Abstract
Background
Cervical Radiculopathy (CR) is a neurologic condition characterized by a dysfunction of a cervical spinal nerve, the roots of the nerve, or both. In CR, one of the most unpleasant symptoms after radicular pain is cervicogenic dizziness, which is characterized by postural balance disorders. Despite its effectiveness on pain and function, cervical traction has not been used to treat postural balance disorders in CR patients. Thus, the objective of this study was to evaluate the effect of mechanical intermittent cervical traction (MICT) on clinical and posturographic balance parameters in patients with CR.
Methods
Patients with cervical radiculopathy (CR), were randomized into three active intervention groups receiving different traction loads: 2 kg (group A), 8 kg (group B), and 12 kg (group C), allowing for a dose–response comparison within a randomized controlled framework. The 2 kg traction group served as a control condition. Each group underwent 12 sessions of MICT (three sessions per week), combined with a standard rehabilitation program. Assessments were conducted at baseline, at the end of treatment, and at 3 and 6 months post-treatment. Outcome measures included posturographic parameters, clinical balance (Brief BESTest), CR pain, cervical active range of motion, proprioception, muscle strength, handgrip strength, neck-related disability (Neck Disability Index), psychological status (Hospital Anxiety and Depression Scale), and quality of life (WHOQOL-Bref).
Results
The results showed that the surface of postural sway in the eyes-closed condition improved more significantly in group C than in groups A and B at the end of treatment (p = 0.04) and at 6-month (p = 0.014) follow-up. Radicular pain showed greater improvement in group C compared to groups A and B at the end of treatment (p = 0.029). Depression scores improved significantly in group C compared to group A at 3 months (p = 0.038). The physical domain of the WHOQOL-Bref improved more significantly in group C than in groups A and B at 3 months (p = 0.04) and 6 months (p = 0.001). Additionally, the psychological domain of the WHOQOL-Bref improved more significantly in group C than in groups A and B at 6 months (p = 0.017).
Conclusion
MICT demonstrates a beneficial medium-term effects on posturographic parameters, pain, and depression in patients with CR, particularly when using a 12 kg load.
Trial registration
The study protocol was retrospectively registered at the ClinicalTrials.gov Registry (NCT06727747). Date of registration is 2024-10-14.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12891-025-09221-7.
Keywords: Cervical radiculopathy; Physical therapy techniques, postural control; Posturography, stabilometry; Pain; Rehabilitation, randomized controlled trial
Background
Cervical radiculopathy (CR) is a neurological disorder caused by dysfunction of a cervical spinal nerve, its roots, or both [1]. The most common causes include cervical spondylosis and foraminal encroachment secondary to disc herniation, while less frequent etiologies involve instability, trauma, or malignancy [2]. Clinically, CR typically manifests as neck pain radiating to one or both arms, accompanied by sensory disturbances, diminished reflexes, and motor weakness corresponding to the affected nerve root [3]. CR can lead to functional limitations, psychological distress, and a reduced quality of life (QoL), representing a significant health, societal, and economic burden [3]. The condition is relatively common, with a prevalence of 3.5 per 1,000 individuals [4] and an annual incidence of 83.2 per 100,000 [5].
Beyond radicular pain, patients with CR may also experience postural balance disorders, clinically manifesting as cervicogenic dizziness (also referred to as cervical vertigo) [6]. These symptoms (unsteadiness, disorientation, and imbalance) are believed to result from altered proprioceptive input from cervical structures, particularly the deep intervertebral muscles [7–9]. Such disturbances are often detectable via posturographic abnormalities, which represent the most consistent objective markers for distinguishing affected patients from healthy controls [10]. Similar findings have also been observed in athletes following fatigue of the cervical extensor muscles [11].
Evidence regarding the efficacy of rehabilitation programs, typically multimodal, in managing postural balance disorders in patients with cervical spine pathologies, especially CR, remains scarce and inconclusive. The specific contribution of cervical traction (CT) in this context is still debated [12–14]. Nevertheless, some studies suggest that CT may produce acute improvements in posturographic parameters in patients with CR [6]. CT is widely used in CR management for its analgesic and functional benefits [15, 16]. It can be delivered mechanically or manually, and either intermittently or continuously. Its therapeutic effects are believed to include stretching of soft tissues (muscles and ligaments), facet joint mobilization, vertebral space widening, and enlargement of the intervertebral foramina, which collectively reduce nerve root compression and may alleviate radicular pain and associated symptoms such as cervicogenic headache and dizziness [16, 17].
To our knowledge, no previous study has investigated the medium- or long-term effects of CT on postural balance in CR patients.
The present study aimed to evaluate the efficacy of mechanical intermittent cervical traction (MICT) on postural balance in patients with CR, using both clinical and posturographic outcome measures.
Methods
Study design and setting
This randomized controlled clinical trial involved three parallel groups. Patients were recruited from the Physical Medicine and Rehabilitation (PMR) and Rheumatology departments of Fattouma Bourguiba University Hospital in Monastir, Tunisia, between February and June 2023. All assessments and interventions were conducted in the PMR department. The study adhered to the CONSORT guidelines to ensure methodological rigor and transparency in reporting.
Participants
Patients diagnosed with cervical radiculopathy (CR) were screened for eligibility. Inclusion criteria were: age between 18 and 70 years and CR symptoms persisting for at least three months. Exclusion criteria included recent rehabilitation or manual therapy (within three months), neurological or rheumatic conditions involving the cervical spine or affecting balance, prior cervical spine surgery or trauma, ENT or ophthalmologic conditions impacting balance, diabetes with autonomic complications, cardiac arrhythmias, neurological deficits (sensory, motor, or balance), severe osteoporosis, or long-term corticosteroid use. Patients reporting worsening symptoms during manual cervical traction testing were also excluded.
Ethical considerations
All participants provided written informed consent. The study protocol was approved by the ethics committee of the Faculty of Medicine of Monastir (IORG 0009738, No. 121/OMB 0990 − 0279).
Randomization
Randomization was conducted via Randomization.com by an independent statistician using a 1:1:1 allocation ratio. Patients were assigned to one of three groups based on cervical traction load: Group A (2 kg), Group B (8 kg), or Group C (12 kg). Group A served as the control group, as previous biomechanical studies indicated that a load inferior to 5 kg (2 kg in group A) does not significantly affect cervical structures. The clinician responsible for assessing eligibility was not involved in randomization, and outcome assessors were blinded to group allocation. Interventions were administered by three experienced physical therapists.
Interventions
All patients received a standardized rehabilitation program comprising superficial thermotherapy, cervical mobility and strengthening exercises, and postural education. Detailed descriptions of the rehabilitation program are available in a previous study [17].
Mechanical intermittent cervical traction (MICT) was applied in all groups at differing loads (2 kg for Group A, 8 kg for Group B, and 12 kg for Group C), as described in prior literature [17]. While 12 kg traction promotes distraction of the facet joints and intervertebral spaces, 8 kg primarily targets paraspinal musculature. The 2 kg load which does not have any significant effect on cervical anatomical structures, served as a placebo control, enabling equivalent treatment conditions across groups [18, 19]. Patients received 12 sessions (three per week) over one month. Follow-up assessments were conducted immediately post-intervention, and at three and six months. The study followed the CONSORT-Outcomes 2022 Extension.
Outcome measures
Primary outcomes were clinical and posturographic balance parameters. Clinical balance was assessed using the Brief BESTest, a validated tool comprising eight items covering six balance subsystems, scored from 0 to 3 (maximum score: 24), with higher scores indicating better balance) [20]. Posturographic assessment was performed with a Satel1 force platform (model PF2002, software v33.5 8 C, France) [21]. Parameters collected included sway area (CoP/SA, mm²), as well as the amplitude and velocity of mediolateral (LD, LV) and anteroposterior (AD, AV) center-of-pressure displacements. Measurements were taken under eyes-open (EO) and eyes-closed (EC) conditions, each lasting 51.2 s at 40 Hz sampling rate.
Secondary outcomes included CR pain intensity, cervical range of motion (ROM), cervical proprioception, cervical muscles strength, handgrip strength (HGS), disability, psychological status, and quality of life (QoL). CR pain intensity at the time of clinical evaluation was assessed using the 100 mm visual analogue scale. Cervical ROM was assessed using the Cervical Range-of-Motion instrument (CROM; Performance Attainment Associates, St Paul, MN). which, through its three inclinometers, reliably quantifies active cervical spine mobility in flexion, extension, rotation, and lateral flexion [22]. Cervical proprioception was evaluated with the CROM device [23]. Its test-retest reliability for assessing head repositioning error in individuals with cervical radiculopathy demonstrated intra-class correlation coefficients (ICC) ranging from 0.79 to 0.85 [24]. Patients wearing the CROM device were instructed to maintain a neutral head position while seated (reference position). With eyes closed, the examiner passively moved the patient’s head, and the patient was then instructed to actively return to the reference position; the repositioning error, expressed in degrees, was measured by the examiner for flexion and extension movements. Cervical muscle strength was measured in Newtons using a handheld isometric dynamometer (MicroFET2; Hoggan Health Industries) [25]. The device was positioned on the forehead to assess flexor strength and on the occiput to assess extensor strength [25]. HGS was measured in kilograms on both sides using the Jamar hydraulic handheld dynamometer (Lafayette Instrument Company, USA) [26]. This device has demonstrated excellent test-retest reliability in CR patients, with an intraclass correlation coefficient of 0.976 [26]. Neck-related functional disability was assessed using the Arabic version of the Neck Disability Index (NDI), which demonstrates high internal consistency (Cronbach’s α = 0.89) and excellent test-retest reliability (ICC = 0.96; 95% CI: 0.93–0.97) [27]. The NDI comprises 10 items, each scored from 0 (no disability) to 5 (complete disability), with the total score expressed as a percentage; higher scores indicate greater disability [27]. Anxiety and depression were assessed using the Arabic version of the Hospital Anxiety and Depression Scale (HADS), which demonstrated adequate internal consistency, with a Cronbach’s α of 0.83 (95% CI: 0.79–0.88) for the anxiety subscale and 0.77 (95% CI: 0.70–0.83) for the depression subscale [28]. The HADS consists of 14 items (7 assessing anxiety and 7 assessing depression) each rated from 0 to 3. The maximum score for each subscale is 21, with higher scores indicating worse psychological status [29]. The Arabic version of the World Health Organization Quality of Life questionnaire (WHOQOL-BREF) was used to assess participants’ QoL. It demonstrated excellent reliability, with an intraclass correlation coefficient of 0.95 (95% CI: 0.94–0.97) and a Cronbach’s α of 0.93 [30]. It covers 4 domains (physical health, psychological well-being, social relationships, and environment), expressed in percentages with a higher score indicating better QoL [30].
Blinding
Patients were blinded to traction load. Group allocation was concealed from the statistician and clinical assessors. The treating physiotherapists were not blinded.
Sample size
The sample size was calculated using the G*Power software version 3.1.9.4 [31]. The input parameters were an alpha level of 0.01 and 95% statistical power. The study of Chaibi et al. [32] was used as reference using an effect size of 0.4 of pain change. Power analysis indicated that 30 participants were required to detect significant group-by-time interactions. Accounting for an anticipated 20% dropout rate at six months, a total of 36 patients were recruited with 12 patients assigned to each treatment arm.
Statistical analysis
Data were collected and analyzed using SPSS software version 23.0. The Kolmogrov-Smirnov (KS) test was used to verify the normality of quantitative variables. Variables with normal distribution were described as means ± standard deviations (SD), and those with non-normal distribution as medians with interquartile ranges (IQR). Qualitative variables were expressed as frequencies and percentages. Baseline differences between groups were analyzed using one-way ANOVA with Bonferroni post-hoc tests for normally distributed data, or Kruskal–Wallis tests for non-parametric data. Categorical variables were compared using the Chi-square test.
Participants’ parameters were assessed at baseline (T0), post-treatment (T1), three months (T2), and six months (T3) follow-up. After testing assumptions of normality and sphericity, a one-way repeated measures ANOVA was applied to assess changes across time points within groups, with Bonferroni correction for pairwise comparisons. For variables not meeting parametric assumptions, the Friedman test was used as a non-parametric alternative. Between-group comparisons at each time point were performed using one-way ANOVA or Kruskal–Wallis tests as appropriate.
The primary analysis focused on between-group comparisons at post-treatment and follow-up time points. To estimate the magnitude of change, Cohen’s d effect sizes with conventional thresholds (0.2 = small, 0.5 = medium, 0.8 = large) [33] were calculated for repeated measures, along with 95% confidence intervals, to evaluate clinical relevance beyond statistical significance.
The significance level was set at p < 0.05 for all tests.
Results
During the recruitment period, 45 patients were screened for eligibility; 9 were excluded (3 did not meet the inclusion criteria, and 6 declined participation). A total of 36 patients (4 men and 32 women; gender ratio: 0.12) were randomly assigned to the three intervention groups. Two patients discontinued treatment because of pain exacerbation (one each from groups B and C). During follow-up, two additional patients were lost at the three-month mark (one from group A and one from group B), and two additional patients were lost at six months (one from group A and one from group C) (Fig. 1). Compliance was high across all groups, including the higher traction load group (12 kg), with no interruptions or refusals reported.
Fig. 1.
Flowchart of the study
There were no significant baseline differences between the groups regarding sociodemographic or general clinical characteristics (Table 1).
Table 1.
Comparison of sociodemographic and general characteristics between the three groups at baseline
| Group A (n = 12) |
Group B (n = 12) |
Group C (n = 12) |
P | |
|---|---|---|---|---|
| Mean ± SD | ||||
| Age (years) | 46.17 ± 8.70 | 43.25 ± 12.00 | 51.08 ± 8.97 | 0.170 |
| Employment status | ||||
| Strength work | 9 (75%) | 7 (58.3%) | 7 (58.3%) | 0.618 |
| Shiftwork | 3 (25%) | 5 (41.7%) | 5 (41.7%) | |
| Socio-economic level | ||||
| High | 1 (8.3%) | 2 (16.7%) | 3 (25%) | NA |
| Middle | 8 (66.7%) | 5 (41.7%) | 8 (66.7%) | |
| Low | 3 (25%) | 5 (41.7%) | 1 (8.3%) | |
| Medical and surgical history | 5 (41.7%) | 4 (33.3%) | 4 (33.3%) | 0,887 |
| Anthropometric measurements | ||||
| Weight (kg) | 74 ± 13.436 | 72.16 ± 12.02 | 76 ± 12.54 | 0.762 |
| Height (m) | 1.61 ± 0.07 | 1.63 ± 0.06 | 1.68 ± 0.05 | 0.052 |
| Body Mass Index (BMI) | 28.31 ± 3.69 | 26.84 ± 4.18 | 26.89 ± 4.79 | 0.635 |
| Evolution of cervical radiculopathy (months) | 36[17.7;60] | 15.5[12;36] | 30[18;72] | 0.105 |
Group A: MICT with 2 kg load MICT, Group B MICT with 8 kg load, Group C: MICT with 12 kg load
NA Not applicable, SD Standard deviation
At the end of the treatment period, among all posturographic parameters, only the change in CoP/SA under EC condition showed a significant difference between groups (Table 2). In group A, the effect size between the two groups was very small (Cohen’s d = 0.07, 95% CI [− 0.77, 0.91]), indicating that the observed difference is negligible and not statistically significant. In group B, the CoP/SA(ES) improvement from baseline to end of treatment demonstrated a large effect size (Cohen’s d = 0.81) (CI 95%= [−0.02; 1.64]), suggesting a clinically meaningful improvement. In group C, the effect size was moderate (Cohen’s d = 0.62) (CI 95%= [− 0.20;1.44]), also indicating a relevant within-group clinical change.
Table 2.
Comparison of the improvement of stabilometric parameters between the three groups (end of the treatment-baseline)
| Group A (n = 12) |
Group B (n = 11) |
Group C (n = 11) |
p | |
|---|---|---|---|---|
| Median [25th-75th percentile] | ||||
| CoP/SA(EO) mm² | 7.4[−9.9; 33.8] | 10.3[−4; 136.7] | 19.0[−24.3;202.7] | 0.545 |
| LD(EO) mm | 12.4 [−27; 31] | 29.3 [4.8; 56.1] | 0 [−67;111.7] | 0.511 |
| AD(EO) mm | 10.4 [−100.6; 42.7] | 30.2 [4.1; 95.6] | 11.8 [−32.6; 266.5] | 0.612 |
| LV(EO) mm/s | 0.4 [−0.5; 3.4] | 0.5 [0.1–1.1] | −0 0.9 [−2.2; 3.3] | 0.613 |
| AV(EO) mm/s | 0.2 [−1.9; 1.1] | 0.6 [0.08; 2.1] | 1.1 [−0.6; 5.2] | 0.469 |
| CoP/SA(ES) mm² | −112.2 [−512.0; 8.1] | 70.3 [5.3; 428.0] | 222.8 [−1.9; 539.4] | 0.04 |
| LD(ES) mm | 9.7 [−57.9; 48.8] | 28.5 [6.7; 168.1] | 0.0 [−34.7; 192.4] | 0.253 |
| AD(ES) mm | 11.1 [−85.5; 38.5] | 40.2 [0; 128 0.2] | 118.9 [−56.7; 335.4] | 0.225 |
| LV(ES) mm/s | 0.2 [−1.2; 0.9] | 0.5 [0.12; 2.3] | 0.0 [−0.68; 3.7] | 0.253 |
| AV(ES) mm/s | 0.2 [−1.7; 0.7] | 0.8 [0; 2.5] | 2.3 [−1.1; 6.5] | 0.206 |
Group A: MICT with 2 kg load MICT, Group B: MICT with 8 kg load, Group C: MICT with 12 kg load
CoP/SA (EO) Centre of pressure sway area eyes open, CoP/SA(ES) Centre of pressure sway area eyes shut, LD(EO) Lateral displacements eyes open, LD(ES) Lateral displacements eyes shut, AD(EO) Anteroposterior displacements eyes open, AD(ES) Anteroposterior displacements eyes shut, LV (EO) Lateral velocity eyes open, LV(ES) Lateral velocity eyes shut, AV (EO) Anteroposterior velocity eyes open, AV(ES) Anteroposterior velocity eyes shut
Group C showed greater improvement in terms of CR pain and right lateral flexion compared to group A. However, D4 of the WHOQOL-BREF showed significantly greater improvement in group A compared to groups B and C (Table 3).
Table 3.
Comparison of the improvement of clinical, functional, psychological and QoL parameters between the three groups (end of treatment-baseline)
| Group A (n = 12) |
Group B (n = 11) |
Group C (n = 11) |
p | Post hoc | |
|---|---|---|---|---|---|
| Brief BesTest (score) | 2.5[0.25-4] | 3[0–4] | 3[2.25-5] | 0.876 | - |
| CR pain (VAS/100) | 23.33 ± 21.03 | 39.16 ± 11.64 | 40.66 ± 16.34 | 0.029 | C > A |
| Cervical ROM (degree) | |||||
| Flexion | 7.5 ± 8.39 | 11.66 ± 10.07 | 10 ± 9.04 | 0.542 | - |
| Extension | 5.41 ± 9.4 | 12.75 ± 12.99 | 10.83 ± 8.21 | 0.217 | - |
| Right rotation | 9.58 ± 9.4 | 14.83 ± 11,41 | 18.16 ± 14.72 | 0.228 | - |
| Left rotation | 8.5 ± 13.26 | 15 ± 10.87 | 16.66 ± 10.51 | 0.206 | - |
| Right lateral flexion | 2.33 ± 7.19 | 10.75 ± 10.49 | 11.25 ± 6.78 | 0.021 | C > A |
| Left lateral flexion | 5.66 ± 7.96 | 7.66 ± 7.12 | 9.75 ± 8.19 | 0.446 | - |
| Muscle strength (newton) | |||||
| Flexors strength | 0.72 ± 1.35 | 0.96 ± 1.56 | 0.65 ± 0.96 | 0.829 | - |
| Extensors strength | 0.85 ± 1.24 | 1.37 ± 1.3 | 1.85 ± 1.35 | 0.192 | - |
| Right HGS | 2.8 ± 5.04 | 1.83 ± 6.02 | 3.5 ± 4.27 | 0.732 | - |
| Left HGS | 1.83 ± 2.28 | 2.08 ± 6.31 | 0.58 ± 3.82 | 0.681 | - |
| Cervical proprioception (degree) | |||||
| Mean flexion angle error | 1.16 ± 5.02 | 4.41 ± 3.36 | 6.41 ± 13.62 | 0.333 | - |
| Mean extension angle error | 2.58 ± 5.46 | 6.16 ± 3.56 | 4.25 ± 4.53 | 0.176 | - |
| NDI (score) | 9.2[0;28.1] | 14[−3;19] | 12.5[5.1;21.1] | 0.955 | - |
| WHOQOL-BREF domains (score) | |||||
| D1 : physical health | 11.91 ± 7.07 | 7 ± 9.13 | 13.41 ± 6.59 | 0.117 | - |
| D2 : psychological | 11.08 ± 8.98 | 3.25 ± 11.85 | 9.83 ± 9.19 | 0.14 | - |
| D3 : social relationships | 8.58 ± 12,16 | 1.58 ± 11.78 | 1.91 ± 20.77 | 0,466 | - |
| D4 : environment | 11.75 ± 8.57 | 4.16 ± 5.06 | 2.41 ± 10.29 | 0.022 | A > B,C |
| HAD (score) | |||||
| HAD-A | 2.5[0.5;5] | 3[2;4.7] | 2.5[1–3] | 0.388 | - |
| HAD-D | 2[0.25–4.5] | 3[0.5–3.75] | 3[2-3.75] | 0.748 | - |
Group A: MICT with 2 kg load MICT, Group B MICT with 8 kg load, Group C: MICT with 12 kg load; P: comparison between groups with covariance analysis, Post hoc using Dunnett’ test
CR Cervical radiculopathy, VAS Visual analogue scale, HGS Handgrip strength, NDI Neck disability index, HAD Hospital Anxiety and Depression scale
At the three-month follow-up, no significant between-group differences were observed in posturographic parameters (Table 4). However, group A demonstrated significantly smaller improvements than groups B and C in right lateral flexion, and smaller improvements than group C in mean flexion angle error. Group C showed superior improvement in WHOQOL-BREF domain 1 (physical health) compared to groups A and B (p = 0.004), and in HADS depression subscale compared to group A (p = 0.038) (Table 5).
Table 4.
Difference of the improvement of stabilometric parameters between the three groups on follow-up (3 months after the end of the treatment-baseline)
| Group A (n = 11) |
Group B (n = 10) |
Group C (n = 11) |
p | |
|---|---|---|---|---|
| Median [25th-75th percentile] | ||||
| CoP/SA(EO) mm² | 0[−50;40.7] | −6.5[−20.1; −142.0] | 0[47; 445] | 0.053 |
| LD(EO) mm | 9[2.5;34.9] | 5.5[21.0; 48.1] | −28.3[−97.7;65.9] | 0.432 |
| AD(EO) mm | 8.3 [−2.9;85.5] | 42.0[1.8; 123.8] | 0[−206;266] | 0.455 |
| LV(EO) mm/s | 0.69 [−0 0.05; 1.98] | 0.07[−0.33;0.95] | −0.55[−1.91;1.41] | 0.256 |
| AV(EO) mm/s | 4.1 [2.3;5.8] | 2[1.7;3.9] | 3.1[0.8;6.5] | 0.255 |
| CoP/SA(ES) mm² (Mean ± SD) | −13.15 ± 215.3 | 162.26 ± 232.53 | 189.2 ± 541. 8 | 0.365 |
| LD(ES) mm | 8.4 [−71.0; 61.9] | 22.6 [17.2;118.7] | 0[−194; 85.3] | 0.242 |
| AD(ES) mm | 51.9[−30.9;121.6] | 51.1 [−10.2;129.6] | 0[−493.0;297.3] | 0.669 |
| LV(ES) mm/s (Mean ± SD) | 0.11 ± 1.4 | 1.6 ± 3.2 | 1.9 ± 11.1 | 0.806 |
| AV(ES) mm/s (Mean ± SD) | 1.2 ± 2. 4 | 1.5 ± 3.9 | 0.4 ± 9.0 | 0.904 |
Group A: MICT with 2 kg load MICT, Group B: MICT with 8 kg load, Group C: MICT with 12 kg load
CoP/SA (EO) Centre of pressure sway area eyes open, CoP/SA(ES) Centre of pressure sway area eyes shut, LD(EO) Lateral displacements eyes open, LD(ES) Lateral displacements eyes shut, AD(EO) Anteroposterior displacements eyes open, AD(ES) Anteroposterior displacements eyes shut, LV (EO) Lateral velocity eyes open, LV(ES) Lateral velocity eyes shut, AV (EO) Anteroposterior velocity eyes open, AV(ES) Anteroposterior velocity eyes shut, SD Standard deviation
Table 5.
Difference of the improvement of clinical, functional, psychological and QoL parameters between the three groups on follow-up (3 months after the end of treatment-baseline)
| Group A (n = 11) |
Group B (n = 10) |
Group C (n = 11) |
p | Post hoc | |
|---|---|---|---|---|---|
| Mean ± SD | |||||
| Brief BesTest | 2.91 ± 2.35 | 7.08 ± 17.21 | 3.33 ± 1.82 | 0.544 | - |
| CR pain (VAS/100) | 29.7 ± 19.5 | 32.5 ± 21.3 | 36.5 ± 19.7 | 0.724 | - |
| Cervical ROM (degree) | |||||
| Flexion | 9.5 ± 8.5 | 12.91 ± 10.32 | 10.9 ± 11.5 | 0.730 | - |
| Extension | 5.90 ± 7.68 | 11.91 ± 8.33 | 13.33 ± 8.07 | 0.089 | |
| Right rotation | 8.33 ± 9.61 | 14.83 ± 13.86 | 17.33 ± 12.31 | 0.184 | - |
| Left rotation | 10.58 ± 13.33 | 16.66 ± 10.94 | 15.83 ± 10.83 | 0.399 | - |
| Right lateral flexion | 3.45 ± 7.09 | 14.08 ± 8.73 | 13.75 ± 6.07 | 0.002 | A < B,C |
| Left lateral flexion | 8.00 ± 6.16 | 11.41 ± 8.91 | 11.83 ± 7.82 | 0.445 | - |
| Muscle strength (Newton) | |||||
| Flexors strength | 1[0.1–1.5] | 0.9 [0.07-3] | 1[0.25-2] | 0.719 | - |
| Extensors strength | 0.94 ± 1.43 | 0.95 ± 1.48 | 1.95 ± 1.65 | 0.196 | - |
| Right HGS | 2.63 ± 5.45 | 1.46 ± 7.99 | 4.5 ± 4.83 | 0.494 | - |
| Left HGS | 2.83 ± 1.94 | 3.83 ± 4.54 | 1.33 ± 4.61 | 0.301 | - |
| Cervical proprioception (degree) | |||||
| Mean flexion angle error | −0.9 ± 4.72 | 2.7 ± 5.3 | 7.8 ± 10.49 | 0.027 | A < C |
| Mean extension angle error | 0.72 ± 5.08 | 3.25 ± 6.34 | 4.08 ± 4.62 | 0.318 | - |
| NDI (score) | 7.78 ± 12.94 | 7.66 ± 13.1 | 12.57 ± 10.23 | 0.539 | - |
| WHOQOL-BREF | |||||
| D1 : physical health | 11 ± 7.17 | 5.91 ± 7.95 | 18.41 ± 9.87 | 0.004 | C > A,B |
| D2 : psychological | 9.58 ± 7.56 | 5.5 ± 11.18 | 10.75 ± 9.03 | 0.366 | - |
| D3 : social relationships | 5.25 ± 6.03 | 3.75 ± 10.59 | 6.25 ± 7.3 | 0.756 | - |
| D4 : environment | 10.25 ± 8.69 | 3.25 ± 10.27 | 3.25 ± 11.31 | 0.165 | - |
| HAD | |||||
| HAD-A | 2.09 ± 2.91 | 2.41 ± 3.5 | 2.91 ± 1.62 | 0.775 | - |
| HAD-D | 0.9 ± 3.4 | 1.33 ± 2.67 | 3.75 ± 2.09 | 0.038 | C > A |
Group A: MICT with 2 kg load MICT, Group B: MICT with 8 kg load, Group C: MICT with 12 kg load, P: comparison between groups with covariance analysis, Post hoc using Dunnett’ test
CR Cervical radiculopathy, VAS Visual analogue scale, HGS Handgrip strength, NDI Neck disability index, HAD Hospital Anxiety and Depression scale, SD Standard deviation
At six-month follow-up, CoP/SA(ES) continued to show significantly greater improvement in group C compared to group A (Table 6). In group C, the change in CoP/SA(ES) from baseline to six months yielded a moderate effect size (Cohen’s d = 0.42), reflecting a sustained clinical benefit. Group A demonstrated significantly less improvement in right lateral flexion compared to groups B and C. Additionally, group C showed greater improvements in WHOQOL-BREF domains 1 (physical health) and 2 (psychological well-being) than groups A and B (Table 7).
Table 6.
Difference of the improvement of stabilometric parameters between groups on follow-up (6 months after end of treatment-baseline)
| Group A (n = 10) |
Group B (n = 10) |
Group C (n = 10) |
p | Post hoc | |
|---|---|---|---|---|---|
| CoP/SA(EO) mm² | 13.26 ± 96.19 | 118.16 ± 145.03 | 121.78 ± 26,725 | 0.316 | - |
| LD(EO) mm | 15. 1[−21.2; 90.2] | 34.4 [−6.5;86.0] | −30.3[−53.4;32.8] | 0.249 | - |
| AD(EO) mm | 16.79 ± 101.9 | 62.10 ± 114.82 | 172.4 ± 405.9 | 0.350 | - |
| LV(EO) mm/s | 1.77 [−0.41;3.65] | 0.67[−0.12;1.68] | −0.59[−1.05;2.48] | 0.929 | - |
| AV(EO) mm/s | 0.65 ± 2.17 | 1.21 ± 2.24 | 3.35 ± 7.93 | 0.421 | - |
| CoP/SA(ES) mm² | −337.05 ± 365.24 | −208.5 ± 325.9 | 250.7 ± 599.3 | 0.014 | C > A |
| LD(ES) mm | −17.3 [−74.7; 64.6] | 78.1 [17.4;214.6] | −8.3[−73.8;248.3] | 0.141 | - |
| AD(ES) mm | 9.6 ± 144.1 | 110.6 ± 251.5 | 298.8 ± 518.4 | 0.180 | - |
| LV(ES) mm/s | −0.34 [−1.47;1.25] | 1.53[0.34;4.19] | −0.16[−1.44;4.85] | 0.142 | - |
| AV(ES) mm/s | 0.18 ± 2.81 | 3.13 ± 3.96 | 5.92 ± 10.06 | 0.158 | - |
Group A: MICT with 2 kg load MICT, Group B: MICT with 8 kg load, Group C: MICT with 12 kg load, P: comparison between groups with covariance analysis, Post hoc using Dunnett’ test
CoP/SA (EO) Centre of pressure sway area eyes open, CoP/SA(ES) Centre of pressure sway area eyes shut, LD(EO) Lateral displacements eyes open, LD(ES) Lateral displacements eyes shut, AD(EO) Anteroposterior displacements eyes open, AD(ES) Anteroposterior displacements eyes shut, LV (EO) Lateral velocity eyes open, LV(ES) Lateral velocity eyes shut, AV (EO) Anteroposterior velocity eyes open, AV(ES) Anteroposterior velocity eyes shut
Table 7.
Difference of the improvement of clinical, functional, psychological and QoL parameters between the three groups on follow-up (6 months after end of treatment-baseline)
| Group A (n = 10) |
Group B (n = 10) |
Group C (n = 10) |
p | Post hoc | |
|---|---|---|---|---|---|
| Brief BesTest (score) | 3 ± 2.21 | 6.75 ± 17.34 | 4 ± 3.38 | 0.655 | - |
| CR pain (VAS/100) | 10[0;40] | 20[10;40] | 30[20;40] | 0.150 | - |
| Cervical ROM (degree) | |||||
| Flexion | 4.16 ± 10.62 | 9.16 ± 11.64 | 12.08 ± 12.14 | 0.247 | - |
| Extension | 6.25 ± 10.89 | 9.41 ± 7.53 | 14.16 ± 7.92 | 0.107 | - |
| Right rotation | 6.66 ± 7.48 | 11.5 ± 12.74 | 16.91 ± 12.44 | 0.095 | - |
| Left rotation | 7.66 ± 13.2 | 14.58 ± 13.22 | 15.41 ± 10.96 | 0.264 | - |
| Right lateral flexion | 2.09 ± 5.48 | 11.72 ± 9.72 | 12.54 ± 5.31 | 0.003 | A < B,C |
| Left lateral flexion | 4.41 ± 13.8 | 11 ± 10.79 | 11 ± 7.63 | 0.255 | - |
| Muscle strength (newton) | |||||
| Flexors strength | 0.49 ± 1.82 | 1.38 ± 1.85 | 121 ± 1.8 | 0.454 | - |
| Extensors strength | 1 ± 1.42 | 0.63 ± 1.48 | 2.36 ± 2.52 | 0.074 | - |
| Right HGS | 3.21 ± 5.09 | 2.16 ± 5.63 | 6.41 ± 10.48 | 0.36 | - |
| Left HGS | 1.5 ± 2.61 | 2.91 ± 5.03 | 4 ± 5.79 | 0.433 | - |
| Cervical proprioception (newton) | |||||
| Mean flexion angle error | 0.81 ± 5.61 | 3.45 ± 4.86 | 6.27 ± 11.76 | 0.297 | - |
| Mean extension angle error | 0.81 ± 7.74 | 3.72 ± 4.60 | 3.18 ± 3.42 | 0.438 | - |
| NDI (score) | 7.7[−5.4;11] | 10[−13;16] | 11.6[2.4;16] | 0.319 | - |
| WHOQOL-BREF domains (score) | |||||
| D1 : physical health | 9.66 ± 6.08 | 7.08 ± 7.07 | 21.5 ± 12.81 | 0.001 | C > A,B |
| D2 : psychological | 6.08 ± 5.23 | 3.75 ± 10.72 | 13.75 ± 8.33 | 0.017 | C > A,B |
| D3 : social relationships | 2.41 ± 6.12 | 5.16 ± 5.33 | 4.75 ± 4.9 | 0.425 | - |
| D4 : environment | 8.75 ± 9.33 | 3 ± 4.84 | 9 ± 6.1 | 0.075 | - |
| HAD (score) | |||||
| HAD-A | 1[0–3] | 2[1–4] | 2[1–3] | 0.422 | - |
| HAD-D | 1[0;3] | 1[−4;2] | 3[1;5] | 0.059 | - |
Group A: MICT with 2 kg load MICT, Group B: MICT with 8 kg load, Group C: MICT with 12 kg load; P: comparison between groups with covariance analysis, Post hoc using Dunnett’ test
CR Cervical radiculopathy, VAS Visual analogue scale, HGS Handgrip strength, NDI Neck disability index, HAD Hospital Anxiety and Depression scale
Details regarding the baseline and follow-up values across the three study groups are provided in Supplementary Material 1.
Discussion
This randomized controlled trial study was conducted with the aim of assessing the effectiveness of combining different loads of MICT (2, 8, and 12 kg) with conventional rehabilitation program on postural balance in patients with CR. The most salient finding was the superior improvement in postural balance, as indicated by the sway surface area (CoP/SA) under eyes-closed condition, following 12 kg MICT. This effect persisted at six months and supports our primary hypothesis.
Previous work has highlighted the immediate benefits of MICT on postural instability in CR patients, as shown via posturography [6]. However, to date, no study has examined the midium- or long-term effects of mechanical cervical traction on postural stability in this population. Carrasco-Uribarren et al. [12] reported that CT improved sway surface area and LD length in patients with cervicogenic dizziness. However, findings from other studies using posturography to evaluate manual therapy in such patients remain inconclusive [12]. Multimodal rehabilitation programs (supervised or not) have been shown to improve postural stability, particularly sway velocity, under both visual conditions [13, 34]. These protocols vary widely but generally demonstrate beneficial effects on postural performance and dizziness. Karlberg et al. [13] treated patients with recent neck pain and concurrent cervical dizziness or vertigo using a personalized regimen that included soft tissue treatment, trunk and cervical spine stabilization exercises, passive and active mobilization, relaxation techniques, home-based exercises, and minor ergonomic adjustments in the workplace, without incorporating specialized balance rehabilitation. Their physiotherapy program significantly reduced neck pain as well as the intensity and frequency of dizziness, and produced significant improvements in postural stability. Moreover, Piromchai et al. [34] implemented a home-based self-exercise program that included muscle strengthening, mobilization, and oculomotor training exercises, and reported positive effects on dizziness and patients’ daily life activities.
Sustained natural apophyseal glides, a specific rehabilitation technique, have been shown to significantly reduce postural sway in EC condition, which aligns with our findings [35]. In this method, the practitioner applies a sustained passive accessory glide along the plane of the zygapophyseal joint while the patient actively moves the neck toward the symptomatic direction. This supports the hypothesis that cervical spine joint dysfunction contributes to the pathophysiology of postural disorders in patients with cervical complaints.
Cervical spine range of motion showed a weak correlation with postural sway in individuals with common neck pain, suggesting that other factors, particularly muscle tension, may contribute to altered postural stability [14]. Notably, the cervical region contains a high density of proprioceptors, especially in the posterior joint capsules and perivertebral muscles, underscoring the essential role of proprioceptive input from this area [36]. Therefore, dysfunction in the posterior joints or muscle spasms can impair the function of cervical proprioceptors [37]. When inaccurate proprioceptive signals from the cervical spine are integrated with vestibular and visual inputs, the brain’s perception of body orientation may become distorted, resulting in dizziness or instability. Consequently, interventions that reduce cervical pain, muscle tension, and muscle spindle sensitization may help alleviate balance-related symptoms, such as dizziness, in patients with cervical degenerative conditions [38]. Evidence shows that 5 kg of cervical traction primarily stretches neck muscles, whereas 12 kg produces distraction of intervertebral and posterior joints, highlighting their potential beneficial effect on postural disorders in patients with cervical conditions [39]. This also helps explain the effectiveness of MICT in enhancing postural control, as it addresses both muscle tension and joint dysfunction—key contributors to balance and stability. Furthermore, the finding that combined muscle stretching/strengthening and oculomotor training does not yield superior posturography outcomes compared to no specific exercise intervention [34] supports the assumption that CT may play a crucial role in managing postural disorders in patients with CR.
We argue that assessing postural performance using posturography in patients with cervical radiculopathy lasting more than three months, as in our study, is appropriate. Prior research has shown that posturography effectively detects true postural abnormalities in this population [10]. Moreover, sway surface area has been associated with pressure pain thresholds in the neck among patients with neck pain and appears to be the only consistent feature distinguishing cervical dizziness from other conditions [10].
In terms of clinical assessment of balance, the Brief BESTest was improved in all three groups, but no between-group differences were observed even though this test is considered a preferred tool for assessing balance capacity in patients with cervical spine disorders, particularly cervical spondylotic myelopathy. This suggests that the Brief BESTest may lack sensitivity to detect differences in static postural balance improvement between different traction loads, unlike posturography. This may be explained by the fact that the Brief BESTest represents the combined result of static and dynamic postural subsections.
The greater improvement in radicular pain with 12 kg traction compared to 2 kg in this study corroborates prior findings of an immediate analgesic effect with 12 kg cervical traction [6]. Indeed, both manual and mechanical cervical traction are widely recognized as key modalities in the multidisciplinary rehabilitation of cervical radiculopathy pain [15, 16, 40].
Our study found no significant difference in functional improvement between groups, aligning with Young et al. [41], who reported similar functional outcomes comparing manual therapy plus exercises with MICT versus sham traction. Conversely, Fritz et al. [42] observed greater functional gains with MICT compared to exercise and over-door traction in cervical radiculopathy, a discrepancy likely attributable to differences in population characteristics such as gender ratio, age, and symptom duration. It has been reported that combining MICT with thoracic manipulations significantly improves functional impairment in patients with grade 1 cervical compressive myelopathy [43]. In line with Romeo et al. [16], we recommend routine inclusion of CT in rehabilitation programs to address pain and functional limitations in CR patients.
Psychological status, particularly depression, improved more significantly at three months with 12 kg MICT compared to 2 and 8 kg, likely due to the greater pain reduction observed with the higher traction load. This potential link between pain reduction and psychological improvement may explain El Semary et al.’s [44] findings, where intensive mechanical cervical traction combined with multimodal rehabilitation improved depression levels in CR patients more than transcutaneous electrical nerve stimulation alone. Likewise, sustained natural apophyseal glides produced comparable short-term benefits in patients with cervicogenic dizziness [35].
Regarding QoL, the psychological and physical domains of the WHOQOL-BREF improved significantly at six months, especially in the 12 kg MICT group. We attribute this improvement mainly to reduced pain intensity, anxiety, and functional impairment, consistent with Uthaikhup et al. [45]. The subjective and multifaceted nature of QoL may explain the absence of significant changes in other domains.
Mechanical cervical traction appears as effective as Shi-style cervical manipulations (a traditional Chinese medicine technique) for improving QoL at six months [46]. Additionally, neural mobilization combined with cervical isometric exercises provides greater QoL improvements than isometrics alone [47], supporting the use of multimodal approaches to optimize outcomes in CR patients.
Based on our findings and existing literature, MICT may represent a valuable treatment for CR patients with balance disorders, with 12 kg traction showing superior effects on clinical, postural, psychological, and QoL outcomes. These benefits may be explained by traction’s mechanical impact on intervertebral discs, zygapophyseal joints, and intervertebral foramina.
Study limitations
Despite being among the few studies examining the effect of MICT on postural stability in cervical radiculopathy, our study has several limitations: (i) a relatively small sample size per group given the number of outcome measures, (ii) patient blinding was assumed but not confirmed, (iii) gender imbalance, and (iv) absence of long-term follow-up to assess the durability of results. Therefore, larger, multicenter randomized controlled trials with balanced gender representation and extended follow-up are necessary to validate our findings. Additionally, due to limited prior research on posturographic parameters in cervicogenic headache, we based our power analysis on related domains, which may have reduced its precision; future studies should use pilot data for more accurate sample size estimation. Lastly, while within-group comparisons could have added insight into individual changes over time, we restricted analyses to between-group comparisons to maintain clarity and focus on the study’s primary objective.
Conclusions
Our study demonstrated that 12 sessions of MICT with a 12 kg load significantly reduced postural sway surface area (CoP/SA) in the eyes-closed condition and improved radicular pain, depression, and overall QoL in CR patients, with effects lasting up to six months. These findings highlight the potential of combining MICT with rehabilitation as an effective intervention for enhancing well-being and managing balance and pain. Nevertheless, larger studies are warrented to confirm these results and to explore long-term outcomes.
Supplementary Information
Acknowledgements
Not applicable.
Declaration
The authors disclose that an artificial intelligence tool (ChatGPT) was employed solely for language refinement, with the aim of enhancing the clarity and coherence of the manuscript. Its use was limited to editorial assistance, without any modification of the scientific content or generation of original material [48].
Authors’ contributions
Protocol establishment: AJ, MHB, ZBHF, ID, AC. Patients recruitment and assessment: AAA, AK, AC, ID. Randomization and patients’ allocation: MJ, MHB. Data collection entry, recording, and analysis: AJ, CBN, AC, AK. Interpretation of the results: AJ, ID, AC, CBN. Preparation of manuscript and editing: All. Commentary and revisions of manuscript for pertinent content: AJ, ZBSF, MHB, AAA, AK. Final review of manuscript in preparation for submission: AJ, CBN, ID. Manuscript formatting and submission: AJ, MHB, ID, CBN. All authors approved the submitted version.
Funding
This research study was not supported by any research fund.
Data availability
The datasets used and analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The study protocol was approved by the ethics committee of the faculty of medicine of Monastir under the number of IORG 0009738 N°120/OMB 0990 − 0279.
The study was conducted according to the guidelines of the Declaration of Helsinki
Informed consent was obtained from all patients who agreed to participate in the trial.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.