Background and aims
Persistent neck pain is common and can be detrimental to the health of those who are affected. This is particularly common after neck trauma, where it poses a challenge to health care providers. In this paper, we present the design and results of a study aimed primarily at assessing the feasibility of a supervised exercise intervention for patients with persistent neck pain after trauma. As a secondary aim, we analyzed the results of the intervention.
We designed and conducted a feasibility study using a mixed methods design. Ten patients with persistent neck pain (nine with a history of neck trauma and one with sudden onset of neck pain) were recruited from a specialized pain rehabilitation center and underwent a gym-based individual exercise therapy intervention, supervised by a physical therapist. We assessed the feasibility of the exercise therapy intervention based on the experiences of the patients and physical therapists. We analyzed both quantitative and qualitative results using descriptive statistics, content analysis, and questionnaires.
The study found the exercise therapy to be a feasible alternative for patients with persistent neck pain. Most of the practical aspects of the intervention and study were executed as planned, and the study was well received by the patients, who found it a valuable part of their rehabilitation. In the quantitative analysis, improvements were observed on the Neck Disability Index, numerical rating scale for pain, EuroQol 5D, and physical activity, with scores on the Neck Disability Index showing a statistically significant improvement. Scores on the Disability Rating Index showed a non-significant deterioration. The qualitative analysis uncovered one overarching theme and four themes for the patients and three themes for the physical therapist.
The exercise therapy intervention seems to be feasible with favorable outcomes for the patients. The quantitative and qualitative analyses demonstrated exercise therapy to be beneficial from several different perspectives. However, although structured, the training needs customization and individual adaption from a clinical reasoning perspective in order to meet each patient’s individual needs.
This study shows that supervised gym-based exercise therapy is feasible for patients with severe, persistent neck pain. It facilitates and motivates the execution of a larger, controlled trial, which might then lead to a new and potentially effective addition to the toolbox of all health care providers treating patients with persistent neck pain.
We would like to thank the personnel at the Department of Neurosurgery and Pain Rehabilitation at Skåne University Hospital for their expertise and valuable insights during the implementation of the program.
Research funding: This project received funding from Folksam Research Foundation, the Swedish Association for Survivors of Accident and Injury (RTP), and Capio Research Foundation.
Conflict of interest: Authors state no conflict of interest.
Informed consent: Informed consent has been obtained from all individuals included in this study.
Ethical approval: The research related to human use complies with all the relevant national regulations, institutional policies and was performed in accordance with the tenets of the Helsinki Declaration, and has been approved by the regional Ethics Committee of Lund, Sweden on May 9, 2016 (#2016/245).
 Hogg-Johnson S, van der Velde G, Carroll LJ, Holm LW, Cassidy JD, Guzman J, Côté P, Haldeman S, Ammendolia C, Carragee E, Hurwitz E, Nordin M, Peloso P. The burden and determinants of neck pain in the general population: results of the bone and joint decade 2000–2010 task force on neck pain and its associated disorders. Spine 2008;33:S39–51.10.1097/BRS.0b013e31816454c8Search in Google Scholar PubMed
 Hoy D, March L, Woolf A, Blyth F, Brooks P, Smith E, Vos T, Barendregt J, Blore J, Murray C, Burstein R, Buchbinder R. The global burden of neck pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 2014;73:1309–15.10.1136/annrheumdis-2013-204431Search in Google Scholar PubMed
 Westergren H, Larsson J, Freeman M, Carlsson A, Jöud A, Malmström E-M. Sex-based differences in pain distribution in a cohort of patients with persistent post-traumatic neck pain. Disabil Rehabil 2017;40:1085–91.10.1080/09638288.2017.1280543Search in Google Scholar PubMed
 Croft AC, Haneline MT, Freeman MD. Low speed frontal crashes and low speed rear crashes: is there a differential risk for injury? Annu Proc Assoc Adv Automot Med 2002;46:79–91.Search in Google Scholar
 Malfliet A, Kregel J, Cagnie B, Kuipers M, Dolphens M, Roussel N, Meeus M, Danneels L, Bramer WM, Nijs J. Lack of evidence for central sensitization in idiopathic, non-traumatic neck pain: a systematic review. Pain Physician 2015;18:223–35.Search in Google Scholar
 Schug SA, Lavandhomme P, Barke A, Korwisi B, Rief W, Treede R-D, IASP Taskforce for the Classification of Chronic Pain. The IASP classification of chronic pain for ICD-11: chronic postsurgical or posttraumatic pain. Pain 2019;160:45–52.10.1097/j.pain.0000000000001413Search in Google Scholar PubMed
 Varatharajan S, Ferguson B, Chrobak K, Shergill Y, Côté P, Wong JJ, Yu H, Shearer HM, Southerst D, Sutton D, Randhawa K, Jacobs C, Abdulla S, Woitzik E, Marchand A-A, van der Velde G, Carroll LJ, Nordin M, Ammendolia C, Mior S, et al. Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J 2016;25:1971–99.10.1007/s00586-016-4376-9Search in Google Scholar PubMed
 Styrke J, Sojka P, Björnstig U, Stålnacke B-M. Symptoms, disabilities, and life satisfaction five years after whiplash injuries. Scand J Pain 2014;5:229–36.10.1016/j.sjpain.2014.06.001Search in Google Scholar PubMed
 Van Oosterwijck J, Nijs J, Meeus M, Paul L. Evidence for central sensitization in chronic whiplash: a systematic literature review. Eur J Pain (London, England) 2013;17:299–312.10.1002/j.1532-2149.2012.00193.xSearch in Google Scholar PubMed
 Treleaven J. Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control – Part 2: case studies. Man Ther 2008;13:266–75.10.1016/j.math.2007.11.002Search in Google Scholar PubMed
 Szeto GPY, Straker LM, O’Sullivan PB. A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work – 1: neck and shoulder muscle recruitment patterns. Man Ther 2005;10:270–80.10.1016/j.math.2005.01.004Search in Google Scholar PubMed
 MacDermid JC, Walton DM, Bobos P, Lomotan M, Carlesso L. A qualitative description of chronic neck pain has implications for outcome assessment and classification. Open Orthop J 2016;10:746–56.10.2174/1874325001610010746Search in Google Scholar PubMed PubMed Central
 Cagnie B, Struyf F, Cools A, Castelein B, Danneels L, O’leary S. The relevance of scapular dysfunction in neck pain: a brief commentary. J Orthop Sports Phys Ther 2014;44:435–9.10.2519/jospt.2014.5038Search in Google Scholar PubMed
 Blomgren J, Strandell E, Jull G, Vikman I, Röijezon U. Effects of deep cervical flexor training on impaired physiological functions associated with chronic neck pain: a systematic review. BMC Musculoskeletal Disord 2018;19:415.10.1186/s12891-018-2324-zSearch in Google Scholar PubMed PubMed Central
 Brody LT, Hall CM. Therapeutic exercise: moving toward function. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2010.Search in Google Scholar
 Rudolfsson T, Björklund M, Djupsjöbacka M. Range of motion in the upper and lower cervical spine in people with chronic neck pain. Man Ther 2012;17:53–9.10.1016/j.math.2011.08.007Search in Google Scholar PubMed
 Ris I, Søgaard K, Gram B, Agerbo K, Boyle E, Juul-Kristensen B. Does a combination of physical training, specific exercises and pain education improve health-related quality of life in patients with chronic neck pain? A randomised control trial with a 4-month follow up. Man Ther 2016;26:132–40.10.1016/j.math.2016.08.004Search in Google Scholar PubMed
 Falla D, Lindstrøm R, Rechter L, Boudreau S, Petzke F. Effectiveness of an 8-week exercise programme on pain and specificity of neck muscle activity in patients with chronic neck pain: a randomized controlled study. Eur J Pain 2013;17:1517–28.10.1002/j.1532-2149.2013.00321.xSearch in Google Scholar PubMed
 Gross A, Kay TM, Paquin J-P, Blanchette S, Lalonde P, Christie T, Dupont G, Graham N, Burnie SJ, Gelley G. Exercises for mechanical neck disorders. The Cochrane Library 2015;1:1–224.10.1002/14651858.CD004250.pub5Search in Google Scholar PubMed
 Viechtbauer W, Smits L, Kotz D, Budé L, Spigt M, Serroyen J, Crutzen R. A simple formula for the calculation of sample size in pilot studies. J Clin Epidemiol 2015;68:1375–9.10.1016/j.jclinepi.2015.04.014Search in Google Scholar PubMed
 Vernon H, Mior S. The Neck Disability Index: a study of reliability and validity. J Manip Physiol Ther 1991;14:409–15.Search in Google Scholar
 Brage K, Ris I, Falla D, Søgaard K, Juul-Kristensen B. Pain education combined with neck- and aerobic training is more effective at relieving chronic neck pain than pain education alone – A preliminary randomized controlled trial. Man Ther 2015;20:686–93.10.1016/j.math.2015.06.003Search in Google Scholar PubMed
 Andersen CH, Andersen LL, Zebis MK, Sjøgaard G. Effect of scapular function training on chronic pain in the neck/shoulder region: a randomized controlled trial. J Occup Rehabil 2014;24:316–24.10.1007/s10926-013-9441-1Search in Google Scholar PubMed PubMed Central
 Malmström E-M, Westergren H, Fransson P-A, Karlberg M, Magnusson M. Experimentally induced deep cervical muscle pain distorts head on trunk orientation. Eur J Appl Physiol 2013;113:2487–99.10.1007/s00421-013-2698-4Search in Google Scholar
 Meisingset I, Stensdotter A-K, Woodhouse A, Vasseljen O. Neck motion, motor control, pain and disability: a longitudinal study of associations in neck pain patients in physiotherapy treatment. Man Ther 2016;22:94–100.10.1016/j.math.2015.10.013Search in Google Scholar PubMed
 Gallego Izquierdo T, Pecos-Martin D, Lluch Girbés E, Plaza-Manzano G, Rodríguez Caldentey R, Mayor Melús R, Blanco Mariscal D, Falla D. Comparison of cranio-cervical flexion training versus cervical proprioception training in patients with chronic neck pain: a randomized controlled clinical trial. J Rehabil Med 2016;48:48–55.10.2340/16501977-2034Search in Google Scholar PubMed
 Wänman A. Endurance to physical strain in patients with temporomandibular disorders: a case-control study. Acta Odontologica Scandinavica 2012;70:455–62.10.3109/00016357.2011.635599Search in Google Scholar PubMed
 Häggman-Henrikson B, Wiesinger B, Wänman A. The effect of supervised exercise on localized TMD pain and TMD pain associated with generalized pain. Acta Odontologica Scandinavica 2018;76:6–12.10.1080/00016357.2017.1373304Search in Google Scholar PubMed
 Seferiadis A, Ohlin P, Billhult A, Gunnarsson R. Basic body awareness therapy or exercise therapy for the treatment of chronic whiplash associated disorders: a randomized comparative clinical trial. Disabil Rehabil 2016;38:442–51.10.3109/09638288.2015.1044036Search in Google Scholar PubMed
 Lluch E, Arguisuelas MD, Calvente Quesada O, Martínez Noguera E, Peiró Puchades M, Pérez Rodríguez JA, Falla D. Immediate effects of active versus passive scapular correction on pain and pressure pain threshold in patients with chronic neck pain. J Manipulative Physiol Ther 2014;37:660–6.10.1016/j.jmpt.2014.08.007Search in Google Scholar PubMed
 Chaiwanichsiri D, Lorprayoon E, Noomanoch L. Star excursion balance training: effects on ankle functional stability after ankle sprain. J Med Assoc Thai 2005;88(Suppl 4):S90–4.Search in Google Scholar
 Jull GA, O’Leary SP, Falla DL. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. J Manipulative Physiol Ther 2008;31:525–33.10.1016/j.jmpt.2008.08.003Search in Google Scholar PubMed
 Falla D, O’Leary S, Farina D, Jull G. The change in deep cervical flexor activity after training is associated with the degree of pain reduction in patients with chronic neck pain. Clin J Pain 2012;28:628–34.10.1097/AJP.0b013e31823e9378Search in Google Scholar
 Cramer H, Haller H, Lauche R, Dobos G. Mindfulness-based stress reduction for low back pain. A systematic review. BMC Complement Altern Med 2012;12:162.10.1186/1472-6882-12-162Search in Google Scholar
 Herdman M, Gudex C, Lloyd A, Janssen M, Kind P, Parkin D, Bonsel G, Badia X. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res 2011;20:1727–36.10.1007/s11136-011-9903-xSearch in Google Scholar
 van Hout B, Janssen MF, Feng Y-S, Kohlmann T, Busschbach J, Golicki D, Lloyd A, Scalone L, Kind P, Pickard AS. Interim scoring for the EQ-5D-5L: mapping the EQ-5D-5L to EQ-5D-3L value sets. Value Health 2012;15:708–15.10.1016/j.jval.2012.02.008Search in Google Scholar
 Salén B A, Spangfort EV, Nygren AL, Nordemar R. The Disability Rating Index: an instrument for the assessment of disability in clinical settings. J Clin Epidemiol 1994;47:1423–35.10.1016/0895-4356(94)90086-8Search in Google Scholar
 R Core Team. R: a language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing, 2016.Search in Google Scholar
 Hothorn T, Hornik K. exactRankTests: exact distributions for rank and permutation tests. R package version 0.8-30. https://CRAN.R-project.org/package=exactRankTests. 2019.Search in Google Scholar
 Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 2004;24:105–12.10.1016/j.nedt.2003.10.001Search in Google Scholar PubMed
 Monticone M, Ambrosini E, Cedraschi C, Rocca B, Fiorentini R, Restelli M, Gianola S, Ferrante S, Zanoli G, Moja L. Cognitive-behavioral treatment for subacute and chronic neck pain: a Cochrane review. Spine 2015;40:1495–504.10.1097/BRS.0000000000001052Search in Google Scholar PubMed
 Lauche R, Cramer H, Dobos G, Langhorst J, Schmidt S. A systematic review and meta-analysis of mindfulness-based stress reduction for the fibromyalgia syndrome. J Psychosom Res 2013;75:500–10.10.1016/j.jpsychores.2013.10.010Search in Google Scholar PubMed
 Escolar-Reina P, Medina-Mirapeix F, Gascón-Cánovas JJ, Montilla-Herrador J, Jimeno-Serrano FJ, de Oliveira Sousa SL, del Baño-Aledo ME, Lomas-Vega R. How do care-provider and home exercise program characteristics affect patient adherence in chronic neck and back pain: a qualitative study. BMC Health Serv Res 2010;10:60.10.1186/1472-6963-10-60Search in Google Scholar PubMed PubMed Central
 Thompson C, Dowding D. Clinical decision-making and judgement in nursing. 1st ed. Edinburgh: Churchill Livingstone, 2001.Search in Google Scholar
©2020 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.