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Cochrane Database of Systematic Reviews

Exercises for mechanical neck disorders (Review)

Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, Dupont G, Graham N, Burnie SJ,
Gelley G, Goldsmith CH, Forget M, Hoving JL, Brønfort G, Santaguida PL, Cervical Overview Group

Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, Dupont G, Graham N, Burnie SJ, Gelley G, Goldsmith CH, Forget M, Hoving
JL, Brønfort G, Santaguida PL, Cervical Overview Group.
Exercises for mechanical neck disorders.
Cochrane Database of Systematic Reviews 2015, Issue 1. Art. No.: CD004250.
DOI: 10.1002/14651858.CD004250.pub5.

www.cochranelibrary.com

Exercises for mechanical neck disorders (Review)


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS

HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . . 4
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Figure 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Figure 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Figure 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . 23
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Analysis 1.1. Comparison 1 Chronic MND: Breathing Patterns vs CONTROL, Outcome 1 Pain Intensity (Borg 0 to 10):
10 weeks of treatment vs Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Analysis 1.2. Comparison 1 Chronic MND: Breathing Patterns vs CONTROL, Outcome 2 Function (NDI 0 to 100): 10
weeks of treatment vs Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Analysis 1.3. Comparison 1 Chronic MND: Breathing Patterns vs CONTROL, Outcome 3 SF-36 (physical function): 10
weeks of treatment vs Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Analysis 2.1. Comparison 2 Acute to Chronic MND: General Fitness Training vs CONTROL, Outcome 1 Pain Intensity
(VAS): 10 weeks of treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Analysis 2.2. Comparison 2 Acute to Chronic MND: General Fitness Training vs CONTROL, Outcome 2 Pain Intensity
(VAS): 10 weeks of treatment + 10 weeks follow-up. . . . . . . . . . . . . . . . . . . . . 146
Analysis 4.1. Comparison 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM,
Outcome 1 Pain Intensity (VAS): 8 weeks of treatment. . . . . . . . . . . . . . . . . . . . 148
Analysis 4.2. Comparison 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM,
Outcome 2 Pain Intensity (VAS): 8 weeks of treatment + 6 month follow-up. . . . . . . . . . . . . 148
Analysis 4.3. Comparison 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM,
Outcome 3 Pain Intensity (VAS): 8 weeks of treatment + 12 months follow-up. . . . . . . . . . . . 149
Analysis 4.4. Comparison 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM,
Outcome 4 Function (NDI): 8 weeks of treatment. . . . . . . . . . . . . . . . . . . . . . 149
Analysis 4.5. Comparison 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM,
Outcome 5 Function (NDI): 8 weeks of treatment + 6 month follow-up. . . . . . . . . . . . . . 150
Analysis 4.6. Comparison 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM,
Outcome 6 Function (NDI): 8 weeks of treatment + 12 month follow-up. . . . . . . . . . . . . . 150
Analysis 5.1. Comparison 5 Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO INTERVENTION
OR WAIT LIST, Outcome 1 Pain Intensity (VAS): 6 weeks of treatment. . . . . . . . . . . . . . 151
Analysis 5.2. Comparison 5 Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO INTERVENTION
OR WAIT LIST, Outcome 2 Pain Intensity (VAS): 6 weeks of treatment + 6 weeks follow-up. . . . . . . 151
Exercises for mechanical neck disorders (Review) i
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 5.3. Comparison 5 Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO INTERVENTION
OR WAIT LIST, Outcome 3 Function (NPQ): 6 weeks of treatment. . . . . . . . . . . . . . . 152
Analysis 5.4. Comparison 5 Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO INTERVENTION
OR WAIT LIST, Outcome 4 Function (NPQ): 6 weeks of treatment + 6 weeks follow-up. . . . . . . . 152
Analysis 5.6. Comparison 5 Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO INTERVENTION
OR WAIT LIST, Outcome 6 Quality of Life (SF-36): 6 weeks of treatment + 6 w follow-up. . . . . . . 153
Analysis 6.1. Comparison 6 Chronic MND: Pattern synchronization (sitting posture) vs CONTROL, Outcome 1 Pain
intensity (VAS) 2 weeks of treatment. . . . . . . . . . . . . . . . . . . . . . . . . . 153
Analysis 6.2. Comparison 6 Chronic MND: Pattern synchronization (sitting posture) vs CONTROL, Outcome 2 Function
(NDI): 2 weeks of treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Analysis 7.1. Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 1
Pain Intensity (NPS): 4 weeks of treatment. . . . . . . . . . . . . . . . . . . . . . . . 154
Analysis 7.2. Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 2
Pain Intensity: 10 to 20 weeks of treatment. . . . . . . . . . . . . . . . . . . . . . . . 155
Analysis 7.3. Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 3
Pain Intensity: 20 weeks of treatment. . . . . . . . . . . . . . . . . . . . . . . . . . 156
Analysis 7.4. Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 4
Pain Intensity (VAS): 10 weeks of treatment + 10 weeks follow-up. . . . . . . . . . . . . . . . 156
Analysis 7.5. Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 5
Function: 4 weeks of treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Analysis 7.6. Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 6
Function: 20 weeks of treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Analysis 7.7. Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 7
Function: 12 to 20 weeks of treatment/follow-up. . . . . . . . . . . . . . . . . . . . . . 158
Analysis 8.1. Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic
Cervical Stabilization vs PLACEBO or SHAM, Outcome 1 Pain Intensity (VAS): 8 weeks of treatment. . . . 158
Analysis 8.2. Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic
Cervical Stabilization vs PLACEBO or SHAM, Outcome 2 Pain Intensity (VAS): 8 weeks of treatment + 6 month
follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Analysis 8.3. Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic
Cervical Stabilization vs PLACEBO or SHAM, Outcome 3 Pain Intensity (VAS): 8 weeks of treatment + 12 month
follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Analysis 8.4. Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic
Cervical Stabilization vs PLACEBO or SHAM, Outcome 4 Function (NDI): 8 weeks of treatment. . . . . 160
Analysis 8.5. Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic
Cervical Stabilization vs PLACEBO or SHAM, Outcome 5 Function (NDI): 8 weeks of treatment + 6 month follow-
up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Analysis 8.6. Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic
Cervical Stabilization vs PLACEBO or SHAM, Outcome 6 Function (NDI): 8 weeks treatment + 12 month follow-
up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Analysis 9.1. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE
Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 1 Pain Intensity: Immediate Post Treatment (<11w of treatment). . . . . . 161
Analysis 9.2. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE
Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 2 Pain Intensity: 11 w of treatment + 3 month follow-up. . . . . . . . . 162
Analysis 9.3. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE
Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 3 Pain Intensity: Treatment + IT follow-up (11 weeks of treatment + 6 month follow-
up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Analysis 9.4. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE
Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 4 Pain Intensity: Treatment + LT follow-up. . . . . . . . . . . . . 164
Exercises for mechanical neck disorders (Review) ii
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 9.5. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE
Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 5 Function: Immediate Post treatment. . . . . . . . . . . . . . . 164
Analysis 9.6. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE
Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 6 Function: Treatment + ST follow-up. . . . . . . . . . . . . . . 165
Analysis 9.7. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE
Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 7 Function: Treatment + IT follow-up. . . . . . . . . . . . . . . 166
Analysis 9.8. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE
Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 8 Function: Treatment + LT follow-up. . . . . . . . . . . . . . . 166
Analysis 9.9. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE
Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 9 Quality of Life: Immediate Post Treatment. . . . . . . . . . . . . 167
Analysis 9.10. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-
UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 10 Quality of Life: Treatment + ST follow-up. . . . . . . . . . . . . 168
Analysis 9.11. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-
UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 11 Quality of Life: Treatment + IT follow-up. . . . . . . . . . . . . 168
Analysis 9.12. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-
UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 12 Quality of Life: Treatment + LT follow-up. . . . . . . . . . . . . 169
Analysis 9.13. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-
UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 13 Patient Satisfaction: Immediate Post Treatment. . . . . . . . . . . 169
Analysis 9.14. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-
UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 14 Patient Satisfaction: Treatment + ST follow-up. . . . . . . . . . . 170
Analysis 9.15. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-
UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 15 Patient Satisfaction: Treatment + IT follow-up. . . . . . . . . . . 170
Analysis 9.16. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-
UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 16 Patient Satisfaction: Treatment + LT follow-up. . . . . . . . . . . 171
Analysis 9.17. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-
UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 17 Global Perceived Effect: Immediate Post Treatment. . . . . . . . . . 171
Analysis 9.18. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-
UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 18 Global Perceived Effect: Treatment + ST follow-up. . . . . . . . . . 172
Analysis 9.19. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-
UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 19 Global Perceived Effect: Treatment + IT follow-up. . . . . . . . . . 172
Analysis 9.20. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-
UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION, Outcome 20 Global Perceived Effect: Treatment + LT follow-up. . . . . . . . . . 173
Analysis 10.1. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening
+ Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 1 Pain Intensity (VAS): 12 weeks of
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

Exercises for mechanical neck disorders (Review) iii


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Analysis 10.2. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening
+ Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 2 Pain Intensity (VAS): 24 weeks of
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Analysis 10.3. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening
+ Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 3 Function: 12 weeks of treatment. 175
Analysis 10.4. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening
+ Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 4 Function: 24 weeks of treatment. 176
Analysis 10.5. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening
+ Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 5 Global Perceived Effect (General Health
Perception): 12 weeks of treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Analysis 10.6. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening
+ Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 6 Global Perceived Effect (General Health
Perception): 12 weeks of treatment + 12 weeks follow-up. . . . . . . . . . . . . . . . . . . . 177
Analysis 10.7. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening
+ Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 7 Quality of Life (SF-36): 12 weeks of
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Analysis 10.8. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening
+ Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 8 Quality of Life (SF-36): 24 weeks of
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Analysis 11.1. Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO
INTERVENTION or WAIT LIST, Outcome 1 Pain Intensity (VAS): 12 weeks of treatment. . . . . . . 179
Analysis 11.2. Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO
INTERVENTION or WAIT LIST, Outcome 2 Pain Intensity (VAS): 12 weeks of treatment + 3 month follow-up. 180
Analysis 11.3. Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO
INTERVENTION or WAIT LIST, Outcome 3 Pain Intensity (VAS): 12 weeks of treatment + 9 month follow-up. 180
Analysis 11.4. Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO
INTERVENTION or WAIT LIST, Outcome 4 Function (Neck Disability 0-80): 12 weeks of treatment. . . 181
Analysis 11.5. Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO
INTERVENTION or WAIT LIST, Outcome 5 Function (Neck Disability 0-80): 12 weeks of treatment + 3 month
follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Analysis 11.6. Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO
INTERVENTION or WAIT LIST, Outcome 6 Function (Neck Disability 0-80): 12 weeks of treatment + 9 month
follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Analysis 12.1. Comparison 12 Acute to Chronic MND: Pattern synchronization + cervical/scapulothoracic strengthening
+ scapulothoracic endurance vs NO INTERVENTION, Outcome 1 Pain Intensity (VAS 0 to 10): 24 weeks of
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Analysis 13.1. Comparison 13 Chronic MND: Cervical/Scapulothoracic Strengthening + Cervical/Scapulothoracic
Endurance Training, Outcome 1 Pain Prevelance during previous week: 6 weeks of treatment + 46 weeks follow-
up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Analysis 14.1. Comparison 14 Acute to Chronic MND: Scapulothoracic/UE Endurance Training vs CONTROL,
Outcome 1 Pain Intensity (VAS): 10 weeks treatment. . . . . . . . . . . . . . . . . . . . . 183
Analysis 15.1. Comparison 15 Chronic MND: Neuromuscular Education (eye neck coordination/proprioception) +
ANOTHER INTERVENTION VS THAT SAME INTERVENTION, Outcome 1 Pain Intensity (VAS): 8 weeks
treatment + 10 weeks follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Analysis 15.2. Comparison 15 Chronic MND: Neuromuscular Education (eye neck coordination/proprioception) +
ANOTHER INTERVENTION VS THAT SAME INTERVENTION, Outcome 2 Function (pt’s assessment of
functional improvement): 8 weeks treatment + 10 weeks follow-up. . . . . . . . . . . . . . . . 184
Analysis 16.1. Comparison 16 Chronic MND:Trunk/Extremity Stretch + Pattern/Synchronization: Balance and
Coordination + Cardiovascular/Aerobic vs NO TREATMENT, Outcome 1 Pain Intensity (VAS): 10 weeks of
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Analysis 17.1. Comparison 17 Chronic MND:General Endurance Training + Dynamic/Static Lowback/pelvic Stabilization
+ General Stretching + Neuromuscular/body Mechanics Movement Training vs NO INTERVENTION OR WAIT
LIST, Outcome 1 Pain Intensity (VAS): 16 weeks treatment + 6 weeks follow-up. . . . . . . . . . . 185
Exercises for mechanical neck disorders (Review) iv
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Analysis 18.1. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive
(mindfulness & emotional balance) vs WAIT LIST, Outcome 1 Pain Intensity (VAS): 12 weeks of treatment. . 186
Analysis 18.2. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive
(mindfulness & emotional balance) vs WAIT LIST, Outcome 2 Pain Intensity (VAS): 24 weeks of treatment. . 187
Analysis 18.3. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive
(mindfulness & emotional balance) vs WAIT LIST, Outcome 3 Function: 12 weeks of treatment. . . . . . 188
Analysis 18.4. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive
(mindfulness & emotional balance) vs WAIT LIST, Outcome 4 Function: 24 weeks of treatment. . . . . . 189
Analysis 18.5. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive
(mindfulness & emotional balance) vs WAIT LIST, Outcome 5 Global Perceived Effect (General Health Perception):
12 weeks of treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Analysis 18.6. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive
(mindfulness & emotional balance) vs WAIT LIST, Outcome 6 Global Perceived Effect (General Health Perception):
12 weeks of treatment + 12 weeks Follow-up. . . . . . . . . . . . . . . . . . . . . . . . 190
Analysis 18.7. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive
(mindfulness & emotional balance) vs WAIT LIST, Outcome 7 Quality of Life (SF-36 physical component): 12 weeks
of treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Analysis 18.8. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive
(mindfulness & emotional balance) vs WAIT LIST, Outcome 8 Quality of Life: 24 weeks of treatment. . . . 191
Analysis 19.1. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening
+ Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic +
Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 1 Pain
Intensity: (0-10 box scale): 6 weeks of treatment. . . . . . . . . . . . . . . . . . . . . . . 192
Analysis 19.2. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening
+ Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic +
Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 2 Pain
Intensity (0-10 box scale): 6 weeks treatment + 12 month follow-up. . . . . . . . . . . . . . . . 192
Analysis 19.3. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening
+ Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic +
Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 3 Function
(NDI): 6 weeks of treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Analysis 19.4. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening
+ Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic +
Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 4 Function
(NDI): 6 weeks of treatment + 12 month follow-up. . . . . . . . . . . . . . . . . . . . . 193
Analysis 19.5. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening
+ Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic +
Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 5 Global
Perceived Effect (-5 to 5 scale): 6 weeks of treatment. . . . . . . . . . . . . . . . . . . . . 194
Analysis 19.6. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening
+ Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic +
Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 6 Global
Perceived Effect (-5 to 5 scale): 6 weeks of treatment + 12 month follow-up. . . . . . . . . . . . . 194
Analysis 19.7. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening
+ Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic +
Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 7 Quality of
Life (SF-36): 6 weeks of treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Analysis 19.8. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening
+ Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic +
Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 8 Quality of
Life (SF-36): 6 weeks of treatment + 12 month follow-up. . . . . . . . . . . . . . . . . . . 195
Analysis 20.1. Comparison 20 Acute to Subacute CGH: Cervical Stretch/ROM vs SHAM, Outcome 1 Pain Intensity
(Headache Questionnaire): Treatment + 4 weeks follow-up. . . . . . . . . . . . . . . . . . . 196
Exercises for mechanical neck disorders (Review) v
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 20.2. Comparison 20 Acute to Subacute CGH: Cervical Stretch/ROM vs SHAM, Outcome 2 Pain Intensity
(Headache Questionnaire): Treatment + 12 month follow-up. . . . . . . . . . . . . . . . . . 196
Analysis 21.1. Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training +
Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST,
Outcome 1 Headache Intensity (VAS 0-10): 6 weeks of treatment. . . . . . . . . . . . . . . . 197
Analysis 21.2. Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training +
Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST,
Outcome 2 Headache Intensity (VAS 0-10): 6 weeks treatment + 12 month follow-up. . . . . . . . . 197
Analysis 21.3. Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training +
Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST,
Outcome 3 Function (NPNPQ 0-36): 6 weeks treatment. . . . . . . . . . . . . . . . . . . 198
Analysis 21.4. Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training +
Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST,
Outcome 4 Function (NPNPQ 0-36): 6 weeks treatment + 12 month follow-up. . . . . . . . . . . 199
Analysis 21.5. Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training +
Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST,
Outcome 5 Global Perceived Effect (VAS): 6 weeks treatment. . . . . . . . . . . . . . . . . . 199
Analysis 21.6. Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training +
Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST,
Outcome 6 Global Perceived Effect (VAS): 6 weeks treatment + 12 month follow-up. . . . . . . . . . 200
Analysis 22.1. Comparison 22 Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE
Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST, Outcome 1 Pain Intensity (VAS): 6 weeks
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Analysis 22.2. Comparison 22 Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE
Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST, Outcome 2 Pain Intensity (VAS): 6 weeks
treatment + 6 month follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Analysis 22.3. Comparison 22 Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE
Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST, Outcome 3 Function (NDI): 6 weeks
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Analysis 22.4. Comparison 22 Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE
Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST, Outcome 4 Function (NDI): 6 weeks treatment
+ 6 month follow-up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Analysis 22.5. Comparison 22 Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE
Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST, Outcome 5 Satisfaction (5 point scale): 6 weeks
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Analysis 23.1. Comparison 23 Chronic MND: Patterns synchronization + Feedforward/feedback: vestibular rehabilitation
(balance on unstable surfaces and walking with head movements and eyes closed) vs NO INTERVENTION,
Outcome 1 Pain Intensity (VAS) 6 weeks vs Control. . . . . . . . . . . . . . . . . . . . . 203
Analysis 23.2. Comparison 23 Chronic MND: Patterns synchronization + Feedforward/feedback: vestibular rehabilitation
(balance on unstable surfaces and walking with head movements and eyes closed) vs NO INTERVENTION,
Outcome 2 Pain Intensity (VAS) 3 months vs control. . . . . . . . . . . . . . . . . . . . . 204
Analysis 24.1. Comparison 24 Chronic MND: Patterns synchronization + Feedforward/feedback: exercises for coordinating
the neck, eyes and upper limbs vs NO INTERVENTION, Outcome 1 Pain intensity (VAS) 4 weeks vs Control. 204
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

Exercises for mechanical neck disorders (Review) vi


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Exercises for mechanical neck disorders

Anita Gross1 , Theresa M Kay2,3 , Jean-Philippe Paquin4 , Samuel Blanchette5 , Patrick Lalonde6 , Trevor Christie6 , Genevieve Dupont
6,Nadine Graham7 , Stephen J Burnie8 , Geoff Gelley9 , Charles H Goldsmith10 , Mario Forget11 , Jan L Hoving12 , Gert Brønfort13 ,
Pasqualina L Santaguida14 , Cervical Overview Group15
1 School of Rehabilitation Science & Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
2 Women’s College Hospital, Toronto, Canada. 3 Department of Physical Therapy, University of Toronto, Toronto, Canada. 4 Physio St-
Maurice, Trois-Rivières, Canada. 5 Laval University, Québec, Canada. 6 University of Western Ontario, London, Canada. 7 School of Re-
habilitation Science, McMaster University, Hamilton, Canada. 8 Department of Clinical Education, Canadian Memorial Chiropractic
College, Toronto, Canada. 9 Applied Health Sciences, University of Manitoba, Winnipeg, Canada. 10 Faculty of Health Sciences, Simon
Fraser University, Burnaby, Canada. 11 Canadian Forces Health Services Group | Groupe de services de santé des Forces Canadiennes,
National Defence | Défense Nationale, Government of Canada | Gouvernement du Canada, Kingston, Canada. 12 Coronel Institute of
Occupational Health and Research Center for Insurance Medicine, Academic Medical Center, University of Amsterdam, Amsterdam,
Netherlands. 13 Integrative Health & Wellbeing Research Program, Center for Spirituality & Healing, University of Minnesota, Min-
neapolis, MN, USA. 14 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada. 15 Hamilton,
Canada

Contact address: Theresa M Kay, Women’s College Hospital, Toronto, ON, Canada. theresa.m.kay@gmail.com.

Editorial group: Cochrane Back and Neck Group.


Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 1, 2015.

Citation: Gross A, Kay TM, Paquin JP, Blanchette S, Lalonde P, Christie T, Dupont G, Graham N, Burnie SJ, Gelley G, Goldsmith
CH, Forget M, Hoving JL, Brønfort G, Santaguida PL, Cervical Overview Group. Exercises for mechanical neck disorders. Cochrane
Database of Systematic Reviews 2015, Issue 1. Art. No.: CD004250. DOI: 10.1002/14651858.CD004250.pub5.

Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT
Background
Neck pain is common, disabling and costly. Exercise is one treatment approach.
Objectives
To assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect
in adults with neck pain.
Search methods
We searched MEDLINE, MANTIS, ClinicalTrials.gov and three other computerized databases up to between January and May 2014
plus additional sources (reference checking, citation searching, contact with authors).
Selection criteria
We included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control for adults suffering from neck
pain with or without cervicogenic headache or radiculopathy.
Data collection and analysis
Two review authors independently conducted trial selection, data extraction, ’Risk of bias’ assessment and clinical relevance. The quality
of the evidence was assessed using GRADE. Meta-analyses were performed for relative risk and standardized mean differences (SMD)
with 95% confidence intervals (CIs) after judging clinical and statistical heterogeneity.
Exercises for mechanical neck disorders (Review) 1
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Main results
Twenty-seven trials (2485 analyzed /3005 randomized participants) met our inclusion criteria.
For acute neck pain only, no evidence was found.
For chronic neck pain, moderate quality evidence supports 1) cervico-scapulothoracic and upper extremity strength training to improve
pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) -0.71 (95% CI: -1.33 to -0.10)] and at
short-term follow-up; 2) scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post
treatment and short-term follow-up; 3) combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied
from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp -0.33 (95% CI: -0.55 to -0.10)] and
up to long-term follow-up and a medium magnitude of effect improving function at both immediate post treatment and at short-term
follow-up [SMDp -0.45 (95%CI: -0.72 to -0.18)]; 4) cervico-scapulothoracic strengthening/stabilization exercises to improve pain
and function at intermediate term [SMDp -14.90 (95% CI:-22.40 to -7.39)]; 5) Mindfulness exercises (Qigong) minimally improved
function but not global perceived effect at short term. Low evidence suggests 1) breathing exercises; 2) general fitness training; 3)
stretching alone; and 4) feedback exercises combined with pattern synchronization may not change pain or function at immediate post
treatment to short-term follow-up. Very low evidence suggests neuromuscular eye-neck co-ordination/proprioceptive exercises may
improve pain and function at short-term follow-up.
For chronic cervicogenic headache, moderate quality evidence supports static-dynamic cervico-scapulothoracic strengthening/endurance
exercises including pressure biofeedback immediate post treatment and probably improves pain, function and global perceived effect
at long-term follow-up. Low grade evidence supports sustained natural apophyseal glides (SNAG) exercises.
For acute radiculopathy, low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical
stretch/strengthening/stabilization exercises.
Authors’ conclusions
No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using
specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be
beneficial. Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be
beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be
expected. Future research should explore optimal dosage.

PLAIN LANGUAGE SUMMARY


Exercise for Neck Pain
Review question
We reviewed the evidence about the effect of exercise therapy on pain, disability, patient satisfaction, and quality of life among people
with neck pain.
Background
Neck pain is common; it can limit a person’s ability to participate in normal activities and is costly. Exercise therapy is a widely used
treatment for neck pain. This review includes active exercises (including specific neck and shoulder exercises, stretching, strengthening,
postural, breathing, cognitive, functional, eye-fixation and proprioception exercises) prescribed or performed in the treatment of neck
pain. Studies in which exercise therapy was given as part of a multidisciplinary treatment, multimodal treatment (along with other
treatments such as manipulation or ultrasound), or exercises requiring application by a trained individual (such as hold-relax techniques,
rhythmic stabilization, and passive techniques) were excluded.
Study characteristics
The evidence is current to May 2014. We found 27 trials (with a total of 2485 participants) examining whether exercise can help reduce
neck pain and disability; improve function, global perceived effect, patient satisfaction and/or quality of life. In these trials, exercise was
compared to either a placebo treatment, or no treatment (waiting list), or exercise combined with another intervention was compared
with that same intervention (which could include manipulation, education/advice, acupuncture, massage, heat or medications). Twenty-
Exercises for mechanical neck disorders (Review) 2
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
four of 27 trials evaluating neck pain reported on the duration of the disorder: 1 acute; 1 acute to chronic; 1 subacute; 4 subacute/
chronic; and 16 chronic. One study reported on neck disorder with acute radiculopathy; two trials investigated subacute to chronic
cervicogenic headache.
Key results
Results showed that exercise is safe, with temporary and benign side effects, although more than half of the trials did not report on
adverse effects. An exercise classification system was used to ensure similarity between protocols when looking at the effects of different
types of exercises. Some types of exercise did show an advantage over the other comparison groups. There appears to be a role for
strengthening exercises in the treatment of chronic neck pain, cervicogenic headache and cervical radiculopathy if these exercises are
focused on the neck, shoulder and shoulder blade region. Furthermore, the use of strengthening exercises, combined with endurance
or stretching exercises has also been shown to be beneficial. There is some evidence to suggest the beneficial effects of specific exercises
(e.g. sustained natural apophyseal glides) with cervicogenic headaches and mindfulness exercises (e.g. Qigong) for chronic mechanical
neck pain. There appears to be minimal effect on neck pain and function when only stretching or endurance type exercises are used
for the neck, shoulder and shoulder blade region.
Quality of the evidence
No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Future
research is likely to have an important impact on the effect estimate.There were a number of challenges with this review; for example,
the number of participants in most trials was small, more than half of the included studies were either of low or very low quality and
there was limited evidence on optimum dosage requirements.

Exercises for mechanical neck disorders (Review) 3


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Exercises for mechanical neck disorders (Review) S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]

Cervical/ UE Stretch/ ROM Exercises + Cervical/ Scapulothoracic+/ - UE Strengthening + Dynamic/ Static Cervical Stabilization + ANOTHER INTERVENTION compared to THAT
SAM E INTERVENTION for chronic mechanical neck disorders

Patient or population: patients with m echanical neck disorders


Settings: am bulatory care clinic
Intervention: Cervical/ UE Stretch/ ROM Exercises + Cervical/ Scapulothoracic+/ -UE Strengthening + Dynam ic/ Static Cervical Stabilization + ANOTHER INTERVENTION
Comparison: THAT SAM E INTERVENTION

Outcomes Effects No of Participants Quality of the evidence


(studies) (GRADE)

Pain Intensity: VAS 0 no pain to 10 worst Three trials showed a sm all reduction in 241 ⊕⊕⊕
pain pain. (3 studies: Bronf ort 2011, Chiu 2005, moderate 1
(f ollow-up: 6 m onths) Pooled scores estim ated using a m ean Franca 2008)
dif f erence of -0.67 (-1.32 to -0.02)

Function: NDI 0 no disability to 50 m axi- Three trials showed a sm all to m oderate 241 ⊕⊕⊕
m um disability (f ollow-up: 6 m onths) im provem ent in f unction (3 studies: Bronf ort 2011, Chiu 2005, moderate 1
Pooled scores estim ated using a m ean Franca 2008)
dif f erence of -2.80 (-6.36 to 0.76)

Quality of Life: SF-36 (physical com po- Two trials showed no signif icant dif f erence 165 ⊕⊕
nent) 0 worse to 100 better, SF-12. Pooled scores estim ated using a standard (2 studies: Bronf ort 2001, M artel 2011) low1
(f ollow-up: Im m ediate post treatm ent) m ean dif f erence of -0.18 (-0.48 to 0.13)

Patient Satisfaction: 1 to 7; com pletely One trial showed m oderate im provem ent 101 ⊕⊕⊕
satisf ied to com pletely dissatisf ied in satisf action (1 study: Bronf ort 2001) moderate
(f ollow-up: 24 m onths) Scores estim ated using a standard m ean
dif f erence of -0.93 (-1.35 to -0.52)

Global Perceived Effect: Patient- Rated One trial showed a sm all to m oderate im - 101 ⊕⊕⊕
Im provem ent 1 m ore im provem ent to 9 provem ent in global perceived ef f ect (1 study: Bronf ort 2001) moderate
less im provem ent Scores estim ated using a standard m ean
(f ollow-up: 24 m onths) dif f erence of -0.42 (-0.81 to -0.03)
4
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Exercises for mechanical neck disorders (Review)

Adverse Effects One study reported increased neck or headache pain: Intervention group (n = 8), com parison group (n = 6); increased radicular
pain intervention group (n = 1); severe thoracic pain com parison group (n = 1); all cases self -lim iting and no perm anent injuries
(Bronf ort 2001). 3 trials reported no com plications or serious adverse events (Chiu 2005, Franca 2008, M artel 2011)

M oderate quality evidence: (4 trials, 341 participants, Bronf ort 2001; Chiu 2005; Franca 2008; M artel 2011) shows m oderate pain relief and im proved f unction up to long-term
f ollow-up f or com bined cervical, scapulothoracic stretching and strengthening f or chronic neck pain. A clinician m ay need to treat 6 to18 people to achieve this type of pain
relief and 4 to 13 to achieve this f unctional benef it. M oderate quality evidence (one trial, 101 participants; Bronf ort 2001) dem onstrates patients are very satisf ied with their
care. Changes in quality of lif e are suggestive of benef it but not conclusive. Changes in global perceived ef f ect m easures indicate a dif f erence im m ediately post treatm ent
and at long-term f ollow-up

GRADE Working Group grades of evidence


High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1
Two of the pooled studies had high risk of bias scores (Franca 4/ 12 and M artel 5/ 12). That is, the studies m et f ewer than 6
of the 12 criteria, indicating high risk of bias.
5
BACKGROUND • patterns and synchronization of muscle recruitment, and
• feed-forward or feedback systems using verbal, visual, tactile
and other proprioceptive input to the patient.
Description of the condition 4. Biomechanical Element: This element is an interface between the
Neck disorders are common (Hogg-Johnson 2008; Hoy 2014), motor control associated with the modulator element and muscu-
painful, and limit function in the general population (Carroll loskeletal function associated with the base element. Components
2008a, Haldeman 2010,), workers (Côté 2008) and people with of the biomechanical element include:
whiplash associated disorders (WAD) (Carroll 2008b; Buitenhuis • static stabilization forces involved in alignment and
2009). The global point prevalence of neck pain was estimated muscle recruitment, and
to be 4.9% in 2010 (Hoy 2014). In the United States, 15.1% of • dynamic stabilization forces involved in arthrokinetics,
adults state having had neck pain within the previous three months osteokinetics and kinematics.
(NCHS 2013). 5. Cognitive or Affective Element: Exercises in this category affect
In 2005, the mean medical expenditure amongst Americans with the functional status of the psychological system as it is related to
spine problems was estimated to be $6096USD per individual an- movement as follows:
nually compared with $3516USD amongst those without spine • the cognitive ability to learn,
problems (Martin 2008). Côté 2008 reported 3% to 11% of • patient and caregiver compliance,
claimants in the work force were sufficiently disabled to lose time • motivation, and
from work each year. Direct and indirect costs are substantive • emotional status.
(Martin 2008).

How the intervention might work


Description of the intervention
Exercise has both physical and mental benefits through its effects
We adopted the Therapeutic Exercise Intervention Model to sub- on numerous systems such as the cardiovascular system; immune
classify exercise (Sahrmann 2002). This model is based on the ele- system; brain function; sleep; mood; and the musculoskeletal sys-
ments of movement system. Sahrmann 2002 originally described tem (Abernethy 2013). Exercise can result in the following.
movement as a system made up of five elements. Hall 2005 further • Increase flexibility and mobility of structures; improve
developed this concept into a three dimensional model. The ele- muscle strength and endurance; increase tensile strength of
ments of movement system intersect with two other axes - activity ligaments and capsule; amplify strength and prevent injury of
and dosage. After determining which element of the movement tendons and cartilage; and is also important for repair of these
system needs to be addressed to restore function, the activity or tissues.
technique to achieve the functional goal is chosen. The dosage • Improve cardiovascular function resulting in less chance of
parameters are modified according to the tissues involved and the developing heart conditions, strokes, or high blood pressure.
principles of tissue healing. A brief description of each element • Relieve stress, anxiety and depression; improve mood; and
follows. increase self-esteem and weight management by producing
1. Support Element: An exercise categorized under this element positive biochemical changes in the body and brain. Endorphins
would affect the functional status of the cardiac, pulmonary and released post exercise act as a natural pain reliever and
metabolic systems (e.g. aerobic endurance activities). antidepressant in the body.
2. Base Element: Exercises categorized under base element would • Reduce the risk of premature mortality; improve functional
affect the functional status of the muscular and skeletal systems and capacity and help older adults maintain independence. Exercise
is commonly linked to the biomechanical element. This element increases circulation throughout the spine and supporting
provides the basis for movement as follows: structures, which is crucial to promote healing.
• extensibility/stiffness properties of muscle, fascia and • Improve quality and duration of sleep and help sleep
periarticular tissues for range of motion and stretching exercises, disorders such as insomnia.
• mobility of neuromeningeal tissue for neural mobilization • Enhance cognitive function in older adults through
exercises, physical activity and aerobic exercise.
• force or torque capability of muscles and the related muscle • Positively benefit the human immune system if done in
length-tension properties for strengthening exercises, and moderation.
• endurance of muscle also involved in strengthening for
Central to these benefits are the stages of change, encompassing
endurance-strength training.
the health belief and cognitive behavior models, used to help pa-
3. Modulator Element: Exercises under this element relate to motor tients make the lifestyle changes necessary for successful adher-
control for neuromuscular reeducation as follows: ence to exercise, maintain new behaviours over time and address

Exercises for mechanical neck disorders (Review) 6


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
anticipated relapses (Zimmerman 2000). Helping patients change In the current update, our objective was to adapt a therapeutic
behavior is an important role for all clinicians. model for exercise and sub-classify the different exercises. This
allowed us to link the specific aims of the exercise activity to its
anatomical rationale. As a result, we gained a better perspective
on the intended aim of the specific exercise, which allowed us to
Why it is important to do this review clarify some of the reporting variances and the variance in exercise
types that may have been affecting the estimates of effect size. We
In our last update on exercise therapy, we found low to mod-
wanted to determine the more accurate effect of exercises, which
erate quality evidence of pain relief benefit for combined cer-
have clinical implications in patients with neck pain.
vical, scapulothoracic stretching and strengthening for chronic
neck pain in the short and long term. The relative benefit of
other types of exercise was not clear (Kay 2012). Since then, five
other reviews have found primarily very low to low grade ev-
idence as follows: 1) Stretching and strengthening for chronic OBJECTIVES
neck pain (Bertozzi 2013; Southerst 2014; Vincent 2013), 2) This systematic review assessed the short- to long-term effect of
Strengthening, endurance and modular element (Bronfort 2009; exercise therapy on pain, function, patient satisfaction, quality of
Racicki 2012) for chronic cervicogenic headache, 3) Neuromus- life, and global perceived effect in adults experiencing mechanical
cular exercises (proprioception/eye-neck co-ordination) (Leaver neck pain with or without cervicogenic headache or radiculopathy.
2010; Teasell 2010a) for subacute and chronic WAD, 4) Stretch- Where appropriate, the influence of risk of bias, duration of the
ing and range of motion (ROM) exercises (Leaver 2010) for disorder and subtypes of neck disorder on the treatment effect was
non-specific neck pain, 5) Stretching, strengthening, endurance assessed.
training, balance/co-ordination, cardio and cognitive/affective el-
ements (Leaver 2010; Lee 2009; Salt 2011; Southerst 2014; Teasell
2010c) for chronic neck pain, 6) Qigong exercises (; Lee 2009;
METHODS
Southerst 2014) for chronic neck pain, 7) Supervised exercise
(Teasell 2010c) for chronic WAD, and 8) Strengthening neck ex-
ercises (Bertozzi 2013; Southerst 2014) for chronic neck pain.
In contrast, reviews found low grade evidence for no beneficial Criteria for considering studies for this review
effect on pain as follows: 1) Stretching and strengthening (Salt
2011; Southerst 2014) for radiculopathy, 2) General fitness train-
Types of studies
ing (Bertozzi 2013; Kay 2012) for acute to chronic neck pain,
and 3) Stretching and endurance training in chronic neck pain We included any published or unpublished randomized controlled
(Bertozzi 2013; Kay 2012). There may be more than one way to trials (RCTs) in any language. We excluded quasi-RCTs and clin-
summarize the results but few used the grade system. The GRADE ical controlled trials (CCTs).
approach considers a number of additional factors (adverse events,
costs, temporality, plausibility, dose response, strength of associ- Types of participants
ation, and clinical applicability) to place the results into a larger
Participants included in the review were adults (males or females
context (Guyatt 2006).
aged 18 years or older) with acute (less than 30 days), subacute (30
Many previous reviews looked at multimodal approaches such as
days to 90 days) or chronic (greater than 90 days) neck disorders
manual therapy and exercise (Bronfort 2009; Clar 2014; Miller
categorized as:
2010; Schroeder 2013) but our focus is on exercise alone.
• mechanical neck disorders (MND), which included
A number of these reviews included studies that were not clearly
whiplash associated disorders (WAD) category I and II (Spitzer
categorized; they also included studies that were not single inter-
1987; Spitzer 1995), myofascial neck pain, and degenerative
vention trials. The results limited our ability to understand the
changes that encompassed osteoarthritis and cervical spondylosis
comparative effectiveness of exercise interventions for the man-
(Schumacher 1993),
agement of neck pain. Therefore, the true impact of exercise alone
• cervicogenic headache (CGH) (Olesen 1988; Olesen 1997;
could not be determined with strong evidence. Although there
Sjaastad 1990; Sjaastad 1998; Sjaastad 2008), and
was some evidence of benefit as noted above, it became clear that
• neck disorders with radicular findings (NDR) (Spitzer
categorizing exercises into a classification system according to their
1987; Spitzer 1995).
elements was essential in differentiating the intended effect that
different types of exercises may have had. Exploring the dosage and We excluded studies if they investigated neck disorders with
mode of delivery of recommended exercises is essential in future definitive or possible long tract signs (e.g. myelopathies); neck
reviews. pain caused by other pathological entities (Schumacher 1993);

Exercises for mechanical neck disorders (Review) 7


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
headache associated with the neck, but not of cervical origin; co- words included anatomical terms, disorder or syndrome terms,
existing headache, when either neck pain was not dominant or the treatment terms and methodological terms.
headache was not provoked by neck movements or sustained neck
postures; and ’mixed’ headache.
Electronic searches
We searched the following databases from their inception up to
Types of interventions
between January and May 2014:
We included studies that used one or more type of exercise ther- • Cochrane Central Register of Controlled Trials
apy specified in the Therapeutic Exercise Intervention Model to (CENTRAL, which includes the CBRG Trials Register; Ovid,
sub-classify exercise (Sahrmann 2002) prescribed or performed in 21 May 2014),
the treatment of neck pain. For the purposes of this review, we • MEDLINE(Ovid, 1950 to April 2014 week 4),
excluded studies in which exercise therapy was given as part of a • Embase (Ovid, 1980 to April 21, 2014),
multidisciplinary treatment, multimodal treatment (e.g. manual • Manual Alternative and Natural Therapy (MANTIS; Ovid,
therapy plus exercise), or exercises that required manual therapy 1980 to May 2014),
techniques by a trained individual (such as hold-relax techniques, • Cumulative Index to Nursing and Allied Health Literature
rhythmic stabilization, and passive techniques). (CINAHL; EBSCO, 1982 to March 2014),
• Index to Chiropractic literature (ICL; Jan 2014), and
• ClinicalTrials.gov (May 2014).
Types of comparisons
We contrasted interventions against the following comparisons: See Appendix 1 for the search strategies used for CENTRAL,
• sham or placebo, MEDLINE, Embase, MANTIS, CINAHL, and ICL.
• no treatment or wait list, and
• exercise plus another intervention versus that same
intervention (for example, exercise plus manual therapy versus Searching other resources
manual therapy). We also screened references of all retrieved full-text articles, iden-
tified content experts and searched conference proceedings from
We excluded all other comparisons. the World Confederation of Physical Therapist ( WCPT 2007;
WCPT 2011, International Federation of Orthopaedic and Ma-
Types of outcome measures nipulative Therapists IFOMPT 2012; IFOMPT 2008 - hardcopy
used), World Federation of Chiropractic ( WFC 2013 - CD copy
A study was included if it used at least one of the four primary
used), and searched personal files up to May 2014 for grey litera-
outcome measures of interest:
ture.
• pain,
• measures of function/disability (including, but not limited
to, neck disability index, activities of daily living, return to work,
and sick leave), Data collection and analysis
• patient satisfaction, and
For continuous data, standardized mean differences (SMD) with
• global perceived effect/quality of life. 95% confidence intervals (CI) were calculated using a random-
We extracted information on adverse events and costs of care when effects model. Standard mean difference was selected over mean
available. difference (WMD) because different types of exercises were as-
We defined the duration of follow-up as: sessed and most interventions used different outcome measures
• immediately post treatment (≤ one day), that used different scales.
• short-term follow-up (one day to three months),
• intermediate-term follow-up (three months up to, but not
Selection of studies
including, one year), and
• long-term follow-up (one year or longer). Two review authors with expertise in medicine, physiotherapy, chi-
ropractic, massage therapy, statistics, or clinical epidemiology in-
dependently conducted citation identification and study selection
using pre-piloted forms. The assembled group did not author any
Search methods for identification of studies of the primary trials. We assessed agreement for study selection us-
A research librarian searched computerized bibliographic ing the quadratic weighted Kappa statistic (Kw), Cicchetti weights
databases, without language restrictions, for medical, chiroprac- (Cicchetti 1976). We resolved disagreements through consensus
tic and allied health literature. Subject headings (MeSH) and key and consultation with a third party if required.

Exercises for mechanical neck disorders (Review) 8


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Data extraction and management considered the effect to be small when it was less than 10% of the
Two review authors independently conducted data abstraction on visual analogue scale (VAS) scale, medium when it was between
pre-piloted forms. We resolved disagreements through consensus. 10% and 20% of the VAS scale, and large when it was 20% to 30%
We consulted a neutral third party if consensus was not reached. of the VAS scale. For the neck disability index (NDI), we used a
We contacted study authors for missing information and data clar- MCID of 7/50 neck disability index units (MacDermid 2009). It
ification. We extracted data on design (RCT, number analyzed/ is noted that the minimal detectable change varies from 5/50 for
number randomized, intention-to-treat analysis, power analysis), non-complicated neck pain to 10/50 for cervical radiculopathy
participants (disorder subtype, duration of disorder), intervention (MacDermid 2009). For other outcomes (i.e. global perceived ef-
(treatment characteristics for the treatment and comparison group, fect and quality of life), where there was an absence of clear guid-
dosage/treatment parameters, co-intervention, treatment sched- ance on the size of clinically important effect sizes, we used the
ule, duration of follow-up), and outcomes (baseline mean, end common hierarchy of Cohen 1988: small (0.20), medium (0.50)
of study mean, absolute benefit, reported results, point estimate or large (0.80). Risk ratios (RR) were calculated for dichotomous
with 95% CI, power, side effects, cost of care, and adverse events). outcomes. When neither continuous nor dichotomous data were
These factors are noted in the Characteristics of included studies available, we extracted the findings and the statistical significance
table. as reported by the author(s) in the original study.

Assessment of risk of bias in included studies Dealing with missing data


Two review authors independently conducted assessment of risk Where data were not extractable, we contacted the primary au-
of bias in included studies using pre-piloted forms. Disagreements thors. For continuous outcomes reported as medians, we calcu-
were resolved through consensus (Graham 2011). The Cervical lated effect sizes (Kendal 1963; p 237).
Overview Group used a calibrated team of assessors and at least
two assessors independently assessed the risk of bias. ’Risk of bias’ Assessment of heterogeneity
tables were presented and discussed by the broader validity assess- Prior to calculation of a pooled effect measure, the reasonableness
ment team to maximize inter-rater reliability (Graham 2011), and of pooling was assessed, based on clinical judgement. Using a ran-
consensus was reached on final ’Risk of bias’ assessments. We did dom-effects model, statistical heterogeneity was tested using the
not exclude studies from this review on the basis of the ’Risk of Chi2 method between the studies. In the absence of heterogeneity
bias’ assessment results. The following biases were assessed: selec- (P > 0.10), we calculated a pooled SMD, MD or RR.
tion bias (random sequence generation, allocation concealment,
groups similarity at baseline); performance bias (blinding of per-
sonnel/care providers, co-intervention, and compliance); detec- Assessment of reporting biases
tion bias (blinding of outcome assessor); attrition bias (incomplete We planned to assess reporting bias using sensitivity analysis but
outcome data); reporting bias (selective reporting) (see Appendix this was not possible due to a paucity of trials in any one category.
2 for the ’Risk of bias’ criteria recommended by the Cochrane Assessment of publication bias included use of the graphical aide
Back Review Group (Furlan 2009)). We rated each ’Risk of bias’ funnel plot.
item as low, high, or unclear and entered it into the ’Risk of bias’
table for each included study.
Data synthesis
We assessed the quality of the body of the evidence using the
Measures of treatment effect GRADE approach (Guyatt 2006). Domains that may have de-
We used primarily SMD with 95% CIs for continuous data. There creased the quality of the evidence are: 1) study design, 2) risk
are two summary statistics used for meta-analysis of continuous of bias, 3) inconsistency of results, 4) indirectness (not generaliz-
data, the mean difference (MD) and the standard mean difference able), 5) imprecision (insufficient data), other factors (e.g. report-
(SMD). The selection of the summary statistic was determined by ing bias) (Higgins 2009). The quality of the evidence was adjusted
whether all studies in a homogenous meta-analysis group reported by a level based on the performance of the studies against the five
an outcome using the same scale (pooled MD) or using a differ- domains. All plausible confounding factors were considered, as
ent scale (pooled SMD). The estimation of minimal clinically im- were their effects on the demonstrated treatment effects and their
portant difference (MCID) for pain, function and disability were impact on the dose-response gradient (Atkins 2004).
in accordance with the Cochrane Back Group recommendations Levels of evidence were defined as follows.
(Furlan 2009). For the purpose of the review, the MCID for pain • High quality evidence: Further research is very unlikely to
was 10 on a 100-point pain intensity scale (Farrar 2001; Felson change our confidence in the estimate of effect. There are
1995; Goldsmith 1993). To assign some descriptors on the size of consistent findings among 75% of RCTs, with low risk of bias,
the difference between the treatment group and control groups, we that generalize to the population in question. There are sufficient

Exercises for mechanical neck disorders (Review) 9


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
data, with narrow confidence intervals. There are no known or Sensitivity analysis
suspected reporting biases (all of the domains are met). Sensitivity analysis or meta-regression for the factors: symptom
• Moderate quality evidence: Further research is likely to duration, methodological quality and subtype of neck disorder
have an important impact on our confidence in the estimate of were planned but were not carried out because we did not have
effect and may change the estimate (one of the domains is not enough data in any one category.
met).
• Low quality evidence: Further research is very likely to
have an important impact on our confidence in the estimate of
effect and is likely to change the estimate (two of the domains are
RESULTS
not met).
• Very low quality evidence: We are very uncertain about
the estimate (three of the domains are not met).
• No evidence: No RCTs were identified that measured this Description of studies
outcome.

We used the Cochrane GRADE approach and considered a num- Results of the search
ber of additional factors (adverse events, costs, temporality, plau- Considering all sources, we identified 5614 records through
sibility, dose response, strength of association, and clinical appli- database searches and we found 44 records from other sources
cability) to place the results into a larger context. The number searched from start up to November 2013. Following screening
needed to treat to benefit (NNTB) and treatment advantages were of 201 full text articles, 192 were assessed for eligibility, (agree-
calculated to communicate the magnitude of effect for main find- ment on selection showed weighted kappa 0.94, SE 0.02). After
ings (Gross 2002). further application of the eligibility criteria, we found 27 trials
that used exercise treatment for non-specific subacute and chronic
neck pain, and selected them for this review; Figure 1 describes the
Subgroup analysis and investigation of heterogeneity flow of included, excluded, and ongoing, as well as those awaiting
Not conducted due to lack of data. classification.

Exercises for mechanical neck disorders (Review) 10


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Figure 1. Study flow diagram (PRISMA).

Exercises for mechanical neck disorders (Review) 11


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Studies varied in sample size from 16 to 340 (n analyzed), and 27
Included studies
of 28 trials were considered small (less than 70 participants per
Twenty-seven trials [(2485/3005) analyzed at end of study /ran- intervention arm).
domized participants] were selected for this review.
• Three studies described different aspects of the same study
population under additional publications: Andersen 2008 - one Excluded studies
trial, two publications; Bronfort 2001 - one trial, four Studies (n=130 primary papers and 30 companion paper) were
publications; Stewart 2007 - one trial, three publications. excluded for the following reasons: two used a quasi-RCT design,
one used a prospective observational design, 12 examined a dif-
• Twenty-four trials evaluated neck pain: one evaluated acute
ferent type of participant (e.g. chronic tension headache, cervical
neck pain (Lange 2013); one evaluated acute/subacute/chronic
dystonia), one reported on a subgroup of the included popula-
neck pain (Kjellman 2002); one evaluated subacute neck pain
tion, 96 tested a different intervention (e.g. not active exercise, the
(Chiu 2005); four evaluated subacute/chronic neck pain
exercise was the same in all groups, or the exercise group could
(Andersen 2008; Andersen 2011; Andersen Ch 2012; Stewart
not be separated out from a multimodal intervention), 11 used a
2007); 16 trials evaluated chronic neck pain (Allan 2003; Ang
comparison group and seven did not measure any of the identified
2009; Beer 2012; Bronfort 2001; Dellve 2011; Franca 2008;
primary outcomes. See Characteristics of excluded studies tables
Hansson 2013; Helewa 2007; Humphreys 2002; Lundblad
for more details.
1999; Hallman 2011; Martel 2011; Rendant 2011; Revel 1994;
Viljanen 2003; von Trott 2009); and one trial did not specify the
duration of neck pain (Takala 1994). Risk of bias in included studies
We used the quadratic weighted Kappa (Kw) statistic to assess
• One study reported on neck disorder with radicular signs agreement on a per question basis (Kw 0.23 to 1.00). Each ’Risk
and symptoms (Kuijper 2009) and 14 studies did not specify if of Bias’ item is presented as a percentage across all included studies
radicular signs and symptoms were present (Andersen 2011; Figure 2. Common methodological weaknesses included each of
Andersen Ch 2012; Beer 2012; Dellve 2011; Hall 2007; the criteria listed below (see ’Risk of Bias’ tables). Methodological
Hallman 2011; Hansson 2013; Helewa 2007; Humphreys 2002; quality did not appear to influence the end results of the reviews;
Lange 2013; Lundblad 1999; Rendant 2011; Viljanen 2003; von both high and low quality studies had similar outcome directions.
Trott 2009). Albeit, limited data were available to analyze for publication bias;
• Two trials investigated cervicogenic headache, one subacute Figure 3 suggests that we cannot rule out publication bias. This
(Hall 2007) and the other chronic (Jull 2002). relationship between risk of bias and end results of the review was
not formally tested using sensitivity analysis or meta-regression, as
• One trial investigated acute radiculopathy (Kuijper 2009). there were not enough trials in any one meta-analysis.

Exercises for mechanical neck disorders (Review) 12


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Figure 2. ’Risk of bias’ graph: review authors’ judgements about each risk of bias item presented as
percentages across all included studies.

Figure 3. Funnel plot of comparison: 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs


CONTROL, outcome: 7.2 Pain Intensity: 10 to 20 weeks of treatment.

Exercises for mechanical neck disorders (Review) 13


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Allocation
Cervical Stabilization vs WAIT LIST; Summary of findings
There was failure to describe or use appropriate concealment of 5 Acute to subacute CGH: Cervical stretch/ROM vs SHAM;
allocation in 42.9% of studies. Summary of findings 6 Chronic CGH: Cervical/Scapulothoracic
Strengthening with Endurance Training + Craniocervical
Pressure Biofeedback + Dynamic Cervical Stabilization vs NO
Blinding INTERVENTION; Summary of findings 7 Chronic CGH:
There was a lack of effective “blinding” procedures in 92.9% of Cervical/Scapulothoracic Strengthening with Endurance Training
trials - the minimum expectation being blinding of the outcome + Craniocervical Pressure Biofeedback + Dynamic Cervical
assessor. Stabilization + Manual Therapy vs Manual Therapy; Summary of
findings 8 Chronic MND: Cervical/UE Stretch/ROM Exercise
+ Cervical/UE Strengthening + Dynamic Cervical Stabilization
Incomplete outcome data vs PLACEBO or SHAM; Summary of findings 9 Chronic
There were incomplete outcome data provided by 28.6% of the MND: Cervical Stretch/ROM Exercises + Dynamic Cervical
trials. Stabilization vs SHAM; Summary of findings 10 Chronic MND:
Cervical/Scapulothoracic/UE Stretch + UE Endurance Training
vs NO INTERVENTION or WAIT LIST; Summary of findings
Selective reporting 11 Acute to Chronic MND: Scapulothoracic/UE Endurance
Training vs CONTROL; Summary of findings 12 Subacute
There was selective reporting bias with 78.6% of the trials.
to Chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/
Extremity Strengthening + Trunk/Extremity Endurance Training
Other potential sources of bias + Pattern/Synchronization: Coordination + Cardiovascular/
Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs
Compliance was monitored and acceptable in only 42.9% of trials,
THAT SAME OTHER TREATMENT; Summary of findings
and co-intervention was either not avoided or not described in
13 Acute to Chronic MND: Scapulothoracic + UE Strengthening
71.4% of trials. The funnel plot (Figure 3) has the classic small
vs CONTROL
negative trial missing that may suggest publication bias (language
bias); we did not search non-English databases. Alternatively, it
could reflect the poor methodological quality leading to inflated Chronic Mechanical Neck Pain
effects in smaller trials.

Effects of interventions 1. Support Element

See: Summary of findings for the main comparison


Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/ a) Breathing Exercises
Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical
Stabilization + ANOTHER INTERVENTION compared to
THAT SAME INTERVENTION; Summary of findings 2 Diaphragmatic Breathing Exercises versus Control
Chronic MND: Cervical Stretch/ROM Exercises + Cervical/
One trial Hallman 2011 compared diaphragmatic breathing with
Scapulothoracic Strengthening + Static/Dynamic Cervical/
a no treatment control. This latter group took part in the breathing
Shoulder Stabilization compared to WAIT LIST; Summary of
protocol in sessions 1 and 10, without any prescribed treatment
findings 3 Chronic MND: Qigong Stretch/ROM + Endurance
in between.
Training + Dynamic Stabilization + Cognitive (mindfulness
• Pain Intensity outcomes
& emotional balance) compared to WAIT LIST; Summary
of findings 4 Acute Radiculopathy: Cervical Stretch/ROM + No difference in pain between groups immediately post treatment
Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic (Figure 4).

Exercises for mechanical neck disorders (Review) 14


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Figure 4. Forest plot of comparison: 1 Chronic MND: Breathing Patterns vs CONTROL, outcome: 1.1 Pain
Intensity (Borg 0 to 10): 10 weeks of treatment vs Control.

• Function outcomes
b) Cardiovascular/Aerobic Training
No difference in function between groups immediately post treat-
ment.
• Quality of Life outcomes
General Fitness Training versus Control
No difference in quality of life between groups immediately post One trial with two publications (Andersen 2008) compared a gen-
treatment. eral exercise program with a no treatment control (general health
Conclusion: There is low quality evidence (one trial, 24 partici- information) intervention.
pants, Hallman 2011) that diaphragmatic breathing may have no • Pain Intensity Outcomes
effect on pain, function and quality of life when compared to a no
treatment control for chronic mechanical neck pain immediately No difference in pain between both (see above: general exercise
post treatment (50 sessions over 10 weeks). versus control) groups immediately post treatment (Figure 5).

Figure 5. Forest plot of comparison: 2 Acute to Chronic MND: General Fitness Training vs CONTROL,
outcome: 2.2 Pain Intensity (VAS): 10 weeks of treatment + 10 weeks follow-up.

Conclusion: There is low quality evidence (one trial with two publi-
cations, 24 participants, Andersen 2008) that general fitness train- One trial (Allan 2003) evaluated neck stretching either before or
ing exercises may have no difference in pain when compared with after manipulation compared with manipulation alone.
a reference intervention for (sub)acute/chronic neck pain imme- • Pain Intensity Outcomes
diately post treatment.
No difference in pain between all groups immediately post treat-
ment.
2. Base Element • Function Outcomes

No difference in function between all groups immediately post


a) Stretching treatment.
Conclusion: There is low quality evidence (one trial, 16 partici-
pants, Allan 2003) that stretching exercises, either before or after
a manipulation, made no difference on pain and function when
Cervical Stretch/range of motion (ROM) Exercises + Another compared with that same manipulation for chronic neck pain im-
Intervention versus That Same Intervention mediately post treatment. Manipulation was the control group in
Exercises for mechanical neck disorders (Review) 15
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
both arms of the trial and therefore, the contribution of the base
element of stretching could be factored out.

Cervical Stretch/ROM Exercises + Dynamic Cervical


Stabilization versus Sham
One trial (Kjellman 2002) compared cervical movement exercises
(McKenzie protocol) with sham ultrasound.
• Pain Intensity Outcomes
There is no evidence of benefit on pain immediately post treat-
ment, at intermediate-term or long-term follow-up (Figure 6).

Figure 6. Forest plot of comparison: 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical
Stabilization vs SHAM, outcome: 4.3 Pain Intensity (VAS): 8 weeks of treatment + 12 months follow-up.

• Function Outcomes
fit (exercise + an intervention versus that same intervention) on
There was no evidence of benefit on function immediately post
function immediately post treatment and at short-term follow-up.
treatment, at intermediate-term or long-term follow-up.
(Helewa 2007).
Conclusion: Low quality evidence (one trial, 50 participants,
• Function Outcomes
Kjellman 2002) shows no difference for pain relief and function
immediately post intervention, at six- and 12-month follow-up Of the two comparisons, one showed no evidence of benefit (ex-
using Cervical Stretch/ROM Exercise + Dynamic Cervical Stabi- ercise versus control) while the other showed evidence of bene-
lization for chronic MND. fit (exercise + an intervention versus that same intervention) on
function immediately post treatment and at short-term follow-up.
b) Strengthening (Helewa 2007).
• Quality of Life

Static Cervical Strengthening + Static Stabilization versus No In two comparisons (exercise versus control, exercise + an inter-
Intervention or Wait List vention versus that same intervention), there was no evidence of
benefit immediately post treatment and at short-term follow-up
One trials (two comparisons) studying chronic neck pain com-
on quality of life (Helewa 2007), albeit there may be a clinically
pared either manually (1) resisted isometric neck exercise plus pos-
important effect favouring exercise + pillow versus pillow alone.
tural training with mirror feedback to a control, or (2) these same
Conclusion : Evidence exists from two trials (three comparisons)
isometric neck exercises and the use of an orthopaedic pillow were
where data are not combinable. Low quality evidence from one
compared with the use of an orthopaedic pillow (Helewa 2007).
trial (two independent comparisons, 50 participants, Helewa
• Pain Intensity Outcomes
2007) gives varying results. Evidence of benefit showed people
Of the two comparisons, one showed no evidence of benefit (ex- may improve slightly when exercise was added to a pillow versus a
ercise versus control) while the other showed evidence of bene- pillow alone (NNTB = 9). However, this was not observed when
Exercises for mechanical neck disorders (Review) 16
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
isometric exercise alone was evaluated for function and quality of on pain and function when compared to control for chronic me-
life, from immediately post treatment to short-term follow-up. chanical neck pain immediately post treatment (two-week inter-
vention).

Postural Exercise versus Control


Scapulothoracic + Upper Extremity (UE) Strengthening
One trial Beer 2012 compared sitting postural exercises versus versus Control
control. Three trials (Andersen 2008; Andersen Ch 2012; Dellve 2011),
• Pain Intensity Outcomes: each with different dosages compared specific strength training of
the scapulothoracic region and upper extremity with a reference
No difference in pain between groups immediately post treatment.
intervention.
• Physical Function outcomes • Pain Intensity Outcomes
No difference in physical function between groups immediately No difference in pain at four weeks of treatment. There is a mod-
post treatment. erate to large difference in pain reduction between groups at 10
Conclusion: We are uncertain whether postural exercises improve to 20 weeks of treatment, [SMD pooled -0.71 (95%CI:-1.33 to -
pain or function. There is very low quality evidence (one trial, 20 0.10); Figure 7]. Additionally one and nine weekly sessions were
participants, Beer 2012) that postural exercises have no difference no different when contrasted with the reference group.

Figure 7. Forest plot of comparison for (sub)Acute/Chronic MND: Scapulothoracic + UE Strengthening vs


CONTROL, outcome: Pain Intensity: 10 to 20 weeks of treatment.

• Physical Function Outcomes


c) Stretch and Strengthening

No statistical difference in physical function between groups im-


mediately post treatment, but may achieve a minimal clinically
important difference at short-term follow-up.
Cervical/UE Stretch/ROM Exercise + Cervical/UE
Conclusion: There is moderate quality evidence (three trials, 157
Strengthening + Dynamic Cervical Stabilization versus
participants, Andersen 2008; Andersen Ch 2012; Dellve 2011)
Placebo or Sham
that scapulothoracic and UE strength training probably improves
pain a moderate to large amount immediately post treatment One trial (Kjellman 2002) compared general exercises including
and at short-term follow-up. It may improve functional outcomes neck and shoulder ROM, active neck endurance and strength ex-
when compared to control at short-term follow-up (10 to 20 weeks ercises with sham ultrasound.
of intervention). • Pain Intensity Outcomes
Exercises for mechanical neck disorders (Review) 17
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
There was no evidence of benefit immediately post treatment, at Stabilization versus Wait List
intermediate-term and long-term follow-up. Two trials (Rendant 2011; von Trott 2009) compared a standard-
• Physical Function Outcomes ized exercise program for neck pain including repeated active cer-
There was no evidence of benefit immediately post treatment, at vical rotations, strength and flexibility exercises to a wait list. The
intermediate-term and long-term follow-up. two trials appeared clinically similar and were pooled.
Conclusion: Low quality evidence (one trial, 50 participants, • Pain Intensity Outcomes
Kjellman 2002) shows no difference for pain relief and function
immediately post intervention, at six and 12 months follow-up us- When two studies (Rendant 2011; von Trott 2009) were pooled,
ing Cervical/UE Stretch/ROM Exercise + Cervical/UE Strength- there was a significant difference, moderate clinically important
ening + Dynamic Cervical Stabilization for chronic MND. 15-point change post treatment [Heterogeneity: Chi² = 0.74, df
= 1 (P = 0.39); I² = 0% MD pooled -14.90 (CI 95% -22.40 to -
7.39), NNTB =4]. This reduced to a small difference of [pooled
Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic MD -10.94 (CI 95% -18.81 to -3.08)] at short-term follow-up
Strengthening + Static/Dynamic Cervical/Shoulder (Figure 8).

Figure 8. Forest plot of comparison for Chronic MND: Cervical Stretch/ROM Exercises +
Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST,
outcome: Pain Intensity (VAS): 24 weeks of treatment.

• Function Outcomes
When the two trials were pooled, no significant difference in qual-
One trial (Rendant 2011), showed evidence of benefit for function ity of life was found at any time point. [Heterogeneity: Tau² =
post treatment. One trial (von Trott 2009) showed no significant 0.00; Chi² = 0.95, df = 1 (P = 0.33); I² = 0% MD pooled at
difference immediately post treatment and at short-term follow- 12 weeks -2.22 (CI 95% -5.17 to 0.72) (Analysis 10.7), at short-
up. When the two studies were pooled, there was a significantly term follow-up pooled MD 0.01 (CI 95% -0.47 to 0.49) (Analysis
different, clinically important, moderate change in function. [Het- 10.8)].
erogeneity: Tau² = 0.09; Chi² = 2.63, df = 1 (P = 0.10); I² = 62% Conclusion : Moderate quality evidence (two trials, 147 partic-
SMD pooled:-0.50 (CI 95% -1.04 to 0.03), NNTB = 5 (Analysis ipants, Rendant 2011; von Trott 2009) shows cervical stretch/
10.3)]. At short-term follow-up (24 weeks of treatment), pooled ROM exercises + cervical/scapulothoracic strengthening + static/
SMD: -0.40 (CI 95% -0.74 to -0.06) (Analysis 10.4). dynamic cervical/shoulder stabilization probably has moderate
• Global Perceived Effect benefit for pain and function, but not global perceived effect and
quality of life immediately post treatment and at short-term fol-
No significant difference in global perceived effect was found at low-up. A clinician may need to treat four people to achieve a
any time points. moderate degree of pain relief and five to achieve moderate func-
• Quality of Life tional benefit in one patient.

Exercises for mechanical neck disorders (Review) 18


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cervical/UE Stretch/ROM Exercises + ilar; that is, they all contained an exercise component, which ap-
Cervical/Scapulothoracic +/-UE Strengthening + plied a resistance force directly to the cervicoscapular region. Other
Dynamic/Static Cervical Stabilization + Another similar clinical elements included the dosage and duration of care.
Intervention versus That Same Intervention We judged these exercise trials to be both clinically and statistically
homogeneous (P = 0.67, I2 = 0%).
Four trials studying chronic neck pain compared the following • Pain Intensity Outcomes
exercise interventions with a control group:
When data were pooled into a summary estimate, we found con-
1. deep neck flexor retraining with pressure biofeedback and
sistent evidence of reduced pain from immediately post treat-
resisted neck flexion/extension strengthening using multicervical
ment pooled SMD -0.33 (95% CI:-0.55 to -0.10) (Analysis 9.1;
rehabilitation unit (Chiu 2005);
Bronfort 2001; Chiu 2005; Franca 2008; Martel 2011) to inter-
2. low technology exercise including progressive resisted neck
mediate-term (Analysis 9.3) and long-term follow-up (Bronfort
and upper body strengthening using dumbells and pulley
2001). This suggests an initial small- to longer-term large treat-
systems, light stretching and a short aerobic warm-up program
ment benefit. The number needed to treat for one patient to ben-
(Bronfort 2001);
efit varies from six to 18.
3. muscle stretching and strengthening exercises of the neck
• Function Outcomes
and upper limb regions including strengthening of the deep
cervical flexor muscles (Franca 2008); and There was evidence of benefit in function immediately post treat-
4. a home exercise program of ROM, stretching/mobilization ment pooled SMD -0.25 (95% CI: -0.48 to -0.01), intermedi-
and strengthening exercises of the cervical and upper thoracic ate-term pooled SMD -0.45 (95% CI: -0.72, to -0.18) (Figure 9;
spine (Martel 2011). Bronfort 2001; Chiu 2005; Franca 2008) and long-term follow-
Both treatment arms of all groups received another intervention up (Bronfort 2001). The latter represents the largest improvement.
and were compared with that same intervention combined with The number needed to treat for one patient to benefit varies from
exercise. We considered the exercise protocols to be clinically sim- four to 13.

Figure 9. Forest plot of comparison for chronic MND: Cervical/UE Stretch/ROM Exercises +
Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION in the outcome Function at intermediate term follow-up.

• Global Perceived Effect and Quality of Life


patient satisfaction noted at all time points (Bronfort 2001).
There was a statistically important difference in global perceived Conclusion : Moderate quality evidence (four trials, 341 partic-
effect noted immediately post treatment (Analysis 9.9) and at long- ipants, Bronfort 2001; Chiu 2005; Franca 2008; Martel 2011)
term follow-up (Bronfort 2001; Martel 2011). shows moderate pain relief and improved function up to long-
• Patient Satisfaction term follow-up for combined cervical, scapulothoracic stretching
and strengthening for chronic neck pain. A clinician may need
There were statistically and clinically important differences for
Exercises for mechanical neck disorders (Review) 19
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
to treat six to 18 people to achieve this type of pain relief and • Pain Intensity Outcomes
four to 13 to achieve this functional benefit. Moderate quality ev-
idence (one trial, 101 participants) demonstrates patients are very There was evidence of a very small change in pain intensity im-
satisfied with their care. Changes in quality of life are suggestive mediately post treatment (24 weeks of treatment).
of benefit but not conclusive. Changes in global perceived effect Conclusion: Low quality evidence due to floor effect (one trial,
measures indicate a difference immediately post treatment and at 55 participants, Lange 2013) shows deep neck flexor recruitment
long-term follow-up. combined with UE strengthening/endurance exercises may have
little difference in pain immediately post treatment.

d) Stretching and Endurance Training


f ) Endurance Training

Cervical/Scapulothoracic/UE Stretch + UE Endurance


Training versus No Intervention
Scapulothoracic/UE Endurance Training versus Control
One trial (Viljanen 2003) compared dynamic muscle training with
free weights with ordinary activity. One trial (Andersen 2011) with two comparisons compared shoul-
• Pain Intensity Outcomes der abduction endurance training for two minutes or 12 minutes
with a control group.
There was no significant pain relief immediately post treatment • Pain Intensity Outcomes
and at short-term or long-term follow-up.
• Function Outcomes There was evidence of benefit immediately post treatment for pain
There was no significant change in function at the same three time for both the two-minute and 12-minute training programs.
points. Conclusion: Moderate quality evidence (one trial, 198 participants,
Conclusion : Moderate quality evidence (one trial, 393 participants, Andersen 2011) shows moderate benefit for pain relief immedi-
Viljanen 2003), shows little to no difference for UE stretching and ately post intervention using scapulothoracic/UE endurance train-
endurance training for chronic neck pain and function immedi- ing for (sub)acute/chronic MND. A clinician may need to treat
ately post treatment, at short-term and long-term follow-up. four people to achieve this type of pain relief.

e) Strengthening and Endurance Training 3. Modulator Elements

Cervical/Scapulothoracic Strengthening + Endurance


Training versus Control Neuromuscular Exercise (eye-neck co-
ordination/proprioception) + Another Intervention versus
One trial (Ang 2009) compared non-postural and postural
That Same Intervention
strengthening exercises and endurance-strength exercises versus a
control group. One trial (Revel 1994) compared eye-neck co-ordination exercises
• Pain Prevalence Outcomes and analgesic/anti-inflammatory medication with that same med-
ication only for chronic neck pain.
There was no significant decrease in pain prevalence immediately • Pain Intensity
post treatment or at long-term follow-up.
Conclusion: Very low quality evidence (one trial, 68 participants, There was evidence of benefit on pain at short-term follow-up.
Ang 2009) shows we are uncertain whether cervical/scapulotho- The number needed to treat for one patient to benefit is four.
racic strengthening and endurance-strength exercises improves the • Function
prevalence of neck pain in chronic neck pain at immediately post
treatment and at long-term follow-up. There was evidence of benefit on function at short-term follow-
up. The number needed to treat for one patient to benefit is three.
Conclusion: We are uncertain whether eye-neck co-ordination ex-
Pattern synchronization and Cervical/Scapulothoracic ercises improve pain or function. Very low quality evidence (one
Strengthening and Scapulothoracic Endurance versus trial, 60 participants, Revel 1994) shows a moderate reduction in
Control pain and improved function in chronic neck pain in the short term
One trial Lange 2013 compared deep neck flexor recruitment for eye-neck co-ordination exercises. A clinician may need to treat
combined with upper extremity strengthening/endurance exer- four people to achieve this type of pain relief and three to achieve
cises versus control. this functional benefit in one person.

Exercises for mechanical neck disorders (Review) 20


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Patterns synchronization + Feedforward/feedback exercises General Endurance Training + Dynamic/Static
for co-ordinating the neck, eyes and upper limbs versus No Lowback/pelvic Stabilization + General Stretching +
Intervention Neuromuscular/body Mechanics Movement Training versus
No Intervention
One trial (Humphreys 2002) compared eye-neck-upper limb co-
ordination exercises versus no intervention in patients with chronic One trial (Lundblad 1999) compared lumbopelvic stabilization,
neck pain. ergonomic exercises, endurance, general strengthening, and co-
• Pain Intensity ordination exercises with no treatment.
• Pain Intensity
No difference in pain between groups immediately post treatment. There was no evidence of benefit for pain reduction at short-term
follow-up.
Conclusion : Low quality evidence (one trial, 56 participants, Conclusion: Low quality evidence (one trial, 38 participants,
Humphreys 2002) shows eye-neck-upper limb exercises show lit- Lundblad 1999) shows little to no difference for pain reduction
tle or no difference in pain immediately post treatment. with a combined exercise approach of stabilization of the low back
and pelvis, posture awareness, ergonomic training, and strength,
co-ordination, endurance, flexibility/smoothness and rhythm ex-
Patterns synchronization + Feedforward/feedback: vestibular ercises when compared to no intervention or a wait list control in
rehabilitation (balance on unstable surfaces and walking chronic neck pain at short-term follow-up.
with head movements and eyes closed) vs No Intervention
One trial (Hansson 2013) compared vestibular rehabilitation pro- 5. Base + Cognitive/Affective Element
gram vs no intervention in patients with chronic neck pain.
• Pain Intensity
Stretch/ROM + Endurance Training + Dynamic Stabilization
No difference in pain between groups immediately post treatment + Cognitive (mindfulness & emotional balance) versus Wait
or at short-term follow-up. List
Conclusion: Low quality evidence (one trial, 29 participants, Two trials (Rendant 2011; von Trott 2009) compared a program of
Hansson 2013) shows vestibular rehabilitation type exercises may Qigong exercises (Dantian Qigong) including relaxation of mind
have little or no difference in neck pain both immediately post and body, conscious breathing and movement exercises of the hip,
treatment and at short-term follow-up. legs, shoulders, arms and head with a wait list.
• Pain Intensity
When data were pooled into a summary estimate, there was ev-
4. Base + Modulator Elements + Support idence of reduced pain post treatment at 12 weeks [pooled MD
-13.28 (-20.98 to -5.58)] (Analysis 18.1) and 24 weeks [pooled
MD -7.82 (-14.57, -1.07)] (Analysis 18.2) of treatment (Rendant
2011; von Trott 2009).
Trunk and Extremity Stretch + Pattern/Synchronization: • Function
Balance Co-ordination + Cardiovascular/Aerobic versus No
When data were pooled into a summary estimate, there was ev-
Intervention
idence of reduced function post treatment at 12 weeks [pooled
One trial (Takala 1994) with unspecified duration of neck pain SMD -0.36 (-0.68 to -0.03); Analysis 18.3] and 24 weeks [pooled
at baseline, compared a group of whole body exercise program, SMD -0.28 (-0.68 to 0.11); Analysis 18.4] of treatment (Rendant
which included aerobic training and shoulder/thoracic exercises, 2011; von Trott 2009)
with no treatment. • Global Perceived Effect
• Pain Intensity
There was no evidence of benefit for global perceived effect im-
mediately post treatment and at short-term follow-up.
There was no evidence of benefit for pain reduction immediately
• Quality of Life
post treatment.
Conclusion: Low quality evidence (one trial, 44 participants,Takala There was evidence of benefit for SF36 physical component im-
1994) shows little to no difference for pain reduction immediately mediately post 12 weeks of treatment [pooled MD -2.72 (95% CI:
post treatment in patients with neck pain of unspecified duration -5.42 to -0.01); Analysis 18.7]; but not at short-term follow-up
when treated with group exercise that combined extensibility and of 24 weeks [pooled MD -1.88 (95%CI: -5.80 to 2.04); Analysis
co-ordination exercises with cardiovascular training. 18.8] (Rendant 2011; von Trott 2009).

Exercises for mechanical neck disorders (Review) 21


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Conclusion: Moderate quality evidence (two trials, 191 partici- One trial (Hall 2007) investigated patients with subacute cervico-
pants, Rendant 2011; von Trott 2009) shows Qigong exercises genic headache; this trial compared C1-C2 self-sustained natural
(Dantian Qigong) may improve pain and function slightly when apophyseal glide (SNAG) exercises with a sham mobilization.
compared with a wait list control at immediate- and short-term • Pain Intensity Outcomes
follow-up. It may have little or no benefit at immediate and short-
There was pain reduction at both short- and long-term follow-up.
term follow-up on quality of life and global perceived effect. A
The number needed to treat for one patient to benefit is three.
clinician may need to treat four to six people to achieve this type of
Conclusion: Low quality evidence (one trial, 32 participants, Hall
pain relief, five to eight people to achieve this functional benefit,
2007) shows people may improve a large amount for pain reduc-
and seven to 10 people for this improvement in quality of life.
tion at short- and long-term follow-up with the use of C1-C2
self-SNAG exercises when compared with a sham for (sub)acute
6. Base + Modular + Cognitive Affective + Support cervicogenic headache. A clinician may need to treat three people
to achieve this type of long-term pain relief.

Stretch/ROM + Strength and Endurance Training (trunk and 2. Base and Modular Element
limb) + Pattern/Synchronization: Balance Co-ordination +
Cardiovascular/Aerobic + Cognitive (Coaching +
Motivational) versus that Same Intervention Cervical/Scapulothoracic Strengthening with Endurance
One trial (Stewart 2007) compared an individualized, progressive Training + Craniocervical Pressure Biofeedback + Dynamic
submaximal program, which included aerobic training, trunk and Cervical Stabilization versus No Intervention
limb exercises and advice compared with advice alone. One trial (Jull 2002) studied chronic cervicogenic headache and
• Pain Intensity compared endurance exercises including pressure biofeedback for
the cervicoscapular region with no treatment.
There was evidence of small benefit on pain post treatment but
• Pain Intensity
not at long-term follow-up.
• Function When compared with no treatment, there was evidence of a large
benefit post treatment and a moderate size benefit at long-term
There was evidence of small benefit on function post treatment follow-up (Analysis 21.2) for pain relief. The number needed to
and at long-term follow-up. treat for one patient to benefit is six.
• Global Perceived Effect • Function
There was evidence of small benefit on global perceived effect post When compared with no treatment, there was evidence of a mod-
treatment but not at long-term follow-up. erate degree of benefit at post treatment and at long-term follow-
• Quality of Life up (Analysis 21.4) on function. The number needed to treat for
There was evidence of small benefit on quality of life post treatment one patient to benefit is six.
but not at long-term follow-up. • Global Perceived Effect
Conclusion: Low quality evidence (one trial, 132 participants, When compared with no treatment, there was evidence of a large
Stewart 2007) shows small benefits for pain relief, function,global benefit post treatment and at long-term follow-up (Analysis 21.6)
perceived effect and quality of life immediately post treatment and on global perceived effect.
small benefit at 12-month follow-up for function using Trunk/Ex- Conclusion : Moderate quality evidence (one trial, 97 partici-
tremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/ pants, Jull 2002) shows cervicoscapular strengthening and en-
Extremity Endurance Training + Pattern/Synchronization: Co-or- durance exercises including pressure biofeedback probably im-
dination + Cardiovascular/Aerobic + Cognitive (CBT) + another prove pain, function and global perceived effect for chronic cer-
treatment for Subacute/chronic WAD. vicogenic headaches at long-term follow-up when compared to
no treatment. A clinician may need to treat six people to achieve
this type (medium to large amount) of pain relief and functional
Cervicogenic Headache benefit in one patient.

1. Base Element Cervical/Scapulothoracic Strengthening with Endurance


Training + Craniocervical Pressure Biofeedback + Dynamic
Cervical Stabilization + Manual Therapy versus Manual
Stretch/ROM exercises versus Sham Therapy

Exercises for mechanical neck disorders (Review) 22


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
One trial (Jull 2002) studied chronic cervicogenic headache and One trial (Kuijper 2009) studying acute cervical radiculopathy
compared endurance exercises including pressure biofeedback plus compared cervical mobilizing and stabilizing exercises with a wait
manual therapy for the cervicoscapular region with manual ther- list control.
apy. • Pain Intensity
• Pain Intensity
There was a significant difference in reduction of pain immediately
When compared with manual therapy, there was evidence of no
post treatment but no difference at intermediate-term follow-up.
difference post treatment and at long-term follow-up for pain re-
• Function
lief.
• Function
There was no statistical significant difference in improved function
When compared with manual therapy, there was evidence of no immediately post treatment and at intermediate-term follow-up.
difference post treatment and at long-term follow-up on function. • Patient Satisfaction
• Global Perceived Effect
When compared with manual therapy, there was evidence of no There was no difference between groups in patient satisfaction at
difference post treatment and at long-term follow-up on global immediate post treatment follow-up.
perceived effect. However, we believe there may be a clinically Conclusion : There is low quality evidence (one trial, 133 partici-
important but not statistical difference at long-term follow-up. pants, Kuijper 2009) showing cervical mobilization and stabiliza-
Conclusion : Moderate quality evidence (one trial, 96 participants, tion exercises may improve pain slightly, but may make no differ-
Jull 2002) shows when exercise combined with manual therapy ence in function and patient satisfaction when compared imme-
contrasted with manual therapy alone there is probably no dif- diately post treatment with a control for acute cervical radiculopa-
ference in pain, function and global perceived effect for chronic thy. However, there may be no difference in pain and functional
cervicogenic headaches at long-term follow-up. improvement at intermediate-term follow-up.

Acute Radiculopathy
Adverse Events
Fifteen of the 27 trials did not report on adverse events (Andersen
1. Base Element 2008; Andersen Ch 2012; Ang 2009; Beer 2012; Dellve 2011; Hall
2007; Hallman 2011; Hansson 2013; Humphreys 2002; Kjellman
2002; Kuijper 2009; Lundblad 1999; Revel 1994; Takala 1994;
a) Stretching and Strengthening Viljanen 2003); six trials found patients did not report any adverse
events (Allan 2003; Chiu 2005; Franca 2008; Helewa 2007; Lange
2013; Martel 2011; six studies reported self-limiting side effects
Cervical Stretch/ROM + Cervical/Scapulothoracic/UE such as headache, neck, shoulder or thoracic pain or worsening of
Strengthening + Static/Dynamic Cervical Stabilization versus symptoms (Andersen 2011; Bronfort 2001; Jull 2002; Rendant
Wait List 2011; Stewart 2007; von Trott 2009).

Exercises for mechanical neck disorders (Review) 23


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Exercises for mechanical neck disorders (Review) A D D I T I O N A L S U M M A R Y O F F I N D I N G S [Explanation]

Cervical Stretch/ ROM Exercises + Cervical/ Scapulothoracic Strengthening + Static/ Dynamic Cervical/ Shoulder Stabilization compared to WAIT LIST for mechanical neck
disorders

Patient or population: patients with chronic m echanical neck disorders


Settings: residential com m unity
Intervention: Cervical Stretch/ ROM Exercises + Cervical/ Scapulothoracic Strengthening + Static/ Dynam ic Cervical/ Shoulder Stabilization
Comparison: WAIT LIST

Outcomes Effects No of Participants Quality of the evidence


(studies) (GRADE)

Pain Intensity: VAS 0 no pain to 100 Two trials showed a m edium reduction in 147 ⊕⊕⊕
worst pain; (f ollow-up: im m ediate post pain. (2 studies: Rendant 2011, von Trott 2009) moderate 1,2
treatm ent) a. Pooled m ean dif f erence -14.90 (-22.40
a. 12 weeks of treatm ent to -7.39)
b. 24 weeks of treatm ent or 12 weeks of b. Pooled m ean dif f erence -10.94 (-18.81
treatm ent+ 12 weeks f ollow-up to -3.08)

Function: NPDI or NDI 0 no disability to 100 Two trials showed a m edium im provem ent 147 ⊕⊕⊕
m axim um disability; (f ollow-up: im m ediate in f unction. (2 studies: Rendant 2011, von Trott 2009) moderate 1,2
post treatm ent) a. Pooled SM D -0.50 (-1.04 to 0.03)
a. 12 weeks of treatm ent b. Pooled SM D -0.40 (-0.74 to -0.06)
b. 24 weeks of treatm ent or 12 weeks
treatm ent + 12 weeks f ollow-up

Quality of Life: SF-36 (physical com po- Two trials showed no signif icant dif f erence 143 ⊕⊕⊕
nent) 0 worse to 100 better; (f ollow-up: in quality of lif e scores (2 studies: Rendant 2011, von Trott 2009) moderate 1,2
im m ediate post treatm ent) a. Pooled m ean dif f erence -2.22 (-5.17 to
a. 12 weeks of treatm ent 0.72)
b. 24 weeks of treatm ent or 12 weeks b. Pooled m ean dif f erence 0.06 (-4.06 to
treatm ent + 12 weeks f ollow-up 4.17)
24
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Exercises for mechanical neck disorders (Review)

Global Perceived Effect: General Health One trial showed no signif icant dif f erence 70 ⊕⊕⊕
Perception 0 worse to 100 better (f ollow- in GPE. (1 study: von Trott 2009) moderate 2
up: im m ediate post treatm ent)
a. 12 weeks of treatm ent
b. 24 weeks of treatm ent

Adverse Effects Reported by 18 patients in exercise group:


m uscle soreness (n = 15), m yogelosis (n
= 11), headaches (n = 5), vertigo (n = 2),
change in m ood (n = 1), worsening of neck
pain (n = 1), worsening of tinnitus (n = 1) ,
nausea (n = 1), m uscle tensions (n = 2)

M oderate quality evidence (two trials, 147 participants, von Trott 2009; Rendant 2011) shows cervical stretch/ ROM exercises + cervical/ scapulothoracic strengthening +
static/ dynam ic cervical/ shoulder stabilization probably has m oderate benef it f or pain and f unction, but not GPE and QoL at im m ediate post treatm ent and short-term f ollow-
up. A clinician m ay need to treat f our people to achieve m oderate degree of pain relief and f ive to achieve m oderate f unctional benef it in one patient

GRADE Working Group grades of evidence


High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1 One of the studies (Rendant 2011) scored 6/ 12 on ’Risk of bias’ assessm ent.That is, the study m et 6 or f ewer than 6 of the
12 criteria, indicating high risk of bias.
2 Sm all studies
25
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Exercises for mechanical neck disorders (Review)

Stretch/ ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) compared to WAIT LIST for mechanical neck disorders

Patient or population: patients with chronic m echanical neck disorders


Settings: residential com m unity
Intervention: Stretch/ ROM + Endurance Training + Dynam ic Stabilization + Cognitive (m indf ulness & em otional balance)
Comparison: WAIT LIST

Outcomes Effects No of Participants Quality of the evidence


(studies) (GRADE)

Pain Intensity: VAS 0 no pain to 100 worst Two trials showed a m oderate reduction in 148 ⊕⊕⊕
pain (f ollow-up: im m ediate post treatm ent) pain (2 studies: Rendant 2011, von Trott 2009) moderate 1
a. 12 weeks of treatm ent Pooled scores estim ated using a
b. 24 weeks of treatm ent or 12 treatm ents a. M ean dif f erence of -13.28 (-20.98 to -5.
+ 12 weeks f ollow-up 58)
b. M ean dif f erence of -7.82 (-14.57 to -1.
07)

Function: NPDI 0 no disability to 100 m axi- Two trials showed a sm all im provem ent in 148 ⊕⊕⊕
m um disability (f ollow-up: im m ediate post f unction (2 studies: Rendant 2011, von Trott 2009) moderate 1
treatm ent) Pooled scores estim ated using a
a. 12 weeks of treatm ent a. Standard m ean dif f erence of -0.36 (-0.
b. 24 weeks of treatm ent or 12 weeks 68 to -0.03)
treatm ent + 12 weeks f ollow-up b. Standard m ean dif f erence of -0.28 (-0.
68 to 0.11)

Quality of Life: SF-36 (physical com po- Two trials showed little to no dif f erence in 148 ⊕⊕⊕ 1
nent) 0 worse to 100 better (f ollow-up: im - quality of lif e (2 studies: Rendant 2011, von Trott 2009) moderate
m ediate post treatm ent) Pooled scores estim ated using a
a. 12 weeks of treatm ent a. M ean dif f erence of -2.72 (-5.42 to -0.01)
b. 24 weeks of treatm ent or 12 weeks b. M ean dif f erence of -1.88 (-5.80 to 2.04)
treatm ent + 12 weeks f ollow-up
26
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Exercises for mechanical neck disorders (Review)

Global Perceived Effect: General Health One trial showed no signif icant dif f erence 70 ⊕⊕⊕
Perception 0 worse to 100 better (f ollow- in GPE. (1 study: von Trott 2009) moderate 1,2
up im m ediate post treatm ent and short-
term )

Adverse Effects Reported by 23 patients in qigong group


including: m uscle soreness (n = 17), m yo-
gelosis (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
lef t shoulder (n = 1), nausea (n = 2), m uscle
tension (n = 1)

M oderate quality evidence: (2 trials, 148 participants, Rendant 2011; von Trott 2009) shows Qigong exercises (Dantian Qigong) m ay im prove pain and f unction slightly when
com pared with a wait list control at im m ediate and short-term f ollow-up. It m ay have little or no benef it at im m ediate and short-term f ollow-up on quality of lif e and global
perceived ef f ect. A clinician m ay need to treat f our to six people to achieve this type of pain relief , f ive to eight people to achieve this f unctional benef it, and seven to 10
people f or this im provem ent in quality of lif e

GRADE Working Group grades of evidence


High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1 One included study (Rendant 2011) scored 6/ 12 on risk of bias assessm ent.That is, the study m et 6 or f ewer than 6 of the
12 criteria, indicating high risk of bias.
2 Sm all studies.
27
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Exercises for mechanical neck disorders (Review)

Cervical Stretch/ ROM + Cervical/ Scapulothoracic/ UE Strengthening + Static/ Dynamic Cervical Stabilization compared with wait list for acute radiculopathy

Patient or population: patients with acute radiculopathy


Settings: Three hospitals in Netherlands
Intervention: Cervical Stretch/ ROM + Cervical/ Scapulothoracic/ UE Strengthening + Static/ Dynam ic Cervical Stabilization
Comparison: Wait list

Outcomes Relative effect No of Participants Quality of the evidence


(95% CI) (studies) (GRADE)

Pain Intensity: VAS 0 no pain to 10 worst One trial showed a sm all reduction in pain 133 participants ⊕⊕ 1,2
pain im m ediately post treatm ent and no benef it (1 study: Kuijper 2009) low
(f ollow-up: im m ediate post treatm ent) at 6 m onths f ollow-up
a. 6 weeks of treatm ent a. Standard m ean dif f erence are -0.47 (-0.
(f ollow-up period af ter treatm ent) 81 to -0.12) post intervention
b. 6 m onths b. Standard m ean dif f erence are 0.16 (-0.
19 to 0.51) at 6 m onths f ollow-up

Function: NDI 0 no disability to 50 m axi- One trial showed a sm all reduction in f unc- 133 participants ⊕⊕ 1,2
m um disability (f ollow-up: im m ediate post tional disability im m ediately post treat- (1 study: Kuijper 2009) low
treatm ent) m ent and no benef it at 6 m onths f ollow-up
a. 6 weeks of treatm ent a. Standard m ean dif f erence are -0.11 (-0.
(f ollow-up period af ter treatm ent) 45 to 0.23) post intervention
b. 6 m onths b. Standard m ean dif f erence are 0.06 (-0.
29 to 0.40) at 6 m onth f ollow-up

Patient Satisfaction: 5-point scale, 1 to 5; a. One trial showed no dif f erence in patient 129 participants ⊕⊕ 1,2
very satisf ied to unsatisf ied satisf action im m ediately post treatm ent. (1 study: Kuijper 2009) low
(f ollow-up: im m ediate post treatm ent) relative risk ratio are 0.92 (0.62 to 1.37)
a. 6 weeks of treatm ent post intervention

Adverse Effects Not reported

Low quality evidence: (one trial, 133 participants, Kuijper 2009) Cervical Stretch/ ROM + Cervical/ Scapulothoracic/ UE Strengthening + Static/ Dynam ic Cervical Stabilization
m ay im prove pain slightly, but m ay m ake no dif f erence in f unction and patient satisf action when com pared im m ediately post treatm ent with a control f or acute cervical
radiculopathy. However, there m ay be no dif f erence in pain and f unctional im provem ent at interm ediate-term f ollow-up
28
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Exercises for mechanical neck disorders (Review)

GRADE Working Group grades of evidence


High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1 One included study (Kuijper 2009) scored 4/ 12 on risk of bias assessm ent.That is, the study m et 6 or f ewer than 6 of the 12
criteria, indicating high risk of bias.
2
Sm all study.
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Exercises for mechanical neck disorders (Review)

Cervical stretch/ ROM vs SHAM compared with SHAM intervention for subAcute CGH

Patient or population: patients with subAcute cervicogenic headache (CGH)


Settings: Physiotherapy Private Practice
Intervention: Cervical stretch/ ROM
Comparison: SHAM INTERVENTION

Outcomes Relative effect No of Participants Quality of the evidence


(95% CI) (studies) (GRADE)

Pain Intensity: VAS 0 no pain to 100 worst One trial showed a sm all reduction in pain 32 ⊕⊕
pain a. Standard m ean dif f erence are -1.58 (-2. (1 study: Hall 2007) low1,2
(f ollow-up: im m ediate post treatm ent ) 38 to -0.77) at 4 weeks
a. 4 weeks of treatm ent b. Standard m ean dif f erence are -1.74 (-2.
(f ollow-up period af ter treatm ent) 57 to -0.91) at 12 m onths
b. 12 m onths

Adverse effects Not reported

Low quality evidence: (one trial, 32 participants, Hall 2007 ) shows Cervical stretch/ ROM m ay im prove a large am ount f or pain reduction at short- and long-term f ollow-up with
the use of C1 to C2 self -SNAG exercises when com pared with a sham f or (sub)acute cervicogenic headache. A clinician m ay need to treat three people to achieve this type of
long-term pain relief

GRADE Working Group grades of evidence


High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1
Percision: Sm all study (n=16 per arm ).
2
Reporting bias: due to trial size and single outcom e, f uture research is likely to inf luence the direction of reported ef f ect.
Replication in a second trial is needed.
30
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Exercises for mechanical neck disorders (Review)

Cervical/ Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization compared with NO INTERVENTION
for Chronic CGH

Patient or population: patients with chronic CGH


Settings: m ultiple trial centres
Intervention: Cervical/ Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biof eedback + Dynam ic Cervical Stabilization
Comparison: NO INTERVENTION

Outcomes Relative effect No of Participants Quality of the evidence


(95% CI) (studies) (GRADE)

Pain Intensity: VAS 0 no pain to 10 worst One trial showed a large reduction in pain 97 ⊕⊕⊕
pain at 6 weeks and 12 m onths f ollow up (1 study: Jull 2002) moderate 1
(f ollow-up: im m ediate post treatm ent) a. Standard m ean dif f erence are -0.75 (-1.
a. 6 weeks 16 to -0.34) at 6 weeks
(f ollow-up period af ter treatm ent) b. Standard m ean dif f erence are -0.59 (-1.
b. 12 m onths 00 to -0.18) at 12 m onths f ollow-up

Function: NPNPQ 0% no disability to 100% One trial showed a m oderate reduction in 97 ⊕⊕⊕
m axim um disability f unctional disability (1 study: Jull 2002) moderate 1
(f ollow-up: im m ediate post treatm ent) a. Standard m ean dif f erence are -0.56 (-0.
a. 6 weeks 96 to -0.15) at 6 weeks
(f ollow-up period af ter treatm ent) b. Standard m ean dif f erence are -0.70 (-1.
b. 12 m onths 11 to 0.29) at 12 m onths f ollow-up

Global Perceived Effect: VAS 0 to 100 One trial showed a large benef it in global 97 ⊕⊕⊕
(f ollow-up: im m ediate post treatm ent) perceived ef f ect (1 study: Jull 2002) moderate 1
a. 6 weeks a. Standard m ean dif f erence are -2.96 (-3.
(f ollow-up period af ter treatm ent) 55 to -2.38) at 6 weeks
b. 12 m onths b. Standard m ean dif f erence are -2.51 (-3.
05 to -1.97) at 12 m onths f ollow-up

Adverse effects M inor and tem porary adverse ef f ects were noted: 6.7% of headaches were provoked by treatm ent
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Exercises for mechanical neck disorders (Review)

M oderate quality evidence: (one trial, 97 participants, Jull 2002) shows cervicoscapular strengthening and endurance exercises including pressure biof eedback probably
im proves pain, f unction and global perceived ef f ect f or chronic cervicogenic headaches at long term f ollow-up when com pared to no treatm ent. A clinician m ay need to treat
six people to achieve this type of pain relief and f unctional benef it in one patient

GRADE Working Group grades of evidence


High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1 Percision: Although sm all study, consistent f indings are noted across m ultiple outcom es at long term f ollow-up.
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Exercises for mechanical neck disorders (Review)

Cervical/ Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization + M anual Therapy compared with
M anual Therapy for Chronic CGH

Patient or population: patients with Chronic CGH


Settings: m ultiple trial centres
Intervention: Cervical/ Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biof eedback + Dynam ic Cervical Stabilization + M anual Therapy
Comparison: M ANUAL THERAPY

Outcomes Relative effect No of Participants Quality of the evidence


(95% CI) (studies) (GRADE)

Pain Intensity: 6 weeks treatm ent VAS 0 One trial showed a sm all reduction in pain 96 ⊕⊕⊕
no pain to 10 worst pain a. Standard m ean dif f erence are -0.11 (-0. (1 study: Jull 2002) moderate 1
(f ollow-up: im m ediate post treatm ent) 50 to 0.29) at 6 weeks
a. 6 weeks b. Standard m ean dif f erence are -0.17 (-0.
(f ollow-up period af ter treatm ent) 57 to 0.23) at 12 m onths f ollow-up
b. 12 m onths

Function: NPNPQ 0% no disability to 100% One trial showed a sm all reduction in f unc- 96 ⊕⊕⊕
m axim um disability tional disability (1 study: Jull 2002) moderate 1
(f ollow-up: im m ediate post treatm ent) a. Standard m ean dif f erence are -0.11 (-0.
a. 6 weeks of treatm ent 51 to 0.28) at 6 weeks
(f ollow-up period af ter treatm ent) b. Standard m ean dif f erence are -0.23 (-0.
b. 12 m onths 63 to 0.17) at 12 m onths f ollow-up

Global Perceived Effect: VAS 0 to 100 One trial showed a sm all benef it in global 96 ⊕⊕⊕
(f ollow-up: im m ediate post treatm ent) perceived ef f ect (1 study: Jull 2002) moderate 1
a. 6 weeks of treatm ent a. Standard m ean dif f erence are -0.29 (-0.
(f ollow-up period af ter treatm ent) 68 to 0.11) at 6 weeks
b. 12 m onths b. Standard m ean dif f erence -0.30 (-0.70
to 0.10) at 12 m onths f ollow-up

Adverse effects M inor and tem porary adverse ef f ects were noted: 6.7% of headaches were provoked by treatm ent

M oderate quality evidence (one trial, 96 participants, Jull 2002) shows when exercise com bined with m anual therapy contrasted with m anual therapy alone there is probably
no dif f erence in pain, f unction and global perceived ef f ect f or chronic cervicogenic headaches at long-term f ollow-up
33
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Exercises for mechanical neck disorders (Review)

GRADE Working Group grades of evidence


High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1 Percision: Although sm all study, consistent f indings are noted across m ultiple outcom es at long term f ollow-up.
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Exercises for mechanical neck disorders (Review)

Cervical/ UE Stretch/ ROM Exercise + Cervical/ UE Strengthening + Dynamic Cervical Stabilization compared with PLACEBO or SHAM for Chronic M ND

Patient or population: patients with chronic M ND


Settings: Prim ary care physical therapy and private physical therapy practices
Intervention: Cervical/ UE Stretch/ ROM Exercise + Cervical/ UE Strengthening + Dynam ic Cervical Stabilization
Comparison: PLACEBO or SHAM

Outcomes Relative effect No of Participants Quality of the evidence


(95% CI) (studies) (GRADE)

Pain Intensity: VAS 0 no pain to 100 worst One trial showed no dif f erence in pain 77 ⊕⊕
pain im m ediately post intervention and at 6 and (1 study: Kjellm an 2002) low1,2
(f ollow-up: im m ediate post treatm ent) 12 m onths f ollow-up
a. 2 m onths of treatm ent a. Standard m ean dif f erence 0.26 (-0.33 to
(f ollow-up period af ter treatm ent) 0.85) im m ediately 2 m onths post interven-
b. 6 m onths tion
c. 12 m onths b. Standard m ean dif f erence -0.16 (-0.75
to 0.43) at 6 m onths f ollow-up
c. Standard m ean dif f erence -0.19 (-0.40
to 0.78) at 12 m onths f ollow-up

Function: 2 m onths treatm ent NDI 0 no One trial showed no dif f erence in f unction 77 ⊕⊕
disability to 50 m axim um disability im m ediately post intervention and at 6 and (1 study: Kjellm an 2002) low1,2
(f ollow-up: im m ediate post treatm ent) 12 m onths f ollow-up
a. 2 m onths of treatm ent a. Standard m ean dif f erence are 0.14 (-
(f ollow-up period af ter treatm ent ) 0.45 to 0.73) im m ediately post 2 m onths
b. 6 m onths intervention
c. 12 m onths b. Standard m ean dif f erence -0.06 (-0.66
to 0.53) at 6 m onths f ollow-up
c. Standard m ean dif f erence 0.12 (-0.47 to
0.72) at 12 m onths f ollow-up

Adverse effects Not reported

Low quality evidence: (One trial, 77 participants, Kjellm an 2002) No dif f erence f or pain relief and f unction im m ediately post intervention, at 6 and 12 m onths f ollow-up using
Cervical/ UE Stretch/ ROM Exercise + Cervical/ UE Strengthening + Dynam ic Cervical Stabilization f or chronic M ND
35
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Exercises for mechanical neck disorders (Review)

GRADE Working Group grades of evidence


High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1 One of the studies (Kjellm an 2002)) scored 5/ 12 on ’Risk of bias’ assessm ent.That is, the study m et 6 or f ewer than 6 of the
12 criteria, indicating high risk of bias.
2
Sm all studies
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Exercises for mechanical neck disorders (Review)

Cervical Stretch/ ROM Exercise + Dynamic Cervical Stabilization compared with SHAM for Chronic M ND

Patient or population: patients with chronic M ND


Settings: Prim ary care physical therapy and private physical therapy practices
Intervention: Cervical/ UE Stretch/ ROM Exercise + Cervical/ UE Strengthening + Dynam ic Cervical Stabilization
Comparison: PLACEBO or SHAM

Outcomes Relative effect No of Participants Quality of the evidence


(95% CI) (studies) (GRADE)

Pain Intensity: VAS 0 no pain to 100 worst One trial showed no dif f erence in pain 50 ⊕⊕
pain (f ollow-up: im m ediate post treatm ent) im m ediately post intervention and at 6 and (1 study: Kjellm an 2002) low1,2
a. 2 m onths of treatm ent 12 m onths f ollow-up
(f ollow-up period af ter treatm ent) a. Standard m ean dif f erence are -0.10 (-
b. 6 m onths 0.66 to 0.45) im m ediately post 2 m onths
c. 12 m onths intervention
b. Standard m ean dif f erence -0.29 (-0.85
to 0.27) at 6 m onths f ollow-up
c. Standard m ean dif f erence 0.04 (-0.51 to
0.60) at 12 m onths f ollow-up

Function: NDI 0 no disability to 50 m axi- One trial showed no dif f erence in f unction 50 ⊕⊕
m um disability (f ollow-up: im m ediate post im m ediately post intervention and at 6 and (1 study: Kjellm an 2002) low1,2
treatm ent) 12 m onths f ollow-up
a. 2 m onths of treatm ent a. Standard m ean dif f erence are -0.24 (-
(f ollow-up period af ter treatm ent ) 0.79 to 0.32) im m ediately post 2 m onth
b. 6 m onths intervention
c. 12 m onths b. Standard m ean dif f erence -0.22 (-0.79
to 0.36) at 6 m onths f ollow-up
c. Standard m ean dif f erence 0.14 (-0.44 to
0.71) at 12 m onths f ollow-up

Adverse effects Not reported

Low quality evidence: (One trial, 50 participants, Kjellm an 2002) No dif f erence f or pain relief and f unction im m ediately post intervention, at 6 and 12 m onth f ollow-up using
Cervical Stretch/ ROM Exercise + Dynam ic Cervical Stabilization f or chronic M ND
37
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Exercises for mechanical neck disorders (Review)

GRADE Working Group grades of evidence


High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1 One of the studies (Kjellm an 2002) scored 5/ 12 on ’Risk of bias’ assessm ent.That is, the study m et 6 or f ewer than 6 of the
12 criteria, indicating high risk of bias.
2
Sm all studies
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Exercises for mechanical neck disorders (Review)

Chronic M ND: Cervical/ Scapulothoracic/ UE Stretch + UE Endurance Training compared with NO INTERVENTION or WAIT LIST for chronic M ND

Patient or population: patients with chronic M ND


Settings: of f ice workers
Intervention: Cervical/ Scapulothoracic/ UE Stretch + UE Endurance Training
Comparison: NO INTERVENTION or WAIT LIST

Outcomes Relative effect No of Participants Quality of the evidence


(95% CI) (studies) (GRADE)

Pain Intensity: VAS 0 no pain to 100 worst One trial showed no dif f erence in pain 393 ⊕⊕⊕
pain im m ediately post intervention and at 3 (1 study: Viljanen 2003) moderate 1
(f ollow-up: im m ediate post treatm ent) and 9 m onths f ollow-up
a. 12 weeks of treatm ent a. Standard m ean dif f erence are 0.08 (-
(f ollow-up period af ter treatm ent) 0.16 to 0.32) im m ediately post 12 weeks
b. 3 m onths intervention
c. 9 m onths b. Standard m ean dif f erence 0.00 (-0.24
to 0.24) at 3 m onths f ollow-up
c. Standard m ean dif f erence -0.04 (-0.28
to 0.20) at 9 m onths f ollow-up

Function: NDI 0 no disability to 50 m axi- One trial showed no dif f erence in f unction 393 ⊕⊕⊕
m um disability im m ediately post intervention and at 3 (1 study: Viljanen 2003) moderate 1
(f ollow-up: im m ediate post treatm ent) and 9 m onths f ollow up
a. 12 weeks of treatm ent a. Standard m ean dif f erence 0.07 (-0.17
(f ollow-up period af ter treatm ent) to 0.31) im m ediately post 12 weeks inter-
b. 3 m onths vention
c. 9 m onths b. Standard m ean dif f erence 0.07 (-0.17
to 0.31) at 3 m onths f ollow-up
c. Standard m ean dif f erence 0.14 (-0.11
to 0.38) at 9 m onths f ollow-up

Adverse effects Not reported

M oderate quality evidence: (one trial, 393 participants, Viljanen 2003) Little to no dif f erence f or pain relief and f unction im m ediately post intervention, at 3 and 9 m onths
f ollow-up using Cervical/ Scapulothoracic/ UE Stretch + UE Endurance Training f or chronic M ND
39
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Exercises for mechanical neck disorders (Review)

GRADE Working Group grades of evidence


High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1 Percision: high drop out rate (14%); reason f or dropout not described.
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Exercises for mechanical neck disorders (Review)

Scapulothoracic/ UE Endurance Training compared with CONTROL for (sub)Acute/ Chroninc M ND

Patient or population: patients with Acute to Chronic M ND


Settings: two large withe collar organizations
Intervention: Scapulothoracic/ UE Endurance Training
Comparison: CONTROL

Outcomes Relative effect No of Participants Quality of the evidence


(95% CI) (studies) (GRADE)

Pain Intensity: VAS 0 no pain to 10 worst One trial showed m oderate pain relief im - 198 ⊕⊕⊕
pain (f ollow-up: im m ediate post 10 weeks m ediately post intervention (1 study: Andersen 2011) moderate 1
treatm ent) a. Standard m ean dif f erence f or the 2
a. 2-m inute training group m inute training group -0.66 (-1.02 to -0.30)
b. 12-m inute training group b. Standard m ean dif f erence f or the 12
m inute training group -0.59 (-0.94 to -0.23)

Adverse effects Reported worsening of neck m uscle tension during and/ or in the days af ter training (2-m inute n = 1, 12-m inute n = 4), shoulder
joint pain during training (2-m inute n = 1, 12-m inute n = 4), pain in the upper arm during training (2-m inute n = 1, 12-m inute n = 1),
pain of the f orearm / wrist during training (12-m inute n = 2), worsening of headache af ter training (2-m inute n = 1, 12-m inute n = 1).
No long-lasting or m ajor com plications resulted f rom the training program

M oderate quality evidence: (one trial, 198 participants, Andersen 2011) M oderate benef it f or pain relief im m ediately post intervention using Scapulothoracic/ UE Endurance
Training f or (sub)Acute/ Chronic M ND. A clinician m ay need to treat f our people to achieve this type of pain relief

GRADE Working Group grades of evidence


High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1 Percision: sm all sam ple (n = 63 or 64 per Arm ) m easured at Im m ediate post treatm ent.
41
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Exercises for mechanical neck disorders (Review)

Trunk/ Extremity Stretch/ ROM + Trunk/ Extremity Strengthening + Trunk/ Extremity Endurance Training + Pattern/ Synchronization: Coordination + Cardiovascular/ Aerobic +
Cognitive (CBT) + ANOTHER TREATM ENT compared with THAT SAM E OTHER TREATM ENT for Subacute/ chronic WAD

Patient or population: patients with subacute/ chronic WAD


Settings: two physiotherapy clinics
Intervention: Trunk/ Extrem ity Stretch/ ROM + Trunk/ Extrem ity Strengthening + Trunk/ Extrem ity Endurance Training + Pattern/ Synchronization: Coordination + Cardiovascular/
Aerobic + Cognitive (CBT) + ANOTHER TREATM ENT
Comparison: THAT SAM E OTHER TREATM ENT

Outcomes Relative effect No of Participants Quality of the evidence


(95% CI) (studies) (GRADE)

Pain Intensity: VAS 0 no pain to 10 worst One trial showed sm all pain relief im m e- 132 ⊕⊕
pain diately post intervention and no dif f erence (1 study: Stewart 2007) low1,2
(f ollow-up: im m ediate post treatm ent) at 12 m onths f ollow-up
a. 6 weeks of treatm ent a. Standard m ean dif f erence -0.46 (-0.81
(f ollow-up period af ter treatm ent) to -0.12) im m ediately post 6 weeks inter-
b. 12 m onths vention
b. Standard m ean dif f erence -0.12 (-0.47
to 0.23) at 12 m onths f ollow-up

Function: NDI 0 no disability to 50 m axi- One trial showed sm all benef it in f unction 132 ⊕⊕
m um disability im m ediately post intervention and at 12 (1 study: Stewart 2007) low1,2
(f ollow-up: im m ediate post treatm ent) m onths f ollow-up
a. 6 weeks of treatm ent a. Standard m ean dif f erence -0.50 (-0.85
(f ollow-up period af ter treatm ent) to -0.15) im m ediately post 6 weeks inter-
b. 12 m onths vention
b. Standard m ean dif f erence -0.39 (-0.74
to -0.03) at 12 m onths f ollow-up

Global perceived effect: -5 to 5 scale; One trial showed sm all benef it in global 132 ⊕⊕
vastly worse to com pletely recovered perceived ef f ect im m ediately post inter- (1 study: Stewart 2007) low1,2
(f ollow-up: im m ediate post treatm ent) vention and no dif f erence at 12 m onths
a. 6 weeks of treatm ent f ollow-up
(f ollow-up af ter treatm ent) a. Standard m ean dif f erence -0.46 (-0.80
b. 12 m onths to -0.11) im m ediately post 6 weeks inter-
vention
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Exercises for mechanical neck disorders (Review)

b. Standard m ean dif f erence -0.18 (-0.54


to 0.17) at 12 m onths f ollow-up

Quality of Life: SF-36 0 high disability One trial showed sm all benef it in global 132 ⊕⊕
to 100 no disability (f ollow-up: im m ediate perceived ef f ect im m ediately post inter- (1 study: Stewart 2007) low1,2
post treatm ent) vention and no dif f erence at 12 m onth f ol-
a. 6 weeks of treatm ent low-up
(f ollow-up af ter treatm ent) a. Standard m ean dif f erence -0.35 (-0.69
b. 12 m onths to -0.01) im m ediately post 6 weeks inter-
vention
b. Standard m ean dif f erence -0.15 (-0.50
to 0.20) at 12 m onth f ollow-up

Adverse effects Reported; The m ain com plaint in this group was m uscle pain with exercise (3) f ollowed
by knee pain (2) and lum bar spine pain (2).

Low quality evidence: (one trial, 132 participants, Stewart 2007) Sm all benef it f or pain relief , f unction, global perceived ef f ect and quality of lif e im m ediately post treatm ent
and sm all benef it at 12 m onth f ollow up f or f unction using Trunk/ Extrem ity Stretch/ ROM + Trunk/ Extrem ity Strengthening + Trunk/ Extrem ity Endurance Training + Pattern/
Synchronization: Coordination + Cardiovascular/ Aerobic + Cognitive (CBT) + ANOTHER TREATM ENT f or Subacute/ chronic WAD

GRADE Working Group grades of evidence


High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1 One of the studies (Stewart 2007) scored 6/ 12 on ’Risk of bias’ assessm ent.That is, the study m et 6 or f ewer than 6 of the
12 criteria, indicating high risk of bias.
2 Sm all studies
43
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Exercises for mechanical neck disorders (Review)

Scapulothoracic + UE Strengthening compared with CONTROL for (sub)Acute/ Chronic M ND

Patient or population: patients with Acute to Chronic M ND


Settings: Seven workplaces
Intervention: Scapulothoracic + UE Strengthening
Comparison: CONTROL

Outcomes Relative effect No of Participants Quality of the evidence


(95% CI) (studies) (GRADE)

Pain Intensity: VAS 0 no pain to 100 worst Three trials showed a m oderate reduction 157 ⊕⊕⊕
pain (f ollow-up: im m ediate post 10 to 20 in pain. Pooled scores estim ated using a (3 studies: Andesen 2008, Andersen CH moderate
weeks of treatm ent) standard m ean dif f erence -0.71 (-1.33 to - 2012, Dellve 2011)
0.10)

Pain Intensity: VAS 0 no pain to 100 worst One trial (two com parisons) showed no 163
pain (f ollow-up: im m ediate post 20 weeks dif f erence in pain relief im m ediately post (1 study: three groups, Andersen CH 2012) very low1
of treatm ent) intervention
a. 1 weekly session a. One weekly session of 60 m inutes,
b. 9 weekly sessions scores using a standard m ean dif f erence -
0.20 (-0.63 to 0.22)
b. Nine weekly sessions of seven m inutes,
scores using a standard m ean dif f erence -
0.13 (-0.61 to 0.34)

Pain Intensity: VAS 0 no pain to 100 worst One trial showed m oderate reduction in 26 ⊕⊕
pain (f ollow-up: im m ediate post 10 weeks pain 10 weeks post intervention. Scores (1 study: Andersen 2008) low
of treatm ent) using a standard m ean dif f erence -0.89 (-
1.76 to -0.01) at 10 week f ollow-up

Function: DASH 20% no dif f iculty to 100% One trial showed no dif f erence in f unction 163
f ully unable (f ollow-up: im m ediate post 20 im m ediately post intervention (1 study: Andersen CH 2012) very low1
weeks of treatm ent) a. Standard m ean dif f erence -0.17 (-0.58
a. 1 weekly session to 0.24) im m ediately post intervention f or
b. 9 weekly sessions one weekly session of 60 m inutes
b. Standard m ean dif f erence -0.06 (-0.53
44
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Exercises for mechanical neck disorders (Review)

to 0.41) f or nine weekly sessions of seven


m inutes

Work ability index: 7 poor ability to 49 One trial showed a sm all im provem ent in 88 ⊕⊕
excellent ability treatm ent (f ollow-up: im - work ability im m ediately post intervention. (1 study: Dellve 2011) low
m ediate post 20 weeks treatm ent) Standard m ean dif f erence -0.23 (-0.66 to
0.19) im m ediately post 20 weeks interven-
tion

Adverse effects Not reported

M oderate quality evidence: (3 trials, 157 participants, Andersen 2008, Andersen Ch 2012, Dellve 2011) that scapulothoracic and upper extrem ity strength training probably
im proves pain. It probably f unctional outcom es when com pared to control f or chronic m echanical neck pain im m ediately post treatm ent (10 or 20 week interventions).
However low quality evidence suggests that scapulothoracic and upper extrem ity strength training m ay im prove pain slightly

GRADE Working Group grades of evidence


High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect.
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate.
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate.
Very low quality: We are very uncertain about the estim ate.
1 Design: 0, Lim itations: -1, Inconsistency: 0, Indirectness: 0, Im precision: -1, Other: -1 subgroup analysis.
45
DISCUSSION cervicogenic headaches at long-term follow-up. There was also a
moderate beneficial effect on function immediately post
Summary of main results treatment and at long-term follow-up.

Limiting the eligible trials to those with single interventions that • Low quality evidence suggest that there is a slight beneficial
compared exercise with a control or comparative group maximized effect on pain with acute cervical radiculopathy when combining
the opportunity to evaluate the treatment effect of exercise inter- the use of static and dynamic cervical, scapulothoracic and upper
ventions. Moreover, having selected a priori an exercise classifi- extremity stretching and strengthening immediately post
cation system allowed us to use a clinical rationale for selecting treatment but not at intermediate-term follow-up. There was
studies with similar interventions for interpretation and inclusion little to no difference in function.
within meta-analyses, particularly for the outcomes of pain and
function. Although there were only 28 studies eligible for this sys- • Low grade evidence suggests there is little to no difference
tematic review, these two new strategies provided greater clarity in chronic mechanical neck pain and function with respect to the
in our conclusions about the effectiveness of exercise therapy. In use of breathing exercises or general fitness training
summary, for moderate quality evidence there is still uncertainty
• Low grade evidence suggests there is little to no difference
about the effectiveness of exercise for neck pain. Further research
in chronic mechanical neck pain and function with respect to the
is likely to have an important impact on the effect estimate. Fur-
use of cervical spine stretches and range of motion exercises.
thermore, for low quality evidence further research is very likely
to have an important impact on the effect estimate. The reader • Moderate grade evidence suggests there is little to no
should take these limitations into account when interpreting the difference in chronic neck pain and function with the use of
following evidence statements. cervical, scapulothoracic and upper extremity stretching and
• Moderate to low quality evidence suggests there can be endurance training both immediately post treatment as well as
small to large beneficial effects on chronic mechanical neck pain short- and long-term follow-up.
when combining the use of cervical, shoulder/scapulothoracic
strengthening and stretching exercises immediately post • Low quality evidence suggests that there is little to no
treatment and at short- and long-term follow-up. There may also difference in chronic mechanical neck pain when combining the
be a small to moderate beneficial effect on function when use of trunk and upper extremity stretching, balance exercises
combining the use of cervical, shoulder/scapulothoracic and aerobic training immediately post treatment.
strengthening and stretching exercises immediately post
• Low quality evidence suggests that there is little to no
treatment and at short- to long-term follow-up.
difference in chronic mechanical neck pain when combining the
• Moderate grade evidence suggests there may be a slight use of endurance, general stretching, body mechanics and
beneficial effect on chronic mechanical neck pain with the use of lumbar stabilization exercises at short-term follow-up.
scapulothoracic and upper extremity endurance training
immediately post treatment. Knowledge of key multimodal approaches like exercise and manual
therapy is still needed as this model of combined care is commonly
• Moderate quality evidence suggests there may be a slight used in clinical practice.
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
Overall completeness and applicability of
treatment and at short-term follow-up. There may be little to no
evidence
difference in quality of life and general perceived effect measures Our group looked at the clinical applicability of 28 trials associ-
with the use of qigong exercises. ated with neck disorders versus control: 25 studies were interested
in neck pain, two in cervicogenic headache and one in cervical
• Low quality evidence suggests there may be a large
radiculopathy. The level of evidence ranged from low to moderate.
beneficial effect in cervicogenic headaches with the use of
Most studies adequately described the study population. Three
craniovertebral stretch and range of motion exercises (C1-C2
studies did not specify the duration of neck pain. Radicular signs
Self-SNAG) both at short- and long-term follow-up.
and symptoms were present in 14% of the studies, absent in 29%
• Moderate quality evidence suggests there is a large beneficial and not specified in 57%. Of the 28 studies in this update, 36%
effect on pain in cervicogenic headaches when combining the use provided sufficient details for the treatment protocol to be repli-
of static and dynamic cervical, scapulothoracic strengthening and cated and 18 studies omitted important details about the treat-
endurance exercises including pressure biofeedback immediately ment administration or included insufficient description of the
post treatment and probably improves pain moderately in qualifications of the treatment provider.

Exercises for mechanical neck disorders (Review) 46


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
The outcomes were as follow: 96% of the studies reported pain, grouping based on diagnosis, treatment or prognosis system classi-
64% reported function and 36% reported quality of life or patient fication would be useful to increase homogeneity for research and
satisfaction. Of the ones that reported pain, function and quality clinical applicability.
of life, benefit was shown in respectively 81%, 89% and 80%, but Exercise classification is also of utmost importance when inter-
no study reached the minimal clinically important difference for ested in the nature of the intervention. The model implemented
any outcome. These results can be applied to an adult population in this review, proposed by Sahrmann 2002, reveals the interac-
suffering from acute, subacute and chronic mechanical neck pain. tion between dosage, elements of movement system and activity
Follow-up was reported at immediate or short term in 54% of the by describing the physiological effect of exercise on the body rather
studies and the remaining trials (46%) had intermediate- or long- than describing the types of activity used to produce that effect.
term measurement timing. Minor and short lasting adverse events Using this kind of model would allow practitioners and researchers
were reported in 25% of the studies, their occurrence was not to classify exercises into a specific category by recognizing their
specified in 57%, and no adverse events happened in the remaining mechanisms of actions. It also allows placement of similar exercise
studies (18%). Drop-outs occurred in 68% of the studies and interventions from different trials into more homogeneous sub-
none evaluated the cost of care. To better understand the direct groups enabling meta-analyses. Thus, by a better understanding
and indirect costs of the different treatments and make decisions and classification of the physical impairments, exercise interven-
regarding the most effective and efficient type of care, attempts to tions and stage or type of pathology, accuracy in the clinical ap-
evaluate and report cost-related outcomes are required. plicability of results could be improved.
The clinical applicability was evaluated in 28 studies contrasting In general, there is also limited evidence on optimal dosage re-
the use of exercise for neck pain compared with a control group. quirements (Bronfort 2001; Jull 2002) for exercise therapies, and
Sample population was adequately described in 82% of the trials. other modalities used to treat neck disorders. To address ques-
Treatment protocol was adequately described in 36% of the tri- tions regarding the dose of therapies used to treat the neck, re-
als; the remaining studies omitted information about treatment searchers (Gross 2007) have recommended using factorial designs
providers and exercise dosage, which hinders reproducibility. The and studying only single interventions (Carroll 2008b; Helewa
magnitude of effect and clinical applicability showed benefits that 2007). Subsequently, dosage comparisons of similar types of ex-
outweigh any transient and minor side effects. The level of evi- ercises (or exercises that address the same element) can be made;
dence of these studies varied from low to moderate; thus clinicians these comparisons can be used to evaluate the impact of dosage
should not underestimate their clinical judgement in the choice variation of the exercise element on the magnitude of treatment
of optimal treatment modality for client needs. outcomes. Specific dosage information is clinically relevant and
The stage of the pathology, commonly described as acute, subacute specific therapeutic recommendations can be drawn from such
and chronic, can certainly affect the effect size of an intervention clinical trials.
such as exercise. For instance, in regards to pain, none of the Different control interventions have been used in the reference
included trials reached the minimal clinically important difference group, but were absent in the experimental group in eight trials
of 2.0 points (NPRS) or 20 mm (VAS); this could be related to of this review. A study design comparing exercise and another
the low to moderate pain levels experienced by the chronic neck intervention with the same intervention was used in four trials. No
pain population with lesser room for improvement compared to intervention or wait list as a control intervention was used in the
an acute neck pain population with high initial levels of pain. remaining 12 studies. Using different control interventions could
Thus, according to the stage of the pathology, it could respectively lead to underestimation of the effect of exercise if that intervention
under or overestimate the size effect of a specific exercise. also shows beneficial effects. Using the same intervention in both
To date, there is no standardized definition of mechanical neck exercise and control group may provide a better idea of adding
pain even if it has evolved over the last three decades. Spitzer 1987 exercise to a treatment plan, but an interaction of effect is also
defined mechanical neck pain as complaints of pain, stiffness, and possible and could lead to overestimation of the effect of exercise.
tenderness with or without referral to proximal extremity. Merskey Self-reported outcome measures of function are popular in the
1994 proposed the following definition: “pain perceived as aris- literature to evaluate the effectiveness of treatment in a patient’s
ing from anywhere within the region bounded superiorly by the everyday life. The Neck Disability Index (NDI) is well accepted
superior nuchal line through the tip of the first thoracic spinous in the current literature and is one of the most used tools to assess
process, and laterally by the sagittal plane tangential to the lateral patient’s functional capacities. However, the NDI recently showed
borders of the neck.” More recently, other authors suggested dif- an insufficient unidimensionality ( Ailliet 2013;Hung 2014; van
ferent definitions such as generalized neck and/or shoulder pain der Velde 2009) and a very large floor effect. Its use in research in
with mechanical characteristics including: symptoms provoked by regards to construct validity is now questioned.
maintained neck postures or by movement, or by palpation of The use of only self-reported outcome measures may bias the ef-
the cervical muscles (Fernandez-de-las-Penas 2007). Thus, con- fect estimate. More objective and performance-based measures of
sidering that mechanical neck pain is a heterogeneous group, sub- functional tasks should be used in conjunction with subjective

Exercises for mechanical neck disorders (Review) 47


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
measures and questionnaires to establish a complete picture of the ipation has been linked to types of personal benefit, including fi-
results. Such tools need to be developed and integrated into future nancial and therapeutic (Nappo 2013). Although financial incen-
research. tives are important in recruiting healthy volunteers, their motiva-
The timing of outcome measurement has been well reported in all tions are not limited to financial gains (Stunkel 2011). It has been
trials. However, most studies did not specify if participants contin- proposed that altruism should be the main reason for a person’s
ued their exercises program at home after the end of the interven- decision to participate in a research study (Grady 2001). Ideally,
tion period. Knowing the instructions given for the continuation the volunteer is capable of making decisions based on the infor-
or cessation of the exercise before follow-up would improve the ac- mation provided about the proposed study, and understands the
curacy of their effectiveness according to how long they were per- purpose, risks, benefits, alternatives and requirements of the study.
formed. This information could lead to conclusions about carry- After receiving this information, the volunteer is able to decide
over effect of the exercise program. to participate, free from coercion or improper influences (Grady
2001). Second, clinician recruitment may be difficult. Technology
has the potential to facilitate this task. With the emerging presence
Quality of the evidence of electronic medical charting, data sharing has become a point of
interest. By training clinicians around the world, patients could be
One of the major methodological difficulties inherent to studies
screened on a global scale. A standardized protocol could then be
evaluating exercise interventions is blinding of therapists and pa-
applied in a standardized setting to those who meet the inclusion
tients. None of the trials in this review blinded the care provider,
criteria. As a result, valid and reliable objective measures with low
as this is not possible in an exercise trial. Patient blinding can
risk of bias could be gathered and accessed by researchers interna-
minimize expectation bias by ensuring the treatments are equally
tionally. Finally, it is imperative for investigators to clearly articu-
credible and acceptable to patients; patients have limited experi-
late the relevance of the study to the appropriate stakeholders: the
ence or expectations for either the index treatment or control in-
neck pain patients who will allocate a significant amount of time
tervention. However, the nature of exercise interventions makes it
to the trial and the clinicians who will contribute patients to the
difficult to blind the patient and care provider. Therefore, it is very
study and, in the process, upset their usual routine and suffer some
important to control for measurement bias by blinding the out-
financial loss. The relevance of the study needs to emphasize the
come assessor and the data analyst. A caveat to this is that the use
possible benefits to present and future patients, to the healthcare
of self-reported outcome measures de facto makes the patient the
system and to society in general.
outcome assessor and blinding cannot be achieved easily. Two of
This being said, the overarching feature to low precision resides
the 28 trials did blind the outcome assessor and therefore, blinding
in the subclassification of control trials and restriction of their
can be obtained for certain outcomes.
use. What first must be done is to establish a firm foundation of
Other issues that are important in studies evaluating exercise ther-
the effect of (x type of ) exercise in clinical control trials and not
apy are that of compliance (reducing the treatment effect), co-in-
include head-to-head exercise comparison trials. We believe once
tervention (increasing the treatment effect and reducing the mag-
sound evidence has been formed, the next step is to do comparison
nitude of effect if it occurs in the control group) and contamina-
trials to establish the superiority of different variations of similar
tion (reducing the magnitude of effect). The intervention requires
exercises.
patient motivation and therefore strategies to support behavior
changes (Teixeira 2012). Twelve of the 28 studies had acceptable
compliance, and eight of 28 studies monitored co-interventions.
This provides greater confidence that the outcome is due to the Potential biases in the review process
exercise intervention and that the dosage is consistent between in-
The validity of any systematic review is dependent on the selection
dividual participants and treatment groups.
of all relevant studies. Although studies published in any language
Adequate randomization is a crucial component for a randomized
were accepted, many scientific journals in non-English languages
controlled trial. However, adequate sequence generation was ev-
are not indexed in MEDLINE and Embase. We did not search
ident in only 46% (13/28) of the trials included in this review.
non-English databases, which may have introduced ’language bias’
Greater care should be taken to ensure the method of randomiza-
in the review. Studies without a control or comparative group
tion is adequate and clearly reported.
were excluded so that exercise treatment effectiveness and efficacy
Ninety-six per cent (27/28) of the clinical trials contained small
could be properly ascertained (Carroll 2008b). This review con-
sample sizes (<70 per arm analyzed). Risk of random error will
tains only published studies therefore ’publication bias’ was not
of course be reduced with increased precision or increased sample
guarded against.
size. Request for larger trials is a challenge on a per site basis. A co-
ordinated multi-centre trial is one answer but recruiting and retain-
ing is the challenge. For this it is helpful to identify the motivation
factors for participation. First, motivation for clinical study partic- Agreements and disagreements with other

Exercises for mechanical neck disorders (Review) 48


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
studies or reviews idence (Kuijper 2009) showing cervical mobilization and specific
stabilization exercises may improve pain slightly, but may make
This review has provided more detailed informations with respect
no difference in function and patient satisfaction when compared
to the degree of evidence and the types of exercise that have an
immediately post treatment with a control. There may be no dif-
impact on neck pain.
ference in pain and functional improvement at intermediate-term
There were no new trials added to our update with respect to acute
follow-up. The challenge in acute radiculopathy is to determine
whiplash associated disorders (WAD) that compared exercise with
the utility of exercises that provide immediate relief but not longer-
a control.
term benefit.
For chronic neck pain, Leaver 2010 showed evidence supporting
Our review is in agreement with 1) The reports by Racicki 2012,
stretching/range of motion (ROM) exercises for pain relief imme-
Bronfort 2009, and Hurwitz 2008, suggesting evidence of benefit
diately post treatment but no change in the intermediate and long
for exercise in subacute/chronic cervicogenic headache and 2)
term for pain and function. Our review disagreed with these find-
Bertozzi 2013 about cardiovascular/aerobic training. There is low
ings while using the same evidence. We found low quality evidence
quality evidence (Andersen 2008) that 3) general fitness training
that neck stretching or ROM had no benefit relative to a control
may have no difference in pain when compared with a reference
treatment for chronic neck pain and function from immediately
intervention for (sub)acute/chronic neck pain immediately post
post treatment up to long-term follow-up.
treatment.
Three reviews included Qigong (an approach encompassing
stretching, strengthening, endurance training, balance/co-ordina-
tion, cardiovascular and cognitive/affective elements). Lee 2009
showed no evidence of benefit in the short term while Southerst
2014 and Teasell 2010c found Qigong exercise effective on pain AUTHORS’ CONCLUSIONS
in the short term for chronic WAD. Although our review sup-
ported the latter findings, there was only a very small magnitude Implications for practice
of effect on pain and function, but not on global perceived ef- This review shows that there is still no high quality evidence and
fect and quality of life immediately post treatment. Additionally, a uncertainty about the effectiveness of exercise for neck pain. Fur-
non-significant effect of a three-point change on NDI (zero to 50 ther research is likely and in some cases very likely to have an
scale) for function was noted at long-term follow-up. For cervico- important impact on the effect estimate. Moderate quality evi-
scapulothoracic and upper extremity stretching and strengthening, dence supports the use specific strengthening exercises as a part
Bertozzi 2013, similarly to our data, suggested that it may improve of routine practice for chronic neck pain, cervicogenic headache
pain immediately post treatment and at short-term follow-up. A and radiculopathy. Specifically the use of strengthening exercises
meta-analysis of four studies (Bronfort 2001; Chiu 2005; Franca for the cervical spine, scapulothoracic and shoulders may be ben-
2008; Martel 2011) of moderate quality evidence showed medium eficial in reducing pain and improving function when used for the
pain relief and function improvement at immediately post treat- treatment of chronic mechanical neck pain, cervicogenic headache
ment and long-term follow-up. Changes in global perceived effect and cervical radiculopathy. Moderate quality evidence supports
measures indicated a difference immediately post treatment and the use of strengthening exercises, combined with endurance or
at long-term follow-up. Finally, for stretching and strengthening, stretching exercises may also yield similar beneficial results. How-
two new reviews (Bertozzi 2013; Southerst 2014) showed evidence ever, low quality evidence notes when only stretching or only en-
of benefit on pain and function in long-term follow-up. Our re- durance type exercises were used for the cervical, scapulothoracic
view concurred with these reviews. The studies showed moderate and shoulders regions, there may be minimal beneficial effects for
quality evidence and two trials (Rendant 2011; von Trott 2009) both neck pain and function. There is moderate quality evidence
showed cervico-scapulothoracic and shoulder stretching, strength- to suggest beneficial effects of a specific type exercises (e.g. sus-
ening and stabilization exercises probably have medium benefit tained natural apophyseal glides) for cervicogenic headache.
for pain and function, but not global perceived effect and quality
of life at immediately post treatment and at short-term follow-up. Implications for research
Neuromuscular exercises (Leaver 2010; Teasell 2010b) showed
evidence of benefit for subacute/chronic neck pain with or without This update shows some positive findings for using exercise for
WAD in the short term for pain and function. This review found neck pain, but further research is warranted because it is (very)
very low quality evidence (Revel 1994) for a moderate reduction likely to have an important impact on the effect estimate. On-
in pain and function improvement in the short term for eye-neck going research to increase sample size and to pool similar data is
co-ordination exercises. required to further validate these findings, particularly in the area
Salt 2011 found a multimodal exercise approach favoured exer- of cervicogenic headache and cervical radiculopathy.
cise in acute radiculopathy. There was inconclusive evidence for Neck pain continues to be a somewhat heterogeneous classifica-
the effect of non-invasive management. We found low quality ev- tion. Use of prognostic and treatment classification variables may

Exercises for mechanical neck disorders (Review) 49


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
aid in distilling, which subgroups will most benefit from what ACKNOWLEDGEMENTS
specific exercise. An international standardization of a ‘core out-
come measure set’ is needed to improve reporting of effects and
to aid in the systematic review process. The length of follow-up in
many studies is limited and adherence to exercise not monitored.
Adequate recording of the types and exact dosage of the exercise We thank the Cervical Overview Group, Bruce Craven, for their
programs is also important to assist in translation of its use into contribution to this document. Dr. Craven was instrumental in
practice as well as for the pooling of data to improve in directness directing us to the exercise classification framework that was used
of the outcomes. as our foundation within this review.

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physiotherapy: A comparative clinical trial (pilot study). Martel J, Dugas C, Dubois JD, Descarreaux M.
Complementary Therapies in Medicine 2008;16:268–77. A randomised controlled trial of preventive spinal
Hall 2007 {published data only} manipulation with and without a home exercise program
Hall T, Chan H, Christensen L, Odenthal B, Wells for patients with chronic neck pain. BMC Musculoskeletal
C, Robinson K. Efficacy of a C1-C2 self-sustained Disorders 2011;12:41–54.
natural apophyseal glide (SNAG) in the management of
Rendant 2011 {published and unpublished data}
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Rendant D, Pach D, Ludtke R, Reishauer A, Mietzner A,
Physical Therapy 2007;37(3):100–7.
Willich SN, et al. Qigong versus exercise versus no therapy
Hallman 2011 {published data only} for patients with chronic neck pain. Spine 2011;36(6):
Hallman D, Olsson E, Schéele B, Melin L, Lyskov E. 419–29.
Effects of heart rate variability biofeedback in subjects with
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stress-related chronic neck pain: a pilot study. Applied
Revel M, Minguet M, Gergoy P, Vaillant J, Manuel JL.
Psychophysiology and Biofeedback 2011;36(2):71–80.
Changes in cervicocephalic kinesthesia after a proprioceptive
Hansson 2013 {published data only} rehabilitation program in patients with neck pain: a
Hansson EE, Persson L, Malmström EM. Influence of randomized controlled study. Archives of Physical Medicine
vestibular rehabilitation on neck pain and cervical range of Rehabilitation 1994;75:895–9.
motion among patients with whiplash associated disorders:
Stewart 2007 {published data only}
a randomized controlled trial. Journal of Rehabilitation ∗
Stewart MJ, Maher CG, Refshauge KM, Herbert RD,
Medicine 2013;45(9):906-10.
Bogduk N, Nicholas M. Randomized controlled trial of
Helewa 2007 {published data only} exercise for chronic whiplash-associated disorders. Pain
Helewa A, Goldsmith C, Smythe H, Lee P, Obright K. 2007;128:59–68.
Effect of therapeutic exercise and sleeping neck support on Stewart MJ, Maher CG, Refshauge KM, Herbert RD,
patients with chronic neck pain: a randomized clinical trial. Bogduk N, Nicholas N. Advice or exercise for chronic
Journal of Rheumatology 2007;34(1):151–8. whiplash disorders? Design of a randomized controlled trial.
Humphreys 2002 {published data only} BMC Musculoskeletal Disorders 2003;4:18.
Humphreys BK, Irgens PM. The effect of a rehabilitation Stewart MJ, Maher CG, Refshauge KM, Herbert RD,
exercise program on head repositioning accuracy and Nicholas MK. Patient and clinician treatment preferences
reported levels of pain in chronic neck pain subjects. Journal do not moderate the effect of exercise treatment in chronic
of Whiplash & Related Disorders 2002;1(1):99–112. whiplash-associated disorders. European Journal of Pain
Jull 2002 {published data only} 2008;12:879–85.
Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. Takala 1994 {published data only}
A randomized controlled trial of exercise and manipulative Takala EP, Viikari-Juntura E, Tynkkynen EM. Does group
therapy for cervicogenic headache. Spine 2002;27(17): gymnastics at the workplace help in neck pain? A controlled
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Kjellman G, Oberg B. A randomized clinical trial comparing Viljanen 2003 {published data only}
general exercise, McKenzie treatment and a control group in Viljanen M, Malmivaara A, Uitti J, Rinne M, Palmroos
patients with neck pain. Journal of Rehabilitation Medicine P, Laippala P. Effectiveness of dynamic muscle training,
2002;34:183–90. relaxation training, or ordinary activity for chronic neck
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Kuijper B, Tans JT, Beelen A, Nollet F, de Visser M. Cervical 475–80.
collar or physiotherapy versus wait and see policy for recent
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von Trott P, Wiedemann A, Ludtke R, Reibhauer A, Willich
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ST, Witt CM. Qigong and exercise therapy for elderly
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Lange B, Toft P, Myburgh C, Sjogaard G. Effect of targeted controlled study. Journal of Pain 2009;10(5):501–8.
strength, endurance, and coordination exercise on neck
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Acar 2012 {published data only} computer workers with neck and upper limb symptoms.
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and Musculoskeletal Rehabilitation 2012;25(4):261–7. The effectiveness of a work style intervention and a lifestyle
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physical-activity programs to reduce musculoskeletal
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symptoms in the neck and shoulder among office workers.
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muscles. Journal of Applied Physiology 2009;107:1413–19. Bosmans 2011 {published data only}

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983–90. Boyce 2012 {published data only}
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Andersen LL, Christensen KB, Holtermann A, Poulsen J, Fung VS. Active exercise for individuals with cervical
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The effectiveness of a work style intervention and a lifestyle 1–10.
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132:142–53. patients with whiplash associated disorders - a prospective
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Bernaards CM, Ariens GAM, Simons M, Knol DL, Burketorp L, Lindh M, Carlsson J, Stener-Victorin E.
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tailored to the individual needs of patients with whiplash- pacientes con cervicalgia mecanica en atencion primaria:
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Escortell-Mayor E, Lebrijo-Perez G, Perez-Martin Y,
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Gustavsson 2006 {published data only} therapy, physical therapy, or continued care by a general
Gustavsson C, Van Koch L. Applied relaxation in the practitioner for patients with neck pain. Annals of Internal
treatment of long-lasting neck pain: a randomized Medicine 2002;136(10):713–59. [CO2002]
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2006;38:100–7. Deville WJLM, Van der Windt DAWM, et al. Manual
Guzel 2006 {published data only} therapy, physical therapy, or continued care by the general
Guzel R, Akkoca H, Seydaoglu G, Uguz S, Kozanoglu practitioner for patients with neck pain: long-term results
E, Sarpel T. Efficacy of local anesthetic injection versus from a pragmatic randomized trial. In: Hoving JL editor(s).
dry needling in myofascial pain syndrome treatment Neck pain in primary care. 1st Edition. Wageningen: Pons
[Miyofasiyal agri sendromunun tedavisinde lokal anestezik & Looijen bv, 2001:59–73. [CO97]
enjeksiyonu ve kuru lgneleme yontemlerinin etkinliginin Korthals-de Bos IBC, Hoving JL, Van Tulder MW, Rutten-
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Rehabilitation 2006;52(1):22–7. therapy is more cost-effective than physical therapy and GP
Hagberg 2000 {published data only} care for patients with neck pain. In: Hoving JL editor(s).
Hagberg M, Harms-Ringdahl K, Nisell R, Hjelm EW. Neck pain in primary care. 1st Edition. Wageningen: Pons
Rehabilitation of neck-shoulder pain in women industrial & Looijen bv, 2001:75–90. [CO97]
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endurance training with isometric shoulder strength Hoving JL, de Vet HC, Koes BW, van Mameren H, Devillé
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2000;81:1051–8. therapy, or continued care by the general practitioner for
Häkkinen 2008 {published data only} patients with neck pain long-term results from a pragmatic
Häkkinen A, Kautiainen H, Hannonen P, Ylinen J. randomized clinical trial. Clinical Journal of Pain May 2006;
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dysfunction in neck and shoulder girdle muscles as the
Hamberg-van Reenen 2009 {published data only}
reason of cervicogenic headache among office workers.
Hamberg-van Reenen HH, Visser B, Van der Beek AJ,
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Hansson EE, Mansson N, Ringsberg KAM, Hakansson A. Hurwitz 2002 {published data only}
Dizziness among patients with whiplash-associated disorder: Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F,
A randomized controlled trial. Journal of Rehabilitation Adams AH. A randomized trial of chiropractic manipulation
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Henning 1997 {published data only} on rapid force development in painful neck and shoulder
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DOI: 10.1002/14651858.CD004250.pub4

Indicates the major publication for the study

Exercises for mechanical neck disorders (Review) 63


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID]

Allan 2003

Methods Type of Trial: RCT


Number Analyzed/Randomized: 16/16
Intention-to-treat Analysis: N/A
Power Analysis: NR

Participants Chronic MND (Myofascial Pain Syndrome)


Radicular signs/symptoms: Absent
Setting: Outpatient university teaching clinic
Country: UK

Interventions INDEX TREATMENT


Arm 1- a. Stretch before Manipulation: Activity- Static passive stretches into Movement
- lateral flexion and rotation on both sides of neck, held for 15 seconds, Mode- adminis-
tered by chiropractor with patient in supine position, immediately followed by cervical
manipulation given in accordance with the motion palpation findings. Manipulation
was administered with patient in supine position and the chiropractor making an index-
finger contact on the affected cervical segment(s); Dosage- 8 sessions over 4 weeks,
b. Cervical manipulation given in accordance with the motion palpation findings. Maip-
ulation was administered with patient in supine position and the chiropractor making an
index-finger contact on the affected cervical segment(s) immediately followed by static
passive stretches in lateral flexion and rotation on both sides of neck, held for 15 seconds,
administered by chiropractor with patient in seated position;
Arm 2- 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- Manipulation: Cervical manipulation given in accordance with the motion
palpation findings. Maipulation was administered with patient in supine position and
the chiropractor making an index-finger contact on the affected cervical segment(s); 8
sessions over 4 weeks
Treatment Schedule: 4 weeks, 20 sessions
Duration of Follow-up: none
CO-INTERVENTION: avoided in trial design

Outcomes PAIN
NRS, 0 to 100
Baseline Mean: Manip 30, Stretch before 58, Stretch After 63
Reported Results: no significant difference between groups
FUNCTION
NDI, 0 to 50
Baseline Mean: Manip 5, Stretch before 16, Stretch After 11
Reported Results: no significant difference between groups
REASON FOR DROP-OUTS: N/A

Exercises for mechanical neck disorders (Review) 64


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Allan 2003 (Continued)

SIDE EFFECTS: none


COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk No description


bias)

Allocation concealment (selection bias) Unclear risk No description given

Blinding (performance bias and detection High risk Not possible due to design
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to design
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Not possible due to design
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk See abstract


All outcomes - drop-outs?

Incomplete outcome data (attrition bias) Low risk No drop-outs


All outcomes - ITT analysis?

Selective reporting (reporting bias) Unclear risk No protocol available

Similarity of baseline characteristics? High risk ROM different between groups

Co-interventions avoided or similar? Unclear risk No mention

Compliance acceptable? Low risk See abstract

Timing outcome assessments similar? Low risk Tables 1 and 2

Exercises for mechanical neck disorders (Review) 65


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Andersen 2008

Methods Type of Trial: RCT


Number Analyzed/Randomized: 42/48
Intention-to-treat Analysis: NR
Power Analysis: NR

Participants (sub) Acute/Chronic MND (Trapezius Myalgia)


Radicular signs/symptoms: Absent
Setting: Seven workplaces
Country: Denmark

Interventions INDEX TREATMENT


Arm 1- Specific Strength Training (SST) or General Fitness Training (GFT): Activity-
(SST): high intensity specific strength training locally for neck and shoulder muscles.
(GFT): Cycling high-intensity general fitness training with legs only, upright position
without holding onto the handlebars (relaxing shoulders during training), Mode- (SST)
: 5 dumbbell exercises. (GFT): Monark bicycle ergometer, Movement- (SST): single
arm row, shoulder abduction, shoulder elevation, reverse flies, and upright row).Training
program progressively increased using the principles of periodization 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- (SST): performed using consecutive concentric and eccentric muscle contrac-
tions (raising and lowering pair of dumbbells) in a controlled manner without pause,
each set lasting 25-35 seconds. 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 minutes,
3x/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 (V02max ). 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 minutes 3
times/week for 10 weeks of intervention for an average of 25 ± 4.8 sessions. (GFT): 20
minutes 3 times/week for 10 weeks
COMPARISON TREATMENT
Arm 2- Health Counseling Group: Lectures with information on activities promoting
general health and individual: workplace ergonomics, diet, health, relaxation, and stress
management. 1 hour per week for 10 weeks for an average of average 27 ± 2.8 sessions
Treatment Schedule: 10 weeks, 20 sessions
Duration of Follow-up: 10 weeks
CO-INTERVENTION: Not avoided
COMPARISON TREATMENT
Reference intervention without physical activity (REF): Activity-the participants re-
ceived health counselling on group and individual levels regarding workplace ergonomics,
diet, health, relaxation, and stress management, frequency: 3x per week. Dosage- 20-
minutes sessions
Treatment Schedule: 30 sessions over 10 weeks
Duration of Follow-up: none
CO-INTERVENTION: Not specified

Exercises for mechanical neck disorders (Review) 66


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Andersen 2008 (Continued)

Outcomes PAIN in trapezius muscle


VAS, 0 to 100
Baseline Mean: SST 44, GFT 50, REF 43
Reported Results: no significant difference between groups
SMD immediate post: 0.18 (-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 specified
SIDE EFFECTS: NR
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not described


bias)

Allocation concealment (selection bias) Unclear risk No description of concealment

Blinding (performance bias and detection High risk Not possible due to intervention
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to intervention
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Unclear risk 9% drop-out acceptable, but reason for
All outcomes - drop-outs? drop-outs not described. Furthermore, it
is unclear which groups’ data were missing
(see Sogaard 2012)

Incomplete outcome data (attrition bias) Unclear risk p 90 - 6 drop-outs in the REF group - not
All outcomes - ITT analysis? analyzed

Selective reporting (reporting bias) Low risk Trial registration adequate. International
Standard Randomized Controlled Trial
Number Register: ISRCTN87055459.
(see Sogaard 2012)

Similarity of baseline characteristics? Unclear risk Table 1 p 88

Exercises for mechanical neck disorders (Review) 67


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Andersen 2008 (Continued)

Co-interventions avoided or similar? Unclear risk Not reported

Compliance acceptable? High risk p 87

Timing outcome assessments similar? Low risk P175, right column, 2nd paragraph (So-
gaard 2012)

Andersen 2011

Methods Type of Trial: RCT


Number Analyzed/Randomized: 192/198
Intention-to-treat Analysis: calculated
Power Analysis: 95%

Participants (sub) Acute/Chronic MND (Myofascial Pain Syndrome/Cervicogenic headache/tension


type headache?)
Radicular signs/symptoms: Not specified
Setting: two large white collar organizations
Country: Denmark

Interventions INDEX TREATMENT


Arm 1- 2 minute training (2-minutes):Activity- Progressive resistance training with
theraband. Mode-Shoulder Movement- abduction- lateral raise. Dosage: 2 minutes, 5
times/week for 10 weeks of intervention for an average of 26 ± 3.6 sessions
Arm 2- 12-minute training: Activity- Progressive resistance training with theraband.
Mode-Shoulder, Movement- abduction- lateral raise. Dosage- 12 minutes 5 times/week
for 10 weeks of intervention for an average of 25 ± 4.8 sessions
COMPARISON TREATMENT
Arm 3- 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
Duration of Follow-up: 10 weeks
CO-INTERVENTION: Not avoided

Outcomes PAIN
VAS, 0 to 10
Baseline Mean: 2 minutes 3.5, 12 minutes 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 significantly 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 12 minutes group, 2 in
Control group, reasons reported
SIDE EFFECTS: Reported worsening of neck muscle tension during and/or in the days
after training (2-minute n = 1, 12-minute n = 4), shoulder joint pain during training
(2-minute n = 1, 12-minute n = 4), pain in the upper arm during training (2-minute

Exercises for mechanical neck disorders (Review) 68


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Andersen 2011 (Continued)

n = 1, 12-minute n = 1), pain of the forearm/wrist during training (12-minute n = 2),


worsening of headache after training (2-minute n = 1, 12-minute n = 1). No long-lasting
or major complications resulted from the training program.
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk pg 444 second column/ pg 442 first column
bias)

Allocation concealment (selection bias) Low risk Described pg 444

Blinding (performance bias and detection High risk Not possible due to intervention
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to intervention
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Not possible self- assessment evaluation
bias) NPRS
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk p 443 second column
All outcomes - drop-outs?

Incomplete outcome data (attrition bias) High risk Figure 1 p 441 - not all participants ran-
All outcomes - ITT analysis? domized were analyzed

Selective reporting (reporting bias) Unclear risk No protocol

Similarity of baseline characteristics? Low risk

Co-interventions avoided or similar? Low risk Co-interventions similar p 443 section 2.5

Compliance acceptable? Low risk p 443 second column

Timing outcome assessments similar? Low risk p 443 top of 1st/p 441 under methods

Exercises for mechanical neck disorders (Review) 69


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Andersen Ch 2012

Methods Type of trial: RCT


Number Analyzed/Randomized: 158/449
Intention-to-treat analysis: calculated
Power Analysis: 95%

Participants Non specific neck pain


Radicular signs/symptoms: NR
Setting: NR
Country: Denmark

Interventions INDEX TREATMENT


Arm 1- Training groups (WS): Activity- Upper extremity strength training Mode-
Weights. Movement- Dumbbell exercises front raise, lateral raise, reverse flies shrugs
and wrist extension.Dosage- Type of contraction (dynamic); Intensity (20 repetition
maximum at baseline to 8 repetition maximum at later phase); Speed (NR); Duration/
Frequency (1-weekly session WS = 1hour/week, 3WS = 20 minutes at 3 sessions/week,
9 WS = 7 minutes at 9 sessions/week; Sequence (NR); Environment (NR); Feedback
(experienced instructor supervised every other training session)
Treatment Schedule: 20 weeks.
COMPARISON TREATMENT
Arm 2- Reference group: No treatment
Treatment Schedule: 20 weeks
Duration of Follow-up: NR
CO-INTERVENTION: NR

Outcomes PAIN
Modified Nordic Questionnaire (MNQ), 0 to 9
Baseline Mean: 1WS (4.83), 3WS (4.96), 9WS (4.71), REF (4.83)
Reported Results: no significant difference between groups
SMD (1WS vs control): -0.44 (95% CI: -1.31 to 0.43); SMD (3WS vs control): -0.67
(95% CI: -1.59 to 0.25); SMD (9WS vs control): -0.30 (95% CI: -1.36 to 0.76)
FUNCTION
Disability of the arm, shoulder and hand (DASH), 0 to100
Baseline Mean: 1WS (16), 3WS (18), 9WS (15), REF (16)
Reported Results: no significant difference between groups
SMD (1WS vs control): -0.17 (95% CI: -0.58 to 0.24); SMD (3WS vs control): -0.23
(95% CI: -0.66 to 0.19); SMD (9WS vs control): -0.06 (95% CI: -0.53 to 0.41)
REASON FOR DROP-OUTS: NR
SIDE EFFECTS: NR
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not described in this paper, but Anderson
bias) 2010 is referenced to have details

Exercises for mechanical neck disorders (Review) 70


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Andersen Ch 2012 (Continued)

Allocation concealment (selection bias) Unclear risk Not described in this paper, but Anderson
2010 is referenced to have details

Blinding (performance bias and detection High risk Perceptible difference between groups
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Perceptible difference between groups
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Patient is the assessor
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) High risk 38% drop-out rate
All outcomes - drop-outs?

Incomplete outcome data (attrition bias) Unclear risk Minimum supervision group not described
All outcomes - ITT analysis? (Figure 1); P1007Lp

Selective reporting (reporting bias) Low risk See trial registration

Similarity of baseline characteristics? Low risk Table 2 - gave yes, but some hesitation be-
cause of higher proportion of males in 3WS
group

Co-interventions avoided or similar? Unclear risk Not reported

Compliance acceptable? High risk P1007Lp1; 56% did more than 20 min-
utes exercise per week - 60min/week was
planned

Timing outcome assessments similar? Low risk Baseline, 20 weeks

Ang 2009

Methods Type of Trial: RCT


Number Analyzed/Randomized: 56/68
Intention-to-treat Analysis: Calculated
Power Analysis: Calculated

Participants Chronic MND (Mechanical Neck Pain & Myofascial Pain Syndrome)
Radicular signs/symptoms: Absent
Setting: 2 air force helicopter bases
Country: Sweden

Exercises for mechanical neck disorders (Review) 71


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Ang 2009 (Continued)

Interventions INDEX TREATMENT


Arm 1- Exercise Group: Activity- Patterns and synchronization of muscle recruitment,
Endurance-Strengthening exercises, Mode- Progression from non postural (supine,
prone) low-load active craniocervical flexion at 5 pressure levels (22 to 30 mmHg), seated
postural exercises with active craniocervical flexion and active scapular retraction. Seated
and standing elastic resistance, Movement- supine craniocervical flexion exercises, prone
isometric shoulder/scapular, seated active craniocervical flexion 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- Non postural exercises-held isometri-
cally (low load) for 10 seconds, repeated 10 times. Postural (seated, isometric held at 5
pressure levels like supine, holding 10 seconds, repeated 10 times, neck rotation to end
range 3 sets repeated 10 to 15 times on each side. Endurance-strength exercises 3 sets
of 15 repetitions (elastic bands were used to replicate the exercises at home). Feedback
The supervising physiotherapist monitored potential surface flexor activity visually, with
palpation if necessary
Treatment schedule: Assigned exercises (2 to 4) were to be completed 2 times/day lasting
10 to 15 minutes, supervised weekly by a physiotherapist providing instruction and
manual guidance
COMPARISON TREATMENT
Arm 2- Control: No exercise, encouraged to continue with ordinary exercise activity
Treatment Schedule: 6 weeks, instructed to do 2 to 4 exercises 2 times/day, for 10 to
15 minutes, supervised by physiotherapist weekly.
Duration of Follow-up: 12 months
CO-INTERVENTION: Not specified

Outcomes PAIN
Prevelance 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% to 15% and 76% to 44% respectively,
whereas in controls it was unchanged
RR (exercise group vs control): 0.45 (95% CI: 0.18 to 1.14). 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

Notes

Risk of bias

Exercises for mechanical neck disorders (Review) 72


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Ang 2009 (Continued)

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Randomization technique not adequately
bias) described

Allocation concealment (selection bias) Unclear risk Not adequately described

Blinding (performance bias and detection High risk Not possible


bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible


bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Patient is assessor


bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk Described in Figure 2


All outcomes - drop-outs?

Incomplete outcome data (attrition bias) Low risk Figure 2; P 457Lp3


All outcomes - ITT analysis?

Selective reporting (reporting bias) Unclear risk No protocol

Similarity of baseline characteristics? Low risk See Tables 1-3

Co-interventions avoided or similar? Unclear risk Not reported

Compliance acceptable? Unclear risk Unsure of long-term compliance in exercise


group; unsure what compliance data refer
to

Timing outcome assessments similar? Low risk Baseline, 6 weeks, 1 year

Beer 2012

Methods Type of Trial: RCT


Number Analyzed/Randomized: 20/20
Intention-to-treat Analysis: Not calculated
Power Analysis: Not calculated

Participants Persistent neck pain


Radicular signs/symptoms: Not specified
Setting: Local university and newsletter, sedentary office workers

Exercises for mechanical neck disorders (Review) 73


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Beer 2012 (Continued)

Country: Australia

Interventions INDEX TREATMENT


Arm 1- Exercise group: Activity- Functional postural exercise. Mode- Sitting. Move-
ment- 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- concentric-isometric hold with postural awareness, low in-
tensity,10 second hold every 15 to 20 minutes 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
COMPARISON TREATMENT
Arm 2- Control group: Did not undertake any exercise intervention during the study
Treatment schedule: 2 weeks
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

Outcomes PAIN
VAS, 0 to 10
Baseline mean: treatment 3.0 control 2.6
Reported results: no significant
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 significant
SMD (exercise vs control): -0.32 (95% CI: -1.21 to 0.56)
REASONS FOR DROP-OUTS: NR
SIDE EFFECTS: NR
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Randomization technique not adequately
bias) described (p.221- left column)

Allocation concealment (selection bias) Unclear risk Not described.

Blinding (performance bias and detection High risk Not possible. Required active patient par-
bias) ticipation (exercise/posture)
All outcomes - patients?

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Beer 2012 (Continued)

Blinding (performance bias and detection High risk Not possible. Required active provider
bias) participation (exercise prescription/posture
All outcomes - providers? education)

Blinding (performance bias and detection High risk Patient is the outcome assessor.
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Unclear risk Not described.


All outcomes - drop-outs?

Incomplete outcome data (attrition bias) Unclear risk Not described.


All outcomes - ITT analysis?

Selective reporting (reporting bias) Unclear risk No protocol.

Similarity of baseline characteristics? Low risk p.222- Table 1

Co-interventions avoided or similar? Unclear risk Not measured

Compliance acceptable? Unclear risk Study group was supposed to do exercise


every 15-20 minutes; see p.222/right col-
umn/paragraph 1 for vast range

Timing outcome assessments similar? Low risk Baseline and 2 weeks

Bronfort 2001

Methods Type of Trial: RCT


Number Analyzed/Randomized: 158 to 160/191
Intention-to-treat analysis: NR
Power Analysis: NR

Participants Chronic MND


Radicular signs/symptoms: Absent
Setting: University Centre for Clinical Studies and the Physician’s Neck and Back Clinic
Country: USA, Canada

Interventions INDEX TREATMENT


Arm 1- MedX Exercise (MedX): Activity- High technology exercise, Mode/Movement-
medically supervised rehabilitative exercise. Dosage- 20 sessions over 3 months
Arm 2- Manipulation and low tech Exercise (SMT/Ex):Activity- Chiropractic manip-
ulation, supervised low technology rehabilitative exercise, Mode- progressive strength-
ening exercises for the neck and upper body proceeded by a short aerobic warm up of
the upper body and light stretching, Movement- the upper body strengthening exercises
included push ups and dumbbell shoulder exercises as described by Dyrssen et al 1989.
Dosage- 45 minutes total, 2 sets of 15 to 30 repetitions, weight 2 to 10 lbs; cervical
progressive resisted strengthening exercises where performed while lying on a therapy

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Bronfort 2001 (Continued)

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
COMPARISON TREATMENT
Arm 3- Spinal Manipulative (SMT): Chiropractic manipulation, 20 sessions over 3
months
Treatment Schedule: 11 weeks, 20 session
Duration of Follow-up: 12 months
CO-INTERVENTION: NR

Outcomes CUMULATIVE ADVANTAGE for six patient-oriented outcomes


Reported Results: favours SMT/Ex over SMT; MONOVA value yielded a significant
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%
FUNCTION
NDI, 0 to 50
Reported Results: no significant group differences were found ANOVA: F(2, 156) = 2.
04, P = 0.13
SMD (SMT/Ex vs SMT) at LT follow-up: -0.38 (95% CI: -0.78 to 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 satisfied to completely dissatisfied
Reported Results: A clinically worthwhile cumulative advantage was reported favouring
manipulation/exercise (low tech) group over exercise (high tech) and manipulation alone
ANOVA: F(2, 158) = 6.7, P = 0.002
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
SMD (SMT/Ex vs SMT) at LT follow-up: -0.42 (95% CI: -0.81 to 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: 0.23 to 1.55) RR(SMT vs MedX): 0.61 (95%
CI: 0.23 to 1.55)
COST OF CARE: NR

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Bronfort 2001 (Continued)

Notes Final data since there was small difference in reporting data between Bronfort 2001 and
Evans 2002, we elected to abstract Evans 2002 data for the data and analyses table.

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Sequentially numbered, opaque envelopes,
bias) prepared using a computer-generated list
prior to start of study p2384

Allocation concealment (selection bias) Low risk Study staff, investigators, clinicians, and
patients were masked to upcoming treat-
ment assignments p2384

Blinding (performance bias and detection High risk Not possible due to self-report measures
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Not possible due to study design.
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) High risk 93% at 11 weeks, 76% overall, but not de-
All outcomes - drop-outs? scribed.

Incomplete outcome data (attrition bias) High risk Only 145 out of 178 participants were an-
All outcomes - ITT analysis? alyzed according to Table 2

Selective reporting (reporting bias) Unclear risk No protocol available

Similarity of baseline characteristics? Low risk Comparable on measured clinical and de-
mographic characteristics, see Table 1

Co-interventions avoided or similar? Unclear risk Not reported

Compliance acceptable? Unclear risk Not reported with respect to exercise

Timing outcome assessments similar? Low risk 5, 11 weeks of treatment, 3, 6, 12 months

Exercises for mechanical neck disorders (Review) 77


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Chiu 2005

Methods Type of Trial: RCT cross-over design


Number Analyzed/Ransomized: 109/145
Intention-to-treat Analysis: Calculated
Power Analysis: 90%

Participants Subacute MND (Cervical Brachial Pain Syndrome)


Radicular signs/symptoms: Absent
Setting: Physiotherapy Outpatient Department
Country: Hong Kong

Interventions INDEX TREATMENT


Arm 1- Craniocervical Flexion and isometric neck strengthening (CCF): Activity- deep
neck flexor strengthening, Infrared irradiation Mode- -using pressure sensor @20mmhg
x10 minutes (10 seconds on/15 seconds off ) Strengthening using a Multi Cervical Re-
habilitation Unit (MCRU). Movement/Dosage- 15 repetitions of flexion, extension at
20% of Peak Isometric Strength (PIS) as warm-up. Then dynamic flexion and extension
with variable resistance x 0 to 12 repetitions.
Treatment Schedule: 35 minutes of exercise per session
COMPARISON TREATMENT:
Arm 2- Transcutaneous Electrical Nerve Stimulation (TENS): 30 minutes of dual chan-
nel portable TENS unit (ITO model 1302). Continuous trains of 150ms square pulse
at 80Hz. 4 Electrodes (4x4cm)
Arm 3- Control Group: Infrared Irradiation (IR): place on Ex 21, GB21, LI 11, intensity
2 to 3 times of participants sensory threshold education on neck care
Treatment schedule: 20 minutes per session, 6 weeks, 2 sessions/wk
Duration of Follow-up: 6 months
CO-INTERVENTION: NS

Outcomes PAIN
VAS, 0 to 10
Baseline Mean: CCF 4.61, TENS 4.69, IR 4.26
Reported Results: NS
SMD (CCF vs IR): -0.34 (95% CI: -0.72 to 0.04); NNTB 6, treatment advantage 24%
FUNCTION
Northwick Park Questionnaire (NPQ) - Chinese version, 0 to 4
Baseline Mean: CCF 1.39, TENS 1.55, IR 1.36
Reported Results: CCF vs IR was significant (P = 0.02)
SMD (CCF vs IR): -0.33 (95% CI: -0.71 to 0.05); NNTB 6, treatment advantage 16%
REASON FOR DROP-OUTS: Reported
SIDE EFFECTS: No complications occurred.
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Computer-generated minimization


bias) method

Exercises for mechanical neck disorders (Review) 78


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Chiu 2005 (Continued)

Allocation concealment (selection bias) Low risk Computer-based randomization

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk


All outcomes - drop-outs?

Incomplete outcome data (attrition bias) Low risk


All outcomes - ITT analysis?

Selective reporting (reporting bias) Low risk

Similarity of baseline characteristics? Low risk See Table 1

Co-interventions avoided or similar? Low risk

Compliance acceptable? Low risk

Timing outcome assessments similar? Low risk See Table 2

Dellve 2011

Methods Type of trial: RCT


Number Analyzed/Randomized: 60/73
Intention-to-treat Analysis: NR
Power Analysis: Not calculated

Participants Chronic cervical neck pain or cervicobrachial pain syndrome


Radicular signs/symptoms: NR
Setting: University Hospital Clinic
Country: Sweden

Interventions INDEX TREATMENT


Arm 1- Myofeedback Training (MT): Activity- activities of daily living; Mode- wearing a
myofeedback device; Movement- ergonomic adjustments; Dosage- Duration/Frequency
(minimum of 8 hours per week, typically 2 hours per day and 4 days per week); ;
Environment (various); Feedback (discussion with ergonomist once per week)

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Dellve 2011 (Continued)

Arm 2- Intensive Muscular Strength Training (IMST): Activity- Upper extremity


strength training Mode- resistance bands Movement- Exercises for strengthening and
co-ordinating the upper extremities. Dosage- Type of contraction (NR); Intensity (NR)
; Speed (NR); Duration/Frequency (2 times per day, 6 days per week for 4 weeks);
Sequence (warm-up movements followed by strengthening exercises then ending with
breathing and slow down movements); Environment (participant’s home); Feedback (er-
gonomist coaching)
Treatment Schedule: 4 weeks
COMPARISON TREATMENT
Arm 3- Control Group: Diary entries to record activities, discomfort, pain and sleeping
disturbances
Treatment Schedule: 4 weeks
Duration of Follow-up: 2 months
CO-INTERVENTION: not avoided

Outcomes PAIN
Numeric Pain Scale, 0 to 10
Baseline Mean: MT (6.0), IMST (6.3), Control (6.2)
Reported Results: no significant difference between groups
SMD (IMST vs control) at immediate post-treatment: -0.30 (95% CI: -0.92 to 0.33);
SMD (IMST vs control) at 2 months follow-up: -0.63 (95% CI: -1.27 to 0.00)
FUNCTION
Work Ability Index, 7 to 49
Baseline Mean: MT (19.3), IMST (19.0), Control (19.0)
Reported Results: no significant difference between groups
SMD (IMST vs control) at immediate post-treatment: -0.18 (95% CI: -0.80 to 0.44);
SMD (IMST vs control) at 2 months follow-up: 0.38 (95% CI: -0.25 to 1.01)
REASON FOR DROP-OUTS: 5 in MT Group, 7 in IMST Group, 1 in Control Group,
reasons reported
SIDE EFFECTS: NR
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not described


bias)

Allocation concealment (selection bias) Unclear risk Not described

Blinding (performance bias and detection High risk Not possible due to design
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to design
bias)
All outcomes - providers?
Exercises for mechanical neck disorders (Review) 80
Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Dellve 2011 (Continued)

Blinding (performance bias and detection High risk Not possible due to design
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Unclear risk High drop-out rate in second group; rea-
All outcomes - drop-outs? sons for drop-outs not described

Incomplete outcome data (attrition bias) High risk Figure 1 - only 20 analyzed per group
All outcomes - ITT analysis?

Selective reporting (reporting bias) Unclear risk No protocol

Similarity of baseline characteristics? Low risk Table 1

Co-interventions avoided or similar? Unclear risk Not reported by group

Compliance acceptable? Unclear risk Not reported

Timing outcome assessments similar? Low risk Baseline, 1 month, 3 months

Franca 2008

Methods Type of Trial: RCT


Number Analyzed/Randomized: 46/49
Intention-to-treat Analysis: Not specified
Power Analysis: Not calculated

Participants Chronic MND (Myofascial Pain Syndrome)


Radicular signs/symptoms: Absent
Setting: University Research and Rehabilitation Department
Country: Brazil

Interventions INDEX TREATMENT


Arm 1- Physiotherapy protocol performed according to Hall and Brody consisting of
Activity-stretching, strengthening Mode- muscle stretching of neck and upper limbs
regions; recruitment exercise of Deep Cervical Flexion Muscles; Movement- strengthen-
ing exercise of Deep Cervical Flexion Muscles and upper limbs. Duration of treatment
20 minutes, 1 to 2 times/week for 10 weeks
Arm 2- Acupuncture combined with Physiotherapy (G1) Activity- Stage 1: acupuncture
therapy based on the TCM theory of biao-li (symptom/root) treatment. Mode- Chinese
acupuncture, as the root treatment, was performed with a selection of body points by
means of the diagnostic of syndromes of TCM. Movement- Disposable stainless steel
needles (0.25 mm x 30 mm) with guide-tubes (Dong-bang Acupuncture Needle, Korea)
inserted bilaterally into the body points to a depth of 10 to 15 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

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Franca 2008 (Continued)

measuring 0.25 mm x 5 to 15 mm (Dongbang Acupuncture Needle, Korea) to a depth


of 1 to 2 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 minutes to maintain the needling sensation. Chinese
acupuncture was performed in 20 minutes and YNSA was maintained until 40 minutes.
Stage 2: Physiotherapy given simultaneously with YNSA
COMPARISON TREATMENTS:
Arm 3- Acupuncture (G2): Same protocol of acupuncture therapy as described in the
first stage of G1 for 20 minutes
Arm 4- Physiotherapy (G3): Same protocol of physiotherapy as described in the second
stage of G1 for 20 minutes
Treatment Schedule: 10 weeks, 20 sessions
Duration of Follow-up: 6 months follow-up
CO-INTERVENTION: avoided in trial

Outcomes PAIN
VAS, 0 to 100
Baseline Mean: PT+Acup 85.0, Acup 80.0, PT 70.0
Reported Results: According to KWT (Kruskal-Wallis test), the statistical analysis of
the inter-groups demonstrated significant (P < 0.05) differences among the groups. The
DMCT (Dunn’s Multiple Comparison test) showed that G1 was superior to G3 in pain
improvement (P < 0.05)
SMD (PT+ Acup vs Acup) at immediate post treatment: -0.73 (95% CI: -1.46 to -0.
00), treatment advantage 11%
FUNCTION
NDI - Brazilian/Portuguese version
Baseline Mean: PT+Acup 24.0, Acup 30.0, PT 28.0
Reported Results: The DMCT (Dunn’s Multiple Comparison test) showed that G1
was superior to G3 in reducing functional disability (P < 0.0001)
SMD (PT + Acup vs Acup) at IT follow-up: -0.95 (95% CI: -1.70 to -0.20), NNTB13,
treatment advantage 13%
REASONS FOR DROP-OUTS: Reported (3 drop-outs, 1 in each group)
SIDE EFFECTS: Reported; no record of serious complication of acupuncture or phys-
iotherapy 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

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk


bias)

Allocation concealment (selection bias) Low risk

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Franca 2008 (Continued)

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk 1 per group


All outcomes - drop-outs?

Incomplete outcome data (attrition bias) High risk No ITT performed


All outcomes - ITT analysis?

Selective reporting (reporting bias) Unclear risk No protocol available

Similarity of baseline characteristics? High risk VAS scores were significantly different be-
tween groups

Co-interventions avoided or similar? Unclear risk Not clear

Compliance acceptable? Unclear risk Not clear

Timing outcome assessments similar? Low risk 10 weeks and 6 months

Hall 2007

Methods Type of Trial: RCT


Number Analyzed/Randomized: 32/32
Intention-to-treat Analysis: NR
Power Analysis: NR

Participants (sub)acute Cervicogenic headache (CGH)


Radicular symptoms/signs: NS
Setting: Physiotherapy Private Practice
Country: USA, Canada

Interventions INDEX TREATMENT


Arm 1- C1-2 self SNAG (SSng): Activity-Belt was used as per Mulligans detailed tech-
niques. Mode- The participant was instructed by the PT on the proper positioning and
technique of mobilization belt on 3 trials to familiarize themselves. The participant was
instructed to perform technique without producing pain. Movement- (supplemental
video available on line)

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Hall 2007 (Continued)

Treatment schedule: 1 day


COMPARISON TREATMENT
Arm 2- Control group (Mock): Sham mobilizations 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
CO-INTERVENTION: Not avoided

Outcomes 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: N/A
SIDE EFFECTS: NR
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection High risk Participans were allocated to treatment
bias) group using lottery ticket randomization
chosen from a concealed container

Allocation concealment (selection bias) High risk

Blinding (performance bias and detection Low risk


bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - providers?

Blinding (performance bias and detection Low risk


bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk


All outcomes - drop-outs?

Incomplete outcome data (attrition bias) Low risk No drop-outs


All outcomes - ITT analysis?

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Hall 2007 (Continued)

Selective reporting (reporting bias) Unclear risk No protocol available

Similarity of baseline characteristics? Low risk No significant differences were detected


between the 2 groups in terms of age,
headache history, FRT range, and headache
severity index score. Gender distribution
was similar. See Table 2

Co-interventions avoided or similar? High risk Not addressed

Compliance acceptable? Low risk Compliance investigated

Timing outcome assessments similar? Low risk 4 weeks postintervention and 12 months
postintervention

Hallman 2011

Methods Type of Trial: RCT


Number Analyzed/Randomized: 23/24
Intention-to-treat Analysis: Not calculated
Power Analysis: Not calculated

Participants Stress-related chronic neck-shoulder pain


Radicular signs/symptoms: NR
Setting: NR
Country: Sweden

Interventions INDEX TREATMENT


Arm 1- Practice paced breathing: Activity- breathing exercises;Mode- resonance heart
rate variability (HRV) biofeedback (BF) training and paced breathing; Movement- res-
piration.Dosage- Type of contraction (concentric diaphragm concentrically contracts
with this breathing exercise), intensity (low as was breathing exercises), On-site sessions:
speed (Sessions 1 and 10: between 4.5 to 6.5 breaths per minute to determine speed with
highest HRV. Sessions 2 to 9: performed at speed of highest HRV.), duration (Sessions 1
and 10: 2-minutes of paced breathing for 2-minutes of free, non-paced breathing. Ses-
sions 2 to 9: 4 times 5-minutes of resonant HRV BF with 2-minutes breaks), frequency
(1time/week), environment in which exercise is performed (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-minutes of paced breathing with watch or easy air
pacer software, 5 times/week
Treatment schedule: 10 weeks
COMPARISON TREATMENT
Arm 2- 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
CO-INTERVENTION: Not specified

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Hallman 2011 (Continued)

Outcomes PAIN
Borg Scale, 0 to 10
Baseline Mean : Treatment 2.6, Control 2.5
Reported Results: no significant difference between groups
SMD (treatment vs control): -0.19 (95% CI: -1.01 to 0.63)
FUNCTION
NDI, 0 to 100
Baseline Mean: Treatment 21.3, Control 25.6
Reported Results: no significant difference between groups
SMD (treatment vs control): -0.52 (95% CI: -1.35 to 0.32)
QUALITY OF LIFE
SF-36 (physical function subscale)
Baseline mean: Treatment 89.6, Control 77.5
Reported Results: no significant difference between groups
SMD (treatment vs control): 0.65 (95% CI: -0.19 to 1.49)
REASONS FOR DROP-OUTS: NR
SIDE EFFECTS: NR
COST OF CARE: NR

Notes Author contacted but no response

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Method not described


bias)

Allocation concealment (selection bias) Unclear risk Method not described

Blinding (performance bias and detection High risk Not possible due to design
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to design
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Patient is outcome assessor
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk P.74, right column
All outcomes - drop-outs?

Incomplete outcome data (attrition bias) High risk 1 drop-out not included in analysis - Table
All outcomes - ITT analysis? 1

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Hallman 2011 (Continued)

Selective reporting (reporting bias) Unclear risk No protocol

Similarity of baseline characteristics? Unclear risk See Table 2 - differences in physical func-
tion, vitality, social function, depression

Co-interventions avoided or similar? Unclear risk Not reported

Compliance acceptable? Unclear risk Not reported

Timing outcome assessments similar? Low risk Baseline and 10 weeks

Hansson 2013

Methods Type of Trial: RCT


Number Analyzed/Randomized: 29/29
Intention-to-treat Analysis: calculated
Power Analysis: calculated

Participants WAD
Radicular signs/symptoms: Not specified
Setting: Physiotherapy centre
Country: Sweden

Interventions INDEX TREATMENT


Arm 1- Vestibular rehabilitation program: Activity- circuit training of six balance ex-
ercises with warm-up and recovery phases;Mode- static and dynamic balance exercises
with neck movements, eyes opened and closed; Movement- 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 train-
ing- 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 flexing the
knees and turning the head from side to side simultaneously. Standing on a 10 cm foam
with eyes closed and turning the head from side to side. Standing on a sport mat, walk-
ing 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- Warm-up duration- 10-minutes. Circuit training duration- 2- minutes
per exercise, 2 laps. Recovery phase duration- 5-minutes. Frequency (2 times/week), en-
vironment in which exercise is performed (physical therapy centre), feedback (supervised
group sessions)
Treatment Schedule: 6 weeks, 12 sessions
COMPARISON TREATMENT
Arm 2- Control Group: no intervention
Treatment Schedule: 6 weeks
Duration of Follow-up: 6 weeks and 3 months
CO-INTERVENTION: reported and not avoided

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Hansson 2013 (Continued)

Outcomes PAIN
VAS, 0 to 100
Baseline Median : Intervention 60, Control 60
Reported Results: no significant 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

Notes We utilized median values (SD) rather than mean scores (SMD) to calculate SMD

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk p.907 L bottom column: Random number
bias) table

Allocation concealment (selection bias) High risk p. 907 L bottom column: The same inde-
pendent person also carried out the inter-
vention

Blinding (performance bias and detection High risk Not possible due to design
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to design
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Not possible since pt is outcome assessor
bias) for VAS.
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) High risk Drop- out rate too high: 17/29 dropped
All outcomes - drop-outs? out (figure 1)

Incomplete outcome data (attrition bias) High risk Table 3- 6 weeks control (N = 12)
All outcomes - ITT analysis?

Selective reporting (reporting bias) Unclear risk Unable to find registration online (reg.
number lu 702-01)

Similarity of baseline characteristics? Low risk Table 2

Co-interventions avoided or similar? High risk P907 Lp1 - 5 patients underwent other
types of physio during the study

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Hansson 2013 (Continued)

Compliance acceptable? Unclear risk Not reported

Timing outcome assessments similar? Low risk p.907 bottom right column: the control
group was tested at the same intervals as the
intervention group

Helewa 2007

Methods Type of Trial: RCT


Number Analyzed/Randomized: 128/151
Intention-to-treat Analysis: Calculated
Power Analysis: Calculated: For factorial effects (not differences between treatment
groups) and based on a change on the Northwick Park Questionnaire

Participants Chronic MND


Radicular signs/symptoms: NS
Setting: University School of Physical Therapy
Country: Canada

Interventions INDEX TREATMENT


Arm 1- Exercise: Activity-Standard Pillow + Exercise + Active Control Treatment Group:
Standard (regular) pillow is assumed to be used by this group. Mode- Exercise includ-
ing: Posture, Relaxation, Active Movement- 1-Postural correction in sitting, standing
or during work and leisure activities emphasizing chin in retracted position with cer-
vical spine elongations not beyond normal curves of cervical spine practised with mir-
ror feedback first, then freely using other prompts to become habitual), 2-Relaxation
Exercise Techniques designed to interrupt cycle of pain and muscle spasm (hold-relax
approach repeated up to 5 times and/or rhythmic stabilization 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 flexion
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 flexion and extension, using the principles of successive induc-
tion (Sherrington 1961)). Dosage- 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- Neck Support (Pillow): Activity- Orthopaedic Pillow(s) + Active Control Treat-
ment Group: Mode- Neck Support Pillows Movement- 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 firmness of
the foam. The pillow use was combined with the Active Control treatment (massage and
thermal modality)
COMPARISON TREATMENT

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Helewa 2007 (Continued)

Arm 3- 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 firmness of
the foam. Pillow use, plus Exercise plus Active control treatment (massage and thermal
modality) were administered in this group
Arm 4- Massage Therapy and thermal modality (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,
Efflurage 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- Thermal modality: 20 minutes of moist heat or ice.
Treatment Schedule: 6 weeks (assume that the use of the pillow was constrained to these
6 weeks)
Duration of Follow-up: 6 weeks
CO-INTERVENTION: avoided in trial design

Outcomes PAIN
VAS, 0 to 10
Baseline Mean: Exercise 2.9, Pillow 3.6, Exercise + Pillow 2.3, Control 2.5
Reported Results: Not significant at all points
SMD (Exercise v Control): SMD -0.00 (95% CI: -0.52 to 0.52) SMD (Exercise + Pillow
v Pillow): SMD -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 significant 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
Reported Results: no significant difference between groups
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%
REASON FOR DROP-OUTS: Reported
SIDE EFFECTS: None present
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk 2x2 balanced factorial design, balanced
bias) treatment-group allocation was done us-

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Helewa 2007 (Continued)

ing randomly selected randomly ordered


blocks

Allocation concealment (selection bias) Low risk

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk


All outcomes - drop-outs?

Incomplete outcome data (attrition bias) High risk Not reported


All outcomes - ITT analysis?

Selective reporting (reporting bias) Unclear risk No protocol available

Similarity of baseline characteristics? Low risk See Table 1

Co-interventions avoided or similar? Low risk Reminder to participants at 12 weeks

Compliance acceptable? Low risk

Timing outcome assessments similar? Low risk Post treatment, 6 weeks treatment + 6
weeks follow-up, 6 weeks treatment + 18
weeks follow-up, 6 weeks treatment + 46
weeks follow-up

Humphreys 2002

Methods Type of trial: RCT


Number Analyzed/Randomized: 56/56
Intention-to-treat Analysis: Not specified
Power Analysis: NR

Participants Chronic neck pain


Radicular Signs/Symptoms: Not specified
Setting: Students attending a chiropractic college
Country: United Kingdom

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Humphreys 2002 (Continued)

Interventions INDEX TREATMENT


Arm 1- Symptomatic exercise group (SEG): Activity- One eye-head-neck co-ordination
and one eye-head-neck-upper limb co-ordination. Mode- sitting. Movement- Exercise
one: participants were required to fix 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 fixed 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 fixed on one thumb as the ipsilateral arm went through the sequential
movements of the left and right rotation, flexion and extension, with the eyes and head
followed the movement in a slow and co-ordinated fashion. Dosage- Speed (slow and
co-ordinated movement), Duration/Frequency (4 weeks, 2 times/day), Feedback (one
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- Control group: Symptomatic non-exercise group (SNEG).
Treatment Schedule: 4 weeks
Duration of Follow-up: none
CO-INTERVENTION: NR

Outcomes PAIN
VAS, 0 to 100
Baseline Mean: SEG 55, SNEG 49
Reported Results: no significant difference between groups SMD (SEG vs SNEG): 0.
00 (95% CI: -0.74 to 0.74)
REASON FOR DROP-OUTS: NR
SIDE EFFECTS: NR
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Unclear risk Not described


bias)

Allocation concealment (selection bias) Unclear risk Not described

Blinding (performance bias and detection High risk Not possible


bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible


bias)
All outcomes - providers?

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Humphreys 2002 (Continued)

Blinding (performance bias and detection High risk Patient is the assessor
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk p.105, Results: 56/63
All outcomes - drop-outs?

Incomplete outcome data (attrition bias) Unclear risk Not described


All outcomes - ITT analysis?

Selective reporting (reporting bias) Unclear risk No registration or protocol

Similarity of baseline characteristics? Unclear risk Inadequate information provided

Co-interventions avoided or similar? Unclear risk Not described

Compliance acceptable? Low risk p.107-108 Exercise Compliance: 95% &


89% compliance per group

Timing outcome assessments similar? Low risk Baseline, 2 weeks & 4 weeks

Jull 2002

Methods Type of Trial: RCT


Number Analyzed/Randomized: 193/200
Intention-to-treat Analysis: calculated
Power Analysis: NR

Participants Chronic CGH


Radicular signs/symptoms: NR
Setting: Multiple trial centres
Country: Australia

Interventions INDEX TREATMENT


Arm 1- Exercise Therapy (CCF/ISO) Activity- therapeutic low load exercise to cervical-
scapular region Mode- craniocervical flexor training with pressure biofeedback, scapular
muscle training, postural correction, Movement- exercise performed throughout the day,
isometric strengthening with co-contraction of neck flexion and extension, stretching
as needed. Treatment Schedule: 30-minute session duration, 2 sessions/weeks, 8 to 12
sessions total
Arm 2- Combined Therapy (MT/ET): Activity- manipulation, mobilization & exercise
Treatment Schedule: 30-minute session duration, two sessions/weeks, 8 to 12 sessions
total
COMPARISON TREATMENT
Arm 3- Manipulative Therapy (SMT): manipulation: high velocity, low-amplitude ma-
nipulation described by Maitland; mobilization (low velocity), 30-minute session dura-
tion. Dosage: 2 sessions/week, 8 to 12 sessions total

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Jull 2002 (Continued)

Arm 4- Control Group (NT): no treatment


Treatment Schedule: 6 weeks, 8 to 12 sessions
Duration of Follow-up: 52 weeks
CO-INTERVENTION: NR

Outcomes 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: significant favouring SMT and CCF
SMD (CCF v 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: significant favouring MT or MT/ET over control; no significant
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: significant favouring SMT and MT/ET over NT, not significant for
SMT or MT/ET when compared to CCF
SMD (CCF vs NT):-2.51 (95% CI:-3.05 to -1.97)
REASONS FOR DROP-OUTS: reported
SIDE EFFECT: minor and temporary, 6.7% of headaches were provoked by treatment
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk 2x2 factorial design, randomized permuted
bias) block design was used with stratification
for length of headache history and city of
residence

Allocation concealment (selection bias) Low risk An independent body implemented ran-
domization by telephone contact with each
trial centre

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - providers?

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Jull 2002 (Continued)

Blinding (performance bias and detection Low risk


bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk


All outcomes - drop-outs?

Incomplete outcome data (attrition bias) Low risk ITT analysis performed
All outcomes - ITT analysis?

Selective reporting (reporting bias) Unclear risk No protocol provided

Similarity of baseline characteristics? Low risk Baseline characteristics across the four
treatment groups were similar (See Table 1)
. The only exception was the distribution
of females across treatment groups, subse-
quently included as a covariate in the anal-
ysis

Co-interventions avoided or similar? High risk Present

Compliance acceptable? Low risk Reported

Timing outcome assessments similar? Low risk 6 weeks treatment + 1 week, 3 months, 6
months and 12 months follow-up

Kjellman 2002

Methods Type of Trial: RCT


Number Analyzed/Randomized: 70/77
Intention-to-treat Analysis: Calculated
Power Analysis: NR

Participants (sub)Acute to Chronic MND with or without radiation


Radicular signs/symptoms: Present
Setting: Primary care physical therapy and private physical therapy practices
Country: Sweden

Interventions INDEX TREATMENT


Arm 1- General Exercise (ET): Activity-stretching, strengthening, Mode- neck and
shoulder, Movement- ROM, active neck endurance and strength exercises, 16 sessions
over 2 months
Arm 2- McKenzie Exercise (McK): Specific McKenzie protocol. Sessions over 2 months.
Number not specified
COMPARISON TREATMENT
Arm 3- Sham Ultrasound (SUS): Set at lowest setting for 7 minutes. Applied over the
superior portion of the trapezius

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Kjellman 2002 (Continued)

Treatment Schedule: 4 weeks of treatment


Duration of Follow-up: 6 and 12 months
CO-INTERVENTION: Comparable between index and control groups.

Outcomes PAIN
VAS, 0 to 100
Baseline Mean: ET 27.0, McK 19, SUS 21
Reported Results: no significant difference between groups
SMD (ET vs SUS) at LT follow-up: -0.19 (95% CI: -0.41 to 0.80)
SMD (McK vs SUS) at LT follow-up: 0.04 (95% CI: -0.51 to 0.60)
FUNCTION
NDI, 0 to 50
Baseline Mean: ET 27.0, McK 19, US 21
Reported Results: no significant difference between groups
SMD (ET vs SUS) at LT follow-up: -0.19 (95% CI: -0.41 to 0.80)
SMD (McK vs SUS) at LT follow-up: 0.04 (95% CI: -0.51 to 0.60)
REASONS FOR DROP-OUTS: reported
SIDE EFFECTS: NR
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Randomization by drawing sealed en-
bias) velopes out of a box

Allocation concealment (selection bias) High risk Not reported

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk Drop-outs noted


All outcomes - drop-outs?

Incomplete outcome data (attrition bias) High risk Not reported


All outcomes - ITT analysis?

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Kjellman 2002 (Continued)

Selective reporting (reporting bias) Unclear risk No protocol available

Similarity of baseline characteristics? High risk Reported Table 1; no analysis

Co-interventions avoided or similar? High risk Table 5, higher use by control group

Compliance acceptable? Low risk

Timing outcome assessments similar? Low risk Post treatment, 8 weeks treatment + 6
months, 8 weeks treatment + 52 weeks fol-
low-up

Kuijper 2009

Methods Type of Trial: RCT


Number Analyzed/Randomized: 200/205 at 6 weeks, 192/205 at 6-month follow-up
Intention-to-treat Analysis: Calculated; sample size based on 90% power and to detect
a 10mm difference in the VAS (primary outcome) for arm pain (not neck pain).
Power Analysis: calculated

Participants Acute NDR


Radicular signs/symptoms: Present
Setting: Three Hospitals
Country: Netherlands

Interventions INDEX TREATMENT


Arm 1- Physiotherapy Group (PG): Activity-Therapy was focused on mobilizing and
stabilizing the neck and was characterized as “hands off ”. Mode- The sessions were
standardized provided by a certified Physiotherapist, the patient was instructed on graded
exercise activities to strengthen the superficial and deep muscle of the neck. The patients
were also instructed in a home exercise program. Movement- 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- Wait and see list Group (WLG): Patients in the control 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- Collar Group (CG): Semi-hard collar (Cerviflex S, Bauerfeind and available in 6
sizes), The best size (to fit 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
Treatment Schedule: 6 weeks, 12 sessions
Duration of Follow-up: 6 months
CO-INTERVENTION: Comparable between index and control groups. Patients were
asked to take paracetamol (usually) either with or without a non-steriodal antiinflam-
matory. If necessary opioids were prescribed

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Kuijper 2009 (Continued)

Outcomes PAIN
VAS, 0 to100
Baseline Mean: Cervical Collar 57.4, Physiotherapy 61.7, WLG 55.6
Reported Results: At 6 weeks there was a significant 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%
FUNCTION
NDI, 0 to 100
Baseline Mean: Cervical Collar 41.0, Physiotherapy 45.1, WLG 39.8
Reported Results: The collar group showed a significant difference in rate of improve-
ment compared with the control group, the weekly change in the physiotherapy group
was not significantly 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 to 1.37)
REASONS FOR DROP-OUTS: NR
SIDE EFFECT: NR
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk


bias)

Allocation concealment (selection bias) Low risk Sealed envelopes prepared by an employee
who had no other involvement with the
study. The investigator assigned patients to
specific groups

Blinding (performance bias and detection High risk Stated within text page 2
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Stated within text page 2
bias)
All outcomes - providers?

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Kuijper 2009 (Continued)

Blinding (performance bias and detection High risk Patient self-report so not blinded
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) High risk There were 5 participants who were not
All outcomes - drop-outs? available for follow-up at 6 weeks;similarly
there were 13 participants lost to follow-up
at 6 months. Figure one details this

Incomplete outcome data (attrition bias) High risk Not all those randomized were included in
All outcomes - ITT analysis? the analysis ( those without follow-up data
were excluded). However this was a very
small number and unlikely to affect the es-
timates. They undertook a LOCF analysis
but did not state an ITT analysis within the
report

Selective reporting (reporting bias) Unclear risk No protocol available

Similarity of baseline characteristics? High risk Greater arm pain in the collar group. Also
the control group had the smallest evidence
for root compression based on MRI

Co-interventions avoided or similar? Unclear risk All groups were allowed to take anal-
gesics and anitinflammatories.All patients
received the same information about the
natural course of the disease

Compliance acceptable? Low risk Compliance was monitored for both collar
use and physiotherapy. A total of 6 patients
(almost 10%) did not wear the collar at all
during the first 3 weeks

Timing outcome assessments similar? Low risk 6 weeks of treatment + 6 months and 12
months follow-up

Lange 2013

Methods Type of trial: RCT


Number Analyzed/Randomized: 55/55
Intention-to-treat Analysis: calculated
Power Analysis: NR

Participants Acute to chronic non-specific neck and shoulder pain


Radicular Signs/Symptoms: Not specified
Setting: Air force base- Fighter Wing Skrydstrup
Country: Denmark

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Lange 2013 (Continued)

Interventions INDEX TREATMENT


Arm 1- Training group: Activity- Patterns and synchronization of muscle recruitment,
Strengthening exercises, Endurance exercises Mode- Patterns and synchronization -
Standing supine and gentle rotation stood erect, Strenthening-the 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
degrees forward with a straight back for reverse flies. Endurance-holding the bodyblade
with both hands, and with shoulders 90% flexed and elbows 5% flexed Movement-
Patterns and synchronization-3 conditioning exercises focusing on activation of the deep
cervical flexors, Strengthening-Static pull in 8 directions, shrugs, reverse flys, Endurance-
Small shoulder extensions and flexions were performed to make the bodyblade oscillate
Dosage- Patterns and synchronization-Type of contraction (concentric), Speed (slow
and controlled movement), Duration/Frequency (5 reps, 3x 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% to 85% of 1 repetition
maximum), Duration/Frequency (8-15 reps, 3x week), Shrugs and static neck pull were
performed during every session and reverse flies were performed every second session),
Sequence (after warm-up), Feedback (the pilots had access to help from educated trainers
at the base and at Tactical Air Command Karup), Endurance-Type of contraction (dy-
namic), Intensity (equivalent to 70% to 85% of 1 repetition maximum), Speed (as the
participants became more accustomed to the bodyblade exercise, they attempted to make
it oscillate increasingly more rapidly) Duration/Frequency (up to 60 seconds, performed
every second session, 3x week), Sequence (after strengthening), Feedback (the pilots had
access to help from educated trainers at the base and at Tactical Air Command Karup).
Dosage- 3 sessions a week, 20 minutes of training session for 24 weeks
COMPARISON TREATMENT
Arm 2- Control group: No intervention but offered the training after the study. Encour-
aged to continue their physical activity as usual
Treatment Schedule: 24 weeks
Duration of Follow-up: none
CO-INTERVENTION: comparable between index and control groups

Outcomes PAIN
VAS, 0 to 10
Baseline Mean:Training group 1 and control 1.2
Reported Results: no significant difference between groups
SMD (training vs control): -0.58 (95% CI: -1.12 to -0.04)
REASON FOR DROP-OUTS: Reported
SIDE EFFECTS: Reported
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

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Lange 2013 (Continued)

Random sequence generation (selection Unclear risk P.51, right column, 1st paragraph: method
bias) of randomization very unconventional

Allocation concealment (selection bias) Low risk p.51, top R column

Blinding (performance bias and detection High risk Not possible due to design.
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to design
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Not possible due to design
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk P53, left column: 1 drop-out per group
All outcomes - drop-outs?

Incomplete outcome data (attrition bias) Low risk P53, left column, paragraph 6
All outcomes - ITT analysis?

Selective reporting (reporting bias) Low risk Consistent with registration

Similarity of baseline characteristics? Low risk Table 1, Table 3, Table 4

Co-interventions avoided or similar? Unclear risk Not monitored

Compliance acceptable? High risk P54, right column, Figure 3: 58% compli-
ance

Timing outcome assessments similar? Low risk Baseline and 24 weeks

Lundblad 1999

Methods Type of Trial: RCT


Number Analyzed/Randomized: 58/97
Intention-to-treat Analysis: NR
Power Analysis: NR

Participants Chronic MND


Radicular signs/symptoms: NS
Setting: Factory
Country: Sweden

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Lundblad 1999 (Continued)

Interventions INDEX TREATMENT


Arm 1- Feldenkrais Intervention (F): Activity-Education Mode- Individualized (func-
tional integration) teacher guides through movement sequences; Group (awareness
through movement) verbally guided through exercises for Movement- neck-shoulder
complaints, home exercises, frequency (individually 4 times and in group (7 to 8 par-
ticipants) 12 times; required 50% participation in both segments of program). Dosage-
50 minutes per week
Arm 2- Physiotherapy Intervention (MmPT): Activity- Stabilization exercises for low
back and pelvis, isolated and relaxed shoulder movements Mode- Education use of
body emphasizing self-directed control and responsibility for body, ability to cope with
pain, muscle tension, and complaints. Awareness of body posture. Movement- Practice
work-related lift and movement techniques. Exercise program of strength, co-ordination,
endurance, flexibility/smoothness and rhythm, Home exercises. Dosage- 50 minutes; 2
times/week for 16 weeks in group of 5 to 8 participants; Required 50% participation in
the exercises
COMPARISON GROUP
Arm 3- Control Regimen (NT): no treatment
Treatment Schedule: 16 weeks, 32 sessions
Duration of Follow-up: 52 weeks
CO-INTERVENTION: NR

Outcomes PAIN
VAS, 0 to 10
Baseline Mean: VAS - usually MmPT 1.2, F 1.5, NT 2.0, VAS - worst MmPT 4.1, F
4.4, NT 5.5
Reported Results: no significant differences
SMD (PT vs no treatment) at LT follow-up: -0.14 (95% CI: -0.80 to 0.51)
DISABILITY
Work and leisure, 0 to 4; Sick leave, days and %
Baseline Mean:
Disability - work MmPT 1.3, F 1.2, NT 1.3,
Disability - leisure MmPT 0.6, F 0.9, NT 0.6
Sick leave (days) MmPT 12.7, F 12.0, NT 11.5,
Sick leave (%) MmPT 6.5, F 5.8, NT 5.9
Reported Results: no significant differences
REASON FOR DROP-OUTS: Reported
SIDE EFFECTS: NR
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection High risk Randomization not described


bias)

Allocation concealment (selection bias) High risk Concealment not described

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Lundblad 1999 (Continued)

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) High risk Not reported


All outcomes - drop-outs?

Incomplete outcome data (attrition bias) High risk No ITT analysis


All outcomes - ITT analysis?

Selective reporting (reporting bias) Unclear risk No protocol available

Similarity of baseline characteristics? Low risk Table 3 no significant difference

Co-interventions avoided or similar? Low risk Avoided in trial design

Compliance acceptable? Low risk

Timing outcome assessments similar? Low risk 16 weeks of treatment + 6 weeks follow-up

Martel 2011

Methods Type of Trial: RCT


Number Analyzed/Randomized: 64/69
Intention-to-treat Analysis: Calculated
Power Analysis: NR

Participants Chronic MND with or without referral/radiation to the head, trunk or limbs
Radicular signs/symptoms: Present
Setting: Chiropractic Clinic and Human Research Laboratory of the Department of
Chiropractice at the Universite du Quebec
Country: Canada

Interventions INDEX TREATMENT


Arm 1- SMT Group: Activity- Spinal Manipulation Mode- Maximum 4 spinal ma-
nipulations Movement- cervical and upper thoracic areas. Dosage- One treatment per
month, lasted 10 to 15 minutes
Arm 2- SMT + Exercise Group:Activity- Spinal Manipulation + Home Exercise Pro-
gram, range of motion, stretching, strengthening Mode- Maximum 4 spinal manipula-

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Martel 2011 (Continued)

tions. Advised to perform a home exercise program Movement- manipulation- cervical


and upper thoracic areas (down to T4). home exercise program- range of motion exer-
cises, followed by 4 stretching/ mobilization, and 4 strengthening exercises (concentric
and isometric contractions) of the cervical and upper thoracic spine (primarily flexion,
extension, lateral flexion and rotation of the cervical spine). Dosage- manipulation- one
treatment per month, lasted 10 to15 minutes. Home exercise program 3x/week. Three
series of each exercises with a 30 to 60 second rest between series were performed during
each training session. A training session lasted 20 to 30 minutes
All participants were instructed in the same routine, exercise volume was tailored to each
participant’s strength, flexibility and ability to complete the routine with minimal neck
pain. Each patient received a written copy of the program. Exercise checked every 2
months by a kinesiologist
COMPARISON TREATMENT
Arm 3- Control Group: Attention-control, No treatment, attended clinic once every 2
months, visited lasted 20 to 30 minutes for data collection
Treatment Schedule: 10 months, 10 sessions
Duration of Follow-up: none
CO-INTERVENTION: NR

Outcomes PAIN
VAS, 0 to 10
Baseline Mean: SMT 3.1, SMT + Ex 3.8
Reported Results: no significant differences
FUNCTION
NDI, 0 to 50
Baseline Mean: SMT 21.4, SMT + Ex 22.2
Reported Results: no significant differences
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
Reported Results: no significant differences
REASON FOR DROP-OUTS: Reported
SIDE EFFECTS: Reported: No serious adverse events were reported during RCT
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk


bias)

Allocation concealment (selection bias) Low risk Sealed, opaque envelopes

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - patients?
Exercises for mechanical neck disorders (Review) 104
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Martel 2011 (Continued)

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk


All outcomes - drop-outs?

Incomplete outcome data (attrition bias) High risk No ITT analysis


All outcomes - ITT analysis?

Selective reporting (reporting bias) Unclear risk No protocol available

Similarity of baseline characteristics? Low risk Table 1

Co-interventions avoided or similar? High risk

Compliance acceptable? High risk Not Reported

Timing outcome assessments similar? Low risk 10 months of treatment

Rendant 2011

Methods Type of Trial: RCT


Number Analyzed/Randomized: 113/122
Intention-to-treat Analysis: calculated
Power Analysis: calculated

Participants Chronic MND


Radicular signs/symptoms: NS
Setting: Community
Country: Germany

Interventions INDEX TREATMENT


Arm 1- Qigong: Activity-12 neck exercises, 9 shoulder exercises Mode/Movement-
ROM/mobility, imagery, breathing and moving exercise (Figure 1) home exercise with
a manual; Qigong qualified teacher was certified by German Qigong Society Dosage-
18 sessions, 90 minute sessions over 6 months
Arm 2- Exercise: Activity- ROM, stretching, strengthening Mode/Movement- Warm-
up included neck ROM, use of soft ball, strengthening using a theraband; flexibility
exercise, home exercise with a manual, individual pain level was not exceeded;Dosage-
18 sessions over 6 months; exercise is monitored by a qualified physiotherapist
COMPARISON TREATMENT

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Rendant 2011 (Continued)

Arm 3- Control: no intervention


Treatment Schedule: 24 weeks treatment, 18 sessions
Duration Follow-up: none
CO-INTERVENTION: not avoided

Outcomes PAIN
VAS, 0 to 100
Baseline Mean: Qigong 57.7, E 57.5, NT 53.4
Reported Results: significant differences Qigong vs no treatment;
MD (Qigong vs no treatment) at 12 weeks treatment: -15.60 (-24.72 to -6.48)
MD (Qigong vs no treatment) at 24 weeks treatment: -8.10 (-15.72 to -0.48)
MD (Exercise vs no treatment) at 12 weeks treatment:-17.30 (95%CI: -26.60 to -8.00)
MD (Exercise vs no treatment) at 24 weeks treatment:-10.30 (95%CI: -19.97 to -0.63)
No significant difference Qigong vs exercise
FUNCTION
NPDI, 0 to 100
Baseline Mean: Qigong 44.0, E 39.5, NT 43.2
Reported Results: significant differences Qigong vs no treatment;
SMD (Qigong vs no treatment) at 12 weeks treatment: -0.48 (95%CI: -0.92 to -0.04)
SMD (Qigong vs no treatment) at 24 weeks treatment: -0.47 (95%CI: -0.92 to -0.02)
SMD (Exercise vs no treatment) at 12 weeks treatment: -0.78 (95%CI: -1.24 to -0.31)
SMD (Exercise vs no treatment) at 24 weeks treatment: -0.50 (95%CI: -0.97 to -0.04)
No difference Qigong vs exercise
QUALITY of LIFE
SF 36, physical component
Baseline Mean: Qigong 43.1, E 43.7, NT 43.3
Reported Results: significant differences qigong vs no treatment;
MD (Qigong vs no treatment) at 12 weeks treatment: -3.40 (95% CI: -6.97 to 0.17)
MD (Qigong vs no treatment) at 24 weeks treatment: -3.90 (95%CI: -8.07 to 0.27)
MD (Exercise vs no treatment) at 12 weeks treatment:-2.70 (95%CI: -6.76 to 1.36)
MD (Exercise vs no treatment) at 24 weeks treatment:-2.00 (95%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

Notes Additional unpublished data received from author


* attrition bias may exist as ITT analysis are not presented in this overviews; ITT was
performed in the RCT report

Risk of bias

Bias Authors’ judgement Support for judgement

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Rendant 2011 (Continued)

Random sequence generation (selection Low risk page 420


bias)

Allocation concealment (selection bias) Low risk page 420

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk The outcome assessor was the patient (i.e.
bias) VAS) therefore not blind to previous an-
All outcomes - outcome assessors? swer

Incomplete outcome data (attrition bias) Low risk Quigong 39/42 - acceptable; exercise 35/
All outcomes - drop-outs? 39 acceptable ; Wait list 39/41

Incomplete outcome data (attrition bias) Low risk ITT was stated
All outcomes - ITT analysis?

Selective reporting (reporting bias) Unclear risk No study protocol

Similarity of baseline characteristics? Low risk Table 1, Overall no difference noted be-
tween most variables albeit perceived effec-
tiveness has some differences

Co-interventions avoided or similar? Unclear risk Not noted

Compliance acceptable? Unclear risk Not reported

Timing outcome assessments similar? Low risk Baseline, 3 months and 6 months

Revel 1994

Methods Type of Trial: RCT


Number Analyzed/Randomized: 60/60
Intention-to-treat: NA
Power analysis: NR

Participants Chronic MND (osteoarthritic changes 27 of 30)


Radicular signs/symptoms: Absent
Setting: Outpatient Rheumatology Department
Country: France

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Revel 1994 (Continued)

Interventions INDEX TREATMENT


Arm 1- Proprioception Rehabilitation Group (RG) Activity- Proprioceptive rehabili-
tation program: purpose to improve neck proprioception; Mode- 15 minute individ-
ualized exercise session, exercises were mainly concerned with eye-neck co-ordination
including; Movement- a) slow passive motions of the head with gaze on a fixed 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- 2 times per week; 30 to 40 minute sessions
COMPARISON TREATMENT
Arm 2- Control Group (CG): Medication: analgesic, antiinflammatory typical dosage
was indomethacin 100mg; aspirin, 3000 mg; diclofenac, 150 mg; naproxen, 1000 mg
Treatment Schedule: 8 weeks
Duration of Follow-up: 2 weeks
CO-INTERVENTION: NR

Outcomes PAIN
VAS, 0 to 100
Baseline Mean: RG 50.5, CG 45.9
Reported Results: significant 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, CG 2.3/1.6
Reported Results: not significant
FUNCTIONAL IMPROVEMENT SELF-ASSESSED
scale 0 to 5
Reported Results: significant favouring RG
SMD at ST follow-up: 0.55 (95% CI: 0.33 to 0.89), NNTB 3, treatment advantage NA
REASON FOR DROP-OUTS: NR
SIDE EFFECTS: NR
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection High risk Randomization not described


bias)

Allocation concealment (selection bias) Low risk

Blinding (performance bias and detection Low risk


bias)
All outcomes - patients?

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Revel 1994 (Continued)

Blinding (performance bias and detection High risk Not possible due to intervention
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Patient self-report so not blinded
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk


All outcomes - drop-outs?

Incomplete outcome data (attrition bias) High risk No ITT analysis


All outcomes - ITT analysis?

Selective reporting (reporting bias) Unclear risk No protocol available

Similarity of baseline characteristics? High risk

Co-interventions avoided or similar? Low risk

Compliance acceptable? High risk Not reported

Timing outcome assessments similar? Low risk 8 weeks of treatment + 10 weeks follow-up

Stewart 2007

Methods Type of Trial: RCT


Number Analyzed/Randomized: 16/16
Intention-to-treat Analysis: NA
Power Analysis: NR

Participants Subacute and Chronic WAD with or without radiation


Radicular signs/symptoms: Present
Setting: Two physiotherapy clinics
Country: Australia

Interventions INDEX TREATMENT


Arm 1- Exercise and Advice: Activity- Exercise, Mode- aerobic exercise, stretches, func-
tional activities, activities to build speed, endurance and co-ordination, trunk and limb
strengthening, CBT (setting goals of progressively increasing difficulty, shaping, encour-
aging self-monitoring of progress, self-reinforcement), home exercise program (indi-
vidual specified), Movement- graded exercise program supervised by a physiotherapist,
Dosage- duration (1 hour of exercise per session), feedback (supervised for 30 minutes)
Individualized, progressive, intensity (submaximal program) designed to improve par-
ticipants ability to complete functional activities specified by the participant as being
difficult because of whiplash. Regular evaluation by a physiotherapist. Encouraged to
continue home exercises even after intervention was completed. Dosage- 6 weeks, 12

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Stewart 2007 (Continued)

sessions
COMPARISON TREATMENT
Arm 2- Advice Alone: Standardised education, reassurance and encouragement to re-
sume light activity alone. One consultation and 2 follow-up phone contacts. Favorable
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

Outcomes PAIN
VAS, 0 to 10
Baseline Mean: Exercise + Advice 5.2, Advice Alone 5.3
Reported Results: Groups were similar at baseline.
SMD post: -0.46 (95% CI: -0.81 to -0.12) SMD 12 month: -0.12 (95% CI: -0.47 to
0.23)
FUNCTION
NDI, 0 to 50
Baseline Mean: Exercise + Advice 18.2, Advice Alone 19.7
Reported Results: Groups were similar at baseline.
SMD post: -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
Baseline Mean: Exercise + Advice 0.6, Advice Alone 0.3
Reported Results: Groups were similar at baseline.
SMD post: -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
Baseline Mean: Exercise + Advice 36.4, Advice Alone 36.8
Reported Results: Groups were similar at baseline
SMD post: -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 specified
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

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection High risk Randomized method is not described
bias)

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Stewart 2007 (Continued)

Allocation concealment (selection bias) Low risk Reported p 60

Blinding (performance bias and detection High risk Not described


bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible


bias)
All outcomes - providers?

Blinding (performance bias and detection High risk pg 61, self-report scales therefore patient is
bias) assessor even though author reports scales
All outcomes - outcome assessors? being administered and scored by staff
blind to group assignment

Incomplete outcome data (attrition bias) Low risk Although descriptions of drop-outs were
All outcomes - drop-outs? not given, due to the low number of drop-
outs we feel this is acceptable

Incomplete outcome data (attrition bias) High risk


All outcomes - ITT analysis?

Selective reporting (reporting bias) Low risk pg 61, referenced protocol

Similarity of baseline characteristics? Low risk Table 1

Co-interventions avoided or similar? High risk Not similar at 12 months

Compliance acceptable? Low risk Section 3.3

Timing outcome assessments similar? Low risk 6 weeks and 12 months

Takala 1994

Methods Type of Trial: RCT


Number Analyzed/Randomized: 44/45
Intention-to-treat: NR
Power Analysis: NR

Participants MND, disorder duration NR


Radicular signs/symptoms: Absent
Setting: Printing Company
Country: Finland

Interventions INDEX TREATMENT


Arm 1- Exercise treatment (ET): Activity- Group gymnastic, instructional type (group)
, Mode- setting (work); treatment characteristics (exercise planned to train whole body)

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Takala 1994 (Continued)

, Movement- aerobic dynamic exercise (10 minutes walking or stepping), relaxation,


stretching of muscles of the trunk and extremities and dynamic exercises (10 minutes),
Dosage- sequence (10 minutes walking/stepping, 10 minutes stretch/dynamic exercises,
5 minutes walking/stepping, 10 minutes dynamic and co-ordination exercises, 10 min-
utes stretch and relaxation); duration of session (45 minutes);1 time/week
COMPARISON TREATMENT
Arm 2- No treatment (NT)
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 PAIN
VAS, 0 to 100
Baseline Median: ET 40, NT 50
Reported Results: no significant difference
PRESSURE PAIN SENSITIVITY
Algometer (pressure pain threshold (PPT) on upper trapezius, levator scapulae, rhom-
boid, infraspinatus) mean score of 8 measures
Baseline Mean: ET 45.2, NT 44.8
Reported Results: no significant difference
SMD at immediate post treatment: -0.06 (95% CI: -0.65 to 0.53)
REASON FOR DROP-OUTS: NR
SIDE EFFECTS: NR
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection High risk Matching then random allocation not de-
bias) scribed

Allocation concealment (selection bias) Low risk The rater was blinded with respect to the
group status (treatment or control) of the
participant

Blinding (performance bias and detection Low risk


bias)
All outcomes - patients?

Blinding (performance bias and detection High risk


bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Patient self-report so not blinded
bias)

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Takala 1994 (Continued)

All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk


All outcomes - drop-outs?

Incomplete outcome data (attrition bias) High risk ITT not performed
All outcomes - ITT analysis?

Selective reporting (reporting bias) Unclear risk No protocol available

Similarity of baseline characteristics? High risk

Co-interventions avoided or similar? Low risk Similar in all groups

Compliance acceptable? High risk Not monitored

Timing outcome assessments similar? Low risk 10 weeks of treatment

Viljanen 2003

Methods Type of Trial: RCT


Number Analyzed/Randomized: 340/393
Intention-to-treat Analysis: Calculated
Power Analysis: Calculated

Participants Chronic MND (NDR, NDH, WAD)


Radicular signs/symptoms: NR
Setting: Office workers
Country: USA, Canada

Interventions INDEX TREATMENT


Arm 1- Exercise: Activity- muscle training; Mode- activating large muscle groups in
neck and shoulders Movement- dumbbells with weight of 1 to 3 kg; Dosage- Dynamic
muscle training, Sequence (stretching followed each exercise); progression in weeks 5
and 9
Arm 2- Relax: Activity- Relaxation training; Mode/Movement- progressive relaxation,
autogenic training, functional relaxation, systematic desensitization
COMPARISON TREATMENT
Arm 3- Control: No treatment
Treatment Schedule: 12 weeks plus 1 week reinforcement, Arm 1-13.6 sessions; Arm
2- 14.6 sessions
Duration of Follow-up: 3 and 9 months
CO-INTERVENTION: Comparable between groups

Outcomes PAIN
VAS, 0 to 10
Baseline Mean: Exercise 4.8, Relax 4.8, Cntl 4.1
Reported Results: no group difference

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Viljanen 2003 (Continued)

SMD (Exercise v Cntl): -0.04 (95% CI: -0.28 to 0.20)


FUNCTION
NDI, 0 to 50
Baseline Mean: Exercise 29, Relax 2 29, Cntl 26
Reported Results: no significant group differences were found
SMD (Exercise vs Cntl): -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

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Randomization according to a random


bias) numbers table

Allocation concealment (selection bias) Low risk Treatment allocation was concealed in a
numbered opaque envelope, which was
opened by the physician after baseline mea-
surements had been taken

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - patients?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Not possible due to study design
bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) High risk Reasons for drop-outs not described
All outcomes - drop-outs?

Incomplete outcome data (attrition bias) Low risk


All outcomes - ITT analysis?

Selective reporting (reporting bias) Unclear risk No protocol available

Similarity of baseline characteristics? Low risk

Co-interventions avoided or similar? Low risk Comparable between groups

Compliance acceptable? High risk

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Viljanen 2003 (Continued)

Timing outcome assessments similar? Low risk 12 weeks of treatment + 3 and 9 month
follow-up

von Trott 2009

Methods Type of Trial: RCT


Number Analyzed/Randomized: 93/117
Intention-to-treat Analysis: Calculated
Power Analysis: Calculated

Participants Chronic MND in elderly adults


Radicular signs/symptoms: NR
Setting: Residents of residential homes for elderly people
Country: Germany

Interventions INDEX TREATMENT


Arm 1- Qigong: Activity- Qigong, Mode- lessons, Movement- started with about 10
minutes of typical Qigong “opening” exercises, continued with up to 4 exercises of
Dantian Qigong, and finished with about 10 minutes of “closing” exercises. Dosage-
Qigong was provided by 5 approved Qigong therapists; 24 sessions (45 minutes) over 3
months (2 sessions/week)
Arm 2- Exercise: Activity- Exercise therapy Mode- was based on a standardized program
for computer and workplace related neck pain Movement- including repeated active
cervical rotations, strength and flexibility exercises. A detailed description is provided in
Weidmann 2008. Dosage- 24 sessions (45 minutes) over 3 months (2 sessions/week).
Participants were asked to continue exercising on their own for the next 3 months
COMPARISON TREATMENT
Arm 3- Wait List Control: Patients were free to treat their neck pain with the treatment
or therapies they were using prior to randomization. Patients did not received 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

Outcomes PAIN
VAS, 0 to100
Baseline Mean : Qigong 56.4, Exercise 47.1, Wait List Control 49.9
Reported Results: After 3 months there was not significant 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 significant 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)
MD (Qigong vs control) at 12 weeks treatment: -7.50 (95% 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

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von Trott 2009 (Continued)

NDI, 0 to100
Baseline Mean: Qigong 38.5, Exercise 41.8, Wait List Control 36.1
Reported Results: No significant difference was found between the groups after 3 and
6 months
SMD (Qigong vs control) at 12 weeks treatment: -0.21 (95% CI: -0.69 to 0.28)
SMD (Qigong vs control) at 12 weeks treatment + 12 weeks follow-up: -0.06 (95% CI:
-0.57 to 0.45)
SMD (Exercise vs control) at 12 weeks treatment: -0.23 (95%CI: -0.70 to 0.24)
SMD (Exercise vs control) at 12 weeks treatment + 12 weeks follow-up: -0.29 (95%CI:
-0.77 to 0.20)
GLOBAL PERCEIVED EFFECT
SMD (Qigong vs control) at 12 weeks treatment: -0.01 (95% CI: -0.49 to 0.47)
SMD (Qigong vs control) at 12 weeks treatment + 12 weeks follow-up: -0.09 (95% CI:
-0.60 to 0.42)
SMD (Exercise vs control) at 12 weeks treatment: 0.09 (95%CI: -0.38 to 0.56)
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
Baseline Mean: Qigong 30.4, Exercise 28.7, Wait List Control 30.6
Reported Results: No significant difference was found between the groups after 3 and
6 months
MD (Qigong vs control) at 12 weeks treatment: -1.80 (95% CI: -5.94 to 2.34)
MD (Qigong vs control) at 12 weeks treatment + 12 weeks follow-up: 0.10 (95% CI: -
3.99 to 4.19)
MD (Exercise vs control) at 12 weeks treatment: -1.70 (95%CI: -5.96 to 2.56)
MD (Exercise vs control) at 12 weeks treatment + 12 weeks follow-up: 2.20 (95%CI: -
1.81 to 6.21)
REASON FOR DROP-OUTS: Reported
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 acing muscles, 1 nausea)
COST OF CARE: NR

Notes

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk


bias)

Allocation concealment (selection bias) Low risk

Blinding (performance bias and detection High risk Perceptibly different interventions between
bias) groups
All outcomes - patients?

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von Trott 2009 (Continued)

Blinding (performance bias and detection High risk Not possible due to intervention
bias)
All outcomes - providers?

Blinding (performance bias and detection High risk Patient is assessor


bias)
All outcomes - outcome assessors?

Incomplete outcome data (attrition bias) Low risk


All outcomes - drop-outs?

Incomplete outcome data (attrition bias) Low risk


All outcomes - ITT analysis?

Selective reporting (reporting bias) Low risk Wiedmann 2008

Similarity of baseline characteristics? Low risk Table 1

Co-interventions avoided or similar? Unclear risk Unclear about the wait list group

Compliance acceptable? Unclear risk Compliance of home based exercises was


not measured

Timing outcome assessments similar? Low risk 3 months, 6 months

1.0 Definitions of terms


1.1 duration of disorder:
Acute = <30 days (1 month, 4 weeks)
Subacute = 30 days (1 month, 4 weeks) to 90 days (3 months, 12 weeks)
Chronic = > 90 days (3 months, 12 weeks)
1.2 duration of follow-up
immediate post (IP) treatment ≤ one day
short-term (ST) follow-up = one day to three months
intermediate-term (IT) follow-up = three months up to, but not including, one year
long-term (LT) follow-up = one year or longer
2.0 Short forms commonly used in text and tables:
2.1 Clinical terms
CBT = Cognitive Behavioral Therapy
CCF = Craniocervical Flexion
CGH = Cervicogenic
ED = Education
ET = Exercise Therapy
F = Feldenkrais
GFT = General Fitness Training
IR = Infrared Radiation
ISO = Isometric Neck Exercise
ISOSh = Isometric Shoulder Exercise

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ISOShEn = Isometric Shoulder Endurance
ISOShST = Isometric Shoulder Strength
McK = McKenzie
MmPT = Multimodal Phyical Therapy
MND = mechanical neck disorders
Mock = Mock therapy
MT = manual therapy
NDR = neck disorders with radicular findings
NoEG = No Exercise Group
NeuT = Neural Mobilizations
NT = No treatment
Pil = Pillow
REL = Relaxation
ROM = range of motion
SFT = Specific Strength Training
SMP = Self Management Prog
SMT = Manipulation
SMT/ET = Manipulation and exercise
SpvT = supervised training of CSP/Scap
SSng =Self Snag
StEx = Standard exercise
SUS = Sham Ultra Sound
TENS = transcutaneous electrical nerve stimulation
US = ultrasound
WAD = whiplash-associated disorders
2.2 Outcome measures
WHYMPI = West Haven-Yale Multidimensional Pain Inventory [sub scale pain severity]
SF-36 = short-form 36 [short-form with 36 questions yielding an 8-scale health profile]
NDI = neck disability index
VAS = visual analogue scale
NRS-101 = numeric rating scale 101 [0 to 100 point scale]
PPT = pain pressure threshold [measured by algometer]
BORG = Borg pain scale
MNQ = Modified Nordic Pain Questionnaire
NPS = Numeric Pain Scale
NPQ = Northwick Park Questionnaire
DASH = Disability of the Arm, Shoulder and Hand
WAI = Work Ability Index
NPDI = Neck Pain Driving Index
SF-36 = Short Form 36
SF-12 = Short Form 12
2.3 Other
vs = versus
w = weeks
m = months
y = years
CI = Confidence Interval
ITT = Intention-To-Treat
NA = Not Applicable
NR = Not Reported
NNTB = Number-Needed-to-Treat-to-Benefit
RCT = Randomized Controlled Trial
Q-RCT - Quasi-randomized Controlled Trial
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RR = Risk Ratio
SD = Standard Deviation
SMD = Standardized Mean Difference

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Acar 2012 Intervention: exercise in all arms.

Ahlgren 2001 Intervention: exercise in all arms.

Allison 2002 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Andersen 2008a Comparison: Comparison group received equal attention by forming groups which should improve
workplace ergonomics, stress management, etc

Andersen 2010 Comparison: Comparison group received equal attention by forming groups which should improve
workplace ergonomics, stress management, etc

Arami 2012 Intervention: exercise in all arms.

Ardic 2002 Intervention: exercise in all arms.

Bernaards 2007 Intervention: Multimodal including exercise and cognitive behavioral training (companion paper to
Bernaards 2008 and Bernaards 2012.

Bernaards 2008 Intervention: Multimodal including cognitive behavioral training (companion paper to Bernaards
2007 and Bernaards 2012).

Bernaards 2012 Intervention: Multimodal including exercise and cognitive behavioral training (companion to
Bernaards 2007 and Bernaards 2008).

Bissett 1985 Intervention: EMG biofeedback mediated muscle relaxation not active exercise

Blangsted 2008 Comparison: Comparison group received equal attention by forming groups which should improve
workplace etc (companion paper to Andersen 2008).

Bonk 2000 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Bosmans 2011 Intervention: Multimodal approach with intervention groups without ability to differentiate each
treatment techniques contribution

Boyce 2012 Population: cervical dystonia.

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(Continued)

Brewerton 1966 Intervention: Instruction on posture is not considered an exercise. There was no exercise group outside
“instruction on posture”

Brodin 1985 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Bronfort 2012 Comparison: No control group.

Burketorp 2006 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Carlsson 1990 Population: Chronic tension headache (either occipital, temporal and/or frontal)

Cleland 2010 Intervention: Both treatment and control received same exercise intervention

Cramer 2013 Intervention: exercise in all arms, no control group.

Cunha 2008 Intervention: Multimodal - manual therapy and exercise.

Cuzdan 2013 Intervention: exercise in all arms.

Dusunceli 2009 Intervention: Multimodal - exercise and PT agents.

Ehrenborg 2010 Intevention: exercise in all arms.

Escortell-Mayor 2008 Intervention: Both treatment and control received same exercise intervention

Escortell-Mayor 2011 Intevention: Both treatment and control received same exercise intervention

Evans 2002 Intervention: manual therapy, medication and education.

Falla 2006 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Fitz-Ritson 1995 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Foley-Nolan 1992 Intervention: Not exercise.

Friedrich 1996 Intervention: Education comparison, exercise is the same in all 3 groups

Gam 1998 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Giebel 1997 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

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(Continued)

Goldie 1970 Design: Q-RCT

Gustavsson 2006 Intervention: The control treatment was individualized care (acupuncture, massage, mobs, hot pack,
TENS, US, exercise) and we were not able to elucidate the exact treatment mix for the treat as usual
group

Guzel 2006 Intervention: Both groups received the same exercise intervention

Hagberg 2000 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Hamberg-van Reenen 2009 Population: Convenience sample of 22 healthy workers.

Hansson 2006 Population: dizziness not neck pain as main complain.

Hanten 1997 Outcome Measures: Did not use any of the identified outcome measures (only pain pressure threshold
as a proxy for pain)

Hanten 2000 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Henning 1997 Population: Preventional trial, although participants rated neck and shoulder discomfort this subpop-
ulation was never identified, nor was discomfort ratings in neck and shoulders reported

Hoving 2002 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Hoving 2006 Intervention: manual therapy versus exercise versus continued care (medication and education)

Huber 2013 Intervention: exercise in all arms, no control group.

Hudson 2010 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Hurwitz 2002 Intervention: No active exercise.

Hurwitz 2005 Intervention: Exercise was same in all groups.

Häkkinen 2008 Intervention: exercise in all arms.

Jay 2013 Outcome: no patient important outcome.

Jensen 2001 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Jensen 2005 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

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(Continued)

Jordan 1998 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Jull 2007 JOR Intervention: All groups received exercise.

Jull 2007 Pain Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Jull 2009 Intervention: All groups received exercise.

Jull 2013 Intervention: multimodal therapy versus usual care.

Kamwendo 1991 Intervention: Exercises not specified.

Karlberg 1996 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Karlsson 2011 Comparison: comparison was another active exercise treatment

Kietrys 2007 Comparison: Comparison was activities.

Koes 1991 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Kogstad 1978 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Lamb 2013 Intervention: multimodal treatment.

Lansinger 2007 Intevention: Both treatment and control received same exercise intervention

Lansinger 2013 Intervention: one exercise vs another exercise type.

Lee 2013 Intervention: Exercise within a multimodal care approach specifically MT + Ex + PT vs that same PT

Levoska 1993 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Linton 2001a Intervention: Unable to separate exercise group within treatment as usual comparison group

Lluch 2014 Comparison: mobilization versus exercise.

Ma 2011 Intervention: No control group, comparison group received education

Madson 2010 Intevention: Both treatment and control received same exercise intervention

Maiers 2013 Intervention: exercise in all arms.

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(Continued)

Manca 2006 Intervention: Exercise prescription was not a significant component of the study (less than 10%)

Marangoni 2010 Population: less than 80% of the population have neck pain (72%)

McKinney 1989 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Mealy 1986 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Michalsen 2012 Comparison: exercise in all arms.

Moffet 2006 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Mongini 2012 Population: all types of headaches included.

Murphy 2010 Intervention: Both treatment and control received same exercise intervention

Nielsen 2010 Outcome: no patient important outcome.

Nordemar 1981 Intervention: Passive exercise.

O’Leary 2007 Outcome Measures: The reported outcomes are not outcomes of interest to this review

O’Leary 2007 JoPain Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Pato 2010 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Pedersen 2013 Study design: prospective observational study.

Pennie 1990 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Persson 1994 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Pool 2006 Intervention: Protocol only, multimodal approach within intervention groups without ability to dif-
ferentiate each treatment techniques contribution (Ex+graded activity+MT)

Provinciali 1996 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Ragonese 2009 Comparison: Exercise vs. Manual Therapy.

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(Continued)

Randlov 1998 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Rosenfeld 2000 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Rosenfeld 2003 Intervention: Both groups received exercise.

Rundcrantz 1991 Design: This was a quasi-RCT, treatment was individualized and unable to specify exercise

Ryan 2001 Intervention: Both groups received exercise (strength vs endurance)

Salmon 2013 Population: participants did not have neck pain prior to start of trial

Schnabel 2004 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Scholten-Peeters 2006 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Sharan 2011 Intervention: multimodal treatment in all arms.

Skargren 1997 Intervention: Unable to separate data for exercise group (unclear if McKenzie treatment mobilization
or exercise)

Skillgate 2007 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Skoglund 2011 Outcome: no baseline data.

Soderlund 2000 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Soderlund 2001 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Song 2012 Abstract Outcome/Publication: Insufficient information. Further data were sought but not found. No full
publication could be source

Taimela 2000 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Telci 2012 Intervention: Multimodal treatment with exercise VS multimodal treatment VS medicines

Tsauo 2004 Population: Prevention trial, between than 14.3 -58.5 % of participants had neck pain at baseline

van den Heuvel 2003 Population: Prevention trial, greater proportion of participants non-symptomatic in past week at
baseline
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(Continued)

van Ettekoven 2006 Population: The primary diagnosis was tension type headaches

Vasseljen 1995 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Vikne 2007 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Voerman 2007 Intervention: Relaxation therapy using myofeedback versus ergonomic intervention, no active com-
ponent

von Piekartz 2011 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Waling 2002 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Wani 2013 Comparison: exercise in all arms.

Wei 2007 Outcome Measure: not our primary outcomes of interest in this review

Yang 2013 Intervention: multimodal treatment compared with acupuncture

Ylinen 2003 Comparison: Control group included exercise.

Ylinen 2006b Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Ylinen 2007b Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Ylinen 2010 Intervention: Both treatment and control received same exercise intervention

Yogitha 2012 Intervention: Yoga but deep relaxation only.

Youseff 2013 Intervention: mobs + exercises vs massage + exercises.

Zaproudina 2007 Intervention: Multimodal approach within intervention groups without ability to differentiate each
treatment techniques contribution

Zebis 2011 Population: Is for the greater part a prevention trial (2/3 of N without neck pain)

EMG: electromyography
Ex: exercise therapy
MT: manual therapy
PT: physiotherapy

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RCT: randomized controlled trial
TENS: transcutaneous electrical nerve stimulation
US: ultrasound

Characteristics of studies awaiting assessment [ordered by year of study]

Falla 2013

Methods RCT

Participants Chronic neck pain

Interventions 8-week exercise program

Outcomes NDI, pain, EMG

Notes Awaiting data extraction

EMG: electromyographic
NDI: neck disability index
RCT: randomized controlled trial

Characteristics of ongoing studies [ordered by study ID]

Andersen 2010a (Protocol)

Trial name or title Protocol for work place adjusted intelligent physical exercise reducing musculoskeletal pain in shoulder and
neck (VIMS): a cluster randomized controlled trial

Methods

Participants

Interventions Specific strength training with supervision


vs specific strength training with minimal supervision
vs reference groups without training

Outcomes Pain

Starting date

Contact information National Research Centre for the Working Environment, Copenhagen O, Denmark

Notes

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Andersen 2011a (Protocol)

Trial name or title Protocol for shoulder function training reducing musculoskeletal pain in shoulder and neck: A randomized
controlled trial

Methods

Participants Neck pain

Interventions Shoulder function training with supervision


vs reference group receiving advice to stay physically active

Outcomes Pain intensity, strength, work disability

Starting date

Contact information National Research Centre for the Working Environment, Copenhagen O, Denmark

Notes Protocol

Guerriero 1997

Trial name or title Comparative effects of manipulation and physical therapy on motion in the cervical spine

Methods

Participants Chronic neck pain

Interventions Cervical spine manipulation


vs sham treatment
vs cervical spine manipulation, ischaemic compression of myofascial trigger points, PNF, interferential therapy

Outcomes Cervical ROM

Starting date

Contact information Palmer Institute of Graduate Studies and Research, Davenport, Iowa

Notes

Gurumoorthy 2000

Trial name or title A prospective study of acute whiplash injury and its clinical management

Methods

Participants Acute neck injury (WAD)

Interventions Early immobilization


vs early active mobilization

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Gurumoorthy 2000 (Continued)

Outcomes Pain, cervical ROM, neck muscle strength, time to return to normal duties

Starting date

Contact information Curtin University of Technology, Perth, Australia

Notes

Hansen 2011 (Protocol)

Trial name or title Neck exercises, physical and cognitive behavioral-graded activity as a treatment for adult whiplash patients
with chronic neck pain: Design of a randomized controlled trial

Methods

Participants Chronic neck pain (WAD)

Interventions Pain management (control) group


vs combined pain management and training (intervention) group

Outcomes Pain, function, disability, quality of life

Starting date

Contact information Research Unit for Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical
Biomechanics, University of Southern Denmark, Odense M, Denmark

Notes

Michaleff 2009 (Protocol)

Trial name or title A randomized clinical trial of a comprehensive exercise program for chronic whiplash: trial protocol

Methods

Participants Chronic neck pain (WAD I & II)

Interventions Education Booklet + Comprehensive Exercise Program


vs Education Booklet + Advice

Outcomes Pain intensity, disability, health-related quality of life and health service utilization

Starting date

Contact information The George Institute for International Health, The University of Sydney, George Street, Sydney, 2000,
Australia

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Michaleff 2009 (Protocol) (Continued)

Notes

Reginiussen 2000

Trial name or title Efficiency of manual therapy on patients with cervicogenic headache. A randomized single-blinded controlled
trial

Methods

Participants Cervicogenic headache

Interventions Manual therapy (soft tissue methods, stretching/massage, mobilizing and thrust techniques)
vs standardized physiotherapy treatment consisting of SWD, exercises and stretching

Outcomes Headache, neck pain, function, use of drugs, patient satisfaction

Starting date

Contact information Institut of Manual Therapy, Alta, Norway

Notes

Stokke 1995

Trial name or title A randomized comparison of chiropractic and physiotherapy treatment for neck pain of functional (mechan-
ical) origins. A controlled clinical trial

Methods

Participants Neck pain, neck and head pain, neck and shoulder pain

Interventions Chiropractic spinal manipulation


vs physiotherapy
vs medication

Outcomes NDI, pain intensity VAS

Starting date

Contact information Institute of Community Medicine, School of Medicine, Uniersity of Tramso, 9037 Tromso, Norway

Notes

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Williamson 2009 (Protocol

Trial name or title Development and delivery of a physiotherapy intervention for the early management of whiplash injuries:
The Managing Injuries of Neck Trial (MINT) Intervention

Methods

Participants WAD I, II, & III

Interventions Manual therapy, exercise, and psychological strategies and self-management advice

Outcomes

Starting date

Contact information Clinical Trials Unit, Medical School Building, Gibbet Hill Campus, University of Warwick, Coventry CV4
7AL, UK

Notes

NDI: neck disability index


PNF: Proprioceptive neuromuscular facilitation
ROM: range of motion
SWD: short-wave diathermy
vs: versus
VAS: visual analogue scale
WAD: whiplash associated disorders

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DATA AND ANALYSES

Comparison 1. Chronic MND: Breathing Patterns vs CONTROL

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (Borg 0 to 10): 10 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
weeks of treatment vs Control
1.1 Practice paced breathing 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
vs Control
2 Function (NDI 0 to 100): 10 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
weeks of treatment vs Control
2.1 Practice paced breathing 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
vs Control
3 SF-36 (physical function): 10 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
weeks of treatment vs Control

Comparison 2. Acute to Chronic MND: General Fitness Training vs CONTROL

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (VAS): 10 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
of treatment
1.1 General Fitness Training v 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Reference Intervention
2 Pain Intensity (VAS): 10 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
of treatment + 10 weeks
follow-up
2.1 General Fitness Training v 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Reference Intervention

Comparison 3. Chronic MND: Cervical Stretch/ROM Exercises + ANOTHER INTERVENTION vs THAT SAME
INTERVENTION

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (NRS-101): 4 Other data No numeric data


weeks of treatment
1.1 Stretch before Manip v Other data No numeric data
Manip alone
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1.2 Stretch after Manip v Other data No numeric data
Manip alone
2 Function (NDI): 4 weeks of Other data No numeric data
treatment
2.1 Stretch before Manip v Other data No numeric data
Manip alone
2.2 Stretch after Manip v Other data No numeric data
Manip alone

Comparison 4. Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (VAS): 8 weeks of 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment
1.1 McKenzie Treatment v 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Control
2 Pain Intensity (VAS): 8 weeks of 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment + 6 month follow-up
2.1 McKenzie Treatment v 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Control
3 Pain Intensity (VAS): 8 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
of treatment + 12 months
follow-up
3.1 McKenzie Treatment v 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Control
4 Function (NDI): 8 weeks of 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment
4.1 McKenzie Treatment v 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Control
5 Function (NDI): 8 weeks of 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment + 6 month follow-up
5.1 McKenzie Treatment v 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Control
6 Function (NDI): 8 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
of treatment + 12 month
follow-up
6.1 McKenzie Treatment v 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Control

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Comparison 5. Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO INTERVENTION OR
WAIT LIST

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (VAS): 6 weeks of 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment
1.1 Isometric neck exercises +/ 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
- pillow vs control or pillow
2 Pain Intensity (VAS): 6 weeks of 1 Mean Difference (IV, Random, 95% CI) Totals not selected
treatment + 6 weeks follow-up
2.1 Isometric neck exercises +/ 1 Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
- pillow vs pillow or placebo
3 Function (NPQ): 6 weeks of 1 Mean Difference (IV, Random, 95% CI) Totals not selected
treatment
3.1 Isometric neck exercises +/ 1 Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
- pillow vs pillow or placebo
4 Function (NPQ): 6 weeks of 1 Mean Difference (IV, Random, 95% CI) Totals not selected
treatment + 6 weeks follow-up
4.1 Isometric neck exercises +/ 1 Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
- pillow vs pillow or placebo
5 Global Perceived Effect 0 Risk Ratio (M-H, Random, 95% CI) Totals not selected
Treatment (patients assessment)
: 3 weeks of treatment
5.1 Isometric exercises vs no 0 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
intervention
6 Quality of Life (SF-36): 6 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
of treatment + 6 w follow-up
6.1 Isometric neck exercises +/ 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
- pillow vs pillow or placebo

Comparison 6. Chronic MND: Pattern synchronization (sitting posture) vs CONTROL

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain intensity (VAS) 2 weeks of 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment
1.1 Postural Exercise vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Control
2 Function (NDI): 2 weeks of 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment
2.1 Postural Exercise vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Control

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Comparison 7. Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (NPS): 4 weeks of 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment
1.1 Muscle strength training 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
vs CONTROL
2 Pain Intensity: 10 to 20 weeks of 3 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
treatment
2.1 Strength Specific Training 3 157 Std. Mean Difference (IV, Random, 95% CI) -0.71 [-1.33, -0.10]
vs Reference Group
3 Pain Intensity: 20 weeks of 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment
3.1 Strength Specific Training 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
vs Reference Group
4 Pain Intensity (VAS): 10 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
of treatment + 10 weeks
follow-up
4.1 Strength Specific Training 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
vs Reference Group
5 Function: 4 weeks of treatment 1 Mean Difference (IV, Random, 95% CI) Totals not selected
5.1 Intensive muscular 1 Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
strength training vs
CONTROL
6 Function: 20 weeks of treatment 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
6.1 Specific strength training 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
vs Control
7 Function: 12 to 20 weeks of 2 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
treatment/follow-up
7.1 Muscle strength training 2 128 Std. Mean Difference (IV, Random, 95% CI) -0.28 [-0.63, 0.07]
vs CONTROL

Comparison 8. Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic


Cervical Stabilization vs PLACEBO or SHAM

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (VAS): 8 weeks of 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment
1.1 General Exercise vs Sham 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
US
2 Pain Intensity (VAS): 8 weeks of 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment + 6 month follow-up
2.1 General Exercise vs Sham 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
US
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3 Pain Intensity (VAS): 8 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
of treatment + 12 month
follow-up
3.1 General Exercise vs Sham 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
US
4 Function (NDI): 8 weeks of 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment
4.1 General Exercise vs Sham 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
US
5 Function (NDI): 8 weeks of 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment + 6 month follow-up
5.1 General Exercise vs Sham 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
US
6 Function (NDI): 8 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment + 12 month
follow-up
6.1 General Exercise vs Sham 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
US

Comparison 9. Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strength-


ening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity: Immediate Post 4 Mean Difference (IV, Random, 95% CI) Subtotals only
Treatment (<11w of treatment)
1.1 Exercise +/- Infrared 4 317 Mean Difference (IV, Random, 95% CI) -0.66 [-1.28, -0.03]
+/- SMT +/- Acupuncture
vs Infrared or SMT or
Acupuncture
2 Pain Intensity: 11 w of treatment 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
+ 3 month follow-up
2.1 SMT + Rehab Exercises vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
SMT
3 Pain Intensity: Treatment + 3 Mean Difference (IV, Random, 95% CI) Subtotals only
IT follow-up (11 weeks of
treatment + 6 month follow-up
3.1 <11w of treatment + 6 3 241 Mean Difference (IV, Random, 95% CI) -0.67 [-1.32, -0.02]
month follow-up
4 Pain Intensity: Treatment + LT 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
follow-up
4.1 <11w of treatment + 24 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
month follow-up
5 Function: Immediate Post 4 Mean Difference (IV, Random, 95% CI) Subtotals only
treatment
5.1 <11w of treatment 4 317 Mean Difference (IV, Random, 95% CI) -1.91 [-4.65, 0.83]
6 Function: Treatment + ST 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
follow-up
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6.1 <11w of treatment + 3 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
month follow-up
7 Function: Treatment + IT 3 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
follow-up
7.1 <11w of treatment + 6 3 241 Std. Mean Difference (IV, Random, 95% CI) -0.45 [-0.72, -0.18]
month follow-up
8 Function: Treatment + LT 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
follow-up
8.1 <11w of treatment + 24 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
month follow-up
9 Quality of Life: Immediate Post 2 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
Treatment
9.1 <11w of treatment 2 165 Std. Mean Difference (IV, Random, 95% CI) -0.18 [-0.48, 0.13]
10 Quality of Life: Treatment + 1 Mean Difference (IV, Random, 95% CI) Totals not selected
ST follow-up
10.1 11w of treatment + 3 1 Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
month follow-up
11 Quality of Life: Treatment + IT 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
follow-up
11.1 11w of treatment + 6 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
month follow-up
12 Quality of Life: Treatment + 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
LT follow-up
12.1 11w of treatment + 24 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
month follow-up
13 Patient Satisfaction: Immediate 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
Post Treatment
13.1 11>w of treatment 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
14 Patient Satisfaction: Treatment 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
+ ST follow-up
14.1 11w of treatment + 3 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
month follow-up
15 Patient Satisfaction: Treatment 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
+ IT follow-up
15.1 11w of treatment + 6 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
month follow-up
16 Patient Satisfaction: Treatment 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
+ LT follow-up
16.1 11w of treatment + 24 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
month follow-up
17 Global Perceived Effect: 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
Immediate Post Treatment
17.1 11w of treatment 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
18 Global Perceived Effect: 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
Treatment + ST follow-up
18.1 11w of treatment + 3 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
month follow-up
19 Global Perceived Effect: 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
Treatment + IT follow-up
19.1 11w of treatment + 6 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
month follow-up
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20 Global Perceived Effect: 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
Treatment + LT follow-up
20.1 11w of treatment + 24 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
month follow-up

Comparison 10. Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening +


Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (VAS): 12 weeks 2 Mean Difference (IV, Random, 95% CI) Subtotals only
of treatment
1.1 Exercise Therapy vs No 2 147 Mean Difference (IV, Random, 95% CI) -14.90 [-22.40, -7.
Treatment 39]
2 Pain Intensity (VAS): 24 weeks 2 Mean Difference (IV, Random, 95% CI) Subtotals only
of treatment
2.1 Exercise Therapy vs No 2 140 Mean Difference (IV, Random, 95% CI) -10.94 [-18.81, -3.
Treatment 08]
3 Function: 12 weeks of treatment 2 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
3.1 Exercise Therapy vs No 2 147 Std. Mean Difference (IV, Random, 95% CI) -0.50 [-1.04, 0.03]
Treatment
4 Function: 24 weeks of treatment 2 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
4.1 Exercise Therapy vs No 2 140 Std. Mean Difference (IV, Random, 95% CI) -0.40 [-0.74, -0.06]
Treatment
5 Global Perceived Effect (General 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
Health Perception): 12 weeks
of treatment
5.1 Exercise Therapy vs No 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Treatment
6 Global Perceived Effect (General 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
Health Perception): 12 weeks
of treatment + 12 weeks
follow-up
6.1 Exercise Therapy vs No 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Treatment
7 Quality of Life (SF-36): 12 2 Mean Difference (IV, Random, 95% CI) Subtotals only
weeks of treatment
7.1 Exercise Therapy vs No 2 143 Mean Difference (IV, Random, 95% CI) -2.22 [-5.17, 0.72]
Treatment
8 Quality of Life (SF-36): 24 2 Mean Difference (IV, Random, 95% CI) Subtotals only
weeks of treatment
8.1 Exercise Therapy vs No 2 144 Mean Difference (IV, Random, 95% CI) 0.06 [-4.06, 4.17]
Treatment

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Comparison 11. Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTER-
VENTION or WAIT LIST

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (VAS): 12 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
of treatment
1.1 Dynamic muscle training 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
vs control
2 Pain Intensity (VAS): 12 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
of treatment + 3 month
follow-up
2.1 Dynamic muscle training 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
vs control
3 Pain Intensity (VAS): 12 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
of treatment + 9 month
follow-up
3.1 Dynamic muscle training 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
vs control
4 Function (Neck Disability 0-80): 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
12 weeks of treatment
4.1 Dynamic muscle training 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
vs control
5 Function (Neck Disability 0-80): 1 Std. Mean Difference (IV, Fixed, 95% CI) Totals not selected
12 weeks of treatment + 3
month follow-up
5.1 Dynamic muscle training 1 Std. Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
vs control
6 Function (Neck Disability 0-80): 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
12 weeks of treatment + 9
month follow-up
6.1 Dynamic muscle training 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
vs control

Comparison 12. Acute to Chronic MND: Pattern synchronization + cervical/scapulothoracic strengthening +


scapulothoracic endurance vs NO INTERVENTION

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (VAS 0 to 10): 24 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
weeks of treatment
1.1 Training group vs control 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]

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Comparison 13. Chronic MND: Cervical/Scapulothoracic Strengthening + Cervical/Scapulothoracic Endurance
Training

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Prevelance during previous 1 Risk Ratio (M-H, Random, 95% CI) Totals not selected
week: 6 weeks of treatment +
46 weeks follow-up
1.1 Exercise Regimen vs 1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
control group

Comparison 14. Acute to Chronic MND: Scapulothoracic/UE Endurance Training vs CONTROL

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (VAS): 10 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment
1.1 2 minute training group 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
vs Control
1.2 12 minute training group 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
vs Control

Comparison 15. Chronic MND: Neuromuscular Education (eye neck coordination/proprioception) + ANOTHER
INTERVENTION VS THAT SAME INTERVENTION

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (VAS): 8 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment + 10 weeks follow-up
1.1 Rehabilitation Group vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Control Group
2 Function (pt’s assessment of 1 Risk Ratio (M-H, Random, 95% CI) Totals not selected
functional improvement): 8
weeks treatment + 10 weeks
follow-up
2.1 Rehabilitation Group vs 1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]
Control Group

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Comparison 16. Chronic MND:Trunk/Extremity Stretch + Pattern/Synchronization: Balance and Coordination
+ Cardiovascular/Aerobic vs NO TREATMENT

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (VAS): 10 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
of treatment
1.1 Group Gymnastics vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Control

Comparison 17. Chronic MND:General Endurance Training + Dynamic/Static Lowback/pelvic Stabilization +


General Stretching + Neuromuscular/body Mechanics Movement Training vs NO INTERVENTION OR WAIT
LIST

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (VAS): 16 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment + 6 weeks follow-up
1.1 Physiotherapy Group vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Control Group

Comparison 18. Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive
(mindfulness & emotional balance) vs WAIT LIST

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (VAS): 12 weeks 2 Mean Difference (IV, Random, 95% CI) Subtotals only
of treatment
1.1 Qigong vs No Treatment 2 148 Mean Difference (IV, Random, 95% CI) -13.28 [-20.98, -5.
58]
2 Pain Intensity (VAS): 24 weeks 2 Mean Difference (IV, Random, 95% CI) Subtotals only
of treatment
2.1 Qigong vs No Treatment 2 137 Mean Difference (IV, Random, 95% CI) -7.82 [-14.57, -1.07]
3 Function: 12 weeks of treatment 2 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
3.1 Qigong vs No Treatment 2 148 Std. Mean Difference (IV, Random, 95% CI) -0.36 [-0.68, -0.03]
4 Function: 24 weeks of treatment 2 Std. Mean Difference (IV, Random, 95% CI) Subtotals only
4.1 Qigong vs No Treatment 2 137 Std. Mean Difference (IV, Random, 95% CI) -0.28 [-0.68, 0.11]
5 Global Perceived Effect (General 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
Health Perception): 12 weeks
of treatment
5.1 Qigong vs No Treatment 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
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6 Global Perceived Effect (General 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
Health Perception): 12 weeks
of treatment + 12 weeks
Follow-up
6.1 Qigong vs No Treatment 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
7 Quality of Life (SF-36 physical 2 Mean Difference (IV, Random, 95% CI) Subtotals only
component): 12 weeks of
treatment
7.1 Qigong vs No Treatment 2 148 Mean Difference (IV, Random, 95% CI) -2.72 [-5.42, -0.01]
8 Quality of Life: 24 weeks of 2 Mean Difference (IV, Random, 95% CI) Subtotals only
treatment
8.1 Qigong vs No Treatment 2 137 Mean Difference (IV, Random, 95% CI) -1.88 [-5.80, 2.04]

Comparison 19. Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening +


Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cog-
nitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity: (0-10 box scale): 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
6 weeks of treatment
1.1 Exercise + Advice vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Advice
2 Pain Intensity (0-10 box scale): 6 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
weeks treatment + 12 month
follow-up
2.1 Exercise + Advice vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Advice
3 Function (NDI): 6 weeks of 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment
3.1 Exercise + Advice vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Advice
4 Function (NDI): 6 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
of treatment + 12 month
follow-up
4.1 Exercise + Advice vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Advice
5 Global Perceived Effect (-5 to 5 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
scale): 6 weeks of treatment
5.1 Exercise + Advice vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Advice
6 Global Perceived Effect (-5 to 5 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
scale): 6 weeks of treatment +
12 month follow-up
6.1 Exercise + Advice vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Advice
7 Quality of Life (SF-36): 6 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
of treatment
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7.1 Exercise + Advice vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Advice
8 Quality of Life (SF-36): 6 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
of treatment + 12 month
follow-up
8.1 Exercise + Advice vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Advice

Comparison 20. Acute to Subacute CGH: Cervical Stretch/ROM vs SHAM

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (Headache 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
Questionnaire): Treatment + 4
weeks follow-up
1.1 C1-C2 Self Snag vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Placebo Group
2 Pain Intensity (Headache 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
Questionnaire): Treatment +
12 month follow-up
2.1 C1-C2 Self Snag vs 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
Placebo Group

Comparison 21. Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocer-
vical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Headache Intensity (VAS 0-10): 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
6 weeks of treatment
1.1 Therapeutic Exercise +/ 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
- Manip vs Control Group or
Manip
2 Headache Intensity (VAS 0-10): 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
6 weeks treatment + 12 month
follow-up
2.1 Therapeutic Exercise +/ 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
- Manip vs Control Group or
Manip
3 Function (NPNPQ 0-36): 6 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
weeks treatment
3.1 Therapeutic Exercise +/ 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
- Manip vs Control Group or
Manip
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4 Function (NPNPQ 0-36): 6 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
weeks treatment + 12 month
follow-up
4.1 Therapeutic Exercise +/ 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
- Manip vs Control Group or
Manip
5 Global Perceived Effect (VAS): 6 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
weeks treatment
5.1 Therapeutic Exercise +/ 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
- Manip vs Control Group or
Manip
6 Global Perceived Effect (VAS): 6 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
weeks treatment + 12 month
follow-up
6.1 Therapeutic Exercise +/ 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
- Manip vs Control Group or
Manip

Comparison 22. Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strength-


ening + Static/Dynamic Cervical Stabilization vs WAIT LIST

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (VAS): 6 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment
1.1 Physiotherapy vs Control 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
2 Pain Intensity (VAS): 6 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment + 6 month follow-up
2.1 Physiotherapy vs Control 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
3 Function (NDI): 6 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment
3.1 Physiotherapy vs Control 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
4 Function (NDI): 6 weeks 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
treatment + 6 month follow-up
4.1 Physiotherapy vs Control 1 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]
5 Satisfaction (5 point scale): 6 1 Risk Ratio (M-H, Random, 95% CI) Totals not selected
weeks treatment
5.1 Physiotherapy vs Control 1 Risk Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]

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Comparison 23. Chronic MND: Patterns synchronization + Feedforward/feedback: vestibular rehabilitation
(balance on unstable surfaces and walking with head movements and eyes closed) vs NO INTERVENTION

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain Intensity (VAS) 6 weeks vs 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
Control
2 Pain Intensity (VAS) 3 months 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
vs control

Comparison 24. Chronic MND: Patterns synchronization + Feedforward/feedback: exercises for coordinating the
neck, eyes and upper limbs vs NO INTERVENTION

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain intensity (VAS) 4 weeks vs 1 Std. Mean Difference (IV, Random, 95% CI) Totals not selected
Control

Analysis 1.1. Comparison 1 Chronic MND: Breathing Patterns vs CONTROL, Outcome 1 Pain Intensity
(Borg 0 to 10): 10 weeks of treatment vs Control.

Review: Exercises for mechanical neck disorders

Comparison: 1 Chronic MND: Breathing Patterns vs CONTROL

Outcome: 1 Pain Intensity (Borg 0 to 10): 10 weeks of treatment vs Control

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD)[0 to 10] N Mean(SD)[0 to 10] IV,Random,95% CI IV,Random,95% CI

1 Practice paced breathing vs Control


Hallman 2011 12 1.7 (1.4) 11 2 (1.7) -0.19 [ -1.01, 0.63 ]

-4 -2 0 2 4
Favours treatment Favours control

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Analysis 1.2. Comparison 1 Chronic MND: Breathing Patterns vs CONTROL, Outcome 2 Function (NDI 0
to 100): 10 weeks of treatment vs Control.

Review: Exercises for mechanical neck disorders

Comparison: 1 Chronic MND: Breathing Patterns vs CONTROL

Outcome: 2 Function (NDI 0 to 100): 10 weeks of treatment vs Control

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD)[0 to 10] N Mean(SD)[0 to 10] IV,Random,95% CI IV,Random,95% CI

1 Practice paced breathing vs Control


Hallman 2011 12 14 (10) 11 20.6 (14.4) -0.52 [ -1.35, 0.32 ]

-10 -5 0 5 10
Favours treatment Favours control

Analysis 1.3. Comparison 1 Chronic MND: Breathing Patterns vs CONTROL, Outcome 3 SF-36 (physical
function): 10 weeks of treatment vs Control.

Review: Exercises for mechanical neck disorders

Comparison: 1 Chronic MND: Breathing Patterns vs CONTROL

Outcome: 3 SF-36 (physical function): 10 weeks of treatment vs Control

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

Hallman 2011 12 -92.5 (8) 11 -84.5 (15) -0.65 [ -1.49, 0.19 ]

-4 -2 0 2 4
Favours treatment Favours control

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Analysis 2.1. Comparison 2 Acute to Chronic MND: General Fitness Training vs CONTROL, Outcome 1
Pain Intensity (VAS): 10 weeks of treatment.

Review: Exercises for mechanical neck disorders

Comparison: 2 Acute to Chronic MND: General Fitness Training vs CONTROL

Outcome: 1 Pain Intensity (VAS): 10 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
Mean(SD)[VAS Mean(SD)[VAS
N 0-100] N 0-100] IV,Random,95% CI IV,Random,95% CI

1 General Fitness Training v Reference Intervention


Andersen 2008 (1) 16 33 (12) 8 30 (22) 0.18 [ -0.67, 1.03 ]

-100 -50 0 50 100


Favours treatment Favours control

(1) GFT v REF

Analysis 2.2. Comparison 2 Acute to Chronic MND: General Fitness Training vs CONTROL, Outcome 2
Pain Intensity (VAS): 10 weeks of treatment + 10 weeks follow-up.

Review: Exercises for mechanical neck disorders

Comparison: 2 Acute to Chronic MND: General Fitness Training vs CONTROL

Outcome: 2 Pain Intensity (VAS): 10 weeks of treatment + 10 weeks follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 General Fitness Training v Reference Intervention


Andersen 2008 16 29 (15) 8 30 (18) -0.06 [ -0.91, 0.79 ]

-4 -2 0 2 4
Favours treatment Favours control

Exercises for mechanical neck disorders (Review) 146


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Analysis 3.1. Comparison 3 Chronic MND: Cervical Stretch/ROM Exercises + ANOTHER INTERVENTION
vs THAT SAME INTERVENTION, Outcome 1 Pain Intensity (NRS-101): 4 weeks of treatment.
Pain Intensity (NRS-101): 4 weeks of treatment

Study

Stretch before Manip v Manip alone

Allan 2003 Although the stretch before manipulation group had 30% (n = 2) greater decrease in intra-group pain by the end of the
study than those who received maniplation alone, inter-group analysis using the Kruskal-Wallis test found no statistical
signifance between the groups (X2 = 2.447, d.f. = 2, P = 0.294)
There was no statistically significant difference in pain between the stretch before manipulation group and the control
group of manipulation alone
There was no statistically significant difference between the stretch before manipulation vs stretch after manipulation

Stretch after Manip v Manip alone

Allan 2003 Although the manipulation then stretch group had 26% (n = 2) greater decrease in intra-group pain by the end of the
study than those who received maniplation alone, inter-group analysis using the Kruskal-Wallis test found no statistical
signifance between the groups (X2 = 2.447, d.f. = 2, P = 0.294)
There was no statistically significant difference in pain between the stretch after manipulation group from the control
group of manipulation alone
There was no statistically significant difference between the stretch before manipulation vs stretch after manipulation

Analysis 3.2. Comparison 3 Chronic MND: Cervical Stretch/ROM Exercises + ANOTHER INTERVENTION
vs THAT SAME INTERVENTION, Outcome 2 Function (NDI): 4 weeks of treatment.
Function (NDI): 4 weeks of treatment

Study

Stretch before Manip v Manip alone

Allan 2003 There was no statistically significant difference in function between the stretch before manipulation and the control
group of manipulation alone
There was no statistically significant difference in function between stretch before manipulation vs stretch after manip-
ulation

Stretch after Manip v Manip alone

Allan 2003 no statistically significant difference in function between stretch after manipulation groups from control group of
manipulation alone
no statistically significant difference in function between stretch before manipulation vs stretch after manipulation

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Analysis 4.1. Comparison 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical
Stabilization vs SHAM, Outcome 1 Pain Intensity (VAS): 8 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM
Outcome: 1 Pain Intensity (VAS): 8 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 McKenzie Treatment v Control


Kjellman 2002 (1) 25 19 (18) 25 21 (20) -0.10 [ -0.66, 0.45 ]

-4 -2 0 2 4
Favours treatment Favours control

(1) MCKENZIE treatment vs Sham US

Analysis 4.2. Comparison 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical
Stabilization vs SHAM, Outcome 2 Pain Intensity (VAS): 8 weeks of treatment + 6 month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM
Outcome: 2 Pain Intensity (VAS): 8 weeks of treatment + 6 month follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 McKenzie Treatment v Control


Kjellman 2002 (1) 25 21 (17) 25 27 (23) -0.29 [ -0.85, 0.27 ]

-4 -2 0 2 4
Favours treatment Favours control

(1) MCKENZIE Treatment vs Sham US

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Analysis 4.3. Comparison 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical
Stabilization vs SHAM, Outcome 3 Pain Intensity (VAS): 8 weeks of treatment + 12 months follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM
Outcome: 3 Pain Intensity (VAS): 8 weeks of treatment + 12 months follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 McKenzie Treatment v Control


Kjellman 2002 (1) 25 26 (23) 25 25 (24) 0.04 [ -0.51, 0.60 ]

-4 -2 0 2 4
Favours treatment Favours control

(1) MCKENZIE Treatment vs Sham US

Analysis 4.4. Comparison 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical
Stabilization vs SHAM, Outcome 4 Function (NDI): 8 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM
Outcome: 4 Function (NDI): 8 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 McKenzie Treatment v Control


Kjellman 2002 (1) 25 16 (12) 25 19 (13) -0.24 [ -0.79, 0.32 ]

-4 -2 0 2 4
Favours experimental Favours control

(1) MCKENZIE Treatment vs Sham US

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Analysis 4.5. Comparison 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical
Stabilization vs SHAM, Outcome 5 Function (NDI): 8 weeks of treatment + 6 month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM
Outcome: 5 Function (NDI): 8 weeks of treatment + 6 month follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 McKenzie Treatment v Control


Kjellman 2002 (1) 23 15 (12) 24 18 (15) -0.22 [ -0.79, 0.36 ]

-4 -2 0 2 4
Favours experimental Favours control

(1) MCKENZIE Treatment vs Sham US

Analysis 4.6. Comparison 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical
Stabilization vs SHAM, Outcome 6 Function (NDI): 8 weeks of treatment + 12 month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 4 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM
Outcome: 6 Function (NDI): 8 weeks of treatment + 12 month follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 McKenzie Treatment v Control


Kjellman 2002 (1) 23 18 (14) 24 16 (15) 0.14 [ -0.44, 0.71 ]

-4 -2 0 2 4
Favours experimental Favours control

(1) MCKENZIE Treatment vs Sham US

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Analysis 5.1. Comparison 5 Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO
INTERVENTION OR WAIT LIST, Outcome 1 Pain Intensity (VAS): 6 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 5 Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO INTERVENTION OR WAIT LIST
Outcome: 1 Pain Intensity (VAS): 6 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Isometric neck exercises +/- pillow vs control or pillow


Helewa 2007 (1) 31 1.3 (1.2) 31 2.3 (1.7) -0.67 [ -1.18, -0.16 ]

Helewa 2007 (2) 28 1.9 (1.8) 33 1.7 (1.7) 0.11 [ -0.39, 0.62 ]

-4 -2 0 2 4
Favours treatment Favours control

(1) Exercise + Pillow vs Pillow


(2) Exercise vs Control

Analysis 5.2. Comparison 5 Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO
INTERVENTION OR WAIT LIST, Outcome 2 Pain Intensity (VAS): 6 weeks of treatment + 6 weeks follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 5 Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO INTERVENTION OR WAIT LIST
Outcome: 2 Pain Intensity (VAS): 6 weeks of treatment + 6 weeks follow-up

Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Isometric neck exercises +/- pillow vs pillow or placebo


Helewa 2007 (1) 25 1.7 (1.4) 33 1.7 (1.6) 0.0 [ -0.77, 0.77 ]

Helewa 2007 (2) 32 1 (1.3) 32 1.9 (1.7) -0.90 [ -1.64, -0.16 ]

-100 -50 0 50 100


Favours treatment Favours control

(1) Exercise vs Control


(2) Exercise + Pillow vs Pillow

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Analysis 5.3. Comparison 5 Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO
INTERVENTION OR WAIT LIST, Outcome 3 Function (NPQ): 6 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 5 Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO INTERVENTION OR WAIT LIST
Outcome: 3 Function (NPQ): 6 weeks of treatment

Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Isometric neck exercises +/- pillow vs pillow or placebo


Helewa 2007 (1) 28 21.1 (13.3) 33 18.8 (9.4) 2.30 [ -3.58, 8.18 ]

Helewa 2007 (2) 31 17.7 (11.6) 31 26.1 (13.5) -8.40 [ -14.67, -2.13 ]

-100 -50 0 50 100


Favours experimental Favours control

(1) Exercise vs Control


(2) Exercise + Pillow vs Pillow

Analysis 5.4. Comparison 5 Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO
INTERVENTION OR WAIT LIST, Outcome 4 Function (NPQ): 6 weeks of treatment + 6 weeks follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 5 Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO INTERVENTION OR WAIT LIST
Outcome: 4 Function (NPQ): 6 weeks of treatment + 6 weeks follow-up

Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Isometric neck exercises +/- pillow vs pillow or placebo


Helewa 2007 (1) 33 14.1 (10.6) 32 21.5 (13.1) -7.40 [ -13.20, -1.60 ]

Helewa 2007 (2) 29 20.1 (11.6) 34 18.6 (10) 1.50 [ -3.90, 6.90 ]

-100 -50 0 50 100


Favours treatment Favours control

(1) Exercise + Pillow vs Pillow


(2) Exercise vs Control

Exercises for mechanical neck disorders (Review) 152


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Analysis 5.6. Comparison 5 Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO
INTERVENTION OR WAIT LIST, Outcome 6 Quality of Life (SF-36): 6 weeks of treatment + 6 w follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 5 Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO INTERVENTION OR WAIT LIST
Outcome: 6 Quality of Life (SF-36): 6 weeks of treatment + 6 w follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Isometric neck exercises +/- pillow vs pillow or placebo


Helewa 2007 (1) 29 -48.7 (9.6) 34 -50 (7) 0.15 [ -0.34, 0.65 ]

Helewa 2007 (2) 33 -52.1 (6.5) 32 -48.5 (8.9) -0.46 [ -0.95, 0.04 ]

-4 -2 0 2 4
Favours experimental Favours control

(1) Exercise vs Control


(2) Exercise + Pillow vs Pillow

Analysis 6.1. Comparison 6 Chronic MND: Pattern synchronization (sitting posture) vs CONTROL,
Outcome 1 Pain intensity (VAS) 2 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 6 Chronic MND: Pattern synchronization (sitting posture) vs CONTROL
Outcome: 1 Pain intensity (VAS) 2 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Postural Exercise vs Control


Beer 2012 10 3 (2.8) 10 2.6 (2.9) 0.13 [ -0.74, 1.01 ]

-10 -5 0 5 10
Favours treatment Favours control

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Analysis 6.2. Comparison 6 Chronic MND: Pattern synchronization (sitting posture) vs CONTROL,
Outcome 2 Function (NDI): 2 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 6 Chronic MND: Pattern synchronization (sitting posture) vs CONTROL
Outcome: 2 Function (NDI): 2 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Postural Exercise vs Control


Beer 2012 10 17.8 (11.9) 10 21.8 (11.8) -0.32 [ -1.21, 0.56 ]

-10 -5 0 5 10
Favours treatment Favours control

Analysis 7.1. Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL,


Outcome 1 Pain Intensity (NPS): 4 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL
Outcome: 1 Pain Intensity (NPS): 4 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Muscle strength training vs CONTROL


Dellve 2011 (1) 20 -0.1 (1.7) 20 0.5 (1.6) -0.36 [ -0.98, 0.27 ]

-10 -5 0 5 10
Favours experimental Favours control

(1) Delve 2001: Intensive muscular strength training vs Control: Duration: 4 weeks of treatment: follow-up: Instrument: NPS 0 to 10.

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Analysis 7.2. Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL,
Outcome 2 Pain Intensity: 10 to 20 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL
Outcome: 2 Pain Intensity: 10 to 20 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Strength Specific Training vs Reference Group


Andersen 2008 (1) 18 8 (9) 8 30 (22) 23.5 % -1.51 [ -2.46, -0.57 ]

Andersen Ch 2012 (2) 43 3.19 (2.18) 48 3.86 (2.2) 42.9 % -0.30 [ -0.72, 0.11 ]

Dellve 2011 (3) 20 -0.3 (1.8) 20 1.1 (2.2) 33.7 % -0.68 [ -1.32, -0.04 ]

Subtotal (95% CI) 81 76 100.0 % -0.71 [ -1.33, -0.10 ]


Heterogeneity: Tau2 = 0.18; Chi2 = 5.51, df = 2 (P = 0.06); I2 =64%
Test for overall effect: Z = 2.29 (P = 0.022)

-4 -2 0 2 4
Favours treatment Favours control

(1) Andersen 2008: Specific strength training vs Health councelling group: Duration: 10 weeks of treatment: follow-up: none: Instrument: VAS 0 to 100
(2) Andersen Ch 2012: Training group (3 weekly sessions of 20 minutes) vs Reference group: Duration: 20 weeks of treatment: follow-up: none: Instrument: modified
nordic questionnaire 0 to 9.
(3) Delve 2011: Intensive muscular strength training vs Control: Duration: 4 weeks of treatment: follow-up: 2 months: Instrument: NPS 0 to 10.

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Analysis 7.3. Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL,
Outcome 3 Pain Intensity: 20 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL
Outcome: 3 Pain Intensity: 20 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Strength Specific Training vs Reference Group


Andersen Ch 2012 (1) 40 3.42 (2.05) 48 3.86 (2.2) -0.20 [ -0.63, 0.22 ]

Andersen Ch 2012 (2) 27 3.56 (2.26) 48 3.86 (2.2) -0.13 [ -0.61, 0.34 ]

-4 -2 0 2 4
Favours treatment Favours control

(1) Andersen Ch 2012: Training group (1 weekly sessions of 60 minutes) vs Reference group: Duration: 20 weeks of treatment: follow-up: none: Instrument: modified
nordic questionnaire 0 to 9.
(2) Andersen Ch 2012: Training group (9 weekly sessions of 7 minutes) vs Reference group: Duration: 20 weeks of treatment: follow-up: none: Instrument: modified
nordic questionnaire 0 to 9.

Analysis 7.4. Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL,


Outcome 4 Pain Intensity (VAS): 10 weeks of treatment + 10 weeks follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL
Outcome: 4 Pain Intensity (VAS): 10 weeks of treatment + 10 weeks follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Strength Specific Training vs Reference Group


Andersen 2008 (1) 18 16 (14) 8 30 (18) -0.89 [ -1.76, -0.01 ]

-4 -2 0 2 4
Favours treatment Favours control

(1) Andersen 2008: Specific strength training vs Health counselling group: Duration: 10 weeks of treatment: follow-up: 10 weeks: Instrument: VAS 0 to 100

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Analysis 7.5. Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL,
Outcome 5 Function: 4 weeks of treatment.
Review: Exercises for mechanical neck disorders
Comparison: 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL
Outcome: 5 Function: 4 weeks of treatment

Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Intensive muscular strength training vs CONTROL


Dellve 2011 (1) 20 -1.5 (3.4) 20 -2.4 (6.1) 0.90 [ -2.16, 3.96 ]

-10 -5 0 5 10
Favours treatment Favours control

(1) Delve 2011: Intensive muscular strength training vs Control: Duration: 4 weeks of treatment: follow-up: none: Instrument: Work Ability Index.

Analysis 7.6. Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL,


Outcome 6 Function: 20 weeks of treatment.
Review: Exercises for mechanical neck disorders
Comparison: 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL
Outcome: 6 Function: 20 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Specific strength training vs Control


Andersen Ch 2012 (1) 43 14 (19) 48 17 (16) -0.17 [ -0.58, 0.24 ]

Andersen Ch 2012 (2) 27 16 (19) 48 17 (16) -0.06 [ -0.53, 0.41 ]

-4 -2 0 2 4
Favours treatment Favours control

(1) Andersen Ch 2012: Training group (1 weekly sessions of 60 minutes) vs Reference group: Duration: 20 weeks of treatment: follow-up: none: Instrument: DASH.
(2) Andersen Ch 2012: Training group (9 weekly sessions of 7 minutes) vs Reference group: Duration: 20 weeks of treatment: follow-up: none: Instrument: DASH.

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Analysis 7.7. Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL,
Outcome 7 Function: 12 to 20 weeks of treatment/follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL
Outcome: 7 Function: 12 to 20 weeks of treatment/follow-up

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Muscle strength training vs CONTROL


Dellve 2011 (1) 20 -3.9 (4.8) 20 -2 (5) 31.2 % -0.38 [ -1.01, 0.25 ]

Andersen Ch 2012 (2) 40 13 (18) 48 17 (16) 68.8 % -0.23 [ -0.66, 0.19 ]

Subtotal (95% CI) 60 68 100.0 % -0.28 [ -0.63, 0.07 ]


Heterogeneity: Tau2 = 0.0; Chi2 = 0.14, df = 1 (P = 0.70); I2 =0.0%
Test for overall effect: Z = 1.57 (P = 0.12)

-4 -2 0 2 4
Favours experimental Favours control

(1) Delve 2011: Intensive muscular strength training vs Control: Duration: 4 weeks of treatment: follow-up: 2 months (with home program): Instrument: Work ability
index.
(2) Andersen Ch 2012: Training group (3 weekly sessions of 20 minutes) vs Reference group: Duration: 20 weeks of treatment: follow-up: none: Instrument: DASH.

Analysis 8.1. Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening
+ Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 1 Pain Intensity (VAS): 8 weeks of
treatment.
Review: Exercises for mechanical neck disorders
Comparison: 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM
Outcome: 1 Pain Intensity (VAS): 8 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 General Exercise vs Sham US


Kjellman 2002 (1) 20 27 (26) 25 21 (20) 0.26 [ -0.33, 0.85 ]

-4 -2 0 2 4
Favours treatment Favours control

(1) GENERAL EXERCISE vs Sham US

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Analysis 8.2. Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening
+ Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 2 Pain Intensity (VAS): 8 weeks of
treatment + 6 month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM
Outcome: 2 Pain Intensity (VAS): 8 weeks of treatment + 6 month follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 General Exercise vs Sham US


Kjellman 2002 (1) 20 23 (26) 25 27 (23) -0.16 [ -0.75, 0.43 ]

-4 -2 0 2 4
Favours treatment Favours control

(1) GENERAL EX vs Sham US

Analysis 8.3. Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening
+ Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 3 Pain Intensity (VAS): 8 weeks of
treatment + 12 month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM
Outcome: 3 Pain Intensity (VAS): 8 weeks of treatment + 12 month follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 General Exercise vs Sham US


Kjellman 2002 (1) 20 30 (27) 25 25 (24) 0.19 [ -0.40, 0.78 ]

-4 -2 0 2 4
Favours treatment Favours control

(1) GENERAL EX vs Sham US

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Analysis 8.4. Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening
+ Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 4 Function (NDI): 8 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM
Outcome: 4 Function (NDI): 8 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 General Exercise vs Sham US


Kjellman 2002 (1) 20 21 (16) 25 19 (13) 0.14 [ -0.45, 0.73 ]

-4 -2 0 2 4
Favours treatment Favours control

(1) GENERAL EX vs Sham US

Analysis 8.5. Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening
+ Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 5 Function (NDI): 8 weeks of treatment +
6 month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM
Outcome: 5 Function (NDI): 8 weeks of treatment + 6 month follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 General Exercise vs Sham US


Kjellman 2002 (1) 20 17 (17) 24 18 (15) -0.06 [ -0.66, 0.53 ]

-4 -2 0 2 4
Favours treatment Favours control

(1) General EX vs Sham US

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Analysis 8.6. Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening
+ Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 6 Function (NDI): 8 weeks treatment + 12
month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM
Outcome: 6 Function (NDI): 8 weeks treatment + 12 month follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 General Exercise vs Sham US


Kjellman 2002 (1) 20 18 (17) 24 16 (15) 0.12 [ -0.47, 0.72 ]

-4 -2 0 2 4
Favours treatment Favours control

(1) General EX vs Sham US

Analysis 9.1. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +


Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 1 Pain Intensity: Immediate Post Treatment
(<11w of treatment).

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 1 Pain Intensity: Immediate Post Treatment (<11w of treatment)

Mean Mean
Study or subgroup Treatment Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise +/- Infrared +/- SMT +/- Acupuncture vs Infrared or SMT or Acupuncture
Bronfort 2001 (1) 51 2.4 (1.8) 50 2.9 (2.1) 39.7 % -0.50 [ -1.26, 0.26 ]

Chiu 2005 59 3 (2.3) 62 3.8 (2.3) 36.4 % -0.80 [ -1.62, 0.02 ]

Franca 2008 16 6.8 (9.4) 15 15.3 (13) 0.6 % -8.50 [ -16.53, -0.47 ]

Martel 2011 32 1.6 (2.3) 32 2.1 (2.3) 23.3 % -0.50 [ -1.63, 0.63 ]

Subtotal (95% CI) 158 159 100.0 % -0.66 [ -1.28, -0.03 ]


Heterogeneity: Tau2 = 0.10; Chi2 = 4.01, df = 3 (P = 0.26); I2 =25%
Test for overall effect: Z = 2.07 (P = 0.039)

-4 -2 0 2 4
Favours treatment Favours control

Exercises for mechanical neck disorders (Review) 161


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(1) G2: low technology exercise

Analysis 9.2. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +


Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 2 Pain Intensity: 11 w of treatment + 3 month
follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 2 Pain Intensity: 11 w of treatment + 3 month follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 SMT + Rehab Exercises vs SMT


Bronfort 2001 (1) 51 2.9 (2.1) 50 3.7 (2.3) -0.36 [ -0.75, 0.03 ]

-100 -50 0 50 100


Favours treatment Favours control

(1) G2: low technology exercise

Exercises for mechanical neck disorders (Review) 162


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 9.3. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +
Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 3 Pain Intensity: Treatment + IT follow-up (11
weeks of treatment + 6 month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 3 Pain Intensity: Treatment + IT follow-up (11 weeks of treatment + 6 month follow-up

Mean Mean
Study or subgroup Treatment Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 <11w of treatment + 6 month follow-up


Bronfort 2001 (1) 51 3 (2.1) 50 3.5 (2.5) 50.2 % -0.50 [ -1.40, 0.40 ]

Chiu 2005 48 3.1 (2.4) 61 3.9 (2.4) 49.5 % -0.80 [ -1.71, 0.11 ]

Franca 2008 16 10.06 (12.3) 15 19.3 (21.5) 0.3 % -9.24 [ -21.68, 3.20 ]

Subtotal (95% CI) 115 126 100.0 % -0.67 [ -1.32, -0.02 ]


Heterogeneity: Tau2 = 0.01; Chi2 = 2.04, df = 2 (P = 0.36); I2 =2%
Test for overall effect: Z = 2.02 (P = 0.043)

-100 -50 0 50 100


Favours treatment Favours control

(1) G2: low technology excercise (SMT/Ex vs SMT)

Exercises for mechanical neck disorders (Review) 163


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 9.4. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +
Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 4 Pain Intensity: Treatment + LT follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 4 Pain Intensity: Treatment + LT follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 <11w of treatment + 24 month follow-up


Bronfort 2001 (1) 51 3.4 (2.4) 50 3.9 (2.3) -0.21 [ -0.60, 0.18 ]

-100 -50 0 50 100


Favours treatment Favours control

(1) G2: low technology exercise (SMT/Ex vs SMT)

Analysis 9.5. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +


Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 5 Function: Immediate Post treatment.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 5 Function: Immediate Post treatment

Mean Mean
Study or subgroup Treatment Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 <11w of treatment
Bronfort 2001 (1) 51 13.8 (8.6) 50 15.4 (11.7) 23.0 % -1.60 [ -5.61, 2.41 ]

Chiu 2005 59 1 (0.5) 62 1.1 (0.6) 45.2 % -0.10 [ -0.30, 0.10 ]

Franca 2008 16 7.3 (3.7) 15 14 (9.7) 17.1 % -6.70 [ -11.93, -1.47 ]

Martel 2011 32 11.3 (11.8) 32 13.7 (12.1) 14.7 % -2.40 [ -8.26, 3.46 ]

Subtotal (95% CI) 158 159 100.0 % -1.91 [ -4.65, 0.83 ]


Heterogeneity: Tau2 = 4.31; Chi2 = 7.22, df = 3 (P = 0.07); I2 =58%
Test for overall effect: Z = 1.37 (P = 0.17)

-100 -50 0 50 100


Favours experimental Favours control

Exercises for mechanical neck disorders (Review) 164


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(1) SMT/Ex vs SMT

Analysis 9.6. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +


Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 6 Function: Treatment + ST follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 6 Function: Treatment + ST follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 <11w of treatment + 3 month follow-up


Bronfort 2001 (1) 51 13.6 (10.2) 50 18.7 (13) -0.43 [ -0.83, -0.04 ]

-100 -50 0 50 100


Favours treatment Favours control

(1) G2: low technology exercise (SMT/Ex vs SMT)

Exercises for mechanical neck disorders (Review) 165


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 9.7. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +
Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 7 Function: Treatment + IT follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 7 Function: Treatment + IT follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 <11w of treatment + 6 month follow-up


Franca 2008 16 10.2 (6.4) 15 17.6 (8.7) 12.7 % -0.95 [ -1.70, -0.20 ]

Bronfort 2001 (1) 51 14.3 (10.2) 50 17.5 (2.1) 42.2 % -0.43 [ -0.82, -0.03 ]

Chiu 2005 48 1 (0.5) 61 1.2 (0.7) 45.1 % -0.32 [ -0.70, 0.06 ]

Subtotal (95% CI) 115 126 100.0 % -0.45 [ -0.72, -0.18 ]


Heterogeneity: Tau2 = 0.00; Chi2 = 2.16, df = 2 (P = 0.34); I2 =7%
Test for overall effect: Z = 3.23 (P = 0.0012)

-4 -2 0 2 4
Favours treatment Favours control

(1) G2: low technology exercise

Analysis 9.8. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +


Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 8 Function: Treatment + LT follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 8 Function: Treatment + LT follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 <11w of treatment + 24 month follow-up


Bronfort 2001 (1) 51 15.6 (11.8) 50 20.5 (13.5) -0.38 [ -0.78, 0.01 ]

-100 -50 0 50 100


Favours treatment Favours control

Exercises for mechanical neck disorders (Review) 166


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(1) SMT/Ex vs SMT

Analysis 9.9. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +


Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 9 Quality of Life: Immediate Post Treatment.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 9 Quality of Life: Immediate Post Treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 <11w of treatment
Bronfort 2001 (1) 51 -81.7 (12) 50 -78.8 (16.1) 61.1 % -0.20 [ -0.59, 0.19 ]

Martel 2011 32 -54.1 (7.2) 32 -53.1 (6.9) 38.9 % -0.14 [ -0.63, 0.35 ]

Subtotal (95% CI) 83 82 100.0 % -0.18 [ -0.48, 0.13 ]


Heterogeneity: Tau2 = 0.0; Chi2 = 0.04, df = 1 (P = 0.84); I2 =0.0%
Test for overall effect: Z = 1.14 (P = 0.25)
Test for subgroup differences: Not applicable

-100 -50 0 50 100


Favours experimental Favours control

(1) G2: low technology exercise (SMT/Ex vs SMT)

Exercises for mechanical neck disorders (Review) 167


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 9.10. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +
Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 10 Quality of Life: Treatment + ST follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 10 Quality of Life: Treatment + ST follow-up

Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 11w of treatment + 3 month follow-up


Bronfort 2001 (1) 51 -78.4 (14.2) 50 -74.9 (17.8) -3.50 [ -9.79, 2.79 ]

-100 -50 0 50 100


Favours experimental Favours control

(1) G2: low technology exercise (SMT/Ex vs SMT)

Analysis 9.11. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +


Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 11 Quality of Life: Treatment + IT follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 11 Quality of Life: Treatment + IT follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 11w of treatment + 6 month follow-up


Bronfort 2001 (1) 51 -79.8 (12.4) 50 -74.9 (17.8) -0.32 [ -0.71, 0.08 ]

-100 -50 0 50 100


Favours experimental Favours control

(1) G2: low technology exercise (SMT/Ex vs SMT)

Exercises for mechanical neck disorders (Review) 168


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 9.12. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +
Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 12 Quality of Life: Treatment + LT follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 12 Quality of Life: Treatment + LT follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 11w of treatment + 24 month follow-up


Bronfort 2001 (1) 51 -76.2 (15.3) 50 -70.8 (20.4) -0.30 [ -0.69, 0.09 ]

-100 -50 0 50 100


Favours experimental Favours control

(1) G2: low technology exercise (SMT/Ex vs SMT)

Analysis 9.13. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +


Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 13 Patient Satisfaction: Immediate Post
Treatment.
Review: Exercises for mechanical neck disorders
Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 13 Patient Satisfaction: Immediate Post Treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 11>w of treatment
Bronfort 2001 (1) 51 76.9 (41.8) 50 95.2 (48.6) -0.40 [ -0.80, -0.01 ]

-1 -0.5 0 0.5 1
Favours experimental Favours control

(1) G2: low technology exercise (SMT/Ex vs SMT)

Exercises for mechanical neck disorders (Review) 169


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 9.14. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +
Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 14 Patient Satisfaction: Treatment + ST follow-
up.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 14 Patient Satisfaction: Treatment + ST follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 11w of treatment + 3 month follow-up


Bronfort 2001 (1) 51 70.8 (41) 50 91.7 (44.9) -0.48 [ -0.88, -0.09 ]

-2 -1 0 1 2
Favours experimental Favours control

(1) G2: low technology exercise (SMT/Ex vs SMT)

Analysis 9.15. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +


Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 15 Patient Satisfaction: Treatment + IT follow-
up.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 15 Patient Satisfaction: Treatment + IT follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 11w of treatment + 6 month follow-up


Bronfort 2001 (1) 51 67.7 (39.6) 50 91.9 (48.5) -0.54 [ -0.94, -0.15 ]

-4 -2 0 2 4
Favours experimental Favours control

(1) G2: low technology exercise (SMT/Ex vs SMT)

Exercises for mechanical neck disorders (Review) 170


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 9.16. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +
Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 16 Patient Satisfaction: Treatment + LT follow-
up.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 16 Patient Satisfaction: Treatment + LT follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 11w of treatment + 24 month follow-up


Bronfort 2001 (1) 51 54.4 (34.6) 50 88.3 (37.4) -0.93 [ -1.35, -0.52 ]

-2 -1 0 1 2
Favours experimental Favours control

(1) G2: low technology exercise (SMT/Ex vs SMT)

Analysis 9.17. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +


Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 17 Global Perceived Effect: Immediate Post
Treatment.
Review: Exercises for mechanical neck disorders
Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 17 Global Perceived Effect: Immediate Post Treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 11w of treatment
Bronfort 2001 (1) 51 76.6 (43.3) 50 95.6 (46.8) -0.42 [ -0.81, -0.02 ]

-100 -50 0 50 100


Favours experimental Favours control

(1) G2: low technology exercise (SMT/Ex vs SMT)

Exercises for mechanical neck disorders (Review) 171


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 9.18. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +
Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 18 Global Perceived Effect: Treatment + ST
follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 18 Global Perceived Effect: Treatment + ST follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 11w of treatment + 3 month follow-up


Bronfort 2001 (1) 51 77.5 (41.9) 50 91.3 (44.6) -0.32 [ -0.71, 0.08 ]

-0.5 -0.25 0 0.25 0.5


Favours experimental Favours control

(1) G2: low technology exercise (SMT/Ex vs SMT)

Analysis 9.19. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +


Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 19 Global Perceived Effect: Treatment + IT
follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 19 Global Perceived Effect: Treatment + IT follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 11w of treatment + 6 month follow-up


Bronfort 2001 (1) 51 75.7 (43.5) 50 90.9 (45.7) -0.34 [ -0.73, 0.05 ]

-2 -1 0 1 2
Favours experimental Favours control

(1) G2: low technology exercise (SMT/Ex vs SMT)

Exercises for mechanical neck disorders (Review) 172


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 9.20. Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises +
Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION, Outcome 20 Global Perceived Effect: Treatment + LT
follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/-UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER
INTERVENTION vs THAT SAME INTERVENTION
Outcome: 20 Global Perceived Effect: Treatment + LT follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 11w of treatment + 24 month follow-up


Bronfort 2001 (1) 51 65.7 (40.6) 50 83.1 (41.7) -0.42 [ -0.81, -0.03 ]

-1 -0.5 0 0.5 1
Favours experimental Favours control

(1) G2: low technology exercise (SMT/Ex vs SMT)

Analysis 10.1. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic


Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 1 Pain Intensity
(VAS): 12 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT
LIST
Outcome: 1 Pain Intensity (VAS): 12 weeks of treatment

Mean Mean
Study or subgroup Treatment Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise Therapy vs No Treatment


Rendant 2011 (1) 36 28.2 (21.9) 41 45.5 (19.4) 65.2 % -17.30 [ -26.60, -8.00 ]

von Trott 2009 (2) 35 44.5 (25.7) 35 54.9 (28.5) 34.8 % -10.40 [ -23.11, 2.31 ]

Subtotal (95% CI) 71 76 100.0 % -14.90 [ -22.40, -7.39 ]


Heterogeneity: Tau2 = 0.0; Chi2 = 0.74, df = 1 (P = 0.39); I2 =0.0%
Test for overall effect: Z = 3.89 (P = 0.00010)
Test for subgroup differences: Not applicable

-100 -50 0 50 100


Favours treatment Favours control

Exercises for mechanical neck disorders (Review) 173


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(1) Rendant 2011: Exercise therapy vs Wait list control; duration: 3 months; follow-up: none; instrument: VAS:
(2) von Trott 2009: Exercise therapy vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: VAS:

Analysis 10.2. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic


Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 2 Pain Intensity
(VAS): 24 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT
LIST
Outcome: 2 Pain Intensity (VAS): 24 weeks of treatment

Mean Mean
Study or subgroup Treatment Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise Therapy vs No Treatment


Rendant 2011 (1) 35 28.5 (20.8) 39 38.8 (21.6) 66.2 % -10.30 [ -19.97, -0.63 ]

von Trott 2009 (2) 34 47.7 (30.5) 32 59.9 (25.5) 33.8 % -12.20 [ -25.73, 1.33 ]

Subtotal (95% CI) 69 71 100.0 % -10.94 [ -18.81, -3.08 ]


Heterogeneity: Tau2 = 0.0; Chi2 = 0.05, df = 1 (P = 0.82); I2 =0.0%
Test for overall effect: Z = 2.73 (P = 0.0064)

-50 -25 0 25 50
Favours treatment Favours control

(1) Rendant 2011: Exercise therapy vs Wait list control; duration: 18 sessions over 6 months; follow-up: none; instrument: VAS:
(2) von Trott 2009: Exercise therapy vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: VAS:

Exercises for mechanical neck disorders (Review) 174


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 10.3. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic
Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 3 Function: 12 weeks
of treatment.
Review: Exercises for mechanical neck disorders
Comparison: 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT
LIST
Outcome: 3 Function: 12 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise Therapy vs No Treatment


Rendant 2011 (1) 36 29.2 (17.5) 41 42 (15.2) 50.2 % -0.78 [ -1.24, -0.31 ]

von Trott 2009 (2) 35 33.6 (25.5) 35 39.1 (21.7) 49.8 % -0.23 [ -0.70, 0.24 ]

Subtotal (95% CI) 71 76 100.0 % -0.50 [ -1.04, 0.03 ]


Heterogeneity: Tau2 = 0.09; Chi2 = 2.63, df = 1 (P = 0.10); I2 =62%
Test for overall effect: Z = 1.84 (P = 0.065)

-4 -2 0 2 4
Favours experimental Favours control

(1) Rendant 2011: Exercise therapy vs Wait list control; duration: 3 months; follow-up: none; instrument: NPDI 0 - 100
(2) von Trott 2009 Exercise therapy vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: NDI 0 - 100

Exercises for mechanical neck disorders (Review) 175


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 10.4. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic
Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 4 Function: 24 weeks
of treatment.
Review: Exercises for mechanical neck disorders
Comparison: 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT
LIST
Outcome: 4 Function: 24 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise Therapy vs No Treatment


Rendant 2011 (1) 35 29.7 (18.1) 39 38.9 (18.1) 52.3 % -0.50 [ -0.97, -0.04 ]

von Trott 2009 (2) 34 34.3 (24.8) 32 41.3 (23.4) 47.7 % -0.29 [ -0.77, 0.20 ]

Subtotal (95% CI) 69 71 100.0 % -0.40 [ -0.74, -0.06 ]


Heterogeneity: Tau2 = 0.0; Chi2 = 0.40, df = 1 (P = 0.53); I2 =0.0%
Test for overall effect: Z = 2.34 (P = 0.019)

-4 -2 0 2 4
Favours treatment Favours control

(1) Rendant 2011: Exercise therapy vs Wait list control; duration: 18 sessions over 6 months; follow-up: none; instrument: NPDI 0 - 100
(2) von Trott 2009: Exercise therapy vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: NDI 0 -100:

Analysis 10.5. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic


Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 5 Global Perceived
Effect (General Health Perception): 12 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT
LIST
Outcome: 5 Global Perceived Effect (General Health Perception): 12 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise Therapy vs No Treatment


von Trott 2009 (1) 35 37.2 (7.2) 35 36.4 (9.8) 0.09 [ -0.38, 0.56 ]

-4 -2 0 2 4
Favours experimental Favours control

Exercises for mechanical neck disorders (Review) 176


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(1) von Trott 2009 Exercise therapy vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: GPE:

Analysis 10.6. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic


Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 6 Global Perceived
Effect (General Health Perception): 12 weeks of treatment + 12 weeks follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT
LIST
Outcome: 6 Global Perceived Effect (General Health Perception): 12 weeks of treatment + 12 weeks follow-up

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise Therapy vs No Treatment


von Trott 2009 (1) 34 34.8 (10.6) 32 36.9 (9.2) -0.21 [ -0.69, 0.28 ]

-4 -2 0 2 4
Favours experimental Favours control

(1) von Trott 2009: Exercise therapy vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: GPE:

Exercises for mechanical neck disorders (Review) 177


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 10.7. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic
Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 7 Quality of Life (SF-
36): 12 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT
LIST
Outcome: 7 Quality of Life (SF-36): 12 weeks of treatment

Mean Mean
Study or subgroup Experimental Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise Therapy vs No Treatment


Rendant 2011 (1) 36 -45.7 (9.4) 41 -43 (8.7) 52.4 % -2.70 [ -6.76, 1.36 ]

von Trott 2009 (2) 34 -30.3 (7.8) 32 -28.6 (9.7) 47.6 % -1.70 [ -5.96, 2.56 ]

Subtotal (95% CI) 70 73 100.0 % -2.22 [ -5.17, 0.72 ]


Heterogeneity: Tau2 = 0.0; Chi2 = 0.11, df = 1 (P = 0.74); I2 =0.0%
Test for overall effect: Z = 1.48 (P = 0.14)

-100 -50 0 50 100


Favours experimental Favours control

(1) Rendant 2011: Exercise therapy vs Wait list control; duration: 3 months; follow-up: none; instrument: SF-36:
(2) von Trott 2009: Exercise therapy vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: SF-36:

Analysis 10.8. Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic


Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 8 Quality of Life (SF-
36): 24 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT
LIST
Outcome: 8 Quality of Life (SF-36): 24 weeks of treatment

Mean Mean
Study or subgroup Treatement Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise Therapy vs No Treatment


Rendant 2011 (1) 35 -45 (8.3) 39 -43 (8.5) 51.0 % -2.00 [ -5.83, 1.83 ]

von Trott 2009 (2) 35 -29.3 (8.8) 35 -31.5 (8.3) 49.0 % 2.20 [ -1.81, 6.21 ]

Subtotal (95% CI) 70 74 100.0 % 0.06 [ -4.06, 4.17 ]


Heterogeneity: Tau2 = 4.82; Chi2 = 2.20, df = 1 (P = 0.14); I2 =55%
Test for overall effect: Z = 0.03 (P = 0.98)

-100 -50 0 50 100


Favours treatment Favours control

Exercises for mechanical neck disorders (Review) 178


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(1) Rendant 2011: Exercise therapy vs Wait list control; duration: 18 sessions over 6 months; follow-up: none; instrument: SF-36:
(2) von Trott 2009: Exercise therapy vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: SF-36:

Analysis 11.1. Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance


Training vs NO INTERVENTION or WAIT LIST, Outcome 1 Pain Intensity (VAS): 12 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST
Outcome: 1 Pain Intensity (VAS): 12 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Dynamic muscle training vs control


Viljanen 2003 135 2.9 (2.6) 130 2.7 (2.5) 0.08 [ -0.16, 0.32 ]

-4 -2 0 2 4
Favours treatment Favours control

Exercises for mechanical neck disorders (Review) 179


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 11.2. Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance
Training vs NO INTERVENTION or WAIT LIST, Outcome 2 Pain Intensity (VAS): 12 weeks of treatment + 3
month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST
Outcome: 2 Pain Intensity (VAS): 12 weeks of treatment + 3 month follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Dynamic muscle training vs control


Viljanen 2003 135 2.9 (2.8) 130 2.9 (2.8) 0.0 [ -0.24, 0.24 ]

-4 -2 0 2 4
Favours treatment Favours control

Analysis 11.3. Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance


Training vs NO INTERVENTION or WAIT LIST, Outcome 3 Pain Intensity (VAS): 12 weeks of treatment + 9
month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST
Outcome: 3 Pain Intensity (VAS): 12 weeks of treatment + 9 month follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Dynamic muscle training vs control


Viljanen 2003 135 3.1 (2.5) 130 3.2 (2.5) -0.04 [ -0.28, 0.20 ]

-10 -5 0 5 10
Favours treatment Favours control

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Analysis 11.4. Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training
vs NO INTERVENTION or WAIT LIST, Outcome 4 Function (Neck Disability 0-80): 12 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST
Outcome: 4 Function (Neck Disability 0-80): 12 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Dynamic muscle training vs control


Viljanen 2003 135 15 (14.6) 130 14 (13.8) 0.07 [ -0.17, 0.31 ]

-4 -2 0 2 4
Favours experimental Favours control

Analysis 11.5. Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance


Training vs NO INTERVENTION or WAIT LIST, Outcome 5 Function (Neck Disability 0-80): 12 weeks of
treatment + 3 month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST
Outcome: 5 Function (Neck Disability 0-80): 12 weeks of treatment + 3 month follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 Dynamic muscle training vs control


Viljanen 2003 135 15 (15.4) 130 14 (13.8) 0.07 [ -0.17, 0.31 ]

-4 -2 0 2 4
Favours experimental Favours control

Exercises for mechanical neck disorders (Review) 181


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Analysis 11.6. Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance
Training vs NO INTERVENTION or WAIT LIST, Outcome 6 Function (Neck Disability 0-80): 12 weeks of
treatment + 9 month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST
Outcome: 6 Function (Neck Disability 0-80): 12 weeks of treatment + 9 month follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Dynamic muscle training vs control


Viljanen 2003 135 19 (15.5) 128 17 (13.7) 0.14 [ -0.11, 0.38 ]

-4 -2 0 2 4
Favours experimental Favours control

Analysis 12.1. Comparison 12 Acute to Chronic MND: Pattern synchronization + cervical/scapulothoracic


strengthening + scapulothoracic endurance vs NO INTERVENTION, Outcome 1 Pain Intensity (VAS 0 to 10):
24 weeks of treatment.
Review: Exercises for mechanical neck disorders
Comparison: 12 Acute to Chronic MND: Pattern synchronization + cervical/scapulothoracic strengthening + scapulothoracic endurance vs NO INTERVENTION
Outcome: 1 Pain Intensity (VAS 0 to 10): 24 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD)[0 to 10] N Mean(SD)[0 to 10] IV,Random,95% CI IV,Random,95% CI

1 Training group vs control


Lange 2013 27 0.3 (0.52) 28 1 (1.59) -0.58 [ -1.12, -0.04 ]

-4 -2 0 2 4
Favours treatment Favours control

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 13.1. Comparison 13 Chronic MND: Cervical/Scapulothoracic Strengthening +
Cervical/Scapulothoracic Endurance Training, Outcome 1 Pain Prevelance during previous week: 6 weeks of
treatment + 46 weeks follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 13 Chronic MND: Cervical/Scapulothoracic Strengthening + Cervical/Scapulothoracic Endurance Training
Outcome: 1 Pain Prevelance during previous week: 6 weeks of treatment + 46 weeks follow-up

Study or subgroup Exercise Control Risk Ratio Risk Ratio


M- M-
H,Random,95% H,Random,95%
n/N n/N CI CI

1 Exercise Regimen vs control group


Ang 2009 5/28 11/28 0.45 [ 0.18, 1.14 ]

0.005 0.1 1 10 200


Favours treatment Favours control

Analysis 14.1. Comparison 14 Acute to Chronic MND: Scapulothoracic/UE Endurance Training vs


CONTROL, Outcome 1 Pain Intensity (VAS): 10 weeks treatment.

Review: Exercises for mechanical neck disorders


Comparison: 14 Acute to Chronic MND: Scapulothoracic/UE Endurance Training vs CONTROL
Outcome: 1 Pain Intensity (VAS): 10 weeks treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 2 minute training group vs Control


Andersen 2011 (1) 63 2.2 (1.8) 64 3.5 (2.1) -0.66 [ -1.02, -0.30 ]

2 12 minute training group vs Control


Andersen 2011 (2) 65 2.2 (2.3) 64 3.5 (2.1) -0.59 [ -0.94, -0.23 ]

-4 -2 0 2 4
Favours treatment Favours control

(1) 2 min vs Control


(2) 12 min vs Control

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Analysis 15.1. Comparison 15 Chronic MND: Neuromuscular Education (eye neck
coordination/proprioception) + ANOTHER INTERVENTION VS THAT SAME INTERVENTION, Outcome 1
Pain Intensity (VAS): 8 weeks treatment + 10 weeks follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 15 Chronic MND: Neuromuscular Education (eye neck coordination/proprioception) + ANOTHER INTERVENTION VS THAT SAME INTERVENTION
Outcome: 1 Pain Intensity (VAS): 8 weeks treatment + 10 weeks follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Rehabilitation Group vs Control Group


Revel 1994 30 -21.8 (25.2) 30 -4.3 (19.6) -0.77 [ -1.29, -0.24 ]

-10 -5 0 5 10
Favours treatment Favours control

Analysis 15.2. Comparison 15 Chronic MND: Neuromuscular Education (eye neck


coordination/proprioception) + ANOTHER INTERVENTION VS THAT SAME INTERVENTION, Outcome 2
Function (pt’s assessment of functional improvement): 8 weeks treatment + 10 weeks follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 15 Chronic MND: Neuromuscular Education (eye neck coordination/proprioception) + ANOTHER INTERVENTION VS THAT SAME INTERVENTION
Outcome: 2 Function (pt’s assessment of functional improvement): 8 weeks treatment + 10 weeks follow-up

Study or subgroup Treatment Control Risk Ratio Risk Ratio


M- M-
H,Random,95% H,Random,95%
n/N n/N CI CI

1 Rehabilitation Group vs Control Group


Revel 1994 12/30 22/30 0.55 [ 0.33, 0.89 ]

0.01 0.1 1 10 100


Favours experimental Favours control

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 16.1. Comparison 16 Chronic MND:Trunk/Extremity Stretch + Pattern/Synchronization: Balance
and Coordination + Cardiovascular/Aerobic vs NO TREATMENT, Outcome 1 Pain Intensity (VAS): 10 weeks
of treatment.
Review: Exercises for mechanical neck disorders
Comparison: 16 Chronic MND:Trunk/Extremity Stretch + Pattern/Synchronization: Balance and Coordination + Cardiovascular/Aerobic vs NO TREATMENT
Outcome: 1 Pain Intensity (VAS): 10 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Group Gymnastics vs Control


Takala 1994 22 -9 (12) 22 -8 (18.5) -0.06 [ -0.65, 0.53 ]

-10 -5 0 5 10
Favours treatment Favours control

Analysis 17.1. Comparison 17 Chronic MND:General Endurance Training + Dynamic/Static Lowback/pelvic


Stabilization + General Stretching + Neuromuscular/body Mechanics Movement Training vs NO
INTERVENTION OR WAIT LIST, Outcome 1 Pain Intensity (VAS): 16 weeks treatment + 6 weeks follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 17 Chronic MND:General Endurance Training + Dynamic/Static Lowback/pelvic Stabilization + General Stretching + Neuromuscular/body Mechanics
Movement Training vs NO INTERVENTION OR WAIT LIST
Outcome: 1 Pain Intensity (VAS): 16 weeks treatment + 6 weeks follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Physiotherapy Group vs Control Group


Lundblad 1999 (1) 15 0.9 (1.3) 23 1.1 (1.4) -0.14 [ -0.80, 0.51 ]

-10 -5 0 5 10
Favours treatment Favours control

(1) PT vs no treatment

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 18.1. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization +
Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 1 Pain Intensity (VAS): 12 weeks of
treatment.
Review: Exercises for mechanical neck disorders
Comparison: 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness % emotional balance) vs WAIT LIST
Outcome: 1 Pain Intensity (VAS): 12 weeks of treatment

Mean Mean
Study or subgroup Treatment Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Qigong vs No Treatment
Rendant 2011 (1) 41 29.9 (22.6) 41 45.5 (19.4) 71.3 % -15.60 [ -24.72, -6.48 ]

von Trott 2009 (2) 31 47.4 (30.8) 35 54.9 (28.5) 28.7 % -7.50 [ -21.88, 6.88 ]

Subtotal (95% CI) 72 76 100.0 % -13.28 [ -20.98, -5.58 ]


Heterogeneity: Tau2 = 0.0; Chi2 = 0.87, df = 1 (P = 0.35); I2 =0.0%
Test for overall effect: Z = 3.38 (P = 0.00073)
Test for subgroup differences: Not applicable

-100 -50 0 50 100


Favours treatment Favours control

(1) Rendant 2011: Qigong vs Wait list control; duration: 3 months; follow-up: none; instrument: VAS:
(2) von Trott 2009: Qigong vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: VAS:

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 18.2. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization +
Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 2 Pain Intensity (VAS): 24 weeks of
treatment.
Review: Exercises for mechanical neck disorders
Comparison: 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness % emotional balance) vs WAIT LIST
Outcome: 2 Pain Intensity (VAS): 24 weeks of treatment

Mean Mean
Study or subgroup Experimental Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Qigong vs No Treatment
Rendant 2011 (1) 39 30.8 (16.2) 39 38.9 (18.1) 78.4 % -8.10 [ -15.72, -0.48 ]

von Trott 2009 (2) 27 53.1 (30.6) 32 59.9 (25.5) 21.6 % -6.80 [ -21.34, 7.74 ]

Subtotal (95% CI) 66 71 100.0 % -7.82 [ -14.57, -1.07 ]


Heterogeneity: Tau2 = 0.0; Chi2 = 0.02, df = 1 (P = 0.88); I2 =0.0%
Test for overall effect: Z = 2.27 (P = 0.023)

-50 -25 0 25 50
Favours experimental Favours control

(1) Rendant 2011: Qigong vs Wait list control; duration: 18 sessions over 6 months; follow-up: none; instrument: VAS:
(2) von Trott 2009: Qigong vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: VAS:

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 18.3. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization +
Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 3 Function: 12 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness % emotional balance) vs WAIT LIST
Outcome: 3 Function: 12 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Qigong vs No Treatment
Rendant 2011 (1) 41 34.2 (16.9) 41 42 (15.2) 54.9 % -0.48 [ -0.92, -0.04 ]

von Trott 2009 (2) 31 34.3 (23.6) 35 39.1 (21.7) 45.1 % -0.21 [ -0.69, 0.28 ]

Subtotal (95% CI) 72 76 100.0 % -0.36 [ -0.68, -0.03 ]


Heterogeneity: Tau2 = 0.0; Chi2 = 0.66, df = 1 (P = 0.42); I2 =0.0%
Test for overall effect: Z = 2.16 (P = 0.031)
Test for subgroup differences: Not applicable

-4 -2 0 2 4
Favours experimental Favours control

(1) Rendant 2011: Qigong vs Wait list control; duration: 3 months; follow-up: none; instrument: NPDI :
(2) von Trott 2009: Qigong vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: NDI:

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 18.4. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization +
Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 4 Function: 24 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness % emotional balance) vs WAIT LIST
Outcome: 4 Function: 24 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Qigong vs No Treatment
Rendant 2011 (1) 39 30.8 (16.2) 39 38.9 (18.1) 54.7 % -0.47 [ -0.92, -0.02 ]

von Trott 2009 (2) 27 39.8 (25.8) 32 41.3 (23.4) 45.3 % -0.06 [ -0.57, 0.45 ]

Subtotal (95% CI) 66 71 100.0 % -0.28 [ -0.68, 0.11 ]


Heterogeneity: Tau2 = 0.02; Chi2 = 1.37, df = 1 (P = 0.24); I2 =27%
Test for overall effect: Z = 1.40 (P = 0.16)

-4 -2 0 2 4
Favours experimental Favours control

(1) Rendant 2011: Qigong vs Wait list control; duration: 18 sessions over 6 months; follow-up: none; instrument: NPDI:
(2) von Trott 2009: Qigong vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: NDI 0-100:

Analysis 18.5. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization +
Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 5 Global Perceived Effect (General
Health Perception): 12 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness % emotional balance) vs WAIT LIST
Outcome: 5 Global Perceived Effect (General Health Perception): 12 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Qigong vs No Treatment
von Trott 2009 (1) 31 36.3 (9.1) 35 36.4 (9.8) -0.01 [ -0.49, 0.47 ]

-4 -2 0 2 4
Favours experimental Favours control

(1) von Trott 2009: Qigong vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: general health perception:

Exercises for mechanical neck disorders (Review) 189


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 18.6. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization +
Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 6 Global Perceived Effect (General
Health Perception): 12 weeks of treatment + 12 weeks Follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness % emotional balance) vs WAIT LIST
Outcome: 6 Global Perceived Effect (General Health Perception): 12 weeks of treatment + 12 weeks Follow-up

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Qigong vs No Treatment
von Trott 2009 (1) 27 36.1 (8.4) 32 36.9 (9.2) -0.09 [ -0.60, 0.42 ]

-4 -2 0 2 4
Favours experimental Favours control

(1) von Trott 2009: Qigong vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: general health perception:

Analysis 18.7. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization +
Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 7 Quality of Life (SF-36 physical
component): 12 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness % emotional balance) vs WAIT LIST
Outcome: 7 Quality of Life (SF-36 physical component): 12 weeks of treatment

Mean Mean
Study or subgroup Experimental Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Qigong vs No Treatment
Rendant 2011 (1) 41 -46.6 (8.3) 41 -43.2 (8.2) 57.3 % -3.40 [ -6.97, 0.17 ]

von Trott 2009 (2) 31 -30.4 (7.4) 35 -28.6 (9.7) 42.7 % -1.80 [ -5.94, 2.34 ]

Subtotal (95% CI) 72 76 100.0 % -2.72 [ -5.42, -0.01 ]


Heterogeneity: Tau2 = 0.0; Chi2 = 0.33, df = 1 (P = 0.57); I2 =0.0%
Test for overall effect: Z = 1.97 (P = 0.049)
Test for subgroup differences: Not applicable

-100 -50 0 50 100


Favours experimental Favours control

Exercises for mechanical neck disorders (Review) 190


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(1) Rendant 2011: Qigong vs Wait list control; duration: 3 months; follow-up: none; instrument: SF-36:
(2) von Trott 2009: Qigong vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: SF-36:

Analysis 18.8. Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization +
Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 8 Quality of Life: 24 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness % emotional balance) vs WAIT LIST
Outcome: 8 Quality of Life: 24 weeks of treatment

Mean Mean
Study or subgroup Experimental Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Qigong vs No Treatment
Rendant 2011 (1) 39 -47 (10.2) 39 -43.1 (8.5) 49.5 % -3.90 [ -8.07, 0.27 ]

von Trott 2009 (2) 27 -31.4 (7.7) 32 -31.5 (8.3) 50.5 % 0.10 [ -3.99, 4.19 ]

Subtotal (95% CI) 66 71 100.0 % -1.88 [ -5.80, 2.04 ]


Heterogeneity: Tau2 = 3.57; Chi2 = 1.80, df = 1 (P = 0.18); I2 =45%
Test for overall effect: Z = 0.94 (P = 0.35)

-20 -10 0 10 20
Favours experimental Favours control

(1) Rendant 2011: Qigong vs Wait list control; duration: 18 sessions over 6 months; follow-up: none; instrument: SF-36:
(2) von Trott 2009: Qigong vs Wait list control; duration: 24 sessions over 3 months; follow-up: 3 months with home program; instrument: SF-36:

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Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 19.1. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity
Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination +
Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT,
Outcome 1 Pain Intensity: (0-10 box scale): 6 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pat-
tern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT
Outcome: 1 Pain Intensity: (0-10 box scale): 6 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise + Advice vs Advice


Stewart 2007 66 3.2 (2.2) 66 4.3 (2.5) -0.46 [ -0.81, -0.12 ]

-2 -1 0 1 2
Favours experimental Favours control

Analysis 19.2. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity


Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination +
Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT,
Outcome 2 Pain Intensity (0-10 box scale): 6 weeks treatment + 12 month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pat-
tern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT
Outcome: 2 Pain Intensity (0-10 box scale): 6 weeks treatment + 12 month follow-up

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise + Advice vs Advice


Stewart 2007 63 3.5 (2.3) 62 3.8 (2.7) -0.12 [ -0.47, 0.23 ]

-4 -2 0 2 4
Favours experimental Favours control

Exercises for mechanical neck disorders (Review) 192


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 19.3. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity
Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination +
Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT,
Outcome 3 Function (NDI): 6 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pat-
tern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT
Outcome: 3 Function (NDI): 6 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise + Advice vs Advice


Stewart 2007 66 12 (6.8) 66 15.7 (7.9) -0.50 [ -0.85, -0.15 ]

-4 -2 0 2 4
Favours experimental Favours control

Analysis 19.4. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity


Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination +
Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT,
Outcome 4 Function (NDI): 6 weeks of treatment + 12 month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pat-
tern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT
Outcome: 4 Function (NDI): 6 weeks of treatment + 12 month follow-up

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise + Advice vs Advice


Stewart 2007 63 12.1 (7.5) 62 15.5 (9.9) -0.39 [ -0.74, -0.03 ]

-4 -2 0 2 4
Favours experimental Favours control

Exercises for mechanical neck disorders (Review) 193


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 19.5. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity
Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination +
Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT,
Outcome 5 Global Perceived Effect (-5 to 5 scale): 6 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pat-
tern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT
Outcome: 5 Global Perceived Effect (-5 to 5 scale): 6 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise + Advice vs Advice


Stewart 2007 66 -2.5 (1.8) 66 -1.5 (2.5) -0.46 [ -0.80, -0.11 ]

-4 -2 0 2 4
Favours experimental Favours control

Analysis 19.6. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity


Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination +
Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT,
Outcome 6 Global Perceived Effect (-5 to 5 scale): 6 weeks of treatment + 12 month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pat-
tern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT
Outcome: 6 Global Perceived Effect (-5 to 5 scale): 6 weeks of treatment + 12 month follow-up

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise + Advice vs Advice


Stewart 2007 63 -2.3 (2) 62 -1.9 (2.3) -0.18 [ -0.54, 0.17 ]

-4 -2 0 2 4
Favours experimental Favours control

Exercises for mechanical neck disorders (Review) 194


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 19.7. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity
Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination +
Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT,
Outcome 7 Quality of Life (SF-36): 6 weeks of treatment.

Review: Exercises for mechanical neck disorders


Comparison: 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pat-
tern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT
Outcome: 7 Quality of Life (SF-36): 6 weeks of treatment

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise + Advice vs Advice


Stewart 2007 66 -42.1 (8.9) 66 -38.9 (9.3) -0.35 [ -0.69, -0.01 ]

-4 -2 0 2 4
Favours experimental Favours control

Analysis 19.8. Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity


Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination +
Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT,
Outcome 8 Quality of Life (SF-36): 6 weeks of treatment + 12 month follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pat-
tern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT
Outcome: 8 Quality of Life (SF-36): 6 weeks of treatment + 12 month follow-up

Std. Std.
Mean Mean
Study or subgroup Experimental Control Difference Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 Exercise + Advice vs Advice


Stewart 2007 63 -42.3 (9.8) 62 -40.7 (11.3) -0.15 [ -0.50, 0.20 ]

-4 -2 0 2 4
Favours experimental Favours control

Exercises for mechanical neck disorders (Review) 195


Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 20.1. Comparison 20 Acute to Subacute CGH: Cervical Stretch/ROM vs SHAM, Outcome 1 Pain
Intensity (Headache Questionnaire): Treatment + 4 weeks follow-up.

Review: Exercises for mechanical neck disorders


Comparison: 20 Acute to Subacute CGH: Cervical Stretch/ROM vs SHAM
Outcome: 1 Pain Intensity (Headache Questionnaire): Treatment + 4 weeks follow-up

Std. Std.
Mean Mean
Study or subgroup Treatment Control Difference Difference
N Mean(SD) N Mean(SD)