Research Review By Dr. Christopher M. Coulis©

Date Posted:

December 2009

Study Title:

Cervical Collar or Physiotherapy versus Wait and See Policy for Recent Onset Cervical Radiculopathy: Randomised Trial

Authors:

Kuijper B. et al.

Author's Affiliations:

Department of Neurology, Medical Center Haaglanden, Netherlands

Publication Information:

British Medical Journal 2009; 339.b3883.

Background Information:

Cervical radiculopathy is a common disorder that has a favorable prognosis. Typically resolving within 6 weeks, symptoms include neck pain and radiating pain into the arm and possibly the hand as well. Symptoms can be excruciating and therapeutic modalities that accelerate the improvement of pain and function are of value.

Several therapeutic modalities exist for the treatment of cervical radiculopathy. However, evidence is lacking for the effectiveness of any non-surgical treatment. This study attempted to asses the effectiveness of a semi-hard cervical collar with rest or physiotherapy versus a traditional wait and see policy on the rate of improvement of recent onset cervical radiculopathy.

Pertinent Results:

205 patients were randomly allocated to 3 groups; cervical collar and rest for 3-6 weeks, physiotherapy (12 treatments over 6 weeks) and control. 12 patients required surgery and were equally distributed among the 3 cohorts.

Main Findings:
  • The average Visual Analogue Scale scores at baseline were ~70mm for arm pain and ~60mm for neck pain (NP)
  • At 6 weeks, VAS values reflected significant reductions in arm pain (average value 33 mm – hence a reduction of ~37mm) and neck pain (average 31mm – hence a reduction of ~29mm) for the collar group and physiotherapy group (both averaged 31mm – hence reductions of ~40mm and 30mm respectively) were observed vs. the control group (reductions were only 19mm and 5mm respectively)
  • Neck Disability Index (NDI) improvements were statistically significant for the collar group and not for the physiotherapy group (despite both groups showing an improvement)
  • No difference was noted between groups at 6 months in NDI or VAS for cervical/arm pain – reflecting the natural history of this condition that was mentioned above
  • No significant difference was noted between groups in secondary outcomes at 3 and 6 weeks: satisfaction, use of opiates/NSAIDS, working status (non-significant pattern for PT group for partial or complete sick leave vs. collar and control group)

Clinical Application & Conclusions:

Traditionally it has been understood that immobilization is contraindicated for stable cervical spine conditions, as a lack of movement is believed to lead to disuse atrophy, deconditioning and increased likelihood of disability and chronicity (1). The authors, however, have found that a short course (3-6 weeks) of immobilization and rest for acute onset cervical radiculopathy may be a viable treatment option and may be equally as effective as strengthening exercises.

Past studies have attempted to answer the same question, however, they have looked at a different patient population, namely those with chronic radiculopathy. These previous studies failed to show any benefit with a cervical collar or strengthening exercises (2). This may indicate that cervical radiculopathy is a heterogenous condition, requiring specific management based on acuity.

It is also important to realize that the changes in VAS scores in this study were deemed significant with a change 3 cm for arm pain and 1.7/1.4 cm (collar/PT) for NP. The patients in this study had a mean VAS of > 70mm at intake. The Minimal Clinically Important Difference (MCID) for VAS of that magnitude is > 20 mm, indicating that the change in neck pain may have been clinically significant but not statistically significant (3).

This paper provides the framework for future studies, including a comparison of immobilization to cervical traction and spinal manipulation for acute cervical radiculopathy. It also provides a possible option for patient self management. Patients can utilize a cervical collar when not receiving treatment which may speed recovery and possibly empower the patient to achieve independence from care.

Study Methods:

This was a prospective randomized trial of acute cervical radiculopathy (onset < 1 month). 210 patients were randomized into 3 groups: semi-hard cervical collar, physiotherapy with home exercise, and a control group.

Inclusion Criteria:
  • age 18-75 years
  • symptoms for less than one month
  • arm pain on a visual analogue scale of 40mm or more
  • radiation of arm pain distal to the elbow
  • provocation of arm pain by neck movements
...and one of the following:
  • sensory changes in one or more adjacent dermatomes
  • diminished deep tendon reflexes in the affected arm
  • muscle weakness in one or more adjacent myotomes
Exclusion criteria:
  • clinical signs of spinal cord compression
  • previous treatment with physiotherapy or a cervical collar
  • insufficient understanding of the Dutch or English language
The collar group was required to wear the brace daily for the first 3 weeks of care, minimize activity and take as much rest as possible. At week 4 they were to “wean” off of the brace and discontinue use by week 6. Each patient was also required to keep a daily journal recording time of brace use and medication use.

The physiotherapy group was treated 2x/week for 6 weeks. No passive care was provided. Instead, therapy was supervised active strengthening of the superficial and deep cervical musculature. Patients were given home exercises to compliment the in-office care.

The control group was instructed to continue with their activities of daily living.

Outcomes Measures:
  • Cervical spine and arm VAS, NDI, self reported opiate use, working status and satisfaction
  • Outcomes were assessed at baseline, 3 weeks, 6 weeks and 6 months

Study Strengths / Weaknesses:

Weaknesses of this study:
  • Both patients and examiners were not blinded
  • The calculated sample size of 240 patients was not reached, therefore power was not achieved.
  • All patients presented with sensory disturbance which is subjective and has been previously shown to have a high false positive rate. Few patients presented with motor deficit or hyporeflexia which are objective and more indicative of a neurocompression lesion.

Additional References:

  1. Polston DW. Cervical radiculopathy. Neurol Clin 2007; 25:373.
  2. Persson LC, Carlsson CA, Carlsson JY. Long-lasting cervical radicular pain managed with surgery, physiotherapy, or a cervical collar: a prospective, randomized study. Spine 1997; 22: 751-8.
  3. Bird SB, Dickson EW. Clinically significant changes in pain along the visual analog scale. Ann Emerg Med 2001; 38: 639-43.