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Neck disability in patients with cervical radiculopathy and evaluation of structured postoperative physiotherapy
Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0003-3464-1538
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Non-surgical and surgical approaches to treatment are used in patients with cervical radiculopathy (CR) due to disc disease. Overall, good effects of surgery have been reported on arm pain and neurological symptoms. However, the effects on neck functioning are more uncertain. Studies have shown persistent activity limitations; participation restrictions; and impairments in neck-related body functions after surgery. Structured physiotherapy combining neck-specific exercises with a behavioural approach has been suggested as treatment before as well as after surgery to improve clinical outcomes in patients with CR. Randomized clinical trials of postoperative physiotherapy to inform evidence-based clinical guidelines for the treatment of patients with CR are lacking.

The overall aim of the thesis was to investigate the additional benefit of structured postoperative physiotherapy combining neck-specific exercises with a behavioural approach compared to standard postoperative approach in patients with CR. A further aim was to evaluate the  contribution of different aspects of neck-related body functions and mental functions on preoperative neck disability in these patients.

A total of 202 patients with CR who were scheduled for surgery were recruited, and randomized preoperatively to either structured postoperative physiotherapy, or standard postoperative approach. Standard postoperative approach was in accordance with Swedish postoperative care, and may have included pragmatic physiotherapy after surgery when needed. Patients were evaluated with a set of questionnaires and clinical examinations before surgery and at 3 and 6 months after surgery. Outcomes included patient-reported measures of pain, neck functioning, global outcome, clinical evaluation of neckrelated body functions, self-efficacy and coping strategies, as well as expectation fulfilment and enablement. Differences between treatment groups were investigated in complete case and per-protocol approaches (Paper III & IV). A sub-sample of patients with CR who were scheduled for surgery were also compared with neck-healthy individuals for assessment of head repositioning accuracy with a cervical range of motion device (Paper I). In patients with CR who were scheduled for surgery, associations between preoperative measures of neck-related body functions, mental functions, and other contextual factors with patientreported neck disability were studied (Paper II).

With the exception of greater expectation fulfilment in patients who received structured postoperative physiotherapy (p = 0.01), there were no differences between the treatment groups in outcomes at 6 months after surgery. There were no differences reported for changes in  outcomes from before surgery to 6 months after surgery between the groups, but all outcomes significantly improved from baseline in both groups (p<0.001) (Paper III & IV). However, global outcome and frequency of neck pain improved during the postoperative period only in patients who received structured postoperative physiotherapy (p< 0.01) (Paper III). Six months after surgery, patients with at least 50% attendance to treatment sessions in the structured postoperative physiotherapy group reported less neck pain frequency (p = 0.05), and greater expectation fulfilment (p = 0.001), and enablement (p = 0.04) than those who received standard postoperative approach. These patients also had larger improvements in neck functioning, arm pain and catastrophizing during the rehabilitation period from 3 to 6 months after surgery (p< 0.03). Sixty-one percent of the patients who received standard postoperative approach reported additional use ofpostoperative physiotherapy. These patients had a worse surgical outcome compared with patients who reported no additional use of postoperative physiotherapy. In patients with CR who were scheduled for surgery, larger errors in head repositioning accuracy were found compared to neck-healthy individuals (Paper I). Preoperative measures of neck-related body functions, mental functions and other contextual factors explained 73% of the variance in Neck Disability Index scores in patients with CR who were scheduled for surgery (Paper II).

The results may suggest a benefit from combining surgery with structured postoperative physiotherapy in patients with CR. Moreover, the results confirm that neck-specific exercises are tolerated by patients with CR after surgery. However, CR is a heterogeneous condition and specific subgroups of patients are likely to benefit from different interventions. More studies are needed to inform evidence-based clinical guidelines for the treatment of patients with CR. A broader preoperative assessment in patients with CR improved the description of patient-reported neck disability.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. , 95 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1480
National Category
Physiotherapy Neurology
Identifiers
URN: urn:nbn:se:liu:diva-122695DOI: 10.3384/diss.diva-122695ISBN: 978-91-7685-959-9 (print)OAI: oai:DiVA.org:liu-122695DiVA: diva2:871659
Public defence
2015-12-11, Berzeliussalen, Campus US, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2015-11-16 Created: 2015-11-16 Last updated: 2015-11-24Bibliographically approved
List of papers
1. Using the cervical range of motion (CROM) device to assess head repositioning accuracy in individuals with cervical radiculopathy in comparison to neck- healthy individuals
Open this publication in new window or tab >>Using the cervical range of motion (CROM) device to assess head repositioning accuracy in individuals with cervical radiculopathy in comparison to neck- healthy individuals
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2013 (English)In: Manual Therapy, ISSN 1356-689X, E-ISSN 1532-2769, Vol. 18, no 5, 403-409 p.Article in journal (Refereed) Published
Abstract [en]

This study had two purposes: to compare head repositioning accuracy (HRA) using the cervical range of motion (CROM) device between individuals with cervical radiculopathy caused by disc disease (CDD; n = 71) and neck- healthy individuals (n = 173); and to evaluate the test–retest reliability of the CROM device in individuals with CDD, and criterion validity between the CROM device and a laser in neck-healthy individuals, with quantification of measurement errors. Parameters of reliability and validity were expressed with intra- class- correlation coefficients (ICCs), and measurement errors with standard error of measurement (SEM) and Bland Altman limits of agreement. HRA (Mdn, IQR) differed significantly between individuals with CDD and neck- healthy individuals after rotation right 2.7° (6.0), 1.7° (2.7); and rotation left 2.7° (3.3), 1.3° (2.7) (p < = 0.021); 31% of individuals with CDD were classified as having impairment in HRA. The test–retest reliability of the CROM device in individuals with CDD showed ICCs of 0.79- 0.85, and SEMs of 1.4°- 2°. The criterion validity between the CROM device and the laser in neck-healthy individuals showed ICCs of 0.43- 0.91 and SEMs of 0.8°- 1.3°. The results support the use of the CROM device for quantifying HRA impairment in individuals with CDD in clinical practice; however, criterion validity between the CROM device and a laser in neck-healthy individuals was questionable. HRA impairment in individuals with CDD may be important to consider during rehabilitation and evaluated with the criterion established with the CROM device in neck-healthy individuals.

Place, publisher, year, edition, pages
Elsevier, 2013
Keyword
Neck pain, Radiculopathy, Head repositioning accuracy, Measurement
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-98660 (URN)10.1016/j.math.2013.02.004 (DOI)000324341300009 ()
Note

Funding Agencies|Swedish Research Council||Swedish Society of Medicine||Medical Research Council of Southeast Sweden||

Available from: 2013-10-10 Created: 2013-10-10 Last updated: 2017-12-06
2. Individual factors associated with neck disability in patients with cervical radiculopathy scheduled for surgery: a study on physical impairments, psychosocial factors, and life style habits
Open this publication in new window or tab >>Individual factors associated with neck disability in patients with cervical radiculopathy scheduled for surgery: a study on physical impairments, psychosocial factors, and life style habits
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2014 (English)In: European spine journal, ISSN 0940-6719, E-ISSN 1432-0932, Vol. 23, no 3, 599-605 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE:

The influence of individual factors on patient-reported outcomes is important in the interpretation of disability and treatment effectiveness. The purpose of this study was to assess how physical impairments, psychosocial factors, and life style habits were associated with neck disability based on the Neck Disability Index (NDI), in patients with cervical radiculopathy scheduled for surgery.

METHODS:

This cross-sectional study included 201 patients (105 men, 96 women; mean age 50 years). Data included self-reported measures and a clinical examination. Multiple linear regressions were performed to identify significant influencing factors.

RESULTS:

Pain, physical impairments in the cervical active range of motion, low self-efficacy, depression, and sickness-related absences explained 73 % of the variance in NDI scores (p < 0.001).

CONCLUSION:

Assessments of physical impairments and psychosocial factors in patients with cervical radiculopathy could improve the description of neck disability and the interpretation of treatment outcomes in longitudinal studies.

Place, publisher, year, edition, pages
Springer Berlin/Heidelberg, 2014
Keyword
Cervical spine, Radiculopathy, Neck Disability Index, Individual factors, Multiple regression analysis
National Category
Neurology
Identifiers
urn:nbn:se:liu:diva-105506 (URN)10.1007/s00586-013-3066-0 (DOI)000332604600018 ()24154827 (PubMedID)
Available from: 2014-03-28 Created: 2014-03-25 Last updated: 2017-12-05Bibliographically approved
3. Postoperative Physiotherapy in patients with cervical radiculopathy: outcomes at six months in a randomized clinical trial
Open this publication in new window or tab >>Postoperative Physiotherapy in patients with cervical radiculopathy: outcomes at six months in a randomized clinical trial
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2015 (English)Manuscript (preprint) (Other academic)
Abstract [en]

Objective: To investigate the additional benefit of structured postoperative physiotherapy combining neck-specific exercises with a behavioral approach to standard postoperative approach in patients with cervical radiculopathy (CR) at 6 months after surgery.

Design: A prospective multi-center randomized clinical trial.

Subjects: Patients with CR (n=202, mean age 50.0, SD 8.4) who were scheduled for surgery.

Methods: Patients were randomized pre-operatively to structured postoperative physiotherapy (n=101) or standard approach (n=101) which in accordance with Swedish usual care may have included pragmatic physiotherapy after surgery when needed. Outcome measures at baseline and at 3 and 6 months follow-up included the Neck Disability Index (NDI), pain intensity in the neck and arm measured with a visual analogue scale (VAS) and global outcome of treatment. Between-group differences were investigated using complete case and per-protocol approaches.

Results: No between-group difference was found in NDI, VAS, or global outcome at 6 months after surgery (p> 0.18). The NDI and VAS neck and arm pain were improved in both groups from before surgery to 6 months after surgery (p< 0.001). Sixty-one percent of the patients who received SA reported additional use of postoperative physiotherapy. Global outcome improved during the postoperative period in patients who received structured postoperative physiotherapy only (p< 0.01).

Conclusions: No additional benefit of structured postoperative physiotherapy compared to standard postoperative approach was found at 6 months of follow-up based on patientreported measures of pain, neck disability and global outcome. However, many patients with CR perceived a need for additional treatments after surgery; and the results may suggest a benefit from combining surgery with structured postoperative physiotherapy in patients with CR. Moreover, the results confirm that neck-specific exercises are tolerated by patients with CR after surgery.

Keyword
Cervical radiculopathy; Postoperative physiotherapy; Neck Disability Index; Global outcome
National Category
Neurology Physiotherapy
Identifiers
urn:nbn:se:liu:diva-122692 (URN)
Available from: 2015-11-16 Created: 2015-11-16 Last updated: 2015-11-16Bibliographically approved
4. Neck-related physical function, self-efficacy and coping strategies in patients with cervical radiculopathy: a randomized clinical trial of postoperative physiotherapy
Open this publication in new window or tab >>Neck-related physical function, self-efficacy and coping strategies in patients with cervical radiculopathy: a randomized clinical trial of postoperative physiotherapy
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2017 (English)In: Journal of Manipulative and Physiological Therapeutics, ISSN 0161-4754, E-ISSN 1532-6586, Vol. 40, no 5, 330-339 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To compare postoperative rehabilitation with structured physiotherapy to standard approach in patients with cervical radiculopathy (CR) based on measures of neck-related physical function, self-efficacy and coping strategies at 6 months follow-up.

Design: A randomized clinical trial of postoperative physiotherapy in patients with CR.

Subjects: Patients (n= 202) with persistent CR who were scheduled for surgery.

Methods: Patients were preoperatively randomized to receive structured postoperative physiotherapy (SPT, n=101) or standard postoperative approach (SA, n=101). SPT combined neck-specific exercises with a behavioral approach. Baseline, 3-month, and 6-month evaluations included questionnaires and clinical examinations. Neck muscle endurance, active cervical range of motion, self-efficacy, pain catastrophizing (CSQ_CAT), perceived control over pain, and ability to decrease pain were analyzed for between-group differences using complete case and per-protocol approaches.

Results: No between-group difference was reported at the 6-month follow-up (p = 0.05 to 0.99), but all outcomes had improved from baseline (p<0.001). Patients in the SPT group with ≥50% attendance to treatment sessions showed larger improvements in CSQ_CAT (p= 0.04) during the rehabilitation period from 3 to 6 months after surgery compared to the patients who received SA.

Conclusion: No between-group difference in outcomes was found at 6 months after surgery based on measures of neck-related physical function, self-efficacy and coping strategies. However, the results confirm that neck-specific exercises are tolerated by patients with CR after surgery, and that there may be a benefit from combining surgery with structured postoperative physiotherapy in patients with CR.

Keyword
Cervical radiculopathy, Postoperative physiotherapy, Randomized clinical trial, Physical function, Coping strategies
National Category
Neurology Physiotherapy
Identifiers
urn:nbn:se:liu:diva-122694 (URN)10.1016/j.jmpt.2017.02.012 (DOI)000404024700003 ()
Note

Funding agencies: Swedish Research Council; Swedish Society of Medicine; Medical Research Council of Southeast Sweden; Region Ostergotland; Lions; Futurum (Academy of Health and Care, Region Jonkoping County)

Available from: 2015-11-16 Created: 2015-11-16 Last updated: 2017-08-21Bibliographically approved

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