Conservative management of non-specific neck pain : effectiveness of treatment, predictors of treatment outcome and upper limb disability
McLean, Sionnadh M.
Thesis or dissertation
- © 2007 Sionnadh M McLean. All rights reserved. No part of this publication may be reproduced without the written permission of the copyright holder.
Neck pain is a prevalent musculoskeletal problem that consumes considerable NHS resources. The socioeconomic impact for individuals, industry and society is high. However research into the management of neck pain is sparse. Reviews of the evidence revealed relatively little high quality evidence relating to the development, progression and management of non-specific neck pain. There is emerging evidence for the use of dynamic strengthening, proprioceptive and postural exercises for neck pain, although it is not known whether group exercise based on this emerging evidence is effective compared to usual physiotherapy. There is little evidence for prognostic factors for the progression of neck pain or outcome of treatment. Consequently clinicians are unable to predict which patients are likely to develop recurrent, persistent or chronic problems and have difficulty directing patients towards the most effective treatment approaches. Finally, there is anecdotal understanding that neck problems may lead to the development of upper limb disability and that upper limb disability may influence treatment outcome for patients with neck pain. Currently the relationship between neck pain and upper limb disability remains unquantified. The information gained from these reviews was utilised in the design of a randomised controlled trial to compare group based Graded Exercise Treatment and Usual Physiotherapy (GET UP) for patients with non-specific neck pain.
The first aim of this thesis was to investigate the effectiveness of a graded neck and upper limb exercise programme (GET) compared with "usual physiotherapy" (UP). A randomised controlled trial of 151 patients showed that patients receiving UP and GET interventions had reduced neck pain and disability six months following intervention. Neck pain and disability scores in the UP group reduced by 7.7% at six month followup whilst those in the GET group reduced by 5.0%. For patients who completed treatment as per protocol, GET (8.8%) was as effective as UP (9.0%). The second aim was to investigate patient psychological, socio-demographic and physical variables which predicted treatment outcome. After adjusting for baseline neck pain and disability and treatment allocation, general linear modelling identified that, regardless of intervention, deprivation status significantly predicted treatment outcome at six months. In addition, baseline fear avoidance and treatment allocation interacted to predict six month outcome. Patients with high fear avoidance were predicted to have better outcome following GET. Those with low fear avoidance were predicted to have better outcome in UP. The final aim was to investigate the relationship between neck pain and upper limb disability. Pair wise analysis revealed a strong positive correlation between neck pain and disability and upper limb disability. Linear regression indicated that the severity of upper limb disability was predicted by two main baseline variables: higher NPQ scores and lower pain self efficacy scores.
In conclusion GET and UP produced small but clinically meaningful reductions in neck pain and disability. Adherence to both forms of treatment, particularly GET, was a problem. For the subgroup group of patients who adhered to the treatment protocol, GET was as effective as UP, therefore the barriers to adhering with these treaments need to be better understood by clinicians and researchers alike. The GET programme appeared to be particularly beneficial for patients exhibiting high levels of fear avoidance beliefs. Therefore patients with neck pain should be assessed for the presence of fear avoidance beliefs and where appropriate directed towards active neck and upper limb rehabilitation. Patients from areas of social deprivation fared less well with physiotherapy than those from more affluent areas, regardless of intervention type. There is a need for more research into the influence of deprivation on treatment outcome. In particular there is a need to develop and evaluate innovative and targeted approaches which are suitable for such patients. Finally, clinicians should be aware that higher levels of neck pain and lower levels of pain self efficacy may provide an early indication of the presence of upper limb disability. Effective ways of managing neck related upper limb disability need further investigation since neither treatment was effective at reducing upper limb disability.
- Poatgraduate Medical Institute, The University of Hull
- Moffett, Jennifer; Sharp, Donald
- Sponsor (Organisation)
- Arthritis Research Campaign; Hull and East Yorkshire Hospitals NHS Trust
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- Filesize: 26 MB