Does The Use of Electrotherapies Increase The.95042

SPINE An International Journal for the study of the spine, Publish Ahead of Print
DOI: 10.1097/BRS.0000000000002663
Does the use of electrotherapies increase the effectiveness of neck stabilization exercises
for improving pain, disability, mood, and quality of life in chronic neck pain? A randomized,
controlled, single blind study
*Hilal Yesil, MD1, Simin Hepguler2, Umit Dundar1, Sahel Taravati, MD.2, Banu Isleten, MD.3
1
Department of Physical Medicine and Rehabilitation, Afyon Kocatepe University Faculty of
Medicine, Afyon, Turkey
2
Department of Physical Medicine and Rehabilitation, Ege University Faculty of Medicine,
Izmir, Turkey
3
Department of Physical Medicine and Rehabilitation, Yalova Aktif Hospital,Yalova, Turkey
Corresponding author:
Hilal Yesil
Afyon Kocatepe Üniversitesi
Hastanesi Ali Çetinkaya Kampusü Dörtyol mah. 2070 sok. No. 3/4 Afyon.
Tel: +90 (272) 4440304 Fax: +90 (272) 246 33 44 e-mail address: dradanur@yahoo.com
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The manuscript submitted does not contain information about medical device(s)/drug(s).
No funds were received in support of this work.
No relevant financial activities outside the submitted work.
Abstract
Study Design: This study was a prospective, randomized, controlled study.
Objective: The aim of this study was to determine if transcutaneous electrical nerve stimulation
(TENS) or interferential current (IFC) increase the effectiveness of neck stabilization exercises
on pain, disability, mood, and quality of life for chronic neck pain (CNP).
Summary of Background Data: Neck pain is one of the three most frequently reported
complaints of the musculoskeletal system. Electrotherapies; such as IFC and TENS have been
applied solo or combined with exercise for management of neck pain; however, the efficacy of
these combinations are unclear.
Methods: A total of 81 patients with CNP were included in this study. Patients were randomly
assigned into 3 groups regarding age and gender. First group had neck stabilization exercise
(NSE), second group had TENS+ NSE and third group had IFC+ NSE. Pain levels (visual
analogue scale (VAS)), limits of cervical range of motion (ROM), quality of life (short form-
36), mood (Beck depression inventory), levels of disability (Neck Pain and Disability Index) and
the need for analgesics of all patients were evaluated prior to treatment, at 6th and 12th week
follow-up. Physical therapy modalities were applied for 15 sessions in all groups. All
participants had group exercise accompanied by a physiotherapist for 3 weeks and an additional
3 weeks of home exercise program.
Results: According to the intra-group assessment, the study achieved its purpose of pain
reduction, ROM increase, improvement of disability, quality of life, mood, and reduction in drug
use in all three treatment groups (p< 0.05). However, clinical outcomes at 6th and 12 th week
had no significant difference among the three groups (p>0,05).
Conclusion: To conclude, TENS and IFC therapies are effective in the treatment of CNP
patients. However they have no additional benefit or superiority over NSE.
Key words: neck pain; TENS, interferential current; stabilization exercise; disability; quality of
life; depression; cervical range of motion; rehabilitation; cervical spine; randomized controlled
study
Level of Evidence: 2
Introduction
Neck pain is an important individual and socioeconomic health problem, and it has been
reported that neck pain become chronic in up to 60% of patients.1,2 Chronic neck pain in
individuals can seriously affect their quality of life (QOL), leading to psychological, behavioral,
mental and psycho-social disorders.3-5
Transcutaneous electrical nerve stimulation (TENS) is the most commonly used
electrotherapy method to produce analgesic effect in patients with acute or chronic pain.6
According to the gate control theory, large-scale afferent nerve fibers are stimulated to block
pain at the spinal level, and the release of endorphins, the natural analgesic substance of the
body, is increased.7 Currently, TENS has been used extensively for the treatment of neck pain,
despite a lack of good quality studies supporting its use.8 Interferential currents (IFC) are also an
often used electrotherapy method in various painful conditions.9-12 While there are supporting
data showing positive effects of IFCs in different types of pain, randomized-controlled studies
(RCS) showing effectiveness in interfering with chronic neck pain (CNP) are very limited.13,14
Exercise training is the other important method for the treatment of neck pain.15 Several
clinical trials have been performed to investigate the efficacy of varied exercise programs in
patients with CNP.16-18 Today’s popular neck stabilization exercises (NSE) aim to maintain
spinal stability. These exercises range from simple and functional to complex and unplanned
activities.19,20
Review of the literature reveals that whether combined therapies or solo treatments are
more effective for pain, disability, and QOL in the short- and long-term for CNP is still a
question to be answered (8, 13, 18, 21). Therefore, in the present study, we aimed to investigate
whether TENS or IFC increased the effectiveness of NSE exercises on pain, disability, mood,
and QOL in patients with CNP.
Materials and Methods:
Partipicants and Study Design:
The study design was a single-blind, multicenter, RCT to test the effect of NSE, TENS,
and IFC in people with chronic neck pain. Eligible patients aged from 20 to 50 years old with at
least three months of neck pain were included in the study. The participants were excluded if
they had history of any contraindication for electrotherapy, involvement of any disease that may
interfere with treatment, a disc herniation with neurological deficits, neoplasia, neck pain
secondary to neurological or vascular diseases, infection or arthritis in the cervical region,
diagnosed with any psychiatric diseases and treated for it, pregnancy, history of spinal surgery,
physical therapy for neck region within the past six months. These exclusion criteria were
verified by history, physical examination, and imaging techniques.
All participants provided written informed consent form and written permission from
their physician allowing their participation and the hospital ethics committee had approved the
study protocol.
Interventions:
Patients were randomized into 3 groups. First group had NSE, second group had TENS+ NSE
and third group had IFC+ NSE. At the beginning of the study, all physiotherapists were
instructed to apply the treatments in a standardized way; besides, all therapists were trained to
conduct therapies.
Exercise program. A physiotherapist assisted NSE program was performed in groups with four-
five patients five times a week for 3 weeks as described previously.21 (Appendix)
Physical therapy agents; Physical therapy agents were applied 5 times a week for 3 weeks by
the same physiotherapist at each center.
TENS (ITO ES-320, Enraf Sonopuls 692, and Chattanooga Intelect) was applied at a
frequency of 80Hz with 10- to 30-mA intensity for 25 minutes. Four surface electrodes (5x5 cm
each) were situated over the painful region in the neck with intensity in the tactile sensation
threshold. Then, NSE were performed in company with physiotherapist for about one hour.
IFCs ( ITO EU-940, Enraf Sonopuls 692, and Chattanooga Intelect) were applied for 25
minutes with an amplitude- modulated frequency of 100Hz generated by 4-kHz sinusoidal
waves. Two electrodes (6cm) were situated onto the neck region with intensity in the tactile
sensation threshold. Then, NSE were performed in company with physiotherapist for about one
hour.
The physiotherapist prescribed a home-based exercise program (three times a week) at
the end of the three-week. All participants also received a full set of premade exercise cards
describing all exercises to make sure that the program would be done properly. Patient
compliance with home exercise program was assured by phone call one time per week and by
questioning during their visit. All patients were allowed to take paracetamol at doses up to 2000
mg/day for pain control and to continue to use medications for systemic illness by preventing to
take non-steroidal anti-inflammatory drugs one week before and during the study period.
Paracetamol intake was recorded in grams. Patients were asked to record their daily dose of
paracetamol and inform us at 6th and 12th week visit.
Outcomes:
The treatment responses were evaluated at the beginning, at the 6. th week, and at the
12th week after the initial examination of the patients. The demographic characteristics of the
patients were recorded at the beginning of the treatment. Pain severity (primary outcome),
cervical range of motion (ROM), disability status, QOL, and mood measurements were used for
assessment. During the study period, patients’ (daily) paracetamol intake needs were also
examined.
Visual analogue scale (VAS) (primary outcome); we used VAS scoring to assess pain
intensity22 VAS scoring is carried out at the time of patient's visit. (0-10 cm, with higher scores
indicating more pain).
The assessment of cervical ROM was performed by using a goniometer. Participants
carried out neck movements to the fullest extent of their mobility of extension, flexion, left and
right lateroflexion, and left and right rotation while sitting.
The assessment of disability status; was performed by Neck Disability index (NDI). This
indicator consists of ten sections, which were titles as severity of pain, headache, personal care,
lifting, concentration, work life, driving, sleeping, reading and leisure. Each question was rated
between 0 and 5 points. Total score scored between 0 (no disability) and 100 (severe
disability).23
Health-related quality of life assessment was done by short form (SF)-36. There are two
main titles that assessed the physical and mental health dimensions of the survey population.
Total score was between 0 (no disability) and 100 (disability). Every subgroup of the
questionnaire has a score scale between 0 and 100. Every increase in the subgroup of SF-36
questionnaire, which is a positive scoring system, indicates increase in quality of life related with
health.24
The Beck Depression Inventory (BDI); was used to assess the depression levels of the
patients. The BDI evaluates 21 symptoms of depression. These symptoms deal with emotions,
behavioral changes, and somatic symptoms. Each symptom is rated on a 4-point intensity scale.
Higher scores indicate more severe depression.25
Sample size:
To determine the effect size, a preliminary study was conducted with 10 individuals within
groups. From the power analysis, based on the descriptive statistics of the pain score levels
obtained from this study, we determined that a total of 63 persons must be examined with each
group containing at least 21 individuals to identify the statistical significance of the difference in
pain scores within each group under 90% power and 5% Type I error conditions. The power
analysis was conducted with R 3.3.1 open source software.
Randomization and blinding:
Randomization was performed by the principal center of the study into three treatment groups,
regarding patients’ age and gender. Considering both inclusion and exclusion criteria of the
study, principal center of the study was informed before enrolling any participant for the study.
Each participant was given a unique subject number. Subject with the given number was
randomized by the principal center of the study regarding age and gender. Randomization
process was conducted by a medical doctor who is not a contributor of the study. Besides,
investigators, and analysts were blinded, with the exception of patients.
Statistics
Statistical analyses were performed using SPSS 22. The intergroup differences with respect to
categorical variables were assessed using Chi-Square tests. Differences between the averages of
three groups were explored using one-way ANOVA. The repeated-measures analysis of variance
was used to evaluate the time of observation for the clinical assessment parameters. The
Bonferroni test as a post hoc test was used to determine the change between groups. In addition,
the standardized effect size (Cohen's d) was calculated to facilitate the interpretation of
significant outcomes. The significance level was set at p<0.05 for all statistical analyses.
Results
Patient characteristics
A total of 81 patients were recruited. Figure 1 summarizes the patient recruitment, participation
and attrition during the study period. One patient in group 1 could not attend follow-up visit at
3th month due to health problems not related neck pain. No adverse events due to electrotherapy
such as irritation or burning of the skin were observed. None of the patients who completed the
study reported complaints about not completing the home exercise program. No patient received
any other therapy except for paracetamol during follow-up. There were no significant differences
among the groups regarding the demographic characteristics and, symptom duration, VAS,
ROM, SF-36, BDI and NDI (Table 1).
Changes in VAS; In the Table 2, the changes in VAS scale are presented. Significant
improvement in VAS score (d values -0.9 and -1.3 in the exercise group; 2.0 and 2.1 in the
exercise + TENS group; and -0.8 and -1.2 in the exercise + IFC group) was seen in all groups
during follow-up (P < 0. 05). At 6 weeks and at 12 weeks, there was no significant difference
among the three groups.
Changes in ROM; Table 2 presents cervical ROM changes. A significant improvement in
ROM-flexion, ROM-extension , ROM-right and lateral flexion, and ROM-right and left rotation
degrees was seen in all groups during follow-up (P < 0. 05). There was no significant difference
among the groups.
Changes in NDI score A significant improvement in NDI scores (d values 1.6 and 1.9 in the
exercise group; 1.0 and 1.1 in the exercise + TENS group; and 0.9 and 1.2 in the exercise + IFC
group) was seen in all groups during follow-up (P < 0. 05). However, at 6 weeks and at 12
weeks, there was no significant difference among the three groups (Figure 2).
Changes in SF-36 score At 12 weeks, there were significant differences pain (p=0.013) and
social functioning (p=0.014) scores among the groups. In the exercise group, the SF-36 scores
for pain and social functioning improved significantly. Three groups showed significant
improvements SF-36 scoring at 6. and at 12. weeks after treatment (p<0.05), except general
health and vitality (Table 3).
Changes in BDI A significant improvement in BDI scores (d values 1.4 and 1.5 in the exercise
group; 0.8 and 0.9 in the exercise + TENS group; and 0.7 and 0.9 in the exercise + IFC group)
was seen in all groups at 6. and at 12. weeks after treatment (P < 0. 05). There was no significant
difference among the groups during follow-up (Figure 3).
Changes in analgesic usage
Mean paracetamol dose was 32.3 ± 36.2 gr at 6th week and reduced to 10.5 ± 14.9 at 12th week
in NSE group (p=0.000), 40.4 ± 35.9 gr at 6th week and reduced to 15.6 ± 26.4 at 12th week in
TENS+NSE group (p=0.001), and 42.0 ± 40.4 gr at 6th week and reduced 17.1 ± 31.4 at 12th
week (p=0.026) in IFC+NSE group. A comparison between groups at 12th week doses
demonstrated no significant difference (p=0.912).
Discussion
According to the intra-group assessment, the study achieved its purpose of pain
reduction, ROM increase, improvement of disability, QOL, mood, and reduced number of drug
use in all treatment groups. Statistically significant differences could not be found between the
treatment groups. TENS is one of the most widely used methods of electrotherapy.
Although substantiated by little evidence, a recent Cochrane review reported that applying TENS
for neck pain, despite not being more effective than exercise, may be more effective than
placebo.8 Evaluation at the literature demonstrates that, there are very few studies investigating
the outcome of concurrent electrotherapies and exercise in patients with chronic neck pain.21,26,27
Escartell Mayor et al.26 have randomly assigned a sum of 90 patients to TENS+exercise
group (n:43) and manual therapy +exercise group (n:47). Primary outcome measure of this study
was pain intensity by VAS scoring system similar to our study. Authors have reported a short-
term pain reduction that is clinically relevant in both groups after 10 sessions of treatment.
However, this study had applied isometric and neck exercise as distinct from our study.
IFC is another very commonly used electrotherapy method in the field of rehabilitation
for analgesic purposes.28 Only a few studies exist on the efficacy of IFC for neck pain. A study
by Hou et al.27 included 71 patients who were randomly assigned to six groups to apply active
ROM exercise with TENS or IFC therapies. Authors have reported significant improvement in
pain in all groups concerning pre/post treatment (p < 0.05). Unlike our study, patients had active
ROM exercise for one session. Acedo et al.13 compared the efficacy of TENS and IFC on
muscle relaxation in the upper trapezius of women. They reported that relaxation with IFC was
achieved after three sessions, bu that TENS caused no change in muscle tension, though there
was a decrease in pain in both groups. We also observed in our study that IFC had positive
effects on pain, and we consider that the muscle spasm reduction effect of IFC may have
contributed to the result, although this is not the only factor. In another study, the efficacies of
TENS and IFC in myofascial pain syndrome (MPS) were compared; 105 patients were randomly
assigned to three groups such as: standart care (hot pack, active range of motion exercises,
myofascial release, and a home exercise program with postural advice), TENS + standard care
and IFC+ standard care; thereafter, patients were were evaluated for pain and ROM after a four-
week treatment program, but unlike our study, no functional outcome measurement was
performed. In their study, significant improvements were observed in the TENS group
immediately after the treatment, compared to the IFC and control group (p< 0.05).14 In our study,
on the other hand, no significant difference was found between the TENS and IFC groups in
terms of variables. However, we included not only MPS patients, but also patients with CNP
which may be associated with other causes, and the difference may be due to this. We also
believe that the additional prescription of exercise for all groups may have caused differing
results.
A study by Düşünceli et al.21; 60 patients were randomized into three groups: Group 1 –
physical therapy agents (TENS + continuous ultrasound + infra-red irradiation); group 2 –
(physical therapy agents + isometric and stretching exercises), and group 3– (physical therapy
agents + NSE). Authors have reported that, compared with baseline, all groups showed a
significant decrease in VAS scores during the first 6 months. However, this improvement was
maintained only in group 3 at 9 and 12 months. We applied physical therapy agents in seperate
fashion concurrent with exercise as distinct from Düşünceli et al.21 In addition we did not use
superficial or deep heat therapies.
In this study, although the possibility of the placebo effect could not be ruled out,
significant improvements were observed in in terms of the variables mentioned in the TENS and
IFC groups within the three-month follow-up period. However, no significant difference was
found in the inter-group evaluations during the follow-up.
Exercise is one of the most commonly used rehabilitation methods in terms of reducing
pain and disability and continuing daily life activities.15 The importance of NSE, including
craniocervical flexion (CCF) exercises in deep group muscle training, is steadily increasing.18,29
These exercises are aimed at supporting the vertebral column by activating the stabilizing
muscles and developing and maintaining proper posture by increasing kinesthetic awareness.
Despite their popularity for back and pelvic pain,30-32 the number of well-designed, RCS
evaluating the efficacy of stabilization exercises for neck pain is very little.
Chung et al.33 evaluated the effect of NSE exercise compared to cervical isometric
exercise on the NDI in patients with CNP, and results indicated that the NSE program was an
effective treatment to reduced functional disabilities in these patients. In the study conducted by
Chiu et al.34 the efficacy of the CCF exercise and dynamic strength training + infrared and neck
care advice in patients with CNP were evaluated in comparison with a control group (just
received IR and neck care advice). After six weeks, patients in the exercise group experienced
significant improvements in terms of pain and disability compared with the control group.
Dusunceli et al.21 reported that NSE practiced for three weeks in patients with CNP caused
several changes; a significant decrease in pain severity after treatment and during long-term
follow-up, and a decrease in the amount of medication taken by the exercise group.
Very few studies have investigated the effects of NSE on QOL and mood in patients with
CNP. Celenay et al.35 reported that stabilization exercises significantly improved QOL scores at
the end of week 4. A study by Dusunceli et al.21 reported a significant decrease in BDI scores in
the stabilization exercise group.
There are limited number of studies investigating the effect of neck stabilization exercise
on cervical ROM in patients with chronic neck pain.21,35,36 Çelenay et al.35 and Dusunceli et al.21
have reported NSE improve cervical ROM in patients with chronic neck pain. Consistent with
existing literature we observed significant improvement of cervical ROM in all groups (NSE,
NSE+TENS, NSE+ IFC) .We attribute this result to the destruction of a vicious cycle between
pain and muscle spasm by treatment.
Medication is another method to relieve symptoms in chronic neck pain. We observed
significantly lower dose of paracetamols needed for pain control in all groups. Likewise, another
study by Grıffıths C et al.37 also has reported lower demand for analgesics in stabilization
exercise group.
In our study, NSE benefited patients with CNP, supporting other studies. Patients
improved during a three-month period in most subsets of QOL score, pain, disability, ROM,
mood states, and drug use. Inhibition of pain through increased muscle strength by stabilization
exercises targeting weakened deep neck muscles and the concomitant decrease in spasm of
superficial muscles, excessive muscle activation, and fatigue may have contributed to the
achievement of these results. At the same time, a reduction in the patient’s level of pain may
have increased their flexibility, thereby increasing ROM and decreasing the dose of the
medications used. Again, the improvement in motor control through exercise may have led to a
reduction in over-straining and an improvement in the mobility of the patients, and thus an
increase in their QOL.
Limitations
There are some limitations in this study. First, methodologically the blindness of the
patients is difficult. Second, we evaluated the intermediate results of the patients in our study.
We consider that it may be more useful to carry out long-term follow-up studies that will confirm
our findings and show longer-lasting effects. In addition, the relatively low number of patients in
the study presents another limitation that restricts the scope of the study. Although patient
compliance and attendance rates were good, the hospital setting (for the first three weeks of the
program) may have been another limitation.
On the other hand, this is the first prospective, RCS in the literature to evaluate the
efficacy of TENS / IFC in exercise and exercise in patients with CNP. In addition, presenting
evidence-based data is the other strenght of this study.
Conclusion
In this study, significant improvements were observed in all groups with respect to pain,
disability, cervical ROM, mood, QOL, and drug use, while we did not observe a statistical
difference in improvements to these variables among groups in patients with CNP. Based on
these results, it can be concluded that TENS and IFC are effective treatment methods in patients
with CNP; however, they have no advantage over CSE, and these agents do not provide any
additional benefits to exercise.
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Figure Legends:
Figure 1. Flow chart of the study
Assessed for eligibility

(n=98)
Excluded (n:7)
Refused to participate (n=10)
Randomized (n=81)
Exercise TENS + IFC + exercise

(n=27) exercise (n=27) (n=27)
27 were 27 were 27 were

followed up at followed up at 6 followed up at
6 weeks weeks 6 weeks
26 were 27 were 27 were

Drop out (n=1)
followed up at followed up at followed up at
Health problems 12 weeks 12 weeks 12 weeks
not related neck
pain (n=1)
Analysed
2 Changes in
Figure 2. n Neck Disab
bility Index score duringg the study
Figure 3. Changes in
n Beck Deprression Inven
ntory score dduring the sttudy
Table 1. Baseline demographic and clinical characteristics of the patients
Variables Exercise Exercise + TENS Exercise + *p value

IFC
n:27 n:27
n:27
Age, years 36.03 ± 38.59 ± 9.19 39.74 ± 0.277

7.86 8.76
Sex, M/F 11 / 16 8 / 19 6 / 21 0.333
Body Mass Index, kg/m2 24.55 ± 25.88 ± 4.72 25.11 ± 0.555
3.73 4.98
Marrital status, Married 25 (92.6) 20 (74.1) 22 (81.5) 0.453
Educational background
Primary / Secondary / High / University 15 / 3 / 8 / 14 / 3 / 1 / 9 14 / 2 / 4 / 0.119
1 7
Symptom duration, months 17.00 ± 21.70 ± 16.69 25.44 ± 0.204
4.96 24.31
Range Of Motion, degree
Flexion 40.14 ± 42.07 ± 5.91 41.07 ± 0.413
4.99 4.92
Extension 50.37 ± 47.96 ± 7.99 47.03 ± 0.223
5.35 7.99
Right lateral flexion 38.03 ± 38.14 ± 6.34 36.18 ± 0.429
4.40 7.45
Left lateral flexion 38.51 ± 37.59 ± 5.77 36.48 ± 0.448
3.87 7.44
Right rotation 62.59 ± 59.29 ± 13.41 61.74 ± 0.572
7.12 13.80
Left rotation 61.85 ± 57.74 ± 14.01 60.85 ± 0.345
7.22 9.82
Visual Analog Scale 6.88 ± 6.59 ± 2.09 5.96 ± 1.12 0.118
1.60
Short Form-36
Physical functioning 60.18 ± 65.92 ± 19.80 65.37 ± 0.323
13.40 11.67
Physical role 24.07 ± 31.48 ± 35.07 24.07 ± 0.628
30.60 29.80
Pain 35.66 ± 37.11 ± 17.58 31.81 ± 0.459
15.62 14.80
General health 46.55 ± 51.44 ± 15.16 43.62 ± 0.063
7.54 12.40
Vitality 49.62 ± 58.33 ± 16.46 51.66 ± 0.107
11.84 17.81
Social functioning 56.01 ± 51.62 ± 17.86 47.38 ± 0.188
16.75 16.79
Emotional role 45.65 ± 30.86 ± 33.27 43.16 ± 0.224
29.44 36.77
Mental health 58.00 ± 58.07 ± 12.22 52.88 ± 0.219
10.32 14.35
Beck Depression Inventory 13.11 ± 12.85 ± 8.57 14.22 ± 0.818
8.58 8.11
Neck Disability Index 45.03 ± 42.07 ± 17.65 40.07 ± 0.559
18.46 14.43
Data were presented as mean ± SD or n (%). *Chi square tests and ANOVA were used for
comparison
Bold values show statistically significant P-values (p < 0.05)
Table 2. Comparison of mean VAS and ROM values of groups at baseline, at 6 week and at
12 Week
Exercise + *p
Exercise Exercise + IFC
TENS value
Visual Analog Scale
Baseline 6.88 ± 1.60 6.59 ± 2.09 5.96 ± 1.12
4.44 ± 1.69 3.59 ±
At 6th week 3.92 ± 2.18 ** 0.232
** 1.55 **
Mean differences 2.44 3 2.04
95% CI 2.09 to 2.8 2.4 to 3.6 1.23 to 2.84
Effect size (d) -0,9 2 -0,8
3.65 ± 3.00 ± 1.35
At 12th week 3.40 ± 1.98 ** 0.323
1.32 ** **
Mean differences 3.23 3.59 2.56
2.91 to
95% CI 2.78 to 3.6 1.89 to 3.23
4.27
Effect size (d) -1.3 2.1 -1.2
ROM, Flexion
42.07 ±
Baseline 40.14 ± 4.99 41.07 ± 4.92
5.91
45.25 ± 45.37 ±
At 6th week 46.22 ± 3.33 ** 0.561
4.01 ** 3.37 **
-5.19 to -
95% CI -5.96 to -4.27 -6.96 to -3.33
1.4
Effect size (d) -2.4 -0.7 -1.1
48.03 ± 2.77 46.66 ±
At 12th week 47.59 ± 2.54 ** 0.2
** 3.10 **
-7.15 to -
95% CI -9.43 to -6.34 -8.38 to -4.65
2.04
Effect size (d) -2.1 -0.7 -1.4
ROM, Extension
47.96 ±
Baseline 50.37 ± 5.35 47.03 ± 7.99
7.99
56.29 ± 3.27 50.92 ±
At 6th week 50.92 ± 6.20 ** 0.002
** 7.84 **
-4.63 to -
95% CI -7.48 to -4.37 -6.3 to -1.48
1.29
Effect size (d) -1.5 -0.7 -0.6
58.46 ± 52.40 ±
At 12th week 52.96 ± 6.24 ** 0.002
2.74 ** 9.23 **
-7.21 to -
95% CI -10.06 to -6.09 -8.44 to -3.41
1.68
Effect size (d) -1.6 -0.6 -0.9
ROM, Right lateral flexion
38.14 ±
Baseline 38.03 ± 4.40 36.18 ± 7.45
6.34
42.29 ± 42.66 ±
At 6th week 41.74 ± 5.31 ** 0.751
3.17 ** 4.77 **
-6.27 to -
95% CI -5.32 to -3.2 -7.55 to -3.56
2.77
Effect size (d) -1.6 -1 -1,1
43.84 ± 2.57 43.77 ±
At 12th week 42.74 ± 4.65 ** 0.489
** 3.76 **
-8.05 to -
95% CI -7.37 to -4.4 -8.62 to -4.49
3.21
Effect size (d) -1.6 -0.9 -1.3
ROM, Left lateral flexion
37.59 ±
Baseline 38.51 ± 3.87 36.48 ± 7.44
5.77
42.22 ± 3.20 42.40 ±
At 6th week 41.66 ± 5.37 ** 0.826
** 4.87 **
-6.59 to -
95% CI -4.74 to -2.66 -7.04 to -3.33
3.04
Effect size (d) -1.4 -1 -1.1
43.84 ± 2.57 43.51 ±
At 12th week 42.77 ± 4.66 ** 0.581
** 3.87 **
-8.32 to -
95% CI -6.65 to -4.12 -8.32 to -4.27
3.53
Effect size (d) -1.7 -0.9 -1.2
ROM, Right rotation
59.29 ±
Baseline 62.59 ± 7.12 61.74 ± 13.80
13.41
70.37 ± 7.58 67.07 ±
At 6th week 69.81 ± 10.60 ** 0.414
** 10.63 **
-10.59 to - -11.88 to -
95% CI -12.09 to -4.05
4.96 3.68
Effect size (d) -1.1 -0.8 -0.8
71.15 ± 70.18 ±
At 12th week 72.51 ± 9.14 ** 0.695
10.12 ** 10.87 **
95% CI -12.33 to -4.6 -15.18 to - -15.77 to -5.78
6.6
Effect size (d) -0.9 -1 -0.9
ROM, Left rotation
57.74 ±
Baseline 61.85 ± 7.22 60.85 ± 9.82
14.01
69.62 ± 65.59 ±
At 6th week 69.00 ± 10.72 ** 0.273
7.06 ** 11.16 **
-10.7 to -
95% CI -10.54 to -5.02 -12.15 to -4.14
5.0
Effect size (d) -1.1 -1.1 -0.8
70.76 ± 9.02 67.59 ±
At 12th week 69.00 ± 9.49 ** 0.489
** 10.31 **
-14.02 to -
95% CI -12.24 to -5.45 -12.34 to -3.96
5.68
Effect size (d) -1.1 -0.9 -0.8
ROM, range of motion. VAS, Visual Analog Scale. Analysis of variance (ANOVAs) for
repeated measurements was used both for * between-group and, for **within-group
comparisons, ** P <0,05, statistically significant difference. Bold p values indicate significant
differences among the groups.
Table 3. SF-36 scoring among groups at baseline, at 6. week and at 12. week
SF-36 scoring Exercise Exercise + Exercise + *p value

TENS IFC
Physical functioning
 Baseline 60.18 ± 13.40 65.92 ± 19.80 65.37 ± 11.67
 At 6th week 72.59 ± 11.71 ** 80.55 ± 12.42 76.29 ± 17.07 0.117
** **
95% CI -15.94 to -8.88 -21.28 to - -18.27 to -
7.98 3.59
Effect size (d) -1.4 -0.9 -0.6
 At 12th week 76.15 ± 11.07 ** 79.4 ± 15.6 ** 78.5 ± 19.2 ** 0.737
95% CI -20.07 to -12.62 -21.85 to - -22.3 to -4.0
5.18
Effect size (d) -1.8 -0.6 -0.6
Physical role
 Baseline 24.07 ± 30.60 31.48 ± 35.07 24.07 ± 29.80
 At 6th week 56.48 ± 36.42 ** 72.22 ± 31.26 57.40 ± 35.90 0.179
** **
95% CI -42.6 to -22.21 -55.29 to - -49.33 to -
26.19 17.34
Effect size (d) -1.3 -1.1 -0.8
 At 12th week 77.8 ± 37.6 ** 80.55 ± 27.15 66.66 ±31.00 0.249
** **
95% CI -69.62 to -36.15 -63.45 to - -59.68 to -
34.7 25.5
Effect size (d) -1.3 -1.4 -1.0
Pain
 Baseline 35.66 ± 15.62 37.11 ± 17.58 31.81 ± 14.80
 At 6th week 55.18 ± 17.48 ** 60.03 ± 20.03 47.96 ± 21.86 0.087
** **
95% CI -28.34 to -10.69 -30.31 to - -24.38 to -
15.55 7.92
Effect size (d) -0.9 -1.2 -0.8
 At 12th week 67.65 ± 14.71 ** 63.07 ± 15.33 54.62 ± 17.37 0.013
** **
95% CI -41.34 to -22.2 -33.21 to - -30.18 to -
18.72 15.45
Effect size (d) -1.3 -1.4 -1.2
General health
 Baseline 46.55 ± 7.54 51.44 ± 15.16 43.62 ± 12.40
 At 6th week 50.81 ± 10.42 53.22 ± 12.47 47.33 ± 17.60 0.296
95% CI -9.67 to 1.15 -4.08 to 0.52 -8.32 to 0.91
Effect size (d) -0.3 -0.3 -0.3
 At 12th week 49.92 ± 7.86 ** 54.18 ± 14.00 47.44 ± 13.85 0.132
**
95% CI -6.14 to -0.09 -5.31 to -0.18 -8.13 to 0.5
Effect size (d) -0.4 -0.4 -0.3
Vitality
 Baseline 49.62 ± 11.84 58.33 ± 16.46 51.66 ± 17.81
 At 6th week 50.74 ± 7.55 60.55 ± 14.43 57.59 ± 22.41 0.075
**
95% CI -5.23 to 3.01 -4.23 to -0.22 -11.55 to -0.3
Effect size (d) -0.1 -0.4 -0.4
 At 12th week 51.92 ± 9.70 61.29 ± 13.12 54.62 ± 19.75 0.066
**
95% CI -8.25 to 4.01 -6.36 to 0.43 -10.75 to 4.82
Effect size (d) -0.1 -0.3 -0.2
Social functioning
 Baseline 56.01 ± 16.75 51.62 ± 17.86 47.38 ± 16.79
 At 6th week 75.92 ± 17.30 ** 68.70 ± 18.97 64.46 ± 21.79 0.098
** **
95% CI -28.93 to -10.89 -25.55 to -8.6 -26.58 to -
7.57
Effect size (d) -0.9 -0.8 -0.7
 At 12th week 79.82 ± 15.82 ** 70.48 ± 16.56 66.27 ± 17.62 0.014
** **
95% CI -34.88 to -14.2 -26.55 to - -27.75 to -
11.15 10.03
Effect size (d) -1.0 -1.0 -0.8
Emotional role
 Baseline 45.65 ± 29.44 30.86 ± 33.27 43.16 ± 36.77
 At 6th week 64.17 ± 35.71 ** 59.16 ± 29.80 66.61 ± 36.99 0.720
** **
95% CI -31.87 to -5.17 -41.33 to - -34.91 to -
15.26 11.98
Effect size (d) -0.5 -0.9 -0.8
 At 12th week 79.46 ± 31.38 ** 74.05 ± 26.74 74.05 ± 32.47 0.756
** **
95% CI -47.6 to -19.09 -58.65 to - -49.88 to -
27.71 11.9
Effect size (d) -0.9 -1.1 -0.6
Mental health
 Baseline 58.00 ± 10.32 58.07 ± 12.22 52.88 ± 14.35
 At 6th week 64.74 ± 10.17 ** 64.59 ± 12.23 62.81 ± 13.71 0.810
** **
95% CI -11.03 to -2.45 -10.73 to - -16.49 to -
2.31 3.37
Effect size (d) -0.6 -0.6 -0.6
 At 12th week 65.92 ± 11.73 ** 65.51 ± 11.46 65.92 ± 12.27 0.990
** **
95% CI -13.56 to -1.82 -12.76 to - -19.67 to -6.4
2.13
Effect size (d) -0.5 -0.6 -0.8
Analysis of variance (ANOVAs) for repeated measurements was used both for * between-group
and, for **within-group comparisons. ** P <0.05 with baseline. * Bold p values indicate
significant differences among the groups.
Appendix. Summary of the neck stabilization exercise programme21
1- Postural re-education To find a neutral balanced position

(in the sitting position)
2- Jogging For warming up (5 min)
3- Stretching exercise Cervical, shoulder, chest and scapular muscles

(in the standing position) (10 repetations)
4- Cervical isometric exercises In the supine position with the head supported on a pillow (10
repetations)
5- Cervical isometric exercises In the sitting position by resisting at the forehead or off the
edge of a table againts gravity (10 repetations) (in a progressive
manner)
6- Varying degrees of upper extremity Progressing from unilateral arm raises, to reciprocal arm raises,
movement exercises to bilateral arm raises
(1st week: in the supine position, 10 repetations) (2nd and 3rd
weeks: in the sitting and standing position, 10 repetations)
7- Resistive exercises Red, blue and green colours of Thera-band tubing were used in
a progressive manner by increasing the density of tubes each
week.
8- Resistive exercises Dumb-bell exercises for upper extremity and shoulder muscles
(two sets, 15 repetations, with 1-2 kg)

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SPINE An International Journal for the study of the spine, Publish Ahead of Print

controlled, single blind study

Medicine, Afyon, Turkey

Study Design: This study was a prospective, randomized, controlled study.

these combinations are unclear.

3 weeks of home exercise program.

had no significant difference among the three groups (p>0,05).

patients. However they have no additional benefit or superiority over NSE.

mental and psycho-social disorders.3-5

Transcutaneous electrical nerve stimulation (TENS) is the most commonly used

and QOL in patients with CNP.

Materials and Methods:

Partipicants and Study Design:

secondary to neurological or vascular diseases, infection or arthritis in the cervical region,

verified by history, physical examination, and imaging techniques.

the same physiotherapist at each center.

minutes with an amplitude- modulated frequency of 100Hz generated by 4-kHz sinusoidal

The physiotherapist prescribed a home-based exercise program (three times a week) at

paracetamol and inform us at 6th and 12th week visit.

indicating more pain).

The assessment of cervical ROM was performed by using a goniometer. Participants

right lateroflexion, and left and right rotation while sitting.

Higher scores indicate more severe depression.25

analysis was conducted with R 3.3.1 open source software.

Randomization and blinding:

investigators, and analysts were blinded, with the exception of patients.

ROM, SF-36, BDI and NDI (Table 1).

among the three groups.

Changes in ROM; Table 2 presents cervical ROM changes. A significant improvement in

among the groups.

health and vitality (Table 3).

difference among the groups during follow-up (Figure 3).

demonstrated no significant difference (p=0.912).

Escartell Mayor et al.26 have randomly assigned a sum of 90 patients to TENS+exercise

physical therapy agents (TENS + continuous ultrasound + infra-red irradiation); group 2 –

superficial or deep heat therapies.

found in the inter-group evaluations during the follow-up.

the stabilization exercise group.

pain and muscle spasm by treatment.

Medication is another method to relieve symptoms in chronic neck pain. We observed

increase in their QOL.

program) may have been another limitation.

evidence-based data is the other strenght of this study.

additional benefits to exercise.

added predictive value of psychosocial variables in addition to clinical variables. Scandinavian

Journal of Pain. 2017; 14: 44–52

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Ther. 2008. 31: 491-02

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transcutaneous electrical nerve stimulation-Induced antihyperalgesia. J Pain. 2005;6:673–80

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9- Goats GC. Interferential Current Therapy. Br J Sports Med 1990;24:87-92

during application in various models of inflammatory pain. Phys Ther 2006;86:800-8

11- Tugay N, Akbayrak T, Demirtürk F, et al. Effectiveness of transcutaneous electrical nerve

stimulation and interferential current in primary dysmenorrhea. Pain Med 2007;8:295-300.

discomfort: An electromyographic analysis. J Back Musculoskelet Rehabil. 2015;28(1):19-24.

in Myofascial Pain Syndrome. Am J Phys Med Rehabil 2016;95:663-72.

Database Syst Rev 2015;28:CD004250

Complement Ther Clin Pract. 2017 Oct 14. pii: S1744-3881(17)30374-2.

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