Effect of an intensive cervical traction protocol on mid-term disability and pain in patients with cervical radiculopathy: An exploratory, prospective, observational pilot study

Thomas Rulleau; Sophie Abeille; Lydie Pastor; Lucie Planche; Pascale Allary; Catherine Chapeleau; Chloé Moreau; Grégoire Cormier; Michel Caulier

doi:10.1371/journal.pone.0255998

Peer Review History

Original SubmissionMarch 26, 2021
4 May 2021 Decision Letter - Panagiotis Kerezoudis, Editor PONE-D-21-09986 Effect of an intensive cervical traction protocol on mid-term disability and pain in patients with cervical radiculopathy: an exploratory, prospective, observational pilot study PLOS ONE Dear Dr. Rulleau, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jun 18 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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The conclusions must be drawn appropriately based on the data presented. Reviewer #1: No Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: No Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Roulleau T and colleagues here present the results of their study named “Effect of an intensive cervical traction protocol on mid-term disability and pain in patients with cervical radiculopathy: an exploratory, prospective, observational pilot study”. In this work the authors conducted an observational study of 36 patients referred by their general practitioner for symptoms suggestive of cervical radiculopathy, submitting them to a specific cervical traction protocol, analyzing post-protocol symptoms and signs also through the help of Neck Disability Index. They found that disability was significantly reduced in almost half of the participants, suggesting such protocol as an alternative to longer traction protocols, at the comparison of whom the present protocol appeared similar in terms of efficacy. Although the work is sufficiently well written and clear from a stylistic point of view, I honestly feel it suffers from heavy scientific rigor issues that definitely affect its potential scientific interest. I list here my major concerns: - Introduction section is really too long, please re-write it in a more summarized manner; - Introduction section, lines 63-66 definitely need references, if available. Moreover, the entire paragraph should be re-written specifying for which pathologies such considerations are referred. Are the authors speaking about cervical radiculopathy due to disk herniation or stenosis or tumors etc.? Anyway, I would be very interested in reading some reference that states that intervention is not indicated for cervical radiculopathy in cervical disk herniations with pain resistant to medications. - Material and methods. Was cervical radiculopathy diagnosed just with clinical examination, without performing MR or CT imaging to patients? No specific radiological control before submitting them to cervical traction? Really? It appears, at least, risky. - No neurosurgeons nor ortophaedic surgeons appeared to be involved in the study. Hence, how can patients be informed about their condition and supposed diagnosis? From the reading of this work it seems that, simply, patients with cervical radiculopathy that come to your clinic are directly submitted to cervical traction, without any diagnosis nor alternative treatment proposal; If it’s not, re-write the section entirely, please; - English written language may beneficiate from a mother-tongue speaker review. Reviewer #2: To Whom It May Concern, This is an exceptional paper. However, there are a few data points that would add to the paper. Those points are a graphic (histogram) representation of the age breakdown in intervals. We know that older patients are more prone to degenerative spondylosis however, it would be helpful to know where the majority of the study population resides in age distribution. Also, in the methods section I could not discern the exact method used to apply traction. For example, did you all use Gardner Wells Tongs or strap system? Otherwise, well written paper. Reviewer #3: First, I would like to express sincere gratitude to get an opportunity to review the manuscript. The endeavor of the authors is appreciated. The authors have studied effect of intensive cervical traction with respect to mid-term disability and pain in patients with cervical radiculopathy. However, there is some scope for its improvement. Specific comments: 1. There are some contradictory statements in the paper. For example, as per methods section 36 patients were enrolled in the study whereas as per results section of main text 42 patients were enrolled. Kindly explain. 2. The study design is not clear. Was there any control arm? The conclusion states there was some comparison done. The details of study design need to be well described. 3. Kindly define mid-term effect and intensive cervical traction. 4. It would be better if study design were clearly mentioned in title, abstract and main text. 5. Methods sections is supposed to be core of any study. Here, methods section contains inadequate information. For example, following components for methods section need to be well described. i. Details of Study design ii. Setting iii. Sampling technique iv. Participant v. Primary and secondary outcome variables with working definition vi. Intervention/issue of interest (exposure) vii. Comparison (if done) viii. Ethics and end point ix. Statistical analysis 6. Kindly re-frame the references as per the guidelines to authors in the home page of journal. Further, most of the studies included in the reference section seem to be the studies published more than 10 years back. If possible, please add recent studies. 7. The tables need to be re-organized. For example, table 2 appears first. Further, kindly provide study size in captions. It would be better to frame all the tables in homogenous format. Section wise comments 1. Abstract contains inadequate information. a. Mention the design of the study clearly. b. Methods section is not well described. c. Kindly start results section with baseline information of participants. 2. The introduction is lengthy. Please DELETE INFORMATION UNRELATED TO OBJECTIVE so that the section is short and sweet. Kindly shorten this section and delete unrelated information. Kindly focus on three elements of introduction a. What is known about the topic? (Background) b. What is not known? (The research problem) c. Why the study was done? (Justification) 3. Methods section determines the results. Kindly follow the checklist. Further, kindly focus on three basic elements of methods section. a. How the study was designed? b. How the study was carried out? c. How the data were analyzed? 4. The discussion section needs to be described scientifically. Kindly frame it along the following lines: a. Main findings of the present study b. Comparison with other studies c. Implication and explanation of findings d. Strengths and limitations e. Conclusion, recommendation and future directions 5. Conclusion needs to provide answers for each objective clearly in a sentence or two. Reviewer #4: Journal of PLOS ONE 27 April 2021 Manuscript No: PONE-D-21-09986_reviewer “Effect of an intensive cervical traction protocol on mid-term disability and pain in patients with cervical radiculopathy: an exploratory, prospective, observational pilot study” Dear editorial Teams In my opinion the manuscript has well written. However, I have several suggestions that I think would improve the manuscript: a) The Introduction and the Discussion sections are long and redundant. b) Additional descriptions as NDI (line 155- 162) should be summarized, and ets. c) Researchers stated that “ forty-two patients were included” and “Only 29 patients could be evaluated at M3: 3 were unavailable as they were undergoing surgery and 4 were lost to follow-up” 42= 29+ 3+ 4+ X? please explain the other 6 patients. d) Please, explain the type of traction used. Parisa Azimi, MD, ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No Reviewer #3: Yes:** Dr. Satish Prasad Barnawal Reviewer #4: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0255998.r001
Revision 1
10 Jun 2021 Author Response We would like to thank the editor and reviewers for taking the time to evaluate our work. We hope that the changes made will meet their expectations. Reviewer #1: Roulleau T and colleagues here present the results of their study named “Effect of an intensive cervical traction protocol on mid-term disability and pain in patients with cervical radiculopathy: an exploratory, prospective, observational pilot study”. In this work the authors conducted an observational study of 36 patients referred by their general practitioner for symptoms suggestive of cervical radiculopathy, submitting them to a specific cervical traction protocol, analyzing post-protocol symptoms and signs also through the help of Neck Disability Index. They found that disability was significantly reduced in almost half of the participants, suggesting such protocol as an alternative to longer traction protocols, at the comparison of whom the present protocol appeared similar in terms of efficacy. Although the work is sufficiently well written and clear from a stylistic point of view, I honestly feel it suffers from heavy scientific rigor issues that definitely affect its potential scientific interest. I list here my major concerns: - Introduction section is really too long, please re-write it in a more summarized manner; We thank reviewer 1 for this suggestion and have modified as suggested - Introduction section, lines 63-66 definitely need references, if available. Moreover, the entire paragraph should be re-written specifying for which pathologies such considerations are referred. Are the authors speaking about cervical radiculopathy due to disk herniation or stenosis or tumors etc.? Anyway, I would be very interested in reading some reference that states that intervention is not indicated for cervical radiculopathy in cervical disk herniations with pain resistant to medications. We have added reference "9" and we have also added "or myelopathy" line 59. Nikolaidis et al (2010) which was quoted after in the paragraph and thank reviewer 1 for this clarification request. Nikolaidis et al (2010) explain a “low quality evidence that surgery may provide pain relief faster than physiotherapy or hard collar immobilization in patients with cervical radiculopathy; but there is little or no difference in the long-term”. We confirm that we do not mention any lack of interest in surgery for patients with cervical radiculopathy in cervical disk herniations with pain resistant to medications. We thank reviewer 1 for his clarification. - Material and methods. Was cervical radiculopathy diagnosed just with clinical examination, without performing MR or CT imaging to patients? No specific radiological control before submitting them to cervical traction? Really? It appears, at least, risky. We thank reviewer 1 for this comment. Patients were diagnosed according to one of the proposals of Romeo et al (2018). In their meta-analysis, they select studies where patients meet these criteria: 1) diagnosis based on magnetic resonance imaging, electromyography, or nerve conduction velocity testing, 2) positive results on at least 3 out of 4 tests, according to clinical prediction rules,21 or 3) symptoms associated with CR, such as pain radiating to the arm, with or without motor or sensitive dysfunction. We have used criteria 3) in this study. To confirm absence of risk, like explain line 159, we performed systematically a cervical spine x-rays - No neurosurgeons nor ortophaedic surgeons appeared to be involved in the study. Hence, how can patients be informed about their condition and supposed diagnosis? From the reading of this work it seems that, simply, patients with cervical radiculopathy that come to your clinic are directly submitted to cervical traction, without any diagnosis nor alternative treatment proposal; If it’s not, re-write the section entirely, please; Indeed, we understand the issue. In our health care system, the intervention of neurosurgeons is second line. Diagnostic confirmation is provided by rheumatologists and cervical traction is often performed in rheumatology or physical medicine rehabilitation departments. - English written language may beneficiate from a mother-tongue speaker review. We are surprised by this remark. The document has been proofread by Johanna Robertson PT PhD, professional medical and science translator and native British speaker, as evidenced by the attached document. We have written an acknowledgement to this effect (line 437). A new proofreading was done in order to improve manuscript as requested. Reviewer #2: To Whom It May Concern, This is an exceptional paper. However, there are a few data points that would add to the paper. Those points are a graphic (histogram) representation of the age breakdown in intervals. We know that older patients are more prone to degenerative spondylosis however, it would be helpful to know where the majority of the study population resides in age distribution. Also, in the methods section I could not discern the exact method used to apply traction. For example, did you all use Gardner Wells Tongs or strap system? Otherwise, well written paper. We thank reviewer 2 for his compliments and suggestions for improvement. We have added a graphical table in order to have a better representation of the age of the patients. We have also added a picture (fig 1) of the device in Methods section to explain the proposed tractions. Reviewer #3: First, I would like to express sincere gratitude to get an opportunity to review the manuscript. The endeavor of the authors is appreciated. The authors have studied effect of intensive cervical traction with respect to mid-term disability and pain in patients with cervical radiculopathy. However, there is some scope for its improvement. Specific comments: 1. There are some contradictory statements in the paper. For example, as per methods section 36 patients were enrolled in the study whereas as per results section of main text 42 patients were enrolled. Kindly explain. We thank reviewer 3 for this comment. This is an error on our part, there are 36 patients included in this work. We have made the correction on line 26 and line 250 and please apologize to the reviewers for this error. 2. The study design is not clear. Was there any control arm? The conclusion states there was some comparison done. The details of study design need to be well described. We thank reviewer 3 for this question. There is no control arm. The study is observational, as explained in the title and method. We have added the sentence "All patients received the same treatment" to line 136. 3. Kindly define mid-term effect and intensive cervical traction. To explicit “mid-term”, we have changed the phrase "at three month" to "at mid-term" line 31. We have also made this clarification on line 197. To explicit an intensive cervical traction, we added : "To propose an intensive cervical traction protocol" just before sentence "thirty-minute traction sessions were performed twice daily for 5 days (total of 10 sessions) by a physiotherapist" ligne 162. We thank Reviewer 3 for requesting these clarifications. 4. It would be better if study design were clearly mentioned in title, abstract and main text. We thank reviewer 2 for this remark. Nevertheless, we have mentioned in the title, abstract and main text the "observational" character of our work. We hesitated with the term "cohort study" which seemed less appropriate for a number of subjects below several hundred. 5. Methods sections is supposed to be core of any study. Here, methods section contains inadequate information. For example, following components for methods section need to be well described. i. Details of Study design ii. Setting iii. Sampling technique iv. Participant v. Primary and secondary outcome variables with working definition vi. Intervention/issue of interest (exposure) vii. Comparison (if done) viii. Ethics and end point ix. Statistical analysis We thank reviewer 2 for this remark. A formatting error has been corrected to clarify this point. We have taken up several missing headings suggested by Reviewer 3 in order to clarify this legitimate request. In particular, we have added "Details of Study design" line 133, "Intervention/issue of interest (exposure)" line 161, and we have moved the paragraph on ethical approaches to conducting this research to line 226 "Ethics". 6. Kindly re-frame the references as per the guidelines to authors in the home page of journal. Further, most of the studies included in the reference section seem to be the studies published more than 10 years back. If possible, please add recent studies. We thank proofreader 3 for these remarks. We have changed the bibliography from the "vancouver" style to the "plos one" style available in Zotero followed by a manual check. We understand the remark about studies that may be more than ten years old. Indeed, it is interesting to note how few recent studies on this subject we could find, which motivated our interest. 7. The tables need to be re-organized. For example, table 2 appears first. Further, kindly provide study size in captions. It would be better to frame all the tables in homogenous format. Table 1 is quoted in the introduction. It therefore seems appropriate to leave it as "Table 1". Nevertheless, we agree with reviewer 3. We have rearranged and modified the tables to make them consistent. Section wise comments 1. Abstract contains inadequate information. a. Mention the design of the study clearly. b. Methods section is not well described. We have added the sentence " All patients underwent the same treatment " to clarify the abstract line 13. c. Kindly start results section with baseline information of participants. We have made this change and thank you for it. 2. The introduction is lengthy. Please DELETE INFORMATION UNRELATED TO OBJECTIVE so that the section is short and sweet. Kindly shorten this section and delete unrelated information. Kindly focus on three elements of introduction a. What is known about the topic? (Background) b. What is not known? (The research problem) c. Why the study was done? (Justification) The introduction has been revised to meet the expectations of reviewers 3 and 4. We thank them for their advice. 3. Methods section determines the results. Kindly follow the checklist. Further, kindly focus on three basic elements of methods section. a. How the study was designed? b. How the study was carried out? c. How the data were analyzed? We hope that the new layout and additions will meet the reviewer's expectations3 4. The discussion section needs to be described scientifically. Kindly frame it along the following lines: a. Main findings of the present study b. Comparison with other studies c. Implication and explanation of findings d. Strengths and limitations e. Conclusion, recommendation and future directions We thank reviewer 3 for this feedback. We have added the suggested headings and redesigned this section to make it easier for practitioners to read. 5. Conclusion needs to provide answers for each objective clearly in a sentence or two. We thank reviewer 3 for this suggestion and have added " In addition, cervical and radiating arm pain, pain with imagined movements and neuropathic pain also improved " line 429. Reviewer #4: Journal of PLOS ONE 27 April 2021 Manuscript No: PONE-D-21-09986_reviewer “Effect of an intensive cervical traction protocol on mid-term disability and pain in patients with cervical radiculopathy: an exploratory, prospective, observational pilot study” Dear editorial Teams In my opinion the manuscript has well written. However, I have several suggestions that I think would improve the manuscript: a) The Introduction and the Discussion sections are long and redundant. We have taken this comment into account and thank reviewer 4. We have amended the text accordingly for the introduction. We have redesigned the discussion to make it slightly shorter, but also more reader friendly. b) Additional descriptions as NDI (line 155- 162) should be summarized, and ets. We thank Reviewer 3 for this remark. We have taken his advice and deleted several parts in the outcomes description that were not essential to the understanding of the study. c) Researchers stated that “ forty-two patients were included” and “Only 29 patients could be evaluated at M3: 3 were unavailable as they were undergoing surgery and 4 were lost to follow-up” 42= 29+ 3+ 4+ X? please explain the other 6 patients. We thank reviewer 4 for this remark which is in line with that of reviewer 3. This is an error on our part, there are 36 patients included in this work. We have made the correction on line 35 and 250. We apologize for this error.. d) Please, explain the type of traction used. We thank reviewer 4 for this comment which is in line with reviewer 2. We have added a picture (fig1 ) to be more explicit about the type of traction. We sincerely thank the reviewers for their time in reviewing our work. We feel that this feedback has been productive and has helped to improve the communication proposal for our work. We hope we have met their expectations. For the authors, Dr Thomas Rulleau PT PhD https://doi.org/10.1371/journal.pone.0255998.r002
22 Jul 2021 Decision Letter - Panagiotis Kerezoudis, Editor PONE-D-21-09986R1 Effect of an intensive cervical traction protocol on mid-term disability and pain in patients with cervical radiculopathy: an exploratory, prospective, observational pilot study PLOS ONE Dear Dr. Rulleau, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. ============================== Please submit your revised manuscript by Sep 05 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-emailutm_source=authorlettersutm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Panagiotis Kerezoudis, M.D., M.S. Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #2: All comments have been addressed Reviewer #3: (No Response) Reviewer #4: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #2: Yes Reviewer #3: Partly Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #2: (No Response) Reviewer #3: The paper is in better shape. Congratulations to the authors for such a nice work. Yet, some modifications need to be made before publication. Kindly refer to the following aspects. 1. Conclusion needs to provide answers for each objective clearly in a sentence or two. a. Here the conclusion does not support the findings of the paper. b. As the study was not comparative study, such statements need to be removed. c. The conclusion should only contain information pertaining to findings of the current paper (not other studies). 2. Abstract contains inadequate information. a. Mention the design of the study clearly. b. Methods section is not well described. 3. Please DELETE INFORMATION UNRELATED TO OBJECTIVE so that the section is short and sweet. Kindly shorten this section and delete unrelated information. Kindly focus on three elements of introduction a. What is known about the topic? (Background) b. What is not known? (The research problem) c. Why the study was done? (Justification) 4. There are too many strikethrough marks. Kindly delete the text completely which has been asked to delete. At the same time, please highlight the changes that have been made. 5. It would be better to shorten the paper. It seems there is too much of information. 6. Kindly mention tables and figures in line with recommendations of journal. For example, table is not required in introduction. Reviewer #4: Thank you for your efforts. All comments have been addressed. In this study the effect of cervical traction on neuropathic pain in the case of cervical radiculopathy was assessed. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #2: No Reviewer #3: Yes:** Dr. Satish Prasad Barnawal Reviewer #4: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0255998.r003
Revision 2
26 Jul 2021 Author Response We thank the reviewers for their positive comments on our work. We hope that this version will fully satisfy them. Reviewer #2: All comments have been addressed Reviewer #3: (No Response) Reviewer #4: All comments have been addressed We thank the reviewers 2 for their validation of our comments and our new version Reviewer #2: (No Response) We thank the reviewer 2 for his validation of this new version Reviewer #3: The paper is in better shape. Congratulations to the authors for such a nice work. Yet, some modifications need to be made before publication. Kindly refer to the following aspects. we thank reviewer 3 for this compliment 1. Conclusion needs to provide answers for each objective clearly in a sentence or two. a. Here the conclusion does not support the findings of the paper. b. As the study was not comparative study, such statements need to be removed. c. The conclusion should only contain information pertaining to findings of the current paper (not other studies). We thank reviewer 3 for these remarks. We have modified the document according to this advice. We have removed the reference to the comparison of other studies line 362-364. 2. Abstract contains inadequate information. a. Mention the design of the study clearly. b. Methods section is not well described. We thank reviewer 3 for this analysis. We have added the words "prospective and open" just before “observational study” line 26. To improve clarity, we have also modified the following paragraph by adding the main objective of the study. Finally, we have rewritten the following sentence to make it clearer (line 29-32). 3. Please DELETE INFORMATION UNRELATED TO OBJECTIVE so that the section is short and sweet. Kindly shorten this section and delete unrelated information. Kindly focus on three elements of introduction a. What is known about the topic? (Background) b. What is not known? (The research problem) c. Why the study was done? (Justification) We understand this remark less. The text has been deeply reworked during our last submission in order to answer this request. It is, in fact, extremely short by keeping only the essential useful to physicians and physiotherapists involved in these tractions. We understand that other expert actors may want an even shorter text, but it seems useful to us here to keep the remaining elements to contextualize. 4. There are too many strikethrough marks. Kindly delete the text completely which has been asked to delete. At the same time, please highlight the changes that have been made. We sent two versions, as requested by the publisher, one with the marks, the other without, to clarify the reviewers' re-reading of the changes. We have, of course, respected this request at every stage. 5. It would be better to shorten the paper. It seems there is too much of information. We thank reviewer 3 for this comment. We have streamlined our text to meet this request. 6. Kindly mention tables and figures in line with recommendations of journal. For example, table is not required in introduction. We understand the comment of reviewer 3. We had quoted the table in the introduction. In accordance with the recommendations to the authors, we have therefore illustrated with the table. We have made the modification requested by reviewer 3 and the table now appears in the discussion when it is quoted a second time in the text. Reviewer #4: Thank you for your efforts. All comments have been addressed. In this study the effect of cervical traction on neuropathic pain in the case of cervical radiculopathy was assessed. We thank the reviewer 4 for this compliment and validation of this new version Attachments Attachment Submitted filename: response to reviewers 20210726.docx https://doi.org/10.1371/journal.pone.0255998.r004
28 Jul 2021 Decision Letter - Panagiotis Kerezoudis, Editor Effect of an intensive cervical traction protocol on mid-term disability and pain in patients with cervical radiculopathy: an exploratory, prospective, observational pilot study PONE-D-21-09986R2 Dear Dr. Rulleau, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Panagiotis Kerezoudis, M.D., M.S. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0255998.r005
Formally Accepted
30 Jul 2021 Acceptance Letter - Panagiotis Kerezoudis, Editor PONE-D-21-09986R2 Effect of an intensive cervical traction protocol on mid-term disability and pain in patients with cervical radiculopathy: an exploratory, prospective, observational pilot study Dear Dr. Rulleau: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Panagiotis Kerezoudis Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0255998.r006

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