The New Agenda for Neck Pain Research: A Modified Delphi Study

WHO research agenda on the role of the institutional safety climate for hand hygiene improvement: a Delphi consensus-building study

BACKGROUND

Creating and sustaining an institutional climate conducive to patient and health worker safety is a critical element of successful multimodal hand hygiene improvement strategies aimed at achieving best practices. Repeated WHO global surveys indicate that the institutional safety climate consistently ranks the lowest among various interventions.

METHODS

To develop an international expert consensus on research agenda priorities related to the role of institutional safety climate within the context of a multimodal hand hygiene improvement strategy, we conducted a structured consensus process involving a purposive sample of international experts. A preliminary list of research priorities was formulated following evidence mapping, and subsequently refined through a modified Delphi consensus process involving two rounds. In round 1, survey respondents were asked to rate the importance of each research priority. In round 2, experts reviewed round 1 ratings to reach a consensus (defined as ≥70% agreement) on the final prioritised items to be included in the research agenda. The research priorities were then reviewed and finalised by members of the WHO Technical Advisory Group on Hand Hygiene Research in Healthcare.

RESULTS

Of the 57 invited participants, 50 completed Delphi round 1 (88%), and 48 completed round 2 (96%). Thirty-six research priority statements were included in round 1 across five thematic categories: (1) safety climate; (2) personal accountability for hand hygiene; (3) leadership; (4) patient participation and empowerment and (5) religion and traditions. In round 1, 75% of the items achieved consensus, with 9 statements carried forward to round 2, leading to a final set of 31 prioritised research statements.

CONCLUSION

This research agenda can be used by researchers, clinicians, policy-makers and funding bodies to address gaps in hand hygiene improvement within the context of an institutional safety climate, thereby enhancing patient and health worker safety globally.

Development and internal validation of a multivariable prognostic model to predict chronic pain after a new episode of non-specific idiopathic, non-traumatic neck pain in physiotherapy primary care practice

OBJECTIVE

To develop and internally validate a prognostic model to predict chronic pain after a new episode of acute or subacute non-specific idiopathic, non-traumatic neck pain in patients presenting to physiotherapy primary care, emphasising modifiable biomedical, psychological and social factors.

DESIGN

A prospective cohort study with a 6-month follow-up between January 2020 and March 2023.

SETTING

30 physiotherapy primary care practices.

PARTICIPANTS

Patients with a new presentation of non-specific idiopathic, non-traumatic neck pain, with a duration lasting no longer than 12 weeks from onset.

BASELINE MEASURES

Candidate prognostic variables collected from participants included age and sex, neck pain symptoms, work-related factors, general factors, psychological and behavioural factors and the remaining factors: therapeutic relation and healthcare provider attitude.

OUTCOME MEASURES

Pain intensity at 6 weeks, 3 months and 6 months on a Numeric Pain Rating Scale (NPRS) after inclusion. An NPRS score of ≥3 at each time point was used to define chronic neck pain.

RESULTS

62 (10%) of the 603 participants developed chronic neck pain. The prognostic factors in the final model were sex, pain intensity, reported pain in different body regions, headache since and before the neck pain, posture during work, employment status, illness beliefs about pain identity and recovery, treatment beliefs, distress and self-efficacy. The model demonstrated an optimism-corrected area under the curve of 0.83 and a corrected R2 of 0.24. Calibration was deemed acceptable to good, as indicated by the calibration curve. The Hosmer-Lemeshow test yielded a p-value of 0.7167, indicating a good model fit.

CONCLUSION

This model has the potential to obtain a valid prognosis for developing chronic pain after a new episode of acute and subacute non-specific idiopathic, non-traumatic neck pain. It includes mostly potentially modifiable factors for physiotherapy practice. External validation of this model is recommended.

Systemic Inflammation, Sleep, and Psychological Factors Determine Recovery Trajectories for People With Neck Pain: An Exploratory Study

We conducted an explorative prospective cohort study with 6 months follow-up to 1) identify different pain and disability trajectories following an episode of acute neck pain, and 2) assess whether neuroimmune/endocrine, psychological, behavioral, nociceptive processing, clinical outcome, demographic and management-related factors differ between these trajectories. Fifty people with acute neck pain (ie, within 2 weeks of onset) were included. At baseline, and at 2, 4, 6, 12, and 26 weeks follow-up, various neuroimmune/endocrine (eg, inflammatory cytokines and endocrine factors), psychological (eg, stress symptoms), behavioral (eg, sleep disturbances), nociceptive processing (eg, condition pain modulation), clinical outcome (eg, trauma), demographic factors (eg, age), and management-related factors (eg, treatment received) were assessed. Latent class models were performed to identify outcome trajectories for neck pain and disability. Linear mixed models or the Pearson chi-square test were used to evaluate differences in these factors between the trajectories at baseline and at each follow-up assessment and over the entire 6 months period. For pain, 3 trajectories were identified. The majority of patients were assigned to the "Moderate pain - Favourable recovery" trajectory (n = 25; 50%) with smaller proportions assigned to the "Severe pain - Favourable recovery" (n = 16; 32%) and the "Severe pain - Unfavourable recovery" (n = 9; 18%) trajectories. For disability, 2 trajectories were identified: "Mild disability - Favourable recovery" (n = 43; 82%) and "Severe disability - Unfavourable recovery" (n = 7; 18%). Ongoing systemic inflammation (increased high-sensitive C-reactive protein), sleep disturbances, and elevated psychological factors (such as depression, stress and anxiety symptoms) were mainly present in the unfavorable outcome trajectories compared to the favorable outcome trajectories. PERSPECTIVE: Using exploratory analyses, different recovery trajectories for acute neck pain were identified based on disability and pain intensity. These trajectories were influenced by systemic inflammation, sleep disturbances, and psychological factors.

Research Priorities in the Mechanical Diagnosis and Therapy Among Diploma Therapists: An International Delphi Study

Introduction Mechanical diagnosis and therapy (MDT) is the most researched approach in musculoskeletal physical therapy and involves classifying patients into sub-groups based on their response to loading strategies. MDT diploma therapists (Dip-MDTs) fully recognize the value of MDT in musculoskeletal physical therapy. MDT is updating its system based on the latest research, but the system has not yet been fully established. Therefore, more research is required to increase the comprehensibility of the system. Thus, we aimed to identify future research priorities of MDT. Methods We conducted a modified Delphi study with three rounds. The Research Advisory Committee (RAC) members (n=7) of the McKenzie Institute International were invited to participate in the initial idea generation round. In the subsequent two consensus rounds, Dip-MDTs (n=299) were asked to indicate their level of agreement with the results of the idea generation round using a five-point Likert scale. The criteria for consensus were mean score ≥4.0, coefficient of variation ≤30%, percent agreement ≥75%, and quartile deviation ≤1. A post-hoc analysis of the consensus was conducted when the number of participants from a certain country exceeded one-third of the total number of participants. Results The participation rates for each round were 57.1%, 52.2%, and 49.8%. The USA accounted for 43.6% and 44.3% of all participants at the two consensus rounds, respectively. Finally, nine items reached consensus in the second consensus round. After the post-hoc analysis, eight items reached consensus: (1) cost-effectiveness, (2) cervical and thoracic spine, (3) extremity classifications, (4) filtered randomized controlled trials (RCTs), (5) spinal source classification, (6) centralization and directional preferences, (7) predictive factors for recurrence, and (8) patient education. Conclusion In this study, we identified the research priorities of MDT that would enhance the completion of the MDT system.

Cervical manipulation versus thoracic or cervicothoracic manipulations for the management of neck pain. A systematic review and meta-analysis

BACKGROUND

Cervical and thoracic thrust or non-thrust manipulations have shown to be effective in patients with neck pain, but there is a lack of studies comparing both interventions in patients with neck pain.

OBJECTIVE

To investigate the effects of cervical thrust or non-thrust manipulations compared to thoracic or cervicothoracic manipulations for improving pain, disability, and range of motion in patients with neck pain.

DESIGN

Systematic review and meta-analysis.

METHOD

Searches were performed in PubMed, PEDro, Cochrane Library, CINHAL, and Web of Science databases from inception to May 22, 2023. Randomized clinical trials comparing cervical thrust or non-thrust manipulations to thoracic or cervicothoracic manipulations were included. Methodological quality was assessed with PEDro scale, and the certainty of evidence was evaluated using GRADE guidelines.

RESULTS

Six studies were included. Meta-analyses revealed no differences between cervical thrust or non-thrust manipulations and thoracic or cervicothoracic manipulations in pain intensity, disability, or cervical range of motion in any plane. The certainty of evidence was downgraded to very low for pain intensity, to moderate or very low for disability and to low or very low for cervical range of motion.

CONCLUSION

There is moderate to very low certainty evidence that there is no difference in effectiveness between cervical thrust or non-thrust manipulations and thoracic or cervicothoracic manipulations for improving pain, disability, and range of motion in patients with neck pain.

PROSPERO REGISTRATION

CRD42023429933.

Effects of matched vs. unmatched physical therapy interventions on pain or disability in patients with neck pain - a systematic review and meta-analysis

BACKGROUND

The interventions performed in most randomized controlled trials (RCTs) on neck pain patients are standardized, irrespective of the high heterogeneity of patients. However, clinicians tend to choose an intervention based on the patients' clinical characteristics, and thus match the treatment to the patient.

OBJECTIVES

To investigate the effectiveness of interventions matched to the clinical characteristics of patients with neck pain versus the same, but unmatched treatment for improving pain or disability.

DESIGN

A systematic review and meta-analysis conducted following Cochrane guidelines.

METHODS

Databases searches were performed from inception to September 2023. RCTs were included if the patients in the experimental group received a treatment matched to clinical presentation or to clinicians' assessment, if the patients in the control group received a similar but unmatched treatment, and if pain or disability were reported as outcome measures.

RESULTS

The literature search produced 9516 records of which 27 met the inclusion criteria. Matched exercise therapy was superior to unmatched exercise for pain (SMD -0.57; 95% CI -0.95, -0.18) and for disability (SMD -0.69; 95% CI -1.14, -0.23) at short term, but not at intermediate-term follow-up. Matched manual treatment was not superior to unmatched manual therapy for pain or for disability at short or intermediate-term follow-up.

CONCLUSIONS

Results suggest that matching exercise to movement limitation, trapezius myalgia, or forward head position may lead to better outcomes in the short term, but not in the intermediate-term. Matched manual therapy was not superior to unmatched treatment either short or intermediate-term. Further research is warranted to verify if those criteria are potentially useful matching criteria.

One step at a time. Shaping consensus on research priorities and terminology in telehealth in musculoskeletal pain: an international modified e-Delphi study

BACKGROUND

Telehealth has emerged as an alternative model for treatment delivery and has become an important component of health service delivery. However, there is inconsistency in the use of terminologies and a lack of research priorities in telehealth in musculoskeletal pain. The purpose of this international, multidisciplinary expert panel assembled in a modified three-round e-Delphi survey is to achieve a consensus on research priorities and for the standard terminology for musculoskeletal pain telehealth practice.

METHODS

In this international modified e-Delphi survey, we invited an expert panel consisting of researchers, clinicians, consumer representatives, industry partners, healthcare managers, and policymakers to participate in a three-round e-Delphi. Expert panels were identified through the Expertscape website, PubMed database, social media, and a snowball approach. In Round 1, potential research priorities and terminologies were presented to panel members. Panel members rated the agreement of each research priority on a 5-point Likert scale and an 11-point numerical scale, and each terminology on a 5-point Likert scale for the "telehealth in musculoskeletal pain " field over rounds. At least 80% of the panel members were required to agree to be deemed a consensus. We analyzed the data descriptively and assessed the stability of the results using the Wilcoxon matched-pairs signed rank test.

RESULTS

We performed an international e-Delphi survey from February to August 2022. Of 694 invited people, 160 panel members participated in the first round, 133 in the second round (83% retention), and 134 in the third round (84% retention). Most of the panel members were researchers 76 (47%), clinicians 57 (36%), and consumer representatives 9 (6%) of both genders especially from Brazil 31 (19%), India 22 (14%), and Australia 19 (12%) in the first round. The panel identified fourteen telehealth research priorities spanned topics including the development of strategies using information and communication technology, telehealth implementation services, the effectiveness and cost-effectiveness of telehealth interventions, equity of telehealth interventions, qualitative research and eHealth literacy in musculoskeletal pain conditions from an initial list of 20 research priorities. The consensus was reached for "digital health" and "telehealth" as standard terminologies from an initial list of 37 terminologies.

CONCLUSION

An international, multidisciplinary expert consensus recommends that future research should consider the 14 research priorities for telehealth musculoskeletal pain reached. Additionally, the terms digital health and telehealth as the most appropriate terminologies to be used in musculoskeletal telehealth research.

REGISTER

Open Science Framework ( https://osf.io/tqmz2/ ).

Effectiveness of Exercise Interventions for Preventing Neck Pain: A Systematic Review With Meta-analysis of Randomized Controlled Trials

OBJECTIVE: To update the evidence on the effectiveness of exercise interventions to prevent episodes of neck pain. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: MEDLINE, Embase, CENTRAL, CINAHL, SPORTDiscus, PEDro, and trial registries from inception to December 2, 2022. Forward and backward citation searches. STUDY SELECTION CRITERIA: Randomized controlled trials (RCTs) that enrolled adults without neck pain at baseline and compared exercise interventions to no intervention, placebo/sham, attention control, or minimal intervention. Military populations and astronauts were excluded. DATA SYNTHESIS: Random-effects meta-analysis. Risk of bias was assessed using the Cochrane RoB 2 tool. The certainty of evidence was judged according to the GRADE approach. RESULTS: Of 4703 records screened, 5 trials (1722 participants at baseline) were included and eligible for meta-analysis. Most (80%) participants were office workers. Risk of bias was rated as some concerns for 2 trials and high for 3 trials. There was moderate-certainty evidence that exercise interventions probably reduce the risk of a new episode of neck pain (OR, 0.49; 95% confidence interval: 0.31, 0.76) compared to no or minimal intervention in the short-term (≤12 months). The results were not robust to sensitivity analyses for missing outcome data. CONCLUSION: There was moderate-certainty evidence supporting exercise interventions for reducing the risk for an episode of neck pain in the next 12 months. The clinical significance of the effect is unclear. J Orthop Sports Phys Ther 2023;53(10):1-16. Epub: 8 September 2023. doi:10.2519/jospt.2023.12063.

A study protocol for the validation of a prognostic model with an emphasis on modifiable factors to predict chronic pain after a new episode of acute- or subacute nonspecific idiopathic, non-traumatic neck pain presenting in primary care

BACKGROUND

The primary objective of this study is to identify which modifiable and non-modifiable factors are independent predictors of the development of chronic pain in patients with acute- or subacute nonspecific idiopathic, non-traumatic neck pain, and secondly, to combine these to develop and internally validate a prognostic prediction model.

METHODS

A prospective cohort study will be conducted by physiotherapists in 30 primary physiotherapy practices between January 26, 2020, and August 31, 2022, with a 6-month follow-up until March 17, 2023. Patients who consult a physiotherapist with a new episode of acute- (0 to 3 weeks) or subacute neck pain (4 to 12 weeks) will complete a baseline questionnaire. After their first appointment, candidate prognostic variables will be collected from participants regarding their neck pain symptoms, prior conditions, work-related factors, general factors, psychological and behavioral factors. Follow-up assessments will be conducted at six weeks, three months, and six months after the initial assessment. The primary outcome measure is the Numeric Pain Rating Scale (NPRS) to examine the presence of chronic pain. If the pain is present at six weeks, three months, and six months with a score of NPRS ≥3, it is classified as chronic pain. An initial exploratory analysis will use univariate logistic regression to assess the relationship between candidate prognostic factors at baseline and outcome. Multiple logistic regression analyses will be conducted. The discriminative ability of the prognostic model will be determined based on the Area Under the receiver operating characteristic Curve (AUC), calibration will be assessed using a calibration plot and formally tested using the Hosmer and Lemeshow goodness-of-fit test, and model fit will be quantified as Nagelkerke's R2. Internal validation will be performed using bootstrapping-resampling to yield a measure of overfitting and the optimism-corrected AUC.

DISCUSSION

The results of this study will improve the understanding of prognostic and potential protective factors, which will help clinicians guide their clinical decision making, develop an individualized treatment approach, and predict chronic neck pain more accurately.

Time Course and Risk Profile of Work-Related Neck Disability: A Longitudinal Latent Class Growth Analysis

OBJECTIVE

Given the economic burden of work-related neck pain and disability, it is important to understand its time course and associated risk factors to direct better management strategies. This study aimed to identify the 1-year trajectories of work-related neck disability in a high-risk occupation group such as sonography and to investigate which baseline biopsychosocial factors are associated with the identified trajectories.

METHODS

A longitudinal study was conducted among 92 sonographers with neck disability assessed at 3 time points-baseline, 6 months, and 12 months-using the Neck Disability Index. Baseline biopsychosocial measures included individual characteristics (demographics and physical activity levels), work-related physical and psychosocial factors (eg, ergonomic risk, workplace social support, job satisfaction), general psychological features (depression, anxiety, pain catastrophizing, and fear-avoidance beliefs), and quantitative sensory testing of somatosensory function (cold and pressure pain thresholds at neck and tibialis anterior, and temporal summation).

RESULTS

Two distinct trajectories of neck disability were identified, including a "low-resolving disability" trajectory showing slow improvement toward no disability (64.8%) and a "moderate-fluctuating disability" trajectory characterized by persistent moderate disability with a small fluctuation across time (35.2%). The trajectory of moderate-fluctuating disability was associated with more severe symptoms, lower vigorous physical activity, higher ergonomic risk, remote cold hyperalgesia, widespread mechanical hyperalgesia, heightened pain facilitation, and several psychosocial factors such as anxiety, depression, lower job satisfaction, and lower workplace social support at baseline.

CONCLUSION

Over one-third of sonographers were at risk of developing a moderate-fluctuating disability trajectory. This unfavorable trajectory was associated with low physical activity level, poor ergonomics, psychosocial distress, and central sensitization at baseline.

IMPACT

This study has important implications for the management of neck disability in workers. Addressing modifiable factors including low vigorous physical activity, poor ergonomics, anxiety, depression, and lack of workplace social support may improve the trajectory of work-related neck disability.

Research priorities for oral healthcare: agenda setting from the practitioners' perspective

OBJECTIVES

The aim of this study was to develop a research agenda based on the most important information needs concerning the effects and outcomes of oral healthcare provided by oral healthcare professionals (OHPs).

METHODS

A two-stage survey study was used to identify and prioritise topics for future research. The first survey generated topics based on information needs by OHPs. Topics were clustered thematically and overlapping topics were merged in 84 research themes. In the second survey, respondents selected their top 5 from the 84 research themes. Themes were sorted by the rank number based on rank sum.

RESULTS

In the first survey, 937 topics were suggested. Almost half (n = 430, 46%) were identified as topics related to endodontology, cariology, oral medicine/surgery or tooth restoration. Topics were grouped in 84 research themes, covering 10 research domains. These were prioritised by 235 OHPs. Behaviour change for oral health and oral healthcare for geriatric patients ranked as most important.

CONCLUSIONS

Consultation of OHPs has resulted in a research agenda, which can be used to inform programming future oral health research. The highest prioritised research themes have an interdisciplinary nature, mainly concern oral disease prevention and are under-represented in the current oral healthcare research portfolio.

Expert consensus on the important chronic non-specific neck pain motor control and segmental exercise and dosage variables: An international e-Delphi study

BACKGROUND

Chronic non-specific neck pain is highly prevalent, resulting in significant disability. Despite exercise being a mainstay treatment, guidance on optimal exercise and dosage variables is lacking. Combining submaximal effort deep cervical muscles exercise (motor control) and superficial cervical muscles exercise (segmental) reduces chronic non-specific neck pain, but evaluation of optimal exercise and dosage variables is prevented by clinical heterogeneity.

OBJECTIVE

To gain consensus on important motor control and segmental exercise and dosage variables for chronic non-specific neck pain.

METHODS

An international 3-round e-Delphi study, was conducted with experts in neck pain management (academic and clinical). In round 1, exercise and dosage variables were obtained from expert opinion and clinical trial data, then analysed thematically (two independent researchers) to develop themes and statements. In rounds 2 and 3, participants rated their agreement with statements (1-5 Likert scale). Statement consensus was evaluated using progressively increased a priori criteria using descriptive statistics.

RESULTS

Thirty-seven experts participated (10 countries). Twenty-nine responded to round 1 (79%), 26 round 2 (70%) and 24 round 3 (65%). Round 1 generated 79 statements outlining the interacting components of exercise prescription. Following rounds 2 and 3, consensus was achieved for 46 important components of exercise and dosage prescription across 5 themes (clinical reasoning, dosage variables, exercise variables, evaluation criteria and progression) and 2 subthemes (progression criteria and progression variables). Excellent agreement and qualitative data supports exercise prescription complexity and the need for individualised, acceptable, and feasible exercise. Only 37% of important exercise components were generated from clinical trial data. Agreement was highest (88%-96%) for 3 dosage variables: intensity of effort, frequency, and repetitions.

CONCLUSION

Multiple exercise and dosage variables are important, resulting in complex and individualised exercise prescription not found in clinical trials. Future research should use these important variables to prescribe an evidence-informed approach to exercise.

The contemporary management of neck pain in adults

Neck pain is a common condition with a high prevalence worldwide. Neck pain is associated with significant levels of disability and is widely considered an important public health problem. Neck pain is defined as pain perceived between the superior nuchal line and the spinous process of the first thoracic vertebra. In some types of neck conditions, the pain can be referred to the head, trunk and upper limbs. This article aims to provide an overview of the available evidence on prevalence, costs, diagnosis, prognosis, risk factors, prevention and management of patients with neck pain.

Clinical indicators to identify neuropathic pain in low back related leg pain: a modified Delphi study

BACKGROUND

Neuropathic pain (NP) is common in patients presenting with low back related leg pain. Accurate diagnosis of NP is fundamental to ensure appropriate intervention. In the absence of a clear gold standard, expert opinion provides a useful methodology to progress research and clinical practice. The aim of this study was to achieve expert consensus on a list of clinical indicators to identify NP in low back related leg pain.

METHODS

A modified Delphi method consisting of three rounds was designed in accordance with the Conducting and Reporting Delphi Studies recommendations. Recruitment involved contacting experts directly and through expressions of interest on social media. Experts were identified using pre-defined eligibility criteria. Priori consensus criteria were defined for each round through descriptive statistics. Following completion of round 3 a list of clinical indicators that achieved consensus were generated.

RESULTS

Thirty-eight participants were recruited across 11 countries. Thirty-five participants completed round 1 (92.1%), 32 (84.2%) round 2 and 30 (78.9%) round 3. Round 1 identified consensus (Kendall's W coefficient of concordance 0.456; p < 0.001) for 10 clinical indicators out of the original 14, and 9 additional indicators were added to round 2 following content analysis of qualitative data. Round 2 identified consensus (Kendall's W coefficient of concordance 0.749; p < 0.001) for 10 clinical indicators out of 19, and 1 additional indicator was added to round 3. Round 3 identified consensus for 8 indicators (Kendall's W coefficient of concordance 0.648; p < 0.001). Following completion of the third round, an expert derived consensus list of 8 items was generated. Two indicators; pain variously described a burning, electric shock like and/or shooting into leg and pain in association with other neurological symptoms (e.g. pins and needles, numbness, weakness), were found to have complete agreement amongst expert participants.

CONCLUSIONS

Good agreement was found for the consensus derived list of 8 clinical indicators to identify NP in low back related leg pain. This list of indicators provide some indication of the criteria upon which clinicians can identify a NP component to low back related leg pain; further research is needed for stronger recommendations to be made.

Effectiveness and optimal dosage of exercise training for chronic non-specific neck pain: A systematic review with a narrative synthesis

BACKGROUND

Clinical guidelines make vague recommendations as to exercise training (ET) type and dosage to manage chronic non-specific neck pain (CNSNP).

OBJECTIVE

To synthesise evidence on the effectiveness of different ET programmes to reduce CNSNP and associated disability, and whether dosage affects outcomes.

METHODS

A systematic review and data synthesis was conducted according to a published registered protocol (PROSPERO CRD42018096187). A sensitive topic-based search was conducted of CINAHL, MEDLINE, EMBASE, PEDro, grey literature sources and key journals from inception to 6th January 2020 for randomised controlled trials, investigating ET for CNSNP or disability. Two reviewers independently completed eligibility screening, data extraction, risk of bias assessment (Cochrane Risk of Bias Tool) and rated the overall strength of evidence using Grading of Recommendations Assessment, Development and Evaluation. Data was tabulated for narrative synthesis and grouped by intervention, outcome and time point to compare across studies.

RESULTS

Twenty-six trials from 3990 citations (n = 2288 participants) investigated fifteen ET programmes. High RoB and low sample sizes reduced evidence quality. Clinical heterogeneity prevented meta-analyses. A range of ET programmes reduce pain/disability in the short term (low to moderate evidence). Pillar exercises reduce pain/disability in the intermediate term (low level evidence). Moderate to very large pain reduction is found with ET packages that include motor control + segmental exercises (low to moderate evidence). No high-quality trials investigated long term outcomes. Increased frequency of motor control exercises and progressively increased load of pillar exercise may improve effectiveness.

CONCLUSIONS

Motor control + segmental exercises are the most effective ET to reduce short term pain/disability, but long-term outcomes have not been investigated. Optimal motor control + segmental exercise variables and dosage is unknown and requires clarification. An adequately powered, low RoB trial is needed to evaluate the effectiveness and optimal dosage of motor control + segmental on long term outcomes.

TRIAL REGISTRATION

PROSPERO CRD42018096187.

Consensus on the exercise and dosage variables of an exercise training programme for chronic non-specific neck pain: protocol for an international e-Delphi study

INTRODUCTION

Clinical guidelines and systematic reviews recommend exercise in the management of chronic non-specific neck pain. Although exercise training programmes that consist of both motor control exercise and exercises for the superficial cervical muscles (segmental exercises) are effective, the exercise variables including dosage vary considerably across trials or are poorly reported. This study aims to gain expert consensus on these exercise variables so that they can be described clearly using intervention reporting checklists to inform clinical practice and future clinical trials.

METHODS AND ANALYSIS

This protocol for an international Delphi study is informed by the Guidance on Conducting and REporting DElphi Studies recommendations and published to ensure quality, rigour and transparency. The study will consist of three rounds using anonymous online questionnaires. Expert exercise professionals (physiotherapists, strength and conditioning coaches and so on) and academics in neck pain management will be identified through literature searches, peer referral and social media calls for expression of interest. In round 1, participants will answer open-ended questions informed by intervention and exercise reporting checklists. Responses will be analysed thematically by two independent reviewers. In round 2, participants will rate their level of agreement with statements generated from round 1 and previous clinical trials using a 5-point Likert scale where 1=strongly disagree and 5=strongly agree. In round 3, participants will re-rate their agreement with statements that achieved consensus in round 2. Statements reaching consensus among participants must meet progressively increased a priori criteria at rounds 2 and 3, measured using descriptive statistics: median, IQR and percentage agreement. Inferential statistics will be used to evaluate measures of agreement between participants (Kendall's coefficient of concordance) and stability between rounds (Wilcoxon rank-sum test). Statements achieving consensus in round 3 will provide expert recommendations of the key exercise and dosage variables in the management of chronic non-specific neck pain.

ETHICS AND DISSEMINATION

Ethical approval was provided by the University of Birmingham Ethics Committee (Ref:ERN_19-1857). Results will be disseminated through peer-reviewed publications and conference presentations.