447
A New 3-Point Bending Traction Method for Restoring
Cervical Lordosis and Cervical Manipulation:
A Nonrandomized Clinical Controlled Trial
Deed E. Harrison, DC, Rene Cailliet, MD, Donald D. Harrison, PhD, DC, MSE, Tadeusz J. Janik, PhD,
Burt Holland, PhD
ABSTRACT. Harrison DE, Cailliet R, Harrison DD, Janik
TJ, Holland B. A new 3-point bending traction method for
restoring cervical lordosis and cervical manipulation: a
nonrandomized clinical controlled trial. Arch Phys Med
Rehabil 2002;83:447-53.
Objective: To evaluate a new 3-point bending type of cer-
vical traction.
Design: Nonrandomized controlled trial of prospective, con-
secutive patients compared with control subjects. Follow-up
patient data were obtained at 3 and 151⁄2 months, and 81⁄10
months for controls.
Setting: Data were collected at a spine clinic in Nevada.
Patients: Volunteer subjects consisted of 30 patients and 24
controls. Subjects had cervicogenic pain (neck pain, headaches,
arm pain, and/or numbness). Subjects were included if their
Ruth Jackson radiographic stress lines measured less than 25°
but were excluded if they had suspected disk herniation or
canal stenosis. All subjects completed the first follow-up ex-
aminations, and 25 of 30 patients completed the long-term
follow-up examination.
Interventions: Spinal manipulation for pain and a new form
of 3-point bending cervical traction to improve lordosis. Cer-
vical manipulation was provided for the first 3 to 4 weeks of
treatment. Traction treatment consisted of 3 to 5 sessions per
week for 9 ⫾ 1 weeks.
Main Outcomes Measures: Besides pain visual analog
scale (VAS) ratings, pre- and posttreatment lateral cervical
radiographs were analyzed.
Results: Control subjects reported no change in the pain
VAS ratings and had no statistically significant change in
segmental or global radiographic alignment. For the traction
group, VAS ratings were 4.3 pretreatment and 1.6 posttreat-
ment. Traction group radiographic measurements showed sta-
tistically significant improvements (P ⬍ .008 in all instances of
statistical significance), including anterior head weight bearing
(improved 6.2mm), Cobb angle at C2–7 (improved 12.1°), and
angle between posterior tangents at C2–7 (improved 14.2°).
For the treatment group, at 151⁄2-month follow-up, only mini-
mal loss of C2–7 lordosis (3.5°) was observed.
From Private Practice, Elko, NV (DE Harrison); University of Southern California
Medical School, Pacific Palisades, CA (Cailliet); Biomechanics Laboratory, Univer-
sité du Québec à Trois-Rivières, Trois-Rivières, Que, Canada (DD Harrison); Comp/
Math RC, Huntsville, AL (Janik); and Department of Statistics, Temple University,
Philadelphia, PA (Holland).
Accepted in revised form May 8, 2001.
Supported in part by CBP Nonprofit Inc.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors(s) or upon any
organization with which the author(s) is/are associated.
Reprint requests to Rene Cailliet, MD, 1339 Luna Vista Dr, Pacific Palisades, CA
90272, e-mail: cailliet@ref.usc.edu.
0003-9993/02/8304-6775$35.00/0
doi:10.1053/apmr.2002.30916
Conclusions: Sagittal cervical traction with transverse load
at midneck (2-way cervical traction) combined with cervical
manipulation can improve cervical lordosis in 8 to 10 weeks as
indicated by increases in segmental and global cervical align-
ment. Magnitude of lordosis at C2–7 remained stable at long-
term follow-up.
Key Words: Cervical vertebrae; Kyphosis; Lordosis; Neck
pain; Posture; Rehabilitation; Spine; Traction.
© 2002 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
ERVICAL SPINE TRACTION as a treatment for spinal
C disorders is now routine, but its physiologic basis remains
obscure. Studies reported in the literature and treatment guide-
lines focus on neck position, traction force, duration of traction,
angle of pull, and position of the patient with disregard of the
biomechanics of the central nervous system, as postulated by
Breig.1
The following statement by Cailliet2 still pertains in today’s
literature: “Only personal experience determines the method,
the amount of weight applied, the duration, and the frequency
of traction, since, unfortunately, no scientific documentation is
available.” As early as 1957, Crue3 stated, “Every physician
has his own preference of halter type, weight, time, schedule,
length of trial, and concurrent use of PT [physical therapy],
neck brace or collar.”
All cervical traction concepts have accepted the premise that
traction in flexion, with consequent decrease of lordosis, is the
goal. This concept implies that lordosis is nonphysiologic and
is the cause of the pathology. Axial and flexion traction in-
crease the posterior disk space and intervertebral foraminal
area but ignore the effects on the spinal cord, the nerve roots,
their dura, and the blood vessels of the nerve roots.
The medical uses of cervical traction include spinal trauma
(fractures, dislocations),4-6 conservative treatment for painful
cervical conditions (neck pain, radicular pain, spondylosis),7-9
and reduction of cervical kyphosis.10,11 Treatment of cervical
spine traumas dates back to 4000 BC.12 The Hippocratic traction
bench was in use in ancient Greece, but safe and effective
methods of cervical traction did not occur until the 20th cen-
tury.12
Although cervical spine traction after trauma is now routine,
there are a multitude of possible complications from skull
traction with tongs.13-15 Cervical spine axial or flexion traction
is also routinely used for a wide range of spinal disorders,16-19
but this treatment is not without complications and critics.20,21
Numerous biomechanic studies have tried to determine the
mechanisms at work in cervical traction, including vertebral
movement, intervertebral foramen separation, optimum angle
of pull, optimum force, optimum time period, friction of body
slippage, ligament deformation, and disk height increases.22-25
Several positions have been suggested for cervical traction,
including sitting, supine, and prone.26-28 Although axial and
Arch Phys Med Rehabil Vol 83, April 2002
448 NEW 3-POINT BENDING CERVICAL TRACTION, Harrison

flexion traction increase the posterior disk space and the inter-
vertebral foramina area,29 the adverse mechanical tensions in
the hind brain, cranial nerves 5 to 12, cervical spinal cord, and
cervical nerves1 roots during these positions are often ig-
nored.1,30-32
Recently, the configuration of the sagittal cervical curve has
reemerged as an important clinical outcome of health care,
especially in cervical postsurgical outcomes33-35 and buckling
injuries.36,37 The cervical lordosis can be considered a primary
curve because it is formed at approximately 10 weeks of fetal
development.38 Cervical lordosis is caused by posterior wedg-
ing of the cervical disks39 and is necessary for proper spinal
coupling.40
Because conservative methods to restore or improve cervical
lordosis are rare,41 we decided to measure global and segmental
angles of lordosis by using a new type of 3-point bending
cervical traction originated by Pope.42 In this extension, which
is a 2-way traction, physiologic lordosis may be restored along
with the biomechanics of the enclosed central nervous system.
We hypothesized that the tension in the anterior cervical
structures at the convexity of this 3-point bending position
would restore lordosis or increase the curvature in neck pain
patients who had lost their cervical lordosis.
METHODS
After undergoing a screening protocol that established their
tolerance to cervical distraction with extension, 30 consecutive,
prospectively selected patients with chronic neck pain and loss
of cervical lordosis volunteered to receive cervical spinal ma-
nipulation for pain relief and a new type of 3-point bending
cervical traction. Patients were included if they had cervico- Fig 1. New 3-point bending (2-way) cervical extension traction. The
genic pain and their lateral cervical radiograph measured less head is distracted, retracted, and extended, while the neck is arched
than 25°, which is 1 standard deviation (SD) below the mean ⫾ into lordosis by an anterior strap applied at midneck or at the level
of any kyphosis. While the head harness angle and strap are fixed
SD asymptomatic person reported as 34° ⫾ 9° in table 7 of posteriorly, the vectors of pull (angles and forces [weights]) can be
Harrison et al.43 When cervicogenic pain and range of motion varied at the anterior strap.
(ROM) were improved, cervical manipulation was discontin-
ued (ie, after approximately 3– 4wk of treatment). The type of
cervical manipulation was a global lateral bending combined
with a small amount of axial torsion of the head and neck. 17.9kg). The control group was composed of 13 women and 11
Subjects were excluded if examination revealed a suspected men (average age, 35 ⫾ 11.7y; mean height, 172.1 ⫾ 8.3cm;
disk herniation or if they had canal stenosis as measured on the mean weight, 75.8 ⫾ 10kg).
radiographs. In the treatment group, the traction trial duration was 3 to 5
Three sets of lateral cervical radiographic measurements times weekly for 8 to 10 weeks. Traction time started at
(pretreatment, after 10wk of traction, mean long-term fol- approximately 3 minutes and increased 1 minute per session
low-up of 151⁄2 ⫾ 81⁄6mo after 10wk of traction) were com- until reaching the goal of 20 minutes per session. The new type
pared with a nonrandomized prospective control group (n ⫽ of cervical traction has been termed “Pope’s 2-way” traction
24) who also had chronic cervicogenic pain and loss of cervical because the anterior strap provides a transverse load at midneck
lordosis. In the control group, who had no treatment interven- and the head halter provides distraction, retraction, and exten-
tion, follow-up lateral cervical radiographs were obtained at an sion. The head halter was fixed posteriorly to cause slight
average of 81⁄10 ⫾ 61⁄6 months. distraction, retraction, and extension, while the front anterior
In addition to lateral cervical radiographic measurements, all strap had weight applied over a pulley that started at 15lb
participants in both groups were evaluated carefully and com- (6.8kg), and increased over consecutive visits to tolerance or a
pleted a history that included (1) a pain drawing to elucidate the maximum of 35lb (15.9kg).
location of pain, (2) a visual analog scale (VAS) on which Figure 1 shows the extended, distracted, and retracted head
patients rated their perceived pain intensity from 0 (no pain) to position with the addition of a transverse load. With weight
10 (excruciating pain and bed ridden), (3) self-reports of the attached over a pulley, the transverse load is applied by an
frequency and duration of their pain, and (4) self-reports of the anterior strap, which pulls posteriorly to anteriorly at the level
extent of perceived functional limitations caused by their neck of any cervical kyphosis.
pain. This history was completed at the beginning and at Standard lateral cervical radiographs were obtained with the
follow-up. The VAS values were compared between the 2 subjects’ right shoulder against the cabinet with a standard tube
groups. distance of 182.9cm. Before exposure, subjects were asked to
Subjects were patients at a spine clinic in Elko, NV. All nod their heads twice and assume a comfortable resting posi-
applicable laws for the use of human subjects in research were tion. This neutral resting posture is highly repeatable.44-46
followed by our institutional review board. The 30 traction Lateral cervical radiographs were analyzed with the poste-
group subjects consisted of 25 women and 5 men (average age, rior tangent method, which includes global and segmental
34 ⫾ 14.3y; mean height, 166.6 ⫾ 8.5cm; mean weight, 72.1 ⫾ angles of lordosis. Cobb angles and a measurement of head

Arch Phys Med Rehabil Vol 83, April 2002

 NEW 3-POINT BENDING CERVICAL TRACTION, Harrison 449

Fig 2. Radiographic measurements. (A) Two types of Cobb angles were drawn, C1–7 and C2–7. (B) An additional global angle of lordosis (ARA
C2–7) was measured at the intersection of the posterior body tangent lines on C2 and C7. (C) For a segmental analysis (eg, relative rotation
angle [RRA] C2–3), intersections of each adjacent pair of vertebral body tangent lines drawn on the posterior body margins of C2 through
C7 are measured. The sum of these RRAs equals the absolute rotation angle, ARA C2–7. (D) A measurement of head protrusion (anterior
weight bearing ⴝ ⴙTz) is the translation distance from a vertical line through posteroinferior T1 to the posterosuperior corner of the atlas
lateral mass. The angle of the atlas to horizontal and Chamberlain line to horizontal were also constructed (not shown).

protrusion were included. The posterior tangent method has
inter- and intraclass correlation coefficients in the good and
high ranges with low standard errors of measurement (stan-
dard error of measurement ⬇2° for angles, ⬇2mm for dis-
tances).47 Figure 2 shows this radiographic method.
Twenty-five of the 30 treatment subjects (83%) volunteered
for a long-term follow-up lateral cervical radiograph. The av-
erage elapsed time between first follow-up and second fol-
low-up radiograph was 151⁄2 months.
To compare between and within groups, 2-sided, 2-sample
t tests and 2-sided paired t tests were conducted with
MINITAB™.a
RESULTS
The 30 subjects who received a new type of 2-point bending
cervical traction and cervical manipulation were compared with
the 24 controls who did not receive treatment. By using 2-sample
t tests, we found no statistically significant differences between the

Arch Phys Med Rehabil Vol 83, April 2002

450 NEW 3-POINT BENDING CERVICAL TRACTION, Harrison

Table 1: Comparison of Control and Treatment Group scores in the traction treatment group (mean, 4.3 ⫾ 1.5 vs 1.6 ⫾
Characteristics and Pain VAS Between Groups
1.2; table 1).
Control Group Treatment Group P*(between For the control group, all differences of the means for the initial
Variable (n ⫽ 24) (n ⫽ 30) groups) and follow-up radiographic angles were less than 1.1°. By using
Men (n) 11 5 paired t tests for equality of the means derived from radiographic
Age (y) 35.1 ⫾ 9.0 38.6 ⫾ 15.3 .65 analysis for control subjects, we found no statistically significant
Height (cm) 176.7 ⫾ 8.1 178.3 ⫾ 5.5 .64 differences in the 5 segmental angles from posterior tangents at
Weight (kg) 79.4 ⫾ 13.7 83.0 ⫾ 9.5 .62 C2–3 to C6–7. Also for the control group, no statistically signif-
VAS icant differences existed in the global absolute rotation angle
Pre† 3.5 ⫾ 2.2 2.9 ⫾ 1.0 .50 (ARA; ARA ⫽ ⫺9.9°, ⫺10.8°), drawn with posterior tangents at
Post 3.6 ⫾ 1.7 1.4 ⫾ 1.1 .011 C2–7; in the Cobb angles at C1–7 (⫺37.9°, ⫺37.7°) and C2–7
Women (n) 13 25 (⫺6.0°, ⫺5.6°); in head flexion angle (Chamberlain’s line vs
Age (y) 35.1 ⫾ 13.9 33.1 ⫾ 14.3 .68 horizontal of ⫺1.7° and ⫺2.7°); and in the head protrusion dis-
Height (cm) 168.2 ⫾ 6.6 164.3 ⫾ 6.9 .09 tances measured at C1 and C2 (eg, TzC1–T1).
Weight (kg) 69.6 ⫾ 5.3 70.7 ⫾ 18.5 .80 For the traction treatment group, all radiographic angle mea-
VAS surements showed statistically significant change (P ⬍ .008) to
Pre 3.7 ⫾ 2.1 4.5 ⫾ 1.5 .19 an increased lordosis, except for the segmental angle at C6 –7.
Post 3.9 ⫾ 2.0 1.6 ⫾ 1.3 .002
The largest clinically significant increases in lordosis were
Combined men 24 30
found in the upper cervical spine (C2–3 ⫽ 3.1°, C3– 4 ⫽ 3.0°,
and women (n)
C4 –5 ⫽ 4.7°). On average, the global angles increased be-
VAS
tween 12° and 15° (ARAC2–7 ⫽ 14.2°, CobbC2–7 ⫽ 12.1°,
Pre 3.6 ⫾ 2.1 4.3 ⫾ 1.5 .17
CobbC1–7 ⫽ 12.7°). The mean inclination of C1 to horizontal
Post 3.8 ⫾ 1.8 1.6 ⫾ 1.2 ⬍.0001
increased (9.3°), the head flexion angle decreased (8.5°), and
P ‡ (within groups) .50 ⬍.0001
head protrusion decreased (6.2mm, table 2). Figures 3A, B, and
NOTE. Values are mean ⫾ SD unless otherwise denoted. C (kyphotic cervical curve) show a case with cervical kyphosis
* Two-sided 2 sample t test. changing to a cervical lordosis after treatment and that this
†
VAS pain range: 0 ⫽ no symptoms, no limitations to daily living; change remained stable at the 7-month follow-up.
10 ⫽ severe pain and bed ridden. For the treatment group at long-term follow-up (average,
‡
Two-sided paired t tests for VAS scores within groups.
151⁄2mo), postradiograph angles indicate minimal loss of C2–7
lordosis of approximately 3.5° from values at the 3-month
radiographic examination. Table 2 provides the comparisons of
2 groups when comparing women and men for age, height, lateral cervical radiographic measurements made at 3- and
weight, and pretreatment VAS scores (table 1). A statistically 151⁄2-month follow-up.
significant difference existed in the posttreatment VAS scores for When we separately analyzed subgroups above and below
the 2 groups. Although paired t tests indicated that the pretreat- the mean age (35y), we found no statistically significant dif-
ment VAS (3.6 ⫾ 2.1) and posttreatment VAS (3.8 ⫾ 1.8) scores ferences in radiographic measurements for younger and older
for the control group were not statistically significant (P ⫽ .49), treatment group subjects for 9 of 10 angles; the exception was
there was a statistically significant difference (P ⬍ .0001) for VAS the segmental angle at C5– 6 (table 3).

Table 2: Treatment Group (n ⴝ 30) Average Lateral Cervical Radiographic Measurement Comparisons

Preradiograph 1st Postradiograph 2nd Postradiograph Change

Variable (mean ⫾ SD) (mean ⫾ SD) Change P* (mean ⫾ SD) (2nd ⫺ 1st)

TzC1–T1 (mm)† 22.1 ⫾ 13.2 15.9 ⫾ 12.9 ⫺6.2 .0001 15.3 ⫾ 13.0 ⫺0.6
TzC2–7 (mm)† 23.6 ⫾ 10.9 18.4 ⫾ 11.1 ⫺5.2 .0001 19.2 ⫾ 11.1 0.8
C1 horizontal ⫺16.7° ⫾ 8.2° ⫺26.0° ⫾ 7.4° 9.3° ⬍.0001 ⫺24.0° ⫾ 8.4° ⫺2.0°
RRA C2–3‡ ⫺6.1° ⫾ 5.6° ⫺9.1° ⫾ 6.1° 3.1° .0011 ⫺6.4° ⫾ 5.2° ⫺2.7°
RRA C3–4 ⫺1.2° ⫾ 6.0° ⫺4.2° ⫾ 6.6° 3.0° .0054 ⫺4.4° ⫾ 6.5° 0.2°
RRA C4–5 ⫺0.1° ⫾ 5.5° ⫺4.8° ⫾ 7.9° 4.7° .0013 ⫺5.5° ⫾ 4.4° 0.7°
RRA C5–6 ⫺0.9° ⫾ 6.1° ⫺3.8° ⫾ 6.0° 2.8° .0075 ⫺2.3° ⫾ 5.8° ⫺1.5°
RRA C6–7 ⫺4.1° ⫾ 5.2° ⫺4.7° ⫾ 5.4° 0.6° .48 ⫺4.3° ⫾ 5.9° ⫺0.4°
ARA C2–7§ ⫺12.4° ⫾ 11.0° ⫺26.6° ⫾ 13.3° 14.2° ⬍.0001 ⫺22.9° ⫾ 13.5° ⫺3.7°
Cobb C1–7㛳 ⫺41.1° ⫾ 11.6° ⫺53.9° ⫾ 13.4° 12.7° ⬍.0001 ⫺49.4° ⫾ 12.9° ⫺4.5°
Cobb C2–7 ⫺4.8° ⫾ 10.9° ⫺16.9° ⫾ 12.7° 12.1° ⬍.0001 ⫺13.7° ⫾ 12.0° ⫺3.2°
Chamberlain¶ ⫺1.4° ⫾ 9.2° ⫺9.9° ⫾ 9.8° 8.5° ⬍.0001 ⫺10.4° ⫾ 10.3° 0.5°

NOTE. First follow-up radiographs were at a mean of 3 months and 35 traction sessions and second follow-up (long-term) at mean of 15.5 ⫾
8.2 months. Negative sign in RRA, ARA, and Cobb means extension.
* Two-sided paired t test.
†
Tz is the horizontal distance of C1 posterosuperior body corner to posteroinferior of T1 or horizontal distance of C2 posterosuperior body
corner to posteroinferior of C7.
‡
RRA is the segmental angle formed by posterior vertebral body tangents.
§
ARA is the total curve angle from C2 to C7 formed by posterior vertebral body tangents.
㛳
Cobb angle C1–7 is the line through C1 arches to inferior endplate of C7 or Cobb angle C2–7 equals the line on inferior endplate of C2 to
inferior endplate of C7.
¶
Chamberlain to horizontal is the posterior hard palate to posterior foramen magnum to horizontal.

Arch Phys Med Rehabil Vol 83, April 2002

 NEW 3-POINT BENDING CERVICAL TRACTION, Harrison 451

Fig 3. Example patient with kyphosis who had a return to lordosis at follow-up. (A) The patient’s lateral cervical radiograph depicts a
kyphotic configuration of 16°. (B) After 9 weeks of a new 3-point bending cervical traction, the configuration is lordotic.

DISCUSSION
Table 3: Mean Radiographic Changes in Treatment Group We hypothesized that the new 3-point bending cervical exten-
for Age Comparisons sion traction procedure would increase anterior disk height and
anterior longitudinal ligament length thereby producing an in-
ⱕ35y (n ⫽ 14) ⬎35y (n ⫽ 16)
Variable Mean ⫾ SD Mean ⫾ SD P* crease in lordosis. The increases in Cobb angles, absolute rotation
angle at C2–7, and all segmental angles supported our hypothesis
TzC1–T1
(mm) †
5.6 ⫾ 5.0 5.7 ⫾ 8.4 .98 of improved lordosis with this new type of extension cervical
TzC2–7 (mm)† 4.9 ⫾ 4.3 5.2 ⫾ 7.3 .91 traction. Whereas the differences between beginning and fol-
C1 horizontal 9.3 ⫾ 6.5 9.4 ⫾ 5.8 .99 low-up lateral cervical radiographic measurements for the control
RRA C2–3‡ 2.9 ⫾ 4.9 3.3 ⫾ 4.6 .82 group were 1.1° or less for all global and segmental angles, the
RRA C3–4 4.5 ⫾ 4.9 1.7 ⫾ 5.6 .16 treatment group had a mean 14° increase in lordosis measured at
RRA C4–5 3.8 ⫾ 9.2 5.6 ⫾ 5.3 .52 the intersection of the posterior tangents on C2 and C7. Also, for
RRA C5–6 5.5 ⫾ 5.6 0.5 ⫾ 4.0 .01 the treatment group, statistically significant increases in lordosis
RRA C6–7 ⫺0.9 ⫾ 5.2 1.9 ⫾ 4.0 .11 were observed for the Cobb angles and all segmental angle means
ARA C2–7§ 15.8 ⫾ 12.0 12.9 ⫾ 8.0 .46 except C6 –7. This is in contrast to the straightening of the cervical
Cobb C1–7¶㛳 13.6 ⫾ 13.2 11.9 ⫾ 7.1 .66 lordosis found with flexion cervical traction.
Cobb C2–7 13.8 ⫾ 13.5 10.7 ⫾ 9.3 .47 It might be thought that spinal manipulation had a part in
Chamberlain¶ 7.5 ⫾ 11.6 9.3 ⫾ 7.3 .63 restoring cervical lordosis. Although evidence exists for pain
* Two-sided paired t test.
relief and increased ROM with cervical manipulation, there are
†
Tz is the horizontal distance of C1 posterosuperior body corner to no reports of changes in cervical lordosis with cervical spine
posteroinferior of T1 or horizontal distance of C2 posterosuperior manipulation.41,48,49
body corner to posteroinferior of C7. Cervical traction applied in the standard manner attempts to
‡
RRA is the segmental angle formed by posterior vertebral body decrease cervical lordosis with traction forces in flexion. Its
tangents.
§
ARA is the total curve angle from C2 from to C7 formed by poste- purpose is to separate the vertebrae, increase the width of the
rior vertebral body tangents. foramina, and stretch the posterior neck muscles. All these
㛳
Cobb angle C1–7 is the line through C1 arches to inferior endplate effects have been documented radiographically.25,50-52
of C7 or Cobb angle C2–7 equals the line on inferior endplate of C2 In ventroflexion the cervical canal is lengthened; whereas in
to inferior endplate of C7.
¶
Chamberlain to horizontal is the posterior hard palate to posterior dorsal extension the canal is shortened (the posterior contour
foramen magnum to horizontal. more than the anterior). This finding has led to the belief that

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452 NEW 3-POINT BENDING CERVICAL TRACTION, Harrison
Fig 3. (Continued ) (C) At 7 months’ follow-up (10mo after initial
examination), the configuration is still lordotic. This subject reported
VAS pain ratings of 5, 0.5, and 0.5 for initial examination, 10-week
follow-up, and at long-term follow-up, respectively. The curved line
depicts the normal lordotic arc of a circle suggested by Harrison et al.43
ventroflexion traction is recommended. However, in ven-
troflexion, the spinal cord is stretched; the nerve root sleeves
unfold and become taut; the dura of the nerve roots straightens
and brings the root into contact with the inferior and medial
margin of the pedicle, decreasing the dural space; and blood
vessels are constricted (Poisson effect). Also, flexion-bending
moments of the cervical spine do not, as has been thought,
involve axial displacement of the cord within the canal, but
rather the cord undergoes elastic and plastic deformation.1
In dorsal extension, the cord and nerve roots are folded and
relaxed, the cord and nerve roots increase in cross-section, and the
vessels increase in cross-section. Because compression of nervous
tissue has been accepted as injurious by all, the previously men-
tioned findings by Breig1 justify rehabilitating the cervical lordo-
sis. With this new type of 3-point bending cervical traction, Cobb
angles and absolute rotation angles from C2–7 show an increase in
lordosis, thereby affording the nerve roots less compression and
the possibility of a greater degree of recovery.
In the present study, the beginning and follow-up (mean,
81⁄10 ⫾ 61⁄2mo) radiographic measurements for the control
group (difference, ⱕ1.1° for all global and segmental angles)
also indicate that lateral cervical posture and radiographic
positioning are repeatable and reliable.
Arch Phys Med Rehabil Vol 83, April 2002
It may be that age could affect the amount of increased
lordosis in the treatment group. However, we found no statis-
tically significant differences in treatment group improvements
for 11 of 12 measurements when comparing 2 age groups
separated by median age (table 3).
It may also be that increased lordosis resulting from this new
type of traction would be transient. However, comparison of
radiographic measurements at 3 and 181⁄2 months (mean long-
term follow-up, 151⁄2 ⫾ 81⁄6mo) indicates that cervical lordotic
improvements were long-lasting. At long-term follow-up (see
table 2), only 3.5° mean loss was observed in the intersection
angle of posterior tangents at C2 and C7.
Only 1 other study41 reporting on cervical lordosis improve-
ments with cervical traction was located. However, the method
used was a type of hyperextension with compression, which
many patients may not be able to tolerate, especially patients
with any form of canal or foraminal stenosis. The present study
achieved similar improvements in cervical lordosis (⬃14°) in
fewer patient visits. However, in the present study, the traction
time for each session (20-min maximum) was twice that of the
previous study (10-min maximum).
It is unknown, because of the nonrandomized nature of the
present study, if the pre- to postintervention difference in the
treatment groups’ VAS pain scores was related to their receiving
cervical traction. The recent literature provides some evidence that
cervical spinal manipulative therapy is an effective treatment for
the relief of some cervical spine pain syndromes.53,54 To answer
this study question, a randomized trial with another treatment
group receiving only spinal manipulation would be needed. Al-
though spinal manipulation has not been shown to be associated
with sagittal curve improvement, our experience is that correction
of cervical kyphosis with cervical extension traction is 1 factor
associated with improvement in some chronic pain syndromes
associated with cervical spine disorders. Future randomized clin-
ical trials should be performed to identify the specific benefits that
correction of cervical lordosis, using 3-point bending cervical
extension traction, may offer patients who suffer from chronic
cervical spinal disorders.
CONCLUSION
Thirty cervical pain subjects had statistically significant
changes in pain scales and lateral cervical radiographic mea-
surements compared with no change in 24 neck pain controls.
The new 3-point bending cervical traction procedure combined
with cervical manipulation produced statistically significant
and clinically significant increases in cervical lordosis for neck
pain subjects. Average improvements in cervical lordosis for
global angles in the treatment group between the Ruth Jackson
lines at C2 and C7 were 14.2° and, in Cobb angles at C1–7 and
C2–7, were 12.7° and 12.1°, respectively. At 151⁄2 ⫾ 81⁄6
months’ follow-up, total cervical lordosis remained stable with
only an approximate mean 3.5° loss compared with the
3-month follow-up values at C2–7. For control subjects, we
found no statistically or clinically significant differences for
beginning and follow-up radiographic measurements at a mean
of 81⁄10 ⫾ 61⁄6 months, indicating the repeatability of radio-
graphic positioning, radiographic line drawing analysis, and
sagittal cervical posture.
Acknowledgments: We thank Dr. Sanghak O. Harrison for her
artwork and Drs. Shirlene Ching and Mark Szostezuk for data collection.
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Arch Phys Med Rehabil Vol 83, April 2002