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ORIGINAL RESEARCH
The Effects of Neck-Specific Training Versus
Prescribed Physical Activity on Pain and Disability in
Patients With Cervical Radiculopathy: A Randomized
Controlled Trial
A
˚sa Dedering, PhD,
a,b
Anneli Peolsson, PhD,
c
Joshua A. Cleland, PhD,
d
Marie Halvorsen, PhD,
a,b
Mikael A. Svensson, PhD,
e,f
Marie Kierkegaard, PhD
a,b
From the
a
Allied Health Professionals Function, Function Area Occupational Therapy and Physiotherapy, Karolinska University Hospital,
Stockholm, Sweden;
b
Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institute, Stockholm,
Sweden;
c
Department of Medical and Health Sciences Physiotherapy, Linko¨ping University, Linko¨ping, Sweden;
d
Franklin Pierce University,
Manchester, NH;
e
Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden; and
f
Department of Neurosurgery, Karolinska
University Hospital, Stockholm, Sweden.
Abstract
Objective: To compare the effects of a neck-specific training program to prescribed physical activity with both groups receiving a cognitive
behavioral approach, on pain and disability in patients with cervical radiculopathy (CR).
Design: Parallel-group randomized clinical trial with follow-up at 3, 6, 12, and 24 months.
Setting: Recruitment and assessments of participants were performed at a university hospital. Interventions were performed in primary care
setting at outpatient physiotherapy clinics.
Participants: Patients (NZ144) with CR were recruited to participate in this clinical trial.
Interventions: Patients were randomly assigned to 3 months of either of a neck-specific training program or prescribed physical activity.
Main Outcome Measures: Primary outcomes included self-rated neck and arm pain as collected by the visual analog scale (VAS). Secondary
outcomes were self-rated headache measured with the VAS, the Neck Disability Index, the EuroQol 5D, the Fear Avoidance Beliefs
Questionnaire, and the Hospital Anxiety and Depression Scale. Assessments were performed at baseline and at 3-, 6-, 12-, and 24-month
follow-up periods.
Results: Intention-to-treat and per-protocol analyses showed no significant interaction (group time) or group effects. There were, however,
significant time effects indicating improvement over time for both groups for all outcomes except for levels of depression.
Conclusions: The study revealed that neck-specific training as well as prescribed physical activity both including additional cognitive behavioral
approach decreased the pain in patients with CR, that is, participants improved regardless of the intervention received. There is a lack of consensus
of how to best manage individuals with CR. However, our findings suggest that CR has a natural favorable long-term outcome when patients are
prescribed neck-specific training and exercise in combination with a behavioral approach.
Archives of Physical Medicine and Rehabilitation 2018;99:2447-56
ª2018 by the American Congress of Rehabilitation Medicine
Cervical radiculopathy (CR) is often described as neck pain
accompanied with radiating pain and neurologic symptoms, such
as numbness, muscle weakness, and diminished reflexes, in 1 or
both upper extremities.
1
Cervical disc herniation or spondylosis,
resulting in nerve compression and inflammation, may be the
Supported by the Swedish Government through the Karolinska Institute, in the Swedish Na-
tional School of Research Education in Health Care Sciences, and the Strategic Research Pro-
gramme in Care Sciences, as well as from the Stockholm County Council Funding ALF Medicine
(grant no 20110071).
Clinical Trial Registration No.: NCT01831271.
Disclosures: none.
0003-9993/18/$36 - see front matter ª2018 by the American Congress of Rehabilitation Medicine
https://doi.org/10.1016/j.apmr.2018.06.008
Archives of Physical Medicine and Rehabilitation
journal homepage: www.archives-pmr.org
Archives of Physical Medicine and Rehabilitation 2018;99:2447-56
cause of CR which reportedly has an annual incidence rate of 83.2
per 100,000 in the general population.
2
Many patients with cer-
vical disc herniation and/or spondylosis may develop chronic pain
resulting in functional impairments, activity limitations, long pe-
riods of sick leave, and difficulties returning to work.
2,3
In addi-
tion to arm- and neck pain, individuals with CR have also reported
headache.
1
The management of patients with cervical disc herni-
ation and/or spondylosis who suffer from CR is initially conser-
vative. Patients may, however, be referred for surgery if symptoms
persist and the radiological findings match the clinical symptoms.
4
Currently, there is no consensus regarding the most effective
management strategies for CR. This may be because there exist
few large randomized controlled studies and because of unclear
diagnostics (no subjective or objective physical examination
findings comparable with magnetic resonance imaging verifying
the neck origin of radiculopathy).
5-7
Further randomized
controlled trials are needed to determine the most efficacious in-
terventions for this population.
Individuals with CR are being sick-listed for extensive periods
of time due to pain, disability, and/or waiting time to be evaluated
by a surgeon.
8-10
A structured physiotherapy program has been
recommended prior to pursuing surgical intervention,
11
but the
optimal treatment approach remains to be elucidated. Currently,
recommended physiotherapy interventions for CR include edu-
cation, exercise, manual therapy, and intermittent cervical trac-
tion.
12
Furthermore, for many patients, surgery may not be the
best approach and therefore they require other noninvasive in-
terventions. There is evidence that neck-specific training may be
an effective management strategy in patients with neck pain of
mechanical origin.
13
In patients with chronic neck pain, a cogni-
tive approach also appears to be effective.
14
However, it is not
known if these approaches are effective in a patient population
with CR.
Physical activity and exercise therapy are currently being used
in the management of a variety of disorders and have been shown
to be beneficial in improving pain severity, mental health, and
physical functioning and physical activity. However, evidence for
physical activity in chronic neck pain is not established because of
lack of studies or small sample studies.
15
We hypothesized that exercise could be effective in reducing
pain and disability in patients with CR and that neck-specific
training would be superior to a more general physical activity
program as previously seen in patients with chronic whiplash
associated disorders.
16,17
Thus, the purpose of this randomized
clinical trial was to compare the effects of a neck-specific training
program to prescribed physical activity with both programs
including a cognitive behavioral approach, on neck and arm pain
and disability in patients with CR.
Materials and methods
Trial design
This was a parallel-group randomized clinical trial with follow-up
assessments at 3, 6, 12, and 24 months.
18
The trial was registered
before participant recruitment began (ClinicalTrials.gov
NCT01831271).
Participants
Patients with CR were recruited from a neurosurgical department
from October 2010 to November 2012. Criteria for eligibility were
as follows: (1) magnetic resonance imaging verified cervical disc
disease showing cervical nerve root compression; and (2) neck
and/or arm pain, verified with a neck extension test or a neuro-
dynamic provocation test.
19
Exclusion criteria included patients
with a previous cervical fracture, subluxation, or surgery; spinal
infection and malignancy; known drug abuse; diagnosed psychi-
atric disorders; other diseases or disorders contradicting partici-
pation; and unfamiliarity with the Swedish language. Patients
were consecutively screened for eligibility by a neurosurgeon and
asked if they would be interested in participating. Those interested
were referred to the project physiotherapist and underwent a
standardized examination including a medical history. About 16 of
160 screened patients declined participation and, thus, 144
patients with CR were included (fig 1). The study was approved of
by the Regional Board of Ethics, and procedures were conducted
in accordance with the Declaration of Helsinki. All patients signed
an informed consent prior to participation in the study.
All assessments were performed at a physiotherapy depart-
ment, that is, before intervention (baseline) and at 3-, 6-, 12-, and
24-month follow-up periods. The same project physiotherapist
administered all assessments and served as contact person for
patients enrolled in the trial once they were randomized. Data
were collected with standardized questionnaires, clinical exami-
nations, and tests.
18,20
In case of unwanted effects or adverse
events, the patients were informed to contact either the contact
person or the principal investigator for documentation and
consideration of termination of their participation in the trial.
Interventions
Once randomization was complete, individuals received either the
(1) neck-specific training or (2) prescribed physical activity. Both
interventions included a cognitive behavioral approach although
continuous for the neck-specific training group and only at first
session for the prescribed physical activity group. The in-
terventions were delivered by a total of 61 primary care physio-
therapists at 36 different locations. At 15 locations, both
interventions were delivered although not during the same period.
Treating physiotherapists were first contacted by phone by the
project physiotherapist who provided a thorough explanation of
the study. Treating physiotherapists then received file folders with
written information about the trial as well as information on
elements to be included in the interventions, that is, pain physi-
ology, consequences of stress and exercise, relaxation techniques,
coping strategies, and ergonomic advice. This latter information
was standardized and the same for the 2 groups, and treating
therapists in the neck-specific training group were given in-
structions stating when the elements were to be included, that is, if
List of abbreviations:
95% CI 95% confidence interval
CR cervical radiculopathy
EQ-5D EuroQol 5D
FABQ Fear Avoidance Beliefs Questionnaire
HADS Hospital Anxiety and Depression Scale
ITT intention to treat
NDI Neck Disability Index
VAS visual analog scale
WAD whiplash associated disorder
2448 A
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during the early, intermediate, or late phase of the intervention
period. A file folder with information about the trial and all the
included elements, that is, the information mentioned above, was
also provided to all participating individuals. The intervention
duration was 3 months, and all patients were requested to train or
exercise 3 times per week. Exercise diaries were provided to
monitor training or physical activity performance and progression.
Adherence to either intervention was defined as at least 50%
performance of the prescribed training or physical activity 3 times
per week.
Neck-specific training
Patients and physiotherapists in the neck-specific training inter-
vention received, in addition to the previously mentioned file
folder, a manual on the standardized neck-specific training
program including instructions for progression. The program has
previously been described in detail when used in chronic
individuals with whiplash-associated disorders and can be
retrieved at https://doi.org/10.3384/report.diva-113865. The neck-
specific training was provided by experienced physiotherapists in
primary care, and patients attended 3 individual sessions per week
during the intervention period. The supervised program focused
on sensorimotor function, neck muscle endurance, and pain
reduction. Patients started with gentle isometric neck movement to
facilitate activation of deep cervical muscles and gradually
progressed the training to low-load endurance training in the gym.
The training aimed to increase endurance and strength of the
muscle that stabilize the neck and the scapula. Although stan-
dardized, the neck-specific training was individually tailored
based on patient’s response for each patient regarding the choice
of exercises and the progression rate. The physiotherapists tailored
the neck-specific training for each patient to ensure the selection
of exercise and dosages to match the patients’ current capacity.
The patients received written instructions including pictures
illustrating the exercises, and they were required to report their
perceived pain before and after each session of the program.
Assessed for eligibility (n=160)
Excluded (n=16)
♦Not meeting inclusion criteria (n=0)
♦Declined to participate (n=16)
♦Other reasons (n=0)
Attending: n=45
Lost to 6-month follow-up (n=0)
Discontinued intervention (n=6)
Attending: n=51
Lost to 3-month follow-up (n=0)
Discontinued intervention (n=21)
Allocated to intervention
Neck-specific training (n=72)
Received allocated intervention (n=72)
Attending: n=42
Lost to 3-month follow-up (time restriction) (n=2)
Discontinued intervention (n=28)
Allocated to intervention
Prescribed physical activity (n=7 2)
Received allocated intervention (n=72)
Attending: n=36
Lost to 6-month follow-up (time restriction) (n=1)
Discontinued intervention (n=7)
Allocation
Follow-Up 6 mo
Follow-Up 3 mo
Randomized (n=144)
Enrollment
Attending: n=43
Lost to 12-month follow-up (n=0)
Discontinued intervention (n=2)
Attending: n=33
Lost to 12-month follow-up (time restriction) (n=1)
Discontinued intervention (n=3)
Follow-Up 12 mo
Attending: n=41
Lost to 24-month follow-up (n=0)
Discontinued intervention (n=2)
Attending: n=32
Lost to 24-month follow-up (n=0)
Discontinued intervention (n=2)
Follow-Up 24 mo
Fig 1 CONSORT flow diagram.
Neck training or physical activity in cervical radiculopathy 2449
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Progression went from isolated low load to synergy exercises and,
last, to endurance-strength exercises. The progression was based
on the patient’s pain and neck movement quality, but also on
fulfillment of specified criteria of number of sets and repetitions to
be completed before proceeding. The neck-specific training also
included a continuous physiotherapist-guided behavioral approach
targeting management of pain and stress, coping, education on
breathing, relaxation, pacing, and ergonomics. Physiotherapists
were supposed to document the performed training and progres-
sion in a patient-specific protocol. Patients were given exercise
diaries to record their performed training or other physical
activities during the study period.
Prescribed physical activity
The prescribed physical activity intervention included 1 patient-
centered counseling session which led to a written prescription of
physical activity.
21
The individual counselling was performed by 1
of 4 physiotherapists with experience between 2 and 4 years
working at the physiotherapy department. The counseling con-
sisted of a motivational interview with a cognitive behavioral
approach at the first session, an approach to facilitate behavior
change, to survey the patient’s health state, history of physical
activity, potential risk factors, and patient’s motivation, and need
of support for physical activity and training. The written pre-
scription was prescribed individually and consisted of recom-
mendations on aerobic and/or muscular physical activity or
training, but no neck-specific training. Thus, each patient was
provided with an individual physical activity training program. In
addition, they were encouraged to perform at least 30 minutes of
physical activity at moderate intensity at least 3 days per week.
The main goal was to increase general physical activity levels.
Patients in the prescribed physical activity group were offered a
physiotherapy contact in primary care to facilitate the imple-
mentation of the prescription, and all but 3 patients started their
training under supervision. Patients were given exercise diaries to
record their performed training or other physical activities during
the study period.
Outcomes
All patients provided demographic data (a study specific ques-
tionnaire included sex, age, social and work status, smoking
habits, pain, neurologic symptoms), physical activity or exercise
habits, medical history, underwent physical examinations and
tests, and completed several self-report measures.
18,20,22
The primary outcomes were neck and arm pain intensity
assessed on a visual analog scale (VAS) ranging from 0 (no) to
100 mm (worst pain imaginable). Secondary outcomes were
headache (VAS), the Neck Disability Index (NDI), the EuroQol
5D (EQ-5D), the Fear Avoidance Beliefs Questionnaire (FABQ),
and the Hospital Anxiety and Depression Scale (HADS).
The VAS is a continuous scale considered to be a valid and
reliable pain measure.
23-25
Present neck pain intensity was defined
and assessed as the pain experienced at the time of data collection.
Average intensity of neck pain, arm pain, and headache were
defined and assessed as the mean of VAS ratings of current, best,
and worst pain intensity during the week before data collection.
The NDI,
26,27
which consists of 10 items rated on a 6-point
scale ranging from 0 to 5, was used to assess neck-specific
disability. Replacement of missing items were performed with
the mean of the answered items if at least 7 of the 10 items had
been answered. Results were summed for a total score and
expressed as a percentage, with higher scores corresponding to
greater disability. The NDI has been reported to be a valid and
reliable measure in individuals with CR.
28,29
The EQ-5D index and the EQ-5D VAS
30,31
were used to assess
health-related quality of life. Five dimensions (mobility, self-care,
usual activities, pain/discomfort, anxiety/depression) were rated
on 3 levels (no problems, some problems, or extreme problems)
and converted to an index score using the time trade-off value set.
Negative index scores were set to zero and possible scores ranged
from 0 to 1 (full health).
31
Current health state was rated on a
20-cm VAS ranging from 0 (worst imaginable) to 100 (best
imaginable).
30,31
The FABQ
32,33
was used to assess the patients’ fear-avoidance
beliefs about how physical activity and work affect their pain. The
scale consists of 16 items rated on a 7-point scale ranging from
0 to 6. Replacement of missing items were performed with the
mean of the answered items if at least 12 of the 16 items had been
answered. Results were summed to a total score, and higher scores
indicate higher levels of fear-avoidance beliefs.
The HADS
34,35
was used to assess anxiety and depression. A
depression and anxiety subscale can be calculated, each consisting
of 7 items rated on a 4-point scale ranging from 0 to 3.
Replacement of missing items were performed with the mean of
the answered items if at least 5 of the 7 items had been answered.
A higher score indicates higher levels of anxiety or depression.
Sample size
Power analysis was based on preliminary data from one of our
studies where the standard deviation for a change in VAS rating
from baseline to follow-up was 28 mm. A sample size of 56 in
each group would have 80% power to detect differences in mean
of 15 mm, if the common standard deviation was 28 mm using 2
group ttest with a 0.05 2-sided significance level.
Randomization
After the baseline examination, individuals were randomized
through concealed allocation that was performed using a
computer-generated randomized table generated by a statistician
not involved in participant recruitment (allocation ratio 1:1 in
blocks of 8). The group assignment was recorded on an index
card. This card was folded in half such that the label with the
patient’s group assignment was on the inside of the fold. The
folded index card was then placed inside the opaque envelope, and
the envelope was sealed. Group allocation was performed by the
principal investigator after baseline assessments, and the sealed
envelope was delivered by the project physiotherapist adminis-
trating the assessments.
Blinding
Both patients and the project physiotherapist were blinded at
baseline assessments. None were blinded after assignment to in-
terventions, that is, no patients, treating physiotherapists, or the
project physiotherapist conducting the follow-up assessments. An
independent individual blinded to the participants’ allocated group
entered all data from questionnaires into a database. All data
analysis was performed by an independent research fellow not
involved in any of the data collection, randomization, or allocation
procedures.
2450 A
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Statistical methods
Descriptive statistics were used to present data, that is, mean,
standard deviation, 95% confidence interval (95% CI), frequency,
and percentage. Dropout analyses were performed with chi-square
test for sex; unpaired ttest for age, neck and arm pain intensity;
and Mann-Whitney Utest for neck and arm pain duration of
randomized patients who discontinued interventions before the
3-month follow-up.
An intention to treat (ITT) approach was used for data analysis
of primary and secondary outcomes, with all patients being
analyzed in the group to which they were originally randomly
assigned even though they might have been lost to follow-up or
noncompliance of the intervention or any other deviation from the
Table 1 Baseline data and clinical characteristics of patients allocated to NST or PPA
Clinical Characteristics
NST Group
n (%)
PPA Group
n (%)
Mean age SD (y) 46.89.6 49.79.5
Sex (women/men), NZ144 38 (53)/34 (47) 37 (51)/35 (49)
Living alone (yes/no), nZ121 14 (25)/42 (75) 19 (29)/46 (71)
Work status, nZ120
Full time/part time 29 (54)/9 (16) 40 (61)/14 (21)
Presently not working 16 (30) 12 (18)
Smoking (yes/no), nZ122 14 (25)/42 (75) 14 (21)/52 (79)
Neck pain duration, nZ103
Subacute (<3mo) 4 (9) 6 (11)
Chronic (3mo) 43 (91) 50 (89)
Arm pain duration, nZ95
Subacute (<3mo) 4 (10) 6 (11)
Chronic (3mo) 38 (90) 47 (89)
Radiating pain, nZ122
Unilateral right/unilateral left 22 (39)/31 (55) 26 (39)/32 (49)
Bilateral 3 (5) 8 (12)
Neck pain frequency, nZ124
Daily/occasionally 41 (72)/16 (28) 48 (72)/19 (28)
Arm pain frequency, nZ123
Daily/occasionally 39 (68)/18 (32) 39 (59)/27 (41)
Headache frequency, nZ120
Daily/occasionally 22 (40)/33 (60) 20 (31)/45 (69)
Dizziness/unsteadiness frequency, nZ123
Daily/occasionally 17 (30)/40 (70) 6 (9)/60 (91)
Hand weakness frequency, nZ121
Daily hand/occasionally 28 (50)/28 (50) 23 (35)/42 (65)
Hand numbness frequency, nZ122
Daily hand/occasionally 31 (55)/25 (45) 41 (62)/25 (38)
Back pain frequency, nZ121
Daily/occasionally 23 (42)/32 (58) 24 (36)/42 (64)
Light touch sensory function, NZ144
Impairment/no impairment 46 (64)/26 (36) 49 (68)/23 32
Pin prick sensory function, NZ144
Impairment/no impairment 18 (25)/54 (75) 28 (39)/44 (61)
Motor function, nZ143
Impairment/no impairment 37 (51)/35 (49) 33 (47)/38 (53)
Reflexes, nZ136
Impairment/no impairment 17 (25)/51 (75) 12 (18)/56 (82)
Physical activity level, summer nZ119
Hardly any to mostly sitting 3 (5) 6 (10)
Light 22 (39) 28 (44)
Moderate to hard 31 (55) 29 (46)
Physical activity level, winter nZ118
Hardly any to mostly sitting 13 (23) 14 (23)
Light 16 (29) 24 (39)
Moderate to hard 27 (48) 24 (39)
Abbreviations: NST, neck-specific training; PPA, prescribed physical activity.
Neck training or physical activity in cervical radiculopathy 2451
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protocol.
36
Linear mixed-model repeated-measurement analyses
using the compound symmetry covariance structure were used for
evaluating within-group (time), between-group (group), and
interaction (time group) effects for primary and secondary
outcomes. Residual and normality plots were used to examine the
assumptions of the fitted model. Post hoc tests, that is, Bonferroni-
adjusted simple main effect pairwise comparisons, were
also performed.
A secondary per protocol analysis, using the same model as in
ITT analysis, was also performed including those patients who had
complied to the interventions, that is, at least 50% performance of
the prescribed 3 times per week training or physical activ-
ity (nZ90).
The level of significance was set to P<.05. All the analyses
were performed using IBM SPSS Statistics 20.
a
Results
Figure 1 provides a flow diagram of patient recruitment and
retention. Recruitment of patients were performed between October
2010 and November 2012, and follow-ups were performed between
Table 2 Results from ITT and per-protocol analyses (group: neck-specific training vs prescribed physical activity; time: baseline, 3, 6, 12, 24
mo; interaction: group time)
Outcomes n
ITT Analyses Per-Protocol Analyses
Group
PValue
Time
PValue
Interaction
PValue n
Group
PValue
Time
PValue
Interaction
PValue
Present neck pain intensity 144 .986 <.001 .594 90 .271 <.001 .848
Average intensity
Neck pain 128 .875 <.001 .846 90 .334 <.001 .699
Arm pain 127 .740 <.001 .232 90 .727 <.001 .169
Headache 127 .315 <.001 .135 90 .892 <.001 .150
NDI 126 .859 <.001 .741 90 .365 <.001 .850
EQ-5D
index 128 .334 <.001 .790 90 .776 <.001 .805
VAS 128 .298 <.001 .809 90 .677 <.001 .826
FABQ 122 .160 <.001 .579 88 .951 <.001 .735
HADS
Anxiety 128 .218 <.001 .341 90 .808 <.001 .262
Depression 128 .641 .138 .515 90 .710 .053 .414
Table 3 Descriptive statistics of primary (neck and arm pain) outcomes over time for patients in NST and PPA groups, and the
between-group mean difference with 95% CI
Outcomes
NST Group PPA Group Group Difference (NST-PPA)*
n Mean SD n Mean SD Mean Difference 95% CI
Present neck pain
Baseline 72 3827 72 3324 5 4to13
3mo 51 2930 42 3128 0 11 to 10
6mo 45 2428 33 3030 314 to 8
12 mo 42 2327 32 2526 1 10 to 12
24 mo 41 1620 31 2230 314 to 9
Average neck pain
Baseline 57 4328 67 4225 0 9to10
3mo 48 3428 42 3726 212 to 8
6mo 43 3428 32 4027 314 to 8
12 mo 38 2829 32 3325 112 to 10
24 mo 36 2724 30 3026 2 9to14
Average arm pain
Baseline 56 4230 67 3527 8 2to18
3mo 47 2931 41 3130 214 to 9
6mo 42 2930 32 3429 113 to 11
12 mo 39 2732 31 2727 2 10 to 14
24 mo 36 2227 30 2629 1 11 to 13
Abbreviations: NST, neck-specific training; PPA, prescribed physical activity.
* Values from pair-wise comparisons from mixed-model ITT analyses.
2452 A
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January 2011 and November 2014. At the 3-month follow-up, 21
patients in the neck-specific training and 28 in the prescribed
physical activity group had discontinued their participation and did
not complete the follow-up assessments. At the 6-month follow-up,
another 6 patients in the neck-specific training and 7 in the
prescribed physical activity group had left the study and therefore
did not complete the follow-up assessments. Altogether, 31 patients
in the neck-specific training group and 40 in the prescribed physical
activity group discontinued participation at some point after
baseline. The main given reasons for losses and discontinuation of
interventions were patients’ lack of time and interest. There were no
significant differences in sex, age, neck and arm pain intensity, and
duration between patients who dropped out before 3 months of
follow-up and those retained in the trial. The physiotherapists’
documentation of the patients who performed training and
progression was incomplete. Adherence according to patient
exercise diaries were reported to be 45 in the neck-specific training
group and 45 in the prescribed physical activity group.
Baseline data and clinical characteristics for both groups are
reported in table 1. The number of patients included in ITT and
Table 4 Descriptive statistics of secondary outcomes over time for patients NST and PPA groups, and the between-group mean difference
with 95% CI
Outcomes
NST Group PPA Group Group Difference (NST-PPA)*
n Mean SD n Mean SD Mean Difference 95% CI
Average headache
Baseline 57 3328 66 2227 10 1-20
3mo 48 2529 42 2126 5 5to15
6mo 42 2127 33 2225 1 10 to 11
12 mo 39 2026 32 1822 4 7to14
24 mo 36 1421 30 1823 3 8to13
NDI
Baseline 56 3522 63 3319 2 6to9
3mo 48 2923 40 3020 2 6to10
6mo 43 2722 32 3022 0 8to8
12 mo 39 2421 31 2923 110 to 7
24 mo 36 2219 30 2823 0 8to9
EQ-5D index
Baseline 57 0.490.34 67 0.560.30 0.08 0.19 to 0.03
3 mo 47 0.640.31 40 0.650.31 0.03 0.15 to 0.09
6 mo 43 0.660.33 32 0.650.32 0.02 0.15 to 0.10
12 mo 39 0.710.25 32 0.670.28 0.04 0.16 to 0.09
24 mo 35 0.720.27 30 0.690.32 0.07 0.20 to 0.06
EQ-5D VAS
Baseline 53 5425 66 5621 210 to 7
3mo 47 6125 42 6323 413 to 5
6mo 43 6528 33 6524 515 to 4
12 mo 35 6924 32 7021 717 to 3
24 mo 36 7420 29 6924 212 to 9
FABQ
Baseline 54 3316 63 2914 5 1to10
3mo 46 2917 38 2614 6 0-12
6mo 42 2517 33 2717 2 4to9
12 mo 37 2418 31 2617 3 3to10
24 mo 34 2620 29 2718 3 3to10
HADS anxiety
Baseline 55 756764 1 0-3
3mo 47 6542551 1to2
6mo 43 6533650 1to2
12 mo 39 6531651 1to3
24 mo 35 552864 1 0-3
HADS depression
Baseline 55 5567441 1to2
3mo 47 5542341 1to2
6mo 43 4533440 1to2
12 mo 39 4531550 2to1
24 mo 35 4328550 1to2
Abbreviations: NST, neck-specific training; PPA, prescribed physical activity.
* Values from pair-wise comparisons from mixed-model ITT analyses.
Neck training or physical activity in cervical radiculopathy 2453
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per-protocol analyses are presented in table 2. The ITT analyses
showed no significant interaction or between-group effects, but a
significant time effect, that is, within-group effects (see table 2).
The additional per-protocol analyses showed the same results (see
table 2). Thus, there were no significant differences between the
neck-specific training and prescribed physical activity groups in
any of the analyzed outcomes. Descriptive results of primary and
secondary outcomes for each group over time are presented in
tables 3 and 4. The estimated between-group mean differences
with 95% CI from simple main effect pairwise comparisons from
ITT analyses are, for descriptive purposes, presented in tables 3
and 4. In general, mean differences were small and the 95% CI
narrow. There were statistically significant within-group differ-
ences for both groups for all outcomes but the HADS depression
subscale over time (see table 2). Figure 2 illustrates the within-
group differences for the primary outcomes, that is, present and
average neck pain and average arm pain. In general, significant
differences indicating pain reductions were found from baseline to
most follow-up assessments in the neck-specific training group,
whereas for the prescribed physical activity group these differ-
ences were mainly identified between baseline and the 24 months
of follow-up (see fig 2). There were no reported harms or unin-
tended effects in either group.
Discussion
The results of the current study demonstrated that both training
groups improved regardless of the intervention received. No
interaction existed for either the primary or secondary outcomes
indicating that 1 treatment was not superior to the other. However,
there appeared to be slightly faster (although not significant)
improvement for the neck-specific training group compared to the
prescribed physical activity group. Because both groups experi-
enced a significant reduction in pain, both neck-specific training
and general physical activity might be beneficial to patients with
CR. Improvement might also be because of the cognitive behav-
ioral approach or education, which was part of both intervention
groups. Both exercise and education are supported treatments
from clinical guidelines.
12
However, because we did not include a
control group due to reduced pain over time might simply be due
to natural history.
The results demonstrated that individuals receiving exercise
prescription experienced benefits consistent with recent guide-
lines
37
and added valuable knowledge for the treatment of patients
with CR. In addition, it has been demonstrated that neck-specific
training can increase neck flexor endurance and reduce coac-
tivation of superficial muscle activation (sternocleidomastoids
muscles).
38
Furthermore, a recent review identified high-quality
studies demonstrating that exercise is beneficial for maximizing
outcomes in patients with CR.
39
Further well-designed clinical
trials are necessary to determine the most effective exercise
management strategies for individuals with CR.
Fig 2 Within-group pair-wise comparisons for primary outcome
measures from mixed-model analyses for the neck-specific training
(NST) and the prescribed physical activity (PPA) groups.
)
P<.05,
))
P<.01,
)))
P<.001.
2454 A
˚. Dedering et al
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Other studies have examined similar approaches for the treat-
ment of different conditions. In a study on whiplash associated
disorders (WAD), neck-specific training relieved pain and
improved function to a higher extent than a group receiving pre-
scribed physical activity
17,40
which differs from the current study.
In the study on individuals with WAD, a behavioral approach was
not included in the prescribed general physical activity group.
However, for WAD, the behavioral therapy did not add any
additional effect to neck-specific exercise training group. In both
previously mentioned studies, and in the current study, the in-
terventions were performed by experienced physiotherapists. The
patients in the neck-specific training group had personal contacts
with their physiotherapist. In the current study, the prescribed
physical activity group did not have regularly scheduled contacts
per the protocol,
18
but most patients took the opportunity to
contact with the physiotherapist which is different from the study
on patients with WAD. However, we have no documentation of the
exact frequency of contact with a physiotherapist. This might have
potentially reduced the likelihood of attention bias in the current
study. Yet, an earlier study in patients after lumbar disc surgery
showed positive results for an intervention based on home training
when patients received careful instructions and have access to the
physiotherapist if questions arose.
41
Study limitations
The relatively high dropout rate of the current study is a major
limitation that should be considered and might have affected the
results and the generalizability of the findings. The dropout rate of
the prescribed physical activity group was higher which might have
been due to less contact with the physiotherapist or lower adherence
to the intervention leading to difficulties maintaining adherence.
The prescribed physical activity intervention included strategies
known to enhance adherence such as goal setting, a personal con-
tract, self-monitoring via a diary, and feedback.
42
However, we did
not document the number of additional visits for the patients in the
prescribed physical activity group. Also, the lack of blinding is a
limitation and might have affected the results. We did not have a
control group; hence, a cause and effect relation cannot be inferred.
It is possible that the interventions of the current study might have
been too similar in nature to demonstrate significant difference
between groups. In a subgroup analysis of electromyogram of the
patients in the current study,
38
the neck-training group showed that
both neck-specific training and prescribed physical activity
increased neck flexor endurance but neck-specific training only
reduced coactivation of antagonist muscles during sustained neck
flexion.
38
An additional possible limitation was that we lack data of
the physiotherapists’ compliance to the specific steps of the protocol
and we therefore do not know the exact treatment content the pa-
tients received. However, along with written and oral information on
the interventions, we only engaged physiotherapists with specific
competence in neck training, behavioral interventions, and physical
activity. Thegeneralizability of the findings of the study is limited to
patients with CR.
The results from the current study suggest that neck-specific
training and prescribed physical activity with guidance and a
behavioral approach appear to result in similar outcomes. It is
possible that either approaches used in the current study may be
beneficial to individuals with CR. The neck-specific training,
although not significant, tended to decrease pain both in the short
and long term, whereas the prescribed physical activity only
decrease pain in the long term. The natural history for CR appears
favorable for exercise and education in combination with a
behavioral approach. The findings may potentially assist with the
management of patients with CR.
Conclusions
The study revealed that neck-specific training as well as
prescribed physical activity, both including additional cognitive
behavioral approach, decreased the pain in patients with CR, that
is, participants improved regardless of the intervention received.
There is a lack of consensus of how to best manage individuals
with CR. However, our findings suggest that CR has a natural
favorable long-term outcome when patients are prescribed neck-
specific training and exercise in combination with a behav-
ioral approach.
Supplier
a. IBM SPSS Statistics, version 20; IBM Corporation.
Keywords
Cervical radiculopathy; Exercise; Neck pain; Physical activity;
Rehabilitation
Corresponding author
A
˚sa Dedering, PhD, Allied Health Professionals Function, Function
Area Occupational Therapy and Physiotherapy, Karolinska
University Hospital, 171 76 Stockholm, Sweden. E-mail address:
Asa.dedering@ki.se.
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