Whilst primary carer advice on natural history and activity is adequate for those with recent onset painful cervical radiculopathy, attending a short course of physiotherapy increases the probability of improvement in these patients at four weeks. This is according to the findings of the PACeR trial which were presented at EUROSPINE 2022 (19–21 October; Milan, Italy) by Louise Keating (Royal College of Surgeons in Ireland, Dublin, Ireland).
The primary aim of this assessor blinded, multicentre randomised controlled trial was to investigate the effects of a four week (eight sessions) physiotherapy programme of advice, manual therapy, exercise and neural unloading tape, compared to weekly phone advice; on disability and pain, in those with recent onset single level, unilateral cervical radiculopathy.
The findings showed that, at four weeks, pain and disability improved within both groups and, although neck pain was statistically significantly better in the treatment group, this did not reach clinical significance. It also highlighted that the probability of meaningful clinical improvement based on the Global Rating of Change (GROC) score was 70% with treatment versus 30% with advice.
Participants with fewer than 12 weeks of symptoms, meeting a clinical prediction rule for cervical radiculopathy diagnosis, were recruited from primary care or self-referral and randomly allocated to receive treatment or phone advice.
Treatment was provided by experienced physiotherapists in primary and secondary care and follow up was at four (primary endpoint), 12 and 24 weeks.
A total of 29 participants were randomised to each group. The mean age was 49 years (standard deviation [SD]: 12 years) and symptom duration was four weeks (SD: 5 weeks). Using intention to treat analysis, linear regression was used to investigate between group effects on outcomes, inclusive of baseline levels.
Between group mean differences at four weeks were –1.1 (95% confidence interval [CI] –2.2 to –0.04, p=0.04) for neck pain and –0.7 (95% CI –1.8 to 0.5, p=0.26) for arm pain. Common language effect size for Neck Disability Index was 0.4 (95% CI 0.4 to 0.5, p=0.35) and 0.69 (95% CI 0.5 to 0.7, p=0.02) for GROC. At 12 weeks, there were no significant between group differences for any primary outcomes.
Speaking to Spinal News International, Keating said: “Patients often present in primary care with acute cervical radiculopathy seeking diagnosis, reassurance and treatment, but it’s important to understand if clinical improvement results from treatment, or simply reflects a favourable natural history over several months.
“As a true waiting list control was unacceptable to potential participants and some therapeutic attention was considered valuable to neutralise impact of a therapeutic alliance, as well as monitor for any clinical deterioration; we found that both groups improved by four weeks in pain and disability, but with greater gains in neck pain made by treatment group.
“By 12 weeks, ongoing improvement had taken place with the control group catching up with the treatment group, across outcomes, including GROC. Higher probability of GROC improvement at four weeks in the treatment group may signify a greater holistic assessment, beyond pain and disability; as some participants found sensory and motor symptoms additionally bothersome.
“We also had three ‘significant adverse events’ and only in the control group, so this represents a natural clinical deterioration rather than a negative response to advice, highlighting the value of clinical monitoring for this group. Shared decision-making with a recent onset radiculopathy patient (without major paresis) should highlight that they have treatment options, with consequent cost implications.”