Effects Of 6-Week Telerehabilitation Exercise Programme On Chronic Non-Specific Neck Pain In Women: A Pilot Randomized Controlled Trial

Introduction

Chronic non-specific neck pain is a growing problem affecting almost 50% of adults in the general population. According to Goode et al. (2010), the majority of individuals with this musculoskeletal illness either never respond to treatment or never find a way to manage their pain, which has a detrimental effect on their ability to work and lead a normal life.¹ Several studies have identified multiple risk factors for neck pain. These include causes such as excessive physical demands at work, unsuitable workplace conditions, psychosocial factors (including stress and anxiety), sleep deprivation, recurrent chronic low back pain, and female sex.^2,3 In general, females are associated with a higher prevalence of pain when compared to males. This has been linked to various psychosocial influences, including views and approaches concerning health, feeling more disagreeable towards pain, greater exposure to psychological distress, and unintentional prejudice among healthcare providers.^3,4 Moreover, the global burden of neck pain, in terms of years lived with a disability, is far greater in women than in men.⁵

The benefits of physical therapy on the intensity of pain experienced, degree of disability, and cervical range of motion (CROM) are becoming increasingly evident. Strengthening exercises, endurance exercises, stretching, and postural education are types of training included in these exercise programmes.⁶ Moreover, active exercise training has been shown to improve the strength of the neck musculature.⁷ Considering that a large part of the exercise programme consists of self-management, in terms of administering the exercises themselves, education, awareness, and lifestyle changes,⁸ home-based exercises are recommended, particularly in those who suffer from chronic pain.⁹ The exercises are taught to the patient, and they are encouraged to follow all the advice provided by the physiotherapist; however, the adherence of patients to these programmes often poses an obstacle to relief from chronic pain.¹⁰ Home-based exercise programmes have shown similar improvements in pain, disability, and cervical muscle endurance compared with supervised exercise programmes.^11,12

In recent decades, exercise programmes that are patient-suitable, time-efficient, and cost-effective have become much greater in demand.¹³ Moreover, in light of the global circumstances raised by the COVID-19 pandemic, telerehabilitation interventions—which are currently getting widely popular—have been chosen in this context.¹⁴ The advantages of this method of delivering healthcare have been demonstrated in numerous studies with a particular focus on patient adherence to treatment.¹² CareSpace software, in collaboration with the Connect2MyDoctor application, was adopted as a means of telerehabilitation in this study. CareSpace Inc.¹⁵ is a US-based multinational digital health company that offers an online platform for patient care management. The facility of this platform to digitize musculoskeletal care via a mobile or webcam powered by visual (AI-powered) learning to measure, record, and recommend personalized care pathways to improve outcomes on the population health scale was utilized based on the requirements of this study for recording exercise sessions.

A potential solution to patients not adhering to prescribed exercise regimens could be telerehabilitation. Due to its advantages in terms of patient adherence, cost-effectiveness, and convenience, healthcare professionals are encouraged to implement this type of intervention, which might be extended to in-patient care. For individuals suffering from chronic non-specific neck pain, telerehabilitation can guarantee the effectiveness of following exercise sessions and, consequently, of the treatment programme itself. The purpose of this study is to determine the effectiveness of telerehabilitation exercise intervention is in females with chronic non-specific neck pain, via measuring the pain score, disability index, CROM, cervical muscle endurance and their adherence to the exercise programme. It is hypothesised that there would be notable improvements in pain score, disability index, CROM, cervical muscle endurance in both groups suffering from chronic non-specific neck pain, but telerehabilitation exercise programme would result in greater improvements in all outcome measures, and particularly better patient adherence, as compared to conventional exercise programme.

Methods

Sample

Convenience sampling was selected for this study. Based on the effect size of 0.95 utilizing the VAS mean and standard deviation values, alpha error of 5%, study power of 80%, and allocation ratio of 1, a total sample size of 30 participants was deemed suitable.¹² Considering that this was a pilot study, 30 participants were anticipated (15 for each group). The final study sample included 31 participants (15 in the TR and 16 in the CG), as shown in Figure 1. Recruited participants were included in this study based on the following criteria: (1) residents of the UAE, only females; (2) aged between 18 and 45 years; (3) had normal BMI: 18.5 – 24.9 kg/m²¹⁶; (4) referred to physiotherapy by an orthopedic surgeon for chronic non-specific neck pain; (5) a minimum pain score of 3 cm on the VAS Pain (Visual Analog Scale for Pain); (6) pain onset at least 3 months ago; and (7) provided informed verbal and written consent for voluntary participation. The exclusion criteria were as follows: (1) diagnosis by an orthopedic surgeon with any pathological condition as the cause of chronic neck pain; (2) presently undergoing any physical treatment or taking any medication for said pain; (3) comorbidities such as diabetes and hypertension; (4) conditions such as migraine and cervicogenic headache; (5) vertigo and/or vertebrobasilar insufficiency; (6) physically disabled or recently immobilizing injury; (7) orthopaedic conditions, such as spondylosis, spondylolisthesis, wryneck; (8) current pregnancy; and (9) history of neurological conditions.

Figure 1. Consolidated standards of reporting trials flow diagram.

Results

All participants (females) completed the 6-week intervention (15 in the TR and 16 in the CG). Table 1 presents baseline demographics and participant characteristics. The mean age was 22.7 ± 2.1 years and all participants had a normal BMI (mean 22.3 ± 2.8 kg/m²). Both groups showed no significant differences in the baseline values of demographic data and all outcome measures, as concluded from the independent sample t-tests (p < 0.05). The mean pain score on VAS Pain was 5.2 ± 1.7 cm (5.1 ± 1.9 cm for TR and 5.3 ± 1.5 cm for CG). The mean NDI was 6.3 ± 2.0 (5.7 ± 1.9 for TR and 6.9 ± 1.9 for CG). The Shapiro–Wilk’s test (p<0.05) was performed to confirm the normal distribution of the data.

To compare the adherence of the participants to the exercise programme, independent samples t-tests (p < 0.05) were carried out based on the mean changes in the number of sessions completed and the average duration of each session. While the number of sessions completed was not significantly different between the groups, it was found that TR followed through for a significantly longer duration of each session (p = 0.02) than CG ( Table 2).

Based on mixed-model ANOVA measures, statistical significance was found in both within-group comparisons, in favor of the exercise programme, for all variables (p < 0.05). TR showed a significantly greater increase in cervical rotation ROM R (0.006) and L (0.03) post-exercise programmes than CG. Between-group comparisons of all other variables showed no significant differences. A large, significant effect on pain score, disability index, cervical flexion, right lateral flexion, and right rotation ROM was found in both groups post-treatment, whereas medium effects on cervical extension, left lateral flexion and left rotation ROM, and cervical muscle endurance were observed. When looking at between-groups values, large effect on pain score (0.14) and disability index (0.17) was found in favor of telerehabilitation ( Table 3). Line graphs depicting the profile plots of the estimated marginal means for all the variables are shown in Figure 2.

Figure 2. Line graphs depicting profile plots of estimated marginal means.

(A) VAS Pain. (B) NDI score. (C) Cervical flexion ROM. (D) Cervical extension ROM. (E) Cervical R lateral flexion ROM. (F) Cervical L lateral flexion ROM. (G) Cervical R rotation ROM. (H) Cervical L rotation ROM. (I) CCFT.

Discussion

This study aimed to investigate the effects of home-based exercise programmes for chronic non-specific neck pain, based on the mode of delivery. Comparisons were made based on neck pain, disability, cervical ROM, cervical muscle endurance, and adherence to the exercise programme. It is known that physiotherapy interventions consisting of strengthening and stretching exercises result in the reduction of neck pain and disability, as well as an enhancement in cervical ROM and cervical muscle endurance.^26–28

Based on our findings, both groups showed significant improvements in neck pain upon successful completion of the prescribed home-based exercise programme. In addition to improvement in self-reported pain, disability experienced as assessed by the NDI also reduced, similar to the findings of previous studies conducted on individuals with chronic non-specific neck pain, by utilizing telerehabilitation.^11,29 Moreover, when comparisons were drawn between the results of both groups, the telerehabilitation group proved to be non-inferior to the conventional group in positively influencing neck pain and disability, in addition to large effect size for pain score and disability index in favour of telerehabilitation.^30,31

Cervical ROM was assessed in terms of cervical flexion, extension, lateral flexion, and rotation on both sides.³² Post-exercise measurements for both groups exhibited an increase in all values of cervical ROM, similar to findings from other studies.^3,33 Both groups presented a significant increase in cervical muscle endurance based on the findings of CCFT; however, no group was found superior to the other in this regard. This finding is in line with that of a study conducted by Ozer et al. (2021). Notably when it comes to improving posture and relieving chronic neck pain, exercises that target the activation of the deep flexor muscle of the neck (such as chin tucks and chin tucks with overpressure) have demonstrated superior outcomes compared to general strengthening exercises.³⁴ This is explained by findings that reveal that cervical muscles that have undergone strength training in addition to endurance training and stretching demonstrate increases in motor unit recruitment, firing rate per unit, and capillarization, all of which result in an increase in the strength and endurance of the cervical musculature.^7,35 Our findings suggest that telerehabilitation provides meaningful clinical improvement in patient symptoms, unlike previous studies.¹³ Healthcare providers and patients alike can be encouraged to consider this mode of treatment delivery when access, time, and costs pose difficulties.^8,31

Regarding adherence to the exercise programme, both methods of treatment delivery were feasible since, overall, both groups showed good compliance with the frequency of sessions (3 times a week for 6 weeks). When looking at adherence to session duration, our study found that TR had longer sessions on average than CG. This may be owed to the video recording and monitoring facilities available from the telerehabilitation software that enable the therapist to review the entire session.^10,36,37 However, both groups exhibited shorter exercise durations than the recommended duration of 30 minutes,³⁸ possibly due to time constraints, busy lifestyles, or experiencing improvement in symptoms even with a shorter session duration.

The effect of confounders cannot be ignored when comparing all variables, particularly pain, as it was the main outcome measure in this study. The diet of an individual is a variable confounding factor that can affect the neck pain experienced by them, which was not anticipated.^39,40 Another such factor is sleeping position, as it is known to greatly affect the intensity of pain, especially waking pain and perceived severity of disability.^41,42 Additionally, anxiety and depression have been identified as psychosocial factors that alter the pain perception of those affected by it.^43,44 Physical activity and chronic pain sensitivity have also been associated in recent studies, particularly in women.^45,46 Moreover, some participants may have used a cervical collar without informing the researcher, which may have influenced the amount of pain felt.

Raising awareness of healthy and active lifestyles is key to a person’s general well-being and is crucial in managing any type of chronic pain. Particularly in cases where people find healthcare inaccessible owing to distance, time, or high costs, telerehabilitation-based care can prove to be quite effective and long-lasting.^12,47 All participants were given general advice after completing the 6-week exercise programme. These included ergonomic training, education about sleeping and sitting posture, and advice to continue with recommended exercises from the home programme, along with general fitness topics.^9,47 Considering that a large proportion of participants in this age group spent long hours using a computer, sitting at a desk posture was explained to them, such as the use of a spinal support chair, distance between eye and monitor, adjusting the desk height so that the forearms could rest on the surface, adjusting the chair height so that the feet could rest on the floor, etc.^48,49 Moreover, the importance of comfortable sleeping posture in either supine or side-lying, with appropriate neck support, was elaborated, in addition to the use of a good pillow with the right amount of thickness (10-12 cm) and firmness.^42,50

For those suffering from chronic non-specific neck pain, especially females, this mode of exercise delivery brings about the success of exercise sessions in terms of symptom improvement as well as increased cervical muscle ROM and endurance. Based on these results, especially considering adherence, treatment is favourable for TR. Telerehabilitation, due to its benefits of increased patient adherence, cost-effectiveness, and providing convenience, gives medical professionals with a robust means to providing healthcare. Although it proves to be a useful tool for home-based exercises, it is crucial to remember that telerehabilitation is recommended as an extension to in-person care and not a replacement for hands-on clinical sessions, such as manual therapy, provided by a physiotherapist. Blinding of neither participants nor researchers was done, which presents a limitation. Because all participants in this study were females, the results cannot be generalized to the entire population. Moreover, all participants who were randomized into the telerehabilitation group were expected to have software-compatible devices, such as laptops or mobile phones, as well as a stable internet connection. The duration of treatment may be another potential limitation. Considering that this is a pilot study, a larger sample size, longer duration of treatment, and extended follow-up periods for randomized controlled trials are recommended for the future. Studies can build on the methods used in this study, and in addition to its findings, by including both gender comparisons, exploring the effects of varying treatment durations is recommended. Furthermore, the influence of factors such as diet, physical activity, sleeping position, and stress should also be studied.

In conclusion, home-based exercises for chronic non-specific neck pain showed significant improvement in neck pain, disability, cervical ROM, and cervical muscle endurance for both groups, when followed for six weeks, in addition to large effect size for pain score and disability index in favour of telerehabilitation. While both groups showed good adherence to the frequency of sessions, telerehabilitation group exhibited better adherence to the duration of the exercise sessions.