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

Abstract

The objective of the study was to develop a clinical prediction rule (CPR) to identify patients with neck pain likely to improve with cervical traction. The study design included prospective cohort of patients with neck pain referred to physical therapy. Development of a CPR will assist clinicians in classifying patients with neck pain likely to benefit from cervical traction. Eighty patients with neck pain received a standardized examination and then completed six sessions of intermittent cervical traction and cervical strengthening exercises twice weekly for 3 weeks. Patient outcome was classified at the end of treatment, based on perceived recovery according to the global rating of change. Patients who achieved a change C?6 (''A great deal better'' or ''A very great deal better'') were classified as having a successful outcome. Univariate analyses (t tests and chi-square) were conducted on historical and physical examination items to determine potential predictors of successful outcome. Variables with a significance level of P B 0.15 were retained as potential prediction variables. Sensitivity, specificity and positive and negative likelihood ratios (LRs) were then calculated for all variables with a significant relationship with the reference criterion of successful outcome. Potential predictor variables were entered into a step-wise logistic regression model to determine the most accurate set of clinical examination items for prediction of treatment success. Sixty-eight patients (38 female) were included in data analysis of which 30 had a successful outcome. A CPR with five variables was identified: (1) patient reported peripheralization with lower cervical spine (C4-7) mobility testing; (2) (2009( ) 18:382-391 DOI 10.1007 test; (3) age C55; (4) positive upper limb tension test A; and (5) positive neck distraction test. Having at least three out of five predictors present resulted in a ?LR equal to 4.81 (95% CI = 2.17-11.4), increasing the likelihood of success with cervical traction from 44 to 79.2%. If at least four out of five variables were present, the ?LR was equal to 23.1 (2.5-227.9), increasing the post-test probability of having improvement with cervical traction to 94.8%. This preliminary CPR provides the ability to a priori identify patients with neck pain likely to experience a dramatic response with cervical traction and exercise. Before the rule can be implemented in routine clinical practice, future studies are necessary to validate the rule. The CPR developed in this study may improve clinical decision-making by assisting clinicians in identifying patients with neck pain likely to benefit from cervical traction and exercise.Eur Spine J

Exercise Only, Exercise With Mechanical Traction, or Exercise With Over-Door Traction for Patients With Cervical Radiculopathy, With or Without Consideration of Status on a Previously Described Subgrouping Rule: A Randomized Clinical Trial

“…18,40,48 Several factors might have influenced the effectiveness of cervical traction in prior clinical trials. Previous studies 6,34 have suggested that inadequate specificity in patient selection may be at least partly responsible for the lack of effectiveness. Improved targeting of treatment to patients most likely to benefit has shown promise toward enhancing effect sizes in clinical trials, 26 yet the characteristics of patients likely to benefit from cervical traction remain mostly a matter of opinion and low-level evidence.…”

“…Observational studies and practice guidelines suggest that traction may be most effective in the subgroup of patients with neck pain who exhibit signs of cervical radiculopathy. 6,8,9,16 Raney and colleagues 34 identified even more-specific criteria associated with clinical benefit from treatment that includes cervical traction. Five clinical factors were predictive of benefit: (1) peripheralization of symptoms with lower cervical mobility testing, (2) positive shoulder abduction sign, (3) positive manual distraction test, (4) positive upper-limb tension test, and (5) age of 55 years or older.…”

“…The presence of at least 3 of these 5 factors provided optimal predictive validity and was proposed to define a subgroup of patients highly likely to respond to cervical traction. 34 Only a few previous clinical trials have exclusively evaluated patients with cervical radiculopathy, and the validity of the more-specific traction subgroup remains unexamined.…”

“…Our primary research question was to evaluate the effectiveness of cervical traction in a sample of patients with signs of radiculopathy and to evaluate the effect on outcomes of the manner in which cervical traction was provided by comparing traction using a motorized device to an over-door unit designed for home use. Secondarily, we examined if targeting traction to a more-specific subgroup of patients, defined by the presence of at least 3 of the 5 previously defined factors, 34 would improve clinical outcomes.…”

Evidence-Based Physical Medicine and Rehabilitation Strategies for Patients with Cervical Radiculopathy Due to Disc Herniation

“…Therefore, a number factors, such as the selection of the appropriate patient who is likely to benefit from cervical traction, appear to be important. A group of researchers identified five clinical criteria age at 55 years or over, reporting of peripheralization with C4-C7 mobility tests, positivity of shoulder abduction test, positivity of upper extremity tension test, and positivity of neck distraction test that might influence successful outcomes for cervical traction; having four of these criteria increases the success probability of cervical traction to 94.8% (50).…”