Traction for Neck Pain CPR


Raney et al[1] developed a Clinical Prediction Rule (CPR) for identifying patients with neck pain likely to respond to mechanical cervical traction. Eighty patients with neck pain received 6 sessions of intermittent cervical traction and cervical exercises 2x/week for 3 weeks. Outcome was measured based on the global rating of change (>  ±6 were classified as having a successful outcome). Based on a significance level of P < 0.15, five variables out of 15 potential variables were retained in the final regression model.

A CPR with 5 variables was identified:

  1. patient reported periperalization with lower cervical spine (C4-7) mobility testing,
  2. positive shoulder abduction test,
  3. age > 55,
  4. positive upper limb tension test A,
  5. positive neck distraction test

Although a following validation study is warranted, this preliminary CPR provides the ability for a clinician to identify the sub-group of patients with neck pain who would most likely to benefit from cervical traction and exercise.

Combination of Predictor Variables and Associated Accuracy Statistics[1]

The probability of successful outcome after cervical traction is calculated using the + LR and pretest probability of 44% (30 out of 68 patients). Accuracy statistics with 95% CI for individual variables for predicting success with cervical traction.

# of predictors present Sensitivity                         Specificity                         + LR                                       - LR                                    Probability of success w/ cervical traction + exercise
> 4 0.30 (0.17-0.48) 1.0 (0.91-1.0) 23.1 (2.25-227.90) 0.71 (0.53-0.85) 94.8%
> 3 0.63 (0.46-0.78) 0.87 (0.73-0.94) 4.81 (2.17-11.4) 0.42 (0.25-0.65) 79.2%
> 2 0.30 (0.17-0.48) 0.97 (0.87-1.00) 1.44 (1.05-2.03) 0.40 (0.16-0.90) 53.2%
> 1 0.07 (0.02-0.21) 0.97 (0.87-1.00) 1.15 (0.97-1.4) 0.21 (0.03-1.23) 47.6%
  • Having at least 3 out of 5 predictors appears to be the optimal threshold for choosing the cervical traction as an intervention.
  • Having fewer than 2 predictors might indicate a sub-group who would preferentially benefit from a different intervention (e.g.) pt had 1/5 predictor variables, the post-test probability of success with cervical traction and exercise is only 47.5%, less than a chance.

Description of Special Tests[1]

Test Procedure Positive Test
Shoulder abduction test Pt in sitting position. Pt is instructed to place the hand of the affected extremity on the head in order to support the extremity in the scapular plane Alleviation of symptoms
Upper limb tension test (ULTT A)

Pt supine. Examiner sequentially introduces the following movements to the symptomatic UE:

  1. Scapular depression
  2. Shoulder abduction
  3. Forearm supination
  4. Wrist and finger extension
  5. Shoulder external rotation
  6. Elbow extension
  7. Contralateral then ipsilateral cervical side bending
Reproduction of Symptoms
Neck distraction test Pt supine w/ neck comfortably positioned. Examiner securely grasps the pt's head under the occiput and chin and gradually applies an axial traction force up to approximately 30 pounds.  Reduction or elimination of symptoms

Description of Exercises[1][2]

Exercise Procedure
Seated posture exercise Pt sitting with spine in a natural lordosis. Pt retract scapulae and gently elongate the cervical spines to achieve a neutral upright postural position. (Hold 10 sec, 2x/hr)
DNF exercise

Pt supine. Perform a slow and controlled craniocervical flexion motion without contracting the large superficial anterior neck muscles. (Hold 10 sec x 10; 2x/day)


  1. 1.0 1.1 1.2 1.3 Raney N, Petersen EJ, Smith TA, Cowan JE, Rendeiro DG, Deyle GD, Childs JD. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J 2009;18:382-391
  2. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, Emberson J, Marschner I, Richardson C. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;27:1835-1843