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Journal of Back and Musculoskeletal Rehabilitation -1 (2017) 1–6 1

DOI 10.3233/BMR-169583
IOS Press

The effect of stabilization exercise training on

pain and functional status in patients with
cervical radiculopathy
Nihal Geleceka and Hakan Akkanb,∗
a
School of Physical Therapy and Rehabilitation, Dokuz Eylul University, Inciralti-Izmir, Turkey
b
Department of Physiotherapy and Rehabilitation, School of Health Sciences, Dumlupinar University, Kutahya,
Turkey

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Abstract.
BACKGROUND: There is no consensus about treatment of neck patients who have radicular symptoms.
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OBJECTIVE: The purpose of the study was to investigate the effect of stabilization exercise training on pain and functional
status in patients with cervical radiculopathy.
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METHODS: The patients (n = 32) with cervical radiculopathy were randomized to two groups as follows: Stabilization exercise
group (Group 1; n = 18); Home-exercise group (Group 2; n = 16). The patients were evaluated with visual analog scale, Neck
Disability Index, SF-36 (Short-Form), Corbin postural assessment scale and hand grip at baseline, after treatment at 4th week
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and 3rd month.

RESULTS: At baseline, there were no statistically differences between groups in terms of evaluated parameters (p > 0.05).
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After treatment and three months later, pain and Neck Disability Index decreased; Corbin postural scores, hand grip and SF-36
scores improved statistically in both groups (p < 0.05). Changes of the measurements in both groups were similar and there were
no significant differences between group 1 and group 2 at 4th week and 3rd month (p > 0.05) except postural scores.
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CONCLUSIONS: This study demonstrates that stabilization exercise training could be an effective intervention for decreasing
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pain and improving quality of life and posture in patients with cervical radiculopathy.

Keywords: Cervical radiculopathy, neck pain, stabilization exercise, disability

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1 1. Introduction dence of cervical radiculopathy has been reported as 10

0.3% [2]. 11

2 Cervical disk herniation and osteophyte are the main Patients with cervical radiculopathy mostly seek 12

3 causes of cervical radiculopathy. Cervical disk hernia- treatment for neck pain, numbness, tingling sensation, 13

4 tion usually causes the inflammation compressing the reduced grip strength, and overall weakness on the up- 14

5 nerve root which may result in radicular symptoms in per extremity muscles. In the advanced disease, cervi- 15

6 the ipsilateral extremity. Symptoms may vary accord- cal muscles, which particularly contribute to the me- 16

7 ing to the affected nerve root, sensory, motor, and auto- chanical stability of the cervical region at a rate of 17

8 nomic branches of the peripheral nerve [1]. Although 80% [3], are affected and disability occurs. Similarly, 18

9 it is not common as lumbar radiculopathy, the inci- the strength loss of the upper extremity depending on 19

the affected nerve root level leads to limitation in the 20

∗ Corresponding author: Hakan Akkan, Department of Physiother-

upper extremity functions. 21

apy and Rehabilitation, School of Health Sciences, Dumlupinar Uni-

On the other hand, forward head posture or postu- 22

versity, 43100 Kutahya, Turkey. Tel.: +90 274 2652031 3615; Fax: ral distortion frequently appears in patients with neck 23

+90 274 265 21 91; E-mail: hakan.akkan@dpu.edu.tr. problems, and continuous forward head posture in- 24

ISSN 1053-8127/17/$35.00
c 2017 – IOS Press and the authors. All rights reserved
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2 N. Gelecek and H. Akkan / The effect of stabilization exercise training on pain and functional status in patients

25 creases the load on the posterior cervical structures, rheumatoid arthritis, fractures or osteoporosis previ- 73

26 leading to weakness of the deep cervical muscles. Sev- ously, and those with a cervical steroid injection his- 74

27 eral studies have shown that forward head posture is tory within the past three months were excluded from 75

28 associated with shortened posterior neck extensors, the study. 76

29 and tightened and weakened anterior neck muscles.

30 The cervical stabilization exercises, which can be per- 2.1. Study design 77

31 formed safely, can be used to increase the cervical

32 stabilization. In addition, these exercises are capable Patients who met the inclusion criteria were divided 78

33 of enhancing mobility, increasing vertebral alignment, into two groups with simple random sampling method. 79

34 and improving sensorimotor function [4]. We used a table of random numbers for generating 80

35 Based on the literature data, therapeutic applica- digit. A standardized physiotherapy protocol and sta- 81

36 tions of lumbar and cervical stenosis include traction, bilization exercises were applied to Group 1 (n = 23), 82

37 manipulation/mobilization, therapeutic exercises, and while only a standardized physiotherapy protocol was 83

38 electrophysical agents [1,5]. However, no consensus applied to Group 2 (n = 23). 84

39 on the most effective treatment intervention has been Baseline characteristics of all patients were evalu- 85

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40 reached upon, yet. Recently, neck stabilization exer- ated, and demographic data were recorded. The VAS 86

41 cises have gained popularity among therapeutic ex- (0–10) was used to evaluate the intensity of pain [10]. 87

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42 ercises, although studies frequently included patients Neck pain-related disability was assessed with the 88

with mechanical neck pain [6,7]. Mitsutake et al. [8] Neck Disability Index, and disability scores of the pa-

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43 89

44 found a significant difference in the muscle structure tients were noted [11]. The Corbin method, which eval-
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45 of the patients with cervical spondylotic radiculopa- uates the patients from the lateral, posterior, and an- 91

46 thy and healthy controls. The authors demonstrated terior view, was used to determine the postural im- 92

fatty infiltration in cervical multifidus muscle in pa- pairments. Each lateral, posterior, and anterior score
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47 93

48 tients with cervical spondylotic radiculopathy, and was marked between ‘0’ and ‘3’ (0: none, 1: mild, 2: 94

49 concluded that it could lead to alteration in this mus- moderate, 3: severe) [12]. The grip strength was mea- 95
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50 cle activity. Therefore, in this study, we aimed to inves- sured using a hand dynamometer (JAMAR) in the sit- 96

51 tigate the effects of cervical stabilization exercises on ting position with 0 degree shoulder abduction, fore- 97
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52 the pain severity, neck disability, grip strength, posture, arm and wrist in the neutral position with 90 de- 98

53 and quality of life in the patients with cervical radicu- gree elbow flexion. Three measurements were applied 99
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54 lopathy. in both sides, and the mean value of the affected 100

side was recorded. Between each measurement, 30- 101

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second offs were given. The Quality of Life Ques- 102

55 2. Material and method tionnaire (QoLQ)-Short Form-36 (SF36) was used to 103
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evaluate the quality of life of the patients. Scores, 104

56 A written informed consent was obtained from each which were obtained from the physical and mental sub- 105
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57 patient. The study protocol was approved by the Non- dimensions, were recorded separately [13]. 106

58 invasive Research Ethics Committee of Dokuz Eylul

59 University (2012/38-07). The study was conducted in 2.2. Treatment protocol 107

60 accordance with the principles of the Declaration of

61 Helsinki. 2.2.1. Standardized physiotherapy protocol 108

62 Forty-six patients who were diagnosed with cervical Electrotherapy modalities consisting of 15-min hot 109

63 radiculopathy and referred to the physical therapy unit pack + 15-min transcutaneous electrical nerve stimu- 110

64 by the treating physician were included in this study. lation (TENS; Intelect Advanced Combo, Chattanooga 111

65 Inclusion criteria were as follows: positive Spurling Medical Supply Inc.) + 5-min therapeutic ultrasound 112

66 test, distraction test, and upper limb tension test results (US) (continuous mode, 1.5 watt/cm2 ) (Intelect Ad- 113

67 (median nerve bias) [9], having less than 60 degree ip- vanced Combo, Chattanooga Medical Supply Inc.) 114

68 silateral cervical rotation with an arm pain more than were applied to the glenohumeral joint. In the onset of 115

69 40 mm, as assessed using the Visual Analogue Scale the treatment, all patients were trained on the postural 116

70 (VAS), having dermatomal arm pain, and not using alignment. The treatment protocol was applied for four 117

71 any analgesic. Patients who had cervical and thoracic weeks and fifteen sessions. During the treatment, com- 118

72 surgery, had upper motor neuron findings, a tumor, bined and special exercise programs for 20 to 30 min 119
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N. Gelecek and H. Akkan / The effect of stabilization exercise training on pain and functional status in patients 3

Table 1
120 including stretching exercises (i.e., cervical neck mus- Characteristics of patients according to treatment groups
121 cles, shoulder muscles and scapular muscles), isomet-
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122 ric exercises (i.e., giving resistance with his/her hand
Age (years) Group 1 18 40.44 7.83 0.381
123 from the forehand in the direction of the cervical flex-
Group 2 14 37.14 9.81
124 ion, extension, rotation and lateral flexion in the sitting Height (cm) Group 1 18 163.50 5.39 0.606
125 position), and postural exercises were administered. Group 2 14 162.86 6.10
126 Before home-based exercise therapy, all exercises were Body weight (kg) Group 1 18 72.05 16.05 0.608
127 conducted under the supervision of the physiotherapist Group 2 14 69.42 13.47
Body mass Group 1 18 26.68 5.21 0.849
128 for four weeks. Exercises were done once a day with index (kg/m2 ) Group 2 14 26.22 5.30
129 one set and 8 to 10 repetitions. Home-based exercises ∗ Results of Mann-Whitney U test.
130 were given to all patients before discharge until week
131 12 with three times a week.
3. Results 170

132 2.2.2. Stabilization exercise protocol

133 Stabilization exercises were added to the standard The study population included a total of 46 patients. 171

program for the patients in Group 1. Initially, postu- However, 32 patients completed the study. In Group 172

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134

135 ral alignment training was given all patients. Then, 1, 18 patients including 16 females and 2 males and 173

136 cervical stabilization exercises were applied. During in Group 2, 14 patients including 13 females and 1 174

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137 the exercises, all patients were instructed to maintain male completed the study. Four patients who received 175

an analgesic due to pain relief, five patients who did

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138 their postural alignment. An exercise protocol, which 176

139 was developed by Ylinen et al. [14] for patients with not perform exercises three times a week regularly,
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140 chronic neck pain and known as stabilization exercise and five patients who did not participate in the final 178

141 program consisting of exercises using an elastic rubber visit were excluded from the analysis. The mean age 179
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142 band, was applied. These exercises included cervical of all study population was 39 (range: 25 to 57) years. 180

143 flexion-dynamic isometric (in the sitting position), cer- Fifteen patients and 12 patients were right-handed in 181

vical extension-dynamic isometric (in the sitting posi- Group 1 and Group 2, respectively. Dominant side
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144 182

145 tion), chest flies, bench press, shoulder shrug, biceps and non-dominant side was equally affected in both 183

146 curl, and bend over roll on the upright position. Exer- groups (Group 1: 9 right side, 9 left side; Group 2: 7 184
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147 cises were initiated with a yellow-color elastic rubber right side, 7 left side). There were no statistical signif- 185

148 band with 15 repetitions. Each week, the number of icant differences in the age, height, body weight, and 186
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149 sets and repetitions increased, and exercises were given body mass index of the patient groups (p > 0.05) (Ta- 187

150 as a home-based program at the end of the week 4. ble 1). In addition, there were no significant differences 188
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151 The follow-up was carried out by phone calls. The in the baseline pain intensity scores, disability levels, 189
152 patients who performed the exercises less than three posture, grip strength, and QoLQ scores between the 190
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153 times in a week or who never did during two consecu- groups (p > 0.05) (Table 2). 191
154 tive weeks were excluded from the analysis. The final On the other hand, the pain severity and Corbin 192
evaluation was performed by phone call at week 12.
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155
postural scores decreased, while the grip strength and 193

QoLQ scores increased in both group, indicating a sig- 194

156 2.3. Statistical analysis
nificant difference (p < 0.05) (Table 2). However, there 195

157 Statistical analysis was performed using the Statis- was no significant difference in the measurements per- 196

158 tical Package for Social Science (SPSS) version 15.0 formed at week 4 and 12, except for the Corbin pos- 197

159 software (SPSS Inc., Chicago, IL, USA). Descrip- tural scores (p > 0.05) (Table 2). The Corbin postural 198

160 tive data were expressed in means and standart de- scores were statistically significantly lower in the sta- 199

161 viations. The Shapiro-Wilk and Kolmogorov-Smirnov bilization exercise group than the standard treatment 200

162 tests were performed to analyze the normality of the group (p < 0.05) (Table 2). 201

163 data. The Levene’s test was applied to analyze the ho-
164 mogeneity of the variance. The analysis of variance
165 (ANOVA) was used to evaluate the intra- and inter- 4. Discussion 202

166 group differences. The Mann-Whitney U test was used

167 to analyze any differences between the demographic In the present study, we aimed to investigate whether 203

168 data of the groups. A p value of 0.05 was considered adding stabilization exercises to the standardized cer- 204

169 statistically significant. vical physiotherapy program improved the outcome in 205
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4 N. Gelecek and H. Akkan / The effect of stabilization exercise training on pain and functional status in patients

Table 2
Measurement results of patients with cervical radiculopathy at baseline, at 4-week and at 12-week
Groups (n) Baseline 4th week 12th week Differences Differences
Mean (SD) Mean (SD) Mean (SD) within between
groups groups
Pain intensity Group 1 (18) 6,65 (1,17) 3,80 (1,38) 1,00 (0,97) P < 0.001a P > 0.05
Group 2 (14) 7,02 (1,43) 3,78 (2,99) 1,21 (2,35) P < 0.001a
Neck Disability Index Group 1 (18) 2,23 (0,85) 1,50 (1,15) 0,81 (0,75) P < 0.001a P > 0.05
Group 2 (14) 2,07 (0,63) 1,11 (0,51) 0,57 (0,26) P < 0.001a
SF-36 Short From Group 1 (18) 37,56 (5,34) 39,71 (7,46) 46,21 (8,32) P < 0.001a P > 0.05
(Physical health) Group 2 (14) 37,90 (5,00) 39,90 (9,13) 47,47 (5,65) P < 0.001a
SF-36 Short From Group 1 (18) 34,51 (12,70) 40,91 (11,20) 44,12 (10,51) P < 0.05a P > 0.05
(Mental Health) Group 2 (14) 35,17 (10,51) 38,85 (9,72) 46,01 (10,46) P < 0.05a
Corbin postural scores Group 1 (18) 14,27 (3,98) 10,00 (3,88) 7,27 (3,72) P < 0.001a P < 0.05a
Group 2 (14) 13,50 (3,36) 11,50 (3,48) 8,64 (2,37) P < 0.001a
Grip strength (kg) Group 1 (18) 18,80 (4,89) 24,00 (7,09) 27,04 (7,31) P < 0.001a P > 0.05
Group 2 (14) 19,07 (6,48) 22,42 (5,06) 25,77 (4,93) P < 0.001a
∗ Results of ANOVA. a Statistically significant difference.

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206 patients with cervical radiculopathy. Although we ob- effects of stabilization exercises in cervical problems. 241

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207 served no significant differences in the pain severity, Celenay et al. [6] reported that cervical stabilization 242

208 neck disability, grip strength, and QoLQ scores at three exercises with manual therapy had positive effects on 243

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209 months between the groups, the Corbin postural scores pain level and quality of life. However, single stabiliza- 244

were statistically significantly lower in the stabilization tion exercises yielded statistically significantly lower
210
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211 group. These findings suggest that, although more pa- outcomes. 246

tients benefited from stabilization exercises, there is no In another study, Ylinen et al. showed that the ef-
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212 247

213 additional benefit of the standardized cervical physio- fect of the standard cervical exercises on grip strength 248

214 therapy program on the pain severity, functional gains, was similar to other treatment protocol in patients 249
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215 and quality of life, except the postural improvement. with chronic neck pain during one-year-period [14]. 250

216 Previous studies have shown that exercises includ- However, Joghataei et al. [21] found that conventional 251
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217 ing neck muscle the training are effective to reduce the treatment increased the grip strength in short-term, al- 252

218 neck pain [15]. However, several studies have reported though it did not reach statistical significance 253
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219 that physiotherapy programs should consist of not only Moreover, specific strengthening exercises have 254

220 active muscle training, but also a multi-modal treat- been shown to be useful in the treatment of radicu- 255
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221 ment program including passive modalities for patients lopathy, although some ambiguity on the efficacy of 256

222 with radicular symptoms [3,16–18]. the exercise in neck pain has been reported [19]. Sev- 257
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223 In a review of exercises for mechanical neck prob- eral studies investigating the effects of exercise on cer- 258

224 lems, Gross et al. [19] found that exercises were effec- vical symptoms demonstrated that both quality of life 259
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225 tive for relieving pain in the early stages of radiculopa- and disability scores improved only in the short-term, 260

226 thy, but not in the long-term. Miller et al. [20] also re- and symptoms tended to relapse when the treatment 261

227 ported that there was a limited number of evidence on discontinued [22–25]. However, these studies highlight 262

228 the optimal treatment of cervical problems and, there- the importance of self-management and brief interven- 263

229 fore, further studies were required. tions. 264

230 Furthermore, pain is the chief complaint of patients In the present study, we used hot-pack, electro- 265

231 with radiculopathy. It can be radiated to the upper therapy, patient education, exercise applications, and 266

232 limbs and follow a dermatomal pattern. Depending on multi-modal treatment program with the aim of reduc- 267

233 the severity and duration of pain, functional disability ing the signs and symptoms in patients with cervical 268

234 may develop, which interferes with the daily life activ- radiculopathy. Our results are consistent with the previ- 269

235 ities. In addition, if the duration of start – up to treat- ous findings, suggesting that multi-modal physiother- 270

236 ment prolongs, the grip strength in the upper extremity apy protocols are effective in reducing symptoms in a 271

237 and postural problems related with pain can be seen, in 12-week-period. 272

238 particular. All these problems can limit the health and The main goal of cervical stabilization exercise pro- 273

239 psychosocial-related quality of life of the patients. Re- tocols is to increase the strength and the endurance 274

240 view of the literature shows controversial results on the of the deep cervical muscles which provide mechanic 275
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N. Gelecek and H. Akkan / The effect of stabilization exercise training on pain and functional status in patients 5

276 cervical stability. We consider that when the balanced Conflict of interest 324

277 muscle strength would ensure, it would increase the

278 stability; therefore, it could be effective in reducing The authors declare that there is no conflict of inter- 325

279 radiculopathy and related symptoms. Although it was est with any organizations or individuals in this study. 326

280 the theoretical reason of the choice of the stabilization

281 exercise training, we were unable to measure the mus-
282 cle strength and endurance, which can be regarded the References 327
283 main limitation of the present study.
284 On the contrary of our expectation, stabilization ex- [1] Waldrop M. Diagnosis and treatment of cervical radiculopa- 328

285 ercises added to standard physiotherapy program did thy using a clinical prediction rule and a multimodal interven- 329

286 not have an anticipated effect on symptoms. This can tion approach: a case series. J Orthop Sports Phys Ther. 2006; 330
36(3): 152-159. 331
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288 ercises are difficult to learn by the patients, and the of cervical radiculopathy. J Orthop Sports Phys Ther. 2000; 333

289 patients may experience problems about doing exer- 30(12): 728-744. 334

290 cises correctly by themselves. During the exercise, [3] Panjabi MM, Cholewicki J, Nibu K, Grauer J, Babat LB, Dvo- 335

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291 even slight changes in the head position may have af- experimental study. Clin Biomech (Bristol, Avon). 1998; 13: 337
292 fected the action of the cervical stabilizer muscles. As 11-17. 338

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293 we were unable to observe any changes in the muscle [4] Im B, Kim Y, Chung Y, Hwang S. The effects of stabilization 339
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297 sion of the physiotherapist at 15 sessions, followed by therapy to therapeutic exercises, to a combination of thera- 344
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