The feasibility of gym-based exercise therapy for patients with persistent neck pain

2.3.1 Outcomes

We used the following outcomes, based on data collected before and after the intervention:

1. The Swedish version [38] of the Neck Disability Index (NDI), presented in % [21].

2. An 11-point Numerical Rating Scale (NRS) of average pain intensity per week (0–100, 0: no pain, 100: worst imaginable pain).

3. EuroQol 5D (EQ-5D), including The EQ Visual Analogue Scale (VAS) [39].

Due to changed assessment routines at the department, some patients used the 3L version and others the 5L version; consequently, we summarized the scores as an EQ-5D index and mapped EQ-5D-5L scores using the crosswalk method [40].

1. The Disability Rating Index (DRI), rating the ability to perform 12 daily physical activities on a 0–100 scale (0: without difficulty, 100: not at all) [41].

2. A custom, ordinal three-item physical activity scale:

   1. Physical activity (e.g. running, exercise, sport) (six levels)

   2. Activities in daily life (e.g. walking, bicycling, gardening) (seven levels)

   3. Sedentary (time of sitting during daytime) (seven levels).

2.3.2 Quantitative analysis

We conducted the descriptive analysis and statistical testing using R 3.5.1 [42]. We used the exact Wilcoxon signed-rank test from the exactRankTests package [43] and set a familywise error rate at 0.05 for hypothesis testing, which was controlled using the Holm–Bonferroni procedure.

2.3.3 Qualitative analysis

The qualitative part of the study analyzed both the patients’ and the physical therapists’ perspectives on the exercise therapy concept. The study included two questionnaires, which were completed after the intervention: one for the patients and one for the physical therapists responsible for the rehabilitation period.

The questionnaire for the patients included 12 questions: five ordinal (Likert-scale) questions and seven open-ended questions. The overall aim with the questionnaire was to evaluate exercise therapy as a concept, to gauge the volume of the training, to determine whether the proper functions were covered, to explore advantages and disadvantages of the training concept, and to document any medical adverse events. The questionnaire for the physical therapists included 11 questions: three were Likert-scales, one was a checklist of various treatment methods, and the remaining questions were open-ended. The questions were designed to allow the physical therapists to voice their perspectives on the training and its impact on the patients, with the same underlying reflections as for the patients.

We employed the content analysis method of Graneheim and Lundman for the qualitative analysis [44]. After the questionnaires were transcribed verbatim, they were read multiple times to extract meaning units, which were then coded. Codes were evaluated for their similarities and differences to arrive at subcategories and categories that could then be further abstracted into the themes.

3.2.1 The patients’ perspectives

The focus of the questionnaire was the overall impact of the exercise therapy and how the patients experienced it. Chiefly, four themes illustrated the patients’ experience of the impact of the exercise therapy: individually adapted, reported change in symptoms, emotional perception/experience, and advantages/disadvantages of individual stations. Together, the themes create an overall understanding of the experience.

All patients found the set up and stations well customized according to length and amount. All patients reported that they also continued with home exercises by themselves. Taken together, these experiences make up the theme individually adapted:

Just the right amount [of stations]. Precisely sufficient and adapted to the allocated time. Should not need to stress to have time for everything. – Patient 10

Feels like I have done just the exercises that I needed. – Patient 10

Small but directed movements that have helped me deal with the pain. – Patient 7

Exercising by the physical therapist’s instructions at home. – Patients 1, 8, and 9

The theme reported change in symptoms included categories such as effect on body, effect on activity level, and difficulties in relation to the actual condition of the day. This theme exhibited considerable variation between patients: some experienced increased symptoms after training, while others experienced the opposite. The following quotes exemplify this theme.

Less stiffness. My pain peaks are less frequent. – Patient 14

Have become a little bit stronger. – Patient 4, 5

My muscles have become more relaxed. – Patient 8

My balance has improved a lot. – Patient 10

Ability on the given day has determined what has worked/not worked. Sometimes not been able to do exercises because of pain. – Patient 2

The theme emotional perception/experience included categories such as the importance of individual approach and enhanced awareness, which describe improved self-efficacy and empowerment. This theme was discernible in the following quotations:

It has helped me along the way, actually strengthened my self-confidence. – Patient 10

I have now seen connections between jaw, neck, and eyes that are helpful. – Patient 7

I feel better mentally, feeling stronger. – Patient 5

It feels like I have experienced improved control. – Patient 9

Nice to see a progression that follows the particular painful condition that I have. First time in five years that I have felt I understand my jaw’s role in my headache and neck. – Patient 7

Good to move one’s body and do exercises, helping not just the body but also making oneself more positive. – Patient 5

Under the category enhanced awareness, we identified the subcategory symptoms interfering with training even though I want to train. It involves both bodily and emotional perspectives, which were indirectly apparent in almost all questionnaires.

The theme advantages/disadvantages of individual exercises sums up the experiences of different exercises on the individual level. The results of Question 7 (“Was there any specific exercise that you appreciated in particular?” If so, then which one?”) revealed that all patients sought effectiveness in particular. Question 8 (“Was there any specific exercise that you had difficulties with? If so, then which one?”) also revealed issues with some of the stations, with individual variations as well. There were also reports about progression. Stations explicitly considered beneficial were 1, 2, 4, 5, 8, 10, and 11. Stations explicitly described as provoking and needing adjustments were 2, 4, and 5.

Have been able to increase the number of repetitions and resistance for some exercises. – Patient 2

Have had problems with the jaw exercise, but it feels like I have made a lot of progress also there. – Patient 10

An example of the themes, categories, and codes is presented in Table 2.

The answers to the Likert-scale questions were similar between patients and predominantly positive (Table 3).

3.2.2 The physical therapists’ perspectives

We arrived at three themes that describe the training concept through the physical therapists’ professional lens: setup/protocol of the concept, objective training effect, and influence of the intervention on physical therapists’ daily work routines.

The theme setup/protocol of the concept included, for instance, the categories training stations and individual adaptation. The answers under this theme indicated that program adjustment based on clinical experience is essential. The following quotes describe some of this theme’s aspects:

With structure and adaptation, clinical reasoning and motivation for what needs to be trained and done is accomplished. – Physical therapist regarding patient 8

Clinical reasoning is necessary. – Physical therapist regarding patients 1, 7, and 10

Furthermore, the answers included the observation that training was guided by patients’ response:

Instructions have in fact been bilateral; the patient has given me feedback and guided me in dosage and choice of exercises. – Physical therapist on patient 14

“Mutual understanding” – one of the great benefits of [this therapy]. – Physical therapist regarding patient 7

The theme objective training effect included categories such as patients in training situation, variation in instructions, and effect on symptoms. The answers in this theme concerned adaptations and responses from the patients:

Most [stations] have been managed with modifications. – Physical therapist regarding patient 1

Stimulated everyday activity and approach to physical activity. – Physical therapist regarding patients 8 and 9

In this theme, a sense of individual adaptation depending on pain is very strong. In question 5 (“Has any station lead to patients experiencing more pain?”), the affirmative answer of every questionnaire shows that pain during training is common and that exercises were adapted to tackle this issue:

Comment on stations 2, 3, 4, 10, and 11: Some stations have had to be modified with regard to functional aspects. – Physical therapist regarding patients 7 and 10

The theme influence of the intervention on physiotherapists’ daily work routines included categories such as work instructions and applicability in motivation:

It is necessary for one to be present in the moment, with adaptation and “mutual understanding.” – Physical therapist regarding patients 7 and 10

If one had only done progression without reflection, it would have been dull and ineffective. – Physical therapist regarding patients 2 and 7

Has alleviated things for me as a therapist since it is very structured and clarifies what we focus on, what we have done, and the progress that has occurred. I feel that [this therapy] relieves me of other matters, which allows me to be more present during my time with the patient. – Physical therapist regarding patient 12

Despite the various training stations, the therapists employed concomitant therapy for nine out of ten patients. However, they performed less manual therapy than first expected. The most common treatments were orthopedic manual therapy, soft tissue treatment, acupuncture, and a cognitive approach according to Acceptance and Commitment Therapy.

An example of the responses from the physiotherapists is provided in Table 4.