CONSENT FORM

Research Title:
Effectiveness of Neck muscles Activation versus Strengthening for patients with Chronic
Cervical Radiculopathy: A Randomized Clinical Trial.
Name of Researcher:
Name of participant: ………………………….
Date of informed consent process: ……………………………………..
Participant Identification Number for this research:
Please ask the participant the following questions: If answer is YES – write YES in the gap and If
the answer is NO – write NO in the gap.
1. Are you sure you have been adequately explained in this study? And you have the opportunity
to consider the information, ask questions, and answer satisfactorily.
Ans:………………..
2. Do you understand that your participation is voluntary and that you can withdraw from this
study at any time without giving any reason?
Ans:………………..
3. Do you understand that your personal data responses will be anonymised before analysis? Did
you give permission for the researcher to have access to your anonymised responses? Do you
understand that any direct quotes if selected for publication will be anonymised?
Ans:………………..
4. Do you agree to take part in this study?
Ans:………………..
5. Do you agree to the interview and this interview will be recorded. All data will be collected so
that it is stored in data set and stored securely by researchers from Jashore University of
Science and Technology (JUST).
Ans:………………..
 Questionnaire (English)

Pre-test
Part-I: Socio-demographic information
Age:
Gender:
Address:
Contact No:
Education:
Occupation:
MRI scan imaging

Part-II: Measurement of Neck muscle Strength by Hand Dynamometer

Neck Muscles Strength Kgf Mean

1 2 3
Cervical flexors
Cervical extensors
Left Side Flexors
Right Side Flexors
Left Side Rotators
Right Side Rotators

Part-III: Measurement of Neck muscle Endurance by Stopwatch

Neck Muscles Endurance Sec

Cervical flexors
Cervical extensors
Left Side Flexors
Right Side Flexors
Left Side Rotators
Right Side Rotators

Part-III: Measurement of Cranio-cervical Angle

Cranio-vertebral Angle Degree

 Part-IV: Brief Pain Inventory

Modified Brief pain inventory (short form)

i) Please rate your pain by marking the box beside the number that best describes your
pain at its worst in the last 24 hours.
0 1 2 3 4 5 6 7 8 9 10
No Pain as
pain bad as
you can
imagine
ii) Please rate your pain by marking the box beside the number that best describes your
pain on the average
0 1 2 3 4 5 6 7 8 9 10
No Pain as
pain bad as
you can
imagine
iii) Please rate your pain by marking the box beside the number that tells how much pain
you have right now.
0 1 2 3 4 5 6 7 8 9 10
No Pain as
pain bad as
you can
imagine
iv) In the last 24 hours, how much relief have pain treatments or medications provided?
Please
mark the box below the percentage that most shows how much relief you have received
0 1 2 3 4 5 6 7 8 9 10
No Pain as
pain bad as
you can
imagine
v) Mark the box beside the number that describes how, during the past 24 hours, pain has
interfered with your:
a) General activity
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
b) Mood
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
 c) Walking ability
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
d) Normal work (includes both work outside the home and housework)
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
e) Relations with other people
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes

f) Sleep
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
g) Enjoyment of life
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes

Part-V: Range of Motion by Inclinometer

Movement Range of Motion (Degree)
Cervical Flexion
Cervical Extension
Cervical Lateral flexion (Right side)
Cervical Lateral flexion (Left side)
Cervical Rotation (Right side)
Cervical Rotation (Left side)
 Part-VI: Neck Disability Index Questionnaire (Oswestry Neck Disability Index)
SECTION 1 Question Response
Pain Intensity: How much pain do 0= I have no pain at the moment.
you have right now? 1= The pain is very mild at the moment.
2= The pain is moderate at the moment.
3= The pain is fairly severe at the moment.
4= The pain is very severe at the moment.
5= The pain is the worst imaginable at the moment.
SECTION 2 Question Response
Personal Care: How independent are 0= I can look after myself without causing extra pain.
you at personal care (washing, 1= I can look after myself normally but it causes extra
dressing etc.) pain.
2= It is painful to look after myself and I am slow and
careful.
3= I need some help but manage most of my personal
care.
4= I need help every day in most aspects of self-care.
5= I do not get dressed, wash with difficulty and stay in
bed.
SECTION 3 Question Response
Lifting: How independent are you 0= I can lift heavy weights without extra pain.
during lifting object? 1= I can lift heavy weights but it gives extra pain.
2= Pain prevents me from lifting heavy objects off the
floor, but I can manage if they are conveniently
positioned, e.g. on a table.
3= Pain prevents me from lifting heavy weights but I can
manage light to medium weights if they are conveniently
positioned.
4= I can lift very light weights.
5= I cannot lift or carry anything at all.
SECTION 4 Question Response
Reading: How do you feel while 0= I can read as much as I want with no pain in my
reading newspaper or books? neck.
1= I can read as much as I want with slight pain in my
neck.
2= I can read as much as I want with moderate pain in
my neck.
3= I cannot read as much as I want because of moderate
pain in my neck.
4= I can hardly read at all because of severe pain in my
neck.
5= I cannot read at all.
SECTION 5 Question Response
0= I have no headaches at all.
Headaches: To which state of 1= I have slight headaches which come infrequently.
headache do you feel? 2= I have moderate headaches which come infrequently.
3= I have moderate headaches which come frequently.
4= I have severe headaches which come frequently.
5= I have headaches almost all the time.
SECTION 6 Question Response
Concentration: To which level of 0= I can concentrate fully when I want to with no
concentration do you keep during difficulty.
working despite of neck pain? 1= I can concentrate fully when I want to with slight
difficulty.
2 = I have a fair degree of difficulty in concentrating
when I want to.
3= I have a lot of difficulty in concentrating when I want
to.
4= I have a great deal of difficulty in concentrating when
I want to.
5= I cannot concentrate at all
SECTION 7 Question Response
Work: To which state neck pain 0= I can do as much work as I want to.
affect your daily work? 1= I can only do my usual work, but no more.
2= I can do most of my usual work, but no more.
3= I cannot do my usual work.
4= I can hardly do any work at all.
5= I cannot do any work at all.
SECTION 8 Question Response
Driving: How do you feel your neck 0= I can drive without any neck pain.
pain during travelling? 1= I can drive as long as I want with slight pain in my
neck.
2= I can drive as long as I want with moderate pain in my
neck.
3= I cannot drive as long as I want because of moderate
pain in my neck.
4= I can hardly drive at all because of severe pain in my
neck.
5=I cannot drive my car at all.
SECTION 9 Question Response
Sleeping: To which state neck pain 0= I have no trouble sleeping.
affect your sleep? 1= My sleep is slightly disturbed (less than 1 hr.
sleepless).
2= My sleep is mildly disturbed (1-2 hrs. sleepless).
3= My sleep is moderately disturbed (2-5 hrs. sleepless).
4= My sleep is greatly disturbed (3-5hrs. sleepless).
5= My sleep is completely disturbed (5-7 hrs. sleepless).
SECTION 10 Question Response
 Recreation: To which state your 0= I am able to engage in all my recreation activities
neck pain affect your recreational with no neck pain at all.
activities? 1= I am able to engage in all my recreation activities
with some pain in my neck.
2= I am able to engage in most, but not all of my usual
recreation activities because of pain in my neck.

3= I am able to engage in a few of my usual recreation

activities because of pain in my neck.

4= I can hardly do any recreation activities because of

pain in my neck.
5= I cannot do any recreation activities at all.

Total score = SUM (points for all 10 findings)

Disability in percent = (total score……….) / 50 * 100
Interpretation:
• Minimum score: 0 with a minimum disability of 0%
• Maximum score: 50 with maximal disability of 100%
Disability Score Interpretations
0 to 4 no disability
5 to 14 mild
15 to 24 moderate
25 to 34 Severe
Above 34 Complete

Please note: The means 15 – 24 out of 50 (the RAW SCORE) equates with moderate disability.
 Post-test
Part-II: Measurement of Neck muscle Strength by Hand Dynamometer
Neck Muscles Strength Kgf Mean
1 2 3
Cervical flexors
Cervical extensors
Left Side Flexors
Right Side Flexors
Left Side Rotators
Right Side Rotators

Part-III: Measurement of Neck muscle Endurance by Stopwatch

Neck Muscles Endurance Sec
Cervical flexors
Cervical extensors
Left Side Flexors
Right Side Flexors
Left Side Rotators
Right Side Rotators

Part-III: Measurement of Cranio-cervical Angle

Cranio-vertebral Angle Degree

Part-IV: Brief Pain Inventory (Short form)

vi) Please rate your pain by marking the box beside the number that best describes your
pain at its worst in the last 24 hours.
0 1 2 3 4 5 6 7 8 9 10
No Pain as
pain bad as
you can
imagine
vii) Please rate your pain by marking the box beside the number that best describes your
pain on the average
0 1 2 3 4 5 6 7 8 9 10
No Pain as
pain bad as
 you can
imagine
viii) Please rate your pain by marking the box beside the number that tells how much pain
you have right now.
0 1 2 3 4 5 6 7 8 9 10
No Pain as
pain bad as
you can
imagine
ix) In the last 24 hours, how much relief have pain treatments or medications provided?
Please
mark the box below the percentage that most shows how much relief you have received
0 1 2 3 4 5 6 7 8 9 10
No Pain as
pain bad as
you can
imagine
x) Mark the box beside the number that describes how, during the past 24 hours, pain has
interfered with your:
h) General activity
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
i) Mood
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
j) Walking ability
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
k) Normal work (includes both work outside the home and housework)
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
l) Relations with other people
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes

m) Sleep
 0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes
n) Enjoyment of life
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes

Part-V: Range of Motion by Inclinometer

Movement Range of Motion (Degree)
Cervical Flexion
Cervical Extension
Cervical Lateral flexion (Right side)
Cervical Lateral flexion (Left side)
Cervical Rotation (Right side)
Cervical Rotation (Left side)

Part-VI: Neck Disability Index Questionnaire (Oswestry Neck Disability Index)

SECTION 1 Question Response
Pain Intensity: How much pain do 0= I have no pain at the moment.
you have right now? 1= The pain is very mild at the moment.
2= The pain is moderate at the moment.
3= The pain is fairly severe at the moment.
4= The pain is very severe at the moment.
5= The pain is the worst imaginable at the moment.
SECTION 2 Question Response
Personal Care: How independent are 0= I can look after myself without causing extra pain.
you at personal care (washing, 1= I can look after myself normally but it causes extra
dressing etc.) pain.
2= It is painful to look after myself and I am slow and
careful.
3= I need some help but manage most of my personal
care.
4= I need help every day in most aspects of self-care.
5= I do not get dressed, wash with difficulty and stay in
bed.
SECTION 3 Question Response
Lifting: How independent are you 0= I can lift heavy weights without extra pain.
during lifting object? 1= I can lift heavy weights but it gives extra pain.
 2= Pain prevents me from lifting heavy objects off the
floor, but I can manage if they are conveniently
positioned, e.g. on a table.
3= Pain prevents me from lifting heavy weights but I can
manage light to medium weights if they are conveniently
positioned.
4= I can lift very light weights.
5= I cannot lift or carry anything at all.
SECTION 4 Question Response
Reading: How do you feel while 0= I can read as much as I want with no pain in my
reading newspaper or books? neck.
1= I can read as much as I want with slight pain in my
neck.
2= I can read as much as I want with moderate pain in
my neck.
3= I cannot read as much as I want because of moderate
pain in my neck.
4= I can hardly read at all because of severe pain in my
neck.
5= I cannot read at all.
SECTION 5 Question Response
Headaches: To which state of 0= I have no headaches at all.
headache do you feel? 1= I have slight headaches which come infrequently.
2= I have moderate headaches which come infrequently.
3= I have moderate headaches which come frequently.
4= I have severe headaches which come frequently.
5= I have headaches almost all the time.
SECTION 6 Question Response
Concentration: To which level of 0= I can concentrate fully when I want to with no
concentration do you keep during difficulty.
working despite of neck pain? 1= I can concentrate fully when I want to with slight
difficulty.
2 = I have a fair degree of difficulty in concentrating
when I want to.
3= I have a lot of difficulty in concentrating when I want
to.
4= I have a great deal of difficulty in concentrating when
I want to.
5= I cannot concentrate at all
SECTION 7 Question Response
Work: To which state neck pain 0= I can do as much work as I want to.
affect your daily work? 1= I can only do my usual work, but no more.
2= I can do most of my usual work, but no more.
3= I cannot do my usual work.
4= I can hardly do any work at all.
 5= I cannot do any work at all.
SECTION 8 Question Response
Driving: How do you feel your neck 0= I can drive without any neck pain.
pain during travelling? 1= I can drive as long as I want with slight pain in my
neck.
2= I can drive as long as I want with moderate pain in my
neck.
3= I cannot drive as long as I want because of moderate
pain in my neck.
4= I can hardly drive at all because of severe pain in my
neck.
5=I cannot drive my car at all.
SECTION 9 Question Response
Sleeping: To which state neck pain 0= I have no trouble sleeping.
affect your sleep? 1= My sleep is slightly disturbed (less than 1 hr.
sleepless).
2= My sleep is mildly disturbed (1-2 hrs. sleepless).
3= My sleep is moderately disturbed (2-5 hrs. sleepless).
4= My sleep is greatly disturbed (3-5hrs. sleepless).
5= My sleep is completely disturbed (5-7 hrs. sleepless).
SECTION 10 Question Response
Recreation: To which state your 0= I am able to engage in all my recreation activities
neck pain affect your recreational with no neck pain at all.
activities? 1= I am able to engage in all my recreation activities
with some pain in my neck.
2= I am able to engage in most, but not all of my usual
recreation activities because of pain in my neck.

3= I am able to engage in a few of my usual recreation

activities because of pain in my neck.

4= I can hardly do any recreation activities because of

pain in my neck.
5= I cannot do any recreation activities at all.

Total score = …………………. Disability in percent = (total score……….) / 50 * 100

Disability Score Interpretations
0 to 4 no disability
5 to 14 mild
15 to 24 moderate
25 to 34 Severe
Above 34 Complete

Please note: The means 15 – 24 out of 50 (the RAW SCORE) equates with moderate disability.