J. Price1,2, A. Rushton2,3, V. Tyros4, N. Heneghan2
1Birmingham Community Healthcare NHS Foundation Trust, 1Musculoskeletal Physiotherapy Services, Birmingham, United Kingdom, 2University of Birmingham, Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), Birmingham, United Kingdom, 3Western University, School of Physical Therapy, Ontario, Canada, 4Edgbaston Physiotherapy Clinic, Physiotherapy, Birmingham, United Kingdom
Background: Neck pain is the 9th leading cause of years lived with disability worldwide with up to 70% experiencing moderate to severe activity limitations. Although combinations of motor control exercise and isotonic superficial cervical muscle exercise (segmental exercise) effectively decrease pain and disability, effects are modest. Precision prescription of exercise and dosage variables can increase effectiveness however evaluating optimal dosage is prevented by poor reporting or heterogeneity across trials. Identifying important exercise and dosage variables would provide consistency, reducing research waste, optimising exercise prescription in research and clinical practice.
Purpose: To gain consensus on motor control and segmental exercise and dosage variables for chronic non-specific neck pain.
Methods: An international, 3 round e-Delphi study was conducted (March-September 2020) according to a published protocol. Experts in neck pain management (academic and clinical practice) were recruited using pre-defined eligibility criteria. In round 1, exercise and dosage variables were obtained from expert opinion and extracted from clinical trial data. Thematic analysis by two independent researchers developed themes and statements. In rounds 2 and 3 participants rated their agreement with statements using a 1-5 Likert scale. Statement consensus was evaluated against progressively increased a priori criteria using descriptive statistics. Kendall’s W evaluated inter-expert agreement (0=no agreement, 1=perfect agreement). Following round 3 the exercise and dosage variables achieving consensus were defined.
Results: Thirty-seven experts participated (10 countries, 3 professions, 32% >200+ peer-reviewed publications & 42% >21 years clinical experience). Twenty-nine responded to round 1 (79%), 26 round 2 (70%) and 24 round 3 (65%). Round 1 thematic analysis identified significant exercise and dosage variable complexity warranting 5 themes (clinical reasoning, dosage variables, exercise variables, evaluation criteria and progression) and 2 subthemes (progression criteria and progression variables) outlining the multiple components of exercise prescription. In total 79 statements were generated.
Following rounds 2 and 3, consensus was achieved for 46 components of exercise and dosage prescription. Qualitative data and low but significant inter-expert agreement across all statements (Kendall’s W=0.260, p<0.0001) supported the complexity of exercise prescription and the need for individualisation.
Key findings with high or complete statement agreement emphasise the importance of:
Following rounds 2 and 3, consensus was achieved for 46 components of exercise and dosage prescription. Qualitative data and low but significant inter-expert agreement across all statements (Kendall’s W=0.260, p<0.0001) supported the complexity of exercise prescription and the need for individualisation.
Key findings with high or complete statement agreement emphasise the importance of:
- Acceptable, feasible and individualised exercise prescribed collaboratively with patients within a framework to improve neuromuscular performance (Theme 1)
- Prescribing the dosage variables intensity of effort, frequency, and repetitions (Theme 2)
- Monitoring dosage with patient effort, technique and compliance (Theme 4)
- Progressing the most pertinent variable to a patient’s functional activity once exercise is no longer perceived to be difficult (Subthemes 5.1-2)
Conclusion(s): Findings evidence 46 important components informing chronic non-specific neck pain exercise prescription. The complexity and importance of individualised exercise prescription is demonstrated by multiple interacting components and low inter-expert agreement.
Implications: Clinical practice: Exercise and dosage variables should be acceptable, feasible and individualised to patient’s assessment findings and functional requirements. Optimal parameters for important variables are unknown.
Research: Optimal intensity of effort, frequency and repetitions for motor control and segmental exercise needs investigating. Exercise complexity warrants an evidence-informed approach to exercise prescription developed using a complex intervention framework.
Research: Optimal intensity of effort, frequency and repetitions for motor control and segmental exercise needs investigating. Exercise complexity warrants an evidence-informed approach to exercise prescription developed using a complex intervention framework.
Funding, acknowledgements: Jonathan Price is funded by an NIHR/HEE Pre-doctoral Clinical Academic Fellowship (ICA-PCAF-2018-01-117).
Keywords: Neck pain, Dosage, Delphi
Topic: Musculoskeletal: spine
Did this work require ethics approval? Yes
Institution: University of Birmingham
Committee: University of Birmingham Ethics Committee
Ethics number: REF:ERN_19-1857
All authors, affiliations and abstracts have been published as submitted.
