PT or cervical collar for cervical radiculopathy?
Active treatment (physical therapy + home-based exercise) and passive treatment (cervical collar + rest) are equally effective at relieving acute neck and arm pain.
By 6 months, differences virtually disappeared
Both the active and passive interventions reduced arm and neck pain faster than the wait-and-see strategy. At 6 weeks, participants in both the PT and cervical collar groups reported a 31-mm reduction in arm pain (P=.007 and .006, respectively), compared with a 19-mm reduction for those in the control group (P=.006). This is a clinically meaningful difference.
The rate of reduction in neck pain over the first 6 weeks was: PT group, 2.4 mm/week, P=.002; cervical collar group, 2.8 mm/week, P=<.001; and control group, 0.9 mm/week. The rate of reduction in the NDI was 1.4 points per week for the control group vs 2.3 points per week for the cervical collar group (P= .024). The PT group fared no better on the NDI measure than the control group. This may reflect the fact that the index predominantly measured disability caused by neck pain, whereas arm pain scores,—which were highest initially—showed the greatest improvement, the authors note.
At 6 months, pain and disability had almost resolved for all the patients, regardless of their treatment group, and secondary outcomes—treatment satisfaction, analgesic use, and working status—were similar for all 3 groups.
WHAT'S NEW: High-quality RCT supports PT and cervical collar
Some investigators have advocated the short-term use of immobilization with either a cervical collar or a cervical pillow during sleep. Until now, however, there was no conclusive evidence about the benefits of this approach.
One earlier RCT (N=493) compared 5 treatment modalities—traction, positioning, collar, placebo tablets, and heat treatment—and found no significant difference in pain and ability to work.7 That trial was done nearly 15 years ago, however, and the investigators did not use validated outcome scales. Therefore, the trial would not meet current RCT standards.
The study we report on here leaves little doubt that the 2 treatments reviewed—PT and cervical collar—provide more rapid relief than a wait-and-see approach.
CAVEATS: Pain meds still needed, unanswered questions remain
Although the cervical collar and PT groups had less pain at 3 and 6 weeks compared with the controls—and all 3 groups showed equal improvement at study’s end—the researchers found little difference in use of analgesics. Data on adherence to treatment was recorded by patients, so treatment adherence may not be completely accurate.8
Patients without severe arm pain or signs of muscle weakness were not included in this study, so we don’t know whether individuals with less severe cervical radiculopathy would benefit from these treatments. What’s more, this study focused only on new cases of acute cervical radiculopathy, and the findings may not apply to patients with chronic, recurrent, or persistent symptoms.
The apparent contradiction in the finding that both immobilization and PT are beneficial does not have a clear scientific explanation. The researchers hypothesize that immobilizing the neck with a collar reduces foraminal root compression and inflammation; this could explain the larger reduction in arm pain compared with neck pain and neck disability found in this study. The mechanism of pain reduction with PT is unclear, although it is probably related to the restoration of the neck musculature’s strength and range of motion.
Cost is another issue. A cervical collar and rest is at least as effective as PT for recent onset cervical radiculopathy, but the collar costs only about $20—far less than the cost of 12 sessions of therapy.
One final caveat: Any patient with persistent or worsening symptoms should undergo additional evaluation, including imaging.
CHALLENGES TO IMPLEMENTATION: Rest is contrary to usual approach
Some physicians may not agree with the recommendation to encourage rest. Indeed, rest and immobilization are contrary to the usual recommendation for musculoskeletal injuries—to resume activity as soon as possible.
Patients might not like wearing a collar for a variety of personal reasons, such as cosmetic appearance or limitations of motion. On the other hand, some patients may feel that their pain is too severe to be able to participate in PT—which may also be too expensive for, or not readily available to, some patients.
Acknowledgement
The PURLs Surveillance System is supported in part by Grant number UL1RR024999 from the National Center for Research Resources; the grant was a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
