Standard physiotherapy appears more effective than a brief, cognitive behavioral-type intervention for neck pain, although patient preference for the brief intervention can enhance its effectiveness, according to a randomized trial.
However, because confidence intervals overlapped in the trial results, “some may argue that there is a role for the brief intervention for all patients,” noted Jennifer A. Klaber Moffett, Ph.D., of the University of Hull (England), and her colleagues (BMJ 2005;330:75). “It seems that the brief intervention should in any case be available for those who prefer it.”
According to the researchers, previous studies have suggested that patients' expectations or preferences for a particular treatment may influence the outcome of that treatment.
A total of 268 adult patients with subacute or chronic neck pain were randomized to receive either standard physiotherapy or the brief intervention. Prior to randomization, all patients were asked to complete a questionnaire, which included the Northwick Park neck pain questionnaire (NPQ), a measure of the level of neck pain and resulting disability; the short form 36 questionnaire (SF-36), a generic health and quality of life questionnaire that includes physical and psychological factors; and the Tampa scale for kinesophobia (a measure of fear and avoidance of movement). Distress was also measured on a scale of 0-10, with 10 representing extreme distress.
Patients were then asked if they had a preference for standard physiotherapy or brief intervention and were then randomized to a treatment independent of their preference.
The 139 patients in the brief intervention arm received between one and three hands-off sessions with a physiotherapist, during which time cognitive behavioral therapy strategies were emphasized and patients were encouraged to return to normal daily activities as soon as possible through self-management.
The 129 standard physiotherapy patients received any combination of electrotherapy, manual therapy or mobilization, advice, home exercises, and other approaches according to therapists' judgments.
Follow-up questionnaires at 3 and 12 months post intervention showed that for the NPQ, the main outcome, the standard physiotherapy group showed more improvement than the brief intervention group—although this difference did not reach significance.
The SF-36 results showed a similar trend. And although the Tampa scores on fear of movement were in favor of brief intervention initially at 3 months, this trend was reversed at 12 months.
When patients' treatment preferences were factored in, those who wanted the brief intervention and got it had the biggest improvement on the NPQ score, although the difference was not statistically significant. Among patients who were indifferent about which treatment they wanted, there was an advantage to being assigned to standard physiotherapy.
Among patients who stated a preference for standard physiotherapy and then received it, the overall treatment effect did not seem to be enhanced. However, if these patients were randomized to the brief intervention, their pain scores at 12 months were increased from baseline.
“Usual physiotherapy produced marginally better treatment outcomes at 12 months than the shorter, hands-off intervention,” reported the authors.