Accepted Manuscript

Exercises for mechanical neck disorders: A Cochrane Review Update

A.R. Gross, J.P. Paquin, G. Dupont, S. Blanchette, P. Lalonde, T. Cristie, N. Graham,

T.M. Kay, S.J. Burnie, G. Gelley, C.H. Goldsmith, M. Forget, P.L. Santaguida, A.J.
Yee, G.G. Radisic, J.L. Hoving, G. Bronfort, Cervical Overview Group

PII: S1356-689X(16)30007-8
DOI: 10.1016/j.math.2016.04.005
Reference: YMATH 1848

To appear in: Manual Therapy

Received Date: 12 April 2016

Accepted Date: 13 April 2016

Please cite this article as: Gross A, Paquin J, Dupont G, Blanchette S, Lalonde P, Cristie T, Graham N,
Kay T, Burnie S, Gelley G, Goldsmith C, Forget M, Santaguida P, Yee A, Radisic G, Hoving J, Bronfort
G, Cervical Overview Group Exercises for mechanical neck disorders: A Cochrane Review Update,
Manual Therapy (2016), doi: 10.1016/j.math.2016.04.005.

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 ACCEPTED MANUSCRIPT

Exercises for mechanical neck disorders: A Cochrane Review Update

Gross AR1, Paquin JP2,3, Dupont G3, Blanchette S3, Lalonde P3, Cristie T3, Graham N1, Kay TM4,5, Burnie SJ6,
Gelley G7, Goldsmith CH1,8, Forget M9, Santaguida PL1, Yee AJ10, Radisic GG11, Hoving JL12, Bronfort G13,
Cervical Overview Group14
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School of Rehabilitation Science & Department of Clinical Epidemiology and Biostatistics, McMaster University,

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Hamilton, Canada
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Physio-Santé, Drummondville, Canada

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3
University of Western Ontario, London, Canada
4

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Women's College Hospital, Toronto, Canada
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Department of Physical Therapy, University of Toronto, Toronto, Canada
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Department of Clinical Education, Canadian Memorial Chiropractic College, Toronto, Canada

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Applied Health Sciences, University of Manitoba, Winnipeg, Canada
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8
Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
9
Canadian Forces Health Services Group | Groupe de services de santé des Forces Canadiennes, National Defence |
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Défense Nationale, Government of Canada | Gouvernement du Canada, Kingston, Canada

10
Kinesiology, Faculty of Health Sciences, McMaster University, Hamilton, Canada
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11
Life Science, Faculty of Health Sciences, Queens Univesity, Kingston, Canada
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12
Coronel Institute of Occupational Health and Research Center for Insurance Medicine, Academic Medical Center,

University of Amsterdam, Amsterdam, Netherlands

13
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Integrative Health & Wellbeing Research Program, Center for Spirituality & Healing, University of Minnesota,

Minneapolis, MN, USA

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Hamilton, Canada
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Exercises for mechanical neck disorders: A Cochrane Review Update

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Abstract

Background

Neck pain (NP) is disabling and costly.

Objectives

To assess the effectiveness of exercise on pain, disability, function, patient satisfaction, quality of life

(QoL) and global perceived effect (GPE) in adults with NP.

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Methods

We searched computerised databases up to May 2014 for randomised controlled trials (RCTs) comparing

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exercise to a control in adults with NP with/without cervicogenic headache (CGH) or radiculopathy. Two

reviewers independently conducted selection, data abstraction and assessed risk of bias. Meta-analyses

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were performed to establish pooled standardised mean differences (SMDp). The Grade of

Recommendation, Assessment, Development and Evaluation (GRADE) was used to summarise the body

of evidence.

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Main Results
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The following exercises (27 trials) were supported by ‘Moderate GRADE’ evidence:

For chronic NP, 1) cervico-scapulothoracic and upper extremity (UE) strengthening for moderate to large
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pain reduction immediately post treatment (IP) and at short-term (ST) follow-up; 2) scapulothoracic and

UE endurance training for a small pain reduction (IP/ST); 3) cervical, shoulder and scapulothoracic
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strengthening and stretching exercise for a small to large pain reduction in the long-term (LT) (SMDp -0.45

[95%CI: -0.72 to -0.18]) and function improvement; 4) cervico-scapulothoracic strengthening/stabilisation

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exercises for pain and function at intermediate-term (IT) (SMDp -14.90 [95%CI: -22.40 to -7.39]). 5)

mindfulness exercises (Qigong) for minor improved function but not GPE (ST).

For chronic CGH, cervico-scapulothoracic strengthening and endurance exercises including pressure

biofeedback for small/moderate improvement of pain, function and GPE (IP/LT).

Authors' conclusions

Specific strengthening exercises of the neck, scapulothoracic and shoulder for chronic NP and chronic

CGH are beneficial. Future research should explore optimal dosage.

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1. Background

1.1 Description of the condition

Neck disorders are common 1,2, painful, and limit function in the general population3,4.The global

point prevalence of neck pain was estimated to be 4.9% in 20102.

1.2 Description of the intervention

We adopted the Therapeutic Exercise Intervention Model to sub-classify exercise5. Hall and Brody

(2005)6 intersects this model with two other axes - activity and dosage (See Table 1).

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Table 1. The Therapeutic Exercise Intervention Model to sub-classify exercise5 is foundational to

classification of exercise in this systematic review.

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Support Element:

An exercise categorised under this element would affect the functional status of the cardiac, pulmonary

and metabolic systems (e.g. aerobic endurance activities).

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Base Element:
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Exercises categorised under base would affect the functional status of the muscular and skeletal systems

and is commonly linked to the biomechanical element. This element provides the basis for movement as

follows:
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• extensibility/stiffness properties of muscle, fascia and periarticular tissues for range of motion and

stretching exercises,
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• mobility of neuromeningeal tissue for neural mobilisation exercises,

• force or torque capability of muscles and the related muscle length-tension properties for
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strengthening exercises, and endurance of muscle also involved in strengthening for

endurance-strength training.

Modulator Element:

Exercises under this element relate to motor control for neuromuscular re-education as follows:

• patterns and synchronisation of muscle recruitment, and

• feed forward or feedback systems using verbal, visual, tactile and other proprioceptive inputs to the

patient.

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Biomechanical Element:

This element is an interface between the motor control associated with the modulator element and

musculoskeletal function associated with the base element. Components of the biomechanical element

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include:

• static stabilisation forces involved in alignment and muscle recruitment, and

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• dynamic stabilisation forces involved in arthrokinetics, osteokinetics and kinematics.

Cognitive or Affective Element:

Exercises in this category affects the functional status of the psychological system as it is related to

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movement as follows:
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• the cognitive ability to learn,

• patient and caregiver compliance,

• motivation, and
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• emotional status.
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1.3 How the intervention might work

Exercise has both physical and mental benefits through its effects on numerous systems such as

the cardiovascular, immune, neurologic, and musculoskeletal systems7. Central to these benefits are the

stages of change, encompassing the health belief and cognitive behavior models.

1.4 Why it is important to do this review

In our last Cochrane update on exercise therapy, we found low to moderate quality evidence of

pain relief benefits for combined cervical, scapulothoracic stretching and strengthening for chronic neck

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pain in the short and long-term. Since then, five other reviews have found primarily very low to low

GRADE evidence, as well as low GRADE evidence for no beneficial effect on pain (Table 2). A number of

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these reviews included studies that were not clearly categorised. Therefore, the true impact of exercise

alone could not be determined with strong evidence.

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Table 2. Review of review shows very low to low GRADE evidence.

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8-10
Very low to low GRADE 1) stretching and strengthening for chronic neck pain
11-13
2) strengthening, endurance, and modular element for chronic cervicogenic headache
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evidence for beneficial
14,15
3) neuromuscular exercises (proprioception/eye-neck coordination)
effect on pain
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4) stretching and range of motion exercises for non specific neck pain

5) stretching, strengthening, endurance training, balance/coordination, cardiovascular

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8,15-18
training and cognitive/affective elements for chronic neck pain
8,16
6) qigong exercises for chronic neck pain
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7) supervised exercises for chronic WAD
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8) strengthening neck exercises for chronic neck pain
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Low GRADE evidence 1) stretching and strengthening for radiculopathy
9,19
for no beneficial effect 2) general fitness training for acute to chronic neck pain
9,19
3) stretching and endurance training in chronic neck pain
on pain

1.5 Objectives

To present an abbreviated report of a Cochrane systematic review that assessed the immediate to

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long-term effect of exercise therapy on pain, function/disability, patient satisfaction, quality of life (QoL),

and global perceived effect (GPE) in adults experiencing mechanical neck pain with or without

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cervicogenic headache or radiculopathy.

2. Methods

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This is an abbreviated co-publication of our Cochrane systematic review update20. See Table 3 for

selection criteria and the primary review for full details. A protocol was previous0ly published (Issue 2,

2003 Cochrane Library).

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Table 3. Criteria for considering studies for this review

Types of Studies Published or unpublished randomised control trials (RCTs) in any language
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Types of Participants Adults (M/F ≥ 18 years with acute ( <30 days), subacute (30-90

days), or chronic (>90 days) neck disorders categorised as:

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- mechanical neck disorder (MND): whiplash associated disorders (WAD)

Category I/II, myofascial neck pain, degenerative changes like

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osteoarthritis / cervical spondylosis

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- cervicogenic headache (CGH)

- neck disorders with radicular findings (NDR)

Excluded: studies of neck disorders with definitive / possible long

term signs (eg. Myelopathies), neck pain caused by other

pathological entities, headache associated with neck but not

cervical origin, co-existing headache when neck pain is not

dominant, headache not provoked by neck movements / sustained

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neck postures, ‘mixed’ headache

Types of Interventions One or more types of exercise therapy specified in Therapeutic

Exercise Intervention Model

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Excluded: exercise therapy as part of a multidisciplinary treatment,

multimodal treatment, or exercise requiring manual therapy

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techniques by a trained individual

Types of Comparisons 1) sham/placebo

2) no treatment or wait list

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3) exercise plus another intervention vs. that same intervention
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Types of Outcomes Included if used any one of five of the primary outcome measures:

1) pain

2) function and disability (eg. Neck Disability Index, activities of daily living,
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return to work, sick leave)

3) patient satisfaction

4) global perceived effect

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5) quality of life (e.g. SF-12)

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When available: adverse events, cost of care

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Timelines included:

• Immediate post treatment: ≤ one day

• Short term follow-up: one day – 3 months

• Intermediate-term follow-up: 3 months – 1 year

• Long-term follow-up: ≥ 1 year

Key: CGH=cervicogenic headache; F=female, M=male; MND=mechanical neck disorder; RCTs=randomised controlled trials;

WAD=whiplash associated disorder

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2.1 Search methods for identification of studies

A research librarian searched computerised bibliographic databases for medical, chiropractic and

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allied health literature. Electronic searches included databases from their start to May 2014 (See Figure 1

and Gross et al 201521 for greater details). See Appendix 1 for Characteristics of Included Studies.

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Figure 1. PRISMA flow diagram for exercise review search results.

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Appendix 1. Characteristics of the Included Studies

Study / Participants Interventions Outcomes

Allan 200322 INDEX TREATMENT PAIN (NRS 0 to 100)

Arm 1- a. Stretch before Manipulation: Activity- Static

Baseline
passive Mean: Manipulation 30, Stretch before 58,

stretches into Movement - lateral flexion and rotation Stretch

on bothAfter 63
Chronic MND (Myofascial
sides of neck, held for 15 seconds; Mode- administered Reported
by Results: no significant difference
Pain Syndrome)
chiropractor with patient in supine position, immediately
groups

followed by cervical manipulation given in accordance with the

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motion palpation findings. Manipulation was administered with
FUNCTION (NDI 0 to 50)
patient in supine position and the chiropractor makingBaseline
an index Mean: Manipulation 5, Stretch before 16,

finger contact on the affected cervical segment(s); Dosage

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Stretch After 11
sessions over 4 weeks, Reported Results: no significant difference between
b. Cervical manipulation given in accordance with thegroups
motion

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palpation findings. Manipulation was administered with patient

in supine position and the chiropractor making an index

SIDE EFFECTS: none
contact on the affected cervical segment(s) immediately followed
COST OF CARE: NR

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by static passive stretches in lateral flexion and rotation on both

sides of neck, held for 15 seconds, administered by chiropractor

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with patient in seated position;

Arm 2- a. Stretch after Manipulation: Stretches as in Arm 1 was

administered after manipulation treatment.

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b. Cervical manipulation administered as in Arm 1.

Treatment Schedule: 8 sessions over 4 weeks

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COMPARISON TREATMENT

Arm 3- Manipulation: Cervical manipulation given in

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accordance with the motion palpation findings. Manipulation

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Study / Participants Interventions Outcomes

was administered with patient in supine position and the

chiropractor making an index-finger contact on the affected

cervical segment(s); 8 sessions over 4 weeks.

Treatment Schedule: 4 weeks, 20 sessions

Duration of Follow-up: none

CO-INTERVENTION: avoided in trial design

Andersen 200823,24INDEX TREATMENT PAIN intensity in trapezius muscle (VAS 0 to 100

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Arm 1- Specific Strength Training (SST) or General Fitness
Baseline Mean: SST 44, GFT 50, Reference

Training (GFT): Activity- SST: high intensity specificReported

strength Results: no significant difference between
(sub) Acute/Chronic MND
training locally for neck and shoulder muscles. GFT: Cycling
groups
(Trapezius Myalgia)

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SMD immediate post: 0.18 (95%CI: -0.67 to 1.03)
high-intensity general fitness training with legs only, upright

position without holding onto the handlebars (relaxingSMD

shoulders
ST: -0.06 (95% CI: -0.91 to 0.79)
during training); Mode- SST: 5 dumbbell exercises. GFT:

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Monark bicycle ergometer; Movement- SST: single arm row,
REASON FOR DROP-OUTS: 6 in Reference
shoulder abduction, shoulder elevation, reverse flies, and upright
group, reason not specified
row).Training program progressively increased using the

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SIDE EFFECTS: NR
principles of periodisation and progressive overload from 12
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COST OF CARE: NR
repetitions maximum (~70% of maximal intensity) at beginning

to 8 repetitions maximum (~80% of maximal intensity) later.

GFT: high-intensity cycling; Dosage- SST: performed using

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consecutive concentric and eccentric muscle contractions

(raising and lowering pair of dumbbells) in a controlled manner

without pause, each set lasting 25 to35 seconds. 30 of 5 different

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exercises with 3 sets per exercise were performed duri

training session in an alternating manner (shoulder elevation was

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Study / Participants Interventions Outcomes

performed during each session). Doubled training load by end of

10 weeks. 20 minutes, 3x/week for 10 weeks of intervention for

an average of 26 ± 3.6 sessions GFT: 20 min at a relati

workloads of 50% (initial training level) to 70% (increased

during following weeks and maintained) of maximal oxygen

uptake (V02 max). Heart rate monitor (Polar Sport Tester, Polar,

Kempele, Finland) used to adjust workload to meet the intended

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relative level.

Treatment schedule: SST: Doubled training load by end of 10

weeks. 20 minutes 3 times/ week for 10 weeks of intervention

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for an average of 25 ± 4.8 sessions. GFT: 20 minutes 3

times/week for 10 weeks.

COMPARISON TREATMENT

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Arm 2- Health Counseling Group: Lectures with information on

activities promoting general health and individual: workplace

ergonomics, diet, health, relaxation, and stress management. 1

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hour per week for 10 weeks for an average of average 27 ± 2.8
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sessions

Treatment Schedule: 10 weeks, 20 sessions

Duration of Follow-up: 10 weeks

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CO-INTERVENTION: Not avoided

COMPARISON TREATMENT

Reference intervention without physical activity : Activity

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participants received health counselling on group and individual

levels regarding workplace ergonomics, diet, health, relaxation,

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Study / Participants Interventions Outcomes

and stress management, frequency: 3x per week. Dosage

minutes sessions

Treatment Schedule: 30 sessions over 10 weeks

Duration of Follow-up: none

CO-INTERVENTION: Not specified

Andersen 201125- INDEX TREATMENT PAIN (VAS 0 to 10)

Arm 1- 2 minute training (2-minutes): Activity- Progressive

Baseline Mean: 2 minutes 3.5, 12 minutes 3.9,

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resistance training with theraband. Mode-Shoulder; Movement
Control 3.5
(sub) Acute/Chronic MND
abduction- lateral raise. Dosage: 2 minutes, 5 times/week
Reported
for 10Results: ANOVA showed a strong group
(Myofascial Pain
weeks of intervention for an average of 26 ± 3.6 sessions
by-time effect for neck/shoulder pain intensity
Syndrome/Cervicogenic

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Arm 2- 12-minute training: Activity- Progressive resistance
(p<0.0001). Compared with the control group,
headache/
training with theraband. Mode-Shoulder; Movement intensity decreased in both training groups. This
tension type headache
lateral raise; Dosage- 12- minutes 5 times/week for 10change
weeks was
of not significantly different between the 2

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intervention for an average of 25 ± 4.8 sessions training groups.

COMPARISON TREATMENT SMD (2-minute): -0.66 (95% CI: -1.02 to

Arm 3- Control Group: Weekly e-mailed information SMD

on various

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(12-minute): -0.59 (95% CI: -0.94 to
aspects of general health and internet links with additional
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relevant information
REASON FOR DROP-OUTS: 3 in 2- minut
Treatment Schedule:10 weeks, 20 sessions
group, 1 in 12- minutes group, 2 in control group,
Duration of Follow-up: 10 weeks
reasons reported
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CO-INTERVENTION: Not avoided

SIDE EFFECTS: Reported worsening of neck

muscle tension during and/or in the days after training

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(2-minute n = 1, 12-minute n = 4), shoulder joint pain

during training (2-minute n = 1, 12-minute n = 4),

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Study / Participants Interventions Outcomes

pain in the upper arm during training (2-minute n = 1,

12-minute n = 1), pain of the forearm/wrist during

training (12-minute n = 2), worsening of headache

after training (2-minute n = 1, 12-minute n = 1). No

long-lasting or major complications resulted from the

training program.

COST OF CARE: NR

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Andersen CH 2012INDEX TREATMENT PAIN (Modified Nordic Questionnaire 0-

Arm 1- Training groups (WS): Activity- Upper extremity

Baseline Mean: 1-WS 4.83, 3-WS 4.96, 9
strength training; Mode- Weights. Movement- Dumbbell (4.71), Reference (4.83)

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Non specific neck pain
exercises front raise, lateral raise, reverse flies shrugs and wrist
Reported Results: no significant difference between
extension. Dosage- Type of contraction (dynamic); Intensity (20
groups

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repetition maximum at baseline to 8 repetition maximum at later
SMD (1-WS vs reference): -0.44 (95% CI:
phase); Speed (NR); Duration/Frequency (1-WS = weekly
0.43);
session 1hour/week, 3-WS = 20 minutes at 3 sessions/week, 9
SMD (3-WS vs reference): -0.67 (95% CI:

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WS = 7 minutes at 9 sessions/week; Sequence (NR);
0.25);
Environment (NR); Feedback (experienced instructor supervised
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SMD (9-WS vs reference): -0.30 (95% CI:
every other training session).
0.76)
Treatment Schedule: 20 weeks.

COMPARISON TREATMENT
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Arm 2- Reference group: No treatment FUNCTION Disability of the arm, shoulder and

Treatment Schedule: 20 weeks hand (DASH 0 to100)

Duration of Follow-up: NR
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Baseline Mean: 1-WS (16), 3-WS (18), 9

CO-INTERVENTION: NR Reference (16)
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Reported Results: no significant difference between

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Study / Participants Interventions Outcomes

groups

SMD (1W-S vs reference): -0.17 (95% CI:

0.24);

SMD (3-WS vs reference): -0.23 (95% CI:

0.19);

SMD (9-WS vs reference): -0.06 (95% CI:

0.41)

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REASON FOR DROP-OUTS: NR

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SIDE EFFECTS: NR

COST OF CARE: NR

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Ang 200929 INDEX TREATMENT PAIN Prevalence during previous week

Arm 1- Exercise Group: Activity- Patterns and synchroni

Baseline Mean (SD): Exercise 13 (38), Control 11

of muscle recruitment, Endurance-Strengthening (32)

Chronic MND

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exercises, Mode-Progression from non-postural (supine, Reported
prone) Results: In the exercise group, the
(Mechanical Neck Pain &
low-load active craniocervical flexion at 5 pressure levels
prevalence
(22 to of cases for the previous week and the
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Myofascial Pain Syndrome)
30 mmHg), seated postural exercises with active craniocervical
previous 3 months decreased from 38% to 15% and

flexion and active scapular retraction. Seated and standing

76% elastic
to 44% respectively, whereas in controls it was

resistance, Movement- supine craniocervical flexion exercises,

unchanged.
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prone isometric shoulder/scapular, seated active craniocervical

RR (exercise vs control): 0.45 (95% CI: 0.18 to 1.14).

flexion with cervical rotation to end range and simultaneous

Between-group regression analyses revealed that the

scapular retraction to mid motion range, sitting controlled

members of the exercising group had a 3.2 times
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dynamic shoulder retraction following a rowing exercise

greater chance (odds ratio) than the control group of
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movement, dynamic scapular retraction with weight load

having
overbeen pain-free during the previous 7 da
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Study / Participants Interventions Outcomes

long movement arms in "rowing" exercises in regular apulls,

1.9 times great chance (odds ratio) of having been

emphasizing shoulder retraction in the initial concentric

pain-free
phase during the previous 3 months, P = 0.01.

and upright trunk postures in the inner range, Dynamic neck

rotation exercises in upright posture against moderate REASON

resistance FOR DROP-OUTS: 6 in Exercise Group,

using elastic bands, Dosage- Non- postural exercises 6 in Control Group, reasons reported

isometrically (low load) for 10 seconds, repeated 10 times.

SIDE EFFECTS: NR

Postural (seated, isometric held at 5 pressure levels like supine,

COST OF CARE: NR

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holding 10 seconds, repeated 10 times, neck rotation to end

range 3 sets repeated 10 to 15 times on each side. Endurance

strength exercises 3 sets of 15 repetitions (elastic bands were

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used to replicate the exercises at home). Feedback The

supervising physiotherapist monitored potential surface flexor

activity visually, with palpation if necessary.

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Treatment schedule: Assigned exercises (2 to 4) wer

completed 2 times/day lasting 10 to 15 minutes, supervised

weekly by a physiotherapist providing instruction and manual

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guidance.
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COMPARISON TREATMENT

Arm 2- Control: No exercise, encouraged to continue with

ordinary exercise activity

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Treatment Schedule: 6 weeks, instructed to do 2 to 4 exercises

2 times/day, for 10 to 15 minutes, supervised by physiotherapist

weekly.
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Duration of Follow-up: 12 months

CO-INTERVENTION: Not specified

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Study / Participants Interventions Outcomes

Beer 201230 INDEX TREATMENT PAIN (VAS 0 to 10)

Arm 1- Exercise group: Activity- Functional postural Baseline mean: Exercise 3.0 Control 2.6

exercise. Mode- Sitting. Movement- Assumes an upright Reported results: no significant

Persistent neck pain
posture in a neutral lumbo-pelvic position and then gently
SMD (exercise vs control): 0.13 (95% CI:

lengthens the cervical spine by imagining they are lifting

1.01)
the

base of their skull from the top of their neck. Dosage

concentric-isometric hold with postural awareness, low

FUNCTION (NDI 0 to100)

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intensity,10 second hold every 15 to 20 minutes throughout
Baseline
the mean: treatment 18.1 control 20.6

day for a total of 2 weeks,all sorts of environment throughout

Reported results: no significant

their waking day, feedback was taught initially but notSMD

reviewed
(exercise vs control): -0.32 (95% CI:

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during the 2 weeks 0.56)

Treatment schedule: 2 weeks

COMPARISON TREATMENT REASONS FOR DROP OUTS: NR

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Arm 2- Control group: Did not undertake any exerciseSIDE EFFECTS: NR

intervention during the study.

Treatment schedule: 2 weeks

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Duration of Follow-up: NR
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CO-INTERVENTION: participants in control group were

requested not to seek other treatment for their neck pain for the 2

weeks.
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Bronfort 200131,32 INDEX TREATMENT CUMULATIVE ADVANTAGE for six patient

Arm 1- MedX Exercise (MedX): Activity- High technology

oriented outcomes

exercise, Mode/Movement- medically supervised rehabilitative

Reported Results: favours SMT/Ex over SMT;
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Chronic MND
exercise. Dosage- 20 sessions over 3 months MONOVA value yielded a significant group

Arm 2- Manipulation and low tech Exercise difference (Wilk's Lambda = 0.85, F(12,302) = 2.2, P
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Study / Participants Interventions Outcomes

(SMT/Ex): Activity- Chiropractic manipulation, supervised

< 0.01)low

technology rehabilitative exercise, Mode- progressive

strengthening exercises for the neck and upper body proceeded

PAIN (VAS 0 to 10)

by a short aerobic warm up of the upper body and lightBaseline Mean: SMT 56.6, MedX 57.1, SMT/Ex

stretching, Movement- the upper body strengthening exercises

56.0

included push ups and dumbbell shoulder exercises asReported

described Results: group difference in patient

by Dyrssen et al 1989. Dosage- 45 minutes total, 2 setspain

of 15
ANOVA
to F(2,156) = 4.2, P = 0.02 favours the

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30 repetitions, weight 2 to 10 lbs; cervical progressivetwo
resisted
exercise groups

strengthening exercises where performed while lying on

SMDa (SMT/Ex vs SMT) at LT follow-up:

therapy table with wearing head gear with variable weights

CI: -0.60
fromto 0.18); power 28%, NNTB 10; treatment

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1.25 lb to 10 lbs guided by a simple pulley system attached
advantage
to the15%

table

Treatment Schedule: 20 sessions over 3 months FUNCTION (NDI 0 to 50)

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COMPARISON TREATMENT Reported Results: no significant group differences

Arm 3- Spinal Manipulative (SMT): Chiropractic manipulation,

were found ANOVA: F(2, 156) = 2.04, P = 0.13

20 sessions over 3 months SMD (SMT/Ex vs SMT) at LT follow-up:

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Treatment Schedule: 11 weeks, 20 session CI: -0.78 to 0.01), power 28%, NNTB 11, treatment
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Duration of Follow-up: 12 months advantage 11%

CO-INTERVENTION: NR

HEALTH-RELATED QUALITY OF LIFE

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0 to 100)

Baseline mean: SMT 69.1, MedX 69.0, SMT/Ex

71.7
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Reported Results: SMD at LT follow-up:

(95% CI: -0.69 to 0.09)

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PATIENT SATISFACTION (scale 1 to 7

completely satisfied to completely dissatisfied

Reported Results: A clinically worthwhile

cumulative advantage was reported favouring

manipulation/exercise (low tech) group over exercise

(high tech) and manipulation alone ANOVA: F(2,

PT
158) = 6.7, P = 0.002

SMD (SMT/Ex vs SMT) at LT follow-up:

CI: -1.35 to -0.52)

RI
PATIENT-RATED IMPROVEMENT

9)

SC
Reported Results: substantial improvement over

time, ANOVA: F(2, 174) = 1.7, P = 0.18

SMD (SMT/Ex vs SMT) at LT follow-up:

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CI: -0.81 to 0.03); power 44%
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REASONS FOR DROP-OUTS: Reported

SIDE EFFECTS: increase neck or headache pain 8

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SMT/Ex, 9 MedX, 6 SMT; increased radicular pain 1

SMT/Ex; severe thoracic pain 1 SMT; all cases self

limiting and no permanent injuries;

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RR(SMT/Ex vs MedX): 0.81 (95% CI: 0.23 to 1.55)

RR(SMT vs MedX): 0.61 (95% CI: 0.23 to 1.55)

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COST OF CARE: NR

Chiu 200533 INDEX TREATMENT PAIN (VAS 0 to 10)

Arm 1- Craniocervical Flexion and isometric neck strengthening

Baseline Mean: CCF 4.61, TENS 4.69, IR

(CCF): Reported Results: NS

Subacute MND (Cervical
Activity- deep neck flexor strengthening, Infrared radiation
SMD (CCF vs IR): -0.34 (95% CI: -0.72 to 0.04);
Brachial Pain Syndrome)
Mode--using pressure sensor @20mmhg x10 minutes NNTB (10 6, treatment advantage 24%

seconds on/15 seconds off) Strengthening using a Multi Cervical

PT
Rehabilitation Unit(MCRU). FUNCTION Chinese version of Northwick Park

Movement/Dosage- 15 repetitions of flexion, extension

Questionnaire
at 20% ( 0 to 4)

of Peak Isometric Strength (PIS) as warm-up. Then dynamic

Baseline Mean: CCF 1.39, TENS 1.55, IR 1.36

RI
flexion and extension with variable resistance x 0 to 12Reported Results: CCF vs IR was significant

repetitions. (p=0.02)

Treatment Schedule: 35 minutes of exercise per session

SMD (CCF v IR): -0.33 (95% CI: -0.71 to 0.05);

SC
COMPARISON TREATMENT: NNTB 6, treatment advantage 16%

Arm 2- Transcutaneous Electrical Nerve Stimulation (TENS): 30

minutes of dual channel portable TENS unit (ITO model 1302). FOR DROP-OUTS: Reported
REASON

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Continuous trains of 150ms square pulse at 80Hz. 4 Electrodes
SIDE EFFECTS: No complications occurred.
AN
(4x4cm). COST OF CARE: NR

Arm 3- Control Group: Infrared radiation (IR): place on E

GB21, LI 11, intensity 2 to 3 times of participants sensory

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threshold education on neck care

Treatment schedule: 20 minutes per session, 6 weeks, 2

sessions/week
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Duration of Follow-up: 6 months

CO-INTERVENTION: NS
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Dellve 201134 INDEX TREATMENT PAIN (Numeric Pain Scale 0 to10)

Arm 1- Myofeedback Training (MyoT): Activity- activities of Mean: MT 6.0, IMST 6.3, Control 6.2
Baseline

daily living; Mode- wearing a myofeedback device; Reported Results: no significant difference between
Chronic cervical neck pain or
ergonomic adjustments; Dosage- Duration/Frequencygroups
cervicobrachial pain syndrome
minimum of 8 hours per week, typically 2 hours per day
SMDand(IMST
4 vs control) at immediate post

days per week; ; Environment -various; Feedback -discussion

-0.30 (95% CI: -0.92 to 0.33);

PT
with ergonomist once per week. SMD (IMST vs control) at 2 months follow

Arm 2- Intensive Muscular Strength Training (IMST):(95% CI: -1.27 to 0.00)

Upper extremity strength training Mode- resistance

RI
bands Movement-Exercises for strengthening and co FUNCTION (Work Ability Index 7 to49)

the upper extremities. Dosage- Type of contraction - Baseline Mean: MT 19.3, IMST 19.0, Control 19.0

Intensity -NR; Speed -NR; Duration/Frequency -2 times

Reported
per day,Results: no significant difference between

SC
6 days per week for 4 weeks; Sequence -warm-up movements
groups

followed by strengthening exercises then ending with SMD

breathing
(IMST vs control) at immediate post

and slow down movements; Environment -participant's-0.18

home;
(95% CI: -0.80 to 0.44);

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Feedback -ergonomist coaching. SMD (IMST vs control) at 2 months follow
AN
Treatment Schedule: 4 weeks (95% CI: -0.25 to 1.01)

COMPARISON TREATMENT

Arm 3- Control Group: Diary entries to record activities,

REASON FOR DROP-OUTS: 5 in MT Group, 7 in
M

discomfort, pain and sleeping disturbances IMST Group, 1 in Control Group, reasons reported

Treatment Schedule: 4 weeks

Duration of Follow-up: 2 months SIDE EFFECTS: NR

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CO-INTERVENTION: not avoided COST OF CARE: NR

Franca 200835 INDEX TREATMENT PAIN (VAS 0 to 100)

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Arm 1- Physiotherapy protocol performed according toBaseline

Hall andMean: PT+Acup 85.0, Acup 80.0, PT 70.0

Brody consisting of Activity-stretching, strengtheningReported Results: According to KWT (Kruskal

Chronic MND (Myofascial

Pain Syndrome) muscle stretching of neck and upper limbs regions; recruitment
Wallis test), the statistical analysis of the inter

exercise of Deep Cervical Flexion Muscles; Movement

demonstrated significant (p < 0.05) differences

strengthening exercise of Deep Cervical Flexion Muscles

amongandthe groups. The DMCT (Dunn's Multiple

upper limbs. Duration of treatment 20 minutes, 1 to 2 Comparison

times/week test) showed that G1 was superior to G3

for 10 weeks. in pain improvement (p < 0.05)

PT
Arm 2- Acupuncture combined with Physiotherapy SMD (PT+ Acup vs Acup) at immediate post

(G1) Activity- Stage 1: acupuncture therapy based on treatment:

the TCM -0.73 (95% CI: -1.46 to -0.00), treatment

theory of biao-li (symptom/root) treatment;. Mode- Chi

advantage 11%

RI
acupuncture, as the root treatment, was performed with a

selection of body points by means of the diagnostic ofFUNCTION (NDI - Brazilian/Portuguese version

syndromes of TCM. Movement- Disposable stainless Baseline

steel Mean: PT+Acup 24.0, Acup 30.0, PT 28.0

SC
needles (0.25 mm x 30 mm) with guide-tubes (Dong- Reported Results: The DMCT (Dunn's Multiple

Acupuncture Needle, Korea) inserted bilaterally into the

Comparison
body test) showed that G1 was superior to G3

points to a depth of 10 to 15 mm. YNSA was carried out

in reducing
as the functional disability (p < 0.0001)

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symptom treatment with a selection of the kinetic and SMD
ypsilon
(PT + Acup vs Acup) at IT follow-up:
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points as the main scalp points to treat TNS. The kinetic
(95%points
CI: -1.70 to -0.20), NNTB13, treatment

were stimulated bilaterally with needle measuring 0.25advantage

mm x 5 13%.

to 15 mm (Dongbang Acupuncture Needle, Korea) to a depth of

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1 to 2 mm, whereas the selection of the ypsilon points REASONS

were FOR DROP-OUTS: Reported (3 drop

ipsilateral of the scalp to the diagnosed side of the neck.

outs,
All1 in each group)

acupoints (body and scalp points) were stimulated in an

SIDE
uneven
EFFECTS: Reported; no record of serious
D

manner every 10 minutes to maintain the needling sen.complication

Chinese of acupuncture or physiotherapy

acupuncture was performed in 20 minutes and YNSA occurred

was during treatments or during the follow
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maintained until 40 minutes. Stage 2: Physiotherapy given

period after any of the treatments that could harm the

simultaneously with YNSA. patients during the assessment all stages of the trial

COMPARISON TREATMENTS: COST OF CARE: NR

Arm 3- Acupuncture (G2): Same protocol of acupuncture

therapy as described in the first stage of G1 for 20 minutes.

Arm 4- Physiotherapy (G3): Same protocol of physiotherapy as

described in the second stage of G1 for 20 minutes.

PT
Treatment Schedule: 10 weeks, 20 sessions

Duration of Follow-up: 6 months follow-up

CO-INTERVENTION: avoided in trial

RI
Hall 200736 INDEX TREATMENT PAIN Headache intensity change score (VAS 0 to

Arm 1- C1-2 self -SNAG (SSng): Activity-Belt was used

100)as per

Mulligans detailed techniques. Mode- The participantBaseline

was Mean: SSng 52 Mock 51

SC
(sub)acute Cervicogenic
instructed by the PT on the proper positioning and technique
Reported
of Results: group difference in patient
headache (CGH)
mobilisation belt on 3 trials to familiarize themselves. pain
The favours the SSng exercise group

participant was instructed to perform technique without

SMD(SSng vs Mock) at ST follow-up: -1.58 (95%

U
producing pain. Movement- supplemental video available
CI: -2.38
on to -0.77); power 100%, NNTB 2, Treatment
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line advantage 40%

Treatment schedule: 1 day SMD(SSng vs Mock) at LT follow-up: -1.74 (95%

COMPARISON TREATMENT CI: -2.57 to -0.91); power 100%, NNTB 3, treatment

M

Arm 2- Control group (Mock): Sham mobilisations with

advantage
same 40%

belt. This group did not receive instruction to rotate head towards

restriction. REASONS FOR DROP-OUTS: NA

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Treatment Schedule: 1 day SIDE EFFECTS: NR

Duration of Follow-up: 4 weeks and 12 months COST OF CARE: NR

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CO-INTERVENTION: Not avoided

Hallman 201137 INDEX TREATMENT PAIN (Borg Scale 0 to 10)

Arm 1- Practice paced breathing: Activity- breathing Baseline Mean : Treatment 2.6, Control 2.5

exercises; Mode- resonance heart rate variability (HRV)Reported Results: no significant difference between
Stress-related chronic
biofeedback (BF) training and paced breathing; Movementgroups
shoulder pain
respiration. Dosage- Type of contraction - concentric SMD (treatment vs control): -0.19 (95% CI:

concentrically contracts with this breathing exercise, intensity

0.63)

PT
low as was breathing exercises, On-site sessions: speed

Sessions 1 and 10: between 4.5 to 6.5 breaths per minute to

FUNCTION (NDI 0 to 100)

determine speed with highest HRV. Sessions 2 to 9: performed

Baseline Mean:
at Treatment 21.3, Control 25.6

RI
speed of highest HRV, duration -Sessions 1 and 10: 2 Reported Results: no significant difference

paced breathing for 2minutes of free, non-paced breathing.

groups

SC
SMD
Sessions 2 to 9: 4 times 5 minutes of resonant HRV BF with(treatment
2 vs control): -0.52 (95% CI:

minutes breaks, frequency 1time/week, environment in0.32)

which

exercise is performed - morning or afternoon is standardized in a

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comfortable semi-reclined chair semi-reclined, 23 Celsius,
QUALITY
dim OF LIFE SF-36 (physical function

light, relaxing atmosphere, feedback -(psychologist weekly

subscale)
AN
session. Baseline mean: Treatment 89.6, Control 77.5

Home exercise-program: at least 15 minutes of paced Reported

breathing Results: no significant difference between

with watch or easy air pacer software, 5 times/week groups

M

Treatment schedule: 10 weeks SMD (treatment vs control): 0.65 (95% CI:

COMPARISON TREATMENT 1.49)

Arm 2- Control Group: This group took part in the breathing

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protocol in sessions 1 and 10, without any prescribed treatment

REASONS FOR DROP-OUTS: NR
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Treatment schedule: week 1 and 10 COST OF CARE: NR

Duration of Follow-up: Directly after 10 weeks

CO-INTERVENTION: Not specified

Hansson 201338 INDEX TREATMENT PAIN (VAS 0 to 100)

Arm 1- Vestibular rehabilitation program: Activity- Baseline Median : Intervention 60, Control 60

training of six balance exercises with warm-up and recovery

Reported Results: no significant difference between
WAD
phases; Mode- static and dynamic balance exercises with
groups;
neck

PT
movements, eyes opened and closed; Movement- Warm
SMD (6 weeks vs control) 6 weeks 0.07 (95% CI:

phase- walking around the room and changing direction

0.68
as to
well
0.82);

as turning the head from side to side. Exercises in standing,

SMD (3 months vs control) -0.60 (95% CI:

RI
including training of co-ordination of movements. Circuit
0.15)

training- Standing up and sitting down on a chair while turning

the head from side to side. Eyes closed if possible. Standing on a FOR DROP-OUTS: reported
REASONS

SC
trampoline, eyes closed and slightly flexing the knees SIDE
and EFFECTS: NR

turning the head from side to side simultaneously. Standing

COSTonOF
a CARE: NR

10 cm foam with eyes closed and turning the head from side to

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side. Standing on a sport mat, walking on the spot and turning
AN
the head from side to side. Eyes closed if possible. Sitting on a

ball, feet on foam, eyes closed and bouncing slightly while

turning the head from side to side. Walking forward and

M

backward while turning the head from side to side. Recovery

phase- Soft, relaxing movements. Stretch of the muscles in the

upper cervical region. Dosage- Warm-up duration- 10

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Circuit training duration- 2- minutes per exercise, 2 laps.

Recovery phase duration- 5 minutes. Frequency -2 times/week,

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environment in which exercise is performed -physical therapy

centre, feedback -supervised group sessions.

Treatment Schedule: 6 weeks, 12 sessions

COMPARISON TREATMENT

Arm 2- Control Group: no intervention

Treatment Schedule: 6 weeks

Duration of Follow-up: 6 weeks and 3 months

PT
CO-INTERVENTION: reported and not avoided

Helewa 200739 INDEX TREATMENT PAIN (VAS 0 to 10)

Arm 1- Exercise: Activity-Standard Pillow + ExerciseBaseline

+ ActiveMean: Exercise 2.9, Pillow 3.6, Exercise +

RI
Control Treatment Group: Standard (regular) pillow Pillow 2.3, Control 2.5
Chronic MND
to be used by this group. Mode- Exercise including: Posture,
Reported Results: Not significant at all points

Relaxation, Active Movement- 1-Postural correction in

SMDsitting,
(exercise vs control): -0.00 (95% CI:

SC
standing or during work and leisure activities emphasizing
0.52)chin

in retracted position with cervical spine elongations not

SMDbeyond
(exercise + pillow vs pillow): -0.59 (95% CI:

normal curves of cervical spine practised with mirror feedback

1.09 to -0.09); power 50.69%

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first, then freely using other prompts to become habitual, 2
AN
Relaxation Exercise Techniques designed to interrupt FUNCTION
cycle of Northwick Park Neck Pain

pain and muscle spasm (hold-relax approach repeated Questionnaire

up to 5 (NPQ 0 to 100)

Baseline
times and/or rhythmic stabilisation applied manually by the PT Mean: Exercise 32.3, Pillow 35.01,
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and taught to the patient), 3-Free Active Exercise (following

Exercise + Pillow 29.9, Control 27.4

relaxation techniques patients freely move head and neck

Reported Results: Interaction of pillow and

according to normal patterns of movement, may initially

exercises
be are statistically significant and clinically
D

helped by the physiotherapists, patterns are diagonal and

important
involve

head flexion and rotation to the right followed by headSMD

extension
(exercise vs control): 0.00 (-0.52 to 0.52);
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and rotation to the left, diagonal patterns are then repeated

powerto100%
the

contralateral sides), and 4- Strengthening Exercises (toSMD (exercise + pillow vs pillow): -0.61 (

strengthen the anterior neck muscles using manual resistance

0.12); power 100%

(within the limit of pain) with a combination of isometric and

isotonic movements, the principle involving reversingQUALITY OF LIFE (SF 36 0 to 100)

movements of flexion and extension, using the principles

Baseline
of Mean: Exercise 42.8, Pillow 41.1, Exercise

successive induction40. Dosage- 13 sessions over 10 weeks,

+ Pillow
as 43.7, Control 43.8

PT
Reported Results: no significant difference between
well as home exercises and Active Control treatment (massage

and thermal modality) were administered to this groupgroups

isometric

rehabilitative exercise. SMD (exercise vs control): 0.15 (95% CI:

RI
Arm 2- Neck Support (Pillow): Activity- Orthopaedic0.65);
Pillow(s)
power 100%

+ Active Control Treatment Group: Mode- Neck Support

SMD (exercise + pillow vs pillow): -0.46 (95% CI

Pillows Movement-could be one of two designs: Shape

0.95,
of Sleep
to 0.04); power 100%

SC
pillow (Manutex Products, Mississauga, ON, Canada) or the

Sissel Design AB pillow (Sissel Design AB, Svedala, REASON

Sweden). FOR DROP-OUTS: Reported

The two types of pillows were randomly assigned equally

SIDE in EFFECTS: None present

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each arm. The pillows did not differ in shape but in theCOST OF CARE: NR
firmness
AN
of the foam. The pillow use was combined with the Active

Control treatment (massage and thermal modality).

COMPARISON TREATMENT
M

Arm 3- Neck Support and Exercise (Exercise + Pillow):

Orthopaedic Pillow(s) + Exercise + Active Control

Treatment: Orthopaedic pillows were used and were of two

D

types: Shape of Sleep pillow (Manutex Products, Mississauga,

ON, Canada) or the Sissel Design AB pillow (Sissel Design AB,

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Svedala, Sweden). The two types of pillows were randomly

assigned equally in each arm. The pillows did not differ in shape

but in the firmness of the foam. Pillow use, plus Exercise plus

Active control treatment (massage and thermal modality) were

administered in this group.

Arm 4- Massage Therapy and thermal modality (Contro

Standard (regular) Pillow + Active Control Group: The

PT
(regular) pillow is assumed to be used by this group. Active

Control treatment that included massage and thermal modality,

Effleurage type massage for 10 sessions in 10 weeks. Visits were

RI
2 sessions/week for 3 weeks, then 1 visit/week for 3 weeks, then

1 visit in 10th week.

Arm 5- Thermal modality: 20 minutes of moist heat or ice.

SC
Treatment Schedule: 6 weeks (assume that the use of the pillow

was constrained to these 6 weeks)

Duration of Follow-up: 6 weeks

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CO-INTERVENTION: avoided in trial design
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Humphreys 2002 INDEX TREATMENT PAIN (VAS 0 to 100)

Arm 1- Symptomatic exercise group (SEG): Activity Baseline Mean: SEG 55, SNEG 49

head-neck co-ordination and one eye-head-neck-upperReported

limb c Results: no significant difference between
Chronic neck pain
M

ordination; Mode- sitting. Movement- Exercise one: participants

groups

were required to fix their eyes on a target in front of them

SMDand
(SEG vs SNEG): 0.00 (95% CI: -0.74 to 0.74)

move their head maximally in a slow and carefully controlled

D

movement in one direction while keeping their eyes fixed

REASON
on the FOR DROP-OUTS: not specified

target straight ahead. Exercise two: participants were required

SIDE EFFECTS:
to NR
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hold up both arms in front of them with their thumb extended

COST OF CARE: NR

upwards and to keep their eyes fixed on one thumb as the

ipsilateral arm went through the sequential movements of the left

and right rotation, flexion and extension, with the eyes and head

followed the movement in a slow and co-ordinated

fashion. Dosage- Speed (slow and co-ordinated movement),

Duration/Frequency (4 weeks, 2 times/day), Feedback (one

PT
training session given by the author and an instruction sheet),

Monitoring (exercise compliance form), Environment (home

exercise program). Dose (NR).

RI
Treatment Schedule: 4 weeks, 2 daily sessions.

COMPARISON TREATMENT

Arm 2- Control group: Symptomatic non-exercise group

SC
(SNEG).

Treatment Schedule: 4 weeks

Duration of Follow-up: none

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CO-INTERVENTION: NR
AN
Jull 200242 INDEX TREATMENT PAIN Headache intensity change score (VAS

Arm 1- Exercise Therapy (CCF/ISO) Activity- therapeutic

10) low

Baseline Mean: SMT 4.8, CCF 5.4, MT/ET 5.1, NT

load exercise to cervical-scapular region Mode- craniocervical
Chronic CGH
M

flexor training with pressure biofeedback, scapular muscle

5.3

training, postural correction, Movement- exercise performed

Reported Results: significant favouring SMT and

throughout the day, isometric strengthening with co-contraction

CCF
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of neck flexion and extension, stretching as needed. Treatment

SMD (CCF vs NT) at LT follow-up:-0.59 (95% CI:

Schedule- 30 minute session duration, 2 sessions/weeks,

1.008 to
to -0.18),
12 NNTB 6, treatment advantage 28%
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sessions total

Arm 2- Combined Therapy (MT/ET): Activity- manipulation,

FUNCTION Northwick Park Neck Pain

mobilisation & exercise Questionnaire (NPQ change score, 0 to 36

Treatment Schedule: 30 minute session duration, twoBaseline Mean: SMT 27.5, CCF 29.6, MT/ET 29.7,

sessions/weeks, 8 to 12 sessions total NT 30.7

COMPARISON TREATMENT Reported Results: significant favouring MT or

Arm 3- Manipulative Therapy (SMT): manipulation: high

MT/ET over control; no significant difference

PT
velocity, low-amplitude manipulation described by Maitland;
between MT, ET and MT/ET comparisons

mobilisation (low velocity), 30 minute session duration.

SMD (CCF vs NT) at LT follow-up:-0.59 (95% CI:

2 sessions/week, 8 to 12 sessions total 1.00 to -0.18), NNTB 6, treatment advantage 32%

RI
Arm 4- Control Group (NT): no treatment

Treatment Schedule: 6 weeks, 8 to 12 sessions GLOBAL PERCEIVED EFFECT Participant

Duration of Follow-up: 52 weeks perceived effect (VAS 0 to 100)

SC
CO-INTERVENTION: NR Reported Results: significant favouring SMT and

MT/ET over NT, not significant for SMT or MT/ET

when compared to CCF

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SMD (CCF vs NT): -2.51 (95% CI: -3.05 to
AN
REASONS FOR DROP-OUTS: reported

SIDE EFFECT: minor and temporary, 6.7% of

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headaches were provoked by treatment

COST OF CARE: NR

Kjellman 200243 INDEX TREATMENT PAIN (VAS 0 to 100)

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Arm 1- General Exercise (ET): Activity-stretching, Baseline Mean: ET 27.0, McK 19, SUS 21

strengthening; Mode- neck and shoulder; Movement Reported Results: no significant difference between
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with or without radiation

active neck endurance and strength exercises, 16 sessions over 2
groups

months SMD (ET vs SUS) at LT follow-up: -0.19 (95% CI:

Arm 2- McKenzie Exercise (McK): Specific McKenzie

0.41
protocol.
to 0.80)

Sessions over 2 months. Number not specified SMD (McK vs SUS) at LT follow-up: 0.04 (95% CI:

COMPARISON TREATMENT -0.51 to 0.60)

Arm 3- Sham Ultrasound (SUS): Set at lowest setting for 7

minutes. Applied over the superior portion of the trapezius

FUNCTION (NDI 0 to 50)

PT
Treatment Schedule: 4 weeks of treatment Baseline Mean: ET 27.0, McK 19, US 21

Duration of Follow-up: 6 and 12 months Reported Results: no significant difference between

CO-INTERVENTION: Comparable between index and

groups
control

RI
groups. SMD (ET vs SUS) at LT follow-up: -0.19 (95% CI:

0.41 to 0.80)

SMD (McK vs SUS) at LT follow-up: 0.04 (95% CI:

SC
-0.51 to 0.60)

REASONS FOR DROP-OUTS: reported

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SIDE EFFECTS: NR
AN
COST OF CARE: NR

Kuijper 200944 INDEX TREATMENT PAIN (VAS 0 to100)

Arm 1- Physiotherapy Group (PG): Activity-Therapy Baseline

was Mean: Cervical Collar 57.4, Physiotherapy
M

focused on mobilizing and stabilizing the neck and was

61.7, WLG 55.6
Acute NDR
characterized as "hands off". Mode- The sessions wereReported Results: At 6 weeks there was a significant

standardized provided by a certified Physiotherapist, the

decrease
patientin neck pain in the collar group 2.8
D

was instructed on graded exercise activities to strengthen

mm/week
the (17 mm in 6 weeks) and 2.4 mm/week in

superficial and deep muscle of the neck. The patients were

the physiotherapy
also group (14 mm in 6 weeks), while
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instructed in a home exercise program. Movement-Patients

the control
were group showed only 0.9 mm reduction in

advised to practice the exercises daily and asked to record

pain the
over the 6 weeks. After 6 months the pain scores

duration of their exercise daily. Dosage: 2 times/weekinforthe

6 two treatment groups did not differ from those

weeks of the control patients.

COMPARISON TREATMENT SMD (PT vs WLG) at Immediate post treatment:

Arm 2- Wait and see list Group (WLG): Patients in the0.47

control
(95% CI: -0.81 to -0.12); NNTB 4, treatment

group were advised to continue their daily activities asadvantage

much as 33%

PT
possible. As well they were asked to note in their diaries the

parts of the day where they were unable to continue their

FUNCTION
normal (NDI 0 to 100)

activities. Patients were asked to contact the investigators

Baseline
if theyMean: Cervical Collar 41.0, Physiotherapy

RI
had any questions. 45.1, WLG 39.8

Arm 3- Collar Group (CG): Semi-hard collar (Cerviflex

Reported
S, Results: The collar group showed a

Bauerfeind and available in 6 sizes), The best size (to significant

fit snugly) difference in rate of improvement

SC
was selected for each patient. Patients advised to wearcompared
the pillowwith the control group, the weekly change

during the day for 3 weeks. Over the next 3 weeks patients
in thewere
physiotherapy group was not significantly

weaned off the collar. After 6 weeks they were asked to

different
no from that of the control patients.

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longer wear the collar. SMD (PT vs WLC) at immediate post treatment:
AN
Treatment Schedule: 6 weeks, 12 sessions 0.11 (95% CI: -0.45 to 0.23)

Duration of Follow-up: 6 months

CO-INTERVENTION: Comparable between index and

PATIENT
control SATISFACTION (scale 0 to 5
M

groups. Patients were asked to take paracetamol (usually)

Reported
either Results: NR

with or without a non-steriodal anti-inflammatory. If necessary

RR (PT vs WLC) at immediate post treatment: 0.92

opioids were prescribed. (95% CI: 0.62 to 1.37)

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REASONS FOR DROP-OUTS: NR

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SIDE EFFECT: NR

COST OF CARE: NR

Lange 201345 INDEX TREATMENT PAIN (VAS 0 to 10)

Arm 1- Training group: Activity- Patterns and synchroni

Acute to chronic non Baseline Mean: Training group 1 and control 1.2

of muscle recruitment, Strengthening exercises, Endurance

neck and shoulder pain Reported Results: no significant difference between

exercises; Mode-Patterns and synchronisation -Standing

groups
supine

and gentle rotation stood erect, Strengthening-the whole

SMDspine
(training vs control): -0.58 (95% CI:

PT
was held in an anatomic neutral position during pull exercises,
0.04)

shrugs standing erect holding the dumbbells in their hands on

both sides and sitting position leaning the upper body REASON
45 degrees FOR DROP-OUTS: Reported

RI
forward with a straight back for reverse flies. Endurance
SIDE EFFECTS: Reported

the body blade with both hands, and with shoulders 90%
COST
flexed
OF CARE: NR

and elbows 5% flexed; Movement- Patterns and

SC
synchronisation-3 conditioning exercises focusing on activation

of the deep cervical flexors, Strengthening-Static pull in 8

directions, shrugs, reverse flies, Endurance-Small shoulder

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extensions and flexions were performed to make the body
AN
oscillate; Dosage- Patterns and synchronisation-Type of

contraction - concentric, Speed -slow and controlled movement,

Duration/Frequency -5 repetitions, 3x week, Sequence

M

warm-up then strengthening then endurance, Feedback

pilots had access to help from educated trainers at the base and at

Tactical Air Command Karup, Strengthening-Type of

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contraction -concentric, Intensity -equivalent to 70% to 85% of 1

repetition maximum, Duration/Frequency -8 to15 rep

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week, Shrugs and static neck pull were performed during every

session and reverse flies were performed every second session,

Sequence -after warm-up, Feedback-(the pilots had access to

help from educated trainers at the base and at Tactical Air

Command Karup, Endurance-Type of contraction -dynamic,

Intensity -equivalent to 70% to 85% of 1 repetition maxi

Speed -as the participants became more accustomed to the body

PT
blade exercise, they attempted to make it oscillate increasingly

more rapidly, Duration/Frequency -up to 60 seconds, performed

every second session, 3x week, Sequence -after strengthening,

RI
Feedback -the pilots had access to help from educated trainers at

the base and at Tactical Air Command Karup. Dosage

sessions a week, 20 minutes of training session for 24 weeks

SC
COMPARISON TREATMENT

Arm 2- Control group: No intervention but offered the training

after the study. Encouraged to continue their physical activity as

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usual.
AN
Treatment Schedule: 24 weeks

Duration of Follow-up: none

CO-INTERVENTION: comparable between index and control

M

groups

Lundblad 199946 INDEX TREATMENT PAIN (VAS 0 to 10)

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Arm 1- Feldenkrais Intervention (F): Activity-Education

Baseline Mean: VAS - usually PT 1.2, F 1.5,
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Individualized (functional integration) teacher guides 2.0,

through
VAS - worst PT 4.1, F 4.4, control 5.5
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Chronic MND movement sequences; Group (awareness through movement)

Reported Results: no significant differences

verbally guided through exercises for Movement- neck

SMD (PT vs control) at LT follow-up: -0.14 (95% CI:

complaints, home exercises, frequency -individually 4-0.80

timestoand
0.51)

in group (7 to 8 participants) 12 times; required 50%

participation in both segments of program. Dosage- 50DISABILITY

minutes Work and leisure ( 0 to 4)

per week days and %

Arm 2- Physiotherapy Intervention (PT): Activity- Stabili

Baseline Mean:

PT
exercises for low back and pelvis, isolated and relaxedDisability
shoulder - work PT 1.3, F 1.2, control 1.3,

movements Mode- Education use of body emphasizing

Disability
self - leisure PT 0.6, F 0.9, control 0.6

directed control and responsibility for body, ability to Sick

cope leave
with (days) PT 12.7, F 12.0, control

RI
pain, muscle tension, and complaints. Awareness of body
Sick leave (%) PT 6.5, F 5.8, control 5.9

posture. Movement- Practice work-related lift and movement

Reported Results: no significant differences

techniques. Exercise program of strength, co-ordination,

SC
endurance, flexibility/smoothness and rhythm, Home REASON FOR DROP-OUTS: Reported

exercises. Dosage- 50 minutes; 2 times/week for 16 weeks

SIDEinEFFECTS: NR

group of 5 to 8 participants; Required 50% participation

COST
in theOF CARE: NR

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exercises
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COMPARISON GROUP

Arm 3- Control Regimen : no treatment

Treatment Schedule: 16 weeks, 32 sessions

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Duration of Follow-up: 52 weeks

CO-INTERVENTION: NR

Martel 201147 INDEX TREATMENT PAIN (VAS 0 to 10)

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Arm 1- SMT Group: Activity- Spinal Manipulation Mode

Baseline Mean: SMT 3.1, SMT + Ex 3.8

Maximum 4 spinal manipulations Movement- cervical

Reported
and Results: no significant differences
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Chronic MND with or without

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referral/radiation toupper
the head,
thoracic areas. Dosage- One treatment per month, lasted

trunk or limbs 10 to 15 minutes FUNCTION (NDI 0 to 50)

Arm 2- SMT + Exercise Group: Activity- Spinal Manipulation +

Baseline Mean: SMT 21.4, SMT + Ex 22.2

Home Exercise Program, range of motion, stretching, Reported Results: no significant differences

strengthening Mode-Maximum 4 spinal manipulations. Advised

to perform a home exercise program Movement- manipulation

HEALTH-RELATED QUALITY OF LIFE

cervical and upper thoracic areas (down to T4). home 0exercise

to 100)

PT
Baseline Mean Physical Scale: SMT 48.7, SMT + Ex
program- range of motion exercises, followed by 4 stretching/

mobilisation, and 4 strengthening exercises (concentric50.0,

and Mental Scale: SMT 45.3, SMT + Ex 44.8

isometric contractions) of the cervical and upper thoracic

Reported
spine Results: no significant differences

RI
(primarily flexion, extension, lateral flexion and rotation of the

cervical spine). Dosage- manipulation- one treatment per

REASON
month FOR DROP-OUTS: Reported

lasted 10 to15 minutes. Home exercise program 3x/week.

SIDEThree
EFFECTS: Reported: No serious adverse

SC
series of each exercise with a 30 to 60 second rest between
eventsseries
were reported during RCT

were performed during each training session. A train COST OF CARE: NR

lasted 20 to 30 minutes

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All participants were instructed in the same routine, exercise
AN
volume was tailored to each participant's strength, flexibility and

ability to complete the routine with minimal neck pain. Each

patient received a written copy of the program. Exercise checked

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every 2 months by a kinesiologist.

COMPARISON TREATMENT

Arm 3- Control Group: Attention-control, No treatment, attended

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clinic once every 2 months, visited lasted 20 to 30 minutes for

data collection.
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Treatment Schedule: 10 months, 10 sessions

Duration of Follow-up: none

CO-INTERVENTION: NR
48
Rendant 2011 INDEX TREATMENT PAIN (VAS 0 to 100)

Baseline Mean: Qigong 57.7, E 57.5, control

Arm 1- Qigong: Activity-12 neck exercises, 9 shoulder

exercises Mode/Movement- ROM/mobility, imagery,Reported

breathing Results: significant differences Qigong vs
Chronic MND
and moving exercise home exercise with a manual; Qigong
control;

PT
qualified teacher was certified by German Qigong MD (Qigong vs control) at 12 weeks treatment:

Society Dosage-18 sessions, 90 minute sessions over 615.60

months
(-24.72 to -6.48)

Arm 2- Exercise: Activity- ROM, stretching, MD (Qigong vs control) at 24 weeks treatment:

RI
strengthening Mode/Movement- Warm-up included neck
(-15.72 to -0.48)

of motion, use of soft ball, strengthening using a theraband;

MD (Exercise vs control) at 12 weeks treatment:

flexibility exercise, home exercise with a manual, individual

17.30 (95%CI:
pain -26.60 to -8.00)

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MD (Exercise vs control) at 24 weeks treatment:
level was not exceeded; Dosage- 18 sessions over 6 months;

exercise is monitored by a qualified physiotherapist 10.30 (95%CI: -19.97 to -0.63)

COMPARISON TREATMENT No significant difference Qigong vs exercise

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Arm 3- Control: no intervention
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Treatment Schedule: 24 weeks treatment, 18 sessionsFUNCTION (NPDI 0 to 100)

Duration Follow-up: none Baseline Mean: Qigong 44.0, E 39.5, control

CO-INTERVENTION: not avoided Reported Results: significant differences Qigong vs

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control;

SMD (Qigong vs control) at 12 weeks treatment:

0.48 (95%CI: -0.92 to -0.04)

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SMD (Qigong vs control) at 24 weeks treatment:

0.47 (95%CI: -0.92 to -0.02)

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SMD (Exercise vs control) at 12 weeks treatment:

0.78 (95%CI: -1.24 to -0.31)

SMD (Exercise vs control) at 24 weeks treatment:

0.50 (95%CI: -0.97 to -0.04)

No difference Qigong vs exercise

QUALITY of LIFE (SF 36, physical component

PT
Baseline Mean: Qigong 43.1, E 43.7, control

Reported Results: significant differences qigong vs

control;

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MD (Qigong vs control) at 12 weeks treatme

(95% CI: -6.97 to 0.17)

MD (Qigong vs control) at 24 weeks treatment:

SC
(95%CI: -8.07 to 0.27)

MD (Exercise vs0 control) at 12 weeks treatment:

2.70 (95%CI: -6.76 to 1.36)

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MD (Exercise vs control) at 24 weeks treatment:
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(95%CI: -5.83 to 1.83)

No difference qigong vs exercise

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REASON FOR DROP-OUTS: detailed

SIDE EFFECTS: Reported by 19 patients in qigong

group including: muscle soreness (n = 15),

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myogelosis (n = 12), vertigo (n = 10), other pain (n =

4), headache (n = 3), thirst (n = 1), engorged hands (n

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= 1), twinge in the neck (n = 1), urinary urgency (n =

1), bursitis of left shoulder (n = 1). Reported by 16

patients muscle soreness (n = 14), myogelosis (n =

11), headaches (n = 5), vertigo (n = 2), change in

mood (n = 1), worsening of neck pain (n = 1),

worsening of tinnitus (n = 1).

COST OF CARE: NR

PT
Revel 199449 INDEX TREATMENT PAIN (VAS 0 to 100)

Arm 1- Proprioception Rehabilitation Group (RG) Activity

Baseline Mean: RG 50.5, control 45.9

Proprioceptive rehabilitation program: purpose to improve neck Results: significant favouring RG

Reported
Chronic MND (osteoarthritic

RI
proprioception; Mode- 15 minute individualized exercise
SMD at ST follow-up: -0.77 (95% CI: -1.29 to
changes 27 of 30)
session, exercises were mainly concerned with eye-neck
NNTB
co 4, treatment advantage 34%

ordination including; Movement- a) slow passive motions of the

SC
head with gaze on a fixed target, b) active movementsDAILY
of the INTAKE OF NSAID / ANALGESICS

head, automatic movements of the neck with passive trunk

Baseline Mean: RG 2.0/1.8, control 2.3/1.6

movements and head position relocation exercises, c) Reported

exercises Results: not significant

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in a wide range of motion with free eye-head coupling (author
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description well detailed in Rehabilitation Procedure page
FUNCTIONAL IMPROVEMENT SELF

896). Dosage- 2 times per week; 30 to 40 minute sessions

ASSESSED (scale 0 to 5)

COMPARISON TREATMENT Reported Results: significant favouring RG

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Arm 2- Control Group (CG): Medication: analgesic, anti

SMD at ST follow-up: 0.55 (95% CI: 0.33 to 0.89),

inflammatory typical dosage was indomethacin 100mg;

NNTB
aspirin,
3, treatment advantage NA

3000 mg; diclofenac, 150 mg; naproxen, 1000 mg

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Treatment Schedule: 8 weeks REASON FOR DROP-OUTS: NR

Duration of Follow-up: 2 weeks SIDE EFFECTS: NR

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CO-INTERVENTION: NR COST OF CARE: NR

Stewart 200750-52 INDEX TREATMENT PAIN (VAS 0 to 10)

Arm 1- Exercise and Advice: Activity- Exercise, Mode

Baseline Mean: Exercise + Advice 5.2, Advice

exercise, stretches, functional activities, activities to build

Alonespeed,
5.3
Subacute and Chronic WAD
endurance and co-ordination, trunk and limb strengthening, Reported
CBTResults: Groups were similar at baseline.
with or without radiation
(setting goals of progressively increasing difficulty, shaping,
SMD immediate posttreatment: -0.46 (95% CI:

encouraging self-monitoring of progress, self-reinforcement),

to -0.12)

PT
SMD at 12 month: -0.12 (95% CI: -0.47 to 0.23)
home exercise program (individual specified), Movement

graded exercise program supervised by a

physiotherapist, Dosage- duration -1 hour of exercise FUNCTION

per (NDI 0 to 50)

RI
session, feedback-supervised for 30 minutes, Individualized,
Baseline Mean: Exercise + Advice 18.2, Advice

progressive, intensity -submaximal program designed Alone

to improve
19.7

participants ability to complete functional activities specified

Reportedby Results: Groups were similar at baseline.

SC
the participant as being difficult because of whiplash. SMD
Regular
immediate post treatment: -0.50 (95% CI:

evaluation by a physiotherapist. Encouraged to continue

to -0.15)
home

exercises even after intervention was completed. Dosage

SMD 12 month: -0.39 (95% CI: -0.74 to -

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weeks, 12 sessions
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COMPARISON TREATMENT GLOBAL PERCEIVED EFFECT

Arm 2- Advice Alone: Standardised education, reassurance

(scale and
-5 to 5)

encouragement to resume light activity alone. One consultation

Baseline Mean: Exercise + Advice 0.6, Advice
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and 2 follow-up phone contacts. Favorable prognosis of

Alone 0.3

whiplash, addressed common inaccurate beliefs about Reported

whiplash, Results: Groups were similar at baseline.

exploration of fear-avoidance beliefs. Participants given

SMDa immediate post treatment: -0.46 (95% CI:
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written report of main points of advice session. Standardized

to -0.11),

advice reinforced at 2 weeks and 4 weeks SMD 12 month: -0.18 (95% CI: -0.54 to 0.17)
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Treatment Schedule: 6 weeks, 12 sessions

Duration of Follow-up: 42 weeks QUALITY OF LIFE (SF-36 Physical 0 to 100

CO-INTERVENTION: avoided in trial design Baseline Mean: Exercise + Advice 36.4, Advice

Alone 36.8

Reported Results: Groups were similar at baseline

SMD immediate post treatment: -0.35 (95% CI:

to -0.01),

PT
SMD 12 month: -0.15 (95% CI: -0.50 to 0.20)

REASON FOR DROP-OUTS: Reported but not

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specified

SIDE EFFECTS: Reported; The main complaint in

this group was muscle pain with exercise (3) followed

SC
by knee pain (2) and lumbar spine pain (2).

COST OF CARE: NR

Takala 199453 INDEX TREATMENT PAIN (VAS 0 to 100)

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Arm 1- Exercise treatment (ET): Activity- Group gymnastic,
Baseline Median: ET 40, control 50
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instructional type (group), Mode- setting -work; treatment
Reported Results: no significant difference
MND, disorder duration NR
characteristics -exercise planned to train whole

body, Movement- aerobic dynamic exercise -10 minutes

PRESSURE PAIN SENSITIVITY
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walking or stepping, relaxation, stretching of muscles Algometer

of the (pressure pain threshold (PPT) on upper

trunk and extremities and dynamic exercises -10 trapezius, levator scapulae, rhomboid, infraspinatus)

minutes, Dosage- sequence-(10 minutes walking/stepping,

mean10score of 8 measures
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minutes stretch/dynamic exercises, 5 minutes walking/stepping,

Baseline Mean: ET 45.2, control 44.8

10 minutes dynamic and co-ordination exercises, 10 minutes

Reported Results: no significant difference
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stretch and relaxation; duration of session -45 minutes;1

SMD at immediate post treatment: -0.06 (95% CI:

time/week 0.65 to 0.53)

COMPARISON TREATMENT

Arm 2- Control - no treatment REASON FOR DROP-OUTS: NR

SIDE
Treatment Schedule: 10 weeks, 10 sessions of treatment in EFFECTS:
the NR

COST
spring session -cross-over of placebo group occurred in OF CARE: NR
autumn,

the groups were reversed

PT
Duration of Follow-up: none

CO-INTERVENTION: NR

Viljanen 200354 INDEX TREATMENT PAIN (VAS 0 to 10)

RI
Arm
Chronic MND (NDR, 1- Exercise: Activity- muscle training; Mode- activating
NDH, Baseline Mean: Exercise 4.8, Relax 4.8, C

large muscle groups in neck and shoulders MovementReported Results: no group difference
WAD)
dumbbells with weight of 1 to 3 kg; Dosage- DynamicSMD
muscle
(Exercise vs Control): -0.04 (95% CI:

SC
training, Sequence (stretching followed each exercise);0.20)

progression in weeks 5 and 9.

Arm 2- Relax: Activity- Relaxation training; Mode/Movement

FUNCTION (NDI 0 to 50)

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progressive relaxation, autogenic training, functional Baseline
relaxation,
Mean: Exercise 29, Relax 2 29, C
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systematic desensitisation. Reported Results: no significant group differences

COMPARISON TREATMENT were found

Arm 3- Control: No treatment SMD (Exercise vs Control): -0.11 (95% CI:

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Treatment Schedule: 12 weeks plus 1 week reinforcement,

0.38) Arm

1-13.6 sessions; Arm 2- 14.6 sessions

Duration of Follow-up: 3 and 9 months REASON FOR DROP-OUTS: Noted but no

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CO-INTERVENTION: Comparable between groupsdifference between groups

SIDE EFFECTS: NR
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COST OF CARE: NR

von Trott 200955 INDEX TREATMENT PAIN (VAS 0 to100)

Arm 1- Qigong: Activity- Qigong, Mode- lessons, Movement

Chronic MND in elderly Baseline Mean : Qigong 56.4, Exercise 47.1, Control

adults started with about 10 minutes of typical Qigong "opening"

49.9

exercises, continued with up to 4 exercises of Dantian Reported

Qigong, Results: After 3 months there was not

and finished with about 10 minutes of "closing" significant difference for the average neck pain

exercises. Dosage- Qigong was provided by 5 approved

between
Qigongthe Qigong and the wait list group

PT
therapists; 24 sessions (45 minutes) over 3 months (2 (95% CI: -24.0 to 2.1; p = 0.99, ANCOVA), and no

sessions/week). significant difference between the Qigong and the

Arm 2- Exercise: Activity- Exercise therapy; Mode- exercise therapy group the group difference being

RI
on a standardized program for computer and workplace
2.5related
mm (95% CI: -15.4 to 10.3, p = 0.68).

neck pain; Movement- including repeated active cervical

MD (Qigong vs control) at 12 weeks treatment:

rotations, strength and flexibility exercises. A detailed(95% CI: -21.88 to 6.88)

SC
description is provided in Weidmann 2008. Dosage- MD (Qigong vs control) at 12 weeks treatment + 12

(45 minutes) over 3 months (2 sessions/week). Participants

weekswere
follow-up: -6.80 (95% CI: -21.34 to 7.74)

asked to continue exercising on their own for the next MD

3 months.
(Exercise vs control) at 12 weeks treatment:

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COMPARISON TREATMENT 10.40 (95%CI: -23.11 to 2.31)
AN
Arm 3- Wait List Control: Patients were free to treat their
MD neck
(Exercise vs control) at 12 weeks treatment + 12

pain with the treatment or therapies they were using prior

weeksto follow-up: -12.20 (95%CI: -25.73 to 1.33)

randomisation. Patients did not receive Qigong or exercise

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therapy. After 6 months they were offered an intervention

FUNCTION
of (NDI 0 to100)

their choice. Baseline Mean: Qigong 38.5, Exercise 41.8, Control

Treatment Schedule: 12 weeks, 24 sessions 36.1

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Duration of Follow-up: 12 weeks follow-up Reported Results: No significant difference was

CO-INTERVENTION: Comparable between index and

found
control
between the groups after 3 and 6 months.
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groups SMD (Qigong vs control) at 12 weeks treatment:

0.21 (95% CI: -0.69 to 0.28)

SMD (Qigong vs control) at 12 weeks treatment + 12

weeks follow-up: -0.06 (95% CI:-0.57 to 0.

SMD (Exercise vs control) at 12 weeks treatment:

0.23 (95%CI: -0.70 to 0.24)

SMD (Exercise vs control) at 12 weeks treatment +

PT
12 weeks follow-up: -0.29 (95%CI: -0.77 to 0.20)

GLOBAL PERCEIVED EFFECT

RI
SMD (Qigong vs control) at 12 weeks treatment:

0.01 (95% CI: -0.49 to 0.47)

SMD (Qigong vs control) at 12 weeks treatment + 12

SC
weeks follow-up: -0.09 (95% CI: -0.60 to 0.42)

SMD (Exercise vs control) at 12 weeks treatment:

0.09 (95%CI: -0.38 to 0.56)

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SMD (Exercise vs control) at 12 weeks treatment +
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12 weeks follow-up: -0.21 (95% CI: -0.69 to 0.28)

QUALITY OF LIFE (SF-36 physical component

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to 100)

Baseline Mean: Qigong 30.4, Exercise 28.7, Control

30.6
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Reported Results: No significant difference was

found between the groups after 3 and 6 months.

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MD (Qigong vs control) at 12 weeks treatment:

(95% CI: -5.94 to 2.34)

MD (Qigong vs control) at 12 weeks treatment + 12

weeks follow-up: 0.10 (95% CI: -3.99 to 4.19)

MD (Exercise vs control) at 12 weeks treatment:

1.70 (95%CI: -5.96 to 2.56)

MD (Exercise vs control) at 12 weeks treatment + 12

PT
weeks follow-up: 2.20 (95%CI: -1.81 to 6.21)

REASON FOR DROP-OUTS: Reported

RI
SIDE EFFECTS: Reported; 5 side-effects were

reported by 4 patients in the Qigong group (2 nausea,

2 aching muscles, 1 muscle tension) and 4 side effects

SC
by 2 patients in the exercise therapy group (2 muscle

tensions, 1 aching muscles, 1 nausea)

COST OF CARE: NR

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KEY: Intervention: CBT=Cognitive Behavioral Therapy; CCF=Craniocervical Flexion; ET= Exercise Therapy; IR= infrared
AN
Radiation; McK=McKenzie; Mock=Mock therapy; MT = manual therapy; MyoT= Myofeedback training; ROM = range of motion;

SMT=Manipulation; SSng=Self Snag; SUS=Sham Ultra Sound; TENS = transcutaneous electrical nerve stimulation. Outcome

measures: BORG= Borg pain scale; DASH= disability of the arm, shoulder and hand; NDI = neck disability index; NPDI= Neck
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Pain Driving Index; NPQ= Northwick Park questionnaire; PPT = pain pressure threshold [measured by algometer]; SF-12=

Short Form 12; SF-36= Short Form 36; VAS = visual analogue scale. Other: CI= confidence interval; G=group; NA = not

applicable; NNTB = number-needed-to-treat-to-benefit; NR = not reported; p=probability value; RCT = randomised controlled
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trial; RR= relative risk; SMD = standardised mean difference; vs=versus

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2.2 Measures of treatment effect

For continuous data, standard mean difference (SMD) with 95% confidence intervals (CI) was calculated.

The minimal clinically important difference (MCID) for pain was 10 on a 100-point pain intensity scale56-58.

We considered the effect small when it was less than 10% of the Visual Analog Scale (VAS), medium

when between 10% and 20%, and large when it was 20% to 30%. For the Neck Disability Index (NDI), we

used an MCID of 7/50 units59. For other outcomes we used the hierarchy of Cohen 1988 60: small (0.20),

medium (0.50) or large (0.80). Risk ratios (RR) were calculated for dichotomous outcomes. The Number

PT
Needed to Treat (NNT) was calculated. Assessment of heterogeneity was tested using the Chi2 method

and I2 method. In the absence of heterogeneity (p > 0.10), we calculated a pooled SMD, Mean Difference

RI
or RR.

2.3 Data synthesis

SC
We assessed the quality of the evidence using the Grading of Recommendations, Assessment,

Development and Evaluation (GRADE) approach61. Domains that may have decreased the quality of the

evidence are: 1) study design, 2) risk of bias, 3) inconsistency of results, 4) indirectness (not

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generalisable), 5) imprecision (insufficient data), other factors (e.g. reporting bias)62.
AN
3. Results
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We identified 5658 records and found 27 trials that used exercise treatment. The results presented are an

abridged version of our Cochrane review update20; refer to it for full details. We used the quadratic
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weighted Kappa (Kw) statistic to assess agreement on a per question basis (Kw 0.23 to 1.00). Each risk of
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bias item is presented as a percentage across all included studies (See Figure 2).
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Figure 2. ’Risk of bias’ graph: review authors’ judgements about each risk of bias item presented as

percentages across all included studies.

PT
RI
U SC
3.1 Effects of interventions: Chronic Mechanical Neck Pain
AN
3.1.1 Support Element
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3.1.1.1 Breathing OR Cardiovascular/Aerobic Training

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37
There is low quality evidence that diaphragmatic breathing and general fitness training23,24 may have no

effect on pain, function and QoL when compared to no treatment controls for chronic mechanical neck

pain and (sub)acute/chronic neck pain respectively.

3.1.2 Base Element

3.1.2.1 Stretching

PT
Cervical Stretch/ROM Exercises + Another Intervention versus That Same Intervention: There is

low quality evidence (one trial22, 16 participants) that neck stretching exercises, either before or after a

manipulation, made no difference on pain and function when compared with that same manipulation for

RI
chronic neck pain immediately post treatment.

Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilisation versus Sham: Low quality evidence

SC
(one trial43, 50 participants) shows no difference on pain and function immediately post intervention, at six

and 12-month follow-up using cervical movement exercises (McKenzie protocol) contrasted with sham

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ultrasound for chronic MND. AN
3.1.2.2 Strengthening

Static Cervical Strengthening + Static Stabilisation versus No Intervention or Wait List: Two trials (three

comparisons) studying chronic neck pain compared manually (1) resisted isometric neck exercise plus
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postural training with mirror feedback to a control, (2) these same isometric neck exercises and the use of

an orthopaedic pillow compared with the use of an orthopaedic pillow39 or (3) isometric exercise alone
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against no intervention or control63. Evidence of benefit showed people may improve slightly when
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exercise was added to a pillow versus a pillow alone (NNT = 9). However, this was not observed when
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isometric exercise alone was evaluated for function and quality of life, from immediately post treatment to

short-term follow-up. Low quality evidence (one trial63, 47 participants) supports improvement of GPE

favouring isometric exercise immediately post treatment. A clinician may need to treat three people to

achieve this type of benefit in one person.

Postural Exercise versus Control: There is very low quality evidence for postural exercise versus control,

Cervical/Scapulothoracic Strengthening + Endurance Training versus Control, and neuromuscular

exercise + another intervention versus that same intervention. (See Gross et al 201521 for greater details)

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Scapulothoracic + Upper Extremity Strengthening versus Control: Three trials23,28,34, each with different

dosages, compared specific strength training of the scapulothoracic region and upper extremity with a

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reference intervention Figure 3. There is moderate quality evidence [three trials23,28,34, 157 participants;

SMD pooled -0.71 (95%CI:-1.33 to -0.10)] that scapulothoracic and upper extremity strength training

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probably improves pain moderately to a large amount immediately post treatment and at short-term follow-

up. It may improve functional outcomes when compared to a control at short-term follow-up.

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Figure 3: Scapulothoracic + Upper Extremity Strengthening versus Control

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3.1.2.3 Stretch and Strengthening

Cervical/upper extremity Stretch/ROM Exercise + Cervical/upper extremity Strengthening + Dynamic

Cervical Stabilisation versus Placebo or Sham: Low quality evidence (one trial43, 50 participants) shows

no difference for pain relief and function immediately post intervention, at 6 and 12 months follow-up when

general exercises including neck and shoulder ROM, active neck endurance and strengthening exercises

is contrasted against sham ultrasound for chronic MND.

Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic

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Cervical/Shoulder Stabilisation versus Wait List: Moderate quality evidence [two trials48,55, 147

participants, MD pooled -10.94 (CI 95% -18.81 to -3.08)]; Figure 4) shows a standardised exercise

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program for neck pain including repeated active cervical rotations, strengthening and flexibility exercises

compared to a wait list probably has beneficial effect for pain and function, but not GPE and quality of life

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immediately post treatment and at short-term follow-up. A clinician may need to treat four people to

achieve a moderate degree of pain relief and five to achieve moderate functional benefit in one person.

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Figure 4: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic

Cervical/Shoulder Stabilisation versus Wait List

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Cervical/upper extremity Stretch/ROM Exercises + Cervical/Scapulothoracic +/-upper extremity

Strengthening + Dynamic/Static Cervical Stabilisation + Another Intervention versus That Same

Intervention: Four trials studying chronic neck pain compared the following exercise interventions with a

control group:

• deep neck flexor retraining with pressure biofeedback and resisted neck flexion/extension

strengthening using multicervical rehabilitation unit33;

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• low technology exercise including progressive resisted neck and upper body strengthening using

dumbells and pulley systems, light stretching and a short aerobic warm-up program31;

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• muscle stretching and strengthening exercises of the neck and upper limb regions including

strengthening of the deep cervical flexor muscles35;

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• a home exercise program of ROM, stretching/mobilisation and strengthening exercises of the cervical

and upper thoracic spine47.

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For pain outcomes, we found consistent evidence for reduced pain immediately post treatment31,33,35,47, at

intermediate-term and long-term follow-up31.This suggests small treatment benefits initially but larger
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benefits in the long term. For function outcomes, there was evidence of benefit for function immediately

post treatment, at intermediate31,33,35 [SMD pooled -0.45 (95% CI: -0.72, to -0.18); Figure 5] and long-
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term31 follow-up. In conclusion, moderate quality evidence (four trials31,33,35,47, 341 participants) shows

moderate pain relief and improved function up to long-term follow-up for combined cervical,
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scapulothoracic stretching and strengthening for chronic neck pain. A clinician may need to treat six to 18

people to achieve this type of pain relief and four to 13 to achieve this functional benefit. Changes in GPE
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measures indicate a difference immediately post treatment and at long-term follow-up.

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Figure 5: Cervical/upper extremity Stretch/ROM Exercises + Cervical/Scapulothoracic +/-upper extremity

Strengthening + Dynamic/Static Cervical Stabilisation + Another Intervention versus That Same

Intervention

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3.1.2.4 Stretching and Endurance Training

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Cervical/Scapulothoracic/pper extremity Stretch + upper extremity Endurance Training versus No

Intervention: Moderate quality evidence (one trial54, 393 participants), shows little to no difference for

upper extremity stretching and endurance training compared to ordinary activity for chronic neck pain and

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function immediately post treatment, at short-term and long-term follow-up.
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3.1.2.5 Strengthening and Endurance Training

Cervical/Scapulothoracic Strengthening + Endurance Training versus Control: Very low quality evidence
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(one trial, 68 participants29) shows we are uncertain whether cervical/scapulothoracic strengthening and

endurance-strength exercises improves the prevalence of neck pain in chronic neck pain at immediately
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post treatment and at long-term follow-up.

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Pattern synchronisation and cervical/scapulothoracic strengthening and scapulothoracic endurance versus

Control: Low quality evidence (one trial45, 55 participants) shows deep neck flexor recruitment

combined with upper extremity strengthening/endurance exercises may have little difference on pain

immediately post treatment when compared to a control.

3.1.2.6 Endurance Training

Scapulothoracic/UE Endurance Training versus Control: Moderate quality evidence (one trial25, 198

participants25) shows a medium beneficial effect size for pain relief immediately post intervention when

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using shoulder abduction endurance training for two minutes or 12 minutes with a control group for

(sub)acute/chronic MND. A clinician may need to treat four people to achieve this type of pain relief in one

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person.

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3.1.3 Modulator Elements

Neuromuscular Exercise (eye-neck coordination/proprioception) + Another Intervention versus That Same

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Intervention: Very low quality evidence (one trial49, 60 participants) shows a moderate reduction in pain
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and improved function in chronic neck pain in the short-term for eye-neck coordination exercises. A

clinician may need to treat four people to achieve this type of pain relief and three to achieve this
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functional benefit in one person.

Patterns synchronisation + Feedforward/feedback exercises for coordinating the neck, eyes and upper

Low quality evidence (one trial41, 56 participants) shows eye-neck-upper

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limbs versus No Intervention:

limb coordination exercises show little or no difference in pain immediately post treatment when
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contrasted with no intervention for people with chronic neck pain.

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Patterns synchronisation + Feedforward/feedback: vestibular rehabilitation (balance on unstable surfaces

and walking with head movements and eyes closed) versus No Intervention: Low quality evidence (one

trial38, 29 participants) shows vestibular rehabilitation type exercises may have little or no difference from

no intervention for neck pain both immediately post treatment and at short-term follow-up.

3.1.4 Base + Modulator Elements + Support

Trunk and Extremity Stretch + Pattern/Synchronisation: Balance Coordination + Cardiovascular/Aerobic

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versus No Intervention: Low quality evidence (one trial53, 44 participants) shows little to no difference

for pain reduction immediately post treatment in patients with neck pain of unspecified duration when

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treated with group exercise that combined stretching and coordination exercises with cardiovascular

training.

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General Endurance Training + Dynamic/Static Lowback/pelvic Stabilisation + General Stretching +

Neuromuscular/body Mechanics Movement Training versus No Intervention: Low quality evidence (one

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trial46, 38 participants) shows little to no difference for pain reduction with a combined exercise approach

of stabilisation of the low back and pelvis, posture awareness, ergonomic training, and strength,
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coordination, endurance, flexibility/smoothness and rhythm exercises when compared to no intervention or

a wait list control in chronic neck pain at short-term follow-up.

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3.1.5 Base + Cognitive/Affective Element

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Stretch/ROM + Endurance Training + Dynamic Stabilisation + Cognitive (mindfulness & emotional

Two trials48,55 compared a program of Qigong exercises (Dantian

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balance) versus Wait List:

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Qigong).There was evidence of reduced pain and function post treatment at 12 weeks [MD pooled (pain)

-13.28 (-20.98 to -5.58)| [SMD pooled (function) -0.36 (-0.68 to -0.03)] and 24 weeks [MD pooled (pain) -

7.82 (-14.57, -1.07) | SMD pooled (function) -0.28 (-0.68 to 0.11)] of treatment. For quality of life, there

was evidence of benefit for SF36 physical component immediately after 12 weeks of treatment, but not

after 24 weeks. In conclusion, moderate quality evidence (two trials48,55, 191 participants) shows Dantian

Qigong exercises may improve pain and function slightly when compared with a wait list control at

immediate and short-term follow-up. It may have little or no benefit at immediate and short-term follow-up

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on QoL and GPE. A clinician may need to treat four to six people to achieve this type of pain relief, five to

eight people to achieve this functional benefit, and seven to 10 people for this improvement QoL.

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3.1.6 Base + Modular + Cognitive Affective + Support

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Stretch/ROM + Strength and Endurance Training (trunk and limb) + Pattern/Synchronisation: Balance

Coordination + Cardiovascular/Aerobic + Cognitive (Coaching + Motivational) versus that Same

Intervention: Low quality evidence (one trial50, 132 participants) shows small benefits for pain relief,

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function, GPE and quality of life immediately post treatment and small benefit at 12 month follow-up for
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function when an individualised, progressive submaximal program, which included aerobic training, trunk

and limb exercises and advice is compared with advice alone for subacute/chronic WAD.
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3.2 Effects of interventions: Acute to Chronic Cervicogenic Headache

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3.2.1 Base Element

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Stretch/ROM exercises versus Sham: Low quality evidence (one trial36, 32 participants) shows people

may improve a large amount for pain at short and long-term follow-up with the use of C1-C2 self-SNAG

exercises when compared with a sham for (sub)acute cervicogenic headache. A clinician may need to

treat three people to achieve this type of long-term pain relief.

3.2.2 Base and Modular Element

Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback +

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Dynamic Cervical Stabilisation versus No Intervention: Moderate quality evidence (one trial42, 97

participants) shows cervicoscapular strengthening and endurance exercises including pressure

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biofeedback improves pain, function and GPE for chronic cervicogenic headaches at long-term follow-up

when compared to no treatment. A clinician may need to treat six people to achieve this type of pain relief

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and functional benefit in one person.

Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback +

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Dynamic Cervical Stabilisation + Manual Therapy versus Manual Therapy: Moderate quality evidence

(one trial42, 96 participants) shows when endurance exercises including pressure biofeedback plus
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manual therapy for the cervicoscapular region is contrasted with manual therapy alone there is probably

no difference in pain, function and GPE for chronic cervicogenic headaches at long-term follow-up.
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3.3 Effects of interventions: Acute Radiculopathy

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3.3.1 Base Element

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3.3.1.1 Stretching and Strengthening

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Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical

Stabilisation versus Wait List: There is low quality evidence (one trial44, 133 participants) showing

cervical mobilisation and stabilisation exercises may improve pain slightly, but may make no difference in

function and patient satisfaction when compared with a control immediately post treatment for acute

cervical radiculopathy. However, there may be no difference in pain and functional improvement at

intermediate-term follow-up.

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3.4 Adverse Events

Sixteen of the 27 trials23,28-30,34,36-38,41,43,44,46,49,53,54 did not report on adverse events; six

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trials22,33,35,39,45,47 found patients did not report any adverse events; six studies25,42,48,50,55,64 reported self-

limiting side effects such as headache, neck, shoulder or thoracic pain or worsening of symptoms.

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4. Discussion

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4.1 Summary of main results
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Limiting the eligible trials to those with single interventions that compared exercise with a control or

comparative group maximized the opportunity to evaluate the treatment effect of exercise interventions.

Moreover, having selected a priori an exercise classification system allowed us to use a clinical rationale
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for selecting studies with similar interventions for interpretation and inclusion within meta-analyses,

particularly for the outcomes of pain and function. Although there were only 28 studies eligible for this
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systematic review, these two new strategies provided greater clarity in our conclusions about the
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effectiveness of exercise therapy. In summary, for moderate quality evidence there is still uncertainty

about the effectiveness of exercise for neck pain; moderate grade evidence suggests there may be:

• a small beneficial effect on chronic mechanical neck pain with the use of scapulothoracic and upper

extremity endurance training immediately post treatment.

• a small improvement in chronic mechanical neck pain and function with the use of Qigong (stretch,

endurance, dynamic stabilization exercises combined with cognitive exercises emphasizing

mindfulness and emotion) immediately post treatment and at short-term follow-up. There may be little

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to no difference in quality of life and general perceived effect measures with the use of qigong

exercises.

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• a large beneficial effect on pain in cervicogenic headaches when combining the use of static and

dynamic cervical, scapulothoracic strengthening and endurance exercises including pressure

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biofeedback immediately post treatment and probably improves pain moderately in cervicogenic

headaches at long-term follow-up. There was also a moderate beneficial effect on function immediately

post treatment and at long-term follow-up.

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• a small or no difference in chronic neck pain and function with the use of cervical, scapulothoracic and
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upper extremity stretching and endurance training both immediately post treatment as well as short-

and long-term follow-up.

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4.2 Overall completeness and applicability of evidence

Many studies had an incomplete description of exercise details. In general, there is limited
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evidence42,64 on optimal dosage requirements for exercise therapies, and other modalities used to treat

neck disorders. The magnitude of effect and clinical applicability showed benefits that outweigh any
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transient and minor side effects. The use of primarily self-reported outcome measures carries an inherent

bias and may overestimate the magnitude of effect.

4.3 Quality of the evidence

One of the major methodological difficulties is blinding of therapists and patients. None of the trials

in this review blinded the care provider. The use of self-reported outcome measures makes the patient the

outcome assessor and blinding cannot be achieved easily. Two of the 28 trials did blind the outcome

assessor and therefore, blinding can be obtained for certain outcomes. Other issues include compliance

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(reducing the treatment effect), co-intervention (increasing the treatment effect and reducing the

magnitude of effect in the control group) and contamination (reducing the magnitude of effect). Twelve of

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the 28 studies had acceptable compliance, and eight of 28 monitored co-interventions. Adequate

randomisation is crucial; however, adequate sequence generation was evident in only 46% (13/28) of the

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trials. Ninety-six per cent (27/28) of the clinical trials contained small sample sizes (<70 per arm

analysed). Risk of random error can be reduced if future trials increase precision through trials with

adequate sample size.

4.4 Potential Bias in the review process

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The validity of any systematic review is dependent on the selection of all relevant studies. Although

studies published in any language were accepted, many scientific journals in non-English languages are
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not indexed in MEDLINE and Embase. We did not search non-English databases, which may have

introduced 'language bias' in the review. Studies without a control or comparative group were excluded so
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that exercise treatment effectiveness and efficacy could be properly ascertained3. This review contains

only published studies therefore 'publication bias' was not guarded against.
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5. Conclusions

5.1 Implications for practice

This review shows that effectiveness of exercise for neck pain is lacking high quality evidence. The

use of specific strengthening exercise as a part of routine practice is supported by moderate quality

evidence for chronic neck pain and cervicogenic headache and by low quality evidence for cervical

radiculopathy. Strengthening exercises combined with endurance or stretching exercises may also yield

similar beneficial results. However, low quality evidence shows minimal beneficial effects when only

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stretching or endurance type exercises were used for the cervical, scapulothoracic and shoulder regions.

Low quality evidence supports the use of Self-SNAG exercises for cervicogenic headache.

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5.2 Implications for research

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This update shows some positive findings for using exercise for neck pain, but further research is

warranted because it is likely to have an important impact on the effect estimate. Ongoing research to

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increase sample size and to pool similar data is required to further validate these findings. Optimal dosage

to reach efficacy also needs to be explored.Use of prognostic and treatment-based classification variables
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may aid in distilling which subgroups will most benefit from what specific exercise.
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Acknowledgements

We thank the Cochrane Back and Neck Group, the Cervical Overview Group, Bruce Craven,
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Western University student research groups for their contribution to this document. Dr. Craven was
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instrumental in directing us to the exercise classification framework that was used as our foundation within
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this review. This is one review of a series conducted by the Cervical Overview Group: Gross A, Goldsmith

C, Graham N, Santaguida PL, Burnie S, Forget M, Rice M, Miller J, Peloso P, Kay T, Kroeling P, Trinh K,

Langevin P, Patel K, Haines T, Haraldsson B, Radylovick Z, Szeto G, LeBlanc F, Ezzo J, Morien A,

Cameron I, Wang Z, Lilge L, White R, Bronfort G, Hoving J, Gelley G, Lalonde P.

Funding

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No funding was received for this update. Our reviews are supported through the generous

volunteer work of our members from various universities and learning institutes from around the world.

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Conflict of interest

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Gert Bronfort is the first author of one of the trials included in this systematic review. He was not

involved in the selection of studies, quality assessment, or data extraction for the study for which he was

author.

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References

Reference List
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1. Hogg-Johnson S, van der Velde G, Carroll LJ, et al. The burden and determinants of neck pain in the general
population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated
Disorders. Spine. 2008;33((4 Suppl)):S39-S51.
2. Hoy D, March L, Woolf A, et al. The global burden of neck pain: estimates from the global burden of disease
D

2010 study. Ann. Rheum. Dis. 2014;73(7):1309-1315.

3. Carroll LJ, Hogg-Johnson S, van der Velde G, et al. Course and prognostic factors for neck pain in the
general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its
TE

Associated Disorders. Spine. 2008;22(4S):S75-S82.

C EP
AC
 ACCEPTED MANUSCRIPT
4. Haldeman S, Carroll L, Cassidy JD. Findings from the bone and joint decade 2000 to 2010 task force on neck
pain and its associated disorders. J. Occup. Environ. Med. 2010;52:424-427.
5. Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St.Louis: Mosby Inc; 2002.
6. Hall CM, Brody L. Therapeutic Exercise: Moving Toward Function. Baltimore, MD: Lippincott Williams &
Wilkins; 2005.
7. Abernethy B, Kippers V, Hanrahan SJ, Paddy MG, McManus AM, MacKinnon L. Biophysical Foundations
of Human Movement. Champaign: Sheridan Books; 2013.
8. Southerst D, Nordin MC, Cote P, et al. Is exercise effective for the management of neck pain and associated
disorders or whiplash-associated disorders? A systematic review by the Ontario Protocol for Traffic Injury
Management (OPTIMa) Collaboration. Spine J. 2014.
9. Bertozzi L, Gardenghi I, Turoni F, et al. Effect of therapeutic exercise on pain and disability in the
management of chronic nonspecific neck pain: systematic review and meta-analysis of randomized trials.
Phys Ther. 2013;93(8):1026-1036.

PT
10. Vanti C, Bertozzi L, Gardenghi I, Turoni F, Guccione AA, Pillastrini P. Effect of taping on spinal pain and
disability: systematic review and meta-analysis of randomized trials. Phys Ther. 2015;95(4):493-506.
11. Racicki S, Gerwin S, Diclaudio S, Reinmann S, Donaldson M. Conservative physical therapy management
for the treatment of cervicogenic headache: a systematic review. J Manual & Manipul Ther. 2013;21(2):113-
124.

RI
12. Bronfort G, Nilsson N, Haas M, et al. Non-invasive physical treatments for chronic/recurrent headache.
Cochrane Database Syst Rev. 2004(3):CD001878.
13. Kay TM, Gross A, Goldsmith CH, Hoving JL, Bronfort G. Exercises for mechanical neck disorders.
Cochrane Database Syst Rev. 2005;3:Art. No.: CD004250.

SC
14. Teasell RW, McClure JA, Walton D, et al. A research synthesis of therapeutic interventions for whiplash-
associated disorder (WAD): part 2 - interventions for acute WAD. Pain research & management : the journal
of the Canadian Pain Society = journal de la societe canadienne pour le traitement de la douleur.
2010;15(5):295-304.
15. Leaver AM, Refshauge KM, Maher CG, McAuley JH. Conservative interventions provide short-term relief

U
for non-specific neck pain: a systematic review. J Physiother. 2010;56(2):73-85.
16. Lee MS, Pittler MH, Ernst E. Internal Qigong for Pain Conditions: A Systematic Review. J Pain.
2009;10:1121-1127.
AN
17. Salt E, Wright C, Kelly S, Dean A. A systematic literature review on the effectiveness of non-invasive
therapy for cervicobrachial pain. Man Ther. 2011;16(1):53-65.
18. Teasell RW, McClure JA, Walton D, et al. A research synthesis of therapeutic interventions for whiplash-
associated disorder (WAD): part 4 - noninvasive interventions for chronic WAD. Pain research &
management : the journal of the Canadian Pain Society = journal de la societe canadienne pour le traitement
M

de la douleur. 2010;15(5):313-322.
19. Kay TM, Gross A, Goldsmith CH, et al. Exercises for mechanical neck disorders. Cochrane Database of
Systematic Reviews. 2012(8).
20. Kay TM, Gross A, Goldsmith CH, et al. Exercises for mechanical neck disorders. Cochrane Database of
D

Systematic Reviews. 2015(1):N.PAG.

21. Gross A, Kay TM, Paquin JP, et al. Exercise for mechanical neck disorder (Review). Cochrane Database of
Systematic Reviews. 2015(1).
TE
C EP
AC
 ACCEPTED MANUSCRIPT
22. Allan M, Brantingham JW, Menezes A. Stretching as an adjunct to chiropractic manipulation of chronic neck
pain - before, after or not at all? A prospective randomized controlled clinical trial. European Journal of
Chiropractic. 2003;50:41-52.
23. Andersen LL, Kjaer M, Sogaard K, Hansen L, Kryger AI, Sjogaard G. Effect of two contrasting types of
physical exercise on chronic neck muscle pain. Arthrit Rheumat. 2008;59(1):84-91.
24. Sogaard K, Blangsted AK, Nielsen PK, et al. Changed activation, oxygenation, and pain response of
chronically painful muscles to repetitive work after training interventions:a randomized controlled trial. Eur.
J. Appl. Physiol. 2012;112:173-181.
25. Andersen LL, Saervoll CA, Mortensen OS, Poulsen OM, Hannerz H, Zebis MK. Effectiveness of small daily
amounts of progressive resistance training for frequent neck/shoulder pain: Randomised controlled trial.
Pain. 2011;152:440-446.
26. Andersen LL, Mortensen OS, Zebis MK, Jensen Rh, Poulsen OM. Effect of brief daily exercise on headache
among adults--secondary analysis of a randomised controlled trial. Scand J Work, Enviro & Health.
2011;37:547-550.

PT
27. Andersen LL. Influence of psychosocial work environment on adherence to workplace exercise. J Occup &
Enviro Med. 2011;53:182-184.
28. Andersen CH, Andersen Ll GB, Pedersen MT, Mortensen OS, Zebis MK, et al. Influence of frequency and
duration of strength training for effective management of neck and shoulder pain: a randomised controlled

RI
trial. Br. J. Sports Med. 2012;46:1004–1010-1004–1010.
29. Ang BO, Monnier A, Harms-Ringdahl K. Neck/shoulder exercise for neck pain in air force helicopter pilots:
a randomized controlled trial. Spine. 2009;34:E544-E551.
30. Beer A, Treleaven J, Jull G. Can a functional postural exercise improve performance in the cranio-cervical
flexion test?- A preliminary study. Man. Ther. 2012;17:219-224.

SC
31. Bronfort G, Aker PD, Evans R, Goldsmith CH, Nelson B, Vernon H. A randomized controlled clinical trial of
rehabilitative exercise and chiropractic spinal manipulation for chronic neck pain. Spine. 2001;26(7):788-799.
32. Evans R, Bronfort G, Nelson B, Goldsmith C. Two-year follow-up of a randomized clinical trial of spinal
manipulation and two types of exercise for patients with chronic neck pain. Spine. 2002;27:2383-2389.
33. Chiu T, Huiu-Chan C, Cheing G. A randomized clinical trial of TENS and exercise for patients with chronic

U
neck pain. Clin. Rehabil. 2005;19:850-860.
34. Dellve L, Ahlstrom L, Johsson A, et al. Myofeedback training and intensive muscular strength training to
AN
decrease pain and improve work ability among female workers on long-term sick leave with neck pain: a
randomized controlled trial. Int. Arch. Occup. Environ. Health. 2011;84:335-346.
35. Franca DLM, Senna-Fernandes V, Cortez CM, Jackson MN, Bernardo-Filho M, Guimaraes MAM. Tension
neck syndrome treated by acupuncture combined with physiotherapy: A comparative clinical trial (pilot
study). Complement. Ther. Med. 2008;16:268-277.
M

36. Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K. Efficacy of a C1-C2 self-sustained
natural apophyseal glide (SNAG) in the management of cervicogenic headache. JOSPT. 2007;37:100-107.
37. Hallman D, Olsson E, Schéele B, Melin L, Lyskov E. Effects of heart rate variability biofeedback in subjects
with stress-related chronic neck pain: a pilot study. Appl. Psychophysiol. Biofeedback. 2011;36(2):71-80.
38. Hansson EE, Persson L, Malmström EM. Influence of vestibular rehabilitation on neck pain and cervical
D

range of motion among patients with whiplash associated disorders: a randomized controlled trial. J. Rehabil.
Med. 2013;45(9):906–910-906–910.
39. Helewa A, Goldsmith CH, Smythe HA, Lee P, Obright K, Stitt L. Effect of therapeutic exercise and sleeping
TE

neck support on patients with chronic neck pain: a randomized clinical trial. J Rheumatol. 2007;34:151-158.
40. Sherrington C. The Integrative Action of the Nervous System. New Haven: Yale University Press; 1961.
C EP
AC
 ACCEPTED MANUSCRIPT
41. Humphreys BK, Irgens PM. The effect of a rehabilitation exercise program on head repositioning accuracy
and reported levels of pain in chronic neck pain subjects. J Whiplash & Related Disorders. 2002;1(1):99-112.
42. Jull G, Trott P, Potter H, et al. A randomized controlled trial of exercise and manipulative therapy for
cervicogenic headache. Spine. 2002;27(17):1835-1843.
43. Kjellman G, Oberg B. A randomized clinical trial comparing general exercise, McKenzie treatment and a
control group in patients with neck pain. J. Rehabil. Med. 2002;34:183-190.
44. Kuijper B, Tans JT, Beelen A, Nollet F, de Visser M. Cervical collar or physiotherapy versus wait and see
policy for recent onset cervical radiculopathy: randomised trial. BMJ. 2009;339:b3883.
45. Lange B, Toft P, Myburgh C, Sjogaard G. Effect of targeted strength, endurance, and coordination exercise
on neck and shoulder pain among fighter pilots: a randomized controlled trial. Clin. J. Pain. 2013;29(1):50-
59.
46. Lundblad I, Elert J, Gerdle B. Randomized controlled trial of physiotherapy and Feldenkrais interventions in
female workers with neck-shoulder complaints. J Occup Rehabil. 1999;9(3):179-194.
47. Martel J, Dugas C, Dubois JD, Descarreaux M. A randomised controlled trial of preventive spinal

PT
manipulation with and without a home exercise program for patients with chronic neck pain. BMC
Musculoskelet. Disord. 2011;12:41-54.
48. Rendant D, Pach D, Ludtke R, et al. Qigong versus exercise versus no therapy for patients with chronic neck
pain. Spine. 2011;36(6):419-429.

RI
49. Revel M, Minguet M, Gregoy P, Vaillant J, Manuel JL. Changes in cervicocephalic kinesthesia after a
proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study. Arch Phys
Med Rehabil. 1994;75(8):895-899.
50. Stewart MJ, Maher CG, Refshauge KM, Herbert RD, Bogduk N, Nicholas M. Randomized controlled trial of
exercise for chronic whiplash-associated disorders. Pain. 2007;128:59-68.

SC
51. Stewart MJ, Maher CG, Refshauge KM, Herbert RD, Bogduk N, Nicholas N. Advice or exercise for chronic
whiplash disorders? Design of a randomized controlled trial. BMC Musculoskelet. Disord. 2003;4:18-18.
52. Stewart MJ, Maher CG, Refshauge KM, Herbert RD, Nicholas MK. Patient and clinician treatment
preferences do not moderate the effect of exercise treatment in chronic whiplash-associated disorders. Europ
J Pain. 2008;12:879-885.

U
53. Takala EP, Viikari-Juntura E, Tynkkynen EM. Does group gymnastics at the workplace help in neck pain? A
controlled study. Scand. J. Rehabil. Med. 1994;26:17-20.
AN
54. Viljanen M, Malmivaara A, Uitti J, Rinne M, Palmroos P, Laippala P. Effectiveness of dynamic muscle
training relaxation treaining, or ordinary activity for chronic neck pain: randomised controlled trial. BMJ.
2003;327:475-477.
55. von Trott P, Wiedemann AM, Ludtke R, Reishauer A, Willich SN, Witt CM. Qigong and exercise therapy for
elderly patients with chronic neck pain (QIBANE): a randomized controlled study. J Pain. 2009;10:501-508.
M

56. Farrar JT, Young JPJ, LaMoureaux L, Worth JL, Poole RM. Clinical importance of changes in chronic pain
intensity measured on an 11-point numerical rating scale. Pain. 2001;94:149-158.
57. Felson DT, Anderson JJ, Boers M, et al. Preliminary definition of improvement in rheumatoid arthritis.
Arthritis Rheum. 1995;Jun;38(6):727-735.
58. Goldsmith CH, Boers M, Bombardier C, Tugwell P. Criteria for clinically important changes in outcomes.
D

Development, scoring and evaluation of rheumatoid arthritis patients and trial profiles. J. Rheumatol.
1993;20(3):561-565.
59. MacDermid JC, Walton DM, Avery S, et al. Measurement properties of the neck disability index: a
TE

systematic review. JOSPT. 2009;39:400-417.

C EP
AC
 ACCEPTED MANUSCRIPT
60. Cohen J. Statistical Power Analysis for the Behavioural Sciences. 2nd ed. Hilldale, NJ: Lawrence Erlbaum
Associates; 1988.
61. Guyatt G, Gutterman D, Baumann MH, et al. Grading strength of recommendations and quality of evidence
in clinical guidelines:Report fom an American College of Chest Physicians task force. Chest. 2006;129:174-
181.
62. Higgins JPT, Green S. Cochrane Handbookfor Systematic Reviews of Interventions 5.0.2 www.cochrane-
handbook.org. Chichester: John Wiley& Sons, Ltd; 2008.
63. Goldie I, Landquist A. Evaluation of the effects of different forms of physiotherapy in cervical pain. Scand. J.
Rehabil. Med. 1970;2-3:117-121.
64. Bronfort G, Evans R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A randomized clinical trial of exercise
and spinal manipulation for patients with chronic neck pain. Spine. 2001;26:788-797.

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AN
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