Manual Therapy
journal homepage: www.elsevier.com/math
Review article
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
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
1. Background
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:
27
Table 2
Review of review shows very low to low GRADE evidence.
Very low to low GRADE evidence for
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
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).
28
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.
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
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.
31
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
scapulothoracic and shoulder regions. Low quality evidence supports the use of Self-SNAG exercises for cervicogenic headache.
33
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
Reported Results: no signicant difference between groups
SIDE EFFECTS: none
COST OF CARE: NR
34
(continued )
Study/Participants
Interventions
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.
COMPARISON TREATMENT
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
35
(continued )
Study/Participants
Interventions
Outcomes
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
36
(continued )
Study/Participants
Interventions
Outcomes
37
(continued )
Study/Participants
Interventions
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
38
(continued )
Study/Participants
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.
Treatment Schedule: 6 weeks, 12 sessions
COMPARISON TREATMENT
Arm 2 e Control Group: no intervention
Treatment Schedule: 6 weeks
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).
COMPARISON TREATMENT
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
39
(continued )
Study/Participants
Interventions
Duration of Follow-up: 6 weeks
CO-INTERVENTION: avoided in trial design
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.
COMPARISON TREATMENT
Arm 2 e Control group: Symptomatic non-exercise group
(SNEG).
Treatment Schedule: 4 weeks
Duration of Follow-up: none
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
COMPARISON TREATMENT
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
Duration of Follow-up: 52 weeks
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
COMPARISON TREATMENT
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
COMPARISON TREATMENT
Arm 2 e Wait and see list Group (WLG): Patients in the control
Outcomes
40
(continued )
Study/Participants
Interventions
Outcomes
41
(continued )
Study/Participants
Interventions
Outcomes
SIDE EFFECTS: NR
COST OF CARE: NR
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
COMPARISON TREATMENT
Arm 2 e Control Group (Cntl): Medication: analgesic, antiinammatory typical dosage was indomethacin 100 mg; aspirin,
3000 mg; diclofenac, 150 mg; naproxen, 1000 mg
Treatment Schedule: 8 weeks
Duration of Follow-up: 2 weeks
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
COMPARISON TREATMENT
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
Treatment Schedule: 6 weeks, 12 sessions
Duration of Follow-up: 42 weeks
CO-INTERVENTION: avoided in trial design
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
COMPARISON TREATMENT
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
Duration of Follow-up: none
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
REASON FOR DROP-OUTS: NR
SIDE EFFECTS: NR
COST OF CARE: NR
43
(continued )
Study/Participants
Interventions
Outcomes
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.
COMPARISON TREATMENT
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.
COMPARISON TREATMENT
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.
Treatment Schedule: 12 weeks, 24 sessions
Duration of Follow-up: 12 weeks follow-up
CO-INTERVENTION: Comparable between index and control
groups
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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