Is tailored treatment superior to nontailored treatment for pain and disability in women with non-specific neck pain? A randomized controlled trial

Tailored treatment does not seem to be effective over nontailored treatment in women with subacute and chronic neck pain.

The one-year prevalence of neck pain among workers across the world varies between 27% and 48%. Although anyone can experience the neck pain, women are likely to get more affected and people in their middle age are at greater risk. In most of the cases, the specific cause of neck pain is not fully known and treatment is often based on the symptoms and functional impairments. The treatment approach generally used involves assessment of each patient and tailoring the treatment according to the individual’s requirements. However, benefits of the tailored treatment are yet to be confirmed. Most trials on non-specific neck pain have focused on interventions of a single type, producing evidence of modest improvement at its best. The heterogeneity of symptoms and functional impairments in non-specific neck pain could be a reason for the weak evidence for single type treatments. Individualized approaches have been tried for neck pain, but none of the studies discussed enough about the efficacy of tailored treatment that can be replicated. The main idea is to improve the treatment outcomes by prescribing individualized treatments using a detailed decision model. In such a model, indications for the interventions are based on appropriate cut-off values of standardized, reliable and valid assessments. One way to investigate the effect of such an approach is to conduct a randomized trial in which similar treatment components are available but where individuals in one group receive treatment tailored to their needs and the individuals in the other group have non-tailored treatment.

Rationale behind research:

• The evidences supporting  the effect of tailored treatments in neck pain are modest. In the absence of causal treatments, possibility is to tailor the treatment to the individuals’ functional limitations and symptoms.
• The present study was conducted with an aim to evaluate the treatment effects on pain and disability of a tailored treatment versus a non-tailored treatment for women with subacute and chronic non-specific neck pain

Objective:

The aim was to evaluate treatment effects of a tailored treatment versus a non-tailored treatment.

Study outcomes:

• Primary Outcomes: Neck disability (Neck Disability Index, NDI), and average pain intensity last week (0–10 Numeric Rating Scale, NRS).
• Secondary Outcomes: Symptoms of anxiety and depression and isometric forces of shoulder abduction, knee extension, knee flexion and hand grip. The exploratory outcomes were pain intensity, the number of pain localisations and health-related quality of life

Time Points: Baseline, 3, 9 and 15 month

Outcomes

Baseline: There were no significant baseline differences between the groups.

Primary outcomes:

• Compared with TAU, TT and NTT showed significant treatment effects at 3-month follow-up with improved neck disability (absolute within-group differences NDI%: TT, -7 ; NTT, -10 ; TAU, -2,5) and reduced average pain intensity at last week (absolute within-group differences NRS points: TT, -1,9 ; NTT, -2,0 ; TAU, -0,75)
• At 9-month follow-up, there were no differences between groups
• At 15-month follow-up, neck disability of the NTT-group was significantly improved compared with the TAU-group but not compared with the TT-group (absolute within-group differences NDI%: TT,-6,5 ; NTT, -10,5 ; TAU, -6 )

TT:tailored, NTT:non-tailored treatment, TAU:treatment-as-usual, NRS: numeric rating scale.

TT:tailored, NTT:non-tailored treatment, TAU:treatment-as-usual, NDI:numeric disability index.

Secondary outcomes:

• At 9-month follow-up, the TT group showed significantly improved quality of performed work as compared to the NTT-group
• After 15 month, improvement in both quality and quantity of performed work was significantly greater in the TT group compared with the NTT group. In comparison with the TAU group, the TTand the NTT groups reduced intensity and frequency of symptoms (ProFitMap-neck) and showed higher general improvement (PGICS) at the 3-month follow-up. Also pressure pain threshold (PPT) on the left. trapezius was increased in the TT group compared with the TAUgroup at the same follow-up.
• At 9 and 15 month follow-ups, the TT and NTT groups again rated their general improvement higher than the TAU-group. At the 15-month follow-up the TAUgroup improved in work productivity (quantity of performed work) compared with the NTT group.

The current RCT do not support for tailored over nontailored treatment of women with subacute or chronic non-specific neck pain when interventions were prescribed according to a decision model that used cut-off levels in various functional tests. Nevertheless, the evidence based treatment components incorporated in this model, regardless of intervention group, resulted in better short-term effects than TAU.

This was the first attempt to structure and implement a concise decision model for neck rehabilitation, where treatment choices for individuals with non-specific neck pain were based on cut-off levels in specific tests. There is just a single study in the literature implementing a decision model to individualize the treatment for neck pain. In comparison to the model used with cut-off levels in this study and a structured interview, Wang et al used a clinical reasoning algorithm developed by an experienced physiotherapist. Although their study favored the individual approach, the absence of a treatment control group and long-term follow-up reduces the impact of their findings. Other studies evaluating tailored interventions compared with general approaches for neck pain did not include decision models on which the tailoring of interventions is founded.

The results of this study may be a consequence of the decision model lacking precise enough cut-off levels, or that associations between changes in the targeted functions of the model and pain/disability are too weak. Further research into the effects of tailoring interventions for neck pain disorders is warranted, but at the first instance, more precise knowledge is needed regarding cut-off levels to determine impairment if the current decision-model is to be further developed.