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RCT
ACE Report #6012

Home-based strength and stretching exercises for chronic neck pain yield similar outcomes


Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A

Evaluation of pain and function after two home exercise programs in a clinical trial on women with chronic neck pain - with special emphasises on completers and responders

BMC Musculoskelet Disord. 2014 Jan 8;15(1):6. doi: 10.1186/1471-2474-15-6

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Synopsis

57 female patients with chronic neck pain were randomized to undergo either a home-based strength exercise program or stretching exercise program for one-year. The two interventions were compared with respect to changes in neck pain intensity and function. No significant difference was found in either neck pain intensity or function between the treatment groups at the 4-6 and 12-month follow-up assessments. A similar finding was observed when only completers who adhered to the exercise programs were considered. Although the exercise programs were safe, participant adherence rates for both interventions were low, especially after 6 months.

Publication Funding Details +
Funding:
Non-Industry funded
Sponsor:
Swedish Council for Working Life and Social Research (FAS) and the regional Research Council of Southeastern Sweden (FORSS)
Conflicts:
None disclosed

Risk of Bias

4.5/10

Reporting Criteria

15/20

Fragility Index

N/A

Was the allocation sequence adequately generated?

Was allocation adequately concealed?

Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?

Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?

Blinding Patients: Was knowledge of the allocated interventions adequately prevented?

Was loss to follow-up (missing outcome data) infrequent?

Are reports of the study free of suggestion of selective outcome reporting?

Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?

Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?

Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.

2/4

Randomization

2/4

Outcome Measurements

3/4

Inclusion / Exclusion

4/4

Therapy Description

4/4

Statistics

Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65

The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now?

Chronic neck pain, with a prevalence rate of 20-60%, is a debilitating condition that can gravely affect an individual's quality of life. Previous studies have examined the effect of specific exercises which aim to improve pain and function, however the optimal exercise type and dosage has not yet been established. As patients with chronic neck pain are found to have weaker neck muscles when compared to controls, strengthening exercises have been proposed as an effective method of treatment for this condition. No study has previously evaluated the outcomes and adherence rates using only home-based treatments programs for neck pain. Therefore, this study was conducted to compare the effectiveness of two one-year home-based exercise programs with respect to neck pain intensity and neck function.

What was the principal research question?

In women with chronic neck pain, how does a one-year, home-based muscle strengthening program compare to a one-year, home-based muscle stretching program with regards to neck pain intensity and neck function?

Study Characteristics -
Population:
57 female patients (20-60 years old) with neck pain for more than 6 months and symptoms consistent with tension neck syndrome. Patients were only included if they indicated that they were motivated to complete the exercise program. All patients who reported a minimum of 8 consecutive weeks of exercise (at least 1.5 times per week) preceding the follow-up time points (i.e. 4-6 months and 12 months) were defined as "completers". Non-completers failed to meet this required frequency of exercise per week, but remained included in the study and continued with their assigned exercise program.
Intervention:
Strength group: Patients in this group (n=34; 22 at final follow-up; median age: 46 years old) underwent a progressive, 1-year strength exercise program for their neck muscles at home. Exercises in this group included arm abduction, upright rows, biceps curls, flys, reverse flys, pullovers (all using dumbbells), as well as lifting the head up while supine without resistance. For the first 8 weeks, 2-kg dumbbells were used to accomplish a goal of 3 sets of 20 repetitions. Following this initial learning period, the weight of the dumbbells was adjusted to represent the heaviest weight possible to perform 10 repetitions. For the remainder of the 1-year program, three weeks were spent exercising with the heaviest weight possible (3 sets of 10 repetitions), and one week was spent exercising with 2-kg dumbbells (3 sets of 20 repetitions). Participants were instructed to progressively increase the amount of weight for their sets of 10 repetitions once they could perform 3 sets of 15 repetitions with the heaviest weight. Following the strength training, patients performed sit-ups, back extensions, and squats as dynamic exercises (20 times for each exercise). Lastly, patients performed stretching exercises for the neck, shoulders, and upper limb muscles. This exercise program was performed at a frequency of 3 times per week, after patients attended 3 educational sessions.
Comparison:
Stretch group: Patients in this group (n=23; 19 at final follow-up; median age: 42 years) completed a 1-year stretching exercise program at home. This program included only stretching exercises for the neck, shoulders, and upper limb muscles. The following muscles were stretched throughout this exercise program: upper & middle trapezius, sternocleidomastoid, rhomboids, pectoralis major, and the flexor and extensor muscles of the wrist. This exercise program was performed at a frequency of 3 times per week, after patients attended 3 educational sessions.
Outcomes:
The primary outcomes were neck pain intensity (assessed on the Numeric Rating Scale [NRS]) and self-reported neck function (using the Neck Disability Index [NDI]). Secondary outcomes included neck range of motion (using a cervical measurement system), maximal isometric neck strength in flexion and extension (via a handheld dynamometer), and shoulder strength (counting the number of two dynamic movements with a pair of 4-kg dumbbells).
Methods:
RCT; Single Centre
Time:
Follow-up assessments were conducted at 4-6 months (i.e. middle of the intervention) and 12 months (i.e. immediately upon completion of the intervention).

What were the important findings?

  • From baseline to the 4 to 6-month follow-up, function on the NDI (neck function) significantly improved within the strength group (median difference: 2 (0, 5.5); p=0.036), but not within the stretch group (median difference: 1 (-2, 4); p>0.05). Neck and shoulder pain did not significantly improve in either group when assessed at 4-6 months (p>0.05).
  • At the 4 to 6-month follow-up, there were no significant differences between groups with respect to improvement in pain intensities (p=0.59 to 0.93) and neck function (p=0.50). For secondary outcomes, although there were no between-group differences observed in range of motion (except for left neck rotation; p=0.01) (p=0.38 to 0.99), or neck strength (p=0.09 to 0.52), the strength group exhibited significantly better improvements in shoulder abduction (p=0.04) and standing row (p=0.02).
  • From baseline to the 12-month follow-up, function on the NDI significantly improved within both groups (strength: p=0.002; stretch: p=0.015). Following the same timeline, neck and shoulder pain were significantly improved within the stretch group (p=0.009 and p=0.017, respectively), but not within the strength group (p>0.05).
  • At 12 months, there were no significant differences between groups in neck pain intensity improvements (p=0.50 to 0.91), or function (p=0.71). For secondary outcomes, the strength group produced significantly better results for flexion strength of the neck (p=0.031), shoulder abductions (p=0.01) and standing row (p</=0.00). There were no between-group differences in range of motion (p=0.15 to 0.65) or neck strength (p=0.09).
  • At the 4-6-month follow-up, the strength group was performing exercises 1.5-2.5 times per week, with exercise frequency being 1.5 times/week or less thereafter. In the stretch group at the 4-6-month follow-up, exercises were being performed at least 2 times per week. Until month 10, the stretch group was exercising at a frequency of 1.5 times/week or more, and exercise frequency was <1.5 times/week thereafter.
  • There was no significant difference between groups in the number of completers at 4-6 months (strength: 79%; stretch: 89%; p=0.28) or at 12 months (strength: 55%; stretch: 53%; p=0.90). Among the completers, at 12 months, there was no significant difference between groups in the proportion of responders for neck pain (strength: 45%; stretch: 40%; p=0.41), shoulder pain (strength: 55%; stretch: 50%; p=0.64), or function (strength: 55%; stretch: 20%; p=0.07).
  • There were no intervention-related adverse events or harms reported in either group.

What should I remember most?

Neck pain intensity and neck function were similar at both the 4-6- and 12-month follow-up assessments, whether participants underwent a home based strength or stretching exercise program. A similar finding was observed when only completers of the exercise program were considered. Although the exercise programs were safe, participant adherence was low, especially after 6 months.

How will this affect the care of my patients?

This study found that a one-year, home-based strength exercise program yielded similar improvements in pain relief and neck function as a stretching exercise program. However, this finding could be due to the lack of statistical power. As such, additional high-quality studies are needed to confirm these results. Future studies should focus on factors for improving adherence rates for home-based exercise programs.

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