exercises for mechanical neck disorders

EXERCISES FOR MECHANICAL NECK DISORDERSKay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G,

This review should be cited as: Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G, . Exercises for mechanical neck disorders (Cochrane Review). In: The Cochrane Library, Issue 2,

2007. Oxford: Update Software.A substantive amendment to this systematic review was last made on 30 April 2005. Cochrane reviews are regularly checked and updated if necessary.

A B S T R A C T

Background Neck disorders are common, limit function, and are costly to individuals and society. Exercise therapy is a commonly used treatment for neck pain. The effectiveness of exercise therapy remains unclear.Objective To assess the effectiveness of exercise therapy to relieve pain, or improve function, disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders (MND).Search strategy We electronically searched CENTRAL (The Cochrane Library, Issue 2, 2004), MEDLINE, EMBASE, MANTIS, CINAHL, and ICL, without language restrictions, from their beginning up to March 2004, screened reference lists of key articles and authors' personal files.Selection criteria Selected studies were randomised [RCTs] or quasi-randomised trials and investigated the use of exercise therapy as a treatment in adults with MND with or without headache or radicular findings.Data collection and analysis Two reviewers independently conducted study selection, data abstraction, and methodological quality assessment. Using a random effects model, relative risk and standardized mean differences were calculated. Results were ranked using five levels of evidence.Main results Thirty-one trials were selected, 19% (van Tulder criteria) to 35% (Jadad scale) were rated as high quality. There is limited evidence of benefit for strengthening, stretching and strengthening or eye-fixation exercises for neck disorder with headache. There is limited evidence of benefit for active range-of-motion exercises or a home exercise program for acute mechanical neck disorder including whiplash associated disorder. There is limited evidence that an eye-fixation program is beneficial for chronic mechanical neck disorder in the short term but not in the long term. There is unclear evidence of benefit for a stretching and strengthening program in chronic mechanical neck disorder. There is strong evidence of benefit favouring a multimodal care approach of exercise combined with mobilisations or manipulations for subacute and chronic MND with or with headache in the short and long term.Reviewers' conclusions The evidence summarised in this systematic review indicates that there is a role for exercises in the treatment of acute and chronic mechanical neck disorder and neck disorder plus headache. Exercise for neck disorders with radicular findings is not assessed. The relative benefit of each type of exercise needs extensive research. Phase II trials would help identify the most effective treatment characteristics and dosages.

S Y N O P S I S

Neck pain is common, it limits function and is costly. Exercise therapy is a widely used treatment for neck pain. There appears to be a role for exercises in the treatment of neck pain. There is limited evidence of benefit for strengthening, stretching and strengthening or eye-fixation exercises for neck disorder with headache. There is limited evidence of benefit for active range-of-motion exercises or a home exercise program for acute mechanical neck disorder including whiplash associated disorder. There is limited evidence that an eye-fixation program is beneficial for chronic mechanical neck disorder. There is unclear evidence of benefit for a stretching and

strengthening program in chronic mechanical neck disorder. The relative benefit of different exercise approaches is unclear.

B A C K G R O U N D

Neck pain is a common disorder (Côté1998, Makela 1991, Rajala 1995, Takala 1982, Westerling 1980). Most people with neck disorders experience a low level of disability (Côté1998, Linton 1998), however, in a study by Côté, five percent were significantly disabled. Substantive direct and indirect costs for neck disorders can be attributed to visits to health care providers (Borghouts 1999; Hoving 2002; Linton 1998, Lamberts 1987; Skargren 1997; Waalen 1994). Of a large variety of therapeutic interventions available for the treatment of mechanical neck pain, exercise therapy is a widely used treatment. In our earlier systematic review, the effect of exercise therapy on neck pain was inconclusive (Gross 1996). The Verhagen 2004 update indicated the use of active interventions was more effective than passive ones. In 2003, the Australian Acute Musculoskeletal Pain Group determined that advice to stay active was more effective than a collar and rest, and general neck exercises early post-injury were more effective than rest and analgesia, or information and collar in acute neck pain. Further, mobilization plus exercise or exercise plus specific modalities were effective in the short term when compared to rest, collar use and single modality approaches (Australian Guideline). In his 2004 review, Bronfort demonstrated that spinal manipulation therapy (SMT) offered less pain relief in the long term than high technology rehabilitative exercises. There was limited evidence that SMT, in the short and long term, had a similar effect to low technology exercises (Bronfort 2004). In the Gross 2004 review, it appeared that exercise had a primary effect when combined with mobilisation or manipulation (Gross 2002). The inconsistencies in the reviews appear to be due to differences in search dates, mixing of neck disorder types and durations. This lack of consistent evidence and the addition of new trials since the last systematic review justified the need for update.

O B J E C T I V E S

This systematic review assessed the effect of exercise therapy on pain, function, patient satisfaction, and global perceived effect in adults suffering from a mechanical neck disorder. Where appropriate the influence of methodological quality, duration of the disorder, and subtypes of neck disorder on the treatment effect was assessed.

C R I T E R I A F O R C O N S I D E R I N G S T U D I E S F O R T H I S R E V I E W

Types of studies

Any published or unpublished randomised controlled trial (RCTs) or quasi-RCT (a controlled clinical trial that employs a method of allocation that is subject to bias in assignment, such as day of the week), in full text or abstract form, were included.

Types of participants

Participants included in the review were adults (males or females aged 18 years or older) with acute (less than 30 days), subacute (30 days to 90 days) or chronic (greater than 90 days) neck disorders categorized as: Mechanical neck disorders (MND), including whiplash associated disorders (WAD) category I and II (Spitzer 1987, Spitzer 1995), myofascial neck pain, and degenerative changes including osteoarthritis and cervical spondylosis (Schumacher 1993).Neck disorder with headache (NDH) (Olesen 1988, Olesen 1997, Sjaastad 1990), andNeck disorders with radicular findings (NDR) (Spitzer 1987, Spitzer 1995).Studies were excluded if they investigated neck disorders with definitive or possible long tract signs (e.g. myelopathies); neck pain caused by other pathological entities (Schumacher 1993); headache associated with the neck, but not of cervical origin; co-existing headache, when either neck pain was not dominant or the headache was not provoked by neck movements or sustained neck postures; and 'mixed' headache.

Types of intervention

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Studies were included if they used one or more type of exercise therapy such as specific neck exercises, shoulder exercises, active exercise, stretching, strengthening, postural, functional, eye-fixation, and proprioception exercises, if they were prescribed or performed in the treatment of neck pain. Additional physical treatment modalities such as ultrasound or shortwave diathermy were included if they were combined with exercise therapy. For the purpose of our review, studies in which exercise therapy was given as part of a multidisciplinary treatment or exercises requiring a trained individual to apply the technique (such as hold-relax techniques, rhythmic stabilization, and passive techniques) were excluded.

Types of outcome measures

A study was included if it used at least one of the four primary outcome measures of interest: pain,measures of function/disability,patient satisfaction, andglobal perceived effect.

S E A R C H S T R A T E G Y F O R I D E N T I F I C A T I O N O F S T U D I E S

See: Cochrane Back Group search strategySee: methods used in reviews.A research librarian searched computerised bibliographic databases, without language restrictions, for medical, chiropractic and allied health literature. The following databases were searched from their start to March 2004: Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2004), MEDLINE, EMBASE, Manual Alternative and Natural Therapy (MANTIS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Index to Chiropractic literature (ICL), and the Cochrane Back Review Group Trials Register. We also screened references and our personal files, communicated with the Cochrane Back Review Group Co-ordinator and identified content experts. Subject headings (MeSH) and key words included anatomical terms, disorder or syndrome terms, treatment terms and methodological terms. See for the Search Strategy for MEDLINE.

M E T H O D S O F T H E R E V I E W

Two reviewers with expertise in medicine, physiotherapy, chiropractic, massage therapy, statistics, or clinical epidemiology independently conducted citation identification, study selection, data abstraction, and assessment of methodological quality. Agreement was assessed for study selection using the quadratic weighted Kappa statistic (Kw), Cicchetti weights (Cicchetti 1976). Disagreements were resolved through consensus, or a third reviewer was consulted if disagreements persisted. Data were extracted on design (RCT or quasi-RCT, number analysed/number randomised, intention-to-treat analysis, power analysis), participants (disorder subtype, duration of disorder), intervention (treatment characteristics for the treatment and comparison group, dosage/ treatment parameters, co-intervention, treatment schedule, duration follow-up), outcome (baseline mean, end of study mean, absolute benefit, reported results, point estimate with 95% confidence interval (95% CI), power, side effects, cost of care). These factors are noted in the Characteristics of Included Studies Table.For continuous data, standardized mean differences (SMD) (95% CI) were calculated using a random effects model. Standard mean difference was selected over weighted mean difference because different interventions were assessed and most interventions used different outcome measures that used different scales. In the absence of clear guidelines on the size of a clinically important effect size, a commonly applied system by Cohen 1988 was used; small (0.20), medium (0.50) and large (0.80). A minimal clinically important difference between treatments for the purpose of the review was 10 points on a 100-point pain intensity scale. A minimal clinically important difference of five neck disability index units or 10% was considered relevant for the neck disability index (Stratford 1999). For continuous outcomes reported as medians, effect sizes were calculated (Kendal 1963; p 237). Relative risks (RR) were calculated for dichotomous outcomes. The number needed to treat and treatment advantages were calculated for primary findings (Gross 2002; see Table 5). Power analyses were conducted for each article reporting non-significant findings (Dupont 1990). See Characteristics of Included Studies Table for details.Prior to calculation of a pooled effect measure, the reasonableness of pooling was assessed, based on clinical judgement. Using a random effects model, statistical heterogeneity was tested using Chi squared method between the studies. In the absence of heterogeneity (p greater than 0.10), a








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pooled SMD or RR was calculated. Sensitivity analysis or meta-regression for the factors: symptom duration, methodological quality, and subtype of neck disorder were planned but were not carried out because we did not have enough data in one category.To further summarize our findings, we used the following levels of evidence (Sackett 2000; van Tulder 2003) - of benefit, of no benefit, or of reduced benefit relative to the comparison treatment: Strong evidence - denotes consistent findings in multiple high quality randomised controlled trialsModerate evidence - denotes findings in a single, high quality randomised controlled trial or consistent findings in multiple low quality trials.Limited evidence - indicates a single low quality randomised trial.Unclear evidence - denotes inconsistent or contradictory results in multiple randomised trials.No evidence - means no studies were identified.The term 'Strong Evidence of No Benefit' was used for trials or meta-analyses large enough to be negative, with a low risk of false-negative conclusions (e.g. power of 80% or greater; sample size of approximately 70 or greater per arm). The required sample size per arm was based on rheumatoid arthritis trial criteria for clinically important change (Goldsmith 1993), since we are aware of no criterion for neck pain trials specifically.

D E S C R I P T I O N O F S T U D I E S

Thirty-one trials were included in this systematic review. 24 studied mechanical neck disorder: four acute (McKinney 1989; Mealy 1986; Pennie 1990; Rosenfeld 2000), 16 chronic (Allison 2002; Bronfort 2001; Fitz-Ritson 1995; Gam 1998; Goldie 1970; Hagberg 2000; Jordan 1998; Koes 1992; Lundblad 1999; Randlov 1998; Revel 1994; Soderlund 2001; Taimela 2000; Vasseljen 1995; Waling 2002; Ylinen 2003), 1 mixed (Soderlund 2000), three not specified (Hanten 2000; Levoska 1993; Takala 1994)one studied neck disorder with some radicular signs and symptoms: one chronic (Persson 2001)three studied headache of cervical origin: one chronic (Jull 2002), one mixed (Provinciali 1996), one not specified (Karlberg 1996);three studies reported on a mixed population: one mechanical neck disorder and neck disorder with headache of acute, subacute and chronic duration (Hoving 2002); one mechanical neck disorder and neck disorder with some radicular signs and symptoms of subacute and chronic duration (Brodin 1985); one mechanical neck disorder, neck disorder with some radicular signs and symptoms and headache of cervical origin of subacute duration (Kogstad 1978)Studies varied in size from 17 to 179 (n analysed), 61% were considered small (less than 70 subjects per intervention arm). Fourteen studies were excluded from the review because they were not RCTs, examined a different type of participant (i.e. cervical root compression, chronic tension headache), tested a different intervention (i.e. not active exercise, the exercise was the same in all groups, or the exercise group could not be separated out), or they did not measure any of the identified primary outcomes.

M E T H O D O L O G I C A L Q U A L I T Y

Two reviewers independently assessed the methodological quality based on three different scales (see ): the validated Jadad 1996 criteria (maximum score five, high score greater than two, moderate score two, and low score one; the abbreviated Cochrane collaboration Back Review Group criteria (van Tulder 1997; van Tulder 2000) (maximum score equal 9, high score greater than four) and the Cochrane grading system for concealment of allocation (A to D; see Characteristics of Included Studies Table), which refers to how well the allocation to treatment group was concealed.The methodological quality scores for each trial are listed in (Jadad criteria) and (van Tulder criteria). Of the 31 selected trials, 19% (van Tulder scale) to 35% (Jadad scale) were rated as high quality. Common methodological weaknesses included failure to describe or use appropriate concealment of allocation (48%) and lack of effective "blinding" procedures - the minimum expectation being blinding of the outcome assessor (65%). Compliance was monitored in only 25%, and co-intervention was not avoided in 71% of trials. Methodological quality did not appear to influence the end results of the review, as both high and low quality studies had similar outcome directions. This relationship between methodological quality and end results of the review was not formally tested using sensitivity analysis/meta-regression, because there were not enough data in any one disorder and treatment category.








































R E S U L T S

A quick summary of various forms of exercises compared to a control can be found in . Formal sensitivity analysis was not conducted, as there were not enough trials in each subgroup.Active Range-of-Motion Exercises Active range-of-motion (AROM) exercises consisted of any exercises done by the individual patient/subject that included active movement without resistance. Exercises could be gentle, active, small range, and amplitude movements (Rosenfeld 2000) or end range sustained stretches (Hanten 2000). Three trials assessed the effects of AROM exercises, two trials measured pain in patients with MND/WAD of acute duration (Rosenfeld 2000, McKinney 1989 and one trial MND of unspecified duration (Hanten 2000). When physiotherapy (heat, cold, SWD, hydrotherapy, traction, and exercises) was compared with a control of rest for 10 to 14 days followed by general advice to mobilise, in a single high quality trial, there was limited evidence of benefit for pain in the short term (six weeks of treatment) that did not persist in the long term (six weeks of treatment and 104 weeks follow-up) in acute WAD (McKinney 1989). When a trial of moderate quality compared a program of early and delayed education, there was limited evidence of benefit on pain relief in the short and long term (four treatment sessions (average) and 24 weeks follow-up) for acute WAD (Rosenfeld 2000). To understand the effectiveness of different subtypes of exercises, or the impact of the timing of exercises, comparisons evaluating one exercise type against another were examined. In a moderate quality study there was limited evidence of no difference in pain relief when neck AROM exercises were compared with ischemic pressure and stretching neck and upper back muscles in the short term (five days) for MND (disorder duration not specified) (Hanten 2000). In a trial of moderate quality, there was limited evidence of benefit for pain relief when early exercise was compared with delayed exercise in the short and long term (four treatment sessions (average) and 24 weeks follow-up) for acute WAD (Rosenfeld 2000).In summary, there are few comparisons for AROM. There is limited evidenced of benefit that AROM may reduce pain in acute WAD in the short term.Strengthening Exercises Strengthening exercises consist of any exercise done by the individual/patient that includes resistance, for example isometric, isokinetic or isotonic. It could include strength training with machines (Waling 2002), free weights, or low load endurance exercises to train muscle control (Jull 2002). Of five trials assessing strengthening exercises, four compared strengthening to a placebo or control, two of chronic MND (Goldie 1970, Waling 2002), one chronic NDH (Jull 2002), and one mixture of subacute MND/NDR/NDH (Kogstad 1978). In a moderate quality trial, there was no evidence of benefit for pain or function when strength or endurance training through the arms was compared with a control in the short (ten weeks of treatment and two weeks follow-up) or long term (ten weeks of treatment and 144 weeks follow-up) in chronic MND (Waling 2002). However, there was evidence of benefit on global perceived effect in a low quality trial, when strengthening through the neck was compared with a (treatment) control in the short term (three weeks of treatment and three weeks follow-up) for chronic MND (Goldie 1970). In a high quality trial, when strengthening through the neck was compared with a control, there was limited evidence of benefit in the short (seven weeks of treatment and long term (seven weeks of treatment and 45 weeks follow-up) for headaches (intensity and frequency), disability and global perceived effect for chronic NDH (Jull 2002). When manual therapy was added to this exercise treatment, there was an additional benefit for headache duration (Jull 2002). In a low quality trial, when a conventional approach (heat, soft tissue massage, traction) including exercise (isometric) was compared with a placebo treatment (placebo tablets plus education and ergonomics) there was no evidence of difference in global perceived effect in the short term (five weeks of treatment) in all disorder types of subacute duration (Kogstad 1978). Three trials compared strengthening exercises to other treatments (Goldie 1970; Jull 2002; Kogstad 1978). In a low quality trial, a comparison of strengthening and traction showed evidence of no difference on global perceived effect in the short term (three weeks of treatment and three weeks follow-up) for chronic MND (Goldie 1970). In a high quality trial comparing neck strengthening with manual therapy, there was evidence of no difference for pain, function or global perceived effect in the short (seven weeks of treatment) or long term (seven weeks of treatment and 45 weeks follow-up) for chronic NDH (Jull 2002). When exercise was added to a program of physical medicine methods (including soft tissue massage and traction) and compared with manual therapy, there was no evidence of difference on global perceived effect in the short (five weeks of treatment) and long term (five weeks of treatment and 18 months follow-up) for subacute MND, NDH and NDR (Kogstad 1978). Two additional trials (one of moderate quality and one high quality) showed no evidence of difference on pain (Waling 2002, Hagberg 2000) or function (Waling 2002) when strengthening of the arms was compared with endurance or coordination (balance and postural stability) exercises in the short (five or 10 weeks of treatment with two weeks follow-up) and long term (five or 10 weeks of treatment and 18 or 144 weeks follow-up) in chronic MND.These conflicting results for strengthening exercises, when compared with a placebo, control or another treatment, may be in part from the different control groups (for example: (a) stress management; (b) drug therapies; (c) placebo tablets, education, and ergonomics), but it may also have occurred from the different types of exercises [for example: (a) neck or shoulder exercises;































(b) singular (isometric) exercises; (c) multiple exercise approaches (endurance, postural, isometric, proprioception)]. When the exercise focused on strengthening the shoulder/thoracic region, the trials showed no effect (Waling 2002), however, when the strengthening focused on the neck areas, the trials showed a positive effect for exercise (Goldie 1970; Jull 2002).In summary, there is moderate evidence of benefit for neck strengthening exercises for pain, function and global perceived effect for chronic NDH in the short and long term. There is unclear evidence for strengthening exercises for chronic MND for pain relief in the short and long term; this may be confounded by the location of focus of the strengthening exercises (neck or shoulders/upper back). The difference in benefit between an exercise approach and physical medicine methods or manual therapy, or between a strengthening or endurance exercise program is unclear.Stretching and Strengthening ExercisesA combination of stretching and strengthening was used by 16 trials with multiple comparisons.Stretching and strengthening exercises compared with a control treatmentSix studies compared stretching and strengthening exercises to a control treatment, four included chronic MND (Allison 2002; Gam 1998; Lundblad 1999; Ylinen 2003), one trial was MND of unspecified duration (Takala 1994) and one trail was NDH of unspecified duration (Karlberg 1996). A high quality trial of stretching and strengthening (cervical and shoulder region) compared a program of ultrasound, massage and exercise with a no treatment control. There was evidence of benefit on pain in the short term (four weeks of treatment), however, when sham ultrasound was used as the control, there was evidence of no difference for pain in the short term (four weeks of treatment) for chronic MND (Gam 1998). In another moderate quality trial comparing either a strengthening or endurance program of the neck and shoulder with a control of recreation activities, there was limited evidence of benefit for pain relief in the long term (52 weeks of treatment) in chronic MND (Ylinen 2003). Two trials, one chronic MND of low quality (Allison 2002) and one MND (duration not specified) of moderate quality (Takala 1994) compared a shoulder/thoracic exercise program with a no treatment control; there was no evidence of benefit for pain in the short term (eight to 10 weeks of treatment) (Allison 2002; Takala 1994). There was unclear evidence on function as one study showed evidence of benefit for function, and a positive effect on overall handicap and interference with work in the short term (10 weeks of treatment) for MND of unspecified duration (Takala 1994), and another no effect on function (Northwick Park Questionnaire) in the short term (at eight weeks of treatment) for chronic MND (Allison 2002). One trial of moderate quality that did not specify the targeted muscles as either neck or shoulder/trunk showed no evidence of benefit for exercises over a no treatment control group for pain and function in the long term (16 weeks of treatment and 52 weeks follow-up) in chronic MND (Lundblad 1999). Two studies comparing strengthening exercises to a control could be pooled on the basis of outcome (pain), duration (four and eight weeks of treatment) and disorder type (chronic MND). There is moderate evidence of benefit on pain [pooled SMD -0.42 (95%CI Random: -0.83 to -0.01)] (Allison 2002; Gam 1998). One trial of moderate quality showed limited evidence of benefit on pain in the short term (13 weeks of treatment) when stretching and strengthening plus mobilizations, NSAID, and education was compared to a wait period control for subacute NDH (Karlberg 1996). A complete review of the benefits of a multimodal approach has already been published by our group in Gross 2004. Overall, there was strong evidence of benefit favouring multimodal care for pain reduction [pooled SMD -0.85 (95%CI:-1.20 to -0.50)], improvement in function [pooled SMD -0.57 (95%CI: -0.94 to -0.21)] and global perceived effect [SMD -2.73 (95%CI:-3.30 to -2.16)] for subacute and chronic MND with or without headache. The common elements in this care strategy were mobilisation or manipulation plus exercise ().In summary, there is strong evidence of benefit favouring a multimodal care approach of exercise combined with mobilizations or manipulations for subacute and chronic MND with or without headache for pain reduction, improved function, and high global perceived effect in the short and long term, moderate evidence of benefit favouring a stretching and strengthening program in the cervical or cervical and shoulder/trunk region on pain in chronic MND with or without headache in the short and long term, and limited evidence of benefit favouring a multimodal approach of care on pain in the short term for subacute NDH. There is evidence of no difference for a stretching and strengthening program focusing on shoulder musculature or when the focus of exercise is not specified on pain or function in the short or long term. There was no evidence available for NDR.Stretching and strengthening exercises compared with another treatment Four trials compared a treatment including trunk/shoulder and neck stretching and strengthening exercises with another treatment (Bronfort 2001; Jordan 1998; Persson 2001; Hoving 2002). Two trials of high quality compared an intensive neck and shoulder exercise program with manual therapy techniques in chronic MND (Bronfort: MedX v SMT; Jordan 1998). Both trials showed evidence of no difference on pain, disability or global perceived effect in the short term (six to 11 weeks of treatment) or the long term (six to 11 weeks of treatment and 46 to 52 weeks follow-up). When an exercise program was compared with manual treatments in acute/subacute/chronic duration of MND/NDH, there was no evidence of difference for pain in the short term, and global perceived effect in the short and long term (six weeks of treatment and 46 weeks follow-up). However, there was evidence of benefit in improvement in the main functional limitation in the





























long term (six weeks of treatment and 46 weeks follow-up) (Hoving 2002: PT v MT). In a high quality trial comparing an exercise program (neck and shoulder) with a program of education, medication and home exercises, there was evidence of no difference for pain, and global perceived effect in the short or long term (six weeks of treatment and 46 weeks follow-up) for MND/NDH of acute, subacute, or chronic duration (Hoving 2002: PT v GP). In a high quality trial of chronic NDH, a program including manual techniques, modalities and exercise (neck and shoulder) was compared with surgery; there was limited evidence of benefit for pain relief for the surgical treatment in the short term (12 weeks of treatment), however, this did not persist long term (12 weeks of treatment and 52 weeks follow-up) (Persson 2001:PTvsurg). When this same exercise treatment was compared with constant collar use, there was evidence of no difference in pain relief in the short or long term (12 weeks of treatment and 52 weeks follow-up) (Persson 2001:PTv col).In summary, there is unclear evidence on the relative benefit of stretching and strengthening exercises over other treatments such as a manual therapy approach or a program of education, medication and home exercises in MND (either acute, subacute, or chronic duration) for all outcomes (pain, function, and global perceived effect) in the short or long term. In the long term, surgical intervention was no better than a program of modalities plus exercise for NDR.One form of exercise compared with another Nine trials compared one form of exercise with another (Allison 2002; Bronfort 2001; Levoska 1993; Lundblad 1999; Randlov 1998; Soderlund 2000; Soderlund 2001; Vasseljen 1995; Ylinen 2003). When an active stretching muscle training of neck and shoulder was compared against a program consisting of passive modalities and light stretching and exercising (neck and shoulder) there was evidence of benefit in the short term (five weeks of treatment) on pain relief (decreased occurrence of cephalagy or neck and shoulder pain) in a moderate quality trial of MND (duration not specified) (Levoska 1993). In a high quality trial comparing neck and shoulder exercises with no resistance with shoulder exercises with resistance, there was evidence of no difference in patient satisfaction in the short and long term (12 weeks of treatment and 52 weeks follow-up) in chronic MND (Randlov 1998). In a high quality trial, comparing a program of spinal manipulation and neck and upper body stretching and strengthening exercises with a stretching and strengthening program (intensive using machines), there was evidence of no difference for pain or function, however there was evidence of benefit for patient satisfaction in the long term (11 weeks of treatment and 52 weeks follow-up) for chronic MND (Bronfort 2001). There was no evidence of difference when a general exercise program was compared with a Feldenkrais program (less intense) on pain intensity, disability during work/leisure time or sick leave in the long term (16 weeks of treatment and 52 weeks follow-up) for chronic MND (Lundblad 1999). When an articular based program with neck exercises was compared with a neural focus treatment with neck exercises there was no evidence of difference on pain and disability in the short term (eight weeks of treatment) in a low quality trial of chronic MND (Allison 2002). When an exercise program for the neck and shoulders was compared with an endurance program, there was no evidence of difference on pain relief in the long term (52 weeks of treatment) in chronic MND (Ylinen 2003). In a high quality trial comparing eye-fixation/proprioception exercises with another exercise program, there was evidence of benefit on function in the short term for chronic MND/WAD (Fitz-Ritson 1995). When a strategy to address coping and self-efficacy was added to an exercise program, there was no evidence of difference on pain intensity and pain disability index in the short term (12 sessions and 12 weeks follow-up), however, there was evidence of benefit for global perceived effect in the short term (12 sessions and 12 weeks follow-up) in a moderate quality trial of chronic MND/WAD (Soderlund 2001).In summary, there was evidence of no difference between the different exercise approaches, therefore the relative benefit of different exercise approaches appear similar.Eye-Fixation/Proprioception ExercisesTrials classified as dizziness or proprioception exercises used eye-fixation or neck proprioception exercises as a treatment strategy. All studies (except Provinciali 1996) used the term proprioceptive training or discussed affecting proprioception through training. Provinciali 1996 refers to cervicoencephalic syndrome. Generally, the purpose of these trials was to affect sensory integration or sensory and coordination of reflex control rather than mobility and strength. The purpose was to restore coordinated movement or cervicoencephalic kinaesthesia utilizing visual training techniques.Eye-fixation/proprioception exercises compared with a controlFour trials assessed the effect of eye-fixation/proprioception exercises (Taimela 2000; Fitz-Ritson 1995; Revel 1994; Provinciali 1996). When eye-fixation/proprioception exercises were compared with a control in two moderate quality trials of chronic MND, there was limited evidence of benefit for pain relief in the short term (eight to 12 weeks of treatment and two weeks follow-up) with a pooled SMD -0.72 (95% CI Random: -1.12 to -0.32) (Taimela 2000; Revel 1994), however this did not persist in the long term (12 weeks of treatment and 36 weeks follow-up) (Taimela 2000). In the same two trials, there was limited evidence of benefit for functional improvement in the short term (Revel 1994) and on global perceived effect in the short and long term (Taimela 2000).






































Eye-fixation exercises compared with other treatmentsWhen eye-fixation exercises were compared with other treatments in a moderate quality trial of acute and subacute WAD with or without headache, there was limited evidence of benefit on pain and return to work in the long term (two weeks of treatment and 24 weeks follow-up) (Provinciali 1996). When eye-fixation/proprioception exercises were compared with another exercise program, there was evidence of no benefit for pain relief in the short and long term, however, there was limited evidence of benefit on global perceived effect in the short and long term (12 weeks of treatment and 36 weeks follow-up) (Taimela 2000). In one high quality trial for chronic WAD, there was limited evidence of benefit on function in the short term (eight weeks of treatment) (Fitz-Ritson 1995). In summary, program of eye-fixation/proprioception exercises imbedded in a more complete program showed moderate evidence of benefit for pain, function, and global perceived for chronic mechanical neck disorder in short term and on pain and function for acute/subacute neck disorder with headache/whiplash associated disorder in the long term.Home ExercisesHome exercises consist of any exercises given to do at home. The individual may be given instructions (written or verbal) and training but the exercises are not supervised on a continued basis. Studies were not included if the same home exercises were given in the treatment and comparison groups. Ten trials assessed the effects of a home exercise program.Home exercises compared to either a placebo or control groupSix trials compared home exercises to either a placebo (detuned SWD and US) (Koes 1992: GP v pl)] or control group (no treatment, rest with or without collar then general mobilisation or mock therapy of superficial massage, manual traction, electrical stimulation, medication and education) (Allison 2002:AT v CG; McKinney 1989: 3 v 1; Mealy 1986; Pennie 1990; Brodin 1985: 2 v 1). In two high quality trials, there was limited evidence of benefit for pain relief in the short term (four to eight weeks of treatment) (McKinney 1989: 3 v 1; Mealy 1986), however, there was evidence of no difference on global perceived effect in the short term (six to 8 weeks of treatment) (Pennie 1990) for acute WAD when a program of exercises plus other physical modalities was compared with general advise to rest (10 to 14 days with or without a collar), followed by general mobilisation. There was evidence of no benefit for pain in one low quality trial (Allison 2002:AT v CG), one high quality trial (Koes 1992: GP v pl) and moderate quality trial (Brodin 1985: 2 v 1) and for function in one low quality (Allison 2002:AT v CG) and one high quality trial (Koes 1992: GP v pl) for chronic MND in the short term (three to 8 weeks of treatment and one week follow-up). In summary, there is limited evidence of benefit on pain relief in the short term for a mobilisation program with other physical modalities, over a program of rest then gradual mobilisation for acute WAD.Home exercises compared with other treatmentsWhen home exercises were compared with other treatments in two high quality trials of chronic MND and acute, subacute, and chronic MND and NDH, there was evidence of no difference for pain, physical functioning, and global perceived effect in the short term, when treatment by the general practitioner (medication, advice about posture, home exercises and other treatment modalities) was compared with a manual therapy treatment (manipulation and mobilisation) (Koes 1992: GP v MT; Hoving 2002: GP v MT). The manual therapy group was favoured for pain relief and global perceived effect in the short term (six weeks of treatment and one to 7 weeks follow-up) (Hoving 2002: GP v MT), and physical functioning in the short term (nine weeks of treatment and three weeks follow-up) (Koes 1992: GP v MT). In summary, there is evidence of no benefit when home exercises are compared with other treatments in the short term and long term and there appears to be some benefit for using manual therapy program over a general practitioner or home based approach.One home exercise approach compared with anotherTwo trials of moderate quality assessed different types of home exercise approaches (Taimela 2000; Rosenfeld 2000). One moderate trial of acute MND (Rosenfeld 2000) and one moderate trial of chronic MND (Taimela 2000] favoured an individual training program with education (written and verbal) to an education program for pain relief in the short term (12 to 24 weeks of treatment) (Taimela 2000; Rosenfeld 2000) and patient satisfaction in the short and long term (12 weeks of treatment and 36 weeks follow-up) (Taimela 2000). A home program of ischemic pressure plus stretching exercises was compared with a home program of active ROM exercises in MND (disorder duration not specified) there was evidence of no difference for pain in the short term (five days of treatment) (Hanten 2000). In summary, there is limited evidence of benefit for individualised instruction over written information alone for pain in the short term and patient satisfaction in the short and long term for acute and chronic MND.Adverse EventsSide effects were reported by 12% of the trials. They were benign, of short duration and included headache, arm pain, pins and needles, dizziness and worsening of symptoms.Cost of CareThere was moderate evidence favouring reduced costs for multimodal manual therapy and exercise care over physiotherapy, exercise, or general practitioner practice (Hoving 2002; Provinciali 1996).






































D I S C U S S I O N

Study Selection The validity of a systematic review is dependent on the selection of all relevant studies. Although studies published in any language were accepted, many scientific journals in non-English languages are not indexed in MEDLINE and EMBASE. We did not search non-English databases, which may introduce 'language bias' in the review. Multiple sources of literature including writing to authors and institutions was not undertaken due to the lack of productivity of these methods in the last review (Gross 1996). Therefore 'publication bias' was not guarded against in this update.Methodological QualityTwo of the 31 studies met the criterion of double-blinding (blind patients and care providers) (Gam 1998; Goldie 1970), a methodological issue inherent to the nature of exercise therapy. It is therefore very important to have blinded assessment of outcome and analysis; 11 of the 31 trials reported blinding of the observer. This may be challenging for the primary outcomes of pain, function, satisfaction and global perceived effect. Further, it is important for future studies to ensure the treatments are equally credible and acceptable to patients, and patients have limited experience or expectations for either treatment to minimize expectation bias. Another issue that is important in exercise therapy is that of compliance, co-intervention and contamination, which are not commonly monitored during the trial or dealt with through the study design. These have an important impact on "dosage" and an understanding of dose response to exercise.Effectiveness of Exercise TherapyIn our previous systematic review (Gross 1996), results were inconclusive, and there was no ability to look at subgroups of exercise due to the small number of trials and their low power. Since then, 15 randomised clinical trials have been added to the current review. In general, these new trials utilize larger sample sizes and more consistent outcomes. Strong evidence : There is strong evidence of benefit favouring a multimodal care approach of exercise combined with mobilisations or manipulations for subacute and chronic MND with or without headache in the short and long term.Moderate evidence : When the stretching and strengthening program focuses on the cervical or cervical and shoulder/thoracic region, there is moderate evidence of benefit on pain in chronic MND [pooled SMD -0.42 (95%CI: -0.83 to -0.01)] and NDH in the short and long term. A program of eye-fixation/proprioception exercises imbedded in a more complete program shows moderate evidence of benefit for pain, function, and global perceived effect for chronic MND in short term and on pain and function for acute and subacute WAD with or without headache in the long term.Limited evidence: The current results point to limited evidence of benefit that AROM may reduce pain in acute WAD in the short term. There is limited evidence of benefit that neck strengthening exercises will reduce pain, improve function and global perceived effect for chronic NDH in the short and long term. There is limited evidence of benefit on pain relief in the short term for a home mobilisation program with other physical modalities over a program of rest then gradual mobilisation for acute WAD. In the long term, surgical intervention was no better than a program of modalities plus exercise for NDR based on limited evidence.Unclear evidence : There is unclear evidence regarding the impact of a stretching and strengthening program on pain, function and global perceived effect for MND. It is unclear if exercise therapy is more effective than other types of treatment (manual therapies or modalities) and it is impossible to identify the effective components of these multimodal treatments. There was evidence of no difference between the different exercise approaches.Adverse Events and Cost of CareAdverse events were reported in five of the randomised trials in this review and were benign and of short duration (Jull 2002; Brodin 1985; Bronfort 2001; Hoving 2002; Jordan 1998). More consistent reporting over many trials is required to understand the type and severity of side effects from exercise therapy. Only two trials reported on the cost of care (Hoving 2002; Provinciali 1996). To better understand the direct and indirect costs, better reporting is required by each study

R E V I E W E R S ' C O N C L U S I O N S

Implications for practice

Exercise, both stretching and/or strengthening (of the cervical or shoulder region) and vertigo/eye-fixation exercises, are more beneficial than no treatment. A multimodal care approach of exercise combined with mobilisations or manipulations for subacute and chronic MND with or without headache, reduced pain, improved function, and high global perceived effect in the short and long term.













It is unclear what the relative benefit of exercise therapy is when compared to other treatments. The relative benefit of different exercise approaches is unclear. It was not possible to determine which technique or dosage was more beneficial or if certain subgroups benefit more from one form of care than another.

Implications for research

As a result of the numerous types of comparisons, treatment characteristics, and diseases no sensitivity analysis could be performed. Future trials should improve on 'blinding' procedures, co-intervention and compliance. A factorial design would help determine the active treatment agent(s) within a treatment mix. Phase II trials would help identify the most effective treatment characteristics and dosages.

A C K N O W L E D G E M E N T S

We are indebted to the many authors of primary studies for their support in retrieving original research. We thank our volunteers, translators, and the Back Group editors.

P O T E N T I A L C O N F L I C T O F I N T E R E S T

Jan Hoving and Gert Bronfort are the first authors of two of the trials included in this review. They were not involved in the inclusion decisions, quality assessment or data extraction for their respective trials.

N O T E S

T A B L E S

Characteristics of included studies

Study Allison 2002

Methods Type of Trial: RCT crossover designNumber Analysed/Randomised: 36/40Intension-to-treat Analysis: conductedPower Analysis: NR

Participants Chronic MND (cervical brachial pain syndrome)

Interventions

INDEX TREATMENTArticular Treatment (AT): thoracic and glenohumeral mobilisation, home exercise (stretches, theraband strengthening)COMPARISON TREATMENTSNeural treatment (NT): neural tissue techniques, mobilisation, neuromuscular techniques, home mobilisation exercise techniques (10 repetitions, 1 to 3 times/day]Control Group (CG): no treatment, allowed to seek treatment from a non-physiotherapy health care providerCOINTERVENTION: NRTreatment Schedule: 8 weeks, ? sessionDuration of Follow-up: none

Outcomes

PAIN (VAS, 0 to 10)Baseline Median: NT 4.6, AT 5.1, CG 3.3Reported Results: significant favouring NTSMD(AT v CG): -0.15(95%CI:-1.05 to 0.75) [power %]SMD(AT v NT): 0.63(95%CI: -0.20 to 1.46)FUNCTION (Northwick Park Questionnaire, 0 to 36)Baseline Median: NT 12, AT 12.5, CG 12.5Reported Results: not significantSMD(AT v CG): -0.10(95%CI:-1.00 to 0.80) [power %]SMD(AT v NT): 0.24(95%CI: -0.57 to 1.56) power %]SIDE EFFECT: NRCOST OF CARE: NR

Notes

Allocation concealment B - Unclear

Study Allison 2002:AT v CG

Methods [Refer to Allison 2002 for details; author described articular treatment v control group]

Participants

Interventions

Outcomes

Notes


Study Allison 2002:AT v NT

Methods [Refer to Allison 2002 for details; author described articular group v neural group]

Participants

Interventions

Outcomes

Notes


Study Brodin 1985

Methods Type of Trial: RCTNumber Analysed/Randomised: 63/71Intention-to-treat Analysis: NRPower Analysis: NR

Participants Chronic MND (25% of N had NDR or lower cervical degenerative changes)

Interventions

INDEX TREATMENTGroup 3 (G3): mobilisation (passive) described by Stoddard, massage, manual traction, superficial heat, analgesics, education (neck school including exercise, 3 hours), 3 sessions/weekCOMPARISON TREATMENTSGroup 1(G1): analgesicGroup 2 (G2): Mock Therapy included superficial massage, manual traction, electrical stimulation, analgesics, education (neck school including exercise, 3 hours), 3 sessions/weekCOINTERVENTION: NRTreatment Schedule: 3 weeks, 9 sessionsDuration of Follow-up: 1 week

Outcomes

PAIN (9 point linear scale):Baseline: NRReported Results: significant difference favouring G3RR(3 v 1): 0.67(95%CI:0.43 to 1.04) [power 18%]RR(3 v 2): 0.59(95%CI:9.39 to 0.91)SIDE EFFECTS: 10 in G1; G2 reported discomfort, usually small complaints; RR: 9.22(95%CI:0.61 to 14.30); note one subject dropped out due to acute cerebral disease (n=1), others dropped out for the following reasons: acute abdominal pain (n=1); ; vacation and infection (n=1); acute pain in several joints (n=1); incapable of following planned treatment (n=4)COST OF CARE: NR

Notes


Study Brodin 1985: 2 v 1

Methods [Refer to Brodin 1985 for details; author described group 2 v 1]

Participants

Interventions

Outcomes

Notes




Participants

Interventions

Outcomes

Notes




Participants

Interventions

Outcomes

Notes


Study Bronfort 2001

Methods Type of Trial: RCTNumber Randomised: 191Number Analysed: 158 to 160Intention-to-treat Analysis: NRPower Analysis: NR

Participants Chronic MND

Interventions

INDEX TREATMENTMedX Exercise (MedX): high technology exercise, medically supervised rehabilitative exercise, 20 sessions over 3 monthsManipulation and low tech Exercise (SMT/Ex): chiropractic manipulation, supervised low technology rehabilitative exercise, 20 sessions over 3 monthsCOMPARISON TREATMENTSpinal Manipulative (SMT): chiropractic manipulation, 20 sessions over 3 monthsCOINTERVENTION: NRTreatment Schedule: 11 weeks, 20 sessionDuration of Follow-up: 12 months

Outcomes

CUMULATIVE ADVANTAGE for six patient-oriented outcomesReported 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 (11-box scale, 0 to 10)Baseline Mean: SMT 56.6, MedX 57.1, SMT/Ex 56.0Reported Results: group difference in patient-rated pain ANOVA [F(2,156)=4.2, p=0.02] favours the two exercise groupsSMD(MedX v SMT): -0.31(95%CI: -0.68 to 0.06) [power 29%]SMD(SMT v SMT/Ex): 0.24(95%CI:-0.14 to 0.61) [power 28%]SMD(SMT/Ex v MedX): 0.06(95%CI:-0.33 to 0.44) [power 28%]FUNCTION (Neck Disability Index, 0 to 50)Reported Results: no significant group differences were found ANOVA: F[2, 156] = 2.04, p = 0.13SMD(MedX v SMT): -0.33(-0.70 to 0.05) [power 23%]SMD(SMT v SMT/Ex): 0.31(-0.06 to 0.68) [power 28%]SMD(SMT/Ex v MedX): 0.31(-0.06 to 0.68) [power 25%]PATIENT SATISFACTION (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 = 0.002SMD(MedX v SMT): -0.26(-0.63 to 0.12) [power 49%]SMD(SMT v SMT/Ex): 0.71(0.33 to 1.10)SMD(SMT/Ex v MedX): -0.44(-0.83 to -0.05)PATIENT RATED IMPROVEMENT (1 to 9)Reported Results: substantial improvement over time, ANOVA: F[2, 174] = 1.7, p = 0.18SMD(MedX v SMT):-0.29(-0.67 to 0.10) [power 44%]SMD(SMT v SMT/Ex): 0.29(-0.08 to 0.67) [power 44%]SMD(SMT/Ex v MedX): 0.01(-0.37 to 0.39) [power 38%]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 v MedX): 0.81(95%CI:0.23 to 1.55)RR(SMT v MedX): 0.61(95%CI:0.23 to 1.55)COST OF CARE: NR

Notes Source of Reference: Personal FilePublication Type: Abstract from conference proceedingsPeer Reviewed: can't tellSource of Funding: not specifiedFunding Agency has a Peer Review Mechanism: can't tellCountry: USA, Canada

Allocation concealment A - Adequate

Study Bronfort: MedX v SMT

Methods [Refer to Bronfort 2001 for details; author described MedX v SMT]

Participants

Interventions

Outcomes

Notes


Study Bronfort:SMT/ExvMedX

Methods [Refer to Bronfort 2001 for details; author described SMT and exercise v MedX]

Participants

Interventions

Outcomes

Notes


Study Brontfort:SMT/ExvSMT

Methods [Refer to Bronfort 2001 for details; author described SMT and exercise v SMT]

Participants

Interventions

Outcomes

Notes


Study Fitz-Ritson 1995

Methods Type of Trial: RCTNumber Randomised: 30Number Analysed: 30Intension-to-treat Analysis: not applicablePower Analysis: NR

Participants Chronic WAD

Interventions

INDEX TREATMENTGroup 1 (G1), Chiropractic and Exercises (standard rehabilitation):a. chiropracticb. exercises: standard rehabilitative exercises with 4 levels (10 exercises each), each level done for 2 weeks [levels include: a. range of motionb. stretchingc. isometric-toningd. isokinetic strengthening]e. frequency = 5 days per weekCOMPARISON TREATMENT:Group 2 (G2), Chiropractic and Exercises (phasic neck):a. chiropracticb. exercises: phasic exercises of 2 levels (8 exercises each); each level done for 4 weeks; frequency = 5 days per weekCOINTERVENTION: NRTreatment Schedule: 8 weeks, 40 sessionsDuration of Follow-up: none

Outcomes NECK PAIN & DISABILITY INDEXBaseline mean: G1 59.5, G2 60Reported Results: significant favouring G2SIDE EFFECTS: NRCOST OF CARE: NR

Notes Source:Publication Type: journalPeer Reviewed: yesFunding Agency has Peer Review Mechanism: can't tellCountry: Canada


Study Gam 1998

Methods Type of Trial: RCTNumber Randomised: 67Number Analysed: 58Intension-to-treat Analysis: NRPower Analysis: 10%


Interventions INDEX TREATMENTGroup A (US):a. exercise (six exercises focusing on strength and mobility for neck and shoulder region) First 2 session 30 minutes, following 3 weeks 15 minutes, instructed to do 1 time/week at homeb. ultrasound to a maximum of 5 most tender trigger points (frequency 100Hz, pulse=2:8, intensity 3 W/cm2,

treatment time 3 minutes per sound head, radiation area 0.8cm squared, maximum treatment time 15 minutes)c. massage (transverse friction on the MTrP followed by myofascial technique applied on involved muscle groups, maximal duration 10 minutes)frequency: 4 weeks, 2 sessions/weekCOMPARISONGroup B (SUS):a. Sham ultrasoundb. massage (same as Group A)c. exercise (same as Group A)Group C (CG): control group, no treatmentCOINTERVENTION: NRTreatment Schedule: 4 weeks, 8 sessionsDuration of Follow-up: 6 months

Outcomes

PAIN AT REST (VAS, 0 to 10)Baseline Median: US 2.6, SUS 3.7, CG 2Reported Results: no significant differences were found between groups at any timeSMD (SUS v CG): -0.26(95% CI:-0.89 to 0.36)SMD (US v CG): -0.75(95% CI:-1.42, -0.07)FUNCTION (Pain on Function; VAS, 0 to 10)Baseline Median: US 5.4, SUS 4.5, CG 4.5Reported Results: no significant differences between groupsANALGESIC USEBaseline Median: US 4, SUS 2, CG 4Reported Results: no significant difference between groupsINDEX SCOREBaseline Median: US 11.5, SUS 10, CG 12.5Reported Results: significant reduction in index score for US and SUS at end of study compared to CG [p<0.05]SIDE EFFECTS: NRCOST OF CARE: NR

Notes


Study Gam SUSvsCG

Methods [Refer to Gam 1998 for details; author described sham ultrasound v control group]

Participants

Interventions

Outcomes

Notes


Study Gam USvCG

Methods [Refer to Gam 1998 for details; author described ultrasound v control group]

Participants

Interventions

Outcomes

Notes


Study Geibel 1997


Participants Acute WAD, NDH

Interventions

INDEX TREATMENTGroup 1 (G1):a. exercise: active movement seated, hold-relax/contract-relax technique to scaleni, levator scapula and trapezius in sitting, strengthening of interscapular muscles, further parameters = not specifiedb. mobilisation (passive, neuromuscular): for individual segments active-assisted followed by passive movements under light traction; proprioceptive neuromuscular facilitation: active, hold-relax/contract-relax technique to scaleni, levator scapula and trapezius in sitting; light traction with mobilisationc. medication: analgesic, antiinflammatoryCOMPARISON TREATMENTGroup 2 (G2):a. advised no exerciseb. collar: worn continuously, take off at nightc. medication: analgesic, antiinflammatoryCOINTERVENTION: analgesics and antiinflammatories allowed in both groupsTreatment Schedule: 3 weeksDuration of Follow-up: 9 weeks

Outcomes PAIN (NRS101)Baseline Mean: G1 46.70, G2 49.20Reported Results: Physiotherapy has a clear advantage over collarsSMD@2w treatment: -1.04(95%CI:-1.46 to -0.61)SMD@3w treatment and 9 weeks follow-up: -4.88(95%CI:-5.68 to -4.07)NOTE

that the large effect estimate for pain intensity in Giebel's trial is an artifact of both groups markedly improving from baseline to almost no pain. Clinically this benefit translates to a 5.5% treatment advantage for the multimodal treatment.FUNCTION [household activity, physical activity, activity of daily living, social activity, neck mobility (11 point scale of MOPO Fragenbogens)]Baseline: NRReported Results: significant favour G1SMD: 0.23(95%CI:-0.17 to 0.63) (a positive sign denotes advantage of the first group in the contrast) [power 100%]SIDE EFFECT: NRCOST OF CARE:cost of direct care: G1 155DEM (78USD), G2 113DEM (57USD)sick days [number patients x days off work]: G1 187, G2 330Reported Results: G1 treatment economically favoured

Notes Source of Reference: COCHPublication Type: journalPeer Reviewed: can't tellSource of Funding: not specifiedFunding Agency has a Peer Review Mechanism: not specifiedCountry: Germany


Study Goldie 1970

Methods Type of Trial: CCTNumber Randomised: 73Number Analysed: 73Intention-to-treat: not applicablePower Analysis: NR

Participants Chronic MND with possible NDR (radiation down either of the upper extremities following a segmental pattern, paraesthesiae was uncommon, paresis was absent)

Interventions

INDEX TREATMENT:Isometric Group: isometric exercise against therapist manual pressure to a maximum of the patients' ability under the pain threshold in cervical movement directions, patient either in sitting or supine position, rest for 10 minutes post treatment in lying position, 3 times per week for 10 sessions just over 3 weeks; analgesic; muscle relaxant; education (advice to rest)COMPARISON TREATMENTS:Traction Group:a. tractionb. medication: analgesic, muscle relaxant, c. education (advice to rest)No-treatment Group:a. medication: analgesic, muscle relaxantCOINTERVENTION: avoided in trialTreatment Schedule: 3 weeks, 10 sessionsDuration Follow-up: 3 weeks (assessment), 24 week (letter)

Outcomes

PATIENT GLOBAL PERCEIVED EFFECT (3 point scale)Baseline: NRReported Results: A slight tendency favouring tractionRR (exercise v no treatment): 0.42(95%C: 0.21,0.83)RR (exercise v traction): 0.84(95%CI: 0.37,1.91) [power %]SIDE EFFECTS: patient rated as not improved or worsetraction 9 of 26; exercise 7 of 24; no treatment 16 of 23COST OF CARE: NR

Notes Source of Reference: ref from letterPublication Type: journalPeer Reviewed: yesFunding Agency has a Peer Review Mechanism: can't tellCountry: Scandinavia [Sweden]

Allocation concealment C - Inadequate

Study Goldie: ex v cnt

Methods [Refer to Goldie 1970 for details; author described isometric group v non-treated group]

Participants

Interventions

Outcomes

Notes


Study Goldie: ex v trac

Methods [Refer to Goldie 1970 for details; author described isometric group v traction group]

Participants

Interventions

Outcomes

Notes


Study Hagberg 2000

Methods

Type of Trial: RCTNumber Randomised 77Number Analysed: 69Intention-to-treat Analysis: NRPower analysis: calculated; using the variance of the pain measurements (pain right now = 21 mm on VAS) a power analysis showed 604 patients needed to detect a significant (0.10) 5 mm difference on pain rating between 2 programs with a 90% probability

Participants Chronic MND (ICD-10)

Interventions

INDEX TREATMENTIsometric Shoulder Endurance Training:a. goal to improve endurance in the upper part of the trapezius muscle.b. Position: In a sitting posture, the patient had to lift the arm to 90 degrees of forward flexion with straight arm and the forearm semipronated.c. Intensity: Subject to hold this position for 2 minutes. The exercise was done 4 times with 2 minutes of rest in between, 3 time/week for 12 weeks.d. This exercise corresponds to a contraction level of about 20% to 30% of maximal shoulder joint torque, and approximately the same contraction for the upper part of the trapezius.COMPARISON TREATMENT:Isometric Shoulder Strength Training:a. goal to improve strength in the upper part of the trapezius, and mainly involved the type 2 muscle fibresb. position: sitting posture with the arms in 90 degrees of forward flexion and the forearm semipronated. A sling from the floor was attached to the arms just proximal to the elbow joint.c. intensity: the training contraction was performed as a maximal contraction held for 5 seconds followed by a rest for 2 minutes. The exercise was done as 10 contractions with 2-minute rests in between for 12 weeksCOINTERVENTION: NSAIDTreatment Schedule: 12 weeksDuration of Follow-up: 12 weeks

Outcomes

NECK-SHOULDER PAIN WORST OF PRECEDING WEEK (VAS, 0 to 100)]Baseline Mean: Endurance 43, Strength 35Reported Results: no significant differencePRESENT PAIN (VAS, 0 to 100)Baseline Mean: Endurance 42, Strength 34Reported Results: no significant differenceSICK LEAVEReported Results: substantially the same for both groupsRATING OF PERCEIVED EXERTION AT WORK (BORG, 0 to 10)Baseline Mean: Endurance 6.2, Strength 6.4Reported Results: no significant differenceSHOULDER FUNCTION [arm motion performance test, seconds]Baseline Mean: Right Endurance 10.7, Strength 13.4Left Endurance 10.9, Strength 12.0Reported Results: significant difference on the right favoured the isometric shoulder strength training groupSIDE EFFECT: NRCOST OF CARE: NR

Notes

Allocation concealment D - Not used

Study Hanten 2000

Methods Type of Trial: RCTNumber Randomised: 40Number Analysed: 40Intention-to-treat analysis: not applicablePower analysis: NR

Participants MND, disorder duration NR (myofascial trigger points in neck or upper back)

Interventions

INDEX TREATMENTGroup 1 (G1):a. sustained stretching for the neck and upper back musculature holding each for 30 to 60 seconds at least 2 times/day for 5 days;b. written and verbal instructions, rationale, and a demonstration on performing Ischaemic pressure using a Thera Cane in sitting with muscle in lengthened position applying gradually increasing pressure to the TP and holding until a release was felt. Repeated the process until no further release was obtained. Frequency: primary TP at least 2 times/day for 5 days;c. time to practice the Ischaemic pressure applications and sustained stretches, ask questions, and receive feedback;d. subjects were asked to perform no treatment on days 6 and 7COMPARISON TREATMENT:Group 2 (G2):a. verbal and written instructions, rationale, and a demonstration on performing active neck flexion, neck lateral flexion and neck rotation while seated near the edge of an armless chair with both feet planted on the floor, 10 times each exercise, at least 2 times/day for 5 days;b. returned on day 2 for a session with examiner who assessed technique and answered questions;c. subjects were asked to perform no treatment on days 6 and 7COINTERVENTION: NRTreatment Schedule: 5 daysDuration of Follow-up: 8 days

Outcomes PAIN INTENSITY (VAS, 0 to 100)Baseline mean: G1 25.7, G2 26.6Reported Results: signifianct difference favouring G1PERCENTAGE OF TIME IN PAINBaseline mean: G1

25.1, G2 28.7Reported Results: do difference between groupsPRESSURE PAIN THRESHOLD [pressure algometer]Baseline mean: G1 4.5, G2 3.7SIDE EFFECTS: NRCOST OF CARE: NR

Notes


Study Hoving 2002

Methods Type of Trial: RCTNumberAnalysed/Randomised: 178/183Intention-to-treat Analysis: conductedPower Analysis: conducted

Participants Acute, subacute, chronic MND and NDH

Interventions

INDEX TREATMENTPhysical Therapy (PT):a. active exercise therapies: strengthening, stretching (ROM), postural/ relaxation/ functional exerciseb. optional modalities: manual traction, massage, interferential, heat; excluded specific mobilisations techniques, median 9 (IQR 7-12) sessionsCOMPARISON TREATMENTSManual Therapy (MT):a. muscular and articular mobilisation techniques, low velocity passive movements within or at the limit of joint range; excluded manipulationb. coordination and stabilisation techniquesc. 45 minute sessions, one session per week for a maximum of 6 sessions [median 6 (IQR5-6)]Continued Care by General Practitioner (GP):a. education: advice on prognosis, psychosocial issues, self care (heat, home exercise), ergonomics (pillow, work position), await further recovery; booklet (ergonomics, home exercise);b. medication: paracetamol, NSAIDc. 10 minute follow-up every 2 weeks was optional; excluded referral for other treatment, median 2 (IQR1-4) treatmentsCOINTERVENTION: analgesics and antiinflammatories allowed in both groups, home exercise for all three groupsTreatment Schedule: 6 weeks, 6 sessionsDuration of Follow-up: 52 weeks

Outcomes

PAIN (NRS, 0 to 10)Baseline Mean: MT 5.9, PT 5.7, GP 6.3Reported Results: significant favouring MT over PTSMD (PT v MT): 0.41(95%CI: 0.04 to 0.78) [power %]SMD (PT v GP): 0.34(95%CI: -0.02 to 0.70) [power 96%]FUNCTION (Neck Disability Index, 0-50)Baseline: MT 13.6, PT 13.9, GP 15.9Reported Results: significant favouring MT over PTSMD (PT v GP): 0.28(95% CI:-0.08 to 0.64) [power %]SMD (PT v MT): 0.12(95% CI:-0.25 to 0.48) [power 17%]GLOBAL PERCEIVED EFFECT (perceived recovery, %)Reported Results: significant favouring MT over PT and GPSMD (PT v GP): 0.30(95% CI:-0.05 to 0.66) [power 21%]SMD (PT v MT): 0.42(95% CI:0.05 to 0.78) [power 14%]SIDE EFFECT: benign and transientincreased neck pain > 2 daysRR(MT v GP): 3.91(95%CI: 1.15 to 13.34)RR(MT v PT): 2.70(95%CI: 0.91 to 8.01)RR(PT v GP): 1.45(95%CI: 0.34 to 6.19)increased headacheRR(MT v GP): 1.65(95%CI: 0.84 to 3.23)RR(MT v PT): 0.88(95%CI: 0.51 to 1.52)RR(PT v GP): 1.87(95%CI: 0.98 to 3.60)arm pain/pins&needlesRR(MT v GP): 2.13(95%CI: 0.68 to 6.72)RR(MT v PT): 0.87(95%CI: 0.36 to 2.11)RR(PT v GP): 2.44(95%CI: 0.79 to 7.51)dizzinessRR(MT v GP): 1.60(95%CI: 0.47 to 5.39)RR(MT v PT): 0.84(95%CI: 0.30 to 2.36)RR(PT v GP): 1.90(95%CI: 0.59 to 6.16)COST OF CARE: favours MTtotal costsResults: not significantSMD(MT v GP):-0.41(95%CI:-0.77 to -0.05)SMD(MT v PT): -0.34(95%CI:-0.70 to 0.02)SMD(PT v GP):-0.02(95%CI:-0.3 to 0.33)total direct costsResults: significant favours MT v PTSMD(MT v GP):-0.28(95%CI:-0.64 to 0.07)SMD(MT v PT): -0.49(95%CI:-0.85 to -0.17)SMD(PT v GP):0.21(95%CI:-0.15 to 0.56)total indirect costsResults: significant favour MT v GPSMD(MT v GP):-0.40(95%CI:-0.75 to -0.04)SMD(MT v PT): -0.28(95%CI:-0.64 to 0.08)SMD(PT v GP):-0.07(95%CI:-0.43 to 0.28)duration off workResults: significant favour MT v GPSMD(MT v GP):-0.43(95%CI:-0.85 to -0.01)SMD(MT v PT): -0.29(95%CI:-0.71 to 0.12)SMD(PT v GP):-0.10(95%CI:-0.51 to 0.32)

Notes


Study Hoving 2002: GP v MT

Methods [Refer to Hoving 2002 for details; author described continued care by general practitioner v manual therapy]

Participants

Interventions

Outcomes

Notes


Study Hoving 2002: PT v GP

Methods [Refer to Hoving 2002 for details; author described physical therapy v continued care by general practitioner]

Participants

Interventions

Outcomes

Notes


Study Hoving 2002: PT v MT

Methods [Refer to Hoving 2002 for details; author described physical therapy v manual therapy]

Participants

Interventions

Outcomes

Notes


Study Jordan 1998

Methods Type of Trial: RCTNumber Randomised: 119Number Analysed: 102Intention-to-treat Analysis: NRPower Analysis: NR

Participants chronic MND without radicular signs and symptoms

Interventions

INDEX TREATMENTIntensive Training Group (Int ):a. exercise: group sessions of 4 to 5 patients, under the guidance of a physiotherapist; stationary bicycle, 5 to 6 minutes; stretching, 10 minutes; intensive training of neck muscles on a Neck Exercise Unit [Follo, Norway] including isometric strengthening measures in flexion, extension, left and right lateral flexion, followed by strengthening programs initiated at 30% of maximum obtained values, one series of 12 reps for flexion, three series of 12 reps each in extension and lateral flexion; rest and stretching between series; new isometric measures every 14 days and dosage modified accordingly; strength training of shoulder, scapular and chest muscles with hand-held weights; shoulder pull-down machine to strengthen the latissimus dorsi muscles; at conclusion, 5 to 6 minutes bicycle (cool down)b. massage; traction (manual)c. hot pack, ultrasoundd. proprioceptive neuromuscular facilitatione. neck schoolf. 2 sessions/weekCOMPARISON TREATMENTPhysiotherapy Group (PT):a. proprioceptive neuromuscular facilitationb. mobilisation (passive), massage, traction (manual)c. hot pack, ultrasoundd. neck schoole. 2 sessions/weekChiropractic Group (CH):a. manipulation: high velocity, low-amplitude thrust to cervical, traction (manual), manual treatment: given to tender muscles and trigger pointsb. neck schoolc. 2 sessions/weekCO-INTERVENTION: NRTreatment Schedule: 6 weeks, 12 sessionsDuration of Follow-up: 46 weeks

Outcomes

PAIN (headache intensity, three 11 point box scale, maximum score 30) Baseline: NRReported Results: no significant differenceSMD(PT v Int): 0.00(95%CI:-0.47 to 0.47) [power 11%]SMD(PT v CH and Int v CH): 0.00(95%CI:-0.48 to 0.48) [power 11%]FUNCTION (self-report disability index, maximum score 30)SMD(Int v PT): 0.25(95%CI: -0.22 to 0.73) [power 18%]SMD(PT v CH): 0.00(95%CI:-0.48 to 0.48) [power 11%]SMD(Int V CH): 0.36(95%CI:-0.12 to 0.84) [power 11%]GLOBAL PERCEIVED EFFECT (patient perceived effect, 6 point scale)SMD(PT V CH and Int V CH): 0.00(95%CI:-0.48 to 0.48) [power 11%]SIDE EFFECT: CH: persistent acute pain (n = 1)COST OF CARE: NR

Notes Source of Reference: Personal FilesPublication Type: journalPeer Reviewed:

yesSource of Funding: Danish Medical Research Council, Danish Arthritic Association, Medical Research Fund for Copenhagen, Faroe Islands and Greenland, Foundation for Chiropractic Education and Research, The Fund to Promote Chiropractic Research and Postgraduate EducationFunding Agency has a Peer Review Mechanism: yesCountry: Denmark


Study Jordan 1998: Int vCH

Methods [Refer to Jordan 1998 for details; author described Intensive training V chiropractic]

Participants

Interventions

Outcomes

Notes


Study Jordan 1998:CHvPT

Methods [Refer to Jordan 1998 for details; author described chiropractic v physiotherapy]

Participants

Interventions

Outcomes

Notes


Study Jordan 1998:Int v PT

Methods [Refer to Jordan 1998 for details; author described Intensive training v physiotherapy]

Participants

Interventions

Outcomes

Notes


Study Jull 2002

Methods Type of Trial: RCTNumber Analysed/Randomised: 193/200Intention-to-treat Analysis: calculatedPower Analysis: NR

Participants Chronic NDH

Interventions

INDEX TREATMENTExercise Therapy (ExT): therapeutic low load exercise to cervical-scapular region: craniocervical flexor training with pressure biofeedback, scapular muscle training, postural correction, exercise performed throughout the day, isometric strengthening with co contraction of neck flexion and extension, stretching as needed, 30 minute session duration, two sessions/weeks, 8 to 12 sessions totalCombined Therapy (MT/ExT):a. manipulation, mobilisationb. exercisec. 30 minute session duration, two sessions/weeks, 8 to 12 sessions totalCOMPARISON TREATMENTManipulative Therapy (MT): manipulation: high velocity, low-amplitude manipulation described by Maitland; mobilisation (low velocity), 30 minute session duration, 2 sessions/week, 8 to 12 sessions totalControl Group (Cntl): no treatmentCOINTERVENTION: NRTreatment Schedule: 6 weeks, 8 to 12 sessionsDuration of Follow-up: 52 weeks

Outcomes

PAIN (headache intensity change score; VAS, 0 to 10)Baseline Mean: MT 4.8, ExT 5.4, MT/ExT 5.1, Cntl 5.3Reported Results: significant favouring MT and ExTSMD(ExT v Cntl):-0.59(95%CI:-1.00, -0.18)SMD(Ext v MT): 0.21(95%CI:-0.18 to 0.61) [power 96%]SMD(MT/ExT v ExT): 0.06(95%CI:-0.35, 0.46) [power 98%]SMD(MT/ExT v Cntl):-0.58(95%CI:-1.00,-0.17)FUNCTION (Northwick Park neck pain questionnaire change score, 0 to 36)Baseline Mean: MT 27.5, ExT 29.6, MT/ExT 29.7, Cntl 30.7Reported Results: significant favouring MT or MT/ExT over control; no significant difference between MT, ExT and MT/ExT comparisonsSMD(ExT v Cntl):-0.59(95%CI:-1.00,-0.18)SMD(ExT v MT):-0.32(95%CI:-0.72, 0.08) [power 100%]SMD(MT/ExT v ExT): 0.11(95%CI:-0.29, 0.50) [power 59%]SMD(MT/ExT v Cntl):-0.64(95%CI:-1.06,-0.23)GLOBAL PERCEIVED EFFECT (participant perceived effect; VAS, 0 to 100)Reported Results: significant favouring MT and MT/ExT over control, not significant for MT or MT/ExT when compared to ExTSMD(ExT v Cntl):-2.51(95%CI:-3.05,-1.97)SMD(ExT v MT): -0.29(95%CI:-0.69, 0.10) [power 81%]SMD(MT/ExT v ExT): 0.01(95%CI:-0.38, 0.40) [power 59%]SMD(MT/ExT v Cntl):-2.73(95%CI:-3.30,-2.16)SIDE EFFECT: minor and temporary, 6.7% of headaches were provoked by treatmentCOST OF CARE: NR

Notes


Study Jull 2002:ExT v Cntl

Methods [Refer to Jull 2002 for details; author described exercise treatment v control group]

Participants

Interventions

Outcomes

Notes


Study Jull 2002:ExT v MT

Methods [Refer to Jull 2002 for details; author described exercise treatment v manual therapy group]

Participants

Interventions

Outcomes

Notes


Study Jull 2002:MTExT v MT

Methods [Refer to Jull 2002 for details; author described manual therapy and exercise treatment v manual therapy group]

Participants

Interventions

Outcomes

Notes


Study Jull 2002:MTExT vExT

Methods [Refer to Jull 2002 for details; author described manual therapy and exercise treatment v exercise treatment]

Participants

Interventions

Outcomes

Notes


Study Jull 2002:MTExTvCntl

Methods [Refer to Jull 2002 for details; author described manual therapy and exercise treatment v control group]

Participants

Interventions

Outcomes

Notes


Study Karlberg 1996

Methods Type of Trial: RCTNumber Analysed/Randomised: 17/17Intention-to-treat Analysis: conductedPower Analysis: NR

Participants Subacute NDH

Interventions

INDEX TREATMENTPhysiotherapy Group (PT):a. mobilisation (passive, neuromuscular): technique described by Kaltenborn and Lewit, soft tissue treatmentb. physiotherapy treatment: stabilization exercise described by Feldenkrais, relaxation techniques described by Jacobsonc. NSAIDd. educatione. median 13 sessions (range: 5 to 23) over 8 to 9 weeksCOMPARISON TREATMENTDelayed Treatment Group (D): wait period 8 weeks without treatmentCOINTERVENTION: NRTreatment Schedule: median 8 to 9 weeks, 13 sessionsDuration of Follow-up: none

Outcomes PAIN (headache intensity; VAS, 0 to 100)Baseline Mean: PT 54, D 56Reported Results: significant favouring PTSMD: -1.47(95% CI:-2.58, -0.36)SIDE EFFECTS: NRCOST OF CARE: NR

Notes


Study Koes 1992

Methods Type of Trial: RCTNumber Randomised: 64Number Analysed: 58/64, not specified for 6 month and 1 year follow-up for neck only groupIntention-to-treat Analysis: calculated (see chapter 5, table 6)Power Analysis: calculated, 50 subjects per group

Participants Subacute, chronic MND

Interventions INDEX TREATMENTGeneral Practitioner Group (GP):a. home exercisesb. medication: analgesics, NSAIDc. education: posture, participation in sports, bed rest and other treatment modalities; 1 sessionPhysical Therapy Group (PT):a. massageb. exercisec. heatd. electrotherapy(10% received exercise/massage; 44% heat/ exercise/massage; 12% electrotherapy/exercise/massage; 9% electrotherapy/ heat/ exercise/ massage; 3% exercise only; 9% exercise/heat; 5% electrotherapy/exercise; 5% massage only; 3% massage/heat), exercise, heat, electrotherapy mean 14.7 (SD: 14) sessions/7.8 weeks)COMPARISON TREATMENTManual Therapy Group (MT):a. manipulation and mobilisation: described by Dutch Society of Manual Therapy, [Note: all therapists except for placebo therapists were free to choose from their usual therapeutic domain within explicitly formulated limits, e.g. no manipulative techniques were performed by the physio]; mean 5.4 (SD: 6) sessions/8.9 weeksPlacebo Treatment (Pl):a. de-tuned short wave diathermy & US; 2 times/week, mean 11.1 (SD: 12) sessions/5.8 weeksCOINTERVENTION: detailed in chapter 6, table 5Treatment Schedule: varied from 1 to 9 weeksDuration of Follow-up: 9 weeks of treatment + 3

weeks follow-up Note: 6 & 12 months data not reported due to extensive cross over of care

Outcomes

PAIN (WHYMPI: 10 point scale)Baseline: NRReported Results: better results favouring MTat 9 weeks treatment and 3 weeks follow-upSMD(GP v MT): 0.61(95% CI: -0.18 to 1.40) [power %]SMD(GP v pl): 0.44(95% CI:-0.36 to 1.23) [power %]SMD(MT v PT): -0.64(95% CI:-1.35 to 0.08) [power 14%]FUNCTION (physical functioning,10 point scale)Baseline Mean: MT 6.11, PT 5.6, GP 5.29, Pl 5.71Reported Results: significant favouring MT@ 9 weeks treatment and 3 weeks follow-up:SMD(GP v MT): 0.31(95% CI:-0.48 to 1.10) [power %]SMD(MT v PT): -0.75(95% CI:-1.50 to 0.00) [power 17%]GLOBAL PERCEIVED EFFECT:Reported Results: not significant between groupsSMD(GP v pl): 0.38(-0.41 to 1.18) [power %]SIDE EFFECTS: NRCOST OF CARE: NR

Notes


Study Koes 1992: GP v MT

Methods [Refer to Koes 1992 for details; author described general practitioner [GP] v manual therapy [MT] group]

Participants

Interventions

Outcomes

Notes


Study Koes 1992: GP v pl

Methods [Refer to Koes 1992 for details; author described general practitioner (GP) group v placebo (pl) group]

Participants

Interventions

Outcomes

Notes


Study Koes 1992: PT v GP

Methods [Refer to Koes 1992 for details; author described physical therapy (PT) group v general practitioner (GP) group]

Participants

Interventions

Outcomes

Notes


Study Koes 1992: PT v pl

Methods [Refer to Koes 1992 for details; author described physical therapy (PT) group v placebo (pl) group]

Participants

Interventions

Outcomes

Notes


Study Koes 1992:PT v MT

Methods [Refer to Koes 1992 for details; author described physical therapy (PT) group versus manual therapy (MT) group]

Participants

Interventions

Outcomes

Notes


Study Kogstad 1978

Methods Type of Trial: quasi-RCTNumber Analysed/Randomised: 50/50Intention-to-treat Analysis: NRPower Analysis: NR

Participants NDR, disorder duration NR

Interventions

INDEX TREATMENTConventional Therapy Group (CT):a. isometric exercises, home exercisesb. heatc. soft tissue massaged. 15 minutes intermittent mechanical tractione. 60-minute sessions, 3 sessions/week for 5 weeksCOMPARISON TREATMENTPlacebo Group (Pl): placebo tablets 3 times/day for 5 weeksManual Therapy Group (MT):a. manipulation (described by Brodin)b. heatc. soft tissue massaged. 40-minute sessions, 2 sessions/week for 4 weeksCO-INTERVENTION: 3 patients in placebo group received conventional treatment or manual therapy during 18 month follow-up periodTreatment Schedule: 5 weeks, 8 sessions for MT; 12 sessions for CTDuration of Follow-up: 18 months

Outcomes GLOBAL PERCIEVED EFFECT (objective and subjective findings)Reported Results: not significantRR (CT v Pl): 0.43(95%CI: 0.15 to 1.20)RR (CT v MT): 1.30(95%CI: 0.28 to 6.11)SIDE EFFECTS: NRCOST OF CARE: NR

Notes


Study Kogstad 1978:CT v MT

Methods [Refer to Kogstad 1978 for details; author described conventional therapy v manual therapy]

Participants

Interventions

Outcomes

Notes


Study Kogstad 1978:CT v Pl

Methods [Refer to Kogstad 1978 for details; author described conventional therapy v placebo]

Participants

Interventions

Outcomes

Notes


Study Levoska 1993

Methods Type of Trial: comparison trialNumber Analysed/Randomised: 44/47Intention-to-treat Analysis: NRPower Analysis: NR

Participants MND, disorder duration NR

Interventions

INDEX TREATMENT:Active Exercise Group (AE):a. exercise: resistance based on assessment of endurance force; 60 minutes of omnikinetic training machine or dumbbells (one to 10 kg), movement lasted from 30 to 60 seconds followed by a 60 second pause; resistance was increased as performance improved;b. mean visits 13 (min 7, max 15)COMPARISON TREATMENT:Passive Exercise Group (PE):a. exercise: physical exercising of muscles of the neck and shoulder for 20 minutes; no home exercise programb. manual therapy: massage for 20 minute with slight stretchesc. heat: 20 minutesd. mean visits attended 10.9 (min 10, max 15)COINTERVENTION: NRTreatment Schedule: 5 weeks, PE mean 10.9 sessions; AE mean 13 sessionsDuration of Follow-up: 52 weeks

Outcomes PAIN (occurance of pain symptoms):Baseline: NRReported Results: significant (p < 0.01) favouring active exerciseRR: 0.50(95%CI: 0.18 to 1.42)SIDE EFFECT: NRCOST OF CARE: NR

Notes Source of Reference: MEDLINEPublication Type: journalPeer Reviewed: yesSource of Funding: not specifiedTraining of Primary Author: unknownCountry: Scandinavia


Study Lundblad 1999



Interventions

INDEX TREATMENTFeldenkrais Intervention (F)a. education: Individualised (functional integration) teacher guides through movement sequences; Group (awareness through movement) verbally guided through exercises for neck-shoulder complaintsb. home exercisesc. 50 minutes per week; individually 4 times and in group (7 to 8 subjects) 12 times; required 50% participation in both segments of programPhysiotherapy Intervention (PT)a. stabilisation exercises for low back and pelvis, isolated and relaxed shoulder movementsb. education: use of body emphasising self-directed control and responsibility for body, ability to cope with pain, muscle tension, and complaintsc. awareness of body postured. practice work-related lift and movement techniquese. exercise program of strength, coordination, endurance, flexibility/smoothness and rhythmf. home exercisesg. 50 minutes; 2 times/weeks for 16 weeks in group of 5 to 8 subjects; Required 50% participation in the exercisesCOMPARISON GROUPControl Regime (C): no treatmentTreatment Schedule: 16 weeks, 32 sessionsDuration of Follow-up: 52 weeks

Outcomes

PAIN (VAS, 0 to 10)Baseline Mean:VAS - usually PT 1.2, F 1.5, C 2.0VAS - worst PT 4.1, F 4.4, C 5.5Reported Results: no significant differencesDISABILITY (work and leisure, 4 point scale)Baseline Mean:Disability - work PT 1.3, F 1.2, C 1.3Disability - leisure PT 0.6, F 0.9, C 0.6Sick leave (days) PT 12.7, F 12.0, C 11.5Sick leave (%) PT 6.5, F 5.8, C 5.9Reported Results: no significant differencesSMD: 0.09(95%CI:-0.56 to 0.74) [power %]SIDE EFFECTS: NRCOST OF CARE: NR

Notes


Study Lundblad 1999: PTvCG

Methods [Refer to Lundblad 1999 for details; author described PT group v C group]

Participants

Interventions

Outcomes

Notes


Study Lundblad 1999: PTvFG

Methods [Refer to Lundblad 1999 for details; author described PT group v F group]

Participants

Interventions

Outcomes

Notes


Study McKinney 1989


Participants Acute WAD

Interventions

INDEX TREATMENTGroup 2 (G2):a. mobilisation described as active and passive repetitive movements using principles of Maitland and McKenzieb. heat/cold application, short wave diathermy, hydrotherapyc. tractiond. "the full gamut of physiotherapeutic aids was available as deemed appropriate"e. education: posture and exercise to perform at homef. standard analgesicg. collar: fitted with soft collar, intermittent useh. three 40 minute sessions/weeks for 6 weeksCOMPARISON TREATMENTGroup 1 (G1):a. education: mobilisation after an initial 10 to 14 day rest period, general adviceb. analgesicsc. collar: fitted with soft collar, continuous useGroup 3 (G3):a. education: posture correctionb. collar: restricted to very short periods in situations where their neck was vulnerable to sudden jolting, if collar worn exercise should be performed immediately afterc. heatd. medication: muscle relaxation, analgesicse. encouraged to perform demonstrated mobilisation exercisesCOINTERVENTION: NRTreatment Schedule: 6 weeks, 24 sessionsDuration of Follow-up: 2 weeks

Outcomes PAIN (VAS, 0 to 10)Baseline Median: G1 5.6, G2 5.3, G3 5.3Reported Results: significantly better than rest (G1)SMD(2 v 1): -0.77(95% CI: -1.20,-0.35)SMD(2 v 3): 0.50(95% CI:-0.28, 0.39) [power 16%]SIDE EFFECTS: NRCOST OF CARE: NR

Notes


Study McKinney 1989: 2 v 1

Methods [Refer to McKinney 1989 for details; author described group 2 v 1]

Participants

Interventions

Outcomes

Notes




Participants

Interventions

Outcomes

Notes




Participants

Interventions

Outcomes

Notes


Study Mealy 1986



Interventions

INDEX TREATMENTActive Group (A):a. exercise: within the limits of pain, daily, every hour at homeb. mobilisation (passive): technique described by Maitlandc. heat; iced. analgesicsCOMPARISON TREATMENT:Standard Group (S):a. soft cervical collar, worn for two weeksb. rest for two weeks before beginning gradual mobilisationc. analgesicsCOINTERVENTION: NRDuration of Therapy Period: 8 weeksDuration of Follow-up: none

Outcomes PAIN (pain intensity, 0 to 10)Baseline Mean: A 5.71, S 6.44Reported Results: significant favouring active groupSMD: -0.86(95% CI:-1.44 to -0.29)SIDE EFFECTS: NRCOST OF CARE: NR

Notes


Study Pennie 1990

Methods Type of Trial: CCTNumber Analysed/Randomised: 128/135Intention-to-treat Analysis: NRPower Analysis: NR


Interventions

INDEX TREATMENT:Traction Group:a. education: advice on simple neck and shoulder exercises, neck care, sleep postureb. intermittent halter traction for 10 minutesCOMPARISON TREATMENT:Collar Group:a. collar: 2 weeks rest in a soft collar or moulded one of thermoplastic polyethylene foamb. exercise: taught program of active (home) exercisesCOINTERVENTION: not avoided for collar group after 6-8 weeks of treatment referred for physiotherapy if not improved or deterioratedTreatment Schedule: 6 to 8 weeks [2 times per week for traction and education (exercise, posture) group]Duration Follow-up: 12 weeks

Outcomes PAIN INTENSITY (VAS, 0 to 100)Baseline: NRReported Results: not significantDAYS OFF WORKBaseline: NRReported Results: not significantRR 1.02(95%CI: 0.43 to 2.38)GLOBAL PERCEIVED EFFECT (4 point scale)Baseline: NRRR 1.02(95%CI: 0.43 to 2.38)SIDE EFFECTS: NRCOST OF CARE: NR

Notes Source of Reference: manual searchPublication Type: journalPeer Reviewed: yesFunding Agency has Peer Review Mechanism: can't tellCountry: UK


Study Persson 2001

Methods Type of Trial: RCTNumber Analysed/Randomised: 79/81Intention-to-treat Analysis:

NRPower Analysis: NR

Participants Chronic NDR

Interventions

INDEX TREATMENTPT Group: physiotherapy decided by the physiotherapist according to patient's symptoms and individual preferences [manual therapies (massage, manual traction, gentle mobilisation); modalities for pain relief like TENS, application of heat or cold (moist, ultrasound); exercise (relaxation exercises; active stretching, strengthening, endurance exercises, postural correction); ergonomic instruction]; 15 sessions of 30-45 minutesCOMPARISON TREATMENTS:Surgery Group: surgery [anterior cervical discectomy technique described by Cloward (1958); mobilisation on the 1st postoperative day; cervical collar use for 1-2 days post-operatively ]Collar Group: cervical collar (rigid collars during day; soft collar at night)COINTERVENTION:Surgery group: 8 patients had 2nd operation, 11 patients received physiotherapyPT group: 1 patient had surgeryCollar group: 5 patients had surgery, 12 patients received physiotherapyTreatment Schedule: 12 weeks,15 sessionsDuration of Follow-up: 56 weeks

Outcomes

PAIN INTENSITY (VAS, 0 to 100)Baseline Mean: surgery 47, PT 50, collar 49Reported Results: not significantSMD(PT v collar): 0.16(95%CI:-0.38, 0.70)SMD(PT v surgery): 0.33(95%CI:-0.21, 0.87)WORST PAIN (VAS, 0 to 100)Baseline Mean: surgery 72, PT 70, collar 68Reported Results: not significantSMD(PT v collar): 0.04(95%CI: -0.50, 0.57)SMD(PT v surgery): 0.28(95%CI: -0.27, 0.82)Side Effects: NRCost of Care: NR

Notes


Study Persson 2001:PTv col

Methods [Refer to Persson 2001 for details; author described Physiotherapy v cervical collar]

Participants

Interventions

Outcomes

Notes


Study Persson 2001:PTvsurg

Methods [Refer to Persson 2001 for details; author described Physiotherapy v surgery]

Participants

Interventions

Outcomes

Notes


Study Provinciali 1996

Methods Type of Trial: RCTNumber Analysed/Randomised: 60/60Intention-to-treat Analysis: conductedPower Analysis: NR

Participants Acute, subacute WAD, NDH (cervico-encephalic syndrome = fatigue, dizziness, poor concentration, disturbed accommodation and impaired adaptation to light intensity)

Interventions INDEX TREATMENTGroup A:a. exercise (eye fixation): described by Shutty to alter dizzinessb. mobilisation (passive): technique described by Mealy; massage: technique described by Mealyc. neck school described by Sweeney, relaxation training based on diaphragmatic breathing in supine position according to Shutty, active reduction of cervical and lumbar lordosis based on suggestion provided by Neck School according to Sweeneyd. psychological support to reduce anxiety and limit emotional influence described by Radanov; 10 one-hour sessions/2 weekCOMPARISON TREATMENTGroup B: TENS, pulsed electromagnetic field therapy, US, 10 one-hour sessions/2 weekCO-

INTERVENTION: NRTreatment Schedule: 2 weeks, 10 sessionsDuration of Follow-up: 24 weeks

Outcomes

PAIN (neck pain intensity, VAS 0 to 10)Baseline Median: A 6.8, B 7.4Reported Results: significant favouring group ASMD: -0.79(95%CI:-1.32 to -0.26)FUNCTION (Return to Work)Reported Results: significant favouring group ASMD: -1.05(95%CI:-1.59 to -0.26)GLOBAL PERCEIVED EFFECT (self assessment of outcome, ordinal scale -3 to +3)Reported Result: significant favouring group A, p < 0.001SIDE EFFECTS: NRCOST OF CARE:a. return to workResults: significant difference favours Group A, a treatment advantage of 16 daysSMD: -1.05(95%CI:-1.59 to -0.51)b. sick days savedResults: 143 days saved favouring Group A

Notes Source of Reference: Personal Files, COCHPublication Type: journalPeer Reviewed: yesSource of Funding: not specifiedFunding Agency has a Peer Review Mechanism: can't tellCountry: Italy


Study Randlov 1998

Methods Type of Trial: RCTNumber Analysed/Randomised:52/77Intention-to-treat: NRPower Analysis: NR


Interventions

INDEX TREATMENTGroup A (Light Training)a. stationary bicycling and six stretches for neck and shoulder muscles, carried out once each session including 20 repetitions each for 15 minutesb. hot packs for 14 minutesCOMPARISON TREATMENT:Group B (Intensive Training)a. bicycling and stretching of seven exercises of the neck and shoulder area for 10 minutesb. seven exercises for the neck and shoulder, 20 repetitions per round and five rounds were carried out in each session.c. Additionally, shoulder exercises were carried out with increasing resistanceCOINTERVENTION: pain relieving medicationTreatment Schedule: 12 weeksDuration of Follow-up: none

Outcomes

PAIN (at moment and average, 0 to 20 points)Baseline Median: A 12 , B 12Reported Results: not significantFUNCTION (ADL Scale, 0 to 40 points)Baseline Median: A 16, B 16Reported Results: not significantPATIENT SATISFACTION (5 points)Reported Results: not significantRR 0.95 (95%CI: 0.52 to 1.74)SIDE EFFECTS: NRCOST OF CARE: NR

Notes


Study Revel 1994

Methods Type of Trial: RCTNumber Analysed/Randomised: 60/60Intention-to-treat: NAPower analysis: NR

Participants Chronic MND (osteoarthritic changes 27 of 30)

Interventions

INDEX TREATMENTRehabilitation Group (RG)a. proprioceptive rehabilitation program: purpose to improve neck proprioception; 15 minute individualised exercise session; exercises were mainly concerned with eye-neck coordination including; i. slow passive motions of the head with gaze on a fixed target, ii. active movements of the head, automatic movements of the neck with passive trunk movements and head position relocation exercises, iii. exercises in a wide range of motion with free eye-head coupling [author description well detailed in Rehabilitation Procedure page 896]; 2 times per week; 30 to 40 minute sessionsb. medication: analgesics, antiinflammatoryCOMPARISON TREATMENTControl Group (CG)a. medication: analgesic, antiinflammatory typical dosage was indomethacin 100mg; aspirin, 3000 mg; diclofenac, 150 mg; naproxen, 1000 mgCOINTERVENTION: NRTreatment Schedule: 8 weeksDuration of Follow-up: 2 weeks

Outcomes

PAIN INTENSITY (VAS, 0 to 100)Baseline Mean: RG 50.5, CG 45.9Reported Results: significant favouring RGSMD:-0.77(95% CI: -1.29 to -0.24)DAILY INTAKE OF NSAID / ANAGESICSBaseline Mean: RG 2.0/1.8, CG 2.3/1.6Reported Results: not significantSELF ASSESSED FUNCTIONAL IMPROVEMENT (5 point scale)Reported Results: significant favouring RGSIDE EFFECTS: NRCOST OF CARE: NR

Notes Source of Reference:Publication Type: journalPeer Reviewed: not specifiedSource of Funding: not specifiedFunding Agency has a Peer Review Mechanism: can't

tellCountry: Europe [France]


Study Rosenfeld 2000


Participants Acute MND (WAD)

Interventions

INDEX TREATMENTEarly Exercise (EEx): Active treatment within 96 hours after MVA; active range of motion (small range an amplitude to end of comfort rotation 10 times each waking hour), education (warning signs of recurrence or exacerbation), if symptoms persisted after 20 days individual was assessed and given an individualised program with additional exercises which could include cervical retraction, extension, flexion, rotation, lateral flexion or a combinationCOMPARISON TREATMENTEarly Education (EED): Standard treatment within 96 hours after MVA; education (injury mechanism, rest, advice, posture correction), active range of motion 2 to 3 times/day a few weeks after injury including shoulder elevation, shoulder blade retraction, torso rotation, lateral head flexion, and rotation with flexionDelayed Exercise (DEx): Active treatment same as EEx Group with a delay of 14 days after traumaDelayed Education (DED): Standard Treatment same as EED with a delay of 14 days after traumaCOINTERVENTION: reported to not differ statisticallyTreatment Schedule: 6 months (in active treatment groups 2 patients needed one instruction and treatment session, 13 needed 2 sessions, and 10 needed 3 sessions, 18 required more than 3 sessions). Symptoms persisted more than 20 days in 27/43 (63%) in active treatment groupsDuration of Follow-up: none

Outcomes

PAIN (VAS, 0 to 100)Baseline Mean: EEx 43, EED 34, DEx 40, DED 42Reported Results: the reduction in pain was greater for those receiving active treatment than in those receiving standard treatment (p>0.001)SMD (DEx v DED): 0.47(95% CI: 0.28 to 0.80)SMD (DEx v EED): 0.78(95%CI: 0.41 to 1.48)SMD (EEx v DED): 0.11(95% CI: 0.03 to 0.42)SMD (EEx v EED): 0.18(95% CI: 0.05 to 0.72)SIDE EFFECT: NRCOST OF CARE: NR

Notes


Study Rosenfeld:DExvDED

Methods [Refer to Rosenfeld 2000 for details; author described delayed exercise v delayed education]

Participants

Interventions

Outcomes

Notes


Study Rosenfeld:DExvEED

Methods [Refer to Rosenfeld 2000 for details; author described delayed exercise v early education]

Participants

Interventions

Outcomes

Notes


Study Rosenfeld:EExvDED

Methods [Refer to Rosenfeld 2000 for details; author described early exercise v delayed education]

Participants

Interventions

Outcomes

Notes


Study Rosenfeld:EExvDEx

Methods [Refer to Rosenfeld 2000 for details; author described early exercise v delayed exercise]

Participants

Interventions

Outcomes

Notes


Study Rosenfeld:EExvEED

Methods [Refer to Rosenfeld 2000 for details; author described early exercise v early education]

Participants

Interventions

Outcomes

Notes


Study Soderlund 2000

Methods Type of Trial: RCTNumber Analysed/Randomised: 53/66Intention-to-treat: NRPower Analysis: NR

Participants Subacute, chronic WAD II and III (NDR)

Interventions

INDEX TREATMENTAdditional exercise treatment (AT):a. additional exercises (isometric neck extension)b. instruction (same as RT group)c. exercise (same as RT group)COMPARISON TREATMENTSRegular Treatment (RT):a. exercise (active range of motion in neck rotation, and shoulder flexion)b. instruction (alternating rest with activities and posture)COINTERVENTION: NRTreatment Schedule: 6 weeks, 6 sessions, booster session at 6 weeks to encourage patients to continue the exercises, as well as at 3 and 6 months follow-upDuration of Follow-up: 6 months

Outcomes

PAIN (NRS, 0 to 10)Baseline Mean: AT 4.3, RT 3.7Reported Results: significant positive effects for merged (AT& RT) group over time regarding pain intensity (p<0.001)SELF EFFICACY SCALE (0 to 200)Baseline Mean: AT 140.6, RT 152.0Reported Results: significant positive effects for merged (AT & RT) group over time regarding self-efficacy (p<0.001)FUNCTION (Physical Disability Index, 0 to 70]Baseline Mean: AT 26.4, RT 21.5Reported Results: significant positive effects for merged (AT & RT) group over time regarding pain disability index (p<0.001)SIDE EFFECTS: NRCOST OF CARE: NR

Notes


Study Soderlund 2001

Methods Type of Trial: RCTNumber Analysed/Randomised: 32/33Power Analysis: NR

Participants chronic WAD (grade 1 to 3)

Interventions

INDEX TREATMENTExperimental Treatment [Exp]:a. learning basic skills - relaxation training and reeducation of a balanced cervicothoracic posture based on cervicothoracic muscular stabilisation techniques (Sweeney 1992)b. exercises aimed to increase neck ROM, coordination and endurance of neck muscles and reeducation of normal humeroscapular rhythmc. application of basic skills - basic skills integrated with the everyday activities derived from the functional behavioural analysisd. generalisation of basic skills - basic skills integrated with the everyday activities derived from the functional behavioural analysise. maintenance of basic skills - repetition of key components of last session, written summary of the programf. Individualised for each patient; all skills training was done at home; treatment completed by the experimenter; Duration: maximum 12 appointments Median =11COMPARISON TREATMENT:Comparison Treatment (Cntl):a. exercises: muscular stabilisation of neck; neck and shoulder mobility with stretching and coordination of head movements; maintain the body posture and arm muscle strengthb. given oral or written information (or both) and were expected to practice exercises at home or at the physiotherapy departments' gym (or both)c. treatment could also include pain-relieving methods like relaxation, transcutaneous electric nerve stimulation, acupuncture and heat, given in the physiotherapy departmentCOINTERVENTION: NRTreatment Schedule: treatments were individualised for each patient; Duration: maximised to appointments, median = 6 sessionsDuration of Follow-up: 12 weeks

Outcomes

PAIN INTENSITY (NRS, 0 to 10)Baseline Mean: Exp 4.2, Cntl 3.6Reported Results: no significant difference between groupsSMD: 0.12(95%CI:-0.57 to 0.82) [power %]FUNCTION (Physical Disability Index, 0 to 70)Baseline Mean: Exp 31.1, Cntl 25.9Reported Results: no significant difference between groupsSMD: 0.36(95%CI:-0.34 to 1.06) [power %]SIDE EFFECTS: NRCOST OF CARE: NR

Notes


Study Taimela 2000

Methods Type of Trial: RCTNumber Analysed/Randomised: 61/76Intension-to-treat Analysis: calculatedPower Analysis: NR

Participants Chronic MND (non-specific)

Interventions

INDEX TREATMENTActive (A) Treatment:a. exercises: cervicothoracic endurance exercises, eye fixation exercises, posture control exerciseb. relaxation training, behavioral supportc. education: lecture about neck pain and its consequencesd. written information regarding home exercisesCOMPARISON TREATMENTSHome (H) Group:a. practical training for home exercises with daily diaryb. education: lecture about neck pain and its consequencesc. written information regarding home exercisesControl (Cntl) Group:a. education: lecture about neck pain and its consequencesb. written information regarding home exercisesCOINTERVENTION: Avoided in trial design [47% used anti-inflammatories, 8% reported use of drugs affecting central nervous system; no statistical discernable difference for use of medication between groups]Treatment Schedule: Active: 12 weeks, 24 sessions 2 sessions/ 1 week; Home: 2 sessions/2 week; Control: 1 sessionDuration of Follow-up: 12 months

Outcomes

PAIN INTENSITY (VAS, 0 to 100)Baseline Mean: H 38, A 49, Cntl 51Reported Results: significantly lower in Active group at 3 months , no significant difference at 12 monthsSMD (H v Cntl): 0.24(95%CI:-0.36 to 0.84) [power %]SMD (A v Cntl):-0.51(95%CI:-1.13 to 0.12) [power %]SELF REPORTED WORKING ABILITYReported Results: an improvement in favour of the Active treatment was seen at 3 months (p=0.004) and this difference remained at 12 month follow-up (p=0.01)SELF EXPERIENCED BENEFITS OF TREATMENT (-1 to 5)Reported Results: significantly different favouring Active treatment (p<0.001)SIDE EFFECTS:Active Group: 2/22 had dizziness and muscle painControl Group: no side effectsCOST OF CARE: NR

Notes


Study Taimela:Activevcontr

Methods [Refer to Taimela 2000 for details; author described Active group v Control group]

Participants

Interventions

Outcomes

Notes


Study Taimela:Activevhome

Methods [Refer to Taimela 2000 for details; author described Active group v Home group]

Participants

Interventions

Outcomes

Notes


Study Taimela:Homevcontrol

Methods [Refer to Taimela 2000 for details; author described Home group v Control group]

Participants

Interventions

Outcomes

Notes


Study Takala 1994

Methods Type of Trial: RCTNumber Analysed/Randomised: 44/45Intention-to-treat: NRPower Analysis: NR

Participants MND, disorder duration NR

Interventions

INDEX TREATMENTGroup A: Group gymnastic, instructional type = group; setting = work; treatment characteristics = exercise planned to train whole body a) aerobic dynamic exercise [10 minutes walking or stepping], b) relaxation, c) stretching of muscles of the trunk and extremities and dynamic exercises [10 minutes]; schedule 10 minutes walking/stepping, 10 minutes stretch/dynamic exercises, 5 minutes walking/stepping, 10 minutes dynamic and coordination exercises, 10 minutes stretch and relaxation; duration of session = 45 minutes; frequency = 1 time per weekCOMPARISON TREATMENT:Group B: no treatmentCOINTERVENTION: NRTreatment Schedule: 10 weeks, 10 sessions of treatment in the spring session (crossover of placebo group occurred in autumn, the groups were reversed)Duration of Follow-up: none

Outcomes

PAIN (VAS, 0 to 100)Baseline Median: A 40, B 50Reported Results: no significant differencePRESSURE PAIN SENSITIVITY [algometer (pressure pain threshold on upper trapezius, levator scapulae, rhomboid, infraspinatus) mean score of 8 measures]Baseline Mean: A 45.2, B 44.8Reported Results: no significant differenceSIDE EFFECTS: NRCOST OF CARE: NR

Notes Source of Reference:Publication Type: journalPeer Reviewed: yesFunding Agency has Peer Review Mechanism: can't tellCountry: Scandinavia [Finland]


Study Vasseljen 1995

Methods Type of Trial: RCT [for Groups 1 and 2; Group 3 not randomised]Number Analysed/Randomised: 24/24Intention-to-treat Analysis: not applicablePower Analysis: NR


Interventions

INDEX TREATMENTGroup 1 (G1):a. mobilisation (passive): provided when indicated; massage: 5 to 10 minutesb. exercise: strength on weight training apparatus, 5-10 minutes & stretching 3 to 4 minutes, total 20-30 minutesc. education: ergonomic principlesd. home exercise on postural control, strength and flexibility training of the shoulder/neck region;e. two one hour sessions/week for 10 sessionsCOMPARISON TREATMENTGroup 2 (G2):a. exercise: adopted from Dyrssen, 1.1kg dumbbells in both hands, 4 arm exercises each performed 10 times, cycle repeated 3 times; load adjusted for 10 repetitions, abdominal and back exercises; breathing techniques; 5 minutes stretching exercise to shoulder/neckb. education: same as Group 1c. three 30 minute session/week for 6 weeksCOINTERVENTION: NRTreatment Schedule: 5 to 6 weeks, 10 to 18 sessionsDuration of Follow-up: 24 weeks; mailed questionnaire

Outcomes PAIN (VAS, 0 to 10)Baseline Mean: G14.2, G2 4.2Reported Result: not significantSMD: 0.09 (95%CI:-0.71, 0.89) [power 9%]RR: 0.29 (95% CI: 0.07, 1.10)SIDE EFFECTS: NRCOST OF CARE: NR

Notes Source of Reference: Personal Files, MANTISPublication Type: journalPeer Reviewed: yesSource of Funding: The Norwegian Fund for Postgraduate Education in Physiotherapy and The Norwegian Research CouncilFunding Agency has Peer Review Mechanism: can't tellCountry: Norway


Study Waling 2002

Methods Type of Trial: CCTNumber Analysed/Randomised: 103/103Intention-to-treat Analysis: calculatedPower Analysis: calculated [power to detect 20 mm reduction on the VAS scale for pain in general was 90%, power to detect a reduction of 10 mm was lower than 50%]

Participants chronic MND [work related trapezius myalgia]

Interventions

INDEX TREATMENTStrength Training Group (S):a. with machines giving resistance in the concentric part of the movement (air machines)b. four different exercises for the neck and shoulder muscles (latissimus pull down, triceps press, shoulder flexion and scapular retraction)c. load individualised to 10 to 12 maximal voluntary contractions in 3 sets, increased as strength was gainedd. during short pauses while waiting for a special machine exercises for abdominal and back muscles were doneEndurance Training Group (E):a. arm cycling on an arm ergometer for 3 minutes alternated with 3 minutes of arm exercises using rubber expandersb. resistance on arm cycling set so a hear rate around 110 to 120 beats per minutewas achievedc. expanders were loaded individually to allow 30 concentric contractions of each exercised. for variation exercises for abdominal and back muscles were includedCo-ordination training Group (Co-ord): Body awareness training was the concept for co-ordination traininga. exercises aimed in getting a better understanding and awareness of the body regarding muscular tension and relaxation in movementsb. most of program consisted of exercises from the Body Awareness Therapy introduced by Roxendal (1985)c. attention is focused on balance and postural stabilityd. emphasis on mental awareness on the performance and a minimum use of force in movements to achieve a better muscular co-ordination and overall functionCOMPARISON TREATMENTControl group (C):a. studied and discussed stress managementb. duration 2 hours at a time, frequency 1 time/week for 10 weeksc. led by an occupational nursed. no exercises were performed in this groupe. Frequency: 3 times/weekCOINTERVENTION: analgesicsTreatment Schedule: 10 weeks, 30 sessionsDuration of Follow-up: 3 years

Outcomes PAIN (in general; VAS, 0 to 100)Baseline Mean: S 39, E 40, Co-ord 41, C 43Reported Results: pain same in all 4 groupsSMD(E v C): 0.48(-0.03, 0.89) [power %]SMD(S v C): 0.58(0.07, 1.10)SMD(Co-ord v C): 0.45(-0.07, 0.97) [power %]PAIN (at worst; VAS, 0 to 100)Baseline Mean: S 74, E 70, Co-ord 77, C 75Reported Results: pain same in all 4 groupsPAIN (at present; VAS, 0 to 100)Baseline Mean: S 26, E 28, Co-ord 33, C 37Reported Results: pain same in all 4 groupsEXTENT OF BODY AREA MARKED AS PAINFUL (PPD%)Baseline Mean: S 5.4, E 4.6, Co-ord 4.8, C 6.9Reported Results: pain same in all 4 groupsFREQUENT NECK-SHOULDER PAIN (%)Baseline Mean: S 90, E 96, Co-ord 96, C 91Reported Results: pain same in all 4 groupsWORRIED ABOUT NECK-SHOULDER PAIN (%)Baseline mean [SD]: S 76 [75], E 57 [59], Co-ord 56 [58], C 35

[44]SIDE EFFECTS: NRCOST OF CARE: NR

Notes


Study Waling 2002:Co v C

Methods

Participants

Interventions

Outcomes

Notes


Study Waling 2002:EvC

Methods [Refer to Waling 2002 for details; author described endurance v control]

Participants

Interventions

Outcomes

Notes


Study Waling 2002:SvC

Methods [Refer to Waling 2002 for details; author described strength v control]

Participants

Interventions

Outcomes

Notes


Study Ylinen 2003

Methods

Type of Trial: RCTNumber Analysed/Randomized: 179/180Intention-to-treat Analysis: calculatedPower Analysis: calculated, expecting endurance and control to improve 15% in pain measured by VAS, strength would have to improve 50% to be better than the other 2 groups. A beta of 0.05 with 95% power and assuming a uniform drop-out of 5%, 60 patients in each group would be sufficient


Interventions INDEX TREATMENTEndurance (E) Group:a. 12 day institutional rehabilitation program b. exercises [neck flexor muscles by lifting the head up from the supine position in 3 series of 20 repetitions; 5 sessions per week; 45 minutes for 12 daysb. dynamic exercises for the shoulders and upper extremities by doing dumbbell shrugs, presses, curls, bent-over rows, flyes, and pullovers performing 3 sets of 20 repetitions for each exercise with a pair of dumbbells each weighing 2 kg.c. exercises for the trunk and leg muscles against their individual body weights by doing a single series of squats, sit-ups, and back extension exercisesd. each training session concluded with stretching exercises for the neck, shoulder, and upper limb muscles for 20 minutese. also advised to perform aerobic exercise 3 times/week for 30 minutesf. received written information about the exercises to be practiced at home 3 times/weekg. multimodal rehabilitation program, including aspects commonly associated with traditional treatment: relaxation training, aerobic training, behavioral support to

reduce fear of pain and improve exercise motivation, and lectures and practical exercises in ergonomicsh. during the rehabilitation course, each patient received 4 sessions of physical therapy, which consisted mainly of massage and mobilisation to alleviate neck pain and to enable those with severe neck pain to perform active physical exercisesStrength (S) Group:a. 12 day institutional rehabilitation programb. exercise used elastic rubber band to train the neck flexor muscles in each session performed in sitting, a single series of 15 repetitions directly forward, obliquely toward right and left, and directly backwardc. aim to maintain the level of resistance at 80% of the participant's maximum isometric strength re coded at the baseline and at follow-up visitsd. load was checked with a handheld isometric strength testing device during the training sessionse. dynamic exercises for the shoulders and upper extremities by doing dumbbell shrugs, presses, curls, bent-over rows, flyes, and pullovers with individually adjusted single dumbbell, 1 set for each exercise with the highest load possible to perform 15 repetitions f. dynamic exercises for the shoulders and upper extremities by doing dumbbell shrugs, presses, curls, bent-over rows, flyes, and pullovers performing 3 sets of 20 repetitions for each exercise with a pair of dumbbells each weighing 2 kg.g. exercises for the trunk and leg muscles against their individual body weights by doing a single series of squats, sit-ups, and back extension exercisesh. each training session concluded with stretching exercises for the neck, shoulder, and upper limb muscles for 20 minutesi. also advised to perform aerobic exercise 3 times/week for 30 minutesj. received written information about the exercises to be practiced at home 3 times/weekk. multimodal rehabilitation program, including aspects commonly associated with traditional treatment: relaxation training, aerobic training, behavioral support to reduce fear of pain and improve exercise motivation, and lectures and practical exercises in ergonomicsl. during the rehabilitation course, each patient received 4 sessions of physical therapy, which consisted mainly of massage and mobilisation to alleviate neck pain and to enable those with severe neck pain to perform active physical exercisesCOMPARISON TREATMENT3. Control (C) Group:a. 3 days at rehabilitation centre for tests and recreational activitiesb. advised to perform aerobic exercise 3 times/week for 30 minutesc. written information about stretching exercises to practice at home 3 times/week for 20 minutes per dayCOINTERVENTION: analgesics; 80% of Control group, 49% of Endurance group, and 57% of the Strength group used additional therapists as follows: massage and stretching about 65%; hot and ice packs, electrotherapy, acupuncture, traction, and zone therapy from bewteen 5 to7%Treatment Schedule: 12 monthsDuration of Follow-up: 12 months

Outcomes

NECK PAIN (VAS, 0 to 100)Baseline Median: E 57, S 58, C 58Reported Results: pain was at the same level in the 3 groupsRR (E v C): 0.52(95%CI: 0.37, 0.73)RR (S v C): 0.34(95%CI: 0.22, 0.53)MODIFIED NECK & SHOULDER PAIN DISABILITY INDEX (0 to 100)Baseline Median: E 36, S 35, C 38Reported Results: pain and disability index was at the same level in the 3 groupsVERNON NECK DISABILITY INDEX (NDI, 0 to 50)Baseline Median: E 22, S 21, C 22Reported Results: disability index was a the same level in the 3 groupsUSE OF ANALGESICSBaseline Number:None E 13, S 10, C 11Occasionally S 37, S 41, C 41Daily E 9, S 9, C 8SIDE EFFECTS: NRCOST OF CARE: NR

Notes


Study Ylinen 2003: EvC

Methods [Refer to Ylinen 2003 for details; author described endurance v control]

Participants

Interventions

Outcomes

Notes


Study Ylinen 2003: SvC

Methods [Refer to Ylinen 2003 for details; author described strength v control]

Participants

Interventions

Outcomes

Notes


Characteristics of excluded studies

Study Reason for exclusion

Bissett 1985 1. Intervention: EMB biofeedback mediated muscle relaxation not active exercise

Brewerton 1966 1. Population: Cervical root compression

Carlsson 1990 1. Population: chronic tension headache (either occipital, temporal and/or frontal)

Foley-Nolan 1992 1. Intervention: not exercise

Friedrich 1996 1. Intervention: Education comparison, exercise is the same in all 3 groups

Hanten 1997 1. Outcome Measure: did not use any of the identified outcome measures (only Pain pressure threshold as a proxy for pain)

Herring 1992 1. Design: not RCT/CCT2. Outcome Measure: did not use at least one outcome measure

Highland 1992 1. Design = Not RCT or CCT

Hurwitz 2002 1. Intervention: No active exercise

Kamwendo 1991 1. Intervention: Exercises not specified

Linton 2001a 1. Intervention: Unable to seperate exercise group within treatment as usual comparison group

Nordemar 1981 1. Intervention: passive exercise

Rundcrantz 1991

1. Intervention: This was a quasi-RCT, treatment was individualized and unable to specify exercise.

Skargren 1997 1. Intervention: Unable to seperate data for exercise group (unclear if McKenzie treatment mobilisation or exercise)

Characteristics of ongoing studies

Study Trial name or title

Participants Interventions Outcom

esStarting date

Contact informati

onNote

s

Guerriero 1997

Comparative effects of manipulation and physical therapy on

chronic neck pain

cervical spine manipulation v sham treatment v cervical spine manipulation, ischemic

cervical ROM

Palmer Institute of Graduate Studies and Research,

motion in the cervical spine

compression of myofascial trigger points , PNF, interferential therapy

Davenport, Iowa.

Gurumoorthy 2000

A prospective study of actue whiplash injury and its clinical management

acute neck injury (whiplash associated disorder)

early immobilisation v early active mobilisation

pain, cervical ROM, neck muscle strength, time to return to normal duties

Curtin University of Technology, Perth, Australia

Reginiussen 2000

Efficiency of manual therapy on patients with cervicogenci headache. A randomized single blinded controlled trial

cervicogenic headache

manual therapy (soft tissue methods, stretching/massage, mobilising and thrust techniques) v standardised physiotherapy treatment consistening of SWD, exercises and stretching

headache, neck pain, function, use of drugs, patient satisfaction

Institut of Manual Therapy, Alta, Norway

Stokke 1995

A randomised comparison of chiropractic and physiotherapy treatment for neck pain of functional (mechanical) origins. A controlled clinical trial

neck pain, neck and head pain, neck and shoulder pain

chiropractic spinal manipulation v physiotherapy v medication

NDI, pain intensity VAS

Institute of Community Medicine, School of Medicine, Uniersity of Tramso, 9037 Tromso, Norway.

A D D I T I O N A L T A B L E S

Search Strategy for MEDLINE

1. neck/ or neck muscles/ or exp cervical plexus/ or exp cervical vertebrae/ or Atlanto-Axial Joint/ or atlanto-occipital joint/ or axis/ or atlas/ or spinal nerve roots/ or exp brachial plexus/2. (odontoid or cervical or occip: or atlant:).tw.3. 1 or 24. exp arthritis/ or exp myofascial pain syndromes/ or fibromyalgia/ or spondylitis/ or exp spinal osteophytosis/ or spondylolisthesis/5. exp headache/ and cervic:.tw.6. whiplash injuries/ or cervical rib syndrome/ or torticollis/ or cervico-brachial neuralgia.ti,ab,sh. or exp radiculitis/ or polyradiculitis/ or polyradiculoneuritis/ or thoracic outlet syndrome/7. (monoradicul: or monoradicl:).tw.8. 4 or 5 or 6 or 79. random:.ti,ab,sh.10. randomised controlled trial.pt.11. double-blind method/

12. single blind method/13. placebos/14. clinical trial.pt.15. exp clinical trials/16. controlled clinical trial.pt.17. (clin$ adj25 trial$).ti,ab.18. ((singl$ or doubl$ or trebl$) adj25 (blind$ or mask$)).ti,ab.19. placebo$.ti,ab.20. or/9-1921. exp arthritis/rh,th or exp myofascial pain syndromes/rh,th or fibromyalgia/rh,th or spondylitis/rh,th or exp spinal osteophytosis/rh,th or spondylosis/rh,th or spondylolisthesis/rh,th22. exp headache/rh,th and cervic:.tw.23. whiplash injuries/rh,th or cervical rib syndrome/rh,th or thoracic outlet syndrome/rh,th or torticollis/rh,th or cervico-brachial neuralgia/rh,th or exp radiculitis/rh,th or polyradiculitis/rh,th or polyradiculoneuritis/rh,th24. or/21-2325. exp alternative medicine/ or Chiropractic/26. (chiropract: or kinesiology or massage or traditional medicine or relaxation or therapeutic touch).tw.27. or/25-2628. 3 and 2429. 3 and 8 and 2730. 28 or 2931. 20 and 30

Methodological Quality Criteria Author Criteria

Jadad et al

1a. Was the study described as randomised? (Score 1 if yes)1b and 1c. Was the method of randomisation described and appropriate to conceal allocation?(Score 1 if appropriate and -1 if not appropriate)2a. Was the study described as double-blinded? (Score 1 if yes)2b and 2c. Was the method of double blinding described and appropriate to maintain a double blinding?(Score 1 if appropriate and -1 if not appropriate)3. Was there a description of how withdrawals and dropouts were handled? (Score1 if yes)

van Tulder et al 2000

A. Concealment of treatment allocationB. Withdrawal/dropout rateC. Co-intervention avoided or equalD. Blinding of patientsE. Blinding of observerF. Intention-to-treat analysisG. ComplianceH. Similarity of baseline characteristicsI. Blinding of care provider(Score 1 if yes, 0 if no or don't know for all items)

Cochrane Allocation of Concealment

A. Adequate concealment of allocation;B. Uncertainty about whether the allocation was adequately concealed;C. The allocation was definitely not adequately concealed; andD. The score was not assigned.

Methodological Quality: Jadad criteria

Author (Year)

1a-Randomiz

ed

1b-Appropri

ate

1c-Inadequa

te

2a-Doub

le Blind

2b-Appropri

ate

2c-Inadequa

te

3-Withdraw

als

Total

Score

Allison 2002 1 0 0 0 0 0 0 1/5

Brodin 1984 1 0 0 0 0 0 1 2/5

Brodin 1985 1 1 0 0 0 0 1 3/5

Bronfort 2001 1 1 0 0 0 0 1 3/5

Fitz-Ritson 1995

1 0 0 1 0 0 1 3/5

Gam 1998 1 1 0 1 1 0 1 5/5

Geibel 1997 1 0 0 0 0 0 1 2/5

Goldie 1970 1 0 1 0 0 0 1 1/5

Hagberg 2000 1 1 0 0 0 0 1 3/5

Hanten 2000 1 0 0 0 0 0 1 2/5

Hoving 2002 1 1 0 0 0 0 1 3/5

Hoving 2001a 1 1 0 0 0 0 1 3/5

Hoving 2001b 1 1 0 0 0 0 1 3/5

Jordan 1996 1 1 0 0 0 0 1 3/5

Jordan 1998 1 1 0 0 0 0 1 3/5

Jull 2002 1 1 0 0 0 0 1 3/5

Karlberg 1996 1 0 0 0 0 0 1 2/5

Koes 1991 1 1 0 0 0 0 0 2/5

Koes 1992a 1 1 0 1 0 0 1 4/5

Koes 1992b 1 1 0 0 0 0 1 3/5

Koes 1992c 1 1 0 1 0 0 1 4/5

Koes 1992d 1 1 0 0 0 0 1 3/5

Koes 1992e 1 1 0 0 0 0 1 3/5

Koes 1 1 0 0 0 0 1 3/5

1993

Kogstad 2002 1 0 0 0 0 0 1 2/5

Levoska 1993 1 0 0 0 0 0 1 2/5

Lundblad 1999 1 0 0 0 0 0 1 2/5

McKinney 1989a

1 1 0 0 0 0 1 3/5

McKinney 1998b

1 1 0 0 0 0 0 2/5

Mealy 1986 1 1 0 1 0 0 1 4/5

Pennie 1990 1 0 1 0 0 0 1 1/5

Persson 2001 1 1 0 0 0 0 1 3/5

Provinciali 1996 1 0 0 0 0 0 1 2/5

Randlov 1998 1 1 0 0 0 0 1 3/5

Revel 1994 1 0 0 0 0 0 1 2/5

Rosenfeld 2000 1 0 0 0 0 0 1 2/5

Soderlund 2000 1 0 0 0 0 0 1 2/5

Soderlund 2001

Taimela 2000 1 0 0 0 0 0 1 2/5

Takala 1994 1 0 0 0 0 0 1 2/5

Vasseljen 1995 1 0 0 0 0 0 1 2/5

Waling 2002 1 0 0 0 0 0 1 2/5

Ylinen 2003 1 0 0 0 0 0 1 2/5

Methodological Score: van Tulder criteria

Author A B C D E F G H I

Allison 2002 0 1 0 0 1 1 0 0 0

Brodin 1984 0 1 0 0 0 0 0 0 0

Brodin 1985 1 1 0 0 0 0 0 1 0

Bronfort 2001 1 1 1 0 1 1 0 1 0

Fitz-Ritson 1995 1 1 0 1 0 0 0 0 0

Gam 1998 1 1 1 1 1 0 0 0 1

Giebel 1997 0 1 1 0 1 0 0 1 0

Goldie 1970 1 0 1 1 0 0 1 0 1

Hagberg 2000 1 1 0 0 0 0 0 1 0

Hanten 2000 0 1 1 0 1 1 1 0 0

Hoving 2002 1 1 1 0 1 1 1 1 0

Hoving 2001aHoving 2001b 1 1 0 0 1 1 0 0 0

Jordan 1996 1 1 0 0 0 0 0 0 0

Jordan 1998 1 1 1 0 0 0 1 1 0

Jull 2002 1 1 0 0 1 1 1 1 0

Karlberg 1996 0 1 0 0 0 1 0 1 0

Koes 1991 1 1 0 0 1 1 0 0 0

Koes 1992a 1 1 0 0 1 1 0 1 0

Koes 1992b 1 1 0 0 1 1 0 1 0

Koes 1992c 1 1 0 0 1 1 0 1 0

Koes 1992d 1 0 0 0 1 1 0 1 0

Koes 1992e 1 1 0 0 1 1 0 1 0

Koes 1993 1 0 0 0 1 1 0 1 0

Kogstad 1978 0 1 0 0 0 1 1 1 0

Levoska 1993 1 1 1 1 0 0 0 0 0

Lundblad 1999 0 0 1 0 0 0 1 1 0

McKinney 1989a 1 0 0 0 1 0 0 1 0

McKinney 1989b 1 0 0 0 1 0 0 1 0

Mealy 1986 1 1 0 0 1 0 0 1 0

Pennie 1990 1 0 0 1 0 0 0 0 0

Persson 2001 1 1 0 0 0 1 0 1 0

Provinciali 1996 0 1 0 0 1 1 0 1 0

Randlov 2000 1 0 1 0 1 0 0 1 4

Revel 1994 1 1 1 1 0 0 0 0 0

Rosenfeld 2000 0 1 0 0 0 1 1 1 0

Soderlund 2000Soderlund 2001 0 1 0 0 0 1 1 1 0

Taimela 2000 0 1 0 0 1 1 0 0 0

Takala 1994 1 1 1 1 0 0 0 0 0

Vasseljen 1995 0 1 0 0 0 1 1 1 0

Waling 2002 0 1 0 0 0 0 1 1 0

Ylinen 2003 0 1 1 0 0 1 1 1 0

Quick Summary: Exercise vs Control

Exercise Method

Acute WAD

Chronic MND

MND (NR)

NDH

(NR)

Chronic

NDH

Sub MND/NDR/ND

H*

Sub/chr MND/ND

RSub/chr

MND/NDH

Active ROM + pain ST

Strengthening

- pain ST/LT- function ST/LT+ GPE ST/LT

+ pain ST/LT+ function ST/LT+ GPE ST/LT

- GPE ST

Stretching &Strengthening

(multimodal)

- pain ST+ pain LT- function ST

+ function ST

+ pain ST

+ pain (multimodal) ST/LT+ function (multimodal) ST/LT+ GPE (multimodal) ST/LT

Eye Fixation Exercise

+ pain ST+ function ST+ GPE

ST/LT

Home Exercise

+ pain ST- GPE ST

- pain ST- function ST

- pain ST

KEY:

- = negative results+ = positive resultsSub = subacutechr = chronic* = with brachialgia

ST = short term resultsLT = long term resultsGPE = global percieved effectNR = duration not reported

NNT & Treatment Advantage: Pain Relief with Multimodal Care Author/Comparison NNT Advantage (%)

Jull 2002:MT/ExT v Cntl 5 [clinically important pain reduction] 40.8%

Rosenfeld 2000 5 [clinically important pain reduction] 38%

Skargren 1997; Skargren 1998 4 [clinically important pain reduction] 26.1%

R E F E R E N C E S

References to studies included in this review Allison 2002 {published data only} Allison GT, Nagy BM, Hall T. A randomized clinical trial of manual therapy for cervico-brachial pain syndrome - a pilot study. Manual Therapy 2002;7:95-102. Allison 2002:AT v CG {published data only} refer to Allison 2002. . :-. Allison 2002:AT v NT {published data only} refer to Allison 2002. . :-. Brodin 1985 {published data only} Brodin H. Cervical pain and mobilization. Int J Rehab Research 1984;7:190-1. Brodin H. Cervical pain and mobilization. Manual Medicine 1985:18-22. Brodin 1985: 2 v 1 {published data only} refer to Brodin 1985. . :-. Brodin 1985: 3 v 1 {published data only} refer to Brodin 1985. . :-. Brodin 1985: 3 v 2 {published data only} refer to Brodin 1985. . :-. Bronfort 2001 {published data only}

Bronfort G, Aker PD, Evans R, Goldsmith CH, Nelson B, Vernon H. A randomized controlled clinical trial of rehabilitative exercise and chiropractic spinal manipulation for chronic neck pain. Spine 2001;26:788-99. Bronfort G, Evan R, Nelson B. Aker PD, Goldsmith CH, Vernon H. A randomized controlled clinical trial of spinal manipulation and exercise for chronic neck pain: A report on neck performance outcomes after 11 weeks and long-term effects on patient-rated outcomes. Proceedings of the Scientific symposium, 1997 World Chiropractic Congress. 1998:62-8.Bronfort G, Evans R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A randomized controlled clinical trial of rehabilitative exercise and spinal manipulation for chronic neck pain. Effects on neck pain and disability, functional health status, biomechanical neck dysfunction, and somato-visceral symptoms. Proceedings of the 1998 International Conference of Spinal Manipulation. 1998:67-70.Bronfort: MedX v SMT {published data only} refer to Bronfort 2001. . :-. Bronfort:SMT/ExvMedX {published data only} refer to Bronfort 2001. . :-. Brontfort:SMT/ExvSMT {published data only} refer to Bronfort 2001. . :-. Fitz-Ritson 1995 {published data only} Fitz-Ritson D. Phasic exercises for cervcial rehabilitation after "whiplash" trauma. Journal of Manipulative and Physiological Therapeutics 1995;18:21-4. Gam 1998 {published data only} Gam AN, Warming S, Larsen LH, Jensen B, Hoydalsmo O, Allon I. Treatment of myofascial trigger-points with ultrasound combined with massage and exercise - a randomised controlled trial. Pain 1998;77:73-9. Gam SUSvsCG {published data only} refer to Gam 1998. . :-. Gam USvCG {published data only} refer to Gam 1998. . :-. Geibel 1997 {published data only} Giebel GD, Edelmann M, Huser R. Die distorsion der halswirbelsaule: Fruhfunktionalle vs. ruhigstellende behandlung. Zentralbl Chir 1997;122:517-21. Goldie 1970 {published data only} Goldie I, Landquist A. Evaluation of the effects of different forms of physiotherapy in cervical pain. Scand J Rehab Med 1970;2-3:117-21. Goldie: ex v cnt {published data only} refer to Goldie 1970. . :-. Goldie: ex v trac {published data only} refer to Goldie 1970. . :-. Hagberg 2000 {published data only} Hagberg M, Harms-Ringdahl K, Nisell R, Hjelm EW. Rehabilitation of neck-shoulder pain in women industrial workers: A randomized trial comparing isometric shoulder endurance training with isometric shoulder strength training. Arch Phys Med Rehabil 2000;81:1051-8. Hanten 2000 {published data only} Hanten WP, Olson SL, Butts NL, Nowicki AL. Effectiveness of a home program of ischemic pressure followed by sustained stretch for treatment of myofascial trigger points. Physical Therapy 2000;80:997-1003. Hoving 2002 {published data only} Hoving JL, Vet HCW, Koes BW, Mameren H, Deville WJLM, Windt DAWM. Manual therapy, physical therapy, or continued care by the general practitioner for patients with neck pain: long-term results from a pragmatic randomized trial. In: Hoving JL, editor(s). Wageningen: Pons & Looijen bv, 2001:59-73.

Hoving JL, Koes BW, Vet HCW, Windt DAWM, Assendelft WJJ, Mameren H. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. Annals of Internal Medicine 2002;136:713-59. Korthals-de Bos IBC, Hoving JL, Tulder MW, Rutten-van Molken MPMH, Ader HJ, Vet HCW. Manual therapy is more cost-effective than physical therapy and GP care for patients with neck pain. In: Hoving JL, editor(s). Wageningen: Pons & Looijen bv, 2001:75-90. Hoving 2002: GP v MT {published data only} refer to Hoving 2002. . :-. Hoving 2002: PT v GP {published data only} refer to Hoving 2002. . :-. Hoving 2002: PT v MT {published data only} refer to Hoving 2002. . :-. Jordan 1998 {published data only} Jordan A, Bendix T, Nielsen H, Hansen FR, Host D, Winkel A. Intensive training, physiotherapy, or manipulation for patients with chronic neck pain: A prospective single-blind randomized clinical trial. Spine 1998;23:311-9. Jordan A, Bendix T, Nielsen H, Hansen FR, Host D, Winkel A. Intensive training, physiotherapy, or manipulation for patients with chronic neck pain. A prospective single-blind randomized clinical trial. Proceedings of the 1996 International conference on spinal manipulation. 1996.Jordan 1998: Int vCH {published data only} refer to Jordan 1998. . :-. Jordan 1998:CHvPT {published data only} refer to Jordan 1998. . :-. Jordan 1998:Int v PT {published data only} refer to Jordan 1998. . :-. Jull 2002 {published data only} Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;27:1835-43. Jull 2002:ExT v Cntl {published data only} refer to Jull 2002. . :-. Jull 2002:ExT v MT {published data only} refer to Jull 2002. . :-. Jull 2002:MTExT v MT {published data only} refer to Jull 2002. . :-. Jull 2002:MTExT vExT {published data only} refer to Jull 2002. . :-. Jull 2002:MTExTvCntl {published data only} refer to Jull 2002. . :-. Karlberg 1996 {published data only} Karlberg M, Magnusson M, Eva-Maj M, Melander A, Moritz U. Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin. Archives of Physical Medicine and Rehabilitation 1996;77:874-82. Koes 1992 {published data only} Koes B. A randomized clinical trial of manual therapy and physiotherapy for persistent back and neck complaints. Subgroup analysis and relationship between outcomes measure. Journal of Manipulative and Physiological Therapeutics 1993;16:211-9. Koes B, Bouter LM, Knipshild PG. The effectiveness of manual therapy, physiotherapy and continued treatment by general practitioner for chronic nonspecific back and neck complaints. Journal of Manipulative and Physiological Therapeutics 1991:498-502.

Koes BW. In: Efficacy of manual therapy and physiotherapy for back and neck complaints (Thesis) den Haag: Cip-Gegevens Koninklijke Bibliotheek:-. Koes BW, Bouter LM, Mameren H, Esser AH, Verstegen GH, Hofhuizen DM. Randomized clinical trial of manual therapy and physiotherapy for persistent back and neck complaints. Manual Therapy in the Netherlands :7-12. Koes BW, Bouter LM, Mameren H, Esser AH, Verstegen GM, Hofhuizen DM. A blind randomized clinical trial of manual therapy and physiotherapy for chronic back and neck complaints: Physical outcome measures. J Manipulative Physiol Ther ;15:16-23. Koes BW, Bouter LM, Mameren H, Esser AH, Verstegen GM, Hofhuizen DM. Randomized clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: results of one year follow up. BMJ :601-5. Koes BW, Bouter LM, Mameren H, Essers AH, Verstegen GM, Hofhuizen DM. The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific back and neck complaints. Spine ;17:28-35. Koes 1992: GP v MT {published data only} refer to Koes 1992. . :-. Koes 1992: GP v pl {published data only} refer to Koes 1992. . :-. Koes 1992: PT v GP {published data only} refer to Koes 1992. . :-. Koes 1992: PT v pl {published data only} refer to Koes 1992. . :-. Koes 1992:PT v MT {published data only} refer to Koes 1992. . :-. Kogstad 1978 {published data only} Kogstad OA, Karterud S, Gudmundsen J. Cervicobrachialgia. A controlled trial with conventional treatment and manipulation. Tidiskr Nor Loegeforen 1978;98:845-8. Kogstad 1978:CT v MT {published data only} refer to Kogstad 1978. . :-. Kogstad 1978:CT v Pl {published data only} refer to Kogstad 1978. . :-. Levoska 1993 {published data only} Levoska S, Keinanen-Kiukaanneimi S. Active or passive physiotherapy for occupational cervicobrachial disorders? A comparison of two treatment methods with a 1-year follow-up. Arch Phys Med Rehabil 1993;74:425-30. Lundblad 1999 {published data only} Lundblad I, Elert J, Gerdle B. Randomized Controlled Trial of Physiotherapy and Feldenkrais Interventions in Female Workers with Neck-Shoulder Complaints. Journal of Occupational Rehabilitation 1999;9:179-94. Lundblad 1999: PTvCG {published data only} refer to Lundblad 1999. . :-. Lundblad 1999: PTvFG {published data only} refer to Lundblad 1999. . :-. McKinney 1989 {published data only} McKinney LA. Early mobilization and outcome in acute sprain of the neck. BMJ ;299:1006-8. McKinney LA, Dornan JO, Ryan M. The role of physiotherapy in the management of acute neck sprains following road traffic accidents. Archives of Emergency Medicine ;6:27-33. McKinney 1989: 2 v 1 {published data only} refer to McKinney 1989. . :-. McKinney 1989: 2 v 3 {published data only}

refer to McKinney 1989. . :-. McKinney 1989: 3 v 1 {published data only} refer to McKinney 1989. . :-. Mealy 1986 {published data only} Mealy K, Brennan H, Fenelon GC. Early mobilisation of acute whiplash injuries. British Medical Journal 1986;92:656-7. Pennie 1990 {published data only} Pennie B, Agambar L. Whiplash injuries. A trial of early management. J Bone Joint Surg 1990;72:277-9. Persson 2001 {published data only} Persson L, Karlberg M, Magnusson M. Effects of different treatments on postural performance in patients with cervical root compression. A randomized prospective study assessing the importance of the neck in postural control. Journal of Vestibular Research 1996;6:439-53. Persson LCG, Carlsson CA, Carlsson JY. Long-lasting cervical radicular pain managed with surgery, physiotherapy, or a cervical collar. A prospective, randomized study. Spine 1997;22:751-8. Persson LCG, Lilja A. Pain, coping, emotional state and physical function in patients with chronic radicular neck pain. A comparison between patients treated with surgery, physiotherapy or neck collar - a blinded, prospective randomized study. Disability and Rehabilitation 2001;23:325-35. Persson LCG, Moritz U, Brandt L, Carlsson CA. Cervical radiculopathy: pain, muscle weakness and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy or cervical collar. A prospective, controlled study. Eur Spine J 1997;6:256-66. Persson 2001:PTv col {published data only} refer to Persson 2001. . :-. Persson 2001:PTvsurg {published data only} refer to Persson 2001. . :-. Provinciali 1996 {published data only} Provinciali L, Baroni M, Illuminati L, Ceravolo MG. Multimodal treatment to prevent the late whiplash syndrome. Scandinavian Journal of Rehabilitation Medicine 1996;28:105-11. Randlov 1998 {published data only} Randlov A, Ostergaard M, Manniche C, Kryger P, Jordan A, Heegaard S, Holm B. Intensive dynamic training for females with chronic neck/shoulder pain. A randomized controlled trial. Clin Rehabil 1998;12:200-10. Revel 1994 {published data only} Revel M, Minguet M, Gergoy P, Vaillant J, Manuel JL. Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck apin: a randomized controlled study. Archives of Physical Medicine Rehabilitation 1994;75:895-9. Rosenfeld 2000 {published data only} Rosenfeld M, Gunnarsson R, Borenstein P. Early intervention in whiplash-associated disorders. Spine 2000;25:1782-7. Rosenfeld:DExvDED {published data only} refer to Rosenfeld 2000. . :-. Rosenfeld:DExvEED {published data only} refer to Rosenfeld 2000. . :-. Rosenfeld:EExvDED {published data only} refer to Rosenfeld 2000. . :-. Rosenfeld:EExvDEx {published data only} refer to Rosenfeld 2000. . :-. Rosenfeld:EExvEED {published data only} refer to Rosenfeld 2000. . :-. Soderlund 2000 {published data only}

Soderlund A, Lindberg P. Acute whiplash-associated disorders (WAD): the effects of early mobilization and prognostic factors in long-term symptomatology. Clinical Rehabilitation 2000;14:457-67. Soderlund 2001 {published data only} Soderlund A, Lindberg P. Cognitive Behavioural Components in Physiotherapy Management of Chronic Whiplash Associated Disorders (WAD) - A Randomised Group Study. Physiotherapy Theory and Practice 2001;17:229-38. Taimela 2000 {published data only} Taimela S, Takala EP, Asklof T, Seppala K, Parviainen S. Active treatment of chronic neck pain. Spine 2000;25:1021-7. Taimela:Activevcontr {published data only} refer to Taimela 2000. . :-. Taimela:Activevhome {published data only} refer to Taimela 2000. . :-. Taimela:Homevcontrol {published data only} refer to Taimela 2000. . :-. Takala 1994 {published data only} Takala EP, Viikari-Juntura E, Tynkkynen EM. Does group gymnastics at the workplace help in neck pain? A controlled study. Scandinavian Journal of Rehabilitation Medicine 1994;26:17-20. Vasseljen 1995 {published data only} Vasseljen O, Johansen BM, Westgaard RH. The effect of pain reduction on perceived tension and EMG-recoded trapezius muscle activity in workers with shoulder and neck pain. 1995; 27:243-252. Scandinavian Journal of Rehabilitation Medicine 1995;27:243-52. Waling 2002 {published data only} Waling K, Jarvholm B, Sundelin G. Effects of Training on Female Trapezius Myalgia. Spine 2002;27:789-96. Waling K, Sundelin G, Ahlgren C, Jarvholm B. Perceived Pain Before and After Three Exercise Programs - A Controlled Clinical Trial of Women with Work-Related trapezius Myalgia. Pain 2000;85:201-7. Waling 2002:Co v C {published data only} refer to Waling 2002. . :-. Waling 2002:EvC {published data only} refer to Waling 2002. . :-. Waling 2002:SvC {published data only} refer to Waling 2002. . :-. Ylinen 2003 {published data only} Ylinen J, Takala EP, Nykanen M, Hakkinen A, Malkia E, Pohjolainen T. Active Neck Muscle Training in the Treatment of Chronic Neck Pain in Women. JAMA 2003;289:2509-16. Ylinen 2003: EvC {published data only} refer to Ylinen 2003. . :-. Ylinen 2003: SvC {published data only} refer to Ylinen 2003. . :-. * indicates the major publication for the study References to studies excluded from this review Bissett 1985 Bissett A, Mitchell KR, Major G. The cervico-brachial pain syndrome: Muscle activity and pain relief. Behaviour Change 1985;2:129-35. Brewerton 1966

Brewerton DA. Pain in the neck and arm: a multicentre trial of the effects of physiotherapy: Arranged by the British Association of Physical Medicine. BMJ 1966;1:253-8. Carlsson 1990 Carlsson J, Fahlcrantz A, Augustinsson L. Muscle tenderness in tension headache treated with acupuncture or physiotherapy. Cephalgia 1990;10:131-41. Foley-Nolan 1992 Foley-Nolan D, Moore K, Codd M, Barry C, O'Connor P, Coughlan RJ. Low energy high frequency pulsed electromagnetic therapy for acute whiplash injuries: A double blind randomized controlled study. Scandinavian Journal of Rehabilitation Medicine 1992;24:51-9. Friedrich 1996 Friedrich M, Cermak T, Maderbacher P. The effect of brochure use versus therapist teaching on patients performing therapeutic exercise and on changes in impairment status. Physical Therapy 1996;76:1082-8. Hanten 1997 Hanten WP, Barrett M, Gillespie-Plesko M, Jump KA, Olson SL. Effects of active head retraction with retraction/extension and occipital release on the pressure pain threshold of cervical and scapular trigger points. Physiotherapy Theory and Practice 1997;13:285-91. Herring 1992 Herring C. The effects of controlled passive mobilization and controlled passive stretch on cervical intersegmental hypermobility in acute cervical strain/sprain injuries. Transactions of the consortium for chiropractic research. 1992:28.Highland 1992 Highland TR, Dreisinger TE, Vie LL, Russell GS. Changes in isometric strength and range of motion of the isolated cervical spine after eight weeks of clinical rehabilitation. Spine 1992;17:S77-S82. Hurwitz 2002 Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F, Adams AH. A Randomized Trial of Chiropractic Manipulation and Mobilization for Patients With Neck Pain: Clinical Outcomes From the UCLA Neck-Pain Study. Research and Practice 2002;92:1634-41. Kamwendo 1991 Kamwendo K, Linton SJ. A controlled study of the effect of neck school in medical secretaries. Scandinavian Journal of Rehabilitation Medicine 1991;23:143-52. Linton 2001a Linton SJ, Ryberg M. A cognitive-behavioral group intervention as prevention for persistent neck and back pain in a non-patient population: A randomized controlled trial. Pain 2001;90:83-90. Nordemar 1981 Nordemar R, Thorner C. Treatment of acute cervical pain - a comparative group study. Pain 1981;10:93-101. Rundcrantz 1991 Rundcrantz B, Johnsson B, Moritz U, Roxendal G. Cervico-brachial disorders in dentists: A comparison between two kinds of physiotherapeutic interventions. Scandinavian Journal of Rehabilitation Medicine 1991;23:11-7. Skargren 1997 Skargren EI, Carlsson PG, Oberg BE. One-year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as primary management for back pain. Spine 1998;23:1875-84. Skargren EI, Oberg BE, Carlsson PG, Gade M. Cost and effectiveness analysis of chiropractic and physiotherapy treatment for low back and neck pain: Six-month follow-up. Spine 1997;22:2167-71. Ongoing studies Guerriero 1997 Guerriero D. Comparative effects of manipulation and physical therapy on motion in the cervical spine. Proceedings of the International Conference on Spinal Manipulation. 1991.Gurumoorthy 2000

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Graphs and Tables

To view a graph or table, click on the outcome title of the summary table below. ACTIVE RANGE OF MOTION [AROM] / STRETCHING

Outcome title No. of studies No. of participants Statistical method Effect

size01 Exercise [+ modalities, traction, manual therapy] v Control [rest then gentle movement]: Pain Intensity [VAS]

Standardised Mean Difference (Random) 95% CI

Totals not selected

02 Exercise [early/delayed] v Comparison [Education early/delayed]: Pain Intensity [low/no]

Relative Risk (Random) 95% CI

Totals not selected

STRENGTHENING

Outcome title No. of studies

No. of participants

Statistical method

Effect size

01 Exercise [strength +/- endurance] v Control [+/- stress management]: Pain Intensity [VAS]


Totals not selected

02 Exercise [strength + endurance] v Control: Function


Totals not selected

03 Exercise [strength + endurance] v Control: Global Perceived Effect


Totals not selected

04 Exercise [+/-ED +/-analgesics +/- traction /- massage] v Control [+ED +/- analgesics]: Global Perceived Effect


Totals not selected

05 Exercise [strength + endurance] v Comparison [Manual Therapy]: Pain Intensity [VAS]


Totals not selected

06 Exercise [strength + endurance] v Comparison [Manual Therapy]: Function


Totals not selected

07 Exercise [strength + endurance] v Comparison [Manual Therapy]: Global Perceived Effect


Totals not selected

08 Exercise [+ED +analgesics] v Comparison [traction+ ED+ analgesics or manual therapy]: Global Perceived Effect


Totals not selected

STRETCHING AND STRENGTHENING


No. of participants Statistical method Effect size

01 Exercise [+ manual treatment +/- US] v Control [no treatment]: Pain Intensity


Totals not selected

02 Exercise [+ behavioural approach] v Control [recreation]: Pain [considerable or complete]


Totals not selected

03 Exercise [+ manual therapy] v Control [no treatment]: Function


Totals not selected

04 Exercise v Comparison [manual therapy or ED + medication]: Pain Intensity


Totals not selected

05 Exercise v Comparison [manual therapy or ED + medication]: Function


Totals not selected

06 Exercise v Comparison Standardised Mean Difference Totals not

http://cochrane.bvsalud.org/cochrane/img_data/CD004250/image_n/nCD004250-03-06.png











































[manual therapy or ED + medication]: Global Perceived Effect

(Random) 95% CI selected

DIZZINESS/VERTIGO EXERCISES


No. of participants

Statistical method

Effect size

01 Exercise [+ ED or analgesics] v Control [ED or analgesics]: Pain Intensity


Totals not selected

02 Exercise [+ analgesics] v Control [analgesics]: Function Relative Risk

(Random) 95% CI Totals not selected

03 Exercise [+ ED] v Control [ED]: Global Perceived Effect [Patient satisfaction]


Totals not selected

04 Exercise [+ manual therapy + ED] v Comparison [modalities]: Pain Intensity


Totals not selected

05 Exercise [+ manual therapy + ED] v Comparison [modalities]: Global Perceived Effect [Return to Work]


Totals not selected

HOME EXERCISES


No. of participants Statistical method Effect size

01 Exercise [+ manual therapy or modailites] v Control [no/sham treatment or rest + mobilisation]: Pain Intensity


Totals not selected

02 Exercise [mock therapy + neck school + analgesics]v Control [analgesics]: Pain Intensity [pain present]


Totals not selected

03 Exercise [manual therapy or analgesics + advice] v Control [no/sham treatment]: Function


Totals not selected

04 Exercise [+ traction] v Control [rest then active ex]: Global Perceived Effect


Totals not selected

05 Exercise [+ ED + analgesics] v Comparison [manual therapy]: Pain Intensity


Totals not selected

06 Exercise [+ED + analgesics] v Comparison [manual therapy]: Function


Totals not selected

07 Exercise [+ ED + analgesics] v Comparison [manual therapy]: Global Perceived Effect


Totals not selected

Cover sheet

Exercises for mechanical neck disorders

Reviewer(s) Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G,

Contribution of Reviewer(s) This is one review of a series conducted by the Cervical Overview Group: Aker P, Bronfort G, Eady A, Goldsmith C, Graham N, Gross A, Haines T, Haraldsson B, Houghton P, Kay T, Kroeling P, Peloso P, Radylovick Z, Santaguida PL, Trinh KPrimary Reviewers - Kay T, Gross A , Santaguida PL, Hoving J, Goldsmith C, Bronfort G






































Statistician - Goldsmith CMethodological Quality Assessment - Goldsmith C, Aker P, Trinh K, Haines T, Peloso PStudy Identification and Selection - Kay T, Santiguida PL, Hoving J, Gross A, Haraldson B, Houghton PResearch Librarian - Eady AData Abstraction, Synthesis, Manuscript Preparation, Public Responsibility, Grants, Administration - primary reviewersFinal Synthesis - full Cervical Overview Group

Issue protocol first published

2003 issue 2

Issue review first published 2005 issue 3Date of last minor amendment

06 June 2005

Date of last substantive amendment

30 April 2005

Most recent changes June 2005 -- we changed the order of the authors, reduced the length of the abstract; made some edits to the text for clarification; corrected the format in some of the references.

Date new studies sought but none found

Information not supplied by reviewer

Date new studies found but not yet included/excluded


Date new studies found and included/excluded


Date reviewers' conclusions section amended


Contact address Ms Theresa KaySunnybrook & Women's College Health Sciences Centre2075 Bayview AvenueNorth YorkONCANADAM3N 3M5Telephone: 416-480-4430Facsimile: 416-480-4057E-mail: [email protected]

Cochrane Library number CD004250Editorial group Cochrane Back Group Editorial group code HM-BACK

S O U R C E S O F S U P P O R T

External sources of support

Hamilton Health Sciences Corporation, Chedoke-McMaster Foundation (1997) CANADA

University of Saskatchewan, Clinical Teaching and Research Award (1997) CANADA Hamilton Hospital Assessment Centre (2002) CANADA Consortial Center for Chiropractic Research - National Institutes of Health, Bethesda,

MD (2002) USA Hamilton District Research Grant (2000) CANADA

Internal sources of support

Sunnybrook & Women's College Health Sciences Centre CANADA University of Toronto, Department of Rehabilitation Medicine CANADA McMaster University, Department of Clinical Epidemiology and Biostatistics, School of

Rehabilitation Science, Occupational Health Program CANADA Monash University, Department of Epidemiology and Preventative Medicine

AUSTRALIA Northwestern Health Sciences University USA

K E Y W O R D S

http://cochrane.bvsalud.org/cochrane/show.php?id=_ID_BACK&lang=pt&lib=COC&backto=review

mailto:[email protected]

exercises for mechanical neck disorders

Documents

acute mechanical neck

mechanical neck disorders

synopsis neck pain

type of exercise

use of exercise therapy

limited evidence of

unclear evidence of

home exercise program