Exercises For Mechanical Neck Disorders A Cochrane Review Update

Manual Therapy 24 (2016) 25e45
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Manual Therapy
journal homepage: www.elsevier.com/math
Review article
Exercises for mechanical neck disorders: A Cochrane review update

A.R. Gross a, b, *, J.P. Paquin c, d, G. Dupont d, S. Blanchette d, P. Lalonde d, T. Cristie d,
N. Graham b, T.M. Kay e, f, S.J. Burnie g, G. Gelley h, C.H. Goldsmith a, i, M. Forget j,
P.L. Santaguida a, A.J. Yee k, G.G. Radisic l, J.L. Hoving m, G. Bronfort n, Cervical Overview
Groupo
a
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada

School of Rehabilitation Science, McMaster University, Hamilton, Canada
Physio-Sant
e, Drummondville, Canada
d
University of Western Ontario, London, Canada
e
Women's College Hospital, Toronto, Canada
f
Department of Physical Therapy, University of Toronto, Toronto, Canada
g
Department of Clinical Education, Canadian Memorial Chiropractic College, Toronto, Canada
h
Applied Health Sciences, University of Manitoba, Winnipeg, Canada
i
Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
j
Canadian Forces Health Services Group, Groupe de Services de Sant
e des Forces Canadiennes, National Defence, D
efense Nationale, Government of Canada,
Gouvernement du Canada, Kingston, Canada
k
Kinesiology, Faculty of Health Sciences, McMaster University, Hamilton, Canada
l
Life Science, Faculty of Health Sciences, Queens Univesity, Kingston, Canada
m
Coronel Institute of Occupational Health and Research Center for Insurance Medicine, Academic Medical Center, University of Amsterdam, Amsterdam,
Netherlands
n
Integrative Health & Wellbeing Research Program, Center for Spirituality & Healing, University of Minnesota, Minneapolis, MN, USA
o
Hamilton, Canada
b
c
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 12 April 2016
Accepted 13 April 2016
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.
Methods: We searched computerised databases up to May 2014 for randomized controlled trials (RCTs)
comparing 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 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.
Main Results: 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
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
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 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: Specic strengthening exercises of the neck, scapulothoracic and shoulder for
chronic NP and chronic CGH are benecial. Future research should explore optimal dosage.
2016 Elsevier Ltd. All rights reserved.
Keywords:
Cochrane review
Meta-analysis
Neck pain
Exercise
* Corresponding author. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
E-mail addresses: grossa@mcmaster.ca, grossa@sympatico.ca (A.R. Gross).
http://dx.doi.org/10.1016/j.math.2016.04.005
1356-689X/ 2016 Elsevier Ltd. All rights reserved.
26
A.R. Gross et al. / Manual Therapy 24 (2016) 25e45
1. Background
categorised. Therefore, the true impact of exercise alone could not

be determined with strong evidence.
1.1. Description of the condition

1.5. Objectives
Neck disorders are common (Hogg-Johnson et al., 2008; Hoy
et al., 2014), painful, and limit function in the general population
(Carroll et al., 2008; Haldeman et al., 2010). The global point
prevalence of neck pain was estimated to be 4.9% in 2010 (Hoy et al.,
2014).
1.2. Description of the intervention
We adopted the Therapeutic Exercise Intervention Model to
sub-classify exercise (Sahrmann, 2002). Hall and Brody (2005) intersects this model with two other axes e activity and dosage (See
Table 1).
1.3. How the intervention might work
Exercise has both physical and mental benets through its effects on numerous systems such as the cardiovascular, immune,
neurologic, and musculoskeletal systems (Abernethy et al., 2013).
Central to these benets are the stages of change, encompassing the
health belief and cognitive behaviour 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 benets for combined
cervical, scapulothoracic stretching and strengthening for chronic
neck pain in the short and long-term. Since then, ve other reviews
have found primarily very low to low GRADE evidence, as well as
low GRADE evidence for no benecial effect on pain (Table 2). A
number of these reviews included studies that were not clearly
To present an abbreviated report of a Cochrane systematic review that assessed the immediate to 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 cervicogenic headache or
radiculopathy.
2. Methods
This is an abbreviated co-publication of our Cochrane systematic
review update (Kay et al., 2015). See Table 3 for selection criteria
and the primary review for full details. A protocol was previous0ly
published (Issue 2, 2003 Cochrane Library).
2.1. Search methods for identication of studies
A research librarian searched computerised bibliographic databases for medical, chiropractic and allied health literature. Electronic searches included databases from their start to May 2014
(See Fig. 1 and Gross et al., 2015 for greater details). See Appendix 1
for Characteristics of Included Studies.
2.2. Measures of treatment effect
For continuous data, standard mean difference (SMD) with 95%
condence intervals (CI) was calculated. The minimal clinically
important difference (MCID) for pain was 10 on a 100-point pain
intensity scale (Goldsmith et al., 1993; Felson et al., 1995; Farrar
et al., 2001). We considered the effect small when it was less
Table 1
The Therapeutic Exercise Intervention Model to sub-classify exercise (Sahrmann, 2002) is foundational to classication of exercise in this systematic review.
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).
Base Element:
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:
extensibility/stiffness properties of muscle, fascia and periarticular tissues for range of motion and stretching exercises,
mobility of neuromeningeal tissue for neural mobilisation exercises,
force or torque capability of muscles and the related muscle lengthetension properties for 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.
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 include:
static stabilisation forces involved in alignment and muscle recruitment, and
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 movement as follows:

the cognitive ability to learn,

patient and caregiver compliance,
motivation, and
emotional status.
27
Table 2
Review of review shows very low to low GRADE evidence.
Very low to low GRADE evidence for
benecial effect on pain
Low GRADE evidence for no benecial

effect on pain
1) stretching and strengthening for chronic neck pain (Bertozzi et al., 2013; Southerst et al., 2014; Vanti et al., 2015)
2) strengthening, endurance, and modular element for chronic cervicogenic headache (Bronfort et al., 2004; Kay et al., 2005;
Racicki et al., 2013)
3) neuromuscular exercises (proprioception/eye-neck coordination) (Leaver et al., 2010; Teasell et al., 2010a)
4) stretching and range of motion exercises for non specic neck pain (Leaver et al., 2010)
5) stretching, strengthening, endurance training, balance/coordination, cardiovascular training and cognitive/affective
elements for chronic neck pain (Lee et al., 2009; Leaver et al., 2010; Teasell et al., 2010b; Salt et al., 2011; Southerst
et al., 2014)
6) qigong exercises for chronic neck pain (Lee et al., 2009; Southerst et al., 2014)
7) supervised exercises for chronic WAD (Teasell et al., 2010b)
8) strengthening neck exercises for chronic neck pain (Bertozzi et al., 2013; Southerst et al., 2014)
1) stretching and strengthening for radiculopathy (Salt et al., 2011; Southerst et al., 2014)
2) general tness training for acute to chronic neck pain (Kay et al., 2012; Bertozzi et al., 2013)
3) stretching and endurance training in chronic neck pain (Kay et al., 2012; Bertozzi et al., 2013)
Table 3
Criteria for considering studies for this review.
Types of studies
Published or unpublished randomized controlled trials (RCTs) in any language
Adults (M/F 18 years with acute (<30 days), subacute (30e90 days), or chronic (>90 days) neck disorders categorised as:
- mechanical neck disorder (MND): whiplash associated disorders (WAD) Category I/II, myofascial neck pain, degenerative changes like
osteoarthritis/cervical spondylosis
- cervicogenic headache (CGH)
- neck disorders with radicular ndings (NDR)
Excluded: studies of neck disorders with denitive/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 neck postures, mixed headache
Types of
One or more types of exercise therapy specied in Therapeutic Exercise Intervention Model Excluded: exercise therapy as part of a multidisciplinary
Interventions
treatment, multimodal treatment, or exercise requiring manual therapy techniques by a trained individual
Types of
1) sham/placebo
Comparisons
2) no treatment or wait list
3) exercise plus another intervention vs. that same intervention
Types of Outcomes Included if used any one of ve of the primary outcome measures:
1) pain
2) function and disability (eg. Neck Disability Index, activities of daily living, return to work, sick leave)
3) patient satisfaction
4) global perceived effect
5) quality of life (e.g. SF-12)
When available: adverse events, cost of care
Timelines included:
Immediate post treatment: one day
Short term follow-up: one day e 3 months
Intermediate-term follow-up: 3 monthse1 year
Long-term follow-up: 1 year
Types of
Participants
Key: CGH cervicogenic headache; F female, M male; MND mechanical neck disorder; RCTs randomized controlled trials; WAD whiplash associated disorder.
than 10% of the Visual Analog Scale (VAS), medium when between
10% and 20%, and large when it was 20%e30%. For the Neck
Disability Index (NDI), we used an MCID of 7/50 units (MacDermid
et al., 2009). For other outcomes we used the hierarchy of Cohen
(1988): small (0.20), medium (0.50) or large (0.80). Risk ratios
(RR) were calculated for dichotomous outcomes. The Number
Needed to Treat (NNT) was calculated. Assessment of heterogeneity
was tested using the Chi (Hoy et al., 2014) method and I2 method. In
the absence of heterogeneity (p > 0.10), we calculated a pooled
SMD, Mean Difference or RR.
3. Results
We identied 5658 records and found 27 trials that used exercise treatment. The results presented are an abridged version of our
Cochrane review update (Kay et al., 2015); refer to it for full details.
We used the quadratic weighted Kappa (Kw) statistic to assess
agreement on a per question basis (Kw 0.23e1.00). Each risk of bias
item is presented as a percentage across all included studies (See
Fig. 2).
3.1. Effects of interventions: chronic mechanical neck pain

2.3. Data synthesis
We assessed the quality of the evidence using the Grading of
Recommendations, Assessment, Development and Evaluation
(GRADE) approach (Guyatt et al., 2006). 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 generalisable),
5) imprecision (insufcient data), other factors (e.g. reporting bias)
(Higgins and Green, 2008).
3.1.1. Support element

3.1.1.1. Breathing OR cardiovascular/aerobic training. There is low
quality evidence that diaphragmatic breathing (Hallman et al.,
2011) and general tness training (Andersen et al., 2008; Sogaard
et al., 2012) 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.
28
Fig. 1. PRISMA ow diagram for exercise review search results.
3.1.2. Base element

3.1.2.1. Stretching. Cervical Stretch/ROM Exercises Another Intervention versus That Same Intervention: There is low quality evidence
(one trial (Allan et al., 2003), 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 chronic neck pain immediately post treatment.
Cervical Stretch/ROM Exercises Dynamic Cervical Stabilisation
versus Sham: Low quality evidence (one trial (Kjellman and Oberg,
2002), 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 ultrasound for chronic MND.
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 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 pillow (Helewa et al., 2007) or (3) isometric exercise
alone against no intervention or control (Goldie and Landquist,
29
Fig. 2. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1970). Evidence of benet showed people may improve slightly

when exercise was added to a pillow versus a pillow alone
(NNT 9). However, this was not observed when isometric exercise
alone was evaluated for function and quality of life, from immediately post treatment to short-term follow-up. Low quality evidence
(one trial (Goldie and Landquist, 1970), 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 benet 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., 2015 for greater details).
Scapulothoracic Upper Extremity Strengthening versus Control:
Three trials (Andersen et al., 2008, 2012; Dellve et al., 2011), each
with different dosages, compared specic strength training of the
scapulothoracic region and upper extremity with a reference
intervention Fig. 3. There is moderate quality evidence [three trials
(Andersen et al., 2008, 2012; Dellve et al., 2011), 157 participants;
SMD pooled 0.71 (95%CI:1.33 to 0.10)] that scapulothoracic
and upper extremity strength training 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.
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 trial (Kjellman and Oberg, 2002), 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 Cervical/Shoulder Stabilisation versus
Wait List: Moderate quality evidence [two trials (von Trott et al.,
2009; Rendant et al., 2011), 147 participants, MD pooled 10.94
(CI 95% 18.81 to 3.08)]; Fig. 4) shows a standardised exercise
program for neck pain including repeated active cervical rotations,
strengthening and exibility exercises compared to a wait list
probably has benecial effect for pain and function, but not GPE and
quality of life immediately post treatment and at short-term
follow-up. A clinician may need to treat four people to achieve a
Fig. 3. Forest Plot of comparison: Scapulothoracic upper extremity strengthening versus control.
30
Fig. 4. Forest Plot of comparison: Cervical stretch/ROM exercises cervical/scapulothoracic strengthening static/dynamic cervical/shoulder stabilisation versus wait list.
moderate degree of pain relief and ve to achieve moderate functional benet in one person.
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 exor retraining with pressure biofeedback and
resisted neck exion/extension strengthening using multicervical rehabilitation unit (Chiu et al., 2005);
low technology exercise including progressive resisted neck and
upper body strengthening using dumbells and pulley systems,
light stretching and a short aerobic warm-up program (Bronfort
et al., 2001a);
muscle stretching and strengthening exercises of the neck and
upper limb regions including strengthening of the deep cervical
exor muscles (Franca et al., 2008);
a home exercise program of ROM, stretching/mobilisation and
strengthening exercises of the cervical and upper thoracic spine
(Martel et al., 2011).
For pain outcomes, we found consistent evidence for reduced
pain immediately post treatment (Bronfort et al., 2001a; Chiu et al.,
2005; Franca et al., 2008; Martel et al., 2011), at intermediate-term
and long-term follow-up (Bronfort et al., 2001a). This suggests
small treatment benets initially but larger benets in the long

term. For function outcomes, there was evidence of benet for
function immediately post treatment, at intermediate (Bronfort
et al., 2001a; Chiu et al., 2005; Franca et al., 2008) [SMD
pooled 0.45 (95% CI: 0.72, to 0.18); Fig. 5] and long-term
(Bronfort et al., 2001a) follow-up. In conclusion, moderate quality
evidence (four trials (Bronfort et al., 2001a; Chiu et al., 2005; Franca
et al., 2008; Martel et al., 2011), 341 participants) shows moderate
pain relief and improved function up to long-term follow-up for
combined cervical, 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 benet. Changes in GPE measures indicate a difference
immediately post treatment and at long-term follow-up.
3.1.2.4. Stretching
and
endurance
training.
Cervical/Scapulothoracic/upper extremity Stretch upper extremity
Endurance Training versus No Intervention: Moderate quality evidence (one trial (Viljanen et al., 2003), 393 participants), shows
little to no difference for upper extremity stretching and endurance
training compared to ordinary activity for chronic neck pain and
function immediately post treatment, at short-term and long-term
follow-up.
3.1.2.5. Strengthening
and
endurance
training.
Cervical/Scapulothoracic Strengthening Endurance Training versus
Fig. 5. Forest Plot of comparison: Cervical/upper extremity stretch/ROM exercises cervical/scapulothoracic upper extremity strengthening dynamic/static cervical
stabilisation another intervention versus that same intervention.
Control: Very low quality evidence (one trial, 68 participants (Ang

et al., 2009)) shows we are uncertain whether cervical/scapulothoracic strengthening and endurance-strength exercises improves the prevalence of neck pain in chronic neck pain at
immediately post treatment and at long-term follow-up.
Pattern synchronisation and cervical/scapulothoracic strengthening and scapulothoracic endurance versus Control: Low quality
evidence (one trial (Lange et al., 2013), 55 participants) shows deep
neck exor 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 trial (Andersen
et al., 2011a), 198 participants (Andersen et al., 2011a)) shows a
medium benecial effect size for pain relief immediately post
intervention when using shoulder abduction endurance training
for 2 min or 12 min 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 person.
3.1.3. Modulator elements

Neuromuscular
Exercise
(eye-neck
coordination/
proprioception) Another Intervention versus That Same Intervention: Very low quality evidence (one trial (Revel et al., 1994), 60
participants) shows a moderate reduction in pain 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 functional
benet in one person.
Patterns synchronisation Feedforward/feedback exercises for
coordinating the neck, eyes and upper limbs versus No Intervention:
Low quality evidence (one trial (Humphreys and Irgens, 2002), 56
participants) shows eye-neck-upper limb coordination exercises
show little or no difference in pain immediately post treatment
when contrasted with no intervention for people with chronic neck
pain.
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 trial (Hansson et al., 2013), 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 versus No Intervention: Low
quality evidence (one trial (Takala et al., 1994), 44 participants)
shows little to no difference for pain reduction immediately post
treatment in patients with neck pain of unspecied duration when
treated with group exercise that combined stretching and coordination exercises with cardiovascular training.
General Endurance Training Dynamic/Static Lowback/pelvic
Stabilisation General Stretching Neuromuscular/body Mechanics
Movement Training versus No Intervention: Low quality evidence
(one trial (Lundblad et al., 1999), 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, coordination, endurance, exibility/
smoothness and rhythm exercises when compared to no intervention or a wait list control in chronic neck pain at short-term
follow-up.
31
3.1.5. Base cognitive/affective element

Stretch/ROM
Endurance
Training
Dynamic
Stabilisation Cognitive (mindfulness & emotional balance) versus
Wait List: Two trials (Rendant et al., 2011; von Trott et al., 2009)
compared a program of Qigong exercises (Dantian Qigong). There
was evidence of reduced pain and function post treatment at 12
weeks [MD pooled (pain) 13.28 (20.98 to 5.58)j [SMD pooled
(function) 0.36 (0.68 to 0.03)] and 24 weeks [MD pooled
(pain) 7.82 (14.57, 1.07) j SMD pooled (function) 0.28 (0.68
to 0.11)] of treatment. For quality of life, there was evidence of
benet for SF36 physical component immediately after 12 weeks of
treatment, but not after 24 weeks. In conclusion, moderate quality
evidence (two trials (Rendant et al., 2011; von Trott et al., 2009), 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
benet at immediate and short-term follow-up on QoL and GPE. A
clinician may need to treat four to six people to achieve this type of
pain relief, ve to eight people to achieve this functional benet,
and seven to 10 people for this improvement QoL.
3.1.6. Base modular cognitive affective support
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 trial (Stewart et al., 2007), 132 participants) shows
small benets for pain relief, function, GPE and quality of life
immediately post treatment and small benet at 12 month followup for 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.
3.2. Effects of interventions: acute to chronic cervicogenic headache
3.2.1. Base element
Stretch/ROM exercises versus Sham: Low quality evidence (one
trial (Hall et al., 2007), 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 Dynamic Cervical
Stabilisation versus No Intervention: Moderate quality evidence (one
trial (Jull et al., 2002), 97 participants) shows cervicoscapular
strengthening and endurance exercises including pressure
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 and functional benet in one person.
Cervical/Scapulothoracic
Strengthening
with
Endurance
Training Craniocervical Pressure Biofeedback Dynamic Cervical
Stabilisation Manual Therapy versus Manual Therapy: Moderate
quality evidence (one trial (Jull et al., 2002), 96 participants) shows
when endurance exercises including pressure biofeedback plus
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.
32
3.3. Effects of interventions: acute radiculopathy

3.3.1. Base element
3.3.1.1. Stretching
and
strengthening. Cervical
Stretch/
ROM Cervical/Scapulothoracic/UE Strengthening Static/Dynamic
Cervical Stabilisation versus Wait List: There is low quality evidence
(one trial (Kuijper et al., 2009), 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 followup.
3.4. Adverse events
Sixteen of the 27 trials (Revel et al., 1994; Takala et al., 1994;
Lundblad et al., 1999; Humphreys and Irgens, 2002; Kjellman and
Oberg, 2002; Viljanen et al., 2003; Hall et al., 2007; Andersen
et al., 2008; Ang et al., 2009; Kuijper et al., 2009; Dellve et al.,
2011; Hallman et al., 2011; Andersen et al., 2012; Beer et al.,
2012; Hansson et al., 2013) did not report on adverse events; six
trials (Allan et al., 2003; Chiu et al., 2005; Helewa et al., 2007;
Franca et al., 2008; Martel et al., 2011; Lange et al., 2013) found
patients did not report any adverse events; six studies (Bronfort
et al., 2001b; Jull et al., 2002; Stewart et al., 2007; von Trott et al.,
2009; Rendant et al., 2011; Andersen et al., 2011a) reported selflimiting side effects such as headache, neck, shoulder or thoracic
pain or worsening of symptoms.
4. Discussion
4.1. Summary of main results
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 classication system allowed us to use a clinical rationale 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
systematic review, these two new strategies provided greater
clarity in our conclusions about the 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 benecial 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 to no
difference in quality of life and general perceived effect measures with the use of qigong exercises.
a large benecial effect on pain in cervicogenic headaches when
combining the use of static and dynamic cervical, scapulothoracic strengthening and endurance exercises including
pressure biofeedback immediately post treatment and probably
improves pain moderately in cervicogenic headaches at longterm follow-up. There was also a moderate benecial effect on
function immediately post treatment and at long-term followup.

a small or no difference in chronic neck pain and function with
the use of cervical, scapulothoracic and upper extremity
stretching and endurance training both immediately post
treatment as well as short- and long-term follow-up.
4.2. Overall completeness and applicability of evidence

Many studies had an incomplete description of exercise details.
In general, there is limited evidence (Bronfort et al., 2001b; Jull
et al., 2002) on optimal dosage requirements for exercise therapies, and other modalities used to treat neck disorders. The
magnitude of effect and clinical applicability showed benets that
outweigh any 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 difculties 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 (reducing the treatment effect), cointervention (increasing the treatment effect and reducing the
magnitude of effect in the control group) and contamination
(reducing the magnitude of effect). Twelve of 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 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
The validity of any systematic review is dependent on the selection of all relevant studies. Although studies published in any
language were accepted, many scientic journals in non-English
languages are 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 that exercise treatment effectiveness and
efcacy could be properly ascertained (Carroll et al., 2008). This
review contains only published studies therefore publication bias
was not guarded against.
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 specic 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 benecial results. However, low quality evidence shows minimal benecial effects when only 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.
33
studies, quality assessment, or data extraction for the study for

which he was author.
5.2. Implications for research

This update shows some positive ndings 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 increase sample size and to pool similar data is required to
further validate these ndings. Optimal dosage to reach efcacy
also needs to be explored. Use of prognostic and treatment-based
classication variables may aid in distilling which subgroups will
most benet from what specic exercise.
Funding
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.
Acknowledgements
We thank the Cochrane Back and Neck Group, the Cervical
Overview Group, Bruce Craven, Western University student
research groups for their contribution to this document. Dr. Craven
was instrumental in directing us to the exercise classication
framework that was used as our foundation within 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.
Conict of interest
Appendix 1. Characteristics of the Included Studies
Gert Bronfort is the rst author of one of the trials included in
this systematic review. He was not involved in the selection of
Study/Participants
Interventions
INDEX TREATMENT
Arm 1 e a. Stretch before Manipulation: Activity e Static passive
stretches into Movement e lateral exion and rotation on both
sides of neck, held for 15 s; Mode e administered by
chiropractor with patient in supine position, immediately
followed by cervical manipulation given in accordance with the
motion palpation ndings. Manipulation was administered with
patient in supine position and the chiropractor making an index
enger contact on the affected cervical segment(s); Dosage e 8
sessions over 4 weeks,
b. Cervical manipulation given in accordance with the motion
palpation ndings. Manipulation was administered with patient
in supine position and the chiropractor making an indexenger
contact on the affected cervical segment(s) immediately
followed by static passive stretches in lateral exion and rotation
on both sides of neck, held for 15 s, administered by chiropractor
with patient in seated position;
Arm 2 e a. Stretch after Manipulation: Stretches as in Arm 1 was
administered after manipulation treatment.
b. Cervical manipulation administered as in Arm 1.
Treatment Schedule: 8 sessions over 4 weeks
COMPARISON TREATMENT
Arm 3 e Manipulation: Cervical manipulation given in
accordance with the motion palpation ndings. Manipulation
was administered with patient in supine position and the
chiropractor making an indexenger 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
INDEX TREATMENT
Andersen et al., 2008 and Sogaard
Arm 1 e Specic Strength Training (SST) or General Fitness
et al., 2012
(sub) Acute/Chronic MND (Trapezius Training (GFT): Activity e SST: high intensity specic strength
Myalgia)
training locally for neck and shoulder muscles. GFT: Cycling
high-intensity general tness training with legs only, upright
position without holding onto the handlebars (relaxing
shoulders during training); Mode e SST: 5 dumbbell exercises.
GFT: Monark bicycle ergometer; Movement e SST: single arm
row, shoulder abduction, shoulder elevation, reverse ies, and
upright row).Training program progressively increased using the
principles of periodisation and progressive overload from 12
repetitions maximum (~70% of maximal intensity) at beginning
to 8 repetitions maximum (~80% of maximal intensity) later.
GFT: high-intensity cycling; Dosage e SST: performed using
Allan et al., 2003
Chronic MND (Myofascial Pain
Syndrome)
Outcomes
PAIN (NRS 0 to 100)
Baseline Mean: Manipulation 30, Stretch before 58, Stretch After
63
Reported Results: no signicant difference between groups
FUNCTION (NDI 0 to 50)
Baseline Mean: Manipulation 5, Stretch before 16, Stretch After
11
SIDE EFFECTS: none
COST OF CARE: NR
PAIN intensity in trapezius muscle (VAS 0 to 100)

Baseline Mean: SST 44, GFT 50, Reference 43
SMD immediate post: 0.18 (95%CI: 0.67 to 1.03)
SMD ST: 0.06 (95% CI: 0.91 to 0.79)
REASON FOR DROP-OUTS: 6 in Reference group, reason not
specied
SIDE EFFECTS: NR
COST OF CARE: NR
(continued on next page)
34
(continued )
Study/Participants
Interventions
consecutive concentric and eccentric muscle contractions

(raising and lowering pair of dumbbells) in a controlled manner
without pause, each set lasting 25e35 s 30 of 5 different
exercises with 3 sets per exercise were performed during each
training session in an alternating manner (shoulder elevation
was performed during each session). Doubled training load by
end of 10 weeks. 20 min, 3/week for 10 weeks of intervention
for an average of 26 3.6 sessions GFT: 20 min at a relative
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 relative
level.
Treatment schedule: SST: Doubled training load by end of 10
weeks. 20 min 3 times/week for 10 weeks of intervention for an
average of 25 4.8 sessions. GFT: 20 min 3 times/week for 10
weeks.
Arm 2 e Health Counselling Group: Lectures with information
on activities promoting general health and individual: workplace
ergonomics, diet, health, relaxation, and stress management. 1 h
per week for 10 weeks for an average of average 27 2.8 sessions
Duration of Follow-up: 10 weeks
CO-INTERVENTION: Not avoided
Reference intervention without physical activity: Activity e the
participants received health counselling on group and individual
levels regarding workplace ergonomics, diet, health, relaxation,
and stress management, frequency: 3 per week. Dosage e 20min sessions
Treatment Schedule: 30 sessions over 10 weeks
CO-INTERVENTION: Not specied
INDEX TREATMENT
Andersen et al., 2011a,b; Andersen,
Arm 1 e 2 min training (2-min): Activity e Progressive
2011
(sub) Acute/Chronic MND (Myofascial resistance training with theraband. Mode e Shoulder;
Pain Syndrome/Cervicogenic
Movement e abduction- lateral raise. Dosage: 2 min, 5 times/
headache/tension type headache) week for 10 weeks of intervention for an average of 26 3.6
sessions
Arm 2 e 12-min training: Activity e Progressive resistance
training with theraband. Mode e Shoulder; Movement e
abduction- lateral raise; Dosage e 12- minutes 5 times/week for
10 weeks of intervention for an average of 25 4.8 sessions
Arm 3 e Control Group: Weekly e-mailed information on various
aspects of general health and internet links with additional
relevant information
Treatment Schedule:10 weeks, 20 sessions
Andersen et al., 2012

Non specic neck pain
INDEX TREATMENT
Arm 1 e Training groups (WS): Activity e Upper extremity
strength training; Mode e Weights. Movement e Dumbbell
exercises front raise, lateral raise, reverse ies shrugs and wrist
extension. Dosage e Type of contraction (dynamic); Intensity
(20 repetition maximum at baseline to 8 repetition maximum at
later phase); Speed (NR); Duration/Frequency (1-WS weekly
session 1 h/week, 3-WS 20 min at 3 sessions/week, 9WS 7 min at 9 sessions/week; Sequence (NR); Environment
(NR); Feedback (experienced instructor supervised every other
training session).
Treatment Schedule: 20 weeks.
Arm 2 e Reference group: No treatment
Treatment Schedule: 20 weeks
Duration of Follow-up: NR
CO-INTERVENTION: NR
INDEX TREATMENT
Ang et al., 2009
Chronic MND (Mechanical Neck Pain Arm 1 e Exercise Group: Activity e Patterns and
& Myofascial Pain Syndrome)
synchronisation of muscle recruitment, EnduranceStrengthening exercises, Mode e Progression from non-postural
(supine, prone) low-load active craniocervical exion at 5
Outcomes
PAIN (VAS 0 to 10)

Baseline Mean: 2 min 3.5, 12 min 3.9, Control 3.5
Reported Results: ANOVA showed a strong group-by-time effect
for neck/shoulder pain intensity (p < 0.0001). Compared with the
control group, pain intensity decreased in both training groups.
This change was not signicantly different between the 2
training groups.
SMD (2-min): 0.66 (95% CI: 1.02 to 0.30)
SMD (12-min): 0.59 (95% CI: 0.94 to 0.23)
REASON FOR DROP-OUTS: 3 in 2- minutes group, 1 in 12minutes group, 2 in control group, reasons reported
SIDE EFFECTS: Reported worsening of neck muscle tension
during and/or in the days after training (2-min n 1, 12min n 4), shoulder joint pain during training (2-min n 1, 12min n 4), pain in the upper arm during training (2-min n 1,
12-min n 1), pain of the forearm/wrist during training (12min n 2), worsening of headache after training (2-min n 1,
12-min n 1). No long-lasting or major complications resulted
from the training program.
COST OF CARE: NR
PAIN (Modied Nordic Questionnaire 0e9)
Baseline Mean: 1-WS 4.83, 3-WS 4.96, 9-WS (4.71), Reference
(4.83)
SMD (1-WS vs reference): 0.44 (95% CI: 1.31 to 0.43);
SMD (9-WS vs reference): 0.30 (95% CI: 1.36 to 0.76)
FUNCTION Disability of the arm, shoulder and hand (DASH
0 to100)
Baseline Mean: 1-WS (16), 3-WS (18), 9-WS (15), Reference (16)
SMD (1W-S vs reference): 0.17 (95% CI: 0.58 to 0.24);
SMD (9-WS vs reference): 0.06 (95% CI: 0.53 to 0.41)
REASON FOR DROP-OUTS: NR
SIDE EFFECTS: NR
COST OF CARE: NR
PAIN Prevalence during previous week
Baseline Mean (SD): Exercise 13 (38), Control 11 (32)
Reported Results: In the exercise group, the prevalence of cases
for the previous week and the previous 3 months decreased from
38%e15% and 76%e44% respectively, whereas in controls it was
35
(continued )
Study/Participants
Beer et al., 2012

Persistent neck pain
Bronfort et al., 2001a; Evans et al.,

2002
Chronic MND
Interventions
Outcomes
pressure levels (22e30 mmHg), seated postural exercises with

active craniocervical exion and active scapular retraction.
Seated and standing elastic resistance, Movement e supine
craniocervical exion exercises, prone isometric shoulder/
scapular, seated active craniocervical exion with cervical
rotation to end range and simultaneous scapular retraction to
mid motion range, sitting controlled dynamic shoulder
retraction following a rowing exercise movement, dynamic
scapular retraction with weight load over long movement arms
in rowing exercises in regular pulls, emphasizing shoulder
retraction in the initial concentric phase and upright trunk
postures in the inner range, Dynamic neck rotation exercises in
upright posture against moderate resistance using elastic bands,
Dosage e Non- postural exercises-held isometrically (low load)
for 10 s, repeated 10 times. Postural (seated, isometric held at 5
pressure levels like supine, holding 10 s, repeated 10 times, neck
rotation to end range 3 sets repeated 10e15 times on each side.
Endurance-strength exercises 3 sets of 15 repetitions (elastic
bands were used to replicate the exercises at home). Feedback
The supervising physiotherapist monitored potential surface
exor activity visually, with palpation if necessary.
Treatment schedule: Assigned exercises (2e4) were to be
completed 2 times/day lasting 10e15 min, supervised weekly by
a physiotherapist providing instruction and manual guidance.
Arm 2 e Control: No exercise, encouraged to continue with
ordinary exercise activity
Treatment Schedule: 6 weeks, instructed to do 2e4 exercises 2
times/day, for 10e15 min, supervised by physiotherapist weekly.
Duration of Follow-up: 12 months
INDEX TREATMENT
Arm 1 e Exercise group: Activity e Functional postural exercise.
Mode e Sitting. Movement e Assumes an upright posture in a
neutral lumbo-pelvic position and then gently lengthens the
cervical spine by imagining they are lifting the base of their skull
from the top of their neck. Dosage e concentric-isometric hold
with postural awareness, low intensity,10 s hold every 15
e20 min throughout the day for a total of 2 weeks, all sorts of
environment throughout their waking day, feedback was taught
initially but not reviewed during the 2 weeks
Treatment schedule: 2 weeks
Arm 2 e Control group: Did not undertake any exercise
intervention during the study.
Duration of Follow-up: NR
CO-INTERVENTION: participants in control group were
requested not to seek other treatment for their neck pain for the
2 weeks.
INDEX TREATMENT
Arm 1 e MedX Exercise (MedX): Activity e High technology
exercise, Mode/Movement e medically supervised
rehabilitative exercise. Dosage e 20 sessions over 3 months
Arm 2 e Manipulation and low tech Exercise (SMT/Ex): Activity
e Chiropractic manipulation, supervised low technology
rehabilitative exercise, Mode e progressive strengthening
exercises for the neck and upper body proceeded by a short
aerobic warm up of the upper body and light stretching,
Movement e the upper body strengthening exercises included
push ups and dumbbell shoulder exercises as described by
Dyrssen et al. (1989). Dosage e 45 min total, 2 sets of 15e30
repetitions, weight 2e10 lbs; cervical progressive resisted
strengthening exercises where performed while lying on a
therapy table with wearing head gear with variable weights from
1.25 lb to 10 lbs guided by a simple pulley system attached to the
table
Treatment Schedule: 20 sessions over 3 months
Arm 3 e Spinal Manipulative (SMT): Chiropractic manipulation,
20 sessions over 3 months
Treatment Schedule: 11 weeks, 20 session
CO-INTERVENTION: NR
unchanged.
RR (exercise vs control): 0.45 (95% CI: 0.18e1.14).
Between-group regression analyses revealed that the members
of the exercising group had a 3.2 times greater chance (odds
ratio) than the control group of having been pain-free during the
previous 7 days and a 1.9 times great chance (odds ratio) of
having been pain-free during the previous 3 months, P 0.01.
REASON FOR DROP-OUTS: 6 in Exercise Group, 6 in Control
Group, reasons reported
SIDE EFFECTS: NR
COST OF CARE: NR
PAIN (VAS 0 to 10)

Baseline mean: Exercise 3.0 Control 2.6
Reported results: no signicant
SMD (exercise vs control): 0.13 (95% CI: 0.74 to 1.01)
FUNCTION (NDI 0 to100)
Baseline mean: treatment 18.1 control 20.6
Reported results: no signicant
REASONS FOR DROP OUTS: NR
SIDE EFFECTS: NR
CUMULATIVE ADVANTAGE for six patient-oriented outcomes

Reported Results: favours SMT/Ex over SMT; MONOVA value
yielded a signicant group difference (Wilk's Lambda 0.85, F
(12,302) 2.2, P < 0.01)
PAIN (VAS 0 to 10)
Baseline Mean: SMT 56.6, MedX 57.1, SMT/Ex 56.0
Reported Results: group difference in patient-rated pain ANOVA
F (2,156) 4.2, P 0.02 favours the two exercise groups
SMD (SMT/Ex vs SMT) at LT follow-up: 0.21 (95% CI: 0.60 to
0.18); power 28%, NNTB 10; treatment advantage 15%
Reported Results: no signicant group differences were found
ANOVA: F (2, 156) 2.04, P 0.13
0.01), power 28%, NNTB 11, treatment advantage 11%
HEALTH-RELATED QUALITY OF LIFE (SF-36 0 to 100)
Baseline mean: SMT 69.1, MedX 69.0, SMT/Ex 71.7
Reported Results: SMD at LT follow-up: 0.30 (95% CI: 0.69 to
0.09)
PATIENT SATISFACTION (scale 1 to 7 completely satised to
completely dissatised)
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,
158) 6.7, P 0.002
36
(continued )
Study/Participants
Interventions
Outcomes
SMD (SMT/Ex vs SMT) at LT follow-up:0.93 (95% CI: 1.35

to 0.52)
PATIENT-RATED IMPROVEMENT (scale 1 to 9)
Reported Results: substantial improvement over time, ANOVA:
F (2, 174) 1.7, P 0.18
0.03); power 44%
REASONS FOR DROP-OUTS: Reported
SIDE EFFECTS: increase neck or headache pain 8 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;
RR (SMT/Ex vs MedX): 0.81 (95% CI: 0.23e1.55)
RR (SMT vs MedX): 0.61 (95% CI: 0.23e1.55)
COST OF CARE: NR
INDEX TREATMENT
Chiu et al., 2005
PAIN (VAS 0 to 10)
Subacute MND (Cervical Brachial Pain Arm 1 e Craniocervical Flexion and isometric neck
Baseline Mean: CCF 4.61, TENS 4.69, IR 4.26
Syndrome)
Reported Results: NS
strengthening (CCF):
Activity e deep neck exor strengthening, Infrared radiation; SMD (CCF vs IR): 0.34 (95% CI: 0.72 to 0.04); NNTB 6,
Mode e using pressure sensor @20 mmhg 10 min (10 s on/15 s treatment advantage 24%
FUNCTION Chinese version of Northwick Park Questionnaire (0
off) Strengthening using a Multi Cervical Rehabilitation Unit
e4)
(MCRU).
Movement/Dosage e 15 repetitions of exion, extension at 20% Baseline Mean: CCF 1.39, TENS 1.55, IR 1.36
Reported Results: CCF vs IR was signicant (p 0.02)
of Peak Isometric Strength (PIS) as warm-up. Then dynamic
SMD (CCF v IR): 0.33 (95% CI: 0.71 to 0.05); NNTB 6, treatment
exion and extension with variable resistance 0 to 12
advantage 16%
repetitions.
REASON FOR DROP-OUTS: Reported
Treatment Schedule: 35 min of exercise per session
SIDE EFFECTS: No complications occurred.
COMPARISON TREATMENT:
COST OF CARE: NR
Arm 2 e Transcutaneous Electrical Nerve Stimulation (TENS):
30 min of dual channel portable TENS unit (ITO model 1302).
Continuous trains of 150 ms square pulse at 80 Hz. 4 Electrodes
(4 4cm).
Arm 3 e Control Group: Infrared radiation (IR): place on EX 21,
GB21, LI 11, intensity 2e3 times of participants sensory
threshold education on neck care
Treatment schedule: 20 min per session, 6 weeks, 2 sessions/
week
CO-INTERVENTION: NS
INDEX TREATMENT
Dellve et al., 2011
PAIN (Numeric Pain Scale 0 to10)
Arm 1 e Myofeedback Training (MyoT): Activity e activities of Baseline Mean: MT 6.0, IMST 6.3, Control 6.2
Chronic cervical neck pain or
cervicobrachial pain syndrome
daily living; Mode e wearing a myofeedback device; Movement Reported Results: no signicant difference between groups
SMD (IMST vs control) at immediate post-treatment: 0.30 (95%
e ergonomic adjustments; Dosage e Duration/Frequency
-minimum of 8 h per week, typically 2 h per day and 4 days per CI: 0.92 to 0.33);
SMD (IMST vs control) at 2 months follow-up: 0.63 (95%
week;; Environment -various; Feedback -discussion with
CI: 1.27 to 0.00)
ergonomist once per week.
Arm 2 e Intensive Muscular Strength Training (IMST): Activity e FUNCTION (Work Ability Index 7 to49)
Baseline Mean: MT 19.3, IMST 19.0, Control 19.0
Upper extremity strength training Mode e resistance bands
Movement e Exercises for strengthening and co-ordinating the Reported Results: no signicant difference between groups
upper extremities. Dosage e Type of contraction -NR; Intensity SMD (IMST vs control) at immediate post-treatment: 0.18 (95%
-NR; Speed -NR; Duration/Frequency 2 times per day, 6 days CI: 0.80 to 0.44);
per week for 4 weeks; Sequence -warm-up movements followed SMD (IMST vs control) at 2 months follow-up: 0.38 (95%
by strengthening exercises then ending with breathing and slow CI: 0.25 to 1.01)
down movements; Environment -participant's home; Feedback REASON FOR DROP-OUTS: 5 in MT Group, 7 in IMST Group, 1 in
Control Group, reasons reported
-ergonomist coaching.
SIDE EFFECTS: NR
COST OF CARE: NR
Arm 3 e Control Group: Diary entries to record activities,
discomfort, pain and sleeping disturbances
CO-INTERVENTION: not avoided
INDEX TREATMENT
Franca et al., 2008
PAIN (VAS 0 to 100)
Arm 1 e Physiotherapy protocol performed according to Hall
Chronic MND (Myofascial Pain
Baseline Mean: PT Acup 85.0, Acup 80.0, PT 70.0
Syndrome)
Reported Results: According to KWT (KruskaleWallis test), the
and Brody consisting of Activity estretching, strengthening;
statistical analysis of the inter-groups demonstrated signicant
Mode e muscle stretching of neck and upper limbs regions;
(p < 0.05) differences among the groups. The DMCT (Dunn's
recruitment exercise of Deep Cervical Flexion Muscles;
Movement e strengthening exercise of Deep Cervical Flexion Multiple Comparison test) showed that G1 was superior to G3 in
pain improvement (p < 0.05)
Muscles and upper limbs. Duration of treatment 20 min, 1e2
SMD (PT Acup vs Acup) at immediate post treatment: 0.73
times/week for 10 weeks.
(95% CI: 1.46 to 0.00), treatment advantage 11%
Arm 2 e Acupuncture combined with Physiotherapy (G1)
FUNCTION (NDI e Brazilian/Portuguese version)
Activity e Stage 1: acupuncture therapy based on the TCM
theory of biao-li (symptom/root) treatment;. Mode e Chinese Baseline Mean: PT Acup 24.0, Acup 30.0, PT 28.0
Reported Results: The DMCT (Dunn's Multiple Comparison test)
acupuncture, as the root treatment, was performed with a
selection of body points by means of the diagnostic of syndromes showed that G1 was superior to G3 in reducing functional
disability (p < 0.0001)
of TCM. Movement e Disposable stainless steel needles
(0.25 mm 30 mm) with guide-tubes (Dong-bang Acupuncture SMD (PT Acup vs Acup) at IT follow-up: 0.95 (95% CI: 1.70
to 0.20), NNTB13, treatment advantage 13%.
Needle, Korea) inserted bilaterally into the body points to a
37
(continued )
Study/Participants
Interventions
depth of 10e15 mm. YNSA was carried out as the symptom

treatment with a selection of the kinetic and ypsilon points as the
main scalp points to treat TNS. The kinetic points were
stimulated bilaterally with needle measuring 0.25 mm x 5
e15 mm (Dongbang Acupuncture Needle, Korea) to a depth of 1
e2 mm, whereas the selection of the ypsilon points were
ipsilateral of the scalp to the diagnosed side of the neck. All
acupoints (body and scalp points) were stimulated in an uneven
manner every 10 min to maintain the needling sen. Chinese
acupuncture was performed in 20 min and YNSA was maintained
until 40 min. Stage 2: Physiotherapy given simultaneously with
YNSA.
COMPARISON TREATMENTS:
Arm 3 e Acupuncture (G2): Same protocol of acupuncture
therapy as described in the rst stage of G1 for 20 min.
Arm 4 e Physiotherapy (G3): Same protocol of physiotherapy as
described in the second stage of G1 for 20 min.
Duration of Follow-up: 6 months follow-up
CO-INTERVENTION: avoided in trial
INDEX TREATMENT
Hall et al., 2007
Arm 1 e C1-2 self -SNAG (SSng): Activity e Belt was used as per
(sub)acute Cervicogenic headache
(CGH)
Mulligans detailed techniques. Mode e The participant was
instructed by the PT on the proper positioning and technique of
mobilisation belt on 3 trials to familiarize themselves. The
participant was instructed to perform technique without
producing pain. Movement e supplemental video available on
line
Treatment schedule: 1 day
Arm 2 e Control group (Mock): Sham mobilisations with same
belt. This group did not receive instruction to rotate head
towards restriction.
Treatment Schedule: 1 day
Duration of Follow-up: 4 weeks and 12 months
INDEX TREATMENT
Hallman et al., 2011
Stress-related chronic neck-shoulder Arm 1 e Practice paced breathing: Activity e breathing
pain
exercises; Mode e resonance heart rate variability (HRV)
biofeedback (BF) training and paced breathing; Movement e
respiration. Dosage e Type of contraction e concentric
diaphragm concentrically contracts with this breathing exercise,
intensity -low as was breathing exercises, On-site sessions:
speed e Sessions 1 and 10: between 4.5 and 6.5 breaths per
minute to determine speed with highest HRV. Sessions 2e9:
performed at speed of highest HRV, duration -Sessions 1 and 10:
2 min of paced breathing for 2 min of free, non-paced breathing.
Sessions 2 to 9: 4 times 5 min of resonant HRV BF with 2min breaks, frequency 1time/week, environment in which
exercise is performed e morning or afternoon is standardized in
a comfortable semi-reclined chair semi-reclined, 23 Celsius, dim
light, relaxing atmosphere, feedback -(psychologist weekly
session.
Home exercise-program: at least 15 min of paced breathing with
watch or easy air pacer software, 5 times/week
Arm 2 e Control Group: This group took part in the breathing
protocol in sessions 1 and 10, without any prescribed treatment
in between.
Treatment schedule: week 1 and 10
Duration of Follow-up: Directly after 10 weeks
Hansson et al., 2013
INDEX TREATMENT
WAD
Arm 1 e Vestibular rehabilitation program: Activity e circuit
training of six balance exercises with warm-up and recovery
phases; Mode e static and dynamic balance exercises with neck
movements, eyes opened and closed; Movement e Warm-up
phase- walking around the room and changing direction as well
as turning the head from side to side. Exercises in standing,
including training of co-ordination of movements. Circuit
training- Standing up and sitting down on a chair while turning
the head from side to side. Eyes closed if possible. Standing on a
trampoline, eyes closed and slightly exing the knees and
turning the head from side to side simultaneously. Standing on a
Outcomes
REASONS FOR DROP-OUTS: Reported (3 drop-outs, 1 in each
group)
SIDE EFFECTS: Reported; no record of serious complication of
acupuncture or physiotherapy occurred during treatments or
during the follow-up period after any of the treatments that
could harm the patients during the assessment all stages of the
trial
COST OF CARE: NR
PAIN Headache intensity change score (VAS 0 to 100)

Baseline Mean: SSng 52 Mock 51
Reported Results: group difference in patient-rated pain favours
the SSng exercise group
SMD(SSng vs Mock) at ST follow-up: 1.58 (95% CI: 2.38
to 0.77); power 100%, NNTB 2, Treatment advantage 40%
SMD(SSng vs Mock) at LT follow-up: 1.74 (95% CI: 2.57
to 0.91); power 100%, NNTB 3, treatment advantage 40%
REASONS FOR DROP-OUTS: NA
SIDE EFFECTS: NR
COST OF CARE: NR
PAIN (Borg Scale 0 to 10)

Baseline Mean: Treatment 2.6, Control 2.5
SMD (treatment vs control): 0.19 (95% CI: 1.01 to 0.63)
Baseline Mean: Treatment 21.3, Control 25.6
QUALITY OF LIFE SF-36 (physical function subscale)
Baseline mean: Treatment 89.6, Control 77.5
REASONS FOR DROP-OUTS: NR
SIDE EFFECTS: NR
COST OF CARE: NR
PAIN (VAS 0 to 100)

Baseline Median: Intervention 60, Control 60
Reported Results: no signicant difference between groups;
SMD (6 weeks vs control) 6 weeks 0.07 (95% CI: 0.68 to 0.82);
SMD (3 months vs control) 0.60 (95% CI: 1.35 to 0.15)
REASONS FOR DROP-OUTS: reported
SIDE EFFECTS: NR
COST OF CARE: NR
38
(continued )
Study/Participants
Helewa et al., 2007

Chronic MND
Interventions
10 cm foam with eyes closed and turning the head from side to
side. Standing on a sport mat, walking on the spot and turning
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
backward while turning the head from side to side. Recovery
phase- Soft, relaxing movements. Stretch of the muscles in the
upper cervical region. Dosage e Warm-up duration- 10 min.
Circuit training duration- 2- minutes per exercise, 2 laps.
Recovery phase duration- 5 min. Frequency 2 times/week,
environment in which exercise is performed -physical therapy
centre, feedback -supervised group sessions.
Arm 2 e Control Group: no intervention
Duration of Follow-up: 6 weeks and 3 months
CO-INTERVENTION: reported and not avoided
INDEX TREATMENT
Arm 1 e Exercise: Activity eStandard Pillow Exercise Active
Control Treatment Group: Standard (regular) pillow is assumed
to be used by this group. Mode e Exercise including: Posture,
Relaxation, Active Movement e 1-Postural correction in sitting,
standing or during work and leisure activities emphasizing chin
in retracted position with cervical spine elongations not beyond
normal curves of cervical spine practised with mirror feedback
rst, then freely using other prompts to become habitual, 2Relaxation Exercise Techniques designed to interrupt cycle of
pain and muscle spasm (hold-relax approach repeated up to 5
times and/or rhythmic stabilisation applied manually by the PT
and taught to the patient), 3-Free Active Exercise (following
relaxation techniques patients freely move head and neck
according to normal patterns of movement, may initially be
helped by the physiotherapists, patterns are diagonal and
involve head exion and rotation to the right followed by head
extension and rotation to the left, diagonal patterns are then
repeated to the contralateral sides), and 4- Strengthening
Exercises (to strengthen the anterior neck muscles using manual
resistance (within the limit of pain) with a combination of
isometric and isotonic movements, the principle involving
reversing movements of exion and extension, using the
principles of successive induction (Sherrington, 1961). Dosage e
13 sessions over 10 weeks, as well as home exercises and Active
Control treatment (massage and thermal modality) were
administered to this group isometric rehabilitative exercise.
Arm 2 e Neck Support (Pillow): Activity e Orthopaedic
Pillow(s) Active Control Treatment Group: Mode e Neck
Support Pillows Movement e could be one of two designs:
Shape of Sleep pillow (Manutex Products, Mississauga, ON,
Canada) or the Sissel Design AB pillow (Sissel Design AB, Svedala,
Sweden). The two types of pillows were randomly assigned
equally in each arm. The pillows did not differ in shape but in the
rmness of the foam. The pillow use was combined with the
Active Control treatment (massage and thermal modality).
Arm 3 e Neck Support and Exercise (Exercise Pillow):
Orthopaedic Pillow(s) Exercise Active Control Treatment:
Orthopaedic pillows were used and were of two types: Shape of
Sleep pillow (Manutex Products, Mississauga, ON, Canada) or the
Sissel Design AB pillow (Sissel Design AB, Svedala, Sweden). The
two types of pillows were randomly assigned equally in each
arm. The pillows did not differ in shape but in the rmness of the
foam. Pillow use, plus Exercise plus Active control treatment
(massage and thermal modality) were administered in this
group.
Arm 4 e Massage Therapy and thermal modality (Control):
Standard (regular) Pillow Active Control Group: The Standard
(regular) pillow is assumed to be used by this group. Active
Control treatment that included massage and thermal modality,
Efeurage type massage for 10 sessions in 10 weeks. Visits were
2 sessions/week for 3 weeks, then 1 visit/week for 3 weeks, then
1 visit in 10th week.
Arm 5 e Thermal modality: 20 min of moist heat or ice.
Treatment Schedule: 6 weeks (assume that the use of the pillow
was constrained to these 6 weeks)
Outcomes
PAIN (VAS 0 to 10)

Baseline Mean: Exercise 2.9, Pillow 3.6, Exercise Pillow 2.3,
Control 2.5
Reported Results: Not signicant at all points
SMD (exercise pillow vs pillow): 0.59 (95% CI: 1.09
to 0.09); power 50.69%
FUNCTION Northwick Park Neck Pain Questionnaire (NPQ 0 to
100)
Baseline Mean: Exercise 32.3, Pillow 35.01, Exercise Pillow
29.9, Control 27.4
Reported Results: Interaction of pillow and exercises are
statistically signicant and clinically important
SMD (exercise vs control): 0.00 (0.52 to 0.52); power 100%
SMD (exercise pillow vs pillow): 0.61 (1.11 to 0.12);
power 100%
QUALITY OF LIFE (SF 36 0 to 100)
Baseline Mean: Exercise 42.8, Pillow 41.1, Exercise Pillow 43.7,
Control 43.8
SMD (exercise vs control): 0.15 (95% CI: 0.34 to 0.65); power
100%
SMD (exercise pillow vs pillow): 0.46 (95% CI: 0.95, to
0.04); power 100%
SIDE EFFECTS: None present
COST OF CARE: NR
39
(continued )
Study/Participants
Humphreys and Irgens, 2002

Chronic neck pain
Jull et al., 2002

Chronic CGH
Kjellman and Oberg, 2002

(sub)Acute to Chronic MND with or
without radiation
Kuijper et al., 2009

Acute NDR
Interventions
INDEX TREATMENT
Arm 1 e Symptomatic exercise group (SEG): Activity e One eyehead-neck co-ordination and one eye-head-neck-upper limb coordination; Mode e sitting. Movement e Exercise one:
participants were required to x their eyes on a target in front of
them and move their head maximally in a slow and carefully
controlled movement in one direction while keeping their eyes
xed on the target straight ahead. Exercise two: participants
were required to hold up both arms in front of them with their
thumb extended upwards and to keep their eyes xed on one
thumb as the ipsilateral arm went through the sequential
movements of the left and right rotation, exion and extension,
with the eyes and head followed the movement in a slow and coordinated fashion. Dosage e Speed (slow and co-ordinated
movement), Duration/Frequency (4 weeks, 2 times/day),
Feedback (one training session given by the author and an
instruction sheet), Monitoring (exercise compliance form),
Environment (home exercise program). Dose (NR).
Treatment Schedule: 4 weeks, 2 daily sessions.
Arm 2 e Control group: Symptomatic non-exercise group
(SNEG).
CO-INTERVENTION: NR
INDEX TREATMENT
Arm 1 e Exercise Therapy (CCF/ISO) Activity e therapeutic low
load exercise to cervical-scapular region Mode e craniocervical
exor training with pressure biofeedback, scapular muscle
training, postural correction, Movement e exercise performed
throughout the day, isometric strengthening with co-contraction
of neck exion and extension, stretching as needed. Treatment
Schedule e 30 min session duration, 2 sessions/weeks, 8e12
sessions total
Arm 2 e Combined Therapy (MT/ET): Activity e manipulation,
mobilisation & exercise
Treatment Schedule: 30 min session duration, two sessions/
weeks, 8e12 sessions total
Arm 3 e Manipulative Therapy (SMT): manipulation: high
velocity, low-amplitude manipulation described by Maitland;
mobilisation (low velocity), 30 min session duration. Dosage: 2
sessions/week, 8e12 sessions total
Arm 4 e Control Group (NT): no treatment
Treatment Schedule: 6 weeks, 8e12 sessions
CO-INTERVENTION: NR
INDEX TREATMENT
Arm 1 e General Exercise (ET): Activity e stretching,
strengthening; Mode e neck and shoulder; Movement e ROM,
active neck endurance and strength exercises, 16 sessions over 2
months
Arm 2 e McKenzie Exercise (McK): Specic McKenzie protocol.
Sessions over 2 months. Number not specied
Arm 3 e Sham Ultrasound (SUS): Set at lowest setting for 7 min.
Applied over the superior portion of the trapezius
Treatment Schedule: 4 weeks of treatment
Duration of Follow-up: 6 and 12 months
CO-INTERVENTION: Comparable between index and control
groups.
INDEX TREATMENT
Arm 1 e Physiotherapy Group (PG): Activity e Therapy was
focused on mobilizing and stabilizing the neck and was
characterized as hands off Mode e The sessions were
standardized provided by a certied Physiotherapist, the patient
was instructed on graded exercise activities to strengthen the
supercial and deep muscle of the neck. The patients were also
instructed in a home exercise program. Movement e Patients
were advised to practice the exercises daily and asked to record
the duration of their exercise daily. Dosage: 2 times/week for 6
weeks
Arm 2 e Wait and see list Group (WLG): Patients in the control
Outcomes
PAIN (VAS 0 to 100)

Baseline Mean: SEG 55, SNEG 49
SMD (SEG vs SNEG): 0.00 (95% CI: 0.74 to 0.74)
REASON FOR DROP-OUTS: not specied
SIDE EFFECTS: NR
COST OF CARE: NR
PAIN Headache intensity change score (VAS 0 to 10)

Baseline Mean: SMT 4.8, CCF 5.4, MT/ET 5.1, NT 5.3
Reported Results: signicant favouring SMT and CCF
SMD (CCF vs NT) at LT follow-up:0.59 (95% CI:1.00 to 0.18),
NNTB 6, treatment advantage 28%
FUNCTION Northwick Park Neck Pain Questionnaire (NPQ
change score, 0 to 36)
Baseline Mean: SMT 27.5, CCF 29.6, MT/ET 29.7, NT 30.7
Reported Results: signicant favouring MT or MT/ET over
control; no signicant difference between MT, ET and MT/ET
comparisons
SMD (CCF vs NT) at LT follow-up:-0.59 (95% CI:1.00 to 0.18),
NNTB 6, treatment advantage 32%
GLOBAL PERCEIVED EFFECT Participant perceived effect (VAS
0 to 100)
Reported Results: signicant favouring SMT and MT/ET over NT,
not signicant for SMT or MT/ET when compared to CCF
SMD (CCF vs NT): 2.51 (95% CI: 3.05 to 1.97)
SIDE EFFECT: minor and temporary, 6.7% of headaches were
provoked by treatment
COST OF CARE: NR
PAIN (VAS 0 to 100)
Baseline Mean: ET 27.0, McK 19, SUS 21
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: 0.51 to 0.60)
Baseline Mean: ET 27.0, McK 19, US 21
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: 0.51 to 0.60)
SIDE EFFECTS: NR
COST OF CARE: NR
PAIN (VAS 0 to100)
Baseline Mean: Cervical Collar 57.4, Physiotherapy 61.7, WLG
55.6
Reported Results: At 6 weeks there was a signicant decrease in
neck pain in the collar group 2.8 mm/week (17 mm in 6 weeks)
and 2.4 mm/week in the physiotherapy group (14 mm in 6
weeks), while the control group showed only 0.9 mm reduction
in pain over the 6 weeks. After 6 months the pain scores in the
two treatment groups did not differ from those of the control
patients.
SMD (PT vs WLG) at Immediate post treatment: 0.47 (95%
CI: 0.81 to 0.12); NNTB 4, treatment advantage 33%
40
(continued )
Study/Participants
Lange et al., 2013

Acute to chronic non-specic neck
and shoulder pain
Lundblad et al., 1999

Chronic MND
Interventions
Outcomes
group were advised to continue their daily activities as much as

possible. As well they were asked to note in their diaries the parts
of the day where they were unable to continue their normal
activities. Patients were asked to contact the investigators if they
had any questions.
Arm 3 e Collar Group (CG): Semi-hard collar (Cerviex S,
Bauerfeind and available in 6 sizes), The best size (to t snugly)
was selected for each patient. Patients advised to wear the pillow
during the day for 3 weeks. Over the next 3 weeks patients were
weaned off the collar. After 6 weeks they were asked to no longer
wear the collar.
groups. Patients were asked to take paracetamol (usually) either
with or without a non-steriodal anti-inammatory. If necessary
opioids were prescribed.
INDEX TREATMENT
Arm 1 e Training group: Activity e Patterns and
synchronisation of muscle recruitment, Strengthening exercises,
Endurance exercises; Mode e Patterns and synchronisation
-Standing supine and gentle rotation stood erect, Strengtheningthe whole spine was held in an anatomic neutral position during
pull exercises, shrugs standing erect holding the dumbbells in
their hands on both sides and sitting position leaning the upper
body 45 forward with a straight back for reverse ies.
Endurance-holding the body blade with both hands, and with
shoulders 90% exed and elbows 5% exed; Movement e
Patterns and synchronisation-3 conditioning exercises focussing
on activation of the deep cervical exors, Strengthening-Static
pull in 8 directions, shrugs, reverse ies, Endurance-Small
shoulder extensions and exions were performed to make the
body blade oscillate; Dosage e Patterns and synchronisationType of contraction e concentric, Speed -slow and controlled
movement, Duration/Frequency 5 repetitions, 3 week,
Sequence -sequence warm-up then strengthening then
endurance, Feedback -the pilots had access to help from
educated trainers at the base and at Tactical Air Command Karup,
Strengthening-Type of contraction -concentric, Intensity
-equivalent to 70%e85% of 1 repetition maximum, Duration/
Frequency 8 to15 repetitionss, 3 week, Shrugs and static neck
pull were performed during every session and reverse ies 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%e85% of 1
repetition maximum, Speed -as the participants became more
accustomed to the body blade exercise, they attempted to make
it oscillate increasingly more rapidly, Duration/Frequency -up to
60 s, performed every second session, 3 week, Sequence -after
strengthening, Feedback -the pilots had access to help from
educated trainers at the base and at Tactical Air Command Karup.
Dosage e 3 sessions a week, 20 min of training session for 24
weeks
Arm 2 e Control group: No intervention but offered the training
after the study. Encouraged to continue their physical activity as
usual.
CO-INTERVENTION: comparable between index and control
groups
INDEX TREATMENT
Arm 1 e Feldenkrais Intervention (F): Activity e Education
Mode e Individualized (functional integration) teacher guides
through movement sequences; Group (awareness through
movement) verbally guided through exercises for Movement e
neck-shoulder complaints, home exercises, frequency
-individually 4 times and in group (7e8 participants) 12 times;
required 50% participation in both segments of program. Dosage
e 50 min per week
Arm 2 e Physiotherapy Intervention (PT): Activity e
Stabilisation exercises for low back and pelvis, isolated and
relaxed shoulder movements Mode e Education use of body
emphasizing self-directed control and responsibility for body,
ability to cope with pain, muscle tension, and complaints.
Baseline Mean: Cervical Collar 41.0, Physiotherapy 45.1, WLG

39.8
Reported Results: The collar group showed a signicant
difference in rate of improvement compared with the control
group, the weekly change in the physiotherapy group was not
signicantly different from that of the control patients.
SMD (PT vs WLC) at immediate post treatment: 0.11 (95%
CI: 0.45 to 0.23)
PATIENT SATISFACTION (scale 0 to 5)
Reported Results: NR
RR (PT vs WLC) at immediate post treatment: 0.92 (95% CI: 0.62
e1.37)
REASONS FOR DROP-OUTS: NR
SIDE EFFECT: NR
COST OF CARE: NR
PAIN (VAS 0 to 10)

Baseline Mean: Training group 1 and control 1.2
SMD (training vs control): 0.58 (95% CI: 1.12 to 0.04)
SIDE EFFECTS: Reported
COST OF CARE: NR
PAIN (VAS 0 to 10)

Baseline Mean: VAS e usually PT 1.2, F 1.5, control 2.0, VAS e
worst PT 4.1, F 4.4, control 5.5
Reported Results: no signicant differences
SMD (PT vs control) at LT follow-up: 0.14 (95% CI: 0.80 to
0.51)
DISABILITY Work and leisure (0e4) Sick leave, days and %
Baseline Mean:
Disability e work PT 1.3, F 1.2, control 1.3,
Disability e leisure PT 0.6, F 0.9, control 0.6
Sick leave (days) PT 12.7, F 12.0, control 11.5,
Sick leave (%) PT 6.5, F 5.8, control 5.9
41
(continued )
Study/Participants
Interventions
Awareness of body posture. Movement e Practice work-related

lift and movement techniques. Exercise program of strength, coordination, endurance, exibility/smoothness and rhythm,
Home exercises. Dosage e 50 min; 2 times/week for 16 weeks in
group of 5e8 participants; Required 50% participation in the
exercises
COMPARISON GROUP
Arm 3 e Control Regimen: no treatment
CO-INTERVENTION: NR
Martel et al., 2011
INDEX TREATMENT
Chronic MND with or without
Arm 1 e SMT Group: Activity e Spinal Manipulation Mode e
referral/radiation to the head, trunk Maximum 4 spinal manipulations Movement e cervical and
or limbs
upper thoracic areas. Dosage e One treatment per month, lasted
10e15 min
Arm 2 e SMT Exercise Group: Activity e Spinal
Manipulation Home Exercise Program, range of motion,
stretching, strengthening Mode e Maximum 4 spinal
manipulations. Advised to perform a home exercise program
Movement e manipulation- cervical and upper thoracic areas
(down to T4). home exercise program- range of motion exercises,
followed by 4 stretching/mobilisation, and 4 strengthening
exercises (concentric and isometric contractions) of the cervical
and upper thoracic spine (primarily exion, extension, lateral
exion and rotation of the cervical spine). Dosage e
manipulation- one treatment per month lasted 10e15 min.
Home exercise program 3/week. Three series of each exercise
with a 30e60 s rest between series were performed during each
training session. A training session lasted 20e30 min
All participants were instructed in the same routine, exercise
volume was tailored to each participant's strength, exibility and
ability to complete the routine with minimal neck pain. Each
patient received a written copy of the program. Exercise checked
every 2 months by a kinesiologist.
Arm 3 e Control Group: Attention-control, No treatment,
attended clinic once every 2 months, visited lasted 20e30 min
for data collection.
Treatment Schedule: 10 months, 10 sessions
CO-INTERVENTION: NR
Rendant et al., 2011
INDEX TREATMENT
Chronic MND
Arm 1 e Qigong: Activity e 12 neck exercises, 9 shoulder
exercises Mode/Movement e ROM/mobility, imagery, breathing
and moving exercise (Fig. 1) home exercise with a manual;
Qigong qualied teacher was certied by German Qigong Society
Dosage e 18 sessions, 90 min sessions over 6 months
Arm 2 e Exercise: Activity e ROM, stretching, strengthening
Mode/Movement e Warm-up included neck range of motion,
use of soft ball, strengthening using a theraband; exibility
exercise, home exercise with a manual, individual pain level was
not exceeded; Dosage e 18 sessions over 6 months; exercise is
monitored by a qualied physiotherapist
Arm 3 e Control: no intervention
Treatment Schedule: 24 weeks treatment, 18 sessions
Duration Follow-up: none
CO-INTERVENTION: not avoided
Outcomes
SIDE EFFECTS: NR
COST OF CARE: NR
PAIN (VAS 0 to 10)

Baseline Mean: SMT 3.1, SMT Ex 3.8
Baseline Mean: SMT 21.4, SMT Ex 22.2
HEALTH-RELATED QUALITY OF LIFE (SF-12 0 to 100)
Baseline Mean Physical Scale: SMT 48.7, SMT Ex 50.0, Mental
Scale: SMT 45.3, SMT Ex 44.8
SIDE EFFECTS: Reported: No serious adverse events were
reported during RCT
COST OF CARE: NR
PAIN (VAS 0 to 100)

Baseline Mean: Qigong 57.7, E 57.5, control 53.4
Reported Results: signicant differences Qigong vs control;
MD (Qigong vs control) at 12 weeks treatment: 15.60 (24.72
to 6.48)
MD (Qigong vs control) at 24 weeks treatment: 8.10 (15.72
to 0.48)
MD (Exercise vs control) at 12 weeks treatment:17.30 (95%
CI: 26.60 to 8.00)
CI: 19.97 to 0.63)
No signicant difference Qigong vs exercise
FUNCTION (NPDI 0 to 100)
Reported Results: signicant differences Qigong vs control;
SMD (Qigong vs control) at 12 weeks treatment: 0.48 (95%
CI: 0.92 to 0.04)
CI: 0.92 to 0.02)
SMD (Exercise vs control) at 12 weeks treatment: 0.78 (95%
CI: 1.24 to 0.31)
CI: 0.97 to 0.04)
No difference Qigong vs exercise
QUALITY of LIFE (SF 36, physical component)
Reported Results: signicant differences qigong vs control;
MD (Qigong vs control) at 12 weeks treatment: 3.40 (95%
CI: 6.97 to 0.17)
CI: 8.07 to 0.27)
MD (Exercise vs0 control) at 12 weeks treatment:2.70 (95%
CI: 6.76 to 1.36)
42
(continued )
Study/Participants
Interventions
INDEX TREATMENT
Revel et al., 1994
Chronic MND (osteoarthritic changes Arm 1 e Proprioception Rehabilitation Group (RG) Activity e
27 of 30)
Proprioceptive rehabilitation program: purpose to improve neck
proprioception; Mode e 15 min individualized exercise session,
exercises were mainly concerned with eye-neck co-ordination
including; Movement e a) slow passive motions of the head
with gaze on a xed target, b) active movements of the head,
automatic movements of the neck with passive trunk
movements and head position relocation exercises, c) exercises
in a wide range of motion with free eye-head coupling (author
description well detailed in Rehabilitation Procedure page 896).
Dosage e 2 times per week; 30e40 min sessions
Arm 2 e Control Group (Cntl): Medication: analgesic, antiinammatory typical dosage was indomethacin 100 mg; aspirin,
3000 mg; diclofenac, 150 mg; naproxen, 1000 mg
CO-INTERVENTION: NR
INDEX TREATMENT
Stewart et al., 2003, 2007, 2008
Subacute and Chronic WAD with or Arm 1 e Exercise and Advice: Activity e Exercise, Mode e
without radiation
aerobic exercise, stretches, functional activities, activities to
build speed, endurance and co-ordination, trunk and limb
strengthening, CBT (setting goals of progressively increasing
difculty, shaping, encouraging self-monitoring of progress, selfreinforcement), home exercise program (individual specied),
Movement e graded exercise program supervised by a
physiotherapist, Dosage e duration -1 h of exercise per session,
feedback-supervised for 30 min, Individualized, progressive,
intensity -submaximal program designed to improve
participants ability to complete functional activities specied by
the participant as being difcult because of whiplash. Regular
evaluation by a physiotherapist. Encouraged to continue home
exercises even after intervention was completed. Dosage e 6
weeks, 12 sessions
Arm 2 e Advice Alone: Standardised education, reassurance and
encouragement to resume light activity alone. One consultation
and 2 follow-up phone contacts. Favourable prognosis of
whiplash, addressed common inaccurate beliefs about whiplash,
exploration of fear-avoidance beliefs. Participants given a
written report of main points of advice session. Standardized
advice reinforced at 2 weeks and 4 weeks
Takala et al., 1994
INDEX TREATMENT
MND, disorder duration NR
Arm 1 e Exercise treatment (ET): Activity e Group gymnastic,
instructional type (group), Mode e setting -work; treatment
characteristics -exercise planned to train whole body,
Movement e aerobic dynamic exercise -10 min walking or
stepping, relaxation, stretching of muscles of the trunk and
extremities and dynamic exercises -10 min, Dosage e sequence(10 min walking/stepping, 10 min stretch/dynamic exercises,
5 min walking/stepping, 10 min dynamic and co-ordination
exercises, 10 min stretch and relaxation; duration of
session 45 min; 1 time/week
Arm 2 e Control - no treatment
Treatment Schedule: 10 weeks, 10 sessions of treatment in the
spring session -cross-over of placebo group occurred in autumn,
the groups were reversed
CO-INTERVENTION: NR
Outcomes
CI: 5.83 to 1.83)
No difference qigong vs exercise
REASON FOR DROP-OUTS: detailed
SIDE EFFECTS: Reported by 19 patients in qigong group
including: muscle soreness (n 15), myogelosis (n 12), vertigo
(n 10), other pain (n 4), headache (n 3), thirst (n 1),
engorged hands (n 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
PAIN (VAS 0 to 100)
Baseline Mean: RG 50.5, control 45.9
Reported Results: signicant favouring RG
SMD at ST follow-up: 0.77 (95% CI: 1.29 to 0.24), NNTB 4,
treatment advantage 34%
DAILY INTAKE OF NSAID/ANALGESICS
Baseline Mean: RG 2.0/1.8, control 2.3/1.6
Reported Results: not signicant
FUNCTIONAL IMPROVEMENT SELF- ASSESSED (scale 0 to 5)
Reported Results: signicant favouring RG
SMD at ST follow-up: 0.55 (95% CI: 0.33e0.89), NNTB 3,
treatment advantage NA
SIDE EFFECTS: NR
COST OF CARE: NR
PAIN (VAS 0 to 10)

Baseline Mean: Exercise Advice 5.2, Advice Alone 5.3
Reported Results: Groups were similar at baseline.
SMD immediate posttreatment: 0.46 (95% CI: 0.81 to 0.12)
SMD at 12 month: 0.12 (95% CI: 0.47 to 0.23)
SMD immediate post treatment: 0.50 (95% CI: 0.85 to 0.15)
SMD 12 month: 0.39 (95% CI: 0.74 to 0.03)
GLOBAL PERCEIVED EFFECT
(scale 5 to 5)
SMD immediate post treatment: 0.46 (95% CI: 0.80 to 0.11),
SMD 12 month: 0.18 (95% CI: 0.54 to 0.17)
QUALITY OF LIFE (SF-36 Physical 0 to 100)
Reported Results: Groups were similar at baseline
SMD immediate post treatment: 0.35 (95% CI: 0.69 to 0.01),
SMD 12 month: 0.15 (95% CI: 0.50 to 0.20)
REASON FOR DROP-OUTS: Reported but not specied
SIDE EFFECTS: Reported; The main complaint in this group was
muscle pain with exercise (3) followed
by knee pain (2) and lumbar spine pain (2).
COST OF CARE: NR
PAIN (VAS 0 to 100)
Baseline Median: ET 40, control 50
Reported Results: no signicant difference
PRESSURE PAIN SENSITIVITY
Algometer (pressure pain threshold (PPT) on upper trapezius,
levator scapulae, rhomboid, infraspinatus) mean score of 8
measures
Baseline Mean: ET 45.2, control 44.8
Reported Results: no signicant difference
SMD at immediate post treatment: 0.06 (95% CI: 0.65 to 0.53)
SIDE EFFECTS: NR
COST OF CARE: NR
43
(continued )
Study/Participants
Interventions
Outcomes
Viljanen et al., 2003

Chronic MND (NDR, NDH, WAD)
INDEX TREATMENT
Arm 1 e Exercise: Activity e muscle training; Mode e activating
large muscle groups in neck and shoulders Movement e
dumbbells with weight of 1e3 kg; Dosage e Dynamic muscle
training, Sequence (stretching followed each exercise);
progression in weeks 5 and 9.
Arm 2 e Relax: Activity e Relaxation training; Mode/Movement
e progressive relaxation, autogenic training, functional
relaxation, systematic desensitisation.
Arm 3 e Control: No treatment
Treatment Schedule: 12 weeks plus 1 week reinforcement, Arm
1e13.6 sessions; Arm 2e14.6 sessions
Duration of Follow-up: 3 and 9 months
CO-INTERVENTION: Comparable between groups
INDEX TREATMENT
Arm 1 e Qigong: Activity e Qigong, Mode e lessons, Movement
e started with about 10 min of typical Qigong opening
exercises, continued with up to 4 exercises of Dantian Qigong,
and nished with about 10 min of closing exercises. Dosage e
Qigong was provided by 5 approved Qigong therapists; 24
sessions (45 min) over 3 months (2 sessions/week).
Arm 2 e Exercise: Activity e Exercise therapy; Mode e was
based on a standardized program for computer and workplace
related neck pain; Movement e including repeated active
cervical rotations, strength and exibility exercises. A detailed
description is provided in Weidmann 2008. Dosage e 24
sessions (45 min) over 3 months (2 sessions/week). Participants
were asked to continue exercising on their own for the next 3
months.
Arm 3 e Wait List Control: Patients were free to treat their neck
pain with the treatment or therapies they were using prior to
randomisation. Patients did not receive Qigong or exercise
therapy. After 6 months they were offered an intervention of
their choice.
Duration of Follow-up: 12 weeks follow-up
groups
PAIN (VAS 0 to 10)

Baseline Mean: Exercise 4.8, Relax 4.8, Control 4.1
Reported Results: no group difference
SMD (Exercise vs Control): 0.04 (95% CI: 0.28 to 0.20)
Baseline Mean: Exercise 29, Relax 2 29, Control 26
Reported Results: no signicant group differences were found
SMD (Exercise vs Control): 0.11 (95% CI: 0.11 to 0.38)
REASON FOR DROP-OUTS: Noted but no difference between
groups
SIDE EFFECTS: NR
COST OF CARE: NR
von Trott et al., 2009

Chronic MND in elderly adults
PAIN (VAS 0 to100)

Baseline Mean: Qigong 56.4, Exercise 47.1, Control 49.9
Reported Results: After 3 months there was not signicant
difference for the average neck pain between the Qigong and the
wait list group 11.0 mm (95% CI: 24.0 to 2.1; p 0.99,
ANCOVA), and no signicant difference between the Qigong and
the exercise therapy group the group difference being 2.5 mm
(95% CI: 15.4 to 10.3, p 0.68).
CI: 21.88 to 6.88)
MD (Qigong vs control) at 12 weeks treatment 12 weeks
follow-up: 6.80 (95% CI: 21.34 to 7.74)
MD (Exercise vs control) at 12 weeks treatment: 10.40 (95%
CI: 23.11 to 2.31)
MD (Exercise vs control) at 12 weeks treatment 12 weeks
follow-up: 12.20 (95%CI: 25.73 to 1.33)
FUNCTION (NDI 0 to100)
Reported Results: No signicant difference was found between
the groups after 3 and 6 months.
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 0.45)
CI: 0.70 to 0.24)
SMD (Exercise vs control) at 12 weeks treatment 12 weeks
follow-up: 0.29 (95%CI: 0.77 to 0.20)
GLOBAL PERCEIVED EFFECT
CI: 0.49 to 0.47)
SMD (Qigong vs control) at 12 weeks treatment 12 weeks
follow-up: 0.09 (95% CI: 0.60 to 0.42)
CI: 0.38 to 0.56)
SMD (Exercise vs control) at 12 weeks treatment 12 weeks
follow-up: 0.21 (95% CI: 0.69 to 0.28)
QUALITY OF LIFE (SF-36 physical component 0 to 100)
Reported Results: No signicant difference was found between
the groups after 3 and 6 months.
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 weeks
follow-up: 2.20 (95%CI: 1.81 to 6.21)
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 by 2 patients in the exercise
therapy group (2 muscle tensions, 1 aching muscles, 1 nausea)
COST OF CARE: NR
KEY: 2.1 Intervention: CBT Cognitive Behavioral Therapy; CCF Craniocervical Flexion; ET Exercise Therapy; IR infrared 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.
2.2 Outcome measures: BORG Borg pain scale; DASH disability of the arm, shoulder and hand; NDI neck disability index; NPDI Neck 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.
2.3 Other: CI condence interval; G group; NA not applicable; NNTB number-needed-to-treat-to-benet; NR not reported; p probability value; RCT randomized
controlled trials; RR relative risk; SMD standardised mean difference; vs versus.
44
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Exercises For Mechanical Neck Disorders A Cochrane Review Update

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Manual Therapy 24 (2016) 25e45

Contents lists available at ScienceDirect

Exercises for mechanical neck disorders: A Cochrane review update

Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada

Background: Neck pain (NP) is disabling and costly.

A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

categorised. Therefore, the true impact of exercise alone could not

1.1. Description of the condition

the cognitive ability to learn,

A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

Low GRADE evidence for no benecial

Published or unpublished randomized controlled trials (RCTs) in any language

3.1. Effects of interventions: chronic mechanical neck pain

3.1.1. Support element

A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

Fig. 1. PRISMA ow diagram for exercise review search results.

3.1.2. Base element

using cervical movement exercises (McKenzie protocol) contrasted

A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

1970). Evidence of benet showed people may improve slightly

short-term follow-up. It may improve functional outcomes when

3.1.2.3. Stretch and strengthening. Cervical/upper extremity Stretch/

A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

small treatment benets initially but larger benets in the long

A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

Control: Very low quality evidence (one trial, 68 participants (Ang

3.1.3. Modulator elements

3.1.5. Base cognitive/affective element

A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

3.3. Effects of interventions: acute radiculopathy

function immediately post treatment and at long-term followup.

4.2. Overall completeness and applicability of evidence

A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

studies, quality assessment, or data extraction for the study for

5.2. Implications for research

PAIN intensity in trapezius muscle (VAS 0 to 100)

(continued on next page)

A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

consecutive concentric and eccentric muscle contractions

Andersen et al., 2012

PAIN (VAS 0 to 10)

A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

Beer et al., 2012

Bronfort et al., 2001a; Evans et al.,

pressure levels (22e30 mmHg), seated postural exercises with

PAIN (VAS 0 to 10)

CUMULATIVE ADVANTAGE for six patient-oriented outcomes

A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

SMD (SMT/Ex vs SMT) at LT follow-up:0.93 (95% CI: 1.35

A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

depth of 10e15 mm. YNSA was carried out as the symptom

PAIN Headache intensity change score (VAS 0 to 100)

PAIN (Borg Scale 0 to 10)

PAIN (VAS 0 to 100)

(continued on next page)

A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

Helewa et al., 2007

PAIN (VAS 0 to 10)

A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

Humphreys and Irgens, 2002

Jull et al., 2002

Kjellman and Oberg, 2002

Kuijper et al., 2009