Journal of Manual & Manipulative Therapy

ISSN: 1066-9817 (Print) 2042-6186 (Online) Journal homepage: https://www.tandfonline.com/loi/yjmt20

Classification by pain pattern for patients with

cervical spine radiculopathy

Richard Yarznbowicz, Matt Wlodarski & Jonathan Dolutan

To cite this article: Richard Yarznbowicz, Matt Wlodarski & Jonathan Dolutan (2019):
Classification by pain pattern for patients with cervical spine radiculopathy, Journal of Manual &
Manipulative Therapy, DOI: 10.1080/10669817.2019.1587135

To link to this article: https://doi.org/10.1080/10669817.2019.1587135

Published online: 02 May 2019.

Submit your article to this journal

Article views: 114

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=yjmt20
JOURNAL OF MANUAL & MANIPULATIVE THERAPY
https://doi.org/10.1080/10669817.2019.1587135

Classification by pain pattern for patients with cervical spine radiculopathy

Richard Yarznbowicza, Matt Wlodarskib and Jonathan Dolutan b

a
DPT, Center for Orthopedic and Sports Physical Therapy, Tallahassee, FL, USA; bDPT, Integrated Mechanical Care, Tallahassee, FL, USA

ABSTRACT KEYWORDS
Objectives: A prospective observational cohort study was conducted to (1) report the Cervical spine; cervical
prevalence of Mechanical Diagnosis and Therapy (MDT) classifications, Centralization (CEN), radiculopathy; neck pain;
and Non-CEN among patients with Cervical Spine Radiculopathy (CSR), and (2) describe the directional preference;
association between classification via CEN and Non-CEN and clinical outcomes at follow-up. centralization; McKenzie;
orthopedic; musculoskeletal
Methods: Data were collected from 680 consecutive patients who presented to outpatient,
orthopedic physical therapy clinics with primary complaints of neck pain with and without
radiculopathy; thirty-nine patients (6%) met the physical examination inclusion criteria for
CSR. First examination and follow-up data were completed by 19 patients.
Results: Seventy-nine percent of patients’ conditions were classified as Reducible
Derangement at first examination and 21% were classified as either Irreducible
Derangement, Entrapment, or Mechanically Inconclusive. The prevalence of CEN and Non-
CEN was 36.8% and 47.4%, respectively. All patients treated via MDT methods made clinically
significant improvements in disability, but not pain intensity, at follow-up. The magnitude of
change in clinical outcomes was greatest for patients who exhibited CEN; however, the
changes in disability and pain intensity at follow-up were not statistically significant com-
pared to patients who exhibited Non-CEN at first examination. Patients who exhibited CEN
were discharged, on average, ten days earlier and had one less treatment visit compared to
patients who exhibited Non-CEN.
Discussion: The findings of this study show that patients with CSR can be classified and
treated via MDT methods and experienced clinically significant improvements in disability,
but not pain intensity, at follow-up. Providers should consider MDT classification and treat-
ment to improve clinical outcomes for their patients affected by CSR.

Introduction neck pain without radiculopathy. In a prospective

study examining patients with CSR who were referred
Neck pain disorders with and without radiculopathy
to board-certified neurosurgeons or orthopedic sur-
are regarded as clinically distinct entities [1–4]. Neck
geons [10], 38% of patients received surgical interven-
pain with radiculopathy, or CSR, involves compression
tions including neural foraminotomy, cervical
of the cervical nerve root [5] as a result of disc hernia-
discectomy, and/or spinal fusion. Due to the substan-
tion or bony osteophyte impingement [5,6]. The clin-
tial burdens related to CSR and neck pain without
ical manifestations of nerve root compression
radiculopathy, the Patient-Centered Outcomes
distinguish CSR from neck pain without radiculopathy
Research Institute (PCORI) has prioritized the need
and include radiating pain into the arm in combina-
for further research to examine the classification of
tion with motor, reflex, and/or sensory changes [6].
both condition types [14]; previous research has sug-
CSR is a common reason patients seek medical care
gested that classifying patients with cervical spine
[7,8] and the annual incidence is 107.3 per 100,000 for
disorders via subgroups based on clinical characteris-
men and 63.5 per 100,000 for women [9]. Many cases
tics and matching these subgroups to management
do not resolve and result in chronic symptoms. CSR
strategies could improve patient outcomes [3,15,16].
leads to lasting paresis and paresthesia at one-year
The authors of the present study sought to contribute
follow-up in as many as 50% of those affected [10,11].
to PCORI’s agenda by examining patients with CSR
A study by Thoomes et al. [12] on the natural course
only. PCORI has also prioritized a need for exploring
of CSR showed that 56% of patients continue to
the classification of neck pain with and without radi-
exhibit symptoms at 19-year follow-up. Furthermore,
culopathy, the effectiveness and safety of nonsurgical
as high as 67% of patients’ symptoms exhibit progres-
options, the effectiveness of assessment instruments,
sive deterioration over time [13]. It is not uncommon
and predictors of chronic pain, opioid dependence, or
in the authors’ clinical experiences that patients with
other undesirable outcomes. The examination of CEN
CSR are more likely to consider invasive and costly
and Non-CEN as a classification criterion has been
procedures such as surgery compared to patients with

CONTACT Richard Yarznbowicz ryarznbowicz@gmail.com DPT, Center for Orthopedic and Sports Physical Therapy, 2615 Centennial Place,
Tallahassee, FL 32308, USA
© 2019 Informa UK Limited, trading as Taylor & Francis Group
2 R. YARZNBOWICZ ET AL.
made a top priority in the PCORI agenda as it relates
to its effect on patient-centered outcomes.
The clinical diagnosis of CSR is established via
a thorough history and physical examination while con-
sidering radiating symptoms into the extremity and
subsequent motor and/or sensory impairments [4].
Several clinical examination findings have been
reported to assist identification of CSR including tests
which reproduce or relieve radiating symptoms with
cervical spine compression, distraction, and/or upper-
limb nerve mobility. For individual tests, the Spurling’s
Test and the Distraction Test have been recommended
for clinical use and have good specificity and positive
likelihood ratio values [4,17]. A negative upper limb
tension test may help rule out the presence of CSR
and has a high sensitivity (Sp = 0.97) and small like-
lihood ratio value (LR- = 0.12) [17]. Composite tests
tend to exhibit better diagnostic accuracy compared
to individual tests for identifying CSR [17,18]. A test-
item cluster (Appendix) was proposed by Wainner
et al. [17] that produced larger post-test probability
changes for the diagnosis of CSR than any single clinical
examination finding. Three positive tests exhibited spe-
cificity, likelihood ratio, and post-test probability values
of 0.94, 6.1, and 65%, respectively. The specificity, like-
lihood ratio, and post-test probability values for four out
of four positive tests increased to 0.99, 30.3, and 90%,
respectively. Indeed, individual tests such as the
Spurling’s Test and Distraction Test exhibit acceptable
diagnostic accuracy for use in clinical practice, and diag-
nostic accuracy is improved when clinicians cluster
patient-reported signs and symptoms and employ
a series of CSR tests.
Non-specific classification systems are used in con-
junction with the aforementioned clinical tests [4]. MDT
is a treatment-based classification system that identifies
non-pathology specific subgroups through a detailed
history and physical examination process consisting of
repeated and sustained end-range movements [16]. The
patient’s symptomatic and mechanical (i.e. range of
movement and strength-related changes) responses to
these movement strategies establish classification
(Appendix) and the subsequent management approach.
CEN is a hallmark classification criterion in the MDT
system and has been extensively studied in patients
with lumbar spine disorders [19,20]. CEN is characterized
by spinal pain and referred spinal symptoms that are
progressively abolished in a distal-to-proximal direction
in response to repeated and/or sustained end-range
movement [16]. The presence of CEN is generally asso-
ciated with a favorable outcome and has been shown to
be a useful indicator of prognosis and guide for man-
agement strategies [19,21]. Non-CEN, or the absence of
CEN, is characterized by symptoms that do not move
proximally toward the midline of the spine, do not
change, or that move distally away from the spine dur-
ing the physical examination [16]. Non-CEN has been
generally associated with apoorer prognosis and inferior
clinical outcomes [22–28]. The interrater reliability for
the use of an overlay template to identify the presence
of CEN and Non-CEN has been reported to be almost
perfect agreement (k = 0.96–1.00) [29].
Although the MDT classification system does not rely
on pathoanatomic causes to diagnose and treat patients,
several studies have linked CEN to discogenic problems
by comparing discography to symptomatic findings in
the lumbar spine [30–34]. A significant association
between positive discography and the occurrence of
CEN and Non-CEN has been established [30].
Considering that posterior disc encroachment has been
purported to be a cause of radiculopathy [1] and that the
morphology of the cervical disc is to some degree similar
to the lumbar disc [35], a study by Kim et al. [36] showed
that cervical spine extension procedures produced ante-
rior migration of the nucleus pulposus away from the
posterior disc margin. The authors concluded that cervi-
cal extension movements may produce favorable clinical
effects as it relates to radiculopathy. Spinal extension
movements are the most common procedures asso-
ciated with CEN [19] and have been shown to improve
radicular signs and symptoms [37–40]. A study by
Abdulwahab et al. [37] showed that repeated neck retrac-
tions, a commonly employed MDT procedure consisting
of mid and lower cervical spine extension movement,
was effective at decompressing cervical neural elements
and reducing cervical radicular pain in patients with CSR.
Spanos et al. [38] described a patient with cervical radi-
culopathy with disc herniation who responded to MDT-
based procedures and subsequently became symptom-
free, and the corresponding MRI findings revealed a 56%
reduction in the size of the disc herniation. A case report
by Schenk et al. showed rapid and sustained improve-
ment with extension-based MDT procedures, deep neck
flexor muscle strengthening, and neuromobilization for
a patient diagnosed with CSR [39]. In another case report,
a patient who presented with radiculopathy and signs of
myelopathy improved rapidly with end-range cervical
spine extension movements that induced CEN [40].
However, no prospective studies have assessed the asso-
ciation between MDT classification and clinical outcomes
for patients with CSR.
Based on the lack of prospective studies examining
MDT classification and outcomes for patients with CSR
and the call for more studies in this regard [14], the
primary aims of this study were to (1) report the
prevalence of MDT classifications, CEN, and Non-CEN
among patients with CSR, and (2) describe the asso-
ciation between classification via CEN and Non-CEN
and clinical outcomes. Since previous reports related
to MDT classification suggest that the Derangement
classification is the most common classification [19],
CEN is less prevalent than Non-CEN at first examina-
tion [24,41], and CEN generally results in more favor-
able clinical outcomes [19], the hypotheses of this

investigation were that (1) the prevalence would be
highest for the Reducible Derangement classification
at first examination, (2) fewer patients would exhibit
CEN at first examination than Non-CEN, and (3)
patients who exhibited CEN would demonstrate clini-
cally significant differences in disability and pain
intensity at follow-up relative to patients who exhib-
ited Non-CEN in patients with CSR.
Methodology
Design
A prospective observational cohort study was con-
ducted. Data were analyzed from 680 consecutive
patients who presented to outpatient, orthopedic phy-
sical therapy clinics with primary complaints of neck
pain with and without radiculopathy (Figure 1). Data
were collected from 2014 through 2015 in Oklahoma,
Florida, South Carolina, and Alabama in four outpatient
orthopedic physical therapy clinics. One chiropractor
and nine physical therapists participated in the study
(average years of clinical experience: 13.5; average age:
39 years (27–64); 70% males). All providers attained at
least a bachelor’s degree. Four physical therapists held
a Doctorate in Physical Therapy (DPT). Six providers
were certified in MDT (Cert. MDT) and four held diplo-
mas in MDT (Dip. MDT). One provider was a Board
Certified Orthopedic Clinical Specialists (OCS). The
Florida State University Institutional Review Board for
Protection of Human Subjects and the Florida
Agricultural and Mechanical University Institutional
Review Board for Protection of Human Subjects
approved the project. Patient informed consent was
not required for the analysis and reporting of data as
this study did not include any change in routine clinical
practice.
Figure 1. Flow of patients.
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 3
Patients were included in the analysis if they (1)
presented with complaints of neck pain with symp-
toms that radiated into the upper extremity, (2) had
sensory, motor, and/or reflex changes in the upper
extremity including paresthesias or numbness, and
(3) had a positive finding for any of the following
tests at first examination: (i) Spurling’s Test, (ii)
Distraction Test, and/or (iii) at least three out of
four positive tests for identifying the presence of
cervical radiculopathy proposed by Wainner et al.
[17]. Patients were excluded from the study if they
had cervical spine surgery within the preceding
twelve months.
Classification and physical examination
procedures
Patients were assessed and treated via MDT methods.
A standard MDT evaluation was conducted consisting
of repeated and sustained end-range movements
while monitoring patients’ symptomatic and mechan-
ical responses [16]. CEN and Non-CEN were recorded
at the first examination by using a body diagram and
overlay template [29]. The patient was instructed to
shade in the body regions on the diagram where he
or she was experiencing symptoms at the moment. If
the patient was not experiencing any resting symp-
toms, the patient’s condition was labeled as Non-
Classifiable (NC). The managing provider asked the
patient to complete the body diagram immediately
before and after movement testing during the MDT
examination. Post evaluation, providers documented
the presence or absence of CEN as well as the MDT
classification (Appendix).
A series of physical examination tests were per-
formed at the first examination in conjunction with
4 R. YARZNBOWICZ ET AL.
a standard MDT evaluation to assist identification of
patients with CSR. A test-item cluster proposed by
Wainner et al. [17] was implemented including
Spurling’s Test [42], the Distraction Test [17], the
Upper Limb Tension Test (ULTT) [43], and assessment
of cervical spine rotation range of motion (Appendix)
[17,44]. A standard neurological examination was con-
ducted including testing of upper extremity myo-
tomes, dermatomes, and reflexes (Appendix) [45,46].
Provider training
Providers in the study had extensive training in ortho-
pedic physical examination and manual therapy tech-
niques. Providers routinely performed physical
examination tests such as ULTTs, myotome and der-
matome assessments, and joint range of motion
assessments via goniometer measurement. Prior to
the start of the study, training and practice sessions
were conducted on how to perform the Spurling’s
Test and the Distraction Test; all providers had pre-
vious experience performing these tests. Providers in
the study were advised to use scripted introductions
and standardized procedures when administering
physical examination tests and self-report question-
naires. Participating providers and supporting admin-
istrative personnel received three, one-hour training
sessions regarding data collection and management
practices. A standard operating procedure was devel-
oped by our research network that provided detailed
study procedures, operational definitions of the con-
structs being measured, and sample case study
vignettes.
Data collection
Providers collected patient-reported and clinical
examination responses at first examination, regularly
throughout the care episode, and at discharge. The
managing providers were responsible for determining
and reporting inclusion, exclusion, and discharge sta-
tus. Pain intensity reported by the patient within ‘the
last few days’ was assessed using an 11-point Numeric
Pain Rating Scale (NPRS) ranging from 0 (‘No pain’) to
10 (‘Worst Pain Imaginable’). The NPRS has been
shown to be reliable and valid [47,48] with
a minimal detectable improvement of 4.1 points in
patients with CSR [48]. The Neck Disability Index (NDI)
is a patient self-report disability questionnaire for
neck pain with and without radiculopathy. The score
ranges from 0 to 50 with higher scores indicating
higher levels of disability. Stratford et al. reported
a minimally important change in the NDI score of 5
points (out of 50) [49]. The NDI has been shown to be
an acceptable clinical measure for patients with cervi-
cal spine disorders [49–51].
Data analysis
Descriptive statistics were generated including pro-
portions, standard deviations, and ranges for patient
characteristics collected at first examination. Chi-
square tests of independence (dichotomous and cate-
gorical data) or two-sample t-tests (continuous data)
were performed to compare patient characteristics
and determine equivalence between patients with
first examination data only and patients with first
examination and follow-up data. Constructs measured
approximated a normal distribution and the signifi-
cance level for all tests was set at p < .05. A summary
table was created for the prevalence of positive neu-
rological test cluster items (i.e. Spurling’s Test, the
Distraction Test, the ULTT, and a cervical spine rota-
tion range of motion measurement of less than 60
degrees), myotome deficits, and dermatome deficits
for CEN and Non-CEN groups (Table 2). In order to
address the first objective of determining classifica-
tion prevalence, we categorized the prevalence at first
examination at two levels: (1) the prevalence of MDT
classifications and (2) the prevalence of CEN and Non-
CEN. Two-sample t-tests considering a normal distri-
bution were used to address the second objective of
determining the association between classification via
CEN and Non-CEN at first examination and clinical
outcomes (i.e. disability and pain intensity) at follow-
up. Difference scores, or the difference between the
clinical outcome measure (i.e. disability or pain inten-
sity) at first examination and follow-up were calcu-
lated and these data were compared to the NPRS
minimal detectable improvement value for pain and
the NDI minimal clinically important difference value
for disability. The average visits and duration of care
were calculated for patients with first examination
and follow-up data and adjusted by CEN and Non-
CEN at first examination.
Results
Six hundred and eighty consecutive patients entered
the clinic during the study period (Figure 1). Forty-
four patients did not complete first examination data
collection resulting in a participation rate of 94%, and
39 patients (6%) met the physical examination inclu-
sion criteria for the study. Nineteen patients com-
pleted first examination and follow-up data
collection (49% completion rate). The characteristics
of the study participants are displayed in Table 1 and
reasons for not commencing data collection can be
found in Figure 1. Patients with first examination data
only did not significantly differ relative to age, gender,
symptom acuity, surgical history, NDI score at first
examination, and pain intensity score at first examina-
tion compared to patients with first examination and
follow-up data; however, patients with first
 JOURNAL OF MANUAL & MANIPULATIVE THERAPY 5

Table 1. Patient characteristics.

First Examination Only
Characteristics (n = 20) First Examination and Follow-up Data (n = 19)
Age (y) 51.04 ± 15.4 (35–74) 50.5 ± 15.1 (34–78)
Missing 1.40% 0.00%
Gender
Male 50.00% 36.80%
Female 50.00% 63.20%
Missing 0.00% 0.00%
Symptom Acuity
Acute (0–2 weeks) 70.00% 63.20%
Sub-Acute (3–11 weeks) 5.00% 5.20%
Chronic (≥12 weeks) 25.00% 31.60%
Missing 0.00% 0.30%
Surgical History
None 75.00% 94.70%
1 or More 10.00% 5.30%
Missing 15.00% 0.80%
Medication for Condition
None 30.00% 15.80%
1 or More 70.00% 84.20%
Missing 0.00% 0.00%
Imaging
None 50.00% 57.90%
1 35.00% 13.60%
2 or More 15.00% 28.50%
Missing 0.00% 0.00%
Exercise History
1 or 2 Times per Week 25.00% 26.30%
At least 3 Times per Week 30.00% 47.40%
Seldom or Not at All 35.00% 26.30%
Missing 10.00% 0.00%
Referral Type
Primary Care 35.00% 63.20%
Specialist 10.00% 10.50%
Self 10.00% 0.00%
Other 40.00% 26.30%
Missing 10.00% 0.00%
Number of Comorbid Conditions
None 20.00% 15.80%
1 26.20% 31.60%
2 or 3 50.00% 36.80%
4 or more 20.00% 15.80%
Missing 10.00% 0.00%
Payer
Auto 0.00% 0.00%
Health Maintenance Organization (HMO) 90.00% 57.90%
Medicaid 0.00% 0.00%
Medicare Part B 0.00% 0.00%
Patient Private Pay 0.00% 0.00%
Preferred Provider Organization (PPO) 10.00% 36.80%
Workers’ Compensation 0.00% 0.00%
Other 0.00% 5.30%
Missing 0.00% 0.00%
Intake NDI 14.1 ± 7.5 (9–29) 14.2 ± 7.4 (4–31)
Missing 0.00% 0.00%
Pain Intensity First Examination 5.0 ± 2.3 (1–10) 5.4 ± 2.4 (1–10)
Missing 0.00% 0.00%

examination data only took less medication for their
conditions (p-value = 0.04) than patients with first
examination and follow-up data.
Neurological physical examination tests were
recorded at first examination and analyzed for
patients with first examination and follow-up data.
For the test-item cluster, 21% of patients exhibited 3
out of 4 criteria and 11% exhibited 4 out of 4 criteria.
For single-item tests, 90% of patients exhibited
a positive Spurling’s Test, 37% exhibited a positive
Distraction Test, 74% exhibited a positive ULTT, and
26% exhibited a cervical spine rotation range of
motion measurement less than 60 degrees. In addi-
tion, 15.8% of patients exhibited myotome deficits via
manual muscle test assessment and 5.0% of patients
exhibited dermatome deficits via light touch assess-
ment. A breakdown of neurological test findings cate-
gorized by CEN and Non-CEN can be found in Table 2.
The prevalence of MDT classifications (95% CI)
among patients with CSR were analyzed. Seventy-
nine percent of patients’ conditions were classified
as Reducible Derangement (0.61, 0.97). Twenty-one
percent of patients’ conditions were classified as
either Irreducible Derangement, Entrapment, or
Mechanically Inconclusive (0.03, 0.39). The prevalence
of CEN and Non-CEN at first examination was 36.8 and
47.4 percent, respectively. Patients who had no rest-
ing pain at the physical examination and were not
6 R. YARZNBOWICZ ET AL.

Table 2. Neurological findings of patients with first examina- (SD = 16.9; Range = 9–56) and 5.0 visits (SD = 1.3;
tion and follow-up data (n = 19). Range = 3–6).
Neurological Finding CEN Non-CEN
3 out of 4 15.8% 5.3%
4 out of 4 5.2% 0.0% Discussion
(+) Spurling’s Test 5.2% 100.0%
(+) Distraction Test 10.5% 5.3% The findings of this study show that (1) patients with
(+) ULTT 31.6% 31.6%
(+) CS Rot <60 Degrees 18.6% 5.3% CSR can be classified and treated via MDT methods,
Myotome Deficits 15.8% 5.3% (2) patients that were classified and treated via MDT
Dermatome Deficits 0.0% 0.0%
Altered Reflexes 0.0% 0.0% methods experienced clinically significant improve-
Notes: CEN = Centralization; Non-CEN = Non-Centralization; ULTT = Upper ments in disability, but not pain intensity, at follow-
Limb Tension Test; CS Rot <60 Degrees = Cervical Spine Rotation less up, and (3) the CEN group exhibited a larger magni-
than 60 degrees; Myotome Deficits were considered present according to
manual muscle testing during the physical examination; Dermatome tude of improvement in disability and pain intensity
Deficits were considered present according to light touch testing during and had less treatment visits and a shorter duration of
the physical examination; Altered Reflexes included assessment of Biceps
Brachii, Brachioradialis, and Triceps reflexes; 3 out of 4 = three out of four
care compared to the Non-CEN group, although the
positive tests were present (i.e. Spurling’s Test, Distraction Test, ULTT, or differences in outcomes were not statistically signifi-
CS Rot < 60 degrees); 4 out of 4 = four out of four positive tests were cant. These results contribute to the PCORI agenda
present (i.e. Spurling’s Test, Distraction Test, ULTT, or CS Rot < 60 degrees)
[14], providers, and researchers by demonstrating
ability to classify patients with CSR, showing the effec-
able to be classified via CEN and Non-CEN criteria [29] tiveness of MDT classification and treatment, and
accounted for 5.3% of the sample, and 10.5% of CEN forming a basis for further classification studies in
data were missing. The association between CEN and this cohort.
Non-CEN and clinical outcomes (i.e. disability and pain This investigation is the first multi-center prospec-
intensity) at follow-up were analyzed. Both CEN and tive study to exclusively assess the prevalence of CEN
Non-CEN categories treated via MDT methods made in consecutive patients with CSR. Previous reports
improvements at follow-up and the magnitude of investigating the prevalence of CEN include samples
improvement was greater for those that exhibited of patients either with neck pain only or with neck
CEN (the CEN group had 5.8 and 1.24 points greater pain with and without radiculopathy. In a systematic
change in disability and pain intensity scores than the review that analyzed the prevalence of CEN [19], 62
Non-CEN group, respectively). Clinically significant out of 168 (36.9%) patients with cervical spine disor-
improvements in disability, but not pain intensity, ders exhibited CEN. In a more recent prospective
were observed for both categories at follow-up study, the prevalence of CEN was found to be 40%
(Table 3); however, the changes in disability and in patients with neck pain [24]. The prevalence find-
pain intensity at follow-up for the CEN group did ings related to CEN (36.8%) in the current investiga-
not exhibit a statistically significant difference com- tion provides support for and aligns with earlier
pared to the Non-CEN group (NDI p-value = 0.24; studies which reported data on patients classified at
NPRS p-value = 0.47). The average time to discharge the first examination. However, further studies should
and treatment visits for patients’ conditions which consider serial assessments of CEN over time [52,53].
exhibited CEN at first examination was 23.5 days A more recent study by Otero et al. [52] showed the
(SD = 9.7; Range = 14–30) and 4.0 visits (SD = 2.2; importance of assessing the prevalence of CEN across
Range = 1–8). For patients’ conditions which exhibited multiple visits. The study evaluated the prevalence of
Non-CEN at first examination, the average time to CEN throughout five visits in patients with non-
discharge and treatment visits were 33.3 days specific neck pain in which CEN increased from
52.9% at the first visit to 76.03% by the fifth visit.
Table 3. Follow-up disability and pain intensity comparison These data express how the prevalence of CEN may
(n = 19). change upon reassessment as patients undergo treat-
CEN Non-CEN ment and also reinforces a previous report [53] that
Mean NDI at First Examination 17.85 22.56 indicated that multiple-visit classification improved
Mean NDI at Follow-Up 3.71 14.22
Mean Difference 14.14 8.34 the precision for discriminating differences in pain
Mean NPRS at First Examination 5.29 7.22 and disability. Our data collection process prohibited
Mean NPRS at Follow-Up 1.71 4.88
Mean Difference 3.58 2.34
analysis of serial assessments of CEN, and further
. studies need to be conducted to assess if and how
Notes: NDI = Neck Disability Index; NPRS = Numeric Pain Rating Scale; the prevalence of CEN at follow-up assessment
CEN = Centralization; Non-CEN = Non-Centralization; p-value NDI changes in patients with CSR.
Difference Score = 0.24; p-value NPRS Difference score = 0.47; 10.5% of
CEN data were missing Patients’ conditions which exhibited CEN (36.8%)
The Mean Difference was calculated by subtracting the mean change and Non-CEN (47.4%) at first examination that were
in the first examination outcome measure (i.e. the NDI or NPRS) from
the mean change in the follow-up measure (first examination mean
assessed and treated via MDT methods demonstrated
change minus follow-up mean change = Mean Difference) clinically significant changes in disability, but not pain

intensity, at follow-up. These findings verify the
results of a similar study by Edmonds et al. [24]
which assessed patients with neck pain and found
that CEN-based categories were not predictive of
pain intensity outcomes. The minimal detectable
improvement value used as a reference criterion in
the study by Edmonds et al. is the same as that used
in the current investigation (4.1 NPRS points). The
groups in the current investigation exhibited greater
than a two-point NPRS change (CEN pain intensity
change = 3.58; Non-CEN pain intensity change = 2.34),
which would have been considered clinically signifi-
cant if referenced to the established low back pain
criteria [54] of two-points of change on the NPRS. An
NPRS change of 4.1 is more than double this criteria
for the necessary magnitude of change to be deemed
clinically significant. Further investigation of the mini-
mal improvement needed to be considered clinically
significant for patients neck pain with and without
radiculopathy may be warranted.
Patients’ conditions which exhibited CEN at first
examination achieved greater magnitudes of
change in both disability and pain intensity
(patients who exhibited CEN had 5.8 and 1.24
points greater change than patients who exhibited
Non-CEN for disability and pain intensity scores,
respectively), however, no significant differences
were found between the groups for disability
(p-value = 0.24) or pain intensity (p-value = 0.47)
outcomes at follow-up. The lack of differences in
outcomes may be attributed to when the outcomes
were collected. Clinical outcomes were assessed at
two time points, first examination and follow-up
(average follow-up time for CEN and Non-CEN
groups was 23.5 and 33.3 days, respectively).
Therefore, it was not possible to determine if each
group exhibited differences at other time points.
CEN is characterized by rapid improvements in
symptoms and function [16] and further studies
may expose clinically significant differences com-
pared to those that exhibit Non-CEN during the
first week of treatment. Furthermore, the interven-
tions in this study were not recorded, thus it was
not possible to determine if the lack of difference in
the outcomes was due to the treatments per-
formed, the prognostic attributes of the system, or
both. Studies which examine patient classification,
treatments performed, and the associated outcomes
obtained are needed.
There are several limitations to consider in the present
study. Although formal feedback was not collected from
the providers in the study, a significant level of burden
was reported in administering the clinical tests proposed
by Wainner et al. [17] in addition to a standard MDT
examination. Further studies should investigate the
level of burden and feasibility of including this test-item
cluster as a part of a standard MDT evaluation. Only 6% of
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 7
patients met the inclusion criteria for having CSR com-
pared to all patients presenting to the clinics with cervical
spine disorders and may be related to referral patterns for
physical therapy services. The practice settings were
diverse and represented typical orthopedic physical ther-
apy clinics (i.e. four outpatient orthopedic physical ther-
apy clinics across four US states). Primary care and
specialist physicians comprised 74% of the sample refer-
ral base; however, it could not be determined how these
sources considered referral for physical therapy services,
and, perhaps, patients with CSR were more likely to be
escalated to services other than physical therapy based
on the characteristics of the patient and provider. More
studies are needed to examine the utility and general-
izability of this test-item cluster across multiple health
care settings and provider types.
Providers in the study were instructed to collect clin-
ical outcome measures regularly throughout the care
episode and at discharge to maximize completion rate
(i.e. the percentage of patients in the sample who had
both first examination and follow-up data). Despite these
requirements, the completion rate was 18% lower than
anticipated (expected = ≥60%; actual = 49%) which
increases the susceptibility of selection bias. Attempts
were made to reschedule patients who missed visits
and did not return for follow-up contrary to advisement
of the providers. Per facility standards, the providers were
required to make at least two follow-up phone calls to
reschedule the patient. Many patients may not have
returned to physical therapy due to several factors includ-
ing high co-pays and geographical location [55].
Conclusion
The findings of this study show that patients with CSR
made clinically significant improvements when classified
and treated via MDT methods and the CEN group exhib-
ited greater improvement in clinical outcomes and
a shorter duration of care compared to the Non-CEN
group; however, the differences in outcomes were not
statistically significant. Providers should consider MDT
classification and treatment to improve clinical outcomes
for their patients affected by CSR. Recommendations for
researchers have been made to further study MDT classi-
fication and outcomes for patients with CSR.
Disclosure statement
No potential conflict of interest was reported by the
authors.
Notes on contributors
Richard Yarznbowicz obtained his doctor of physical ther-
apy from the University of the Sciences in Philadelphia in
2010 before earning his diploma in Mechanical Diagnosis
and Therapy in 2013. He is also a board certified Orthopedic
8 R. YARZNBOWICZ ET AL.
Clinical Specialist. He has authored and co-authored several
publications regarding the assessment and treatment of
patients with musculoskeletal disorders.
Matt Wlodarski obtained his doctor of physical therapy
from Northwestern University and a certification in
Mechanical Diagnosis and Therapy in 2013. He enjoys treat-
ing patients in an outpatient setting and also programs
healthcare technologies and data collection instruments to
improve patient care. He has co-authored publications
regarding Mechanical Diagnosis and Therapy on patients
affected by spinal disorders.
Jonathan Dolutan obtained his Master of Science in
Rehabilitation Science-Physical Therapy in 2004 and his
Doctorate in 2008 from the Medical University of South
Carolina. He was awarded his Diploma in Mechanical
Diagnosis and Therapy in 2011. Jonathan has special inter-
est in research data collection related to physical therapy
intervention and injury prevention.
ORCID
Jonathan Dolutan http://orcid.org/0000-0003-4273-6780
References
[1] Iyer S, Kim HJ. Cervical radiculopathy. Curr Rev
Musculoskelet Med. 2016;9(3):272–280.
[2] Caridi JM, Pumberger M, Hughes AP. Cervical radicu-
lopathy: a review. HSS J. 2011;7(3):265–272.
[3] Childs J, Fritz JM, Piva SR, et al. Proposal of
a classification system for patients with neck pain.
J Orthop Sports Phys Ther. 2004;34(11):686–696.
[4] Blanpied PR, Gross AR, Elliott JM, et al. Neck pain:
revision 2017. J Orthop Sports Phys Ther. 2017;47(7):
A1–A83.
[5] Polston D. Cervical radiculopathy. Neurol Clin.
2007;25(2):373–385.
[6] Malanga G. The diagnosis and treatment of cervical
radiculopathy. Med Sci Sport Exercise. 1997;29
(7):236–245.
[7] Kramer J. Intervertebral disk diseases. 2nd ed.
New York: Thieme Medical Publishers, Inc; 1990.
[8] National Health and Medical Research Council.
Australian acute musculoskeletal pain guidelines.
Bowen Hills, Australia: Bowen Hills Aust Acad Press;
2003.
[9] Radhakrishnan K, Litchy WJ, O’Fallon WM, et al.
Epidemiology of cervical radiculopathy. Brain.
1994;117(2):325–335.
[10] Sampath P. Outcome in patients with cervical radicu-
lopathy. prospective, multicenter study with indepen-
dent clinical review. Spine. 1999;24(6):591–597.
[11] Ahlgren B, Garfin S. Cervical radiculopathy. Orthop
Clin North Am. 1996;27:253–263.
[12] Thoomes EJ, Scholten-Peeters W, Koes B, et al. The
effectiveness of conservative treatment for patients
with cervical radiculopathy: a systematic review. Clin
J Pain. 2013;29(12):1073–1086.
[13] Rao R. Neck pain, cervical radiculopathy, and cervical
myelopathy: pathophysiology, natural history, and
clinical evaluation. J Bone Joint Surg Am. 2002;84(A
(10):):1872–1881.
[14] Coeytaux RR, Lallinger K, Amanda McBroom BM, et al.
Future research identification: comparative
effectiveness of nonsurgical treatment for cervical
disc and neck pain. Pcori. 2015;October:1–52.
[15] Fritz JM, Brennan GP. Preliminary examination of
a proposed treatment-based classification system for
patients receiving physical therapy interventions for
neck pain. Phys Ther. 2007;87(5):513–524.
[16] McKenzie RA, May S. The cervical and thoracic spine:
mechanical diagnosis and therapy. Waikanae, New
Zealand: Spinal Publication, Ltd; 2006.
[17] Wainner RS, Fritz JM, Irrgang J, et al. Reliability and
diagnostic accuracy of the clinical examination and
patient self-report measures for cervical
radiculopathy. Spine. 2003;23(1):A1–A34.
[18] Rubinstein SM, Pool JJM, Van Tulder MW, et al.
A systematic review of the diagnostic accuracy of
provocative tests of the neck for diagnosing cervical
radiculopathy. Eur Spine J. 2007;16(3):307–319.
[19] May S, Aina A. Centralization and directional prefer-
ence: A systematic review. Man Ther. 2012;17
(6):497–506.
[20] Clare HA, Adams R, Maher CG. A systematic review of
efficacy of McKenzie therapy for spinal pain. Aust
J Physiother. 2004;50(4):209–216.
[21] Long A, Donelson R, Fung T. Does it matter which
exercise? Spine. 2004;29(23):2593–2602.
[22] Niemistö L, Sarna S, Lahtinen-Suopanki T, et al.
Predictive factors for 1-year outcome of chronic low
back pain following manipulation, stabilizing exer-
cises, and physician consultation or physician consul-
tation alone. J Rehabil Med. 2004;36(3):104–109.
[23] Werneke MW, Hart DL, Cutrone G, et al. Association
between directional preference and centralization in
patients with low back pain. J Orthop Sports Phys
Ther. 2011;41(1):22–31.
[24] Edmond SL, Cutrone G, Werneke M, et al. Association
between centralization and directional preference
and functional and pain outcomes in patients with
neck pain. J Orthop Sports Phys Ther. 2014;44
(2):68–75.
[25] Yarznbowicz R, Tao M, Owens A, et al. Pain pattern
classification and directional preference are asso-
ciated with clinical outcomes for patients with low
back pain. J Man Manip Ther. 2018;26(1):18–24.
[26] Yarznbowicz R, Tao M, Wlodarski M, et al. Pain pattern
classification and directional preference for patients
with neck pain. J Man Manip Ther. 2018;26(1):18–24.
[27] Werneke MW, Hart DL. Centralization: association
between repeated end-range pain responses and
behavioral signs in patients with acute non-specific
low back pain. J Rehabil Med. 2005;37(5):286–290.
[28] Werneke M, Hart DL. Centralization phenomenon as
a prognostic factor for chronic low back pain and
disability. Spine. 2001;26(7):758–765.
[29] Werneke MW, Hart DL, Cook D. A descriptive study of the
centralization phenomenon. Spine. 1999;24(7):676–683.
[30] Donelson R, April C, Medcalf R, et al. A prospective
study of centralization of lumbar and referred pain.
A predictor of symptomatic discs and anular
competence. Spine. 1997;22(10):1115–1122.
[31] Young S, April C, Laslett M. Correlation of clinical
examination characteristics with three sources of
chronic low back pain. Spine J. 2003;3(6):460–465.
[32] Laslett M, Oberg B, April C, et al. Centralization as
a predictor of provocation discography results in
chronic low back pain, and the influence of disability
and distress on diagnostic power. Spine J.
2005;5:370–380.

[33] Laslett M, April C, McDonald B, et al. Clinical predic-
tors of lumbar provocation discography: a study of
clinical predictors of lumbar provocation discography.
Eur Spine J. 2006;15:1473–1484.
[34] Laslett M, McDonald B, April C, et al. Clinical predic-
tors of screening lumbar zygapophyseal joint blocks:
development of clinical prediction rules. Spine J.
2006;6:370–379.
[35] Mercer SR, Bogduk N. The ligaments and annulus
fibrosus of human adult cervical intervertebral discs.
Spine. 1999;24(7):627–628.
[36] Kim Y, Kim S, Park S, et al. Effects of cervical exten-
sion on deformation of intervertebral disk and
migration of nucleus pulposus. PM&R. 2017;9
(4):329–338.
[37] Abdulwahab SS, Sabbahi M. Neck retractions, cervical
root decompression, and radicular pain. J Orthop
Sports Phys Ther. 2000;30(1):4–12.
[38] Spanos G, Zounis M, Natsika M, et al. The application
of mechanical diagnosis and therapy and changes on
MRI findings in a patient with cervical radiculopathy.
Man Ther. 2013;18(6):606–610.
[39] Schenk RJ, Bhaidani T, Melissa B, et al. Inclusion of
Mechanical Diagnosis and Therapy (MDT) in the
management of cervical radiculopathy: a case
report. J Man Manip Ther. 2008;16(1):e1–e8.
[40] Murphy DR, Beres JL. Is treatment in extension con-
traindicated in the presence of cervical spinal cord
compression without myelopathy? A case report. Man
Ther. 2008;13(5):468–472.
[41] Werneke MW, Hart DL, Resnik L, et al. Centralization:
prevalence and effect on treatment outcomes using
a standardized operational definition and measurement
method. J Orthop Sports Phys Ther. 2008;38(3):116–125.
[42] Spurling R, Scoville W. Lateral rupture of the cervical
intervertebral discs: A common cause of shoulder and
arm pain. Surg Gynecol Obstet. 1944;78:350–358.
[43] Elvey R. The investigation of arm pain: signs of
adverse responses to the physical examination of
the brachial plexus and related tissues. 2nd ed.
New York: Churchill Livingstone; 1994.
[44] Hole DE, Cook JM, Bolton JE. Reliability and concur-
rent validity of two instruments for measuring
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 9
cervical range of motion: effects of age and gender.
Man Ther. 1995;1:36–42.
[45] Kirshblum SC, Waring W, Biering-Sorensen F, et al.
Reference for the 2011 revision of the international
standards for neurological classification of spinal cord
injury. J Spinal Cord Med. 2011;34(6):547–554.
[46] Walker H, Hall W, Hurst J. Clinical methods: the his-
tory, physical, and laboratory examinations. 3rd ed.
Boston: Butterworth-Heinemann; 1990.
[47] Cleland JA, Childs JD, Whitman JM. psychometric
properties of the neck disability index and numeric
pain rating scale in patients with mechanical neck
pain. Arch Phys Med Rehabil. 2008;89(1):69–74.
[48] Young IA, Cleland JA, Michener LA, et al. Reliability,
construct validity, and responsiveness of the neck
disability index, patient-specific functional scale, and
numeric pain rating scale in patients with cervical
radiculopathy. Am J Phys Med Rehabil. 2010;89
(10):831–839.
[49] Stratford PW, Riddle DL, Binkley J, et al. Using the neck
disability index to make decisions concerning individual
patients. Physiother Can. 1999;51(2):107–113.
[50] Vernon H, Mior S. The neck disability index: a study of
reliability and validity. J Manip Physiol Ther. 1991;14
(7):409–415.
[51] Riddle DL, Stratford PW. Use of generic versus
region-specific functional status measures on patients
with cervical spine disorders. Phys Ther. 1998;78
(9):951–963.
[52] Otéro J, Bonnet F. Cervicalgie: prévalence des syn-
dromes McKenzie et des Préférences Directionnelles.
Kinesitherapie. 2016;16(169):2–10.
[53] Werneke M, Hart DL. Discriminant validity and relative
precision for classifying patients with nonspecific
neck and back pain by anatomic pain patterns.
Spine. 2003;28(2):161–166.
[54] Childs J, Piva S, Fritz J. Responsiveness of the numeric
pain rating scale in patients with low back pain.
Spine. 2005;30:1331–1334.
[55] Carvalho E, Bettger JP, Goode AP. Insurance coverage,
costs, and barriers to care for outpatient musculoske-
letal therapy and rehabilitation services. N C Med J.
2017;78(5):312–314.
10 R. YARZNBOWICZ ET AL.

Appendix

MDT Classification
Classification [16] Criteria
Reducible ● In response to therapeutic loading strategies, pain is progressively abolished in a distal to proximal direction and each
Derangement progressive abolition is retained over time until all symptoms are abolished
● Usually accompanied or preceded by improvements in the mechanical presentation (range of movement and/or deformity)
Dysfunction ● Intermittent spinal pain only
● At least one movement is restricted
● The restricted movement consistently produces concordant pain at end-range
● There is no rapid reduction or abolition of symptoms
Posture ● Intermittent spinal pain only
● Concordant pain is reproduced with static prolonged loading
● Abolition of pain with postural correction
● No loss of movement or pain with repeated movements
Other ● There is no rapid reduction or abolition of symptoms
● Does not fit the Derangement, Dysfunction, or Posture criteria
● Classifications include but are not limited to the following: Mechanically Inconclusive, Chemical Pain, Spinal Stenosis,
Chronic Pain State, Irreducible Derangement, Adherent Nerve Root, Entrapment, and Post-Surgical

Test Cluster
CSR Examination Description Positive Test Finding
Tests
Spurling’s Test In a seated position, the patient’s cervical spine is laterally Reproduction of the patient’s concordant sign is provoked
flexed toward the symptomatic side and overpressure
(approximately 7 kg of force) is applied to the patient’s
head [42]
The Distraction Test In the supine position, the patient’s cervical spine is flexed to Reduction or elimination of the patient’s concordant sign
a position of comfort and a distraction force (approximately
14 kg of force) is applied through the posterior occiput and
chin [17]
ULTT In the supine position, the provider sequentially introduces the The test is considered positive if any one of the following is
following movements in the symptomatic upper extremity: present: (1) the patient’s concordant sign is reproduced, (2)
(1) scapular depression, (2) shoulder abduction, (3) forearm a side-to-side difference (>10 degrees) in elbow extension is
supination, (4) wrist and finger extension, (5) shoulder present, (3) contralateral cervical spine lateral flexion
external rotation, (6) elbow extension, and then (7) increases symptoms, or (4) ipsilateral cervical spine lateral
contralateral followed by ipsilateral cervical spine lateral flexion decreases symptoms
flexion [43]
CS Rotation ROM In a seated position, the patient is asked to maximally rotate The test is considered positive if patients’ cervical spine
<60 Degrees their neck, keeping shoulder movement to a minimum. rotation ROM to the involved side is less than 60 degrees
Cervical spine rotation ROM to the involved side is
measured using a standard long-arm goniometer [17,44]

Standard Neurological Examination

Tests Description
Myotome Testing Assessment of upper extremity myotomes via manual muscle testing includes the following: C5 – Elbow flexors (Biceps,
Brachialis), C6 – Wrist extensors (Extensor Carpi Radialis Longus and Brevis), C7 – Elbow extensors (Triceps), C8 – Finger
flexors (Flexor Digitorum Profundus) to the middle finger, and T1 – Small finger abductors (Abductor Digiti Minimi) [45]
Dermatome Testing Assessment of upper extremity dermatomes via light touch testing includes the following: C2 – At least 1 cm lateral to the
occipital protuberance (alternatively 3 cm behind the ear), C3 – Supraclavicular Fossa (posterior to the Clavicle) and at the
midclavicular line, C4 – Over the Acromioclavicular Joint, C5 – Lateral (radial) side of the Antecubital Fossa (just proximal to
elbow crease), C6 – Thumb, dorsal surface, Proximal Phalanx, C7 – Middle finger, dorsal surface, Proximal Phalanx, C8 – Little
finger, dorsal surface, Proximal Phalanx, and T1 – Medial (ulnar) side of the Antecubital Fossa, just proximal to the Medial
Epicondyle of the Humerus [45]
Reflex Testing Assessment of muscle stretch reflexes via a standard reflex hammer includes the following: Biceps (C5–C6), Brachioradialis (C5–
C6), and Triceps (C7). Reflex testing is graded via 0 = no response (always abnormal), 1+ = a slight but definitely present
response (may or may not be normal), 2+ = a brisk response (normal), 3+ = a very brisk response (may or may not be
normal), and 4+ = a tap elicits a repeating reflex or clonus (always abnormal) [46]
Notes: MDT = Mechanical Diagnosis and Therapy; CSR = Cervical Spine Radiculopathy; ULTT = Upper Limb Tension Test; CS = Cervical Spine;
ROM = Range of Motion;