Manual Therapy 24 (2016) 25e45

Contents lists available at ScienceDirect

Manual Therapy
journal homepage: www.elsevier.com/math

Review article

Exercises for mechanical neck disorders: A Cochrane review update

A.R. Gross a, b, *, J.P. Paquin c, d, G. Dupont d, S. Blanchette d, P. Lalonde d, T. Cristie d,
N. Graham b, T.M. Kay e, f, S.J. Burnie g, G. Gelley h, C.H. Goldsmith a, i, M. Forget j,
P.L. Santaguida a, A.J. Yee k, G.G. Radisic l, J.L. Hoving m, G. Bronfort n, Cervical Overview
Groupo
a
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
b
School of Rehabilitation Science, McMaster University, Hamilton, Canada
c
Physio-Sant
e, Drummondville, Canada
d
University of Western Ontario, London, Canada
e
Women's College Hospital, Toronto, Canada
f
Department of Physical Therapy, University of Toronto, Toronto, Canada
g
Department of Clinical Education, Canadian Memorial Chiropractic College, Toronto, Canada
h
Applied Health Sciences, University of Manitoba, Winnipeg, Canada
i
Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
j
Canadian Forces Health Services Group, Groupe de Services de Sant
e des Forces Canadiennes, National Defence, D

efense Nationale, Government of Canada,
Gouvernement du Canada, Kingston, Canada
k
Kinesiology, Faculty of Health Sciences, McMaster University, Hamilton, Canada
l
Life Science, Faculty of Health Sciences, Queens Univesity, Kingston, Canada
m
Coronel Institute of Occupational Health and Research Center for Insurance Medicine, Academic Medical Center, University of Amsterdam, Amsterdam,
Netherlands
n
Integrative Health & Wellbeing Research Program, Center for Spirituality & Healing, University of Minnesota, Minneapolis, MN, USA
o
Hamilton, Canada

a r t i c l e i n f o a b s t r a c t

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

Received 12 April 2016 Objectives: To assess the effectiveness of exercise on pain, disability, function, patient satisfaction, quality
Accepted 13 April 2016 of life (QoL) and global perceived effect (GPE) in adults with NP.
Methods: We searched computerised databases up to May 2014 for randomized controlled trials (RCTs)
Keywords: comparing exercise to a control in adults with NP with/without cervicogenic headache (CGH) or radi-
Cochrane review
culopathy. Two reviewers independently conducted selection, data abstraction and assessed risk of bias.
Meta-analysis
Meta-analyses were performed to establish pooled standardised mean differences (SMDp). The Grade of
Neck pain
Exercise
Recommendation, Assessment, Development and Evaluation (GRADE) was used to summarise the body
of evidence.
Main Results: The following exercises (27 trials) were supported by Moderate GRADE evidence:
For chronic NP, 1) cervico-scapulothoracic and upper extremity (UE) strengthening for moderate to large
pain reduction immediately post treatment (IP) and at short-term (ST) follow-up; 2) scapulothoracic and
UE endurance training for a small pain reduction (IP/ST); 3) cervical, shoulder and scapulothoracic
strengthening and stretching exercise for a small to large pain reduction in the long-term (LT)
(SMDp
0.45 [95%CI:
0.72 to
0.18]) and function improvement; 4) cervico-scapulothoracic strength-
ening/stabilisation exercises for pain and function at intermediate-term (IT) (SMDp
14.90 [95%CI:
22.40
to
7.39]). 5) mindfulness exercises (Qigong) for minor improved function but not GPE (ST).
For chronic CGH, cervico-scapulothoracic strengthening and endurance exercises including pressure
biofeedback for small/moderate improvement of pain, function and GPE (IP/LT).
Authors' conclusions: Specic strengthening exercises of the neck, scapulothoracic and shoulder for
chronic NP and chronic CGH are benecial. Future research should explore optimal dosage.
2016 Elsevier Ltd. All rights reserved.

* Corresponding author. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada.
E-mail addresses: grossa@mcmaster.ca, grossa@sympatico.ca (A.R. Gross).

http://dx.doi.org/10.1016/j.math.2016.04.005
1356-689X/ 2016 Elsevier Ltd. All rights reserved.
26 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

1. Background
1.1. Description of the condition
Neck disorders are common (Hogg-Johnson et al., 2008; Hoy
et al., 2014), painful, and limit function in the general population
(Carroll et al., 2008; Haldeman et al., 2010). The global point
prevalence of neck pain was estimated to be 4.9% in 2010 (Hoy et al.,
2014).
1.2. Description of the intervention
categorised. Therefore, the true impact of exercise alone could not
be determined with strong evidence.
1.5. Objectives
To present an abbreviated report of a Cochrane systematic re-
view that assessed the immediate to long-term effect of exercise
therapy on pain, function/disability, patient satisfaction, quality of
life (QoL), and global perceived effect (GPE) in adults experiencing
mechanical neck pain with or without cervicogenic headache or
radiculopathy.

We adopted the Therapeutic Exercise Intervention Model to 2. Methods

sub-classify exercise (Sahrmann, 2002). Hall and Brody (2005) in-
tersects this model with two other axes e activity and dosage (See
Table 1).
1.3. How the intervention might work
This is an abbreviated co-publication of our Cochrane systematic
review update (Kay et al., 2015). See Table 3 for selection criteria
and the primary review for full details. A protocol was previous0ly
published (Issue 2, 2003 Cochrane Library).

Exercise has both physical and mental benets through its ef-
fects on numerous systems such as the cardiovascular, immune,
neurologic, and musculoskeletal systems (Abernethy et al., 2013).
Central to these benets are the stages of change, encompassing the
health belief and cognitive behaviour models.
1.4. Why it is important to do this review
2.1. Search methods for identication of studies
A research librarian searched computerised bibliographic data-
bases for medical, chiropractic and allied health literature. Elec-
tronic searches included databases from their start to May 2014
(See Fig. 1 and Gross et al., 2015 for greater details). See Appendix 1
for Characteristics of Included Studies.

In our last Cochrane update on exercise therapy, we found low to
moderate quality evidence of pain relief benets for combined
cervical, scapulothoracic stretching and strengthening for chronic
neck pain in the short and long-term. Since then, ve other reviews
have found primarily very low to low GRADE evidence, as well as
low GRADE evidence for no benecial effect on pain (Table 2). A
number of these reviews included studies that were not clearly
2.2. Measures of treatment effect
For continuous data, standard mean difference (SMD) with 95%
condence intervals (CI) was calculated. The minimal clinically
important difference (MCID) for pain was 10 on a 100-point pain
intensity scale (Goldsmith et al., 1993; Felson et al., 1995; Farrar
et al., 2001). We considered the effect small when it was less

Table 1
The Therapeutic Exercise Intervention Model to sub-classify exercise (Sahrmann, 2002) is foundational to classication of exercise in this systematic review.

Support element:
An exercise categorised under this element would affect the functional status of the cardiac, pulmonary and metabolic systems (e.g. aerobic endurance activities).
Base Element:
Exercises categorised under base would affect the functional status of the muscular and skeletal systems and is commonly linked to the biomechanical element. This
element provides the basis for movement as follows:

 extensibility/stiffness properties of muscle, fascia and periarticular tissues for range of motion and stretching exercises,
 mobility of neuromeningeal tissue for neural mobilisation exercises,
 force or torque capability of muscles and the related muscle lengthetension properties for strengthening exercises, and endurance of muscle also involved in
strengthening for endurance-strength training.
Modulator Element:
Exercises under this element relate to motor control for neuromuscular re-education as follows:

 patterns and synchronisation of muscle recruitment, and

 feed forward or feedback systems using verbal, visual, tactile and other proprioceptive inputs to the patient.
Biomechanical Element:
This element is an interface between the motor control associated with the modulator element and musculoskeletal function associated with the base element.
Components of the biomechanical element include:

 static stabilisation forces involved in alignment and muscle recruitment, and

 dynamic stabilisation forces involved in arthrokinetics, osteokinetics and kinematics.
Cognitive or Affective Element:
Exercises in this category affects the functional status of the psychological system as it is related to movement as follows:

 the cognitive ability to learn,

 patient and caregiver compliance,
 motivation, and
 emotional status.
 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45 27

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

Very low to low GRADE evidence for
benecial effect on pain
Low GRADE evidence for no benecial
effect on pain
1) stretching and strengthening for chronic neck pain (Bertozzi et al., 2013; Southerst et al., 2014; Vanti et al., 2015)
2) strengthening, endurance, and modular element for chronic cervicogenic headache (Bronfort et al., 2004; Kay et al., 2005;
Racicki et al., 2013)
3) neuromuscular exercises (proprioception/eye-neck coordination) (Leaver et al., 2010; Teasell et al., 2010a)
4) stretching and range of motion exercises for non specic neck pain (Leaver et al., 2010)
5) stretching, strengthening, endurance training, balance/coordination, cardiovascular training and cognitive/affective
elements for chronic neck pain (Lee et al., 2009; Leaver et al., 2010; Teasell et al., 2010b; Salt et al., 2011; Southerst
et al., 2014)
6) qigong exercises for chronic neck pain (Lee et al., 2009; Southerst et al., 2014)
7) supervised exercises for chronic WAD (Teasell et al., 2010b)
8) strengthening neck exercises for chronic neck pain (Bertozzi et al., 2013; Southerst et al., 2014)
1) stretching and strengthening for radiculopathy (Salt et al., 2011; Southerst et al., 2014)
2) general tness training for acute to chronic neck pain (Kay et al., 2012; Bertozzi et al., 2013)
3) stretching and endurance training in chronic neck pain (Kay et al., 2012; Bertozzi et al., 2013)

Table 3
Criteria for considering studies for this review.

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

Types of Adults (M/F  18 years with acute (<30 days), subacute (30e90 days), or chronic (>90 days) neck disorders categorised as:
Participants - mechanical neck disorder (MND): whiplash associated disorders (WAD) Category I/II, myofascial neck pain, degenerative changes like
osteoarthritis/cervical spondylosis
- cervicogenic headache (CGH)
- neck disorders with radicular ndings (NDR)
Excluded: studies of neck disorders with denitive/possible long term signs (eg. Myelopathies), neck pain caused by other pathological entities,
headache associated with neck but not cervical origin, co-existing headache when neck pain is not dominant, headache not provoked by neck
movements/sustained neck postures, mixed headache
Types of One or more types of exercise therapy specied in Therapeutic Exercise Intervention Model Excluded: exercise therapy as part of a multidisciplinary
Interventions treatment, multimodal treatment, or exercise requiring manual therapy techniques by a trained individual
Types of 1) sham/placebo
Comparisons 2) no treatment or wait list
3) exercise plus another intervention vs. that same intervention
Types of Outcomes Included if used any one of ve of the primary outcome measures:
1) pain
2) function and disability (eg. Neck Disability Index, activities of daily living, return to work, sick leave)
3) patient satisfaction
4) global perceived effect
5) quality of life (e.g. SF-12)
When available: adverse events, cost of care
Timelines included:
 Immediate post treatment:  one day
 Short term follow-up: one day e 3 months
 Intermediate-term follow-up: 3 monthse1 year
 Long-term follow-up:  1 year

Key: CGH cervicogenic headache; F female, M male; MND mechanical neck disorder; RCTs randomized controlled trials; WAD whiplash associated disorder.

than 10% of the Visual Analog Scale (VAS), medium when between
10% and 20%, and large when it was 20%e30%. For the Neck
Disability Index (NDI), we used an MCID of 7/50 units (MacDermid
et al., 2009). For other outcomes we used the hierarchy of Cohen
(1988): small (0.20), medium (0.50) or large (0.80). Risk ratios
(RR) were calculated for dichotomous outcomes. The Number
Needed to Treat (NNT) was calculated. Assessment of heterogeneity
was tested using the Chi (Hoy et al., 2014) method and I2 method. In
the absence of heterogeneity (p > 0.10), we calculated a pooled
SMD, Mean Difference or RR.
3. Results
We identied 5658 records and found 27 trials that used exer-
cise treatment. The results presented are an abridged version of our
Cochrane review update (Kay et al., 2015); refer to it for full details.
We used the quadratic weighted Kappa (Kw) statistic to assess
agreement on a per question basis (Kw 0.23e1.00). Each risk of bias
item is presented as a percentage across all included studies (See
Fig. 2).

3.1. Effects of interventions: chronic mechanical neck pain

2.3. Data synthesis

3.1.1. Support element

We assessed the quality of the evidence using the Grading of

Recommendations, Assessment, Development and Evaluation
(GRADE) approach (Guyatt et al., 2006). Domains that may have
decreased the quality of the evidence are: 1) study design, 2) risk of
bias, 3) inconsistency of results, 4) indirectness (not generalisable),
5) imprecision (insufcient data), other factors (e.g. reporting bias)
(Higgins and Green, 2008).
3.1.1.1. Breathing OR cardiovascular/aerobic training. There is low
quality evidence that diaphragmatic breathing (Hallman et al.,
2011) and general tness training (Andersen et al., 2008; Sogaard
et al., 2012) may have no effect on pain, function and QoL when
compared to no treatment controls for chronic mechanical neck
pain and (sub)acute/chronic neck pain respectively.
28 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

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

3.1.2. Base element
3.1.2.1. Stretching. Cervical Stretch/ROM Exercises Another Inter-
vention versus That Same Intervention: There is low quality evidence
(one trial (Allan et al., 2003), 16 participants) that neck stretching
exercises, either before or after a manipulation, made no difference
on pain and function when compared with that same manipulation
for chronic neck pain immediately post treatment.
Cervical Stretch/ROM Exercises Dynamic Cervical Stabilisation
versus Sham: Low quality evidence (one trial (Kjellman and Oberg,
2002), 50 participants) shows no difference on pain and function
immediately post intervention, at six and 12-month follow-up
using cervical movement exercises (McKenzie protocol) contrasted
with sham ultrasound for chronic MND.
3.1.2.2. Strengthening. Static Cervical Strengthening Static Stabili-
sation versus No Intervention or Wait List: Two trials (three com-
parisons) studying chronic neck pain compared manually (1)
resisted isometric neck exercise plus postural training with mirror
feedback to a control, (2) these same isometric neck exercises and
the use of an orthopaedic pillow compared with the use of an or-
thopaedic pillow (Helewa et al., 2007) or (3) isometric exercise
alone against no intervention or control (Goldie and Landquist,
 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45 29

Fig. 2. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

1970). Evidence of benet showed people may improve slightly
when exercise was added to a pillow versus a pillow alone
(NNT 9). However, this was not observed when isometric exercise
alone was evaluated for function and quality of life, from immedi-
ately post treatment to short-term follow-up. Low quality evidence
(one trial (Goldie and Landquist, 1970), 47 participants) supports
improvement of GPE favouring isometric exercise immediately post
treatment. A clinician may need to treat three people to achieve this
type of benet in one person.
Postural Exercise versus Control: There is very low quality evi-
dence for postural exercise versus control, Cervical/Scapulothoracic
Strengthening Endurance Training versus Control, and neuro-
muscular exercise another intervention versus that same inter-
vention (See Gross et al., 2015 for greater details).
Scapulothoracic Upper Extremity Strengthening versus Control:
Three trials (Andersen et al., 2008, 2012; Dellve et al., 2011), each
with different dosages, compared specic strength training of the
scapulothoracic region and upper extremity with a reference
intervention Fig. 3. There is moderate quality evidence [three trials
(Andersen et al., 2008, 2012; Dellve et al., 2011), 157 participants;
SMD pooled
0.71 (95%CI:
1.33 to
0.10)] that scapulothoracic
and upper extremity strength training probably improves pain
moderately to a large amount immediately post treatment and at
short-term follow-up. It may improve functional outcomes when
compared to a control at short-term follow-up.
3.1.2.3. Stretch and strengthening. Cervical/upper extremity Stretch/
ROM Exercise Cervical/upper extremity Strengthening Dynamic
Cervical Stabilisation versus Placebo or Sham: Low quality evidence
(one trial (Kjellman and Oberg, 2002), 50 participants) shows no
difference for pain relief and function immediately post interven-
tion, at 6 and 12 months follow-up when general exercises
including neck and shoulder ROM, active neck endurance and
strengthening exercises is contrasted against sham ultrasound for
chronic MND.
Cervical Stretch/ROM Exercises Cervical/Scapulothoracic
Strengthening Static/Dynamic Cervical/Shoulder Stabilisation versus
Wait List: Moderate quality evidence [two trials (von Trott et al.,
2009; Rendant et al., 2011), 147 participants, MD pooled
10.94
(CI 95%
18.81 to
3.08)]; Fig. 4) shows a standardised exercise
program for neck pain including repeated active cervical rotations,
strengthening and exibility exercises compared to a wait list
probably has benecial effect for pain and function, but not GPE and
quality of life immediately post treatment and at short-term
follow-up. A clinician may need to treat four people to achieve a

Fig. 3. Forest Plot of comparison: Scapulothoracic upper extremity strengthening versus control.
30 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45
Fig. 4. Forest Plot of comparison: Cervical stretch/ROM exercises cervical/scapulothoracic strengthening static/dynamic cervical/shoulder stabilisation versus wait list.
moderate degree of pain relief and ve to achieve moderate func-
tional benet in one person.
Cervical/upper extremity Stretch/ROM Exercises Cervical/
Scapulothoracic upper extremity Strengthening Dynamic/Static
Cervical Stabilisation Another Intervention versus That Same
Intervention: Four trials studying chronic neck pain compared the
following exercise interventions with a control group:
 deep neck exor retraining with pressure biofeedback and
resisted neck exion/extension strengthening using multi-
cervical rehabilitation unit (Chiu et al., 2005);
 low technology exercise including progressive resisted neck and
upper body strengthening using dumbells and pulley systems,
light stretching and a short aerobic warm-up program (Bronfort
et al., 2001a);
 muscle stretching and strengthening exercises of the neck and
upper limb regions including strengthening of the deep cervical
exor muscles (Franca et al., 2008);
 a home exercise program of ROM, stretching/mobilisation and
strengthening exercises of the cervical and upper thoracic spine
(Martel et al., 2011).
For pain outcomes, we found consistent evidence for reduced
pain immediately post treatment (Bronfort et al., 2001a; Chiu et al.,
2005; Franca et al., 2008; Martel et al., 2011), at intermediate-term
and long-term follow-up (Bronfort et al., 2001a). This suggests
Fig. 5. Forest Plot of comparison: Cervical/upper extremity stretch/ROM exercises cervical/scapulothoracic upper extremity strengthening dynamic/static cervical
stabilisation another intervention versus that same intervention.
small treatment benets initially but larger benets in the long
term. For function outcomes, there was evidence of benet for
function immediately post treatment, at intermediate (Bronfort
et al., 2001a; Chiu et al., 2005; Franca et al., 2008) [SMD
pooled
0.45 (95% CI:
0.72, to
0.18); Fig. 5] and long-term
(Bronfort et al., 2001a) follow-up. In conclusion, moderate quality
evidence (four trials (Bronfort et al., 2001a; Chiu et al., 2005; Franca
et al., 2008; Martel et al., 2011), 341 participants) shows moderate
pain relief and improved function up to long-term follow-up for
combined cervical, scapulothoracic stretching and strengthening
for chronic neck pain. A clinician may need to treat six to 18 people
to achieve this type of pain relief and four to 13 to achieve this
functional benet. Changes in GPE measures indicate a difference
immediately post treatment and at long-term follow-up.
3.1.2.4. Stretching and endurance training.
Cervical/Scapulothoracic/upper extremity Stretch upper extremity
Endurance Training versus No Intervention: Moderate quality evi-
dence (one trial (Viljanen et al., 2003), 393 participants), shows
little to no difference for upper extremity stretching and endurance
training compared to ordinary activity for chronic neck pain and
function immediately post treatment, at short-term and long-term
follow-up.
3.1.2.5. Strengthening and endurance training.
Cervical/Scapulothoracic Strengthening Endurance Training versus
 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45
Control: Very low quality evidence (one trial, 68 participants (Ang
et al., 2009)) shows we are uncertain whether cervical/scap-
ulothoracic strengthening and endurance-strength exercises im-
proves the prevalence of neck pain in chronic neck pain at
immediately post treatment and at long-term follow-up.
Pattern synchronisation and cervical/scapulothoracic strength-
ening and scapulothoracic endurance versus Control: Low quality
evidence (one trial (Lange et al., 2013), 55 participants) shows deep
neck exor recruitment combined with upper extremity strength-
ening/endurance exercises may have little difference on pain
immediately post treatment when compared to a control.
3.1.2.6. Endurance training. Scapulothoracic/UE Endurance Training
versus Control: Moderate quality evidence (one trial (Andersen
et al., 2011a), 198 participants (Andersen et al., 2011a)) shows a
medium benecial effect size for pain relief immediately post
intervention when using shoulder abduction endurance training
for 2 min or 12 min with a control group for (sub)acute/chronic
MND. A clinician may need to treat four people to achieve this type
of pain relief in one person.
3.1.3. Modulator elements
Neuromuscular Exercise (eye-neck coordination/
proprioception) Another Intervention versus That Same Interven-
tion: Very low quality evidence (one trial (Revel et al., 1994), 60
participants) shows a moderate reduction in pain and improved
function in chronic neck pain in the short-term for eye-neck co-
ordination exercises. A clinician may need to treat four people to
achieve this type of pain relief and three to achieve this functional
benet in one person.
Patterns synchronisation Feedforward/feedback exercises for
coordinating the neck, eyes and upper limbs versus No Intervention:
Low quality evidence (one trial (Humphreys and Irgens, 2002), 56
participants) shows eye-neck-upper limb coordination exercises
show little or no difference in pain immediately post treatment
when contrasted with no intervention for people with chronic neck
pain.
Patterns synchronisation Feedforward/feedback: vestibular
rehabilitation (balance on unstable surfaces and walking with head
movements and eyes closed) versus No Intervention: Low quality
evidence (one trial (Hansson et al., 2013), 29 participants) shows
vestibular rehabilitation type exercises may have little or no dif-
ference from no intervention for neck pain both immediately post
treatment and at short-term follow-up.
3.1.4. Base modulator elements support
Trunk and Extremity Stretch Pattern/Synchronisation: Balance
Coordination Cardiovascular/Aerobic versus No Intervention: Low
quality evidence (one trial (Takala et al., 1994), 44 participants)
shows little to no difference for pain reduction immediately post
treatment in patients with neck pain of unspecied duration when
treated with group exercise that combined stretching and coordi-
nation exercises with cardiovascular training.
General Endurance Training Dynamic/Static Lowback/pelvic
Stabilisation General Stretching Neuromuscular/body Mechanics
Movement Training versus No Intervention: Low quality evidence
(one trial (Lundblad et al., 1999), 38 participants) shows little to no
difference for pain reduction with a combined exercise approach of
stabilisation of the low back and pelvis, posture awareness, ergo-
nomic training, and strength, coordination, endurance, exibility/
smoothness and rhythm exercises when compared to no inter-
vention or a wait list control in chronic neck pain at short-term
follow-up.
31
3.1.5. Base cognitive/affective element
Stretch/ROM Endurance Training Dynamic
Stabilisation Cognitive (mindfulness & emotional balance) versus
Wait List: Two trials (Rendant et al., 2011; von Trott et al., 2009)
compared a program of Qigong exercises (Dantian Qigong). There
was evidence of reduced pain and function post treatment at 12
weeks [MD pooled (pain)
13.28 (
20.98 to
5.58)j [SMD pooled
(function)
0.36 (
0.68 to
0.03)] and 24 weeks [MD pooled
(pain)
7.82 (
14.57,
1.07) j SMD pooled (function)
0.28 (
0.68
to 0.11)] of treatment. For quality of life, there was evidence of
benet for SF36 physical component immediately after 12 weeks of
treatment, but not after 24 weeks. In conclusion, moderate quality
evidence (two trials (Rendant et al., 2011; von Trott et al., 2009), 191
participants) shows Dantian Qigong exercises may improve pain
and function slightly when compared with a wait list control at
immediate and short-term follow-up. It may have little or no
benet at immediate and short-term follow-up on QoL and GPE. A
clinician may need to treat four to six people to achieve this type of
pain relief, ve to eight people to achieve this functional benet,
and seven to 10 people for this improvement QoL.
3.1.6. Base modular cognitive affective support
Stretch/ROM Strength and Endurance Training (trunk and
limb) Pattern/Synchronisation: Balance
Coordination Cardiovascular/Aerobic Cognitive
(Coaching Motivational) versus that Same Intervention: Low quality
evidence (one trial (Stewart et al., 2007), 132 participants) shows
small benets for pain relief, function, GPE and quality of life
immediately post treatment and small benet at 12 month follow-
up for function when an individualised, progressive submaximal
program, which included aerobic training, trunk and limb exercises
and advice is compared with advice alone for subacute/chronic
WAD.
3.2. Effects of interventions: acute to chronic cervicogenic headache
3.2.1. Base element
Stretch/ROM exercises versus Sham: Low quality evidence (one
trial (Hall et al., 2007), 32 participants) shows people may improve
a large amount for pain at short and long-term follow-up with the
use of C1-C2 self-SNAG exercises when compared with a sham for
(sub)acute cervicogenic headache. A clinician may need to treat
three people to achieve this type of long-term pain relief.
3.2.2. Base and modular element
Cervical/Scapulothoracic Strengthening with Endurance
Training Craniocervical Pressure Biofeedback Dynamic Cervical
Stabilisation versus No Intervention: Moderate quality evidence (one
trial (Jull et al., 2002), 97 participants) shows cervicoscapular
strengthening and endurance exercises including pressure
biofeedback improves pain, function and GPE for chronic cervico-
genic headaches at long-term follow-up when compared to no
treatment. A clinician may need to treat six people to achieve this
type of pain relief and functional benet in one person.
Cervical/Scapulothoracic Strengthening with Endurance
Training Craniocervical Pressure Biofeedback Dynamic Cervical
Stabilisation Manual Therapy versus Manual Therapy: Moderate
quality evidence (one trial (Jull et al., 2002), 96 participants) shows
when endurance exercises including pressure biofeedback plus
manual therapy for the cervicoscapular region is contrasted with
manual therapy alone there is probably no difference in pain,
function and GPE for chronic cervicogenic headaches at long-term
follow-up.
32 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45
3.3. Effects of interventions: acute radiculopathy
3.3.1. Base element
3.3.1.1. Stretching and strengthening. Cervical Stretch/
ROM Cervical/Scapulothoracic/UE Strengthening Static/Dynamic
Cervical Stabilisation versus Wait List: There is low quality evidence
(one trial (Kuijper et al., 2009), 133 participants) showing cervical
mobilisation and stabilisation exercises may improve pain slightly,
but may make no difference in function and patient satisfaction
when compared with a control immediately post treatment for
acute cervical radiculopathy. However, there may be no difference
in pain and functional improvement at intermediate-term follow-
up.
3.4. Adverse events
Sixteen of the 27 trials (Revel et al., 1994; Takala et al., 1994;
Lundblad et al., 1999; Humphreys and Irgens, 2002; Kjellman and
Oberg, 2002; Viljanen et al., 2003; Hall et al., 2007; Andersen
et al., 2008; Ang et al., 2009; Kuijper et al., 2009; Dellve et al.,
2011; Hallman et al., 2011; Andersen et al., 2012; Beer et al.,
2012; Hansson et al., 2013) did not report on adverse events; six
trials (Allan et al., 2003; Chiu et al., 2005; Helewa et al., 2007;
Franca et al., 2008; Martel et al., 2011; Lange et al., 2013) found
patients did not report any adverse events; six studies (Bronfort
et al., 2001b; Jull et al., 2002; Stewart et al., 2007; von Trott et al.,
2009; Rendant et al., 2011; Andersen et al., 2011a) reported self-
limiting side effects such as headache, neck, shoulder or thoracic
pain or worsening of symptoms.
4. Discussion
4.1. Summary of main results
Limiting the eligible trials to those with single interventions that
compared exercise with a control or comparative group maximized
the opportunity to evaluate the treatment effect of exercise in-
terventions. Moreover, having selected a priori an exercise classi-
cation system allowed us to use a clinical rationale for selecting
studies with similar interventions for interpretation and inclusion
within meta-analyses, particularly for the outcomes of pain and
function. Although there were only 28 studies eligible for this
systematic review, these two new strategies provided greater
clarity in our conclusions about the effectiveness of exercise ther-
apy. In summary, for moderate quality evidence there is still un-
certainty about the effectiveness of exercise for neck pain;
moderate grade evidence suggests there may be:
 a small benecial effect on chronic mechanical neck pain with
the use of scapulothoracic and upper extremity endurance
training immediately post treatment.
 a small improvement in chronic mechanical neck pain and
function with the use of Qigong (stretch, endurance, dynamic
stabilization exercises combined with cognitive exercises
emphasizing mindfulness and emotion) immediately post
treatment and at short-term follow-up. There may be little to no
difference in quality of life and general perceived effect mea-
sures with the use of qigong exercises.
 a large benecial effect on pain in cervicogenic headaches when
combining the use of static and dynamic cervical, scap-
ulothoracic strengthening and endurance exercises including
pressure biofeedback immediately post treatment and probably
improves pain moderately in cervicogenic headaches at long-
term follow-up. There was also a moderate benecial effect on
function immediately post treatment and at long-term follow-
up.
 a small or no difference in chronic neck pain and function with
the use of cervical, scapulothoracic and upper extremity
stretching and endurance training both immediately post
treatment as well as short- and long-term follow-up.
4.2. Overall completeness and applicability of evidence
Many studies had an incomplete description of exercise details.
In general, there is limited evidence (Bronfort et al., 2001b; Jull
et al., 2002) on optimal dosage requirements for exercise thera-
pies, and other modalities used to treat neck disorders. The
magnitude of effect and clinical applicability showed benets that
outweigh any transient and minor side effects. The use of primarily
self-reported outcome measures carries an inherent bias and may
overestimate the magnitude of effect.
4.3. Quality of the evidence
One of the major methodological difculties is blinding of
therapists and patients. None of the trials in this review blinded the
care provider. The use of self-reported outcome measures makes
the patient the outcome assessor and blinding cannot be achieved
easily. Two of the 28 trials did blind the outcome assessor and
therefore, blinding can be obtained for certain outcomes. Other
issues include compliance (reducing the treatment effect), co-
intervention (increasing the treatment effect and reducing the
magnitude of effect in the control group) and contamination
(reducing the magnitude of effect). Twelve of the 28 studies had
acceptable compliance, and eight of 28 monitored co-interventions.
Adequate randomisation is crucial; however, adequate sequence
generation was evident in only 46% (13/28) of the trials. Ninety-six
per cent (27/28) of the clinical trials contained small sample sizes
(<70 per arm analysed). Risk of random error can be reduced if
future trials increase precision through trials with adequate sample
size.
4.4. Potential bias in the review process
The validity of any systematic review is dependent on the se-
lection of all relevant studies. Although studies published in any
language were accepted, many scientic journals in non-English
languages are not indexed in MEDLINE and Embase. We did not
search non-English databases, which may have introduced lan-
guage bias in the review. Studies without a control or comparative
group were excluded so that exercise treatment effectiveness and
efcacy could be properly ascertained (Carroll et al., 2008). This
review contains only published studies therefore publication bias
was not guarded against.
5. Conclusions
5.1. Implications for practice
This review shows that effectiveness of exercise for neck pain is
lacking high quality evidence. The use of specic strengthening
exercise as a part of routine practice is supported by moderate
quality evidence for chronic neck pain and cervicogenic headache
and by low quality evidence for cervical radiculopathy. Strength-
ening exercises combined with endurance or stretching exercises
may also yield similar benecial results. However, low quality ev-
idence shows minimal benecial effects when only stretching or
endurance type exercises were used for the cervical,
 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45 33

scapulothoracic and shoulder regions. Low quality evidence sup- studies, quality assessment, or data extraction for the study for
ports the use of Self-SNAG exercises for cervicogenic headache. which he was author.

5.2. Implications for research

This update shows some positive ndings for using exercise for
neck pain, but further research is warranted because it is likely to
have an important impact on the effect estimate. Ongoing research
to increase sample size and to pool similar data is required to
further validate these ndings. Optimal dosage to reach efcacy
also needs to be explored. Use of prognostic and treatment-based
classication variables may aid in distilling which subgroups will
most benet from what specic exercise.
Funding
No funding was received for this update. Our reviews are sup-
ported through the generous volunteer work of our members from
various universities and learning institutes from around the world.
Acknowledgements
We thank the Cochrane Back and Neck Group, the Cervical
Overview Group, Bruce Craven, Western University student
research groups for their contribution to this document. Dr. Craven
was instrumental in directing us to the exercise classication
framework that was used as our foundation within this review. This
is one review of a series conducted by the Cervical Overview Group:
Gross A, Goldsmith C, Graham N, Santaguida PL, Burnie S, Forget M,
Rice M, Miller J, Peloso P, Kay T, Kroeling P, Trinh K, Langevin P, Patel
K, Haines T, Haraldsson B, Radylovick Z, Szeto G, LeBlanc F, Ezzo J,
Morien A, Cameron I, Wang Z, Lilge L, White R, Bronfort G, Hoving J,
Gelley G, Lalonde P.

Conict of interest
Appendix 1. Characteristics of the Included Studies
Gert Bronfort is the rst author of one of the trials included in
this systematic review. He was not involved in the selection of

Study/Participants Interventions Outcomes

Allan et al., 2003 INDEX TREATMENT PAIN (NRS 0 to 100)

Chronic MND (Myofascial Pain Arm 1 e a. Stretch before Manipulation: Activity e Static passive Baseline Mean: Manipulation 30, Stretch before 58, Stretch After
Syndrome) stretches into Movement e lateral exion and rotation on both 63
sides of neck, held for 15 s; Mode e administered by Reported Results: no signicant difference between groups
chiropractor with patient in supine position, immediately FUNCTION (NDI 0 to 50)
followed by cervical manipulation given in accordance with the Baseline Mean: Manipulation 5, Stretch before 16, Stretch After
motion palpation ndings. Manipulation was administered with 11
patient in supine position and the chiropractor making an index Reported Results: no signicant difference between groups
enger contact on the affected cervical segment(s); Dosage e 8 SIDE EFFECTS: none
sessions over 4 weeks, COST OF CARE: NR
b. Cervical manipulation given in accordance with the motion
palpation ndings. Manipulation was administered with patient
in supine position and the chiropractor making an indexenger
contact on the affected cervical segment(s) immediately
followed by static passive stretches in lateral exion and rotation
on both sides of neck, held for 15 s, administered by chiropractor
with patient in seated position;
Arm 2 e a. Stretch after Manipulation: Stretches as in Arm 1 was
administered after manipulation treatment.
b. Cervical manipulation administered as in Arm 1.
Treatment Schedule: 8 sessions over 4 weeks
COMPARISON TREATMENT
Arm 3 e Manipulation: Cervical manipulation given in
accordance with the motion palpation ndings. Manipulation
was administered with patient in supine position and the
chiropractor making an indexenger contact on the affected
cervical segment(s); 8 sessions over 4 weeks.
Treatment Schedule: 4 weeks, 20 sessions
Duration of Follow-up: none
CO-INTERVENTION: avoided in trial design
Andersen et al., 2008 and Sogaard INDEX TREATMENT PAIN intensity in trapezius muscle (VAS 0 to 100)
et al., 2012 Arm 1 e Specic Strength Training (SST) or General Fitness Baseline Mean: SST 44, GFT 50, Reference 43
(sub) Acute/Chronic MND (Trapezius Training (GFT): Activity e SST: high intensity specic strength Reported Results: no signicant difference between groups
Myalgia) training locally for neck and shoulder muscles. GFT: Cycling SMD immediate post: 0.18 (95%CI:
0.67 to 1.03)
high-intensity general tness training with legs only, upright SMD ST:
0.06 (95% CI:
0.91 to 0.79)
position without holding onto the handlebars (relaxing REASON FOR DROP-OUTS: 6 in Reference group, reason not
shoulders during training); Mode e SST: 5 dumbbell exercises. specied
GFT: Monark bicycle ergometer; Movement e SST: single arm SIDE EFFECTS: NR
row, shoulder abduction, shoulder elevation, reverse ies, and COST OF CARE: NR
upright row).Training program progressively increased using the
principles of periodisation and progressive overload from 12
repetitions maximum (~70% of maximal intensity) at beginning
to 8 repetitions maximum (~80% of maximal intensity) later.
GFT: high-intensity cycling; Dosage e SST: performed using
(continued on next page)
34
(continued )
Study/Participants
Andersen et al., 2011a,b; Andersen, INDEX TREATMENT
2011
(sub) Acute/Chronic MND (Myofascial resistance training with theraband. Mode e Shoulder;
Pain Syndrome/Cervicogenic
headache/tension type headache) week for 10 weeks of intervention for an average of 26 3.6
Andersen et al., 2012
Non specic neck pain
Ang et al., 2009
Chronic MND (Mechanical Neck Pain Arm 1 e Exercise Group: Activity e Patterns and
& Myofascial Pain Syndrome)
A.R. Gross et al. / Manual Therapy 24 (2016) 25e45
Interventions Outcomes
consecutive concentric and eccentric muscle contractions
(raising and lowering pair of dumbbells) in a controlled manner
without pause, each set lasting 25e35 s 30 of 5 different
exercises with 3 sets per exercise were performed during each
training session in an alternating manner (shoulder elevation
was performed during each session). Doubled training load by
end of 10 weeks. 20 min, 3/week for 10 weeks of intervention
for an average of 26 3.6 sessions GFT: 20 min at a relative
workloads of 50% (initial training level) to 70% (increased during
following weeks and maintained) of maximal oxygen uptake
(V02 max). Heart rate monitor (Polar Sport Tester, Polar, Kempele,
Finland) used to adjust workload to meet the intended relative
level.
Treatment schedule: SST: Doubled training load by end of 10
weeks. 20 min 3 times/week for 10 weeks of intervention for an
average of 25 4.8 sessions. GFT: 20 min 3 times/week for 10
weeks.
COMPARISON TREATMENT
Arm 2 e Health Counselling Group: Lectures with information
on activities promoting general health and individual: workplace
ergonomics, diet, health, relaxation, and stress management. 1 h
per week for 10 weeks for an average of average 27 2.8 sessions
Treatment Schedule: 10 weeks, 20 sessions
Duration of Follow-up: 10 weeks
CO-INTERVENTION: Not avoided
COMPARISON TREATMENT
Reference intervention without physical activity: Activity e the
participants received health counselling on group and individual
levels regarding workplace ergonomics, diet, health, relaxation,
and stress management, frequency: 3 per week. Dosage e 20-
min sessions
Treatment Schedule: 30 sessions over 10 weeks
Duration of Follow-up: none
CO-INTERVENTION: Not specied
PAIN (VAS 0 to 10)
Arm 1 e 2 min training (2-min): Activity e Progressive Baseline Mean: 2 min 3.5, 12 min 3.9, Control 3.5
Reported Results: ANOVA showed a strong group-by-time effect
Movement e abduction- lateral raise. Dosage: 2 min, 5 times/ for neck/shoulder pain intensity (p < 0.0001). Compared with the
control group, pain intensity decreased in both training groups.
sessions This change was not signicantly different between the 2
Arm 2 e 12-min training: Activity e Progressive resistance training groups.
training with theraband. Mode e Shoulder; Movement e SMD (2-min):
0.66 (95% CI:
1.02 to
0.30)
abduction- lateral raise; Dosage e 12- minutes 5 times/week for SMD (12-min):
0.59 (95% CI:
0.94 to
0.23)
10 weeks of intervention for an average of 25 4.8 sessions REASON FOR DROP-OUTS: 3 in 2- minutes group, 1 in 12-
COMPARISON TREATMENT minutes group, 2 in control group, reasons reported
Arm 3 e Control Group: Weekly e-mailed information on various SIDE EFFECTS: Reported worsening of neck muscle tension
aspects of general health and internet links with additional during and/or in the days after training (2-min n 1, 12-
relevant information min n 4), shoulder joint pain during training (2-min n 1, 12-
Treatment Schedule:10 weeks, 20 sessions min n 4), pain in the upper arm during training (2-min n 1,
Duration of Follow-up: 10 weeks 12-min n 1), pain of the forearm/wrist during training (12-
CO-INTERVENTION: Not avoided min n 2), worsening of headache after training (2-min n 1,
12-min n 1). No long-lasting or major complications resulted
from the training program.
COST OF CARE: NR
INDEX TREATMENT PAIN (Modied Nordic Questionnaire 0e9)
Arm 1 e Training groups (WS): Activity e Upper extremity Baseline Mean: 1-WS 4.83, 3-WS 4.96, 9-WS (4.71), Reference
strength training; Mode e Weights. Movement e Dumbbell (4.83)
exercises front raise, lateral raise, reverse ies shrugs and wrist Reported Results: no signicant difference between groups
extension. Dosage e Type of contraction (dynamic); Intensity SMD (1-WS vs reference):
0.44 (95% CI:
1.31 to 0.43);
(20 repetition maximum at baseline to 8 repetition maximum at SMD (3-WS vs reference):
0.67 (95% CI:
1.59 to 0.25);
later phase); Speed (NR); Duration/Frequency (1-WS weekly SMD (9-WS vs reference):
0.30 (95% CI:
1.36 to 0.76)
session 1 h/week, 3-WS 20 min at 3 sessions/week, 9- FUNCTION Disability of the arm, shoulder and hand (DASH
WS 7 min at 9 sessions/week; Sequence (NR); Environment 0 to100)
(NR); Feedback (experienced instructor supervised every other Baseline Mean: 1-WS (16), 3-WS (18), 9-WS (15), Reference (16)
training session). Reported Results: no signicant difference between groups
Treatment Schedule: 20 weeks. SMD (1W-S vs reference):
0.17 (95% CI:
0.58 to 0.24);
COMPARISON TREATMENT SMD (3-WS vs reference):
0.23 (95% CI:
0.66 to 0.19);
Arm 2 e Reference group: No treatment SMD (9-WS vs reference):
0.06 (95% CI:
0.53 to 0.41)
Treatment Schedule: 20 weeks REASON FOR DROP-OUTS: NR
Duration of Follow-up: NR SIDE EFFECTS: NR
CO-INTERVENTION: NR COST OF CARE: NR
INDEX TREATMENT PAIN Prevalence during previous week
Baseline Mean (SD): Exercise 13 (38), Control 11 (32)
synchronisation of muscle recruitment, Endurance- Reported Results: In the exercise group, the prevalence of cases
Strengthening exercises, Mode e Progression from non-postural for the previous week and the previous 3 months decreased from
(supine, prone) low-load active craniocervical exion at 5 38%e15% and 76%e44% respectively, whereas in controls it was
 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45
(continued )
Study/Participants Interventions
pressure levels (22e30 mmHg), seated postural exercises with
active craniocervical exion and active scapular retraction.
Seated and standing elastic resistance, Movement e supine
craniocervical exion exercises, prone isometric shoulder/
scapular, seated active craniocervical exion with cervical
rotation to end range and simultaneous scapular retraction to
mid motion range, sitting controlled dynamic shoulder
retraction following a rowing exercise movement, dynamic
scapular retraction with weight load over long movement arms
in rowing exercises in regular pulls, emphasizing shoulder
retraction in the initial concentric phase and upright trunk
postures in the inner range, Dynamic neck rotation exercises in
upright posture against moderate resistance using elastic bands,
Dosage e Non- postural exercises-held isometrically (low load)
for 10 s, repeated 10 times. Postural (seated, isometric held at 5
pressure levels like supine, holding 10 s, repeated 10 times, neck
rotation to end range 3 sets repeated 10e15 times on each side.
Endurance-strength exercises 3 sets of 15 repetitions (elastic
bands were used to replicate the exercises at home). Feedback
The supervising physiotherapist monitored potential surface
exor activity visually, with palpation if necessary.
Treatment schedule: Assigned exercises (2e4) were to be
completed 2 times/day lasting 10e15 min, supervised weekly by
a physiotherapist providing instruction and manual guidance.
COMPARISON TREATMENT
Arm 2 e Control: No exercise, encouraged to continue with
ordinary exercise activity
Treatment Schedule: 6 weeks, instructed to do 2e4 exercises 2
times/day, for 10e15 min, supervised by physiotherapist weekly.
Duration of Follow-up: 12 months
CO-INTERVENTION: Not specied
Beer et al., 2012 INDEX TREATMENT
Persistent neck pain Arm 1 e Exercise group: Activity e Functional postural exercise.
Mode e Sitting. Movement e Assumes an upright posture in a
neutral lumbo-pelvic position and then gently lengthens the
cervical spine by imagining they are lifting the base of their skull
from the top of their neck. Dosage e concentric-isometric hold
with postural awareness, low intensity,10 s hold every 15
e20 min throughout the day for a total of 2 weeks, all sorts of
environment throughout their waking day, feedback was taught
initially but not reviewed during the 2 weeks
Treatment schedule: 2 weeks
COMPARISON TREATMENT
Arm 2 e Control group: Did not undertake any exercise
intervention during the study.
Treatment schedule: 2 weeks
Duration of Follow-up: NR
CO-INTERVENTION: participants in control group were
requested not to seek other treatment for their neck pain for the
2 weeks.
Bronfort et al., 2001a; Evans et al., INDEX TREATMENT
2002 Arm 1 e MedX Exercise (MedX): Activity e High technology
Chronic MND exercise, Mode/Movement e medically supervised
rehabilitative exercise. Dosage e 20 sessions over 3 months
Arm 2 e Manipulation and low tech Exercise (SMT/Ex): Activity
e Chiropractic manipulation, supervised low technology
rehabilitative exercise, Mode e progressive strengthening
exercises for the neck and upper body proceeded by a short
aerobic warm up of the upper body and light stretching,
Movement e the upper body strengthening exercises included
push ups and dumbbell shoulder exercises as described by
Dyrssen et al. (1989). Dosage e 45 min total, 2 sets of 15e30
repetitions, weight 2e10 lbs; cervical progressive resisted
strengthening exercises where performed while lying on a
therapy table with wearing head gear with variable weights from
1.25 lb to 10 lbs guided by a simple pulley system attached to the
table
Treatment Schedule: 20 sessions over 3 months
COMPARISON TREATMENT
Arm 3 e Spinal Manipulative (SMT): Chiropractic manipulation,
20 sessions over 3 months
Treatment Schedule: 11 weeks, 20 session
Duration of Follow-up: 12 months
CO-INTERVENTION: NR
35
Outcomes
unchanged.
RR (exercise vs control): 0.45 (95% CI: 0.18e1.14).
Between-group regression analyses revealed that the members
of the exercising group had a 3.2 times greater chance (odds
ratio) than the control group of having been pain-free during the
previous 7 days and a 1.9 times great chance (odds ratio) of
having been pain-free during the previous 3 months, P 0.01.
REASON FOR DROP-OUTS: 6 in Exercise Group, 6 in Control
Group, reasons reported
SIDE EFFECTS: NR
COST OF CARE: NR
PAIN (VAS 0 to 10)
Baseline mean: Exercise 3.0 Control 2.6
Reported results: no signicant
SMD (exercise vs control): 0.13 (95% CI:
0.74 to 1.01)
FUNCTION (NDI 0 to100)
Baseline mean: treatment 18.1 control 20.6
Reported results: no signicant
SMD (exercise vs control):
0.32 (95% CI:
1.21 to 0.56)
REASONS FOR DROP OUTS: NR
SIDE EFFECTS: NR
CUMULATIVE ADVANTAGE for six patient-oriented outcomes
Reported Results: favours SMT/Ex over SMT; MONOVA value
yielded a signicant group difference (Wilk's Lambda 0.85, F
(12,302) 2.2, P < 0.01)
PAIN (VAS 0 to 10)
Baseline Mean: SMT 56.6, MedX 57.1, SMT/Ex 56.0
Reported Results: group difference in patient-rated pain ANOVA
F (2,156) 4.2, P 0.02 favours the two exercise groups
SMD (SMT/Ex vs SMT) at LT follow-up:
0.21 (95% CI:
0.60 to
0.18); power 28%, NNTB 10; treatment advantage 15%
FUNCTION (NDI 0 to 50)
Reported Results: no signicant group differences were found
ANOVA: F (2, 156) 2.04, P 0.13
SMD (SMT/Ex vs SMT) at LT follow-up:
0.38 (95% CI:
0.78 to
0.01), power 28%, NNTB 11, treatment advantage 11%
HEALTH-RELATED QUALITY OF LIFE (SF-36 0 to 100)
Baseline mean: SMT 69.1, MedX 69.0, SMT/Ex 71.7
Reported Results: SMD at LT follow-up:
0.30 (95% CI:
0.69 to
0.09)
PATIENT SATISFACTION (scale 1 to 7 completely satised to
completely dissatised)
Reported Results: A clinically worthwhile cumulative advantage
was reported favouring manipulation/exercise (low tech) group
over exercise (high tech) and manipulation alone ANOVA: F (2,
158) 6.7, P 0.002
(continued on next page)
36 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

(continued )

Study/Participants Interventions Outcomes

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

Chiu et al., 2005
Subacute MND (Cervical Brachial Pain Arm 1 e Craniocervical Flexion and isometric neck
Syndrome)
Dellve et al., 2011
Chronic cervical neck pain or
cervicobrachial pain syndrome
Franca et al., 2008
Chronic MND (Myofascial Pain
Syndrome)
to
0.52)
PATIENT-RATED IMPROVEMENT (scale 1 to 9)
Reported Results: substantial improvement over time, ANOVA:
F (2, 174) 1.7, P 0.18
SMD (SMT/Ex vs SMT) at LT follow-up:
0.42 (95% CI:
0.81 to
0.03); power 44%
REASONS FOR DROP-OUTS: Reported
SIDE EFFECTS: increase neck or headache pain 8 SMT/Ex, 9
MedX, 6 SMT; increased radicular pain 1 SMT/Ex; severe thoracic
pain 1 SMT; all cases self-limiting and no permanent injuries;
RR (SMT/Ex vs MedX): 0.81 (95% CI: 0.23e1.55)
RR (SMT vs MedX): 0.61 (95% CI: 0.23e1.55)
COST OF CARE: NR
INDEX TREATMENT PAIN (VAS 0 to 10)
Baseline Mean: CCF 4.61, TENS 4.69, IR 4.26
strengthening (CCF): Reported Results: NS
Activity e deep neck exor strengthening, Infrared radiation; SMD (CCF vs IR):
0.34 (95% CI:
0.72 to 0.04); NNTB 6,
Mode e using pressure sensor @20 mmhg 10 min (10 s on/15 s treatment advantage 24%
off) Strengthening using a Multi Cervical Rehabilitation Unit FUNCTION Chinese version of Northwick Park Questionnaire (0
(MCRU). e4)
Movement/Dosage e 15 repetitions of exion, extension at 20% Baseline Mean: CCF 1.39, TENS 1.55, IR 1.36
of Peak Isometric Strength (PIS) as warm-up. Then dynamic Reported Results: CCF vs IR was signicant (p 0.02)
exion and extension with variable resistance  0 to 12 SMD (CCF v IR):
0.33 (95% CI:
0.71 to 0.05); NNTB 6, treatment
repetitions. advantage 16%
Treatment Schedule: 35 min of exercise per session REASON FOR DROP-OUTS: Reported
COMPARISON TREATMENT: SIDE EFFECTS: No complications occurred.
Arm 2 e Transcutaneous Electrical Nerve Stimulation (TENS): COST OF CARE: NR
30 min of dual channel portable TENS unit (ITO model 1302).
Continuous trains of 150 ms square pulse at 80 Hz. 4 Electrodes
(4  4cm).
Arm 3 e Control Group: Infrared radiation (IR): place on EX 21,
GB21, LI 11, intensity 2e3 times of participants sensory
threshold education on neck care
Treatment schedule: 20 min per session, 6 weeks, 2 sessions/
week
Duration of Follow-up: 6 months
CO-INTERVENTION: NS
INDEX TREATMENT PAIN (Numeric Pain Scale 0 to10)
Arm 1 e Myofeedback Training (MyoT): Activity e activities of Baseline Mean: MT 6.0, IMST 6.3, Control 6.2
daily living; Mode e wearing a myofeedback device; Movement Reported Results: no signicant difference between groups
e ergonomic adjustments; Dosage e Duration/Frequency SMD (IMST vs control) at immediate post-treatment:
0.30 (95%
-minimum of 8 h per week, typically 2 h per day and 4 days per CI:
0.92 to 0.33);
week;; Environment -various; Feedback -discussion with SMD (IMST vs control) at 2 months follow-up:
0.63 (95%
ergonomist once per week. CI:
1.27 to 0.00)
Arm 2 e Intensive Muscular Strength Training (IMST): Activity e FUNCTION (Work Ability Index 7 to49)
Upper extremity strength training Mode e resistance bands Baseline Mean: MT 19.3, IMST 19.0, Control 19.0
Movement e Exercises for strengthening and co-ordinating the Reported Results: no signicant difference between groups
upper extremities. Dosage e Type of contraction -NR; Intensity SMD (IMST vs control) at immediate post-treatment:
0.18 (95%
-NR; Speed -NR; Duration/Frequency
2 times per day, 6 days CI:
0.80 to 0.44);
per week for 4 weeks; Sequence -warm-up movements followed SMD (IMST vs control) at 2 months follow-up: 0.38 (95%
by strengthening exercises then ending with breathing and slow CI:
0.25 to 1.01)
down movements; Environment -participant's home; Feedback REASON FOR DROP-OUTS: 5 in MT Group, 7 in IMST Group, 1 in
-ergonomist coaching. Control Group, reasons reported
Treatment Schedule: 4 weeks SIDE EFFECTS: NR
COMPARISON TREATMENT COST OF CARE: NR
Arm 3 e Control Group: Diary entries to record activities,
discomfort, pain and sleeping disturbances
Treatment Schedule: 4 weeks
Duration of Follow-up: 2 months
CO-INTERVENTION: not avoided
INDEX TREATMENT PAIN (VAS 0 to 100)
Arm 1 e Physiotherapy protocol performed according to Hall Baseline Mean: PT Acup 85.0, Acup 80.0, PT 70.0
and Brody consisting of Activity estretching, strengthening; Reported Results: According to KWT (KruskaleWallis test), the
Mode e muscle stretching of neck and upper limbs regions; statistical analysis of the inter-groups demonstrated signicant
recruitment exercise of Deep Cervical Flexion Muscles; (p < 0.05) differences among the groups. The DMCT (Dunn's
Movement e strengthening exercise of Deep Cervical Flexion Multiple Comparison test) showed that G1 was superior to G3 in
Muscles and upper limbs. Duration of treatment 20 min, 1e2 pain improvement (p < 0.05)
times/week for 10 weeks. SMD (PT Acup vs Acup) at immediate post treatment:
0.73
Arm 2 e Acupuncture combined with Physiotherapy (G1) (95% CI:
1.46 to
0.00), treatment advantage 11%
Activity e Stage 1: acupuncture therapy based on the TCM FUNCTION (NDI e Brazilian/Portuguese version)
theory of biao-li (symptom/root) treatment;. Mode e Chinese Baseline Mean: PT Acup 24.0, Acup 30.0, PT 28.0
acupuncture, as the root treatment, was performed with a Reported Results: The DMCT (Dunn's Multiple Comparison test)
selection of body points by means of the diagnostic of syndromes showed that G1 was superior to G3 in reducing functional
of TCM. Movement e Disposable stainless steel needles disability (p < 0.0001)
(0.25 mm  30 mm) with guide-tubes (Dong-bang Acupuncture SMD (PT Acup vs Acup) at IT follow-up:
0.95 (95% CI:
1.70
Needle, Korea) inserted bilaterally into the body points to a to
0.20), NNTB13, treatment advantage 13%.
 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45 37

(continued )

Study/Participants Interventions Outcomes

depth of 10e15 mm. YNSA was carried out as the symptom REASONS FOR DROP-OUTS: Reported (3 drop-outs, 1 in each
treatment with a selection of the kinetic and ypsilon points as the group)
main scalp points to treat TNS. The kinetic points were SIDE EFFECTS: Reported; no record of serious complication of
stimulated bilaterally with needle measuring 0.25 mm x 5 acupuncture or physiotherapy occurred during treatments or
e15 mm (Dongbang Acupuncture Needle, Korea) to a depth of 1 during the follow-up period after any of the treatments that
e2 mm, whereas the selection of the ypsilon points were could harm the patients during the assessment all stages of the
ipsilateral of the scalp to the diagnosed side of the neck. All trial
acupoints (body and scalp points) were stimulated in an uneven COST OF CARE: NR
manner every 10 min to maintain the needling sen. Chinese
acupuncture was performed in 20 min and YNSA was maintained
until 40 min. Stage 2: Physiotherapy given simultaneously with
YNSA.
COMPARISON TREATMENTS:
Arm 3 e Acupuncture (G2): Same protocol of acupuncture
therapy as described in the rst stage of G1 for 20 min.
Arm 4 e Physiotherapy (G3): Same protocol of physiotherapy as
described in the second stage of G1 for 20 min.
Treatment Schedule: 10 weeks, 20 sessions
Duration of Follow-up: 6 months follow-up
CO-INTERVENTION: avoided in trial
Hall et al., 2007 INDEX TREATMENT PAIN Headache intensity change score (VAS 0 to 100)
(sub)acute Cervicogenic headache Arm 1 e C1-2 self -SNAG (SSng): Activity e Belt was used as per Baseline Mean: SSng 52 Mock 51
(CGH) Mulligans detailed techniques. Mode e The participant was Reported Results: group difference in patient-rated pain favours
instructed by the PT on the proper positioning and technique of the SSng exercise group
mobilisation belt on 3 trials to familiarize themselves. The SMD(SSng vs Mock) at ST follow-up:
1.58 (95% CI:
2.38
participant was instructed to perform technique without to
0.77); power 100%, NNTB 2, Treatment advantage 40%
producing pain. Movement e supplemental video available on SMD(SSng vs Mock) at LT follow-up:
1.74 (95% CI:
2.57
line to
0.91); power 100%, NNTB 3, treatment advantage 40%
Treatment schedule: 1 day REASONS FOR DROP-OUTS: NA
COMPARISON TREATMENT SIDE EFFECTS: NR
Arm 2 e Control group (Mock): Sham mobilisations with same COST OF CARE: NR
belt. This group did not receive instruction to rotate head
towards restriction.
Treatment Schedule: 1 day
Duration of Follow-up: 4 weeks and 12 months
CO-INTERVENTION: Not avoided
Hallman et al., 2011 INDEX TREATMENT PAIN (Borg Scale 0 to 10)
Stress-related chronic neck-shoulder Arm 1 e Practice paced breathing: Activity e breathing Baseline Mean: Treatment 2.6, Control 2.5
pain exercises; Mode e resonance heart rate variability (HRV) Reported Results: no signicant difference between groups
biofeedback (BF) training and paced breathing; Movement e SMD (treatment vs control):
0.19 (95% CI:
1.01 to 0.63)
respiration. Dosage e Type of contraction e concentric FUNCTION (NDI 0 to 100)
diaphragm concentrically contracts with this breathing exercise, Baseline Mean: Treatment 21.3, Control 25.6
intensity -low as was breathing exercises, On-site sessions: Reported Results: no signicant difference between groups
speed e Sessions 1 and 10: between 4.5 and 6.5 breaths per SMD (treatment vs control):
0.52 (95% CI:
1.35 to 0.32)
minute to determine speed with highest HRV. Sessions 2e9: QUALITY OF LIFE SF-36 (physical function subscale)
performed at speed of highest HRV, duration -Sessions 1 and 10: Baseline mean: Treatment 89.6, Control 77.5
2 min of paced breathing for 2 min of free, non-paced breathing. Reported Results: no signicant difference between groups
Sessions 2 to 9: 4 times 5 min of resonant HRV BF with 2- SMD (treatment vs control): 0.65 (95% CI:
0.19 to 1.49)
min breaks, frequency 1time/week, environment in which REASONS FOR DROP-OUTS: NR
exercise is performed e morning or afternoon is standardized in SIDE EFFECTS: NR
a comfortable semi-reclined chair semi-reclined, 23 Celsius, dim COST OF CARE: NR
light, relaxing atmosphere, feedback -(psychologist weekly
session.
Home exercise-program: at least 15 min of paced breathing with
watch or easy air pacer software, 5 times/week
Treatment schedule: 10 weeks
COMPARISON TREATMENT
Arm 2 e Control Group: This group took part in the breathing
protocol in sessions 1 and 10, without any prescribed treatment
in between.
Treatment schedule: week 1 and 10
Duration of Follow-up: Directly after 10 weeks
CO-INTERVENTION: Not specied
Hansson et al., 2013 INDEX TREATMENT PAIN (VAS 0 to 100)
WAD Arm 1 e Vestibular rehabilitation program: Activity e circuit Baseline Median: Intervention 60, Control 60
training of six balance exercises with warm-up and recovery Reported Results: no signicant difference between groups;
phases; Mode e static and dynamic balance exercises with neck SMD (6 weeks vs control) 6 weeks 0.07 (95% CI:
0.68 to 0.82);
movements, eyes opened and closed; Movement e Warm-up SMD (3 months vs control)
0.60 (95% CI:
1.35 to 0.15)
phase- walking around the room and changing direction as well REASONS FOR DROP-OUTS: reported
as turning the head from side to side. Exercises in standing, SIDE EFFECTS: NR
including training of co-ordination of movements. Circuit COST OF CARE: NR
training- Standing up and sitting down on a chair while turning
the head from side to side. Eyes closed if possible. Standing on a
trampoline, eyes closed and slightly exing the knees and
turning the head from side to side simultaneously. Standing on a
(continued on next page)
38 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

(continued )

Study/Participants Interventions Outcomes

10 cm foam with eyes closed and turning the head from side to
side. Standing on a sport mat, walking on the spot and turning
the head from side to side. Eyes closed if possible. Sitting on a
ball, feet on foam, eyes closed and bouncing slightly while
turning the head from side to side. Walking forward and
backward while turning the head from side to side. Recovery
phase- Soft, relaxing movements. Stretch of the muscles in the
upper cervical region. Dosage e Warm-up duration- 10 min.
Circuit training duration- 2- minutes per exercise, 2 laps.
Recovery phase duration- 5 min. Frequency
2 times/week,
environment in which exercise is performed -physical therapy
centre, feedback -supervised group sessions.
Treatment Schedule: 6 weeks, 12 sessions
COMPARISON TREATMENT
Arm 2 e Control Group: no intervention
Treatment Schedule: 6 weeks
Duration of Follow-up: 6 weeks and 3 months
CO-INTERVENTION: reported and not avoided
Helewa et al., 2007 INDEX TREATMENT PAIN (VAS 0 to 10)
Chronic MND Arm 1 e Exercise: Activity eStandard Pillow Exercise Active Baseline Mean: Exercise 2.9, Pillow 3.6, Exercise Pillow 2.3,
Control Treatment Group: Standard (regular) pillow is assumed Control 2.5
to be used by this group. Mode e Exercise including: Posture, Reported Results: Not signicant at all points
Relaxation, Active Movement e 1-Postural correction in sitting, SMD (exercise vs control):
0.00 (95% CI:
0.52 to 0.52)
standing or during work and leisure activities emphasizing chin SMD (exercise pillow vs pillow):
0.59 (95% CI:
1.09
in retracted position with cervical spine elongations not beyond to
0.09); power 50.69%
normal curves of cervical spine practised with mirror feedback FUNCTION Northwick Park Neck Pain Questionnaire (NPQ 0 to
rst, then freely using other prompts to become habitual, 2- 100)
Relaxation Exercise Techniques designed to interrupt cycle of Baseline Mean: Exercise 32.3, Pillow 35.01, Exercise Pillow
pain and muscle spasm (hold-relax approach repeated up to 5 29.9, Control 27.4
times and/or rhythmic stabilisation applied manually by the PT Reported Results: Interaction of pillow and exercises are
and taught to the patient), 3-Free Active Exercise (following statistically signicant and clinically important
relaxation techniques patients freely move head and neck SMD (exercise vs control): 0.00 (
0.52 to 0.52); power 100%
according to normal patterns of movement, may initially be SMD (exercise pillow vs pillow):
0.61 (
1.11 to
0.12);
helped by the physiotherapists, patterns are diagonal and power 100%
involve head exion and rotation to the right followed by head QUALITY OF LIFE (SF 36 0 to 100)
extension and rotation to the left, diagonal patterns are then Baseline Mean: Exercise 42.8, Pillow 41.1, Exercise Pillow 43.7,
repeated to the contralateral sides), and 4- Strengthening Control 43.8
Exercises (to strengthen the anterior neck muscles using manual Reported Results: no signicant difference between groups
resistance (within the limit of pain) with a combination of SMD (exercise vs control): 0.15 (95% CI:
0.34 to 0.65); power
isometric and isotonic movements, the principle involving 100%
reversing movements of exion and extension, using the SMD (exercise pillow vs pillow):
0.46 (95% CI:
0.95, to
principles of successive induction (Sherrington, 1961). Dosage e 0.04); power 100%
13 sessions over 10 weeks, as well as home exercises and Active REASON FOR DROP-OUTS: Reported
Control treatment (massage and thermal modality) were SIDE EFFECTS: None present
administered to this group isometric rehabilitative exercise. COST OF CARE: NR
Arm 2 e Neck Support (Pillow): Activity e Orthopaedic
Pillow(s) Active Control Treatment Group: Mode e Neck
Support Pillows Movement e could be one of two designs:
Shape of Sleep pillow (Manutex Products, Mississauga, ON,
Canada) or the Sissel Design AB pillow (Sissel Design AB, Svedala,
Sweden). The two types of pillows were randomly assigned
equally in each arm. The pillows did not differ in shape but in the
rmness of the foam. The pillow use was combined with the
Active Control treatment (massage and thermal modality).
COMPARISON TREATMENT
Arm 3 e Neck Support and Exercise (Exercise Pillow):
Orthopaedic Pillow(s) Exercise Active Control Treatment:
Orthopaedic pillows were used and were of two types: Shape of
Sleep pillow (Manutex Products, Mississauga, ON, Canada) or the
Sissel Design AB pillow (Sissel Design AB, Svedala, Sweden). The
two types of pillows were randomly assigned equally in each
arm. The pillows did not differ in shape but in the rmness of the
foam. Pillow use, plus Exercise plus Active control treatment
(massage and thermal modality) were administered in this
group.
Arm 4 e Massage Therapy and thermal modality (Control):
Standard (regular) Pillow Active Control Group: The Standard
(regular) pillow is assumed to be used by this group. Active
Control treatment that included massage and thermal modality,
Efeurage type massage for 10 sessions in 10 weeks. Visits were
2 sessions/week for 3 weeks, then 1 visit/week for 3 weeks, then
1 visit in 10th week.
Arm 5 e Thermal modality: 20 min of moist heat or ice.
Treatment Schedule: 6 weeks (assume that the use of the pillow
was constrained to these 6 weeks)
 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45
(continued )
Study/Participants Interventions
Duration of Follow-up: 6 weeks
CO-INTERVENTION: avoided in trial design
Humphreys and Irgens, 2002 INDEX TREATMENT
Chronic neck pain Arm 1 e Symptomatic exercise group (SEG): Activity e One eye-
head-neck co-ordination and one eye-head-neck-upper limb co-
ordination; Mode e sitting. Movement e Exercise one:
participants were required to x their eyes on a target in front of
them and move their head maximally in a slow and carefully
controlled movement in one direction while keeping their eyes
xed on the target straight ahead. Exercise two: participants
were required to hold up both arms in front of them with their
thumb extended upwards and to keep their eyes xed on one
thumb as the ipsilateral arm went through the sequential
movements of the left and right rotation, exion and extension,
with the eyes and head followed the movement in a slow and co-
ordinated fashion. Dosage e Speed (slow and co-ordinated
movement), Duration/Frequency (4 weeks, 2 times/day),
Feedback (one training session given by the author and an
instruction sheet), Monitoring (exercise compliance form),
Environment (home exercise program). Dose (NR).
Treatment Schedule: 4 weeks, 2 daily sessions.
COMPARISON TREATMENT
Arm 2 e Control group: Symptomatic non-exercise group
(SNEG).
Treatment Schedule: 4 weeks
Duration of Follow-up: none
CO-INTERVENTION: NR
Jull et al., 2002 INDEX TREATMENT
Chronic CGH Arm 1 e Exercise Therapy (CCF/ISO) Activity e therapeutic low
load exercise to cervical-scapular region Mode e craniocervical
exor training with pressure biofeedback, scapular muscle
training, postural correction, Movement e exercise performed
throughout the day, isometric strengthening with co-contraction
of neck exion and extension, stretching as needed. Treatment
Schedule e 30 min session duration, 2 sessions/weeks, 8e12
sessions total
Arm 2 e Combined Therapy (MT/ET): Activity e manipulation,
mobilisation & exercise
Treatment Schedule: 30 min session duration, two sessions/
weeks, 8e12 sessions total
COMPARISON TREATMENT
Arm 3 e Manipulative Therapy (SMT): manipulation: high
velocity, low-amplitude manipulation described by Maitland;
mobilisation (low velocity), 30 min session duration. Dosage: 2
sessions/week, 8e12 sessions total
Arm 4 e Control Group (NT): no treatment
Treatment Schedule: 6 weeks, 8e12 sessions
Duration of Follow-up: 52 weeks
CO-INTERVENTION: NR
Kjellman and Oberg, 2002 INDEX TREATMENT
(sub)Acute to Chronic MND with or Arm 1 e General Exercise (ET): Activity e stretching,
without radiation strengthening; Mode e neck and shoulder; Movement e ROM,
active neck endurance and strength exercises, 16 sessions over 2
months
Arm 2 e McKenzie Exercise (McK): Specic McKenzie protocol.
Sessions over 2 months. Number not specied
COMPARISON TREATMENT
Arm 3 e Sham Ultrasound (SUS): Set at lowest setting for 7 min.
Applied over the superior portion of the trapezius
Treatment Schedule: 4 weeks of treatment
Duration of Follow-up: 6 and 12 months
CO-INTERVENTION: Comparable between index and control
groups.
Kuijper et al., 2009 INDEX TREATMENT
Acute NDR Arm 1 e Physiotherapy Group (PG): Activity e Therapy was
focused on mobilizing and stabilizing the neck and was
characterized as hands off Mode e The sessions were
standardized provided by a certied Physiotherapist, the patient
was instructed on graded exercise activities to strengthen the
supercial and deep muscle of the neck. The patients were also
instructed in a home exercise program. Movement e Patients
were advised to practice the exercises daily and asked to record
the duration of their exercise daily. Dosage: 2 times/week for 6
weeks
COMPARISON TREATMENT
Arm 2 e Wait and see list Group (WLG): Patients in the control
39
Outcomes
PAIN (VAS 0 to 100)
Baseline Mean: SEG 55, SNEG 49
Reported Results: no signicant difference between groups
SMD (SEG vs SNEG): 0.00 (95% CI:
0.74 to 0.74)
REASON FOR DROP-OUTS: not specied
SIDE EFFECTS: NR
COST OF CARE: NR
PAIN Headache intensity change score (VAS 0 to 10)
Baseline Mean: SMT 4.8, CCF 5.4, MT/ET 5.1, NT 5.3
Reported Results: signicant favouring SMT and CCF
SMD (CCF vs NT) at LT follow-up:
0.59 (95% CI:
1.00 to
0.18),
NNTB 6, treatment advantage 28%
FUNCTION Northwick Park Neck Pain Questionnaire (NPQ
change score, 0 to 36)
Baseline Mean: SMT 27.5, CCF 29.6, MT/ET 29.7, NT 30.7
Reported Results: signicant favouring MT or MT/ET over
control; no signicant difference between MT, ET and MT/ET
comparisons
SMD (CCF vs NT) at LT follow-up:-0.59 (95% CI:
1.00 to
0.18),
NNTB 6, treatment advantage 32%
GLOBAL PERCEIVED EFFECT Participant perceived effect (VAS
0 to 100)
Reported Results: signicant favouring SMT and MT/ET over NT,
not signicant for SMT or MT/ET when compared to CCF
SMD (CCF vs NT):
2.51 (95% CI:
3.05 to
1.97)
REASONS FOR DROP-OUTS: reported
SIDE EFFECT: minor and temporary, 6.7% of headaches were
provoked by treatment
COST OF CARE: NR
PAIN (VAS 0 to 100)
Baseline Mean: ET 27.0, McK 19, SUS 21
Reported Results: no signicant difference between groups
SMD (ET vs SUS) at LT follow-up:
0.19 (95% CI:
0.41 to 0.80)
SMD (McK vs SUS) at LT follow-up: 0.04 (95% CI:
0.51 to 0.60)
FUNCTION (NDI 0 to 50)
Baseline Mean: ET 27.0, McK 19, US 21
Reported Results: no signicant difference between groups
SMD (ET vs SUS) at LT follow-up:
0.19 (95% CI:
0.41 to 0.80)
SMD (McK vs SUS) at LT follow-up: 0.04 (95% CI:
0.51 to 0.60)
REASONS FOR DROP-OUTS: reported
SIDE EFFECTS: NR
COST OF CARE: NR
PAIN (VAS 0 to100)
Baseline Mean: Cervical Collar 57.4, Physiotherapy 61.7, WLG
55.6
Reported Results: At 6 weeks there was a signicant decrease in
neck pain in the collar group 2.8 mm/week (17 mm in 6 weeks)
and 2.4 mm/week in the physiotherapy group (14 mm in 6
weeks), while the control group showed only 0.9 mm reduction
in pain over the 6 weeks. After 6 months the pain scores in the
two treatment groups did not differ from those of the control
patients.
SMD (PT vs WLG) at Immediate post treatment:
0.47 (95%
CI:
0.81 to
0.12); NNTB 4, treatment advantage 33%
FUNCTION (NDI 0 to 100)
(continued on next page)
40
(continued )
Study/Participants
Lange et al., 2013
Acute to chronic non-specic neck
and shoulder pain
Lundblad et al., 1999
Chronic MND
A.R. Gross et al. / Manual Therapy 24 (2016) 25e45
Interventions Outcomes
group were advised to continue their daily activities as much as Baseline Mean: Cervical Collar 41.0, Physiotherapy 45.1, WLG
possible. As well they were asked to note in their diaries the parts 39.8
of the day where they were unable to continue their normal Reported Results: The collar group showed a signicant
activities. Patients were asked to contact the investigators if they difference in rate of improvement compared with the control
had any questions. group, the weekly change in the physiotherapy group was not
Arm 3 e Collar Group (CG): Semi-hard collar (Cerviex S, signicantly different from that of the control patients.
Bauerfeind and available in 6 sizes), The best size (to t snugly) SMD (PT vs WLC) at immediate post treatment:
0.11 (95%
was selected for each patient. Patients advised to wear the pillow CI:
0.45 to 0.23)
during the day for 3 weeks. Over the next 3 weeks patients were PATIENT SATISFACTION (scale 0 to 5)
weaned off the collar. After 6 weeks they were asked to no longer Reported Results: NR
wear the collar. RR (PT vs WLC) at immediate post treatment: 0.92 (95% CI: 0.62
Treatment Schedule: 6 weeks, 12 sessions e1.37)
Duration of Follow-up: 6 months REASONS FOR DROP-OUTS: NR
CO-INTERVENTION: Comparable between index and control SIDE EFFECT: NR
groups. Patients were asked to take paracetamol (usually) either COST OF CARE: NR
with or without a non-steriodal anti-inammatory. If necessary
opioids were prescribed.
INDEX TREATMENT PAIN (VAS 0 to 10)
Arm 1 e Training group: Activity e Patterns and Baseline Mean: Training group 1 and control 1.2
synchronisation of muscle recruitment, Strengthening exercises, Reported Results: no signicant difference between groups
Endurance exercises; Mode e Patterns and synchronisation SMD (training vs control):
0.58 (95% CI:
1.12 to
0.04)
-Standing supine and gentle rotation stood erect, Strengthening- REASON FOR DROP-OUTS: Reported
the whole spine was held in an anatomic neutral position during SIDE EFFECTS: Reported
pull exercises, shrugs standing erect holding the dumbbells in COST OF CARE: NR
their hands on both sides and sitting position leaning the upper
body 45 forward with a straight back for reverse ies.
Endurance-holding the body blade with both hands, and with
shoulders 90% exed and elbows 5% exed; Movement e
Patterns and synchronisation-3 conditioning exercises focussing
on activation of the deep cervical exors, Strengthening-Static
pull in 8 directions, shrugs, reverse ies, Endurance-Small
shoulder extensions and exions were performed to make the
body blade oscillate; Dosage e Patterns and synchronisation-
Type of contraction e concentric, Speed -slow and controlled
movement, Duration/Frequency
5 repetitions, 3 week,
Sequence -sequence warm-up then strengthening then
endurance, Feedback -the pilots had access to help from
educated trainers at the base and at Tactical Air Command Karup,
Strengthening-Type of contraction -concentric, Intensity
-equivalent to 70%e85% of 1 repetition maximum, Duration/
Frequency
8 to15 repetitionss, 3 week, Shrugs and static neck
pull were performed during every session and reverse ies were
performed every second session, Sequence -after warm-up,
Feedback-(the pilots had access to help from educated trainers at
the base and at Tactical Air Command Karup, Endurance-Type of
contraction -dynamic, Intensity -equivalent to 70%e85% of 1
repetition maximum, Speed -as the participants became more
accustomed to the body blade exercise, they attempted to make
it oscillate increasingly more rapidly, Duration/Frequency -up to
60 s, performed every second session, 3 week, Sequence -after
strengthening, Feedback -the pilots had access to help from
educated trainers at the base and at Tactical Air Command Karup.
Dosage e 3 sessions a week, 20 min of training session for 24
weeks
COMPARISON TREATMENT
Arm 2 e Control group: No intervention but offered the training
after the study. Encouraged to continue their physical activity as
usual.
Treatment Schedule: 24 weeks
Duration of Follow-up: none
CO-INTERVENTION: comparable between index and control
groups
INDEX TREATMENT PAIN (VAS 0 to 10)
Arm 1 e Feldenkrais Intervention (F): Activity e Education Baseline Mean: VAS e usually PT 1.2, F 1.5, control 2.0, VAS e
Mode e Individualized (functional integration) teacher guides worst PT 4.1, F 4.4, control 5.5
through movement sequences; Group (awareness through Reported Results: no signicant differences
movement) verbally guided through exercises for Movement e SMD (PT vs control) at LT follow-up:
0.14 (95% CI:
0.80 to
neck-shoulder complaints, home exercises, frequency 0.51)
-individually 4 times and in group (7e8 participants) 12 times; DISABILITY Work and leisure (0e4) Sick leave, days and %
required 50% participation in both segments of program. Dosage Baseline Mean:
e 50 min per week Disability e work PT 1.3, F 1.2, control 1.3,
Arm 2 e Physiotherapy Intervention (PT): Activity e Disability e leisure PT 0.6, F 0.9, control 0.6
Stabilisation exercises for low back and pelvis, isolated and Sick leave (days) PT 12.7, F 12.0, control 11.5,
relaxed shoulder movements Mode e Education use of body Sick leave (%) PT 6.5, F 5.8, control 5.9
emphasizing self-directed control and responsibility for body, Reported Results: no signicant differences
ability to cope with pain, muscle tension, and complaints. REASON FOR DROP-OUTS: Reported
 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45
(continued )
Study/Participants Interventions
Awareness of body posture. Movement e Practice work-related
lift and movement techniques. Exercise program of strength, co-
ordination, endurance, exibility/smoothness and rhythm,
Home exercises. Dosage e 50 min; 2 times/week for 16 weeks in
group of 5e8 participants; Required 50% participation in the
exercises
COMPARISON GROUP
Arm 3 e Control Regimen: no treatment
Treatment Schedule: 16 weeks, 32 sessions
Duration of Follow-up: 52 weeks
CO-INTERVENTION: NR
Martel et al., 2011 INDEX TREATMENT
Chronic MND with or without Arm 1 e SMT Group: Activity e Spinal Manipulation Mode e
referral/radiation to the head, trunk Maximum 4 spinal manipulations Movement e cervical and
or limbs upper thoracic areas. Dosage e One treatment per month, lasted
10e15 min
Arm 2 e SMT Exercise Group: Activity e Spinal
Manipulation Home Exercise Program, range of motion,
stretching, strengthening Mode e Maximum 4 spinal
manipulations. Advised to perform a home exercise program
Movement e manipulation- cervical and upper thoracic areas
(down to T4). home exercise program- range of motion exercises,
followed by 4 stretching/mobilisation, and 4 strengthening
exercises (concentric and isometric contractions) of the cervical
and upper thoracic spine (primarily exion, extension, lateral
exion and rotation of the cervical spine). Dosage e
manipulation- one treatment per month lasted 10e15 min.
Home exercise program 3/week. Three series of each exercise
with a 30e60 s rest between series were performed during each
training session. A training session lasted 20e30 min
All participants were instructed in the same routine, exercise
volume was tailored to each participant's strength, exibility and
ability to complete the routine with minimal neck pain. Each
patient received a written copy of the program. Exercise checked
every 2 months by a kinesiologist.
COMPARISON TREATMENT
Arm 3 e Control Group: Attention-control, No treatment,
attended clinic once every 2 months, visited lasted 20e30 min
for data collection.
Treatment Schedule: 10 months, 10 sessions
Duration of Follow-up: none
CO-INTERVENTION: NR
Rendant et al., 2011 INDEX TREATMENT
Chronic MND Arm 1 e Qigong: Activity e 12 neck exercises, 9 shoulder
exercises Mode/Movement e ROM/mobility, imagery, breathing
and moving exercise (Fig. 1) home exercise with a manual;
Qigong qualied teacher was certied by German Qigong Society
Dosage e 18 sessions, 90 min sessions over 6 months
Arm 2 e Exercise: Activity e ROM, stretching, strengthening
Mode/Movement e Warm-up included neck range of motion,
use of soft ball, strengthening using a theraband; exibility
exercise, home exercise with a manual, individual pain level was
not exceeded; Dosage e 18 sessions over 6 months; exercise is
monitored by a qualied physiotherapist
COMPARISON TREATMENT
Arm 3 e Control: no intervention
Treatment Schedule: 24 weeks treatment, 18 sessions
Duration Follow-up: none
CO-INTERVENTION: not avoided
41
Outcomes
SIDE EFFECTS: NR
COST OF CARE: NR
PAIN (VAS 0 to 10)
Baseline Mean: SMT 3.1, SMT Ex 3.8
Reported Results: no signicant differences
FUNCTION (NDI 0 to 50)
Baseline Mean: SMT 21.4, SMT Ex 22.2
Reported Results: no signicant differences
HEALTH-RELATED QUALITY OF LIFE (SF-12 0 to 100)
Baseline Mean Physical Scale: SMT 48.7, SMT Ex 50.0, Mental
Scale: SMT 45.3, SMT Ex 44.8
Reported Results: no signicant differences
REASON FOR DROP-OUTS: Reported
SIDE EFFECTS: Reported: No serious adverse events were
reported during RCT
COST OF CARE: NR
PAIN (VAS 0 to 100)
Baseline Mean: Qigong 57.7, E 57.5, control 53.4
Reported Results: signicant differences Qigong vs control;
MD (Qigong vs control) at 12 weeks treatment:
15.60 (
24.72
to
6.48)
MD (Qigong vs control) at 24 weeks treatment:
8.10 (
15.72
to
0.48)
MD (Exercise vs control) at 12 weeks treatment:
17.30 (95%
CI:
26.60 to
8.00)
MD (Exercise vs control) at 24 weeks treatment:
10.30 (95%
CI:
19.97 to
0.63)
No signicant difference Qigong vs exercise
FUNCTION (NPDI 0 to 100)
Baseline Mean: Qigong 44.0, E 39.5, control 43.2
Reported Results: signicant differences Qigong vs control;
SMD (Qigong vs control) at 12 weeks treatment:
0.48 (95%
CI:
0.92 to
0.04)
SMD (Qigong vs control) at 24 weeks treatment:
0.47 (95%
CI:
0.92 to
0.02)
SMD (Exercise vs control) at 12 weeks treatment:
0.78 (95%
CI:
1.24 to
0.31)
SMD (Exercise vs control) at 24 weeks treatment:
0.50 (95%
CI:
0.97 to
0.04)
No difference Qigong vs exercise
QUALITY of LIFE (SF 36, physical component)
Baseline Mean: Qigong 43.1, E 43.7, control 43.3
Reported Results: signicant differences qigong vs control;
MD (Qigong vs control) at 12 weeks treatment:
3.40 (95%
CI:
6.97 to 0.17)
MD (Qigong vs control) at 24 weeks treatment:
3.90 (95%
CI:
8.07 to 0.27)
MD (Exercise vs0 control) at 12 weeks treatment:
2.70 (95%
CI:
6.76 to 1.36)
MD (Exercise vs control) at 24 weeks treatment:
2.00 (95%
(continued on next page)
42
(continued )
Study/Participants
Revel et al., 1994
Chronic MND (osteoarthritic changes Arm 1 e Proprioception Rehabilitation Group (RG) Activity e
27 of 30)
Stewart et al., 2003, 2007, 2008
Subacute and Chronic WAD with or Arm 1 e Exercise and Advice: Activity e Exercise, Mode e
without radiation
Takala et al., 1994
MND, disorder duration NR
A.R. Gross et al. / Manual Therapy 24 (2016) 25e45
Interventions
INDEX TREATMENT
Proprioceptive rehabilitation program: purpose to improve neck
proprioception; Mode e 15 min individualized exercise session,
exercises were mainly concerned with eye-neck co-ordination
including; Movement e a) slow passive motions of the head
with gaze on a xed target, b) active movements of the head,
automatic movements of the neck with passive trunk
movements and head position relocation exercises, c) exercises
in a wide range of motion with free eye-head coupling (author
description well detailed in Rehabilitation Procedure page 896).
Dosage e 2 times per week; 30e40 min sessions
COMPARISON TREATMENT
Arm 2 e Control Group (Cntl): Medication: analgesic, anti-
inammatory typical dosage was indomethacin 100 mg; aspirin,
3000 mg; diclofenac, 150 mg; naproxen, 1000 mg
Treatment Schedule: 8 weeks
Duration of Follow-up: 2 weeks
CO-INTERVENTION: NR
INDEX TREATMENT
aerobic exercise, stretches, functional activities, activities to
build speed, endurance and co-ordination, trunk and limb
strengthening, CBT (setting goals of progressively increasing
difculty, shaping, encouraging self-monitoring of progress, self-
reinforcement), home exercise program (individual specied),
Movement e graded exercise program supervised by a
physiotherapist, Dosage e duration -1 h of exercise per session,
feedback-supervised for 30 min, Individualized, progressive,
intensity -submaximal program designed to improve
participants ability to complete functional activities specied by
the participant as being difcult because of whiplash. Regular
evaluation by a physiotherapist. Encouraged to continue home
exercises even after intervention was completed. Dosage e 6
weeks, 12 sessions
COMPARISON TREATMENT
Arm 2 e Advice Alone: Standardised education, reassurance and
encouragement to resume light activity alone. One consultation
and 2 follow-up phone contacts. Favourable prognosis of
whiplash, addressed common inaccurate beliefs about whiplash,
exploration of fear-avoidance beliefs. Participants given a
written report of main points of advice session. Standardized
advice reinforced at 2 weeks and 4 weeks
Treatment Schedule: 6 weeks, 12 sessions
Duration of Follow-up: 42 weeks
CO-INTERVENTION: avoided in trial design
INDEX TREATMENT
Arm 1 e Exercise treatment (ET): Activity e Group gymnastic,
instructional type (group), Mode e setting -work; treatment
characteristics -exercise planned to train whole body,
Movement e aerobic dynamic exercise -10 min walking or
stepping, relaxation, stretching of muscles of the trunk and
extremities and dynamic exercises -10 min, Dosage e sequence-
(10 min walking/stepping, 10 min stretch/dynamic exercises,
5 min walking/stepping, 10 min dynamic and co-ordination
exercises, 10 min stretch and relaxation; duration of
session
45 min; 1 time/week
COMPARISON TREATMENT
Arm 2 e Control - no treatment
Treatment Schedule: 10 weeks, 10 sessions of treatment in the
spring session -cross-over of placebo group occurred in autumn,
the groups were reversed
Duration of Follow-up: none
CO-INTERVENTION: NR
Outcomes
CI:
5.83 to 1.83)
No difference qigong vs exercise
REASON FOR DROP-OUTS: detailed
SIDE EFFECTS: Reported by 19 patients in qigong group
including: muscle soreness (n 15), myogelosis (n 12), vertigo
(n 10), other pain (n 4), headache (n 3), thirst (n 1),
engorged hands (n 1), twinge in the neck (n 1), urinary
urgency (n 1), bursitis of left shoulder (n 1). Reported by 16
patients muscle soreness (n 14), myogelosis (n 11),
headaches (n 5), vertigo (n 2), change in mood (n 1),
worsening of neck pain (n 1), worsening of tinnitus (n 1).
COST OF CARE: NR
PAIN (VAS 0 to 100)
Baseline Mean: RG 50.5, control 45.9
Reported Results: signicant favouring RG
SMD at ST follow-up:
0.77 (95% CI:
1.29 to
0.24), NNTB 4,
treatment advantage 34%
DAILY INTAKE OF NSAID/ANALGESICS
Baseline Mean: RG 2.0/1.8, control 2.3/1.6
Reported Results: not signicant
FUNCTIONAL IMPROVEMENT SELF- ASSESSED (scale 0 to 5)
Reported Results: signicant favouring RG
SMD at ST follow-up: 0.55 (95% CI: 0.33e0.89), NNTB 3,
treatment advantage NA
REASON FOR DROP-OUTS: NR
SIDE EFFECTS: NR
COST OF CARE: NR
PAIN (VAS 0 to 10)
Baseline Mean: Exercise Advice 5.2, Advice Alone 5.3
Reported Results: Groups were similar at baseline.
SMD immediate posttreatment:
0.46 (95% CI:
0.81 to
0.12)
SMD at 12 month:
0.12 (95% CI:
0.47 to 0.23)
FUNCTION (NDI 0 to 50)
Baseline Mean: Exercise Advice 18.2, Advice Alone 19.7
Reported Results: Groups were similar at baseline.
SMD immediate post treatment:
0.50 (95% CI:
0.85 to
0.15)
SMD 12 month:
0.39 (95% CI:
0.74 to
0.03)
GLOBAL PERCEIVED EFFECT
(scale
5 to 5)
Baseline Mean: Exercise Advice 0.6, Advice Alone 0.3
Reported Results: Groups were similar at baseline.
SMD immediate post treatment:
0.46 (95% CI:
0.80 to
0.11),
SMD 12 month:
0.18 (95% CI:
0.54 to 0.17)
QUALITY OF LIFE (SF-36 Physical 0 to 100)
Baseline Mean: Exercise Advice 36.4, Advice Alone 36.8
Reported Results: Groups were similar at baseline
SMD immediate post treatment:
0.35 (95% CI:
0.69 to
0.01),
SMD 12 month:
0.15 (95% CI:
0.50 to 0.20)
REASON FOR DROP-OUTS: Reported but not specied
SIDE EFFECTS: Reported; The main complaint in this group was
muscle pain with exercise (3) followed
by knee pain (2) and lumbar spine pain (2).
COST OF CARE: NR
PAIN (VAS 0 to 100)
Baseline Median: ET 40, control 50
Reported Results: no signicant difference
PRESSURE PAIN SENSITIVITY
Algometer (pressure pain threshold (PPT) on upper trapezius,
levator scapulae, rhomboid, infraspinatus) mean score of 8
measures
Baseline Mean: ET 45.2, control 44.8
Reported Results: no signicant difference
SMD at immediate post treatment:
0.06 (95% CI:
0.65 to 0.53)
REASON FOR DROP-OUTS: NR
SIDE EFFECTS: NR
COST OF CARE: NR

(continued )
Study/Participants
Viljanen et al., 2003
Chronic MND (NDR, NDH, WAD)
von Trott et al., 2009
Chronic MND in elderly adults
KEY: 2.1 Intervention: CBT Cognitive Behavioral Therapy; CCF Craniocervical Flexion; ET Exercise Therapy; IR infrared Radiation; McK McKenzie; Mock Mock
therapy; MT manual therapy; MyoT Myofeedback training; ROM range of motion; SMT Manipulation; SSng Self Snag; SUS Sham Ultra Sound;
TENS transcutaneous electrical nerve stimulation.
2.2 Outcome measures: BORG Borg pain scale; DASH disability of the arm, shoulder and hand; NDI neck disability index; NPDI Neck Pain Driving Index;
NPQ Northwick Park questionnaire; PPT pain pressure threshold [measured by algometer]; SF-12 Short Form 12; SF-36 Short Form 36; VAS visual analogue scale.
2.3 Other: CI condence interval; G group; NA not applicable; NNTB number-needed-to-treat-to-benet; NR not reported; p probability value; RCT randomized
controlled trials; RR relative risk; SMD standardised mean difference; vs versus.
A.R. Gross et al. / Manual Therapy 24 (2016) 25e45
Interventions
INDEX TREATMENT
Arm 1 e Exercise: Activity e muscle training; Mode e activating
large muscle groups in neck and shoulders Movement e
dumbbells with weight of 1e3 kg; Dosage e Dynamic muscle
training, Sequence (stretching followed each exercise);
progression in weeks 5 and 9.
Arm 2 e Relax: Activity e Relaxation training; Mode/Movement
e progressive relaxation, autogenic training, functional
relaxation, systematic desensitisation.
COMPARISON TREATMENT
Arm 3 e Control: No treatment
Treatment Schedule: 12 weeks plus 1 week reinforcement, Arm
1e13.6 sessions; Arm 2e14.6 sessions
Duration of Follow-up: 3 and 9 months
CO-INTERVENTION: Comparable between groups
INDEX TREATMENT
Arm 1 e Qigong: Activity e Qigong, Mode e lessons, Movement
e started with about 10 min of typical Qigong opening
exercises, continued with up to 4 exercises of Dantian Qigong,
and nished with about 10 min of closing exercises. Dosage e
Qigong was provided by 5 approved Qigong therapists; 24
sessions (45 min) over 3 months (2 sessions/week).
Arm 2 e Exercise: Activity e Exercise therapy; Mode e was
based on a standardized program for computer and workplace
related neck pain; Movement e including repeated active
cervical rotations, strength and exibility exercises. A detailed
description is provided in Weidmann 2008. Dosage e 24
sessions (45 min) over 3 months (2 sessions/week). Participants
were asked to continue exercising on their own for the next 3
months.
COMPARISON TREATMENT
Arm 3 e Wait List Control: Patients were free to treat their neck
pain with the treatment or therapies they were using prior to
randomisation. Patients did not receive Qigong or exercise
therapy. After 6 months they were offered an intervention of
their choice.
Treatment Schedule: 12 weeks, 24 sessions
Duration of Follow-up: 12 weeks follow-up
CO-INTERVENTION: Comparable between index and control
groups
43
Outcomes
PAIN (VAS 0 to 10)
Baseline Mean: Exercise 4.8, Relax 4.8, Control 4.1
Reported Results: no group difference
SMD (Exercise vs Control):
0.04 (95% CI:
0.28 to 0.20)
FUNCTION (NDI 0 to 50)
Baseline Mean: Exercise 29, Relax 2 29, Control 26
Reported Results: no signicant group differences were found
SMD (Exercise vs Control):
0.11 (95% CI:
0.11 to 0.38)
REASON FOR DROP-OUTS: Noted but no difference between
groups
SIDE EFFECTS: NR
COST OF CARE: NR
PAIN (VAS 0 to100)
Baseline Mean: Qigong 56.4, Exercise 47.1, Control 49.9
Reported Results: After 3 months there was not signicant
difference for the average neck pain between the Qigong and the
wait list group
11.0 mm (95% CI:
24.0 to 2.1; p 0.99,
ANCOVA), and no signicant difference between the Qigong and
the exercise therapy group the group difference being
2.5 mm
(95% CI:
15.4 to 10.3, p 0.68).
MD (Qigong vs control) at 12 weeks treatment:
7.50 (95%
CI:
21.88 to 6.88)
MD (Qigong vs control) at 12 weeks treatment 12 weeks
follow-up:
6.80 (95% CI:
21.34 to 7.74)
MD (Exercise vs control) at 12 weeks treatment:
10.40 (95%
CI:
23.11 to 2.31)
MD (Exercise vs control) at 12 weeks treatment 12 weeks
follow-up:
12.20 (95%CI:
25.73 to 1.33)
FUNCTION (NDI 0 to100)
Baseline Mean: Qigong 38.5, Exercise 41.8, Control 36.1
Reported Results: No signicant difference was found between
the groups after 3 and 6 months.
SMD (Qigong vs control) at 12 weeks treatment:
0.21 (95%
CI:
0.69 to 0.28)
SMD (Qigong vs control) at 12 weeks treatment 12 weeks
follow-up:
0.06 (95% CI:
0.57 to 0.45)
SMD (Exercise vs control) at 12 weeks treatment:
0.23 (95%
CI:
0.70 to 0.24)
SMD (Exercise vs control) at 12 weeks treatment 12 weeks
follow-up:
0.29 (95%CI:
0.77 to 0.20)
GLOBAL PERCEIVED EFFECT
SMD (Qigong vs control) at 12 weeks treatment:
0.01 (95%
CI:
0.49 to 0.47)
SMD (Qigong vs control) at 12 weeks treatment 12 weeks
follow-up:
0.09 (95% CI:
0.60 to 0.42)
SMD (Exercise vs control) at 12 weeks treatment: 0.09 (95%
CI:
0.38 to 0.56)
SMD (Exercise vs control) at 12 weeks treatment 12 weeks
follow-up:
0.21 (95% CI:
0.69 to 0.28)
QUALITY OF LIFE (SF-36 physical component 0 to 100)
Baseline Mean: Qigong 30.4, Exercise 28.7, Control 30.6
Reported Results: No signicant difference was found between
the groups after 3 and 6 months.
MD (Qigong vs control) at 12 weeks treatment:
1.80 (95%
CI:
5.94 to 2.34)
MD (Qigong vs control) at 12 weeks treatment 12 weeks
follow-up: 0.10 (95% CI:
3.99 to 4.19)
MD (Exercise vs control) at 12 weeks treatment:
1.70 (95%
CI:
5.96 to 2.56)
MD (Exercise vs control) at 12 weeks treatment 12 weeks
follow-up: 2.20 (95%CI:
1.81 to 6.21)
REASON FOR DROP-OUTS: Reported
SIDE EFFECTS: Reported; 5 side-effects were reported by 4
patients in the Qigong group (2 nausea, 2 aching muscles, 1
muscle tension) and 4 side effects by 2 patients in the exercise
therapy group (2 muscle tensions, 1 aching muscles, 1 nausea)
COST OF CARE: NR
44 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45

References Haldeman S, Carroll L, Cassidy JD. Findings from the bone and joint decade 2000 to
2010 task force on neck pain and its associated disorders. J Occup Environ Med
2010;52:424e7.
Abernethy B, Kippers V, Hanrahan SJ, Paddy MG, McManus AM, MacKinnon L.
Hall CM, Brody L. Therapeutic exercise: moving toward function. Baltimore, MD:
Biophysical foundations of human movement. Champaign: Sheridan Books;
Lippincott Williams & Wilkins; 2005.
2013.
Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K. Efcacy of a C1-C2
Allan M, Brantingham JW, Menezes A. Stretching as an adjunct to chiropractic
self-sustained natural apophyseal glide (SNAG) in the management of cervi-
manipulation of chronic neck pain e before, after or not at all? A prospective
cogenic headache. JOSPT 2007;37:100e7.
randomized controlled clinical trial. Eur J Chiropr 2003;50:41e52.
Hallman D, Olsson E, Sche
ele B, Melin L, Lyskov E. Effects of heart rate variability
Andersen LL. Inuence of psychosocial work environment on adherence to work-
biofeedback in subjects with stress-related chronic neck pain: a pilot study.
place exercise. J Occup Environ Med 2011;53:182e4.
Appl Psychophysiol Biofeedback 2011;36(2):71e80.
Andersen LL, Kjaer M, Sogaard K, Hansen L, Kryger AI, Sjogaard G. Effect of two
Hansson EE, Persson L, Malmstro m EM. Inuence of vestibular rehabilitation on
contrasting types of physical exercise on chronic neck muscle pain. Arthrit
neck pain and cervical range of motion among patients with whiplash associ-
Rheumat 2008;59(1):84e91.
ated disorders: a randomized controlled trial. J Rehabil Med 2013;45(9):
Andersen LL, Saervoll CA, Mortensen OS, Poulsen OM, Hannerz H, Zebis MK.
906e10.
Effectiveness of small daily amounts of progressive resistance training for
Helewa A, Goldsmith CH, Smythe HA, Lee P, Obright K, Stitt L. Effect of therapeutic
frequent neck/shoulder pain: randomised controlled trial. Pain 2011;152:
exercise and sleeping neck support on patients with chronic neck pain: a
440e6.
randomized clinical trial. J Rheumatol 2007;34:151e8.
Andersen LL, Mortensen OS, Zebis MK, Jensen Rh, Poulsen OM. Effect of brief daily
Higgins JPT, Green S. Cochrane handbookfor systematic reviews of interventions
exercise on headache among adultsesecondary analysis of a randomised
5.0.2. Chichester: John Wiley& Sons, Ltd; 2008. www.cochrane-handbook.org.
controlled trial. Scand J Work Environ Health 2011;37:547e50.
Hogg-Johnson S, Van der Velde G, Carroll LJ, Holm LW, Cassidy JD, Guzman J, et al.
Andersen CH, Andersen LL, Gram B, Pedersen MT, Mortensen OS, Zebis MK, et al.
The burden and determinants of neck pain in the general population: results of
Inuence of frequency and duration of strength training for effective manage-
the Bone and Joint Decade 2000e2010 Task Force on Neck Pain and Its Asso-
ment of neck and shoulder pain: a randomised controlled trial. Br J Sports Med
ciated Disorders. Spine 2008;33(4 Suppl). S39e51.
2012;46:1004e10.
Hoy D, March L, Woolf A, Blyth F, Brooks P, Smith E, et al. The global burden of neck
Ang BO, Monnier A, Harms-Ringdahl K. Neck/shoulder exercise for neck pain in air
pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis
force helicopter pilots: a randomized controlled trial. Spine 2009;34:E544e51.
2014;73(7):1309e15. http://dx.doi.org/10.1136/annrheumdis-2013-204431.
Beer A, Treleaven J, Jull G. Can a functional postural exercise improve performance
Humphreys BK, Irgens PM. The effect of a rehabilitation exercise program on head
in the cranio-cervical exion test?- A preliminary study. Man Ther 2012;17:
repositioning accuracy and reported levels of pain in chronic neck pain subjects.
219e24.
J Whiplash Relat Disord 2002;1(1):99e112.
Bertozzi L, Gardenghi I, Turoni F, Villafane JH, Capra F, Guccione AA, et al. Effect of
Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A randomized controlled trial
therapeutic exercise on pain and disability in the management of chronic
of exercise and manipulative therapy for cervicogenic headache. Spine
Nonspecic neck pain: systematic review and meta-analysis of randomized
2002;27(17):1835e43.
trials. Phys Ther 2013;93(8):1026e36.
Kay TM, Gross A, Goldsmith CH, Hoving JL, Bronfort G. Exercises for mechanical
Bronfort G, Aker PD, Evans R, Goldsmith CH, Nelson B, Vernon H. A randomized
neck disorders. Cochrane Database Syst Rev 2005;3. Art. No.: CD004250.
controlled clinical trial of rehabilitative exercise and chiropractic spinal
Kay TM, Gross A, Goldsmith CH, Rutherford S, Voth S, Hoving JL, et al. Exercises for
manipulation for chronic neck pain. Spine 2001a;26(7):788e99.
mechanical neck disorders. Cochrane Database Syst Rev 2012;(8). http://
Bronfort G, Evans R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A randomized
dx.doi.org/10.1002/14651858.CD004250.pub4. Art. No.: CD004250.
clinical trial of exercise and spinal manipulation for patients with chronic neck
Kay TM, Gross A, Goldsmith CH, et al. Exercises for mechanical neck disorders.
pain. Spine 2001b;26:788e97.
Cochrane Database Syst Rev 2015;1. N.PAG.
Brnfort G, Nilsson N, Haas M, Evans RL, Goldsmith CH, Assendelft WJJ, et al. Non-
Kjellman G, Oberg B. A randomized clinical trial comparing general exercise,
invasive physical treatments for chronic/recurrent headache (Review).
McKenzie treatment and a control group in patients with neck pain. J Rehabil
Cochrane Database Syst Rev 2004;(3). http://dx.doi.org/10.1002/
Med 2002;34:183e90.
14651858.CD001878.pub2. Art. No.: CD001878.
Kuijper B, Tans JT, Beelen A, Nollet F, de Visser M. Cervical collar or physiotherapy
Carroll LJ, Hogg-Johnson S, Van der Velde G, Haldeman S, Holm LW, Carragee EJ,
versus wait and see policy for recent onset cervical radiculopathy: randomised
et al. Course and prognostic factors for neck pain in the general population:
trial. BMJ 2009;339:b3883.
results of the bone and joint decade 2000e2010 task force on neck pain and its
Lange B, Toft P, Myburgh C, Sjogaard G. Effect of targeted strength, endurance, and
associated disorders. Spine 2008;22(4S):S75e82.
coordination exercise on neck and shoulder pain among ghter pilots: a ran-
Chiu T, Huiu-Chan C, Cheing G. A randomized clinical trial of TENS and exercise for
domized controlled trial. Clin J Pain 2013;29(1):50e9.
patients with chronic neck pain. Clin Rehabil 2005;19:850e60.
Leaver AM, Refshauge KM, Maher CG, McAuley JH. Conservative interventions
Cohen J. Statistical power analysis for the behavioural sciences. 2nd ed. Hilldale, NJ:
provide short-term relief for non-specic neck pain: a systematic review.
Lawrence Erlbaum Associates; 1988.
J Physiother 2010;56(2):73e85.
Dellve L, Ahlstrom L, Johsson A, Sandsjo L, Forsman M, Lindegard A, et al. Myo-
Lee MS, Pittler MH, Ernst E. Internal qigong for pain conditions: a systematic review.
feedback training and intensive muscular strength training to decrease pain
J Pain 2009;10:1121e7.
and improve work ability among female workers on long-term sick leave with
Lundblad I, Elert J, Gerdle B. Randomized controlled trial of physiotherapy and
neck pain: a randomized controlled trial. Int Arch Occup Environ Health
Feldenkrais interventions in female workers with neck-shoulder complaints.
2011;84:335e46.
J Occup Rehabil 1999;9(3):179e94.
Dyrssen T, Svedenkrans M, Paasikivi J. Muskeltraning vid besvar i nacke och skul-
MacDermid JC, Walton DM, Avery S, Blanchard A, Etruw E, McAlpine C, et al.
dror effektiv behandling for att minska smartan. Lakartidningen 1989;86:
Measurement properties of the neck disability index: a systematic review.
2116e20.
JOSPT 2009;39(5):400e17.
Evans R, Bronfort G, Nelson B, Goldsmith C. Two-year follow-up of a randomized
Martel J, Dugas C, Dubois JD, Descarreaux M. A randomised controlled trial of
clinical trial of spinal manipulation and two types of exercise for patients with
preventive spinal manipulation with and without a home exercise program for
chronic neck pain. Spine 2002;27:2383e9.
patients with chronic neck pain. BMC Musculoskelet Disord 2011;12:41e54.
Farrar JT, Young JPJ, LaMoureaux L, Worth JL, Poole RM. Clinical importance of
Racicki S, Gerwin S, Diclaudio S, Reinmann S, Donaldson M. Conservative physical
changes in chronic pain intensity measured on an 11-point numerical rating
therapy management for the treatment of cervicogenic headache: a systematic
scale. Pain 2001;94:149e58.
review. J Man Manip Ther 2013;21(2):113e24.
Felson DT, Anderson JJ, Boers M, Bombardier C, Furst D, Goldsmith C, et al. Pre-
Rendant D, Pach D, Ludtke R, Reishauer A, Mietzner A, Willich SN, et al. Qigong
liminary denition of improvement in rheumatoid arthritis. Arthritis Rheum
versus exercise versus no therapy for patients with chronic neck pain. Spine
1995 Jun;38(6):727e35.
2011;36(6):419e29.
Franca DLM, Senna-Fernandes V, Cortez CM, Jackson MN, Bernardo-Filho M,
Revel M, Minguet M, Gregoy P, Vaillant J, Manuel JL. Changes in cervicocephalic
Guimaraes MAM. Tension neck syndrome treated by acupuncture combined
kinesthesia after a proprioceptive rehabilitation program in patients with neck
with physiotherapy: a comparative clinical trial (pilot study). Complement Ther
pain: a randomized controlled study. Arch Phys Med Rehabil 1994;75(8):
Med 2008;16:268e77.
895e9.
Goldie I, Landquist A. Evaluation of the effects of different forms of physiotherapy in
Sahrmann SA. Diagnosis and treatment of movement impairment syndromes.
cervical pain. Scand J Rehabil Med 1970;2e3:117e21.
St.Louis: Mosby Inc; 2002.
Goldsmith CH, Boers M, Bombardier C, Tugwell P. Criteria for clinically important
Salt E, Wright C, Kelly S, Dean A. A systematic literature review on the effectiveness
changes in outcomes. Development, scoring and evaluation of rheumatoid
of non-invasive therapy for cervicobrachial pain. Man Ther 2011;16(1):53e65.
arthritis patients and trial proles. J Rheumatol 1993;20(3):561e5.
Sherrington C. The integrative action of the nervous system. New Haven: Yale
Gross A, Kay TM, Paquin J-P, Blanchette S, Lalonde P, Christie T, et al. Exercises for
University Press; 1961.
mechanical neck disorders. Cochrane Database Syst Rev 2015;(1). http://
Sggard K, Blangsted AK, Nielsen KP, Hansen L, Vedsted P, Sjgaard G. Changed
dx.doi.org/10.1002/14651858.CD004250.pub5. Art. No.: CD004250.
Actication, oxygenation and pain response of Chronically painful muscles to
Guyatt G, Gutterman D, Baumann MH, Addrizzo-Harris D, Hylek EM, Phillips B, et al.
repetitive work after training interventions: A randomized Controlled Trial. Eur
Grading strength of recommendations and quality of evidence in clinical
J A ppl Physiol 2012;112:173e81.
guidelines: report fom an American College of Chest Physicians task force. Chest
Southerst D, Nordin M, Co ^ te

P, Shearer H, Varatharajan S, Yu H, et al. Is exercise
2006;129:174e81.
effective for the management of neck pain and associated disorders or
 A.R. Gross et al. / Manual Therapy 24 (2016) 25e45
whiplash-associated disorders? A systematic review by the Ontario Protocolfor
Trafc Injury Management (OPTIMa) Collaboration. Spine J 2014:1e70. Avail-
able on line (15 Feb).
Stewart MJ, Maher CG, Refshauge KM, Herbert RD, Bogduk N, Nicholas N. Advice or
exercise for chronic whiplash disorders? Design of a randomized controlled
trial. BMC Musculoskelet Disord 2003;4. 18e18.
Stewart MJ, Maher CG, Refshauge KM, Herbert RD, Bogduk N, Nicholas M. Ran-
domized controlled trial of exercise for chronic whiplash-associated disorders.
Pain 2007;128:59e68.
Stewart MJ, Maher CG, Refshauge KM, Herbert RD, Nicholas MK. Patient and
clinician treatment preferences do not moderate the effect of exercise treat-
ment in chronic whiplash-associated disorders. Eur J Pain 2008;12:879e85.
Takala EP, Viikari-Juntura E, Tynkkynen EM. Does group gymnastics at the work-
place help in neck pain? A controlled study. Scand J Rehabil Med 1994;26:
17e20.
45
Teasell RW, McClure JA, Walton D, Pretty J, Salter K, Meyer M, et al. A research
synthesis of therapeutic interventions for whiplash associated disorder (WAD)
Part 2 - interventions for acute WAD. Pain Res Manag 2010a;15(5):295e304.
Teasell RW, McClure AJ, Walton D, Pretty J, Salter K, Meyer M, et al. A research
synthesis of therapeutic interventions for whiplash-associated disorder (WAD):
Part 3 - interventions for subacute WAD. Pain Res Manag 2010b;15(5):305e12.
Vanti C, Bertozzi L, Gardenghi I, Turoni F, Guccione AA, Pillastrini P. Effect of taping
on spinal pain and disability: systematic review and meta-analysis of ran-
domized trials. Phys Ther 2015;95(4):493e506.
Viljanen M, Malmivaara A, Uitti J, Rinne M, Palmroos P, Laippala P. Effectiveness of
dynamic muscle training relaxation treaining, or ordinary activity for chronic
neck pain: randomised controlled trial. BMJ 2003;327:475e7.
von Trott P, Wiedemann AM, Ludtke R, Reishauer A, Willich SN, Witt CM. Qigong
and exercise therapy for elderly patients with chronic neck pain (QIBANE): a
randomized controlled study. J Pain 2009;10:501e8.