Mechanisms of recovery after neck‐specific or general exercises in patients with cervical radiculopathy

Background The mechanisms of action that facilitate improved outcomes after conservative rehabilitation are unclear in individuals with cervical radiculopathy (CR). This study aims to determine the pathways of recovery of disability with different exercise programs in individuals with CR. Methods We analysed a dataset of 144 individuals with CR undergoing conservative rehabilitation. Eleven variables collected at baseline, 3, 6 and 12 months follow‐up were used to build a Bayesian Network (BN) model: treatment group (neck‐specific vs. general exercises), age, sex, self‐efficacy, catastrophizing, kinesiophobia, anxiety, neck–arm pain intensity, headache pain intensity and disability. The model was used to quantify the contribution of different mediating pathways on the outcome of disability at 12th months. Results All modelled variables were conditionally independent from treatment groups. A one‐point increase in anxiety at 3rd month was associated with a 2.45‐point increase in 12th month disability (p <.001). A one‐point increase in head pain at 3rd month was associated with a 0.08‐point increase in 12th month disability (p <.001). Approximately 83% of the effect of anxiety on disability was attributable to self‐efficacy. Approximately 88% of the effect of head pain on disability was attributable to neck–arm pain. Conclusions No psychological or pain‐related variables mediated the different treatment programs with respect to the outcome of disability. Thus, the specific characteristics investigated in this study did not explain the differences in mechanisms of effect between neck‐specific training and prescribed physical activity. The present study provides candidate modifiable mediators that could be the target of future intervention trials. Significance Psychological and pain characteristics did not differentially explain the mechanism of effect that two exercise regimes had on disability in individuals with cervical radiculopathy. In addition, we found that improvements in self‐efficacy was approximately five times more important than that of neck–arm pain intensity in mediating the anxiety‐disability relationship. A mechanistic understanding of recovery provides candidate modifiable mediators that could be the target of future intervention trials. Trials registration ClinicalTrials.gov identifier: NCT01547611

Physiotherapy Post Lumbar Discectomy: Prospective Feasibility and Pilot Randomised Controlled Trial

Objectives To evaluate: acceptability and feasibility of trial procedures; distribution of scores on the Roland Morris Disability Questionnaire (RMDQ, planned primary outcome); and efficient working of trial components. Design and Setting A feasibility and external pilot randomised controlled trial (ISRCTN33808269, assigned 10/12/2012) was conducted across 2 UK secondary care outpatient physiotherapy departments associated with regional spinal surgery centres. Participants Consecutive consenting patients aged >18 years; post primary, single level, lumbar discectomy. Interventions Participants were randomised to either 1:1 physiotherapy outpatient management including patient leaflet, or patient leaflet alone. Main Outcome Measures Blinded assessments were made at 4 weeks post surgery (baseline) and 12 weeks post baseline (proposed primary end point). Secondary outcomes included: Global Perceived Effect, back/leg pain, straight leg raise, return to work/function, quality of life, fear avoidance, range of movement, medication, re-operation. Results At discharge, 110 (44%) eligible patients gave consent to be contacted. 59 (54%) patients were recruited. Loss to follow up was 39% at 12 weeks, with one site contributing 83% losses. Mean (SD) RMDQ was 10.07 (5.58) leaflet and 10.52 (5.94) physiotherapy/leaflet at baseline; and 5.37 (4.91) leaflet and 5.53 (4.49) physiotherapy/leaflet at 12 weeks. 5.1% zero scores at 12 weeks illustrated no floor effect. Sensitivity to change was assessed at 12 weeks with mean (SD) change -4.53 (6.41), 95%CI -7.61 to -1.44 for leaflet; and -6.18 (5.59), 95%CI -9.01 to -3.30 for physiotherapy/leaflet. RMDQ mean difference (95%CI) between change from baseline to twelve weeks was 1.65(-2.46 to 5.75). Mean difference (95%CI) between groups at 12 weeks was -0.16 (-3.36 to 3.04). Participant adherence with treatment was good. No adverse events were reported. Conclusions Both interventions were acceptable, and it is promising that they both demonstrated a trend in reducing disability in this population. A randomised controlled trial, using a different trial design, is needed to ascertain the effectiveness of combining the interventions into a stepped care intervention and comparing to a no intervention arm. Findings will guide design changes for an adequately powered randomised controlled trial, using RMDQ as the primary outcome

Factors associated with pain and disability reduction following exercise interventions in chronic whiplash

BackgroundSome studies support the prescription of exercise for people with whiplash-associated disorders (WAD); however, the response is highly variable. Further research is necessary to identify factors which predict response. MethodsThis is a secondary analysis of a randomized, multicentre controlled clinical trial of 202 volunteers with chronic WAD (grades 2 and 3). They received either neck-specific exercise with, or without a behavioural approach, or prescription of physical activity for 12weeks. Treatment response, defined as a clinical important reduction in pain or disability, was registered after 3 and 12months, and factors associated with treatment response were explored using logistic regression. ResultsParticipation in the neck-specific exercise group was the only significant factor associated with both neck pain and neck disability reduction both at 3 and 12months. Patients in this group had up to 5.3 times higher odds of disability reduction and 3.9 times higher odds of pain reduction compared to those in the physical activity group. Different baseline features were identified as predictors of response depending on the time point examined and the outcome measure selected (pain vs. disability). ConclusionFactors associated with treatment response after exercise interventions differ in the short and long term and differ depending on whether neck pain or disability is considered as the primary outcome. Participation in a neck-specific exercise intervention, in contrast to general physical activity, was the only factor that consistently indicated higher odds of treatment success. These results support the prescription of neck-specific exercise for individuals with chronic WAD.Funding Agencies|Swedish government through the REH-SAM Foundation; Clinical Research of Ostergotland Council; Clinical Research of Sormland County Council; Medical Research Council of Southeast Sweden; Uppsala-O rebro Regional Research Council Sweden; Swedish Research Council</p

Poststroke Physical Activity Levels No Higher in Rehabilitation than in the Acute Hospital

BACKGROUND: Returning to physical activity is a common goal for stroke survivors undergoing rehabilitation, and higher levels of activity have been linked to better gait and greater independence in activities of daily living. Our aim was to determine if inpatient rehabilitation settings promoted higher levels of physical activity in stroke survivors than an acute stroke unit setting. METHODS: Stroke survivors were recruited from the inpatient rehabilitation wards of 4 different hospitals in southern Sweden and from the acute stroke unit at Karolinska University Hospital in Stockholm. Participants were observed for 1 minute every 10 minutes from 8:00 a.m. to 5:00 p.m. At each observation, the person's highest level of physical activity, location, and other people present were recorded. RESULTS: We collected data from 190 stroke survivors (104 rehabilitation, 86 acute). Contrary to our hypothesis, there was no significant difference between the groups in the amount of time spent in moderate-to-high physical activity (rehabilitation median 24%, acute median 23%; adjusted P = .74). Compared to those in the acute setting, participants in the rehabilitation setting spent less time lying in bed, more time sitting supported out of bed, less time in their bedroom, and more time with a therapist (all adjusted P < .001). CONCLUSION: In the context of stroke, the inpatient rehabilitation environment does not appear to promote higher levels of physical activity than the acute hospital environment

The effect of neck-specific exercise and prescribed physical activity on headache and dizziness in individuals with cervical radiculopathy: Further analyses of a randomized study with a 1-year follow-up

Objective: To evaluate the effect of neck-specific exercise (NSE) compared to prescribed physical activity (PPA) on headache and dizziness in individuals with cervical radiculopathy (CR). Also, to investigate associations between headache or dizziness and pain, neck muscle endurance (NME), neck mobility, physical activity, and fear avoidance beliefs.Methods: Individuals randomized to either NSE or PPA were selected to a headache subgroup (n = 59) and/or a dizziness subgroup (n = 73). Data were evaluated, according to headache and/or dizziness outcomes at baseline and at 3, 6, and 12-month follow-ups.Results: No significant between-group differences were found between NSE and PPA in either subgroup. In the headache subgroup, significant within-group improvements were seen at all follow-ups for NSE (p &amp;lt; .001) and from baseline to 3 (p = .037) and 12 (p = .003) months for PPA. For dizziness, significant within-group improvements were seen from baseline to 3 months for NSE (p = .021) and from baseline to 3 (p = .001) and 6 (p = .044) months for PPA. Multiple regression models showed significant associations at baseline between headache intensity and neck pain (adjusted R-square = 0.35, p &amp;lt; .001), and for dizziness with neck pain and dorsal NME (adjusted R-square = 0.34, p &amp;lt; .001).Conclusion: NSE and PPA show similar improvements in headache intensity and dizziness in individuals with CR. Headache intensity is associated with neck pain, and dizziness with neck pain and dorsal NME, highlighting the importance of these factors when evaluating headache and dizziness.Funding Agencies|County Council of Ostergotland [RO-938436]; Stockholm County Council Funding ALF Medicine [20110071]; Swedish Government through the Karolinska Institutet, in the Swedish National School of Research Education in Health Care Sciences; Strategic Research Programme in Care Sciences</p

Classification criteria for cervical radiculopathy: An international e-Delphi study.

BACKGROUND: Establishing a set of uniform classification criteria (CC) for cervical radiculopathy (CR) is required to aid future recruitment of homogenous populations to clinical trials. OBJECTIVES: To establish expert informed consensus on CC for CR. DESIGN: A pre-defined four round e-Delphi study in accordance with the guidance on Conducting and Reporting Delphi Studies. METHODS: Individuals with a background in physiotherapy who had authored two or more peer-reviewed publications on CR were invited to participate. The initial round asked opinions on CC for CR. Content analysis was performed on round one output and a list of discrete items were generated forming the round two survey. In rounds two to four, participants were asked to rate the level of importance of each item on a six-point Likert scale. Data were analysed descriptively using median, interquartile range and percentage agreement. Items reaching pre-defined consensus criteria were carried forward to the next round. Items remaining after the fourth round constituted expert consensus on CC for CR. RESULTS: Twelve participants participated with one drop out. The final round identified one inclusion CC and 12 exclusion CC. The inclusion CC that remained achieved 82% agreement and was a cluster criterion consisting of radicular pain with arm pain worse than neck pain; paraesthesia or numbness and/or weakness and/or altered reflex; MRI confirmed nerve root compression compatible with clinical findings. CONCLUSIONS: The CC identified can be used to inform eligibility criteria for future CR trials although caution should be practiced as consensus on measurement tools requires further investigation