Abstract
BACKGROUND:
Radiculopathy can cause pain and numbness along a pinched nerve.
OBJECTIVE:
To investigate how people with cervical radiculopathy respond to intense cervical traction in terms of depression, sleeplessness, and quality of life (QoL).
METHODS:
Two equal groups of forty male patients with unilateral cervical radiculopathy were randomly assigned. In addition to transcutaneous electrical nerve stimulation (TENS) and other treatments, twenty individuals in group I received mechanical cervical traction. Group II consisted of twenty individuals who received only TENS treatment. Before and after treatment, every participant completed the Arabic versions of the Hospital Anxiety and Depression Scale (HADS), the Insomnia Severity Index (ISI), and Short-Form 36 Health Survey (SF-36).
RESULTS:
While there was no significant difference in group II, there was a significant decline in group I visual analog scale (P = 0.001), depression subscale of the hospital anxiety and depression score (P = 0.001), and ISI (P = 0.001). Eight domains of SF-36 showed a significant increase in group I. These domains included physical functioning (P = 0.001), role limitations due to physical health (P = 0.001), role limitations due to emotional problems (P = 0.001), and energy (P = 0.001). In group II, there was a non-significant increase nevertheless.
CONCLUSION:
Cervical traction improved individuals’ QoL, depression, and insomnia, suggesting the effectiveness of it with TENS for cervical radiculopathy patients.
Introduction
A rather frequent and incapacitating condition that causes localized pain in the cervical region and discomfort that spreads to the arm and hand is called cervical radiculopathy. Usually, it starts with a disc prolapse or other space-occupying injury that causes the cervical plexus root to intrude and/or become irritated (Woods & Hilibrand, 2015). The annual report varies from 93 subjects to 220 subjects per 100,000 population, with a crest from 45 to 62 years. The prevalence of cervical radiculopathy is reported to be 4.5 per 1000 population. Neurophysiological tests, magnetic resonance imaging (MRI), or clinical evaluation may be used to confirm the diagnosis (Romeo et al., 2018).
Significant advancements are likely to manifest in the interior within the first four to six months following initiation in cases of radiculopathy and symptomatic cervical disc prolapses. While it can take two to three years to fully recover (Wong et al., 2014), this situation is associated with costly expenses due to frequent or extended sick leave, several examinations, and various managements (including physical therapy, cupping, surgical procedure, and drugs) (Barton et al., 2019).
Although management strategies vary, the main objective of recommended strategies is to reduce suffering and penalties in the short term while also preventing recurrence in the long term (Daffner et al., 2003).
Traditional methods include medication, stretching exercises, strengthening training, traction, and manual therapy (Childress & Becker, 2016). The results of cervical traction include the zygapophyseal joints moving, the foramen enlarging, the muscles extending, and the displacement of the vertebral bodies. Prior research found no discernible differences in pain, debility, and flexibility between manual traction, hand treatment, or a combination of the two modalities (Afzal et al., 2019).
It is common to quantify participants’ diminished quality of life (QoL) when they experience worsening cervical pain. The two opposite but mutually exclusive features of psychosomatic diseases that people with neck discomfort perceive are anxiety and sleeplessness. There are far worse experimental outcomes associated with this combination of sadness, sleeplessness, and pain than with any one of the illnesses alone (Sagheer et al., 2013).
Previous research has reported that a few participants with musculoskeletal diseases experience difficulties falling asleep. All the participants with cervical radiculopathy have not yet had their sleep quality thoroughly investigated. They found that among patients with cervical radiculopathy, sleeping disturbances were highly prevalent and likely had high-risk effects. Physicians should carefully evaluate, monitor, and take appropriate management measures for such patients (Shi et al.,2023).
This modality is also inexpensive. Our goal was to investigate the effectiveness of a rigorous three-week cervical traction regimen for radiculopathy patients. Therefore, the main objective of this study was to find out how intense cervical traction operations affected the individuals’ QoL, depression, and insomnia while they had cervical radiculopathy.
Subjects and methods
Study design
By using a two-group pretest and posttest design, the current study was designed to be administered as a randomized clinical trial between November 2023 and February 2024. The study was approved by Cairo University’s Physical Therapy Faculty Research Ethics Committee (P.T.REC/012/004910), registered on ClinicalTrials.gov (registration number: NCT06196385), and adhered to the Declaration of Helsinki Regulations regarding the supervision of human research. Prior to interacting with the patients, informed consent was obtained.
Participants selection
The neurosurgeon diagnosed cervical radiculopathy in forty male patients. The cervical spine MRI, body testing, and the subject’s medical history were used to make the diagnosis. The Spurling test, cervical range of motion, and upper limb tension tests were used among the physical examinations to make the decision. Two equal groups of patients were randomly assigned to each other. A blind research assistant and an unusual research assistant carried out the randomization maneuver by gathering computer-generated cards in sealed envelopes. Group I consisted of twenty patients who were treated with mechanical cervical traction in addition to transcutaneous electrical nerve stimulation (TENS) and group II consisted of twenty individuals who received only TENS treatment.
Male participants aged 30–45 who met the following inclusion criteria: they had to have been diagnosed with cervical radiculopathy based on clinical testing and an MRI of their cervical spine that had been done for more than six months; they also had to have experienced unilateral upper limb pain, numbness, or paresthesia; and they had to have made some progress in terms of remedial management, NSAIDs, muscle relaxants, and neuropathic painkillers, all of which remained constant during cervical traction. To eliminate cervical traction contraindications, a thorough implementation of cervical spine x-rays was made. Any individual with osteomyelitis, myelopathy, spinal cord neoplastic lesions, osteoporosis, fibromyalgia, osteomyelitis, ligamentous impairments, or uncontrolled hypertension was excluded from the study. Individuals with psychiatric impairment records were excluded from the study as well. Forty individuals signed up and finished the procedure. No subject withdrawal occurred.
Instrumentation
Interview inquiry form
An interview survey was used to record social and demographic data, medical history, results of body tests, and screening exams including MRI and x-ray of cervical region.
Visual analog scale (VAS)
The VAS was used to rate the intensity of the discomfort. It was divided into five categories, with zero to one representing no discomfort, two to three representing mild discomfort, four to five representing moderate discomfort, six to seven representing intense discomfort, and eight to ten representing extreme discomfort (Huskisson, 1974).
Subscale of hospital anxiety and depression scale (HAD)
An Arabic version of HAD was used to assess symptoms of anxiety and depression. With a break-off value of eight for anxiety and nine for depression, the HAD measure is an inquiry form that covers 14 components of anxiety and depression, seven of which are implied to be related to anxiety and seven of which are related to depression. Every element fully expressed the passionate state and shows no warning signs in the body. Only the depression subscale was looked at in the current study. The current study took the depression subscale of the HAD assessment into consideration (Terkawi et al., 2017).
Insomnia severity index (ISI)
Seven components make up the ISI (Arabic version), which gauges how severe sleep disruption has been present over the previous two weeks. The five-point Likert scale is used for each component, and the total score indicates the degree of insomnia. It has been suggested that the ideal cutoff point for insomnia as a disturbance is a score of more than 14. Since the ISI is brief, easy to use, and can provide useful information for diagnostic and management planning, it has been widely used in experimental and research settings. According to research, there is a good degree of congruence between the subject’s and the clinician’s evaluation of insomnia severity, and the ISI is sensitive in identifying changes in the patient’s perception of therapeutic results (Hallit et al., 2019).
Short-Form 36 health survey (SF-36)
Using the Arabic version of the SF-36, health-related QoL was assessed. This all-purpose instrument consists of 36 parts that look at the following areas: body function, role constraints brought on by physical health, physical discomfort, overall health perceptions, vitality, social functioning, role constraints brought on by emotional disturbances, and mental health. A value ranging from zero (most affected) to 100 (non-affected) is used to measure the eight things on the scale (El Osta et al., 2019).
Cervical traction apparatus
Tru-Trac Traction Unit, Model 4779 (Chattanooga Group, USA) was used. With user-defined hold, rest, and management durations, the Tru-Trac traction unit is a simple-to-use digital touch screen user interface traction unit that offers static, intermittent, and cyclic traction. Triton, Tru-Trac traction devices are ideal when used with the Adapta ADP400 traction table. By completely programmable pull patterns, the Traction Unit allows doctors to replicate the sensation and effectiveness of hands-on therapy while providing clinically proven pain management that targets the underlying causes of cervical and lumbar pain. The ability to adjust the traction drive’s operating and emission rates is another benefit of using an electrical traction controller. Along with an electrical protection regime, the traction unit has a mechanical pull restraining regime and the ability for the subject to stop the swap, allowing them to stop receiving therapy.
Application
The individual was in a supine position, lying down (Khan et al., 2017). Participants were asked to keep their heads turned forward during the traction to avoid twitching of their muscles in oculocephalogyric pairing (Marylène et al., 2008). The transverse plane formed by the plinth was at a 45° angle to which the automated traction was applied. The cervical traction session lasted for thirty minutes for three weeks, five days a week, for five days in a row twice daily.
The stack was applied progressively over the course of five minutes inside the treatment set, and VAS was used to gauge patient discomfort. The target load was then maintained for 20 minutes in conjunction with TENS, and then gradually decreased during the last five minutes. After that, the individual has 10 minutes to recover before sitting up (Tiffreau & Thevenon, 2004). For the duration of the first treatment set, a physical therapist was present, and for the subsequent treatment sets, the individuals received a bell (Marylène et al., 2008).
Side effects checking
A physiotherapist evaluated for side effects by looking for indicators of pain and nerve invasion, dizziness, headaches, nausea, and strained muscles.
Procedure intervention
Transcutaneous electric nerve stimulation (TENS)
For three weeks, the treatment plan was carried out in 15 20-minute sessions, five days a week, for five days in a row twice daily. TENS and traction were given to the study group, while the Sonopuls-992 (Enraf- Nonius, Dimeq Bu, The Netherlands) was utilized only by the control group. It was put into place to reduce pain. Two surface electrodes were placed on the skin of the area where the pain was radiating and used to transfer electrical stimulation.
Outcome measures
These three outcome measures were used to assess depression: HAD scale, the ISI, and the Arabic version of the SF-36 for QoL.
Statistical analysis
Using SPSS version 29.0 (IBM Corp., Armonk, NY, USA), data was examined. The entire measurement is expressed as mean±SD. The Shapiro-Wilk test was used to determine if the assessment values were distributed normally. A paired samples t-test was used to investigate differences within group, while an independent samples t-test was used to investigate changes between two groups. A significant result was defined as a p value of less than 0.05 (Edelle et al., 2005).
Results
The purpose of this study was to assess how the cervical traction technique affected the QoL and depression and insomnia management of the participants who had radiculopathy. The results of this study showed that traction therapy improved QoL in radiculopathy and can be used to treat depression and sleeplessness.
Table 1 indicates that the two study groups were similar in terms of age, height, weight, and BMI. Table 2 displays the participants’ pain, depression, and insomnia scores both before and after the cervical traction technique. Before treatment, there was no discernible difference in the VAS pain score (P = 0.635), the Hospital Anxiety and Depression Scale (HADS) depression subscale’s values (P = 0.158), or the ISI insomnia scores (P = 0.585). Following treatment, group I showed significantly higher depression (P = 0.001), sleeplessness severity scale (P = 0.001), and pain intensity scores (P = 0.001).
Demographic and physical characteristics of participants
Demographic and physical characteristics of participants
BMI: body mass index; Data expressed as mean±SD.
Pain, depression, insomnia scores in participants pre- and post-treatment
VAS: Visual analog scale; HADS-D: Depression subscale of the Hospital Anxiety and Depression scale; ISI: Insomnia Severity Index; Data expressed as mean±SD; *Significant at P < 0.05.
The SF-36 scores for eight domains in the two study groups before and after the cervical traction approach are shown in Table 3. The eight SF-36 domains showed no discernible variation in the two study groups’ pre-treatment values. Physical functioning (p = 0.001), role limitations due to physical health (p = 0.001), role limitations due to emotional problems (p = 0.001), energy/fatigue (p = 0.001), emotional well-being (p = 0.041), social functioning (p = 0.023), pain (p = 0.019), and general health (p = 0.031) were all significantly higher in group I following the end of management.
SF-36 domains values of quality of life pre- and post-cervical traction in participants
Data expressed as mean±SD; *Significant at P < 0.05.
The study findings demonstrated the superiority of the spinal traction method over TENS in terms of enhancing subjects’ QoL, depression, and sleeplessness.
It is quite difficult for subjects with radicular discomfort to perform physical tasks. Additionally, radicular pain is typically linked to emotional impairments that are difficult to manage and result in severe debility and a lower QoL associated with health (Delitto et al., 2012).
The mean VAS values of the traction group in the current study decreased noticeably from 7.04±1.63 before traction started to 3.44±1.51 after the traction sessions ended. Cervical traction was used in the current investigation as a medical management strategy, but it wasn’t enough to limit the patients’ warning signs, and the traction approach didn’t change that. When compared to prior research, the combination of cervical traction and medication may explain the present study’s superior outcome. This is consistent with the findings of Elnaggar et al. (2009).
In cases where nerve root squeezing is present, spinal traction is thought to provide greater relief by decompressing interspinal joints, relieving pressure on intervertebral discs, expanding intervertebral foramina, lengthening muscles, preventing disc prolapse, releasing entangled synovial sheath, and releasing restricted nerve root inducing principal gap to produce suctioning effect on prolapsed or herniated disc (Di Fabio et al., 1999).
Patients with cervical radiculopathy may benefit from cervical traction. The trial group saw a reduction in pain as well as other advantages like increased blood flow to the brain, the release of muscle spasms, and decompression. According to earlier research, at one month and up to six months after discharge, 84.4% of patients with cervical radicular pain and prolapsed disc evidence reported noticeably higher pain ratings following 16 to 24 sessions of traction in a prone position (Beattie et al., 2008).
Thankfully, the study group’s post-traction progress was significantly advanced as shown by the SF-36 domain of pain. Since the SF-36 domain of pain assesses how specific aching limits daily activities, it may be more reliable to believe its effects than the VAS, which looks at the emotional aspects of ache. On the SF-36, those who underwent cervical traction for three weeks reported more discomfort than those who received TENS treatment.
The present study found that the study group’s mean values on the HADS-D depression subscale considerably decreased from 9.68±3.26 before spinal traction started to 5.96±2.77 after the treatment strategy was stopped.
13.1% of the respondents’ anxiety and depression scores were irregular, according to a Pakistani study that used HADS to assess the occurrence of depression in 150 people with neck pain (HADS 11–21). In a different study, 39% of German participants with neck pain also experienced atypical depression (HADS-D > 8) (Castro et al., 2009). Castro et al. (2009) used HDAS and reported that 60% of backache subjects had depression issues (Delitto et al., 2012).
The study group’s mean ISI values considerably decreased from 11.23±1.16 before spinal traction started to 6.47±1.12 after the treatment strategy was stopped. According to earlier research, insomnia issues were assessed using the ISI, where a score of > 14 indicated moderate-to-severe symptoms of insomnia. Pain and sleep impairment are connected, and the relationship is strengthened if sleep issues are persistent. Physical therapists would effectively treat patients with neck discomfort by taking correlation into account (Kroenke & Spitzer, 2002).
Although there isn’t much research on the subject, numerous authors have also linked neck pain to sleeping disorders. Research by Artner and colleagues revealed that over 45% of patients with neck pain also reported having trouble sleeping (Artner et al., 2013). According to Kovacs and colleagues, people with sleeping problems experienced less progressive cervical pain than people without sleep impairment (Kovacs et al., 2015). Moreover, researchers stated that the amount of pain at neck was greater with unfavorable sleeping features, that suggested it the link between sleeping issue and pain at neck was dependent upon dose. Numerous authors reported that people with sleeping disorders reported a significantly higher percentage of neck discomfort than people without any sleep impairment, indicating a strong correlation between sleeping disorders and neck pain (Yabe et al., 2022).
In the present study, the traction group’s mean scores on the SF-36 eight domains increased dramatically after the treatment course ended compared to before treatment. According to Bentsen and colleagues, a worse QoL is common among patients who report neck pain, and the goal of treatment is to raise the QOL of these patients through improved performance and reduced discomfort. Castro et al. (2009) reported that eight SF-36 domains indicated mean values≤50%, and they stated that anxiety, depression, and QoL in participants with neck pain.
Lamé et al. (2005) investigated 1228 hurting individuals’ perception of pain and QoL. Individuals with neck discomfort and other hurting places experienced the greatest practical limitations. The avalanche disaster emerged as the most valuable QoL forecaster. There was a significant correlation between anguish and misery and social activities, vitality, mental health, and overall health.
Thus, neck discomfort that interferes with the individual’s unique life experiences, negatively impacts QoL, affects mental health, and is associated with worry, fear, and the experience of such pain when engaging in any kind of task. Anxiety and pain worsen a subject’s QoL. Depression is strongly correlated with an increase in anxiety and is elevated by the perception of reduced QoL. As one recovers and has less pain from a variety of diseases, anxiety decreases, QoL increases, and sadness follows suit.
As a result, the data in Table 3 make it evident that respondents’ emotional impairment and depressive symptoms, as well as their QoL, were negatively impacted by neck pain that interfered with their daily activities. More detrimental to QoL than emotional state could be discomfort.
The study’s short management span and small sample size were its main drawbacks. A large sample size and extended management span are recommended for this study. Furthermore, it is possible that every patient in the two research groups received the exact treatment. Only including male individuals could have an impact on the sample’s homogeneity.
Conclusion
When treating patients with cervical radiculopathy, traction combined with TENS method is beneficial for controlling depression, sleeplessness, and QoL. Lastly, broaden the scope of pain dimensions by connecting respondents’ suffering to their jobs rather than using a traditional subjective assessment method.
Footnotes
Acknowledgments
The authors appreciate the great efforts exerted by all participants in this study.
Funding
None to report.
Conflict of interest
The authors declare no conflict of interest.
Ethical statement
This study was approved by Cairo University’s Physical Therapy Faculty Research Ethics Committee (P.T.REC/012/004910) and registered with ClinicalTrials.gov (registration number: NCT06196385).
Author contributions
Conception & design: Moataz El Semary, Radwa Elshorbagy; collection and assembly of data: Youssef Elbalawy, Rasha Elrewainy: analysis and interpretation of data: Ahmed Nagaty, Moataz El Semary; drafting, revision, and approval of article: Moataz El Semary, Radwa Elshorbagy, Youssef Elbalawy, Rasha Elrewainy, and Ahmed Nagaty.