 scale. Lower scores indicate less pain. Values QuickDASH work module (0-100) ‡‖
at 4 and 8 weeks were significantly different from those 4 wk –23.0 (–33.0, –13.1)§ –26.8 (–36.5, –17.1)§ –3.8 (–17.7, 10.1)
at baseline (P<.05). Abbreviations: COM, comparison; 8 wk –30.5 (–40.8, –20.1) §
–36.0 (–46.1, –26.0)§ –5.6 (–20.0, 8.9)
EXP, experimental; NPRS, numeric pain-rating scale. Cervical NPRS (0-10)‡
4 wk –2.5 (–3.4, –1,6)§ –1.9 (–2.8, –1.0)§ 0.6 (–0.6. 1.9)
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

8 8 wk –2.8 (–3.8, –1.8) §

–3.4 (–4.5, –2.5)§ –0.7 (–2.1, 0.7)
Upper-Limb NPRS (0-10)

Upper-limb NPRS (0-10)‡

6
4 wk –2.8 (–4.1, –1.5)§ –2.9 (–4.2, –1.5)§ –0.1 (–1.9, 1.8)
4
8 wk –2.8 (–3.8, –1.8) §
–4.2 (–5.2, –3.1)§ –1.3 (–2.8, 0.2)
2
Cervicothoracic mobility, deg
0 Flexion
–2 4 wk 2.6 (–2.0, 7.1) 3.7 (–0.9, 8.3) 1.2 (–5.3, 7.6)
Baseline 4 wk 8 wk 8 wk 4.0 (–1.2, 9.2) 5.7 (0.5, 10.9)§ 1.7 (–5.6, 9.1)
Extension
Journal of Orthopaedic & Sports Physical Therapy®

EXP group COM group 4 wk 7.2 (0.5, 13.8)§ 10.8 (4.2, 17.5)§ 3.7 (–5.8, 13.1)
8 wk 11.6 (4.8, 18.4)§ 10.4 (3.6, 17.3)§ –1.2 (–10.8, 8.5)
FIGURE 5. Upper-limb NPRS for the COM group
Rotation, affected side
(n = 18) and the EXP group (n = 18) at baseline, end
4 wk 0.1 (–6.4, 6.6) 5.4 (–1.1, 11.8) 5.3 (–3.8, 14.4)
of intervention (4 weeks), and 4 weeks after end of
intervention (8 weeks). Values are mean  SD on a 8 wk 4.9 (–1.5, 11.2) 3.7 (–2.6, 10.1) –1.2 (–10.1, 7.8)
0-to-10 scale. Lower scores indicate less pain. Values Rotation, nonaffected side
at 4 and 8 weeks were significantly different from those 4 wk 5.1 (–1.5, 11.6) 8.8 (2.2, 15.4)§ 3.8 (–5.5, 13.1)
at baseline (P<.05). Abbreviations: COM, comparison; 8 wk 6.8 (–0.5, 14.2) 3.6 (–3.8, 10.9) –3.3 (–13.7, 7.1)
EXP, experimental; NPRS, numeric pain-rating scale.
Lateral flexion, affected side
At the end of the study, the proportion of 4 wk 5.7 (1.1, 10.2)§ 6.1 (1.5, 10.7)§ 0.4 (–6.0, 6.9)
participants who indicated no knowledge 8 wk 7.6 (3.7, 11.4)§ 7.8 (3.9, 11.7)§ 0.3 (–5.2, 5.8)
of the group to which they had been allo- Lateral flexion, nonaffected side

cated was the same in both groups (72%). 4 wk 7.0 (3.1, 10.8)§ 3.4 (–0.5, 7.2) –3.6 (–9.1, 1.9)

Similarly, the physical therapists who 8 wk 8.1 (4.0, 12.1)§ 4.2 (0.2, 8.3)§ –3.8 (–9.7, 2.0)

performed the evaluations were unable
to identify which rehabilitation program
each participant received.
Abbreviations: NDI, Neck Disability Index; NPRS, numeric pain-rating scale; QuickDASH, shortened
version of the Disabilities of the Arm, Shoulder and Hand questionnaire.
*Values in parentheses are 95% confidence interval.
†
Mean differences in change scores between groups: experimental group – comparison group.
‡
A negative change indicates improvement in participant status.

DISCUSSION P<.05.
§

‖
Comparison group, n = 16; experimental group, n = 17.

T
he results of this clinical trial
indicate that there were no statisti-
cally significant differences in out-
comes (NDI, QuickDASH, NPRS scores,
and success/failure rate) between a reha- side and at the same level as the radicu-
bilitation program specifically targeted to lopathy and a rehabilitation program
increase the size of the IVF on the same with no specific intervention to increase

journal of orthopaedic & sports physical therapy | volume 45 | number 1 | january 2015 | 9

45-01 Langevin.indd 9 12/16/2014 6:27:15 PM

 [ research report
the size of the IVF at the affected level.
Both groups achieved highly favorable
outcomes in terms of pain, disability, and
patient-perceived improvement, suggest-
ing that, in this population, the combi-
nation of manual therapy and exercise
is effective. This also suggests that there
are no limitations to using mobilizations
and exercises that are specific to the level
of the radiculopathy in acute or subacute
patients with CR, given that no adverse
event was observed following the rehabil-
itation programs and that the compliance
was excellent regardless of the approach
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used.
Overall, patient improvement for both
programs observed in the present study
was statistically significant and clinically
important (above the MDC and CID)
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
across our primary outcome (NDI) and
secondary outcomes of pain (NPRS) and
disability (QuickDASH). The improve-
ment in self-reported neck pain–related
disability observed with the primary out-
come (mean improvement on the NDI of
20 points at 4 weeks and 24 points at 8
weeks) was more than twice the value of
the MDC (10 points) for this population
Journal of Orthopaedic & Sports Physical Therapy®
and almost twice the value of the CID (14
points) at the 8-week follow-up. These
results are consistent with the findings
of other studies that have demonstrated
favorable outcomes from the combina-
tion of manual therapy and exercises for
individuals with CR.22
Four previous RCTs have looked at the
effect of rehabilitation programs in pa-
tients with CR and found similar results
to those of the present RCT showing the
effectiveness of manual therapy and ex-
ercises. Kuijper et al22 showed that neck
pain and upper-limb pain were signifi-
cantly decreased in 2 of the intervention
groups (cervical collar and active physical
therapy, defined as “hands-off ” exercises
to strengthen the superficial and deep
neck muscles) compared to a wait-and-
see group. In the Kuijper et al22 study,
the active physical therapy group had a
mean improvement of 50% on a visual
analog scale at 6 weeks; in comparison,
the present study showed a mean im-
10 | january 2015 | volume 45 | number 1 | journal of orthopaedic & sports physical therapy
45-01 Langevin.indd 10
provement of 60% in upper-limb pain at
4 weeks and 88% at 8 weeks. Nee et al31
showed significant improvements in pain
and function over 4 weeks in participants
with subacute or chronic neck and upper-
limb pain who enrolled in a rehabilitation
program (advice to stay active, education,
manual therapy, nerve glide mobiliza-
tions, and exercises) compared to partici-
pants who received a COM intervention
(advice to stay active). Those in the EXP
group of the present study showed a simi-
lar improvement in upper-limb pain from
baseline to 4 weeks (mean improvement
of 60%) to the group participating in the
rehabilitation program in the study by
Nee et al31 (mean improvement of 40%).
Young et al48 and Ragonese34 also found
that the combination of manual therapy
and exercises is effective for patients with
CR. In the study by Young et al,48 mean
functional change on the NDI exceeded
the CID at 4 weeks for both groups, but
the authors reported no significant effect
of adding mechanical traction to manual
therapy and exercises. Finally, in the RCT
by Ragonese,34 a combination of manual
therapy and exercises resulted in greater
improvement in pain and function com-
pared to either exercises or manual ther-
apy alone.
Although, in the present study, both
groups reached significant statistical and
clinical improvements following the in-
tervention programs, no between-group
differences were observed. The lack of
between-group differences could be ex-
plained by certain methodological fac-
tors. First, both groups were treated with
the same global manual cervical traction
intervention, 2 manual therapy tech-
niques at the choice of the therapist and
the same stabilization and postural exer-
cises. Therefore, more than 60% of the
plan of care was similar for both groups,
and global traction, although nonspecific,
may theoretically increase the size of the
IVF. Second, anatomical causes of CR
include disc herniation and osteophytes
resulting from degenerative joint dis-
ease.6,33 One of the goals of the interven-
tion for the EXP group was primarily to
]
increase the size of the IVF, which would
decrease the compression on the nerve
root and, in turn, potentially decrease
the swelling produced by the inflamma-
tory process in the IVF. In contrast to
degenerative joint disease, a herniated
cervical disc produces inflammatory me-
diators like matrix metalloproteinases,
prostaglandin E2, interleukin-6, and
nitric oxide.12,18,19 It is therefore possible
that our biomechanical approach was not
as effective for participants with a CR in-
duced by disc herniation, because the disc
itself may produce inflammatory media-
tors. Thus, this approach could be more
helpful for degenerative CR, given that
degenerative CR has never been shown to
produce inflammatory mediators. Mag-
netic resonance imaging was not used
in the present study; therefore, we were
unable to perform subgroup analysis us-
ing these 2 subcategories of CR. Finally,
the same nonspecific neurophysiologi-
cal effect of manual therapy could have
occurred in both groups, which would
also explain why both groups similarly
improved.4
Our results suggest that, for acute and
subacute CR, treating joint and muscle
stiffness without a focus on increasing
the size of the IVF (COM group) is as
effective as a program that specifically
focuses on increasing the size of the IVF
of the affected nerve root. Our study
was adequately powered, based on the
sample-size calculation performed using
the primary outcome measure (NDI).
However, the number of participants in-
cluded may have limited our capacity to
show a significant between-group differ-
ence for cervical and upper-limb pain at 8
weeks. For both cervical and upper-limb
pain, the EXP group showed a tendency
for more improvement compared to the
COM group, but the statistical tests were
underpowered at 41% and 38%, respec-
tively. For upper-limb pain at 8 weeks,
though the mean between-group differ-
ence in change score was greater than
the CID in favor of the EXP group (–1.32
points on the NPRS scale) (TABLE 2), the
difference was not statistically signifi-
12/16/2014 6:27:15 PM
 cant. Therefore, further studies are need-
ed to determine if techniques thought to
increase the size of the IVF are more ef-
fective to reduce upper-limb pain.
Limitations and Strengths
This study does have some limitations.
First, a “no treatment” group was not in-
cluded in this study, as the intent was to
deliver the same quantity of mobilization
techniques and exercise for both groups.
Furthermore, the primary objective was
to modify only the manual therapy tech-
niques and the type of exercises between
Downloaded from www.jospt.org at on January 18, 2019. For personal use only. No other uses without permission.
groups to determine the efficacy of a
specific approach thought to increase
the size of the IVF. Other authors have
already shown the short-term superiority
of mobilization and exercises over a wait-
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
and-see approach for this population.22,31
Still, according to a recent systematic
review,43 there is only low-level evidence
that active rehabilitation interventions
are more effective than a wait-and-see
approach. Thus, some might argue that
a “no treatment” group should have been
included to account for the possibility of
a spontaneous resolution of symptoms
Journal of Orthopaedic & Sports Physical Therapy®
over the course of the study. On the other
hand, the magnitude of changes observed
for the vast majority of the participants
in a relatively short period suggests that
this is unlikely. Second, similar treat-
ment effects have previously been shown
to occur when a nonspecific level versus
a specific level is treated with mobiliza-
tions in patients with mechanical neck
pain.1,39,40 However, this is the first study
to investigate manual therapy mobiliza-
tions at a specific level and in a specific
direction (direction targeting an increase
of the IVF) in patients with CR. Third,
the study was adequately powered for
the primary outcome (NDI) but under-
powered for several secondary outcomes.
However, apart from the NPRS for up-
per-limb pain, only small between-group
differences in change scores were ob-
served at 4 and 8 weeks for the secondary
outcomes. It is therefore doubtful that a
CID between the 2 programs would have
been observed even with a larger sample.
journal of orthopaedic & sports physical therapy | volume 45 | number 1 | january 2015 | 11
45-01 Langevin.indd 11
Finally, the clinical diagnostic test clus-
ter used in the present study has yet to
be validated.44 Therefore, to improve the
clinical accuracy of our diagnosis of CR,
the presence of at least 1 positive neuro-
logical clinical test was included in the
test cluster to increase the likelihood of
radiculopathy. Still, it is possible that
some of the included participants had
nonspecific mechanical neck pain with-
out CR.
Conversely, this study has several
strengths. First, there was no loss to
follow-up at the 8-week evaluation, and
only 1 participant missed the 4-week
evaluation. Second, the compliance to
the intervention was very high, given that
all participants took part in all 4 weeks
of the program. Third, the effectiveness
of blinding was evaluated for the asses-
sors and the participants, with results
suggesting that the blinding was very
effective. Finally, recommended clini-
cal criteria were used for the inclusion
of the participants, validated measures
were chosen as primary and secondary
outcomes, and the programs were pro-
vided by multiple physical therapists at
multiple clinical sites, which enhances
the generalizability of findings.
CONCLUSION
T
he results of this RCT suggest
that manual therapy and exercises
are effective in improving pain,
function, and ROM in patients with CR.
The addition of manual therapy tech-
niques and exercises thought to increase
the size of the IVF corresponding to the
affected nerve root yielded no significant
additional benefits on neck and upper-
limb function, neck pain, and ROM.
Given the absence of a “no treatment”
group, a spontaneous resolution of symp-
toms cannot be excluded. However, the
magnitude of improvement would make
spontaneous resolution unlikely. t
KEY POINTS
FINDINGS: In individuals with CR, a re-
habilitation program including man-
ual therapy techniques and exercises
thought to increase the size of the IVF
corresponding to the affected nerve
root yielded no significant additional
benefits when compared to a rehabilita-
tion program that did not include any
specific techniques to increase the size
of the IVF.
IMPLICATIONS: For acute and subacute CR,
treating joint and muscle stiffness by fo-
cusing on increasing the size of the IVF
is no more effective than using tech-
niques that do not focus on increasing
the size of the IVF of the affected nerve
root. No adverse events were observed
with either approach to treatment, in-
cluding using techniques targeting the
involved segments of the cervical spine.
CAUTION: Given the absence of a “no
treatment” or sham group, we cannot
exclude the possibility of spontaneous
resolution of symptoms over the course
of the study.
ACKNOWLEDGEMENTS: The authors would like
to thank all physical therapists involved in
this study: J.F Esculier for his help in data
collection, as well as A. Malo, V. Brisson, D. La-
perrière, B. Bégin, A. Larouche, M.E. Ménard,
M.C. Melançon, M.H. Dumas, G. Roger, L. Al-
lard, J.P. Paquin, and N. Poirier for providing
the rehabilitation programs. The authors are
grateful to C. Kennedy for reviewing and com-
menting on the manuscript.
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43. T hoomes EJ, Scholten-Peeters W, Koes B,
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MORE INFORMATION
org/10.2519/jospt.2010.3223 BRS.0b013e318183391e WWW.JOSPT.ORG

APPENDIX A
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

MANUAL THERAPY TECHNIQUES USED WITH

THE EXPERIMENTAL AND COMPARISON GROUPS
Manual Therapy Techniques Intended to Increase the Size of the Intervertebral Foramen (IVF), Used in the Experimental Group Only

Technique Description of Technique Illustration

Rotation mobilization at With the patient supine and the cervical spine in neutral, both hands
Journal of Orthopaedic & Sports Physical Therapy®

the cervical spine of the therapist are placed on the posterior arch of the vertebra
(ONLINE VIDEO) at the affected level. The therapist then induces an end-range
rotational force to the targeted level on the level below. A left
rotation is intended to increase the size of the right IVF.

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Technique
Lateral glide in a flexed position
at the cervical spine
(ONLINE VIDEO)
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Anterosuperior lateral glide
at the cervical spine
(ONLINE VIDEO)
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®
14 | january 2015 | volume 45 | number 1 | journal of orthopaedic & sports physical therapy
45-01 Langevin.indd 14
APPENDIX A
Description of Technique Illustration
With the patient supine and the cervical spine in a flexed position,
both hands of the therapist are placed on the posterior arch of
the vertebra at the affected level. An end-range lateral translation
force is applied to the targeted level on the level below. A left lateral
glide, imparted by the right hand of the physical therapist, is
intended to increase the size of the left IVF.
To increase the size of the left IVF, the patient is supine and the
cervical spine is flexed and slightly sidebended and rotated to the
right. The hand of the therapist is placed over the left posterior
arch of the vertebra of the affected level. The therapist then induces
an end-range glide force in anterior, superior, and lateral directions
to the targeted level on the level below.
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Manual Therapy Techniques Intended to Improve Range of Motion, Allowed in Both Groups
Technique
Lateral glide in a neutral position With the patient supine and the cervical spine in neutral, both hands
at the cervical spine
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Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Posteroinferior medial glide
at the cervical spine
(ONLINE VIDEO)
Journal of Orthopaedic & Sports Physical Therapy®
Posteroanterior glide at the
cervical or thoracic spine
(ONLINE VIDEO)
45-01 Langevin.indd 15
APPENDIX A
Description of Technique Illustration
of the therapist are placed on the posterior arch of the vertebra at
the affected level. An end-range lateral translation force is applied
to the affected level on the level below. A left lateral glide, imparted
by the right hand of the physical therapist, is intended to improve a
deficit in left translational mobility in neutral.
With the patient supine and the cervical spine extended, slightly side-
bended, and rotated to the left for a left mobility restriction, the left
hand of the therapist is placed over the left posterior arch of the
vertebra. The therapist then induces an end-range glide force in
posterior, inferior, and medial directions.
With the patient prone and the spine in neutral, the therapist’s
thumbs are placed over a transverse process. An anterior
translational force is induced at mid to end range with both
thumbs. This technique can be applied at the cervical or thoracic
vertebra down to T6.
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 APPENDIX B

HOME EXERCISE PROGRAM

Standardized Exercise Program (Done in Both Treatment Groups)

Exercise Description/Parameter Illustration

Short neck flexor strengthening With the patient in supine and the cervical spine in a neutral position,
a pressure biofeedback unit is placed under the neck. The patient
is asked to gently nod the chin, as if saying “yes,” while keeping
the head/occiput stationary (do not lift, do not push down) to com-
press the unit without compensation (therapist was correcting the
compensation). Ten repetitions, 10 seconds, once a day.
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Axial extension (postural correc- In a sitting position, with the head in a neutral position to start, the
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

tion) exercises patient is asked to gently retract the shoulder, extend the thoracic
spine, and perform a chin nod. The patient is asked to think of an
imaginary rope that would pull his occiput up. Ten repetitions, 5
seconds, once a day.
Journal of Orthopaedic & Sports Physical Therapy®

Third Exercise for the Participants in the Experimental Group*

Exercise Description/Parameter Illustration

Repeated active rotation move- In a sitting position, the patient is asked to keep his neck and thorax
ments (contralateral to the in a neutral position and then repeat rotation of the head to the
affected side) opposite direction of the symptoms. Ten repetitions, 3 seconds, 10
times a day.

*With the intent to increase the size of the intervertebral foramen.

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 APPENDIX B

Third Exercise for the Participants in the Comparison Group*

Exercise Description/Parameter Illustration

Repeated cervical or thoracic
active range of motion
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With the patient in a sitting position, the patient is asked to keep
the neck and thorax in a neutral position and then repeat a
movement of the head or of the thorax in 1 of the 6 following
movement directions: flexion, extension, sidebending (right or
left), rotation (right or left). The therapist chooses the direction
and is not allowed to choose a direction thought to increase
the size of the IVF. The illustrations are some examples of how
the movements were performed. Ten repetitions, 3 seconds,
once a day.

Scapular muscle strengthening With the patient in a prone position and the elbow extended, the
Copyright © 2015 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

patient is asked to lift both arms while moving the shoulder

blades closer together. Ten repetitions, 3 seconds, once a day.

Neck extensor strengthening With the patient in a prone position and the neck in neutral (a
gentle chin nod is performed to keep the neutral position), the
patient is asked to lift and hold the head against gravity. Ten
Journal of Orthopaedic & Sports Physical Therapy®

repetitions, 10 seconds, once a day.

Abbreviation: IVF, intervertebral foramen.

*At the therapist’s discretion, only 1 of the exercises is selected for each participant.

VIEW Videos on JOSPT’s Website

Videos posted with select articles on the Journal’s website (www.jospt.org)
show how conditions are diagnosed and interventions performed. To view
the associated videos for an article, click on Supplementary Material and
scroll down to stream the videos online or download them to your
computer or device.

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