Early results of supervised versus unsupervised rehabilitation of patients with cervical pain

Abstract

Purpose:

Comparison of early effects of supervised (led by physiotherapist) and unsupervised rehabilitation protocols in patients with myofascial pain syndrome, disk-root conflict and degenerative spine disease at cervical level.

Methods:

Three groups of patients (n = 60 each) with clinically and neurophysiologically confirmed myofascial pain syndrome, disk-root conflict and degenerative spine disease were randomly subdivided to supervised and unsupervised treatment subgroups (n = 30 each). Thirty healthy subjects with similar demographic and anthropometric properties as patients were enrolled to control group. Patients were examined before and after rehabilitation with visual analog scale of pain, Spurling’s test, painful passive elongation and active trigger points detection in trapezius muscle, sensory perception studies and surface electromyography (at rest, during maximal contraction) and electroneurography.

Results:

Supervised treatment resulted in decrease of pain intensity (P = .001) and Spurling’s symptoms incidence (P = .008) in patients from disk-root conflict group. Painful elongation and incidence of trigger points in trapezius muscle were the least observed at P = .009 after supervised therapy of myofascial pain syndrome. Supervised therapy resulted in decrease of resting electromyography amplitude and increase of maximal contraction electromyography amplitude from trapezius muscle (P = .02) in myofascial pain syndrome patients and from biceps and abductor pollicis brevis muscles of patients from other groups (P from .05 to .001). Median nerve electroneurography and sensory perception results improved at P = .05 after supervised treatment in disk-root conflict group.

Conclusions:

Twenty-day supervised rehabilitation provides better therapeutic effects than unsupervised one in treatment of muscle dysfunctions in patients with myofascial pain syndrome, degenerative changes and disk-root conflict at cervical spine.

Keywords

Cervical pain supervised and unsupervised rehabilitation clinical studies neurophysiological studies comparative studies

Introduction

The topic on effectiveness of appropriate rehabilitation in patients with symptoms of neck pain originated from muscle dysfunction, disk-root conflict or degenerative spine disease is still disputable. Especially the mode of its application with supervised (led by physiotherapist) and unsupervised (self-performed by the patient after recommendations) procedures remains unsettled. As it has been shown in the previous work, the cervical spine pain has a different origin and clinical picture.¹ Few publications assessed the effects of rehabilitation treatment depending on the initial clinical status and etiology of cervical spine pain.² Even Cochrane database research provides only little information on effectiveness of treatment when chosen applications like manipulation and mobilization, strengthening exercises, and trigger points inactivation were applied.³ There is little high-quality evidence on the best nonoperative therapy in cases of patients with cervical radiculopathy.^4–7

Optimal algorithms of rehabilitation procedures applied to patients with myofascial pain syndrome, disk-root conflict and degenerative spine disease have not been previously described. This study presents the first description of therapeutic procedures created with the own algorithm whose effectiveness is verified by results of comparative clinical and neurophysiological studies in three groups of patients. Among clinical examinations, especially visual analog scale of pain intensity, incidence of positive Spurling’s test, painful elongation of trapezius muscle and the number of detected trigger points together with results of neurophysiological evaluation by means of surface electromyography (sEMG) and electroneurography (ENG) differentiated patients with myofascial pain syndrome, disk-root conflict and degenerative spine disease at cervical spine.¹ It can be hypothesized that presented methods of therapy can be recommended and applied in the general medical practice. The choice of the most effective rehabilitation should be based on data from complex clinical and neurophysiological studies.

The aim of this study was to compare the early effects of supervised and unsupervised rehabilitation treatment in patients with myofascial pain syndrome, disk-root conflict and degenerative spine disease changes at cervical level before and after treatment.

Materials and methods

The study was planned and conducted in accordance with the guidelines of the Helsinki Declaration, and it was approved by the Bioethics Committee at the University of Medical Science (No. 671/16). Each patient and healthy volunteer was informed about the aim of study and gave written consent for examinations and data publication. The study was conducted from January 2016 to November 2017 in Clinical Orthopedic and Rehabilitation Hospital.

Study design, patients and treatment

The preliminary recruitment of patients qualified 334 cases with the diagnosis of cervical neck pain. Forty patients did not fulfill main inclusion criteria (chronic cervical pain which lasted not less than 6 months, restricted to the neck and shoulder girdle area, temporary radiating to only one of the upper extremities). Pregnant women, patients with oncological or epilepsy episodes, neurological disorders such as strokes, plexopathies, inflammatory diseases, previous cervical spine injuries or myelopathies and patients with implants were excluded from the study. Next 16 patients were randomly excluded in order to create three equal subgroups. Finally, patients with clinically, radiologically and neurophysiologically confirmed myofascial pain syndrome (n = 60), disk-root conflict at C5C7 cervical spine (n = 60) and cervical degenerative spine disease (n = 60) participated in the study. Each group was blindly randomized to two equal subgroups of 30 subjects each by an independent person. One of the subgroups underwent the 20-day supervised rehabilitation treatment with the assistance of qualified physiotherapist (with more than 10 years of clinical experience). Patients of the second subgroup were instructed once to perform a certain set of exercises at home for 20 days without professional assistance. The exercise booklet was handed to every patient from the second subgroup where principles, intensities and frequencies of exercises were prescribed. In general, exercises were performed once a day, 5 days a week.

Myofascial pain syndrome subgroup included 60 patients (35 women and 25 men aged 34–51 years, mean of 40.5 ± 5.5), mainly office workers with the same full-time employment for 3 years, working minimum 5 h a day. Cervical disk-root conflicts subgroup included 60 patients (19 women and 41 men aged 42–63 years, mean of 52.2 ± 7.7), as well as another subgroup with the cervical degenerative spine disease (27 women and 33 men aged 49–73 years, mean of 60.3 ± 9.1), professionally active, half of them were office workers (using computers 5.5 h a day), the rest were physical workers. Diagram of diagnostic and therapeutic protocol used in the research is presented in Figure 1.

Figure 1.

Diagram of diagnostic and therapeutic protocol used in the research.

Clinical and neurophysiological evaluation

The set of clinical and neurophysiological studies important for differential diagnosis was performed twice, before and after 20 days of supervised or unsupervised therapy to compare their effectiveness in each of subgroups of patients.

According to previous report,¹ clinical assessment included evaluation of pain intensity with visual analog scale, positive results of Spurling’s test (ipsilateral pain in the cervical spine radiating over dermatomes C5C7 during head rotation), presence of pain during passive trapezius muscle elongation and presence of active trigger points in trapezius muscle. The superficial sensory perception was evaluated with von Frey’s filaments with reference to the dermatomal innervation of median nerves (C6C7 neuromers).

Neurophysiological studies included sEMG recordings of muscles motor units activity and ENG of neural impulses transmission in nerves. Evaluation of sensory perception was performed with chronaxymeter in IC-SD examinations (intensity of current vs stimulus duration method).^8,9

sEMG recordings from trapezius, biceps brachii and abductor pollicis brevis muscles were performed both at rest (rEMG) and during their maximal contraction (mcEMG) lasting 5 s. The parameter of average amplitude was analyzed.⁹

ENG examinations of motor fibers transmission within median nerves were performed (F and M waves). Nerves were stimulated at pre-wrist area; evoked potentials were recorded from abductor pollicis brevis muscles. M-waves amplitudes and corresponding conduction velocities of nerve impulses were calculated to assess peripheral transmission in nerve fibers. F-waves frequencies (during 20 positive recordings of M waves) were analyzed to ascertain transmission in C5C7 ventral roots.

The threshold perception and afferent transmission in IC-SD examinations were measured following application of electrical stimuli to the body areas innervated by median nerve. There was a five-score scale created allowing for the interpretation of results (5: proper sensory perception, 4: lowered but in physiological limit—slightly limited, 3: decreased, 2: significantly decreased, 1: abolished).

The reference values for the same set of examinations (both clinical and neurophysiological) used for studies in the patients were obtained from 30 healthy subjects with similar demographic and anthropometric properties.

Rehabilitation protocol

Sets of certain physiotherapeutic procedures applied to the patients during their treatment are listed in Table 1.

Table 1.

Subsequent physiotherapeutic procedures applied to the patients during treatment.

Groups of patients	MPS	DRC	DSD
Supervised group (applied procedures)	Myofascial relaxation—trigger point inactivation (Figure 2(A))	Myofascial relaxation—trigger point inactivation (Figure 2(A))	Myofascial relaxation—trigger point inactivation (Figure 2(A))
	Postisometric relaxation (Figure 2(B))	Postisometric relaxation (Figure 2(B))	Postisometric relaxation (Figure 2(B))
	Active exercises without resistance (Figure 2(Ca) and (Cb))	Constant spine traction (Figure 2(I))	Passive range of movement exercises performed by physiotherapist (Figure 2(Fa) and (Fb))
	Isometric exercises (Figure 2D)	Active exercises without resistance (Figure 2(Ca) and (Cb))	Active exercises without resistance (Figure 2(Ca) and (Cb))
	Strengthening exercise using the elastic band (Figure 2(E))	Isometric exercises (Figure 2(D))	Isometric exercises (Figure 2(D))
	Self-control exercises of the correct body posture (Figure 2(Ja) and (Jb))	Strengthening exercise using the elastic band (Figure 2(E))	Strengthening exercise using the elastic band (Figure 2(E))
		Self-control exercises of the correct body posture (Figure 2(Ja) and (Jb))	Self-control exercises of the correct body posture (Figure 2(Ja) and (Jb))
Unsupervised group (applied procedures)	Postisometric relaxation (Figure 2(B))	Postisometric relaxation (Figure 2(B))	Postisometric relaxation (Figure 2(B))
	Active exercises without resistance (Figure 2(Ca) and (Cb))	Active exercises without resistance (Figure 2(Ca) and (Cb))	Active exercises without resistance (Figure 2(Ca) and (Cb))
	Isometric exercises (Figure 2(D))	Head protraction and retraction according to McKenzie therapy (Figure 2(Ga) and (Gb))	Self-supported full range of movement exercises (Figure 2(H))
	strengthening exercise using the elastic band (Figure 2(E))	isometric exercises (Figure 2(D))	isometric exercises (Figure 2(D))
	Self-control exercises of the correct body posture (Figure 2(Ja) and (Jb))	Strengthening exercise using the elastic band (Figure 2(E))	Strengthening exercise using the elastic band (Figure 2(E))
		Self-control exercises of the correct body posture (Figure 2(Ja) and (Jb))	Self-control exercises of the correct body posture (Figure 2(Ja) and (Jb))

MPS: myofascial pain syndrome; DRC: disk-root conflict; DSD: degenerative spine disease.

Depending on the evaluated symptoms (results of diagnostic examinations) in three groups of patients, a certain therapeutic algorithm (set of procedures) was applied (Figure 2). In patients with myofascial pain syndrome, techniques aimed at relaxation of the tensed muscles were predominant. Once this effect was reached, the strengthening exercises were introduced. In patients with disk-root conflict, tractions of spine were additionally applied to reduce the compression of the nerve root by the herniated disk. After the acute root symptoms disappeared, similarly like in myofascial pain syndrome group, the strengthening exercises were introduced. In patients from degenerative spine disease group, regardless of muscle relaxation techniques, exercises aimed at improving the range of spinal mobility were applied. In the following, strengthening exercises of the paraspinal muscles were recommended. In all three groups, correct posture exercises were introduced. Some techniques had to be performed by a physiotherapist (supervised subgroup), and others could be used routinely by a patient at home after instruction (nonsupervised subgroup).

Figure 2.

Photographs presenting principles of applied physiotherapeutic procedures in supervised and unsupervised groups of patients. A—myofascial relaxation—trigger point inactivation, B—postisometric relaxation, Ca,b—active exercises without resistance, D—isometric exercises, E- strengthening exercise using the elastic band, Fa,b—passive range of movement exercises performed by physiotherapist, Ga,b—head protraction and retraction according to McKenzie therapy, H—self-supported full range of movement exercises, I—constant spine traction, Ja,b—self-control exercises of the correct body posture.

Statistical analysis

Descriptive statistics included mean values and standard deviations (SDs) for measurable variables while the frequency of incidence was ascertained for categorical variables. For description of ordinal scale variables, minimal and maximal values and median values were used.

The normality distribution and homogeneity of variances were studied with Shapiro-Wilk and Leven’s tests. Lack of data normal distribution required applying the Mann–Whitney U test for evaluation of statistical significance of differences between results recorded in patients and healthy volunteers, and among the three groups of patients.

Analysis of variance (ANOVA) procedures were applied for comparison of results obtained in three groups of patients before versus after treatment with normal distribution of data. Otherwise, the non-parametric Friedman-ANOVA and Mann–Whitney tests were used. Only significant differences at P ⩽ .05 were presented in Results section. The statistical software Statistica version 10.0 was used to determine the required sample size using the primary outcome variable sEMG recordings from trapezius muscle performed at rest (rEMG) before and after treatment with a power of 80% (β = 0.2) and a significance level of 0.05 (two-tailed). In the previous study,¹ this variable parameter was found to be a sensitive marker in evaluation of muscles’ dysfunction in patients with myofascial pain syndrome, degenerative changes and disk-root conflict at cervical spine. The mean and SD was calculated using the data from the first seven subjects in the supervised and unsupervised subgroups from the disk root conflict group. We also calculated the required sample size with the minimal number of participants in one of the three groups, and it should have been 60 and 30 in subgroups regarding supervised and unsupervised treatment each.

All statistical analyses were performed with the use of Statistica software version 10.0 (StatSoft, Poland) and Cytel Studio StatXact version 9.0 (Cytel Software Corporation).

Results

Clinical evaluation of treatment efficiency (results before vs after treatment)

Twenty-day supervised treatment brought the most significant decrease in pain intensity (visual analog scale score) in patients from disk-root conflict group (P = .001) (Table 2). The number of Spurling’s symptoms significantly decreased (at P = .008) in the same patients who underwent supervised treatment. In myofascial pain syndrome and disk-root conflict groups, the supervised therapy brought decrease of painful muscle elongation frequency and number of active trigger points in trapezius muscle at P = .009 and .03, respectively, after application of supervised therapy.

Table 2.

Results of clinical and neurophysiological studies. Median values are presented in parentheses. P values are presented when differences were ascertained between two subgroups of patients.

Test	Myofascial pain syndrome after randomization before treatment, n = 60		Myofascial pain syndrome after treatment, n = 60		Disk-root conflict after randomization before treatment, n = 60		Disk-root conflict after treatment, n = 60		Degenerative spine disease after randomization before treatment, n = 60		Degenerative spine disease after treatment, n = 60
Test	Supervisedn = 30	Unsupervisedn = 30	Supervisedn = 30	Unsupervisedn = 30	Supervisedn = 30	Unsupervisedn = 30	Supervisedn = 30	Unsupervisedn = 30	Supervisedn = 30	Unsupervisedn = 30	Supervisedn = 30	Unsupervisedn = 30
VAS (0–10)	0–8(2)	0–7(2)	0–3 (1), P = .05	0–7(4), P = .03	0–8(5)	0–7(5)	0–6 (3), P = .001	0–7(5)	0–5(3)	0–6(3)	0–4 (2), P = .05	0–5 (4), P = .05
Spurling’s symptom	n = 0, 0%	n = 0, 0%	n = 0, 0%	n = 0, 0%	n = 18, 60%	n = 16, 53.3%	n = 9 30%, P = .008	n = 15, 50%	n = 12, 40%	n = 14, 46.6%	n = 10, 33.3%	n = 12, 40%
Painful passive elongation of trapezius muscle	n = 30, 100%	n = 30, 100%	n = 5 16.6%, P = .009	n = 26, 86.6% P = .05	n = 3, 10%	n = 5, 16.6%	n = 2, 6.6%	n = 6, 20%	n = 2, 6.6%	n = 2, 6.6%	n = 0, 0%	n = 2, 6.6%
Trigger points in trapezius muscle	n = 30, 100%	n = 30, 100%	n = 6, 20%, P = .009	n = 27, 90%	n = 9, 30%	n = 7, 23.3%	n = 4, 13%, P = .03	n = 9, 30%	n = 4, 13.3%	n = 4, 13.3%	n = 3, 10%	n = 4, 13.3%
EMG amplitude at rest (µV): trapezius muscle-biceps brachii muscle-abductor pollicis brevis muscle	30 ± 815 ± 416 ± 4.1	29 ± 7.216 ± 3.615 ± 3.6	20 ± 3.6, P = .02 16 ± 4.216 ± 5.3	28 ± 6.216 ± 3.717 ± 3.9	23 ± 4.125 ± 4.324 ± 5.2	23 ± 5.123 ± 4.424 ± 4.6	20 ± 4.917 ± 4.1, P = .02 18 ± 4.2 P = .02	22 ± 4.323 ± 3.824 ± 2.2	22 ± 3.423 ± 5.021 ± 4.5	22 ± 4.124 ± 3.922 ± 6.0	20 ± 5.018 ± 4.1, P = .04 18 ± 5.2 P = .05	23 ± 5.224 ± 4.923 ± 5.2
EMG amplitude during maximal contraction (µV): trapezius muscle-biceps brachii muscle-abductor pollicis brevis muscle	457 ± 135923 ± 2761357 ± 478	461 ± 165911 ± 2491391 ± 412	592 ± 148, P = .02 985 ± 2421366 ± 452	475 ± 113912 ± 2351299 ± 462	492 ± 150521 ± 219835 ± 315	490 ± 151523 ± 221829 ± 318	502 ± 139789 ± 203, P = .05 1200 ± 225 P = .001	495 ± 142582 ± 245880 ± 229	519 ± 124539 ± 207932 ± 281	520 ± 123541 ± 209949 ± 287	550 ± 119700 ± 192, P = .05 1100 ± 242, P = .03	539 ± 198603 ± 183891 ± 223
ENG M-wave amplitude (µV) median nerve	9492 ± 2215	9522 ± 2335	9327 ± 2325	9421 ± 2424	2889 ± 1526	2922 ± 1479	3050 ± 1425	3102 ± 1348	3511 ± 1551	3507 ± 1499	3822 ± 1238	3498 ± 1211
ENG M-wave conduction velocity (m/s): -median nerve	51.7 ± 2.8	49.5 ± 2.3	51.2 ± 2.2	50.4 ± 2.6	46.3 ± 2.2	47.1 ± 1.9	49.9 ± 2.7	48.9 ± 2.1	48.1 ± 2.7	48.6 ± 4.1	49.7 ± 2.3	48.1 ± 3.8
ENG F-wave frequency: median nerve	17	18	18	18	12	11	16, P = .05	12	14	15	15	15
IC-SD index(1–5): median nerve	4–5(5)	4–5(5)	4–5(5)	4–5(5)	2–5(3)	2–5(3)	2–5 (4), P = .05	2–5(3)	4(2–5)	4(1–5)	3–5 (5), P = .05	2–5(4)
FvF index (0–2): median nerve	1–1(1)	1–1(1)	1–1(1)	1–1(1)	0–1 (0)	0–1 (0)	0–1 (1), P = .05	0–1 (0)	0–1(1)	0–1(1)	0–1(1)	0–1(1)

VAS: visual analog scale; EMG: electromyography; ENG: electroneurography; P: significant differences before vs after treatment; IC-SD: index (1–5): 5 = proper sensory perception, 4 = lowered but in physiological limit—slightly limited, 3 = decreased, 2 = significantly decreased, 1 = abolished; FvF index (0–2): 0 = analgesia, 1 = proper sensory perception, 2 = hyperesthesia.

Unsupervised therapy in patients from myofascial pain syndrome and degenerative spine disease groups caused significant increase of visual analog scale score at P = .05. Unsupervised therapy led also to increase of the painful muscle elongation frequency in patients with myofascial pain syndrome (P = .05).

Neurophysiological evaluation of treatment efficiency (results before vs after treatment)

Decrease of resting amplitude parameter in electromyographical recordings from trapezius muscle in patients with myofascial pain symptom after supervised therapy was detected at P = .02 (Table 2). Both recordings from biceps and abductor pollicis brevis muscles also revealed the significant decrease of resting sEMG amplitude parameter in supervised patients from other two studied groups. Decrease of rEMG amplitude corresponded to significant increase of mcEMG amplitude in recordings during the maximal contraction in the same muscles of the patients from three supervised treated groups (P from .05 to .001).

No significant changes after therapy in the motor fibers transmission (amplitudes of M-wave recordings in ENG studies and corresponding conduction velocities) of the median nerve were found in all patients. On the other hand, electroneurographical recordings of F-waves frequencies showed significant improvement (at P = .05) of C5C7 ventral roots motor fibers neural transmission only after supervised treatment of patients from disk-root conflict group.

Sensory perception studies results referring to median nerve fibers in IC-SD and FvF tests improved at P = .05 after supervised treatment in patients from disk-root conflict and degenerative spine disease groups.

Patients after treatment vs healthy subjects

In general, the supervised treatment was more effective than unsupervised one considering results from clinical and neurophysiological evaluation (Table 3). However, application of both therapy modalities did not bring about full relief from pain symptom in three groups of patients (P from .05 to .01). Spurling’s symptom was still present after therapy in groups of patients with disk-root conflict and degenerative spine disease (P from .005 to .009). Incidence of painful passive elongation of trapezius muscle was recorded only after unsupervised treatment of patients with myofascial pain symptom at P = .003. Presence of active trigger points was detected after unsupervised therapy in patients with myofascial pain symptom (P = .005) and disk-root conflict (P = .01).

Table 3.

Comparison of results from clinical and neurophysiological studies in patients versus healthy volunteers. Mean values with standard deviations or median values are presented.

Test	Reference values (healthy volunteers), n = 30	Myofascial pain syndrome after treatment, n = 60		Disk-root conflict after treatment, n = 60		Degenerative spine disease after treatment, n = 60
Test	Reference values (healthy volunteers), n = 30	Supervised, n = 30	Unsupervised, n = 30	Supervised, n = 30	Unsupervised, n = 30	Supervised, n = 30	Unsupervised, n = 30
VAS (0–10)	0	0–3 (1), P = .05	0–7 (4), P = .01	0–6 (3), P = .02	0–7 (5), P = .01	0–4 (2), P = .03	0–5 (4), P = .01
Spurling’s symptom	n = 0, 0%	n = 0, 0%	n = 0, 0%	n = 9, 30%, P = .005	n = 15, 50%, P = .009	n = 10, 33.3%, P = .008	n = 12, 40%, P = .009
Painful passive elongation of trapezius muscle	n = 6, 20%	n = 5, 16.6%	n = 26, 86.6%, P = .003	n = 2, 6.6%	n = 6, 20%	n = 0, 0%, P = .05	n = 2, 6.6%
Trigger points in trapezius muscle	n = 2, 3.3%	n = 6, 20%	n = 27, 90%, P = .005	n = 4, 13%	n = 9, 30%, P = .01	n = 3, 10%	n = 4, 13.3%
EMG amplitude at rest (µV): trapezius muscle-biceps brachii muscle-abductor pollicis brevis muscle	20 ± 3.717 ± 3.318 ± 4.7	20 ± 3.616 ± 4.216 ± 5.3	28 ± 6.2 P = .05 16 ± 3.717 ± 3.9	20 ± 4.917 ± 4.118 ± 4.2	22 ± 4.323 ± 3.824 ± 2.2	20 ± 5.018 ± 4.118 ± 5.2	23 ± 5.224 ± 4.9, P = .04 23 ± 5.2, P = .05
EMG amplitude during maximal contraction (µV): trapezius muscle-biceps brachii muscle-abductor pollicis brevis muscle	586 ± 107993 ± 3221337 ± 456	592 ± 148985 ± 2421366 ± 452	475 ± 113, P = .04 912 ± 2351299 ± 462	502 ± 139, P = .05 789 ± 203, P = .04 1200 ± 225, P = .04	495 ± 142, P = .05 582 ± 245, P = .02 880 ± 229, P = .02	550 ± 119700 ± 192, P = .02 1100 ± 242, P = .03	539 ± 198603 ± 183, P = .03 891 ± 223, P = .01
ENG M-wave amplitude (µV): median nerve	9533 ± 2009	9327 ± 2325	9421 ± 2424	3050 ± 1425, P = .01	3102 ± 1348, P = .01	3822 ± 1238, P = .01	3498 ± 1211, P = .01
ENG M-wave conduction velocity (m/s): median nerve	51.0 ± 2.5	51.2 ± 2.2	50.4 ± 2.6	49.9 ± 2.7	48.9 ± 2.1	49.7 ± 2.3	48.1 ± 3.8
ENG F-wave frequency: -median nerve	18	18	18	16, P = .05	12, P = .04	15, P = .05	15, P = .05
IC-SD index (1–5): median nerve	4–5 (5)	4–5 (5)	4–5 (5)	2–5 (4), P = .05	2–5 (3), P = .04	3–5 (5)	2–5 (4), P = .05
FvF index (0–2): median nerve	1–1 (1)	1–1 (1)	1–1 (1)	0–1 (1)	0–1 (0), P = .05	0–1 (1)	0–1 (1)

VAS: visual analog scale; EMG: electromyography; ENG: electroneurography; P: significant differences healthy volunteers vs patients after treatment.

Abnormalities in activity of muscle motor units at rest were recorded in trapezius muscle after unsupervised treatment of patients from myofascial pain syndrome group at P = .05 and in biceps and abductor pollicis brevis muscles in cases of patients with degenerative spine disease (P at .04 and .05 respectively). Effectiveness of treatment was the least in all patients with disk root conflict taking into account results of mcEMG tests (see Table 2). Also in all patients with degenerative spine disease, the amplitudes of mcEMG recordings still indicated for abnormalities of motor units’ activity of biceps and abductor pollicis brevis muscles after application of both treatment modalities. In patients with myofascial pain syndrome, only supervised treatment led to normalization of all muscles contractile properties.

ENG and sensory perception studies results were found to be normal only in patients with myofascial pain syndrome after both kinds of treatments in comparison to results recorded in healthy subjects.

Discussion

Available literature from the previous years did not provide sufficient data on the effectiveness of directed, complex kinesitherapeutic treatment in patients with different clinical symptoms commonly termed as the chronic neck pain.^10,11 In these cases, a supervised or unsupervised manner of treatment was used. Usually one kinesitherapeutic procedure was applied and its effectiveness was verified without respect to origin of pain and the associated main symptoms. Therapy supervised by the physiotherapist was realized rarely regardless of whether the performed exercises by patient were active or passive in their nature. Unsupervised therapy was performed by the patient himself and consisted of performing the exercises presented earlier by the physiotherapist. From clinical and practical point of view such a therapy does not guarantee positive results, considering correctness and regularity of performed exercises. During analysis of available literature and considering facts mentioned above, it is not surprising that researchers did not prove the supremacy of one, universal procedure over the others with results of clinical and electromyographical studies. This refers to the studies of Griffiths et al.¹² verifying effectiveness of stabilizing exercises, posture corrective exercises and full range of cervical spine movement exercises in patients treated because of chronic pain without constant physiotherapeutic supervision. Hakkinen et al.¹³ did not find difference in effects of 12 months of applied home-based autotherapy with stretching exercises for neck muscles compared to the same system of treatment supplemented with strength training. It can be assumed that the main reason was lack of a physiotherapist’s assistance. Moreover, these authors (contrary to our concept) did not consider the origin of neck pain and did not guide the physiotherapeutic procedures. Similarly, Jull et al.¹⁴ did not differentiate in neurophysiological studies the effectiveness of two exercises, low-load cranio-cervical flexion and neck flexor strengthening exercises. It is worth stressing, however, that also in this case there was no permanent physiotherapeutic supervision over the performed exercises.

Due to the multifactorial nature of neck pain and its difficulty in treatment, the medical process should consist of continuous monitoring the clinical status in terms of therapeutic effects. The diagnostic and therapeutic protocol used in this study has been presented in Figure 1. The statistics presented in this article confirm (Table 3) that treatment outcomes are different in patients with three different diseases, indicating a significant effect of the origin of pain on the effectiveness of the therapies used. Furthermore, evidently, the supervised rehabilitation has always been more effective than the unsupervised one (Table 3). This is especially true for patients with myofascial pain syndrome, where, mainly due to the difference in supervised and unsupervised myofascial relaxation procedures, we observed a reduction in pain intensity in the supervised group, and the number of trigger points in trapezius muscle, muscle tension and consequent improvement in activity of motor units during contraction (see Table 2). Such complex, clinical and neurophysiological evaluation of multi-component improvement therapy has not yet been presented in the literature.

In disk-root conflict patients, the use of supervised myofascial relaxation and constant spine traction as procedures to differentiate both evaluated treatment systems resulted in decreased pain intensity, improving the sensory perception in referred dermatomes, reduced incidence of Spurling’s symptoms and active trigger points. Recovery of muscle function at rest and during maximal contraction was parallel to improvement in neural transmission of impulses at C5C7 ventral roots observed in neurophysiological tests (Tables 2 and 3). Similar studies have not yet been presented in literature.

In the disk-root conflict patients, procedures that differed supervised and unsupervised treatments were myofascial relaxation and passive range of movement exercises. Advantage of supervised exercised was documented mainly in results of comparative neurophysiological tests. This may prove to be a difficulty in successfully managing advanced degenerative changes in the cervical spine, which is commonly observed in clinical practice. Also, studies on the effects of kinesitherapy on neck pain relief in patients with disk-root conflict have not been published.

Twenty-day more supervised than unsupervised rehabilitation makes the health status of patients with cervical pain closer to healthy subjects (Table 3). To our knowledge, proposed description by us is the first which presents in details principles of physiotherapeutic treatment in cases of patients with cervical pain with examples of certain procedures and verification of their effectiveness. The limitation of the study was the inability to check the correctness of performed physiotherapeutic exercises carried out by patients from the unsupervised group at home. It was also difficult to compare results obtained in this study with that from other centers because of the lack of available data on this issue. Even after careful and repeated searches, we couldn’t find descriptions of study results comparing effects of rehabilitation in patients treated for myofascial pain syndrome, disk-root conflict, and degenerative spine diseases at cervical level.

The preliminary statistical power analysis showed that the minimum required was 80%. We also calculated the required sample size with the minimal number of participants in one of the three groups, and it should have been 60 and 30 in subgroups regarding supervised and unsupervised treatment each. We stated that the samples sizes in our study were correct so it may not limit the confidence of study results.

Conclusion

Results of this study lead to the conclusion that the procedure of myofascial relaxation of dysfunctional muscles should mandatorily initiate sequential kinesitherapeutic algorithms used in treatment of etiologically different neck pain syndromes. Improvements in clinical and neurophysiological studies successively in patients with myofascial pain syndrome, disk-root conflict and degenerative spine disease confirm the appropriateness of the therapy used; however, in the short-term assessment, there was no overall normalization of the results. Further studies should analyze longer treatment periods and possible variants of the procedures used. Currently, based on the results obtained, the supremacy of the supervised treatment was confirmed.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Juliusz Huber

References

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