Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial.
From: BMJ. 2009 Oct 7;339:b3883
Cervical radiculopathy is a common disorder characterised by neck pain radiating to the arm and fingers corresponding to the dermatome involved. On examination, diminished muscle tendon reflexes, sensory disturbances, or motor weakness with dermatomal/ myotomal distribution can be found. The diagnosis is determined primarily on clinical grounds. Magnetic resonance imaging of the cervical spine usually shows the cause of the radiculopathy, which is usually spondylarthrosis or a herniated disc. This is often referred to as a pinched nerve.
Generally, degenerative cervical radiculopathy with subacute onset has a favourable prognosis, allowing a wait and see policy during the first six weeks. However, as pain is often excruciating during the first weeks to months, treatment to accelerate the improvement of pain and function would be highly valuable. Unfortunately, evidence is lacking for the effectiveness of any non-surgical treatment, including a wait and see policy, cervical collar, or physiotherapy. Two randomised trials comparing different non-invasive treatment methods in chronic cervical radiculopathy showed no benefit for physiotherapy or a cervical collar. Treatment in acute or subacute cervical radiculopathy has not yet been studied. Therefore,we evaluated the effectiveness of a semi-hard cervical collar in combination with taking as much rest as possible or physiotherapy and home exercises compared with a wait and see policy in recent onset cervical radiculopathy. We hypothesised that a treatment policy (collar or physiotherapy) would result in a faster decline in pain and improvement in function than would a wait and see policy.
To evaluate the effectiveness of treatment with collar or physiotherapy compared with a wait and see policy in recent onset cervical radiculopathy, neurology outpatient clinics in three Dutch hospitals included 205 patients with symptoms and signs of cervical radiculopathy of less than one month’s duration. Treatment with a semi-hard collar and taking rest for three to six weeks; 12 twice weekly sessions of physiotherapy and home exercises for six weeks; or continuation of daily activities as much as possible without specific treatment (control group).
Time course of changes in pain scores for arm and neck pain on a 100 mm visual analogue scale and in the neck disability index during the first six weeks. In the wait and see group, arm pain diminished by 3 mm/week on the visual analogue scale and by 19 mm in total over six weeks. Patients who were treated with cervical collar or physiotherapy achieved additional pain reduction, resulting in an extra pain reduction compared with the control group of 12 mm after six weeks. In the wait and see group, neck pain did not decrease significantly in the first six weeks. Treatment with the collar resulted in a weekly reduction on the visual analogue scale of 2.8 mm, amounting to 17 mm in six weeks, whereas physiotherapy gave a weekly reduction of 2.4 mm resulting in a decrease of 14 mm after six weeks. Compared with a wait and see policy, the neck disability index showed a significant change with the use of the collar and rest and a non-significant effect with physiotherapy and home exercises.
A semi-hard cervical collar and rest for three to six weeks or physiotherapy accompanied by home exercises for six weeks reduced neck and arm pain substantially compared with a wait and see policy in the early phase of cervical radiculopathy.
In this randomised study of patients with recent onset cervical radiculopathy, the authors found that treatment with a semi-hard cervical collar in combination with taking as much rest as possible for three weeks, with a maximum of six weeks, or standardised physiotherapy and doing home exercises for six weeks resulted in a significant reduction in arm and neck pain compared with a wait and see policy. The differences in pain reduction between the treatment and control groups varied from 12 to17 mm on a 100 mm visual analogue scale in six weeks and were highly statistically significant. Studies on visual analogue scale scores consider this difference to be clinically meaningful. One such study in patients with acute pain, mainly in emergency departments, showed that the meaning of a difference in pain scores depends on the height of the scores. In patients with scores between 34 and 66 mm, as in our patients at three and six weeks, a difference of 17 (SD 10) mm was found to be clinically meaningful. However, the setting differed from this study in which patients with subacute onset cervical radiculopathy were treated, and this may limit the interpretation of these data for our study population.
Disability decreased 9 points on the neck disability index over six weeks in the control patients, with an additional 5 point decrease in both the collar and physiotherapy groups. The additional effect of the collar on disability was small but statistically significant. Although the additional effect of physiotherapy on disability was not significant, a favourable effect on disability occurred, presumably owing to reduction. The less prominent effect on the neck disability index compared with the pain scores may well be explained by the fact that the index predominantly measures the disability caused by neck pain, whereas arm pain scores were highest initially and showed the largest improvement. All differences between the groups on the visual analogue scale and the neck disability index scores were no longer present at the six month follow-up. Most patients had no or limited pain, confirming earlier reports of the favourable natural course of the disease. As the patients had arm and neck pain for a mean of three weeks before entering the study, and as they were treated for six weeks, the authors have shown that both the cervical collar and physiotherapy are efficacious within this time frame. Considering the degree of pain reduction obtained at six weeks, further interventions after this period are not likely to be of benefit in most patients.
Little evidence exists on the mechanisms of collars and physiotherapy in giving pain relief, and the explanations provided in the literature are largely hypothetical. The collar probably reduces foraminal root compression and associated root inflammation by immobilising the neck, which might explain the larger reduction of arm pain compared with neck pain and neck disability as found in this study.
Physiotherapy aims at restoring range of motion and strengthening the neck musculature, probably diminishing secondary musculoskeletal problems, although the mechanism of pain reduction is unclear. Thirteen (6.3%) of the 205 patients, equally distributed over the three groups, were surgically treated during the six months of follow-up. Considerably higher percentages of surgery for cervical radiculopathy are reported in the literature. The authorsdiscussed surgical treatment options with patients who had persisting or intractable pain and referred them to their neurosurgical department. The low rate of surgery in this cohort may be due to the fact that their patients were included at an early stage, whereas previous studies including more chronic cases encompassed a larger number of patients who did not respond to non-surgical treatment. Furthermore, patients were possibly less inclined to have surgery because they participated in a study aimed at reducing signs and symptoms by non-surgical interventions.
The results of this randomised clinical trial show a clinically relevant short term reduction in pain in recent onset cervical radiculopathy with two therapeutic interventions—that is, a semi-hard cervical collar combined with taking rest and standardised physiotherapy accompanied by home exercises—compared with a wait and see policy. The authors recommend a semi-hard cervical collar and taking rest in recent onset cervical radiculopathy because the costs are lower than for physiotherapy, although physiotherapy is a good alternative with an almost similar efficacy.
