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Exercises for mechanical neck disorders

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Background

Neck pain is common, disabling and costly. Exercise is one treatment approach.

Objectives

To assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

Search methods

We searched MEDLINE, MANTIS, ClinicalTrials.gov and three other computerized databases up to between January and May 2014 plus additional sources (reference checking, citation searching, contact with authors).

Selection criteria

We included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control for adults suffering from neck pain with or without cervicogenic headache or radiculopathy.

Data collection and analysis

Two review authors independently conducted trial selection, data extraction, 'Risk of bias' assessment and clinical relevance. The quality of the evidence was assessed using GRADE. Meta‐analyses were performed for relative risk and standardized mean differences (SMD) with 95% confidence intervals (CIs) after judging clinical and statistical heterogeneity.

Main results

Twenty‐seven trials (2485 analyzed /3005 randomized participants) met our inclusion criteria.

For acute neck pain only, no evidence was found.

For chronic neck pain, moderate quality evidence supports 1) cervico‐scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) ‐0.71 (95% CI: ‐1.33 to ‐0.10)] and at short‐term follow‐up; 2) scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short‐term follow‐up; 3) combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp ‐0.33 (95% CI: ‐0.55 to ‐0.10)] and up to long‐term follow‐up and a medium magnitude of effect improving function at both immediate post treatment and at short‐term follow‐up [SMDp ‐0.45 (95%CI: ‐0.72 to ‐0.18)]; 4) cervico‐scapulothoracic strengthening/stabilization exercises to improve pain and function at intermediate term [SMDp ‐14.90 (95% CI:‐22.40 to ‐7.39)]; 5) Mindfulness exercises (Qigong) minimally improved function but not global perceived effect at short term. Low evidence suggests 1) breathing exercises; 2) general fitness training; 3) stretching alone; and 4) feedback exercises combined with pattern synchronization may not change pain or function at immediate post treatment to short‐term follow‐up. Very low evidence suggests neuromuscular eye‐neck co‐ordination/proprioceptive exercises may improve pain and function at short‐term follow‐up.

For chronic cervicogenic headache, moderate quality evidence supports static‐dynamic cervico‐scapulothoracic strengthening/endurance exercises including pressure biofeedback immediate post treatment and probably improves pain, function and global perceived effect at long‐term follow‐up. Low grade evidence supports sustained natural apophyseal glides (SNAG) exercises.

For acute radiculopathy, low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilization exercises.

Authors' conclusions

No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. Research showed the use of strengthening and endurance exercises for the cervico‐scapulothoracic and shoulder may be beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be expected. Future research should explore optimal dosage.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Exercise for Neck Pain

Review question

We reviewed the evidence about the effect of exercise therapy on pain, disability, patient satisfaction, and quality of life among people with neck pain.

Background

Neck pain is common; it can limit a person's ability to participate in normal activities and is costly. Exercise therapy is a widely used treatment for neck pain. This review includes active exercises (including specific neck and shoulder exercises, stretching, strengthening, postural, breathing, cognitive, functional, eye‐fixation and proprioception exercises) prescribed or performed in the treatment of neck pain. Studies in which exercise therapy was given as part of a multidisciplinary treatment, multimodal treatment (along with other treatments such as manipulation or ultrasound), or exercises requiring application by a trained individual (such as hold‐relax techniques, rhythmic stabilization, and passive techniques) were excluded.

Study characteristics

The evidence is current to May 2014. We found 27 trials (with a total of 2485 participants) examining whether exercise can help reduce neck pain and disability; improve function, global perceived effect, patient satisfaction and/or quality of life. In these trials, exercise was compared to either a placebo treatment, or no treatment (waiting list), or exercise combined with another intervention was compared with that same intervention (which could include manipulation, education/advice, acupuncture, massage, heat or medications). Twenty‐four of 27 trials evaluating neck pain reported on the duration of the disorder: 1 acute; 1 acute to chronic; 1 subacute; 4 subacute/chronic; and 16 chronic. One study reported on neck disorder with acute radiculopathy; two trials investigated subacute to chronic cervicogenic headache.

Key results

Results showed that exercise is safe, with temporary and benign side effects, although more than half of the trials did not report on adverse effects. An exercise classification system was used to ensure similarity between protocols when looking at the effects of different types of exercises. Some types of exercise did show an advantage over the other comparison groups. There appears to be a role for strengthening exercises in the treatment of chronic neck pain, cervicogenic headache and cervical radiculopathy if these exercises are focused on the neck, shoulder and shoulder blade region. Furthermore, the use of strengthening exercises, combined with endurance or stretching exercises has also been shown to be beneficial. There is some evidence to suggest the beneficial effects of specific exercises (e.g. sustained natural apophyseal glides) with cervicogenic headaches and mindfulness exercises (e.g. Qigong) for chronic mechanical neck pain. There appears to be minimal effect on neck pain and function when only stretching or endurance type exercises are used for the neck, shoulder and shoulder blade region.

Quality of the evidence

No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Future research is likely to have an important impact on the effect estimate.There were a number of challenges with this review; for example, the number of participants in most trials was small, more than half of the included studies were either of low or very low quality and there was limited evidence on optimum dosage requirements.

Authors' conclusions

Implications for practice

This review shows that there is still no high quality evidence and uncertainty about the effectiveness of exercise for neck pain. Further research is likely and in some cases very likely to have an important impact on the effect estimate. Moderate quality evidence supports the use specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy. Specifically the use of strengthening exercises for the cervical spine, scapulothoracic and shoulders may be beneficial in reducing pain and improving function when used for the treatment of chronic mechanical neck pain, cervicogenic headache and cervical radiculopathy. Moderate quality evidence supports the use of strengthening exercises, combined with endurance or stretching exercises may also yield similar beneficial results. However, low quality evidence notes when only stretching or only endurance type exercises were used for the cervical, scapulothoracic and shoulders regions, there may be minimal beneficial effects for both neck pain and function. There is moderate quality evidence to suggest beneficial effects of a specific type exercises (e.g. sustained natural apophyseal glides) for cervicogenic headache.

Implications for research

This update shows some positive findings for using exercise for neck pain, but further research is warranted because it is (very) 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 findings, particularly in the area of cervicogenic headache and cervical radiculopathy.

Neck pain continues to be a somewhat heterogeneous classification. Use of prognostic and treatment classification variables may aid in distilling, which subgroups will most benefit from what specific exercise. An international standardization of a ‘core outcome measure set’ is needed to improve reporting of effects and to aid in the systematic review process. The length of follow‐up in many studies is limited and adherence to exercise not monitored. Adequate recording of the types and exact dosage of the exercise programs is also important to assist in translation of its use into practice as well as for the pooling of data to improve in directness of the outcomes.

Summary of findings

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Summary of findings for the main comparison. Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION compared to THAT SAME INTERVENTION

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

Patient or population: patients with mechanical neck disorders
Settings: ambulatory care clinic
Intervention: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION
Comparison: THAT SAME INTERVENTION

Outcomes

Effects

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 10 worst pain

(follow‐up: 6 months)

Three trials showed a small reduction in pain.

Pooled scores estimated using a mean difference of ‐0.67 (‐1.32 to ‐0.02)

241
(3 studies: Bronfort 2011, Chiu 2005, Franca 2008)

⊕⊕⊕⊝
moderate1

Function: NDI 0 no disability to 50 maximum disability (follow‐up: 6 months)

Three trials showed a small to moderate improvement in function.

Pooled scores estimated using a mean difference of ‐2.80 (‐6.36 to 0.76)

241
(3 studies: Bronfort 2011, Chiu 2005, Franca 2008)

⊕⊕⊕⊝
moderate1

Quality of Life: SF‐36 (physical component) 0 worse to 100 better, SF‐12.

(follow‐up: Immediate post treatment)

Two trials showed no significant difference

Pooled scores estimated using a standard mean difference of ‐0.18 (‐0.48 to 0.13)

165

(2 studies: Bronfort 2001, Martel 2011)

⊕⊕⊝⊝
low1

Patient Satisfaction: 1 to 7; completely satisfied to completely dissatisfied

(follow‐up: 24 months)

One trial showed moderate improvement in satisfaction

Scores estimated using a standard mean difference of ‐0.93 (‐1.35 to ‐0.52)

101

(1 study: Bronfort 2001)

⊕⊕⊕⊝
moderate

Global Perceived Effect: Patient‐ Rated Improvement 1 more improvement to 9 less improvement

(follow‐up: 24 months)

One trial showed a small to moderate improvement in global perceived effect

Scores estimated using a standard mean difference of ‐0.42 (‐0.81 to ‐0.03)

101

(1 study: Bronfort 2001)

⊕⊕⊕⊝
moderate

Adverse Effects

One study reported increased neck or headache pain: Intervention group (n = 8), comparison group (n = 6); increased radicular pain intervention group (n = 1); severe thoracic pain comparison group (n = 1); all cases self‐limiting and no permanent injuries (Bronfort 2001). 3 trials reported no complications or serious adverse events (Chiu 2005, Franca 2008, Martel 2011)

Moderate quality evidence: (4 trials, 341 participants, Bronfort 2001; Chiu 2005; Franca 2008; Martel 2011) 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 6 to18 people to achieve this type of pain relief and 4 to 13 to achieve this functional benefit. Moderate quality evidence (one trial, 101 participants; Bronfort 2001) demonstrates patients are very satisfied with their care. Changes in quality of life are suggestive of benefit but not conclusive. Changes in global perceived effect measures indicate a difference immediately post treatment and at long‐term follow‐up.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Two of the pooled studies had high risk of bias scores (Franca 4/12 and Martel 5/12). That is, the studies met fewer than 6 of the 12 criteria, indicating high risk of bias.

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Summary of findings 2. Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization compared to WAIT LIST

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

Patient or population: patients with chronic mechanical neck disorders
Settings: residential community
Intervention: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization
Comparison: WAIT LIST

Outcomes

Effects

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 100 worst pain; (follow‐up: immediate post treatment)

a. 12 weeks of treatment

b. 24 weeks of treatment or 12 weeks of treatment+ 12 weeks follow‐up

Two trials showed a medium reduction in pain.

a. Pooled mean difference ‐14.90 (‐22.40 to ‐7.39)

b. Pooled mean difference ‐10.94 (‐18.81 to ‐3.08)

147
(2 studies: Rendant 2011, von Trott 2009)

⊕⊕⊕⊝
moderate1,2

Function: NPDI or NDI 0 no disability to 100 maximum disability; (follow‐up: immediate post treatment)
a. 12 weeks of treatment

b. 24 weeks of treatment or 12 weeks treatment + 12 weeks follow‐up

Two trials showed a medium improvement in function.

a. Pooled SMD ‐0.50 (‐1.04 to 0.03)

b. Pooled SMD ‐0.40 (‐0.74 to ‐0.06)

147
(2 studies: Rendant 2011, von Trott 2009)

⊕⊕⊕⊝
moderate1,2

Quality of Life: SF‐36 (physical component) 0 worse to 100 better; (follow‐up: immediate post treatment)

a. 12 weeks of treatment

b. 24 weeks of treatment or 12 weeks treatment + 12 weeks follow‐up

Two trials showed no significant difference in quality of life scores

a. Pooled mean difference ‐2.22 (‐5.17 to 0.72)

b. Pooled mean difference 0.06 (‐4.06 to 4.17)

143
(2 studies: Rendant 2011, von Trott 2009)

⊕⊕⊕⊝
moderate1,2

Global Perceived Effect: General Health Perception 0 worse to 100 better (follow‐up: immediate post treatment)

a. 12 weeks of treatment

b. 24 weeks of treatment

One trial showed no significant difference in GPE.

70

(1 study: von Trott 2009)

⊕⊕⊕⊝
moderate2

Adverse Effects

Reported by 18 patients in exercise group: muscle soreness (n = 15), 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) , nausea (n = 1), muscle tensions (n = 2)

Moderate quality evidence (two trials, 147 participants, von Trott 2009; Rendant 2011) shows cervical stretch/ROM exercises + cervical/scapulothoracic strengthening + static/dynamic cervical/shoulder stabilization probably has moderate benefit for pain and function, but not GPE and QoL at immediate post treatment and short‐term follow‐up. A clinician may need to treat four people to achieve moderate degree of pain relief and five to achieve moderate functional benefit in one patient.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 One of the studies (Rendant 2011) scored 6/12 on 'Risk of bias' assessment.That is, the study met 6 or fewer than 6 of the 12 criteria, indicating high risk of bias.
2 Small studies

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Summary of findings 3. Chronic MND: Qigong Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) compared to WAIT LIST

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

Patient or population: patients with chronic mechanical neck disorders
Settings: residential community
Intervention: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance)
Comparison: WAIT LIST

Outcomes

Effects

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 100 worst pain (follow‐up: immediate post treatment)

a. 12 weeks of treatment

b. 24 weeks of treatment or 12 treatments + 12 weeks follow‐up

Two trials showed a moderate reduction in pain

Pooled scores estimated using a

a. Mean difference of ‐13.28 (‐20.98 to ‐5.58)

b. Mean difference of ‐7.82 (‐14.57 to ‐1.07)

148
(2 studies: Rendant 2011, von Trott 2009)

⊕⊕⊕⊝
moderate1

Function: NPDI 0 no disability to 100 maximum disability (follow‐up: immediate post treatment)

a. 12 weeks of treatment

b. 24 weeks of treatment or 12 weeks treatment + 12 weeks follow‐up

Two trials showed a small improvement in function

Pooled scores estimated using a

a. Standard mean difference of ‐0.36 (‐0.68 to ‐0.03)

b. Standard mean difference of ‐0.28 (‐0.68 to 0.11)

148
(2 studies: Rendant 2011, von Trott 2009)

⊕⊕⊕⊝
moderate1

Quality of Life: SF‐36 (physical component) 0 worse to 100 better (follow‐up: immediate post treatment)

a. 12 weeks of treatment

b. 24 weeks of treatment or 12 weeks treatment + 12 weeks follow‐up

Two trials showed little to no difference in quality of life

Pooled scores estimated using a

a. Mean difference of ‐2.72 (‐5.42 to ‐0.01)

b. Mean difference of ‐1.88 (‐5.80 to 2.04)

148
(2 studies: Rendant 2011, von Trott 2009)

⊕⊕⊕⊝1
moderate

Global Perceived Effect: General Health Perception 0 worse to 100 better (follow‐up immediate post treatment and short‐term)

One trial showed no significant difference in GPE.

70

(1 study: von Trott 2009)

⊕⊕⊕⊝
moderate1,2

Adverse Effects

Reported by 23 patients in qigong group including: muscle soreness (n = 17), 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), nausea (n = 2), muscle tension (n = 1)

Moderate quality evidence: (2 trials, 148 participants, Rendant 2011; von Trott 2009) shows Qigong exercises (Dantian Qigong) 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 benefit at immediate and short‐term follow‐up on quality of life and global perceived effect. A clinician may need to treat four to six people to achieve this type of pain relief, five to eight people to achieve this functional benefit, and seven to 10 people for this improvement in quality of life.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 One included study (Rendant 2011) scored 6/12 on risk of bias assessment.That is, the study met 6 or fewer than 6 of the 12 criteria, indicating high risk of bias.
2 Small studies.

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Summary of findings 4. Acute Radiculopathy: Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST

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

Patient or population: patients with acute radiculopathy

Settings: Three hospitals in Netherlands

Intervention: Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization

Comparison: Wait list

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 10 worst pain

(follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up period after treatment)

b. 6 months

One trial showed a small reduction in pain immediately post treatment and no benefit at 6 months follow‐up.

a. Standard mean difference are ‐0.47 (‐0.81 to ‐0.12) post intervention

b. Standard mean difference are 0.16 (‐0.19 to 0.51) at 6 months follow‐up.

133 participants
(1 study: Kuijper 2009)

⊕⊕⊝⊝1,2
low

Function: NDI 0 no disability to 50 maximum disability (follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up period after treatment)

b. 6 months

One trial showed a small reduction in functional disability immediately post treatment and no benefit at 6 months follow‐up.

a. Standard mean difference are ‐0.11 (‐0.45 to 0.23) post intervention.

b. Standard mean difference are 0.06 (‐0.29 to 0.40) at 6 month follow‐up.

133 participants
(1 study: Kuijper 2009)

⊕⊕⊝⊝1,2
low

Patient Satisfaction: 5‐point scale, 1 to 5; very satisfied to unsatisfied

(follow‐up: immediate post treatment)

a. 6 weeks of treatment

a. One trial showed no difference in patient satisfaction immediately post treatment. relative risk ratio are 0.92 (0.62 to 1.37) post intervention.

129 participants
(1 study: Kuijper 2009)

⊕⊕⊝⊝1,2
low

Adverse Effects

Not reported

Low quality evidence: (one trial, 133 participants, Kuijper 2009) Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization may improve pain slightly, but may make no difference in function and patient satisfaction when compared immediately post treatment with a control for acute cervical radiculopathy. However, there may be no difference in pain and functional improvement at intermediate‐term follow‐up.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 One included study (Kuijper 2009) scored 4/12 on risk of bias assessment.That is, the study met 6 or fewer than 6 of the 12 criteria, indicating high risk of bias.
2 Small study.

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Summary of findings 5. Acute to subacute CGH: Cervical stretch/ROM vs SHAM

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

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

Settings: Physiotherapy Private Practice

Intervention: Cervical stretch/ROM

Comparison: SHAM INTERVENTION

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 100 worst pain

(follow‐up: immediate post treatment )

a. 4 weeks of treatment

(follow‐up period after treatment)

b. 12 months

One trial showed a small reduction in pain

a. Standard mean difference are ‐1.58 (‐2.38 to ‐0.77) at 4 weeks

b. Standard mean difference are ‐1.74 (‐2.57 to ‐0.91) at 12 months.

32

(1 study: Hall 2007)

⊕⊕⊝⊝
low1,2

Adverse effects

Not reported

Low quality evidence: (one trial, 32 participants, Hall 2007 ) shows Cervical stretch/ROM may improve a large amount for pain reduction at short‐ and long‐term follow‐up with the use of C1 to 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.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Percision: Small study (n=16 per arm).

2 Reporting bias: due to trial size and single outcome, future research is likely to influence the direction of reported effect. Replication in a second trial is needed.

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Summary of findings 6. Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION

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

Patient or population: patients with chronic CGH

Settings: multiple trial centres

Intervention: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization

Comparison: NO INTERVENTION

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 10 worst pain

(follow‐up: immediate post treatment)

a. 6 weeks

(follow‐up period after treatment)

b. 12 months

One trial showed a large reduction in pain at 6 weeks and 12 months follow up.

a. Standard mean difference are ‐0.75 (‐1.16 to ‐0.34) at 6 weeks

b. Standard mean difference are ‐0.59 (‐1.00 to ‐0.18) at 12 months follow‐up.

97

(1 study: Jull 2002)

⊕⊕⊕⊝
moderate1

Function: NPNPQ 0% no disability to 100% maximum disability

(follow‐up: immediate post treatment)

a. 6 weeks

(follow‐up period after treatment)

b. 12 months

One trial showed a moderate reduction in functional disability

a. Standard mean difference are ‐0.56 (‐0.96 to ‐0.15) at 6 weeks

b. Standard mean difference are ‐0.70 (‐1.11 to 0.29) at 12 months follow‐up.

97

(1 study: Jull 2002)

⊕⊕⊕⊝
moderate1

Global Perceived Effect: VAS 0 to 100

(follow‐up: immediate post treatment)

a. 6 weeks

(follow‐up period after treatment)

b. 12 months

One trial showed a large benefit in global perceived effect

a. Standard mean difference are ‐2.96 (‐3.55 to ‐2.38) at 6 weeks.

b. Standard mean difference are ‐2.51 (‐3.05 to ‐1.97) at 12 months follow‐up.

97

(1 study: Jull 2002)

⊕⊕⊕⊝
moderate1

Adverse effects

Minor and temporary adverse effects were noted: 6.7% of headaches were provoked by treatment

Moderate quality evidence: (one trial, 97 participants, Jull 2002) shows cervicoscapular strengthening and endurance exercises including pressure biofeedback probably improves pain, function and global perceived effect for chronic cervicogenic headaches at long term follow‐up when compared to no treatment. A clinician may need to treat six people to achieve this type of pain relief and functional benefit in one patient.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Percision: Although small study, consistent findings are noted across multiple outcomes at long term follow‐up.

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Summary of findings 7. Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization + Manual Therapy vs Manual Therapy

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

Patient or population: patients with Chronic CGH

Settings: multiple trial centres

Intervention: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization + Manual Therapy

Comparison: MANUAL THERAPY

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: 6 weeks treatment VAS 0 no pain to 10 worst pain

(follow‐up: immediate post treatment)

a. 6 weeks

(follow‐up period after treatment)

b. 12 months

One trial showed a small reduction in pain

a. Standard mean difference are ‐0.11 (‐0.50 to 0.29) at 6 weeks

b. Standard mean difference are ‐0.17 (‐0.57 to 0.23) at 12 months follow‐up.

96

(1 study: Jull 2002)

⊕⊕⊕⊝
moderate1

Function: NPNPQ 0% no disability to 100% maximum disability

(follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up period after treatment)

b. 12 months

One trial showed a small reduction in functional disability

a. Standard mean difference are ‐0.11 (‐0.51 to 0.28) at 6 weeks

b. Standard mean difference are ‐0.23 (‐0.63 to 0.17) at 12 months follow‐up.

96

(1 study: Jull 2002)

⊕⊕⊕⊝
moderate1

Global Perceived Effect: VAS 0 to 100 (follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up period after treatment)

b. 12 months

One trial showed a small benefit in global perceived effect

a. Standard mean difference are ‐0.29 (‐0.68 to 0.11) at 6 weeks

b. Standard mean difference ‐0.30 (‐0.70 to 0.10) at 12 months follow‐up.

96

(1 study: Jull 2002)

⊕⊕⊕⊝
moderate1

Adverse effects

Minor and temporary adverse effects were noted: 6.7% of headaches were provoked by treatment

Moderate quality evidence (one trial, 96 participants, Jull 2002) shows when exercise combined with manual therapy contrasted with manual therapy alone there is probably no difference in pain, function and global perceived effect for chronic cervicogenic headaches at long‐term follow‐up.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Percision: Although small study, consistent findings are noted across multiple outcomes at long term follow‐up.

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Summary of findings 8. Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM

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

Patient or population: patients with chronic MND

Settings: Primary care physical therapy and private physical therapy practices

Intervention: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization

Comparison: PLACEBO or SHAM

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 100 worst pain

(follow‐up: immediate post treatment)

a. 2 months of treatment

(follow‐up period after treatment)

b. 6 months

c. 12 months

One trial showed no difference in pain immediately post intervention and at 6 and 12 months follow‐up.

a. Standard mean difference 0.26 (‐0.33 to 0.85) immediately 2 months post intervention.

b. Standard mean difference ‐0.16 (‐0.75 to 0.43) at 6 months follow‐up.

c. Standard mean difference ‐0.19 (‐0.40 to 0.78) at 12 months follow‐up.

77

(1 study: Kjellman 2002)

⊕⊕⊝⊝
low1,2

Function: 2 months treatment NDI 0 no disability to 50 maximum disability

(follow‐up: immediate post treatment)

a. 2 months of treatment

(follow‐up period after treatment )

b. 6 months

c. 12 months

One trial showed no difference in function immediately post intervention and at 6 and 12 months follow‐up.

a. Standard mean difference are 0.14 (‐0.45 to 0.73) immediately post 2 months intervention.

b. Standard mean difference ‐0.06 (‐0.66 to 0.53) at 6 months follow‐up.

c. Standard mean difference 0.12 (‐0.47 to 0.72) at 12 months follow‐up.

77

(1 study: Kjellman 2002)

⊕⊕⊝⊝
low1,2

Adverse effects

Not reported

Low quality evidence: (One trial, 77 participants, Kjellman 2002) No difference for pain relief and function immediately post intervention, at 6 and 12 months follow‐up using Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization for chronic MND.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 One of the studies (Kjellman 2002)) scored 5/12 on 'Risk of bias' assessment.That is, the study met 6 or fewer than 6 of the 12 criteria, indicating high risk of bias.
2 Small studies

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Summary of findings 9. Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM

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

Patient or population: patients with chronic MND

Settings: Primary care physical therapy and private physical therapy practices

Intervention: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization

Comparison: PLACEBO or SHAM

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 100 worst pain (follow‐up: immediate post treatment)

a. 2 months of treatment

(follow‐up period after treatment)

b. 6 months

c. 12 months

One trial showed no difference in pain immediately post intervention and at 6 and 12 months follow‐up.

a. Standard mean difference are ‐0.10 (‐0.66 to 0.45) immediately post 2 months intervention.

b. Standard mean difference ‐0.29 (‐0.85 to 0.27) at 6 months follow‐up.

c. Standard mean difference 0.04 (‐0.51 to 0.60) at 12 months follow‐up.

50

(1 study: Kjellman 2002)

⊕⊕⊝⊝
low1,2

Function: NDI 0 no disability to 50 maximum disability (follow‐up: immediate post treatment)

a. 2 months of treatment

(follow‐up period after treatment )

b. 6 months

c. 12 months

One trial showed no difference in function immediately post intervention and at 6 and 12 months follow‐up.

a. Standard mean difference are ‐0.24 (‐0.79 to 0.32) immediately post 2 month intervention.

b. Standard mean difference ‐0.22 (‐0.79 to 0.36) at 6 months follow‐up

c. Standard mean difference 0.14 (‐0.44 to 0.71) at 12 months follow‐up.

50

(1 study: Kjellman 2002)

⊕⊕⊝⊝
low1,2

Adverse effects

Not reported

Low quality evidence: (One trial, 50 participants, Kjellman 2002) No difference for pain relief and function immediately post intervention, at 6 and 12 month follow‐up using Cervical Stretch/ROM Exercise + Dynamic Cervical Stabilization for chronic MND.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 One of the studies (Kjellman 2002) scored 5/12 on 'Risk of bias' assessment.That is, the study met 6 or fewer than 6 of the 12 criteria, indicating high risk of bias.
2 Small studies

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Summary of findings 10. Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST

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

Patient or population: patients with chronic MND

Settings: office workers

Intervention: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training

Comparison: NO INTERVENTION or WAIT LIST

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 100 worst pain

(follow‐up: immediate post treatment)

a. 12 weeks of treatment

(follow‐up period after treatment)

b. 3 months

c. 9 months

One trial showed no difference in pain immediately post intervention and at 3 and 9 months follow‐up.

a. Standard mean difference are 0.08 (‐0.16 to 0.32) immediately post 12 weeks intervention.

b. Standard mean difference 0.00 (‐0.24 to 0.24) at 3 months follow‐up.

c. Standard mean difference ‐0.04 (‐0.28 to 0.20) at 9 months follow‐up.

393

(1 study: Viljanen 2003)

⊕⊕⊕⊝
moderate1

Function: NDI 0 no disability to 50 maximum disability

(follow‐up: immediate post treatment)

a. 12 weeks of treatment

(follow‐up period after treatment)

b. 3 months

c. 9 months

One trial showed no difference in function immediately post intervention and at 3 and 9 months follow up.

a. Standard mean difference 0.07 (‐0.17 to 0.31) immediately post 12 weeks intervention.

b. Standard mean difference 0.07 (‐0.17 to 0.31) at 3 months follow‐up.

c. Standard mean difference 0.14 (‐0.11 to 0.38) at 9 months follow‐up.

393

(1 study: Viljanen 2003)

⊕⊕⊕⊝
moderate1

Adverse effects

Not reported

Moderate quality evidence: (one trial, 393 participants, Viljanen 2003) Little to no difference for pain relief and function immediately post intervention, at 3 and 9 months follow‐up using Cervical/Scapulothoracic/UE Stretch + UE Endurance Training for chronic MND.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Percision: high drop out rate (14%); reason for dropout not described.

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Summary of findings 11. Acute to Chronic MND: Scapulothoracic/UE Endurance Training vs CONTROL

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

Patient or population: patients with Acute to Chronic MND

Settings: two large withe collar organizations

Intervention: Scapulothoracic/UE Endurance Training

Comparison: CONTROL

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 10 worst pain (follow‐up: immediate post 10 weeks treatment)

a. 2‐minute training group

b. 12‐minute training group

One trial showed moderate pain relief immediately post intervention.

a. Standard mean difference for the 2 minute training group ‐0.66 (‐1.02 to ‐0.30).

b. Standard mean difference for the 12 minute training group ‐0.59 (‐0.94 to ‐0.23).

198

(1 study: Andersen 2011)

⊕⊕⊕⊝
moderate1

Adverse effects

Reported worsening of neck muscle tension during and/or in the days after training (2‐minute n = 1, 12‐minute n = 4), shoulder joint pain during training (2‐minute n = 1, 12‐minute n = 4), pain in the upper arm during training (2‐minute n = 1, 12‐minute n = 1), pain of the forearm/wrist during training (12‐minute n = 2), worsening of headache after training (2‐minute n = 1, 12‐minute n = 1). No long‐lasting or major complications resulted from the training program.

Moderate quality evidence: (one trial, 198 participants, Andersen 2011) Moderate benefit for pain relief immediately post intervention using Scapulothoracic/UE Endurance Training for (sub)Acute/Chronic MND. A clinician may need to treat four people to achieve this type of pain relief.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Percision: small sample (n = 63 or 64 per Arm) measured at Immediate post treatment.

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Summary of findings 12. Subacute to Chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT

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

Patient or population: patients with subacute/chronic WAD

Settings: two physiotherapy clinics

Intervention: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT

Comparison: THAT SAME OTHER TREATMENT

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 10 worst pain

(follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up period after treatment)

b. 12 months

One trial showed small pain relief immediately post intervention and no difference at 12 months follow‐up.

a. Standard mean difference ‐0.46 (‐0.81 to ‐0.12) immediately post 6 weeks intervention.

b. Standard mean difference ‐0.12 (‐0.47 to 0.23) at 12 months follow‐up.

132

(1 study: Stewart 2007)

⊕⊕⊝⊝
low1,2

Function: NDI 0 no disability to 50 maximum disability

(follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up period after treatment)

b. 12 months

One trial showed small benefit in function immediately post intervention and at 12 months follow‐up.

a. Standard mean difference ‐0.50 (‐0.85 to ‐0.15) immediately post 6 weeks intervention.

b. Standard mean difference ‐0.39 (‐0.74 to ‐0.03) at 12 months follow‐up.

132

(1 study: Stewart 2007)

⊕⊕⊝⊝
low1,2

Global perceived effect: ‐5 to 5 scale; vastly worse to completely recovered

(follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up after treatment)

b. 12 months

One trial showed small benefit in global perceived effect immediately post intervention and no difference at 12 months follow‐up.

a. Standard mean difference ‐0.46 (‐0.80 to ‐0.11) immediately post 6 weeks intervention.

b. Standard mean difference ‐0.18 (‐0.54 to 0.17) at 12 months follow‐up.

132

(1 study: Stewart 2007)

⊕⊕⊝⊝
low1,2

Quality of Life: SF‐36 0 high disability to 100 no disability (follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up after treatment)

b. 12 months

One trial showed small benefit in global perceived effect immediately post intervention and no difference at 12 month follow‐up.

a. Standard mean difference ‐0.35 (‐0.69 to ‐0.01) immediately post 6 weeks intervention.

b. Standard mean difference ‐0.15 (‐0.50 to 0.20) at 12 month follow‐up.

132

(1 study: Stewart 2007)

⊕⊕⊝⊝
low1,2

Adverse effects

Reported; The main complaint in this group was muscle pain with exercise (3) followed
by knee pain (2) and lumbar spine pain (2).

Low quality evidence: (one trial, 132 participants, Stewart 2007) Small benefit for pain relief, function, global perceived effect and quality of life immediately post treatment and small benefit at 12 month follow up for function using Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT for Subacute/chronic WAD.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 One of the studies (Stewart 2007) scored 6/12 on 'Risk of bias' assessment.That is, the study met 6 or fewer than 6 of the 12 criteria, indicating high risk of bias.
2 Small studies

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Summary of findings 13. Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL

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

Patient or population: patients with Acute to Chronic MND

Settings: Seven workplaces

Intervention: Scapulothoracic + UE Strengthening

Comparison: CONTROL

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 100 worst pain (follow‐up: immediate post 10 to 20 weeks of treatment)

Three trials showed a moderate reduction in pain. Pooled scores estimated using a standard mean difference ‐0.71 (‐1.33 to ‐0.10).

157

(3 studies: Andesen 2008, Andersen CH 2012, Dellve 2011)

⊕⊕⊕⊝
moderate

Pain Intensity: VAS 0 no pain to 100 worst pain (follow‐up: immediate post 20 weeks of treatment)

a. 1 weekly session

b. 9 weekly sessions

One trial (two comparisons) showed no difference in pain relief immediately post intervention.

a. One weekly session of 60 minutes, scores using a standard mean difference ‐0.20 (‐0.63 to 0.22).

b. Nine weekly sessions of seven minutes, scores using a standard mean difference ‐0.13 (‐0.61 to 0.34).

163

(1 study: three groups, Andersen CH 2012)

⊝⊝⊝⊝
very low1

Pain Intensity: VAS 0 no pain to 100 worst pain (follow‐up: immediate post 10 weeks of treatment)

One trial showed moderate reduction in pain 10 weeks post intervention. Scores using a standard mean difference ‐0.89 (‐1.76 to ‐0.01) at 10 week follow‐up.

26

(1 study: Andersen 2008)

⊕⊕⊝⊝
low

Function: DASH 20% no difficulty to 100% fully unable (follow‐up: immediate post 20 weeks of treatment).

a. 1 weekly session

b. 9 weekly sessions

One trial showed no difference in function immediately post intervention.

a. Standard mean difference ‐0.17 (‐0.58 to 0.24) immediately post intervention for one weekly session of 60 minutes

b. Standard mean difference ‐0.06 (‐0.53 to 0.41) for nine weekly sessions of seven minutes.

163

(1 study: Andersen CH 2012)

⊝⊝⊝⊝
very low1

Work ability index: 7 poor ability to 49 excellent ability treatment (follow‐up: immediate post 20 weeks treatment)

One trial showed a small improvement in work ability immediately post intervention. Standard mean difference ‐0.23 (‐0.66 to 0.19) immediately post 20 weeks intervention.

88

(1 study: Dellve 2011)

⊕⊕⊝⊝
low

Adverse effects

Not reported

Moderate quality evidence: (3 trials, 157 participants, Andersen 2008, Andersen Ch 2012, Dellve 2011) that scapulothoracic and upper extremity strength training probably improves pain. It probably functional outcomes when compared to control for chronic mechanical neck pain immediately post treatment (10 or 20 week interventions). However low quality evidence suggests that scapulothoracic and upper extremity strength training may improve pain slightly.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Design: 0, Limitations: ‐1, Inconsistency: 0, Indirectness: 0, Imprecision: ‐1, Other: ‐1 subgroup analysis.

Background

Description of the condition

Neck disorders are common (Hogg‐Johnson 2008; Hoy 2014), painful, and limit function in the general population (Carroll 2008a, Haldeman 2010,), workers (Côté 2008) and people with whiplash associated disorders (WAD) (Carroll 2008b; Buitenhuis 2009). The global point prevalence of neck pain was estimated to be 4.9% in 2010 (Hoy 2014). In the United States, 15.1% of adults state having had neck pain within the previous three months (NCHS 2013).

In 2005, the mean medical expenditure amongst Americans with spine problems was estimated to be $6096USD per individual annually compared with $3516USD amongst those without spine problems (Martin 2008). Côté 2008 reported 3% to 11% of claimants in the work force were sufficiently disabled to lose time from work each year. Direct and indirect costs are substantive (Martin 2008).

Description of the intervention

We adopted the Therapeutic Exercise Intervention Model to sub‐classify exercise (Sahrmann 2002). This model is based on the elements of movement system. Sahrmann 2002 originally described movement as a system made up of five elements. Hall 2005 further developed this concept into a three dimensional model. The elements of movement system intersect with two other axes ‐ activity and dosage. After determining which element of the movement system needs to be addressed to restore function, the activity or technique to achieve the functional goal is chosen. The dosage parameters are modified according to the tissues involved and the principles of tissue healing. A brief description of each element follows.

1.Support Element: An exercise categorized under this element would affect the functional status of the cardiac, pulmonary and metabolic systems (e.g. aerobic endurance activities).

2. Base Element: Exercises categorized under base element 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 mobilization exercises,

  • force or torque capability of muscles and the related muscle length‐tension properties for strengthening exercises, and

  • endurance of muscle also involved in strengthening for endurance‐strength training.

3.Modulator Element: Exercises under this element relate to motor control for neuromuscular reeducation as follows:

  • patterns and synchronization of muscle recruitment, and

  • feed‐forward or feedback systems using verbal, visual, tactile and other proprioceptive input to the patient.

4. 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 stabilization forces involved in alignment and muscle recruitment, and

  • dynamic stabilization forces involved in arthrokinetics, osteokinetics and kinematics.

5. Cognitive or Affective Element: Exercises in this category affect 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.

How the intervention might work

Exercise has both physical and mental benefits through its effects on numerous systems such as the cardiovascular system; immune system; brain function; sleep; mood; and the musculoskeletal system (Abernethy 2013). Exercise can result in the following.

  • Increase flexibility and mobility of structures; improve muscle strength and endurance; increase tensile strength of ligaments and capsule; amplify strength and prevent injury of tendons and cartilage; and is also important for repair of these tissues.

  • Improve cardiovascular function resulting in less chance of developing heart conditions, strokes, or high blood pressure.

  • Relieve stress, anxiety and depression; improve mood; and increase self‐esteem and weight management by producing positive biochemical changes in the body and brain. Endorphins released post exercise act as a natural pain reliever and antidepressant in the body.

  • Reduce the risk of premature mortality; improve functional capacity and help older adults maintain independence. Exercise increases circulation throughout the spine and supporting structures, which is crucial to promote healing.

  • Improve quality and duration of sleep and help sleep disorders such as insomnia.

  • Enhance cognitive function in older adults through physical activity and aerobic exercise.

  • Positively benefit the human immune system if done in moderation.

Central to these benefits are the stages of change, encompassing the health belief and cognitive behavior models, used to help patients make the lifestyle changes necessary for successful adherence to exercise, maintain new behaviours over time and address anticipated relapses (Zimmerman 2000). Helping patients change behavior is an important role for all clinicians.

Why it is important to do this review

In our last update on exercise therapy, we found low to moderate quality evidence of pain relief benefit for combined cervical, scapulothoracic stretching and strengthening for chronic neck pain in the short and long term. The relative benefit of other types of exercise was not clear (Kay 2012). Since then, five other reviews have found primarily very low to low grade evidence as follows: 1) Stretching and strengthening for chronic neck pain (Bertozzi 2013; Southerst 2014; Vincent 2013), 2) Strengthening, endurance and modular element (Bronfort 2009; Racicki 2012) for chronic cervicogenic headache, 3) Neuromuscular exercises (proprioception/eye‐neck co‐ordination) (Leaver 2010; Teasell 2010a) for subacute and chronic WAD, 4) Stretching and range of motion (ROM) exercises (Leaver 2010) for non‐specific neck pain, 5) Stretching, strengthening, endurance training, balance/co‐ordination, cardio and cognitive/affective elements (Leaver 2010; Lee 2009; Salt 2011; Southerst 2014; Teasell 2010c) for chronic neck pain, 6) Qigong exercises (; Lee 2009; Southerst 2014) for chronic neck pain, 7) Supervised exercise (Teasell 2010c) for chronic WAD, and 8) Strengthening neck exercises (Bertozzi 2013; Southerst 2014) for chronic neck pain.

In contrast, reviews found low grade evidence for no beneficial effect on pain as follows: 1) Stretching and strengthening (Salt 2011; Southerst 2014) for radiculopathy, 2) General fitness training (Bertozzi 2013; Kay 2012) for acute to chronic neck pain, and 3) Stretching and endurance training in chronic neck pain (Bertozzi 2013; Kay 2012). There may be more than one way to summarize the results but few used the grade system. The GRADE approach considers a number of additional factors (adverse events, costs, temporality, plausibility, dose response, strength of association, and clinical applicability) to place the results into a larger context (Guyatt 2006).

Many previous reviews looked at multimodal approaches such as manual therapy and exercise (Bronfort 2009; Clar 2014; Miller 2010; Schroeder 2013) but our focus is on exercise alone.

A number of these reviews included studies that were not clearly categorized; they also included studies that were not single intervention trials. The results limited our ability to understand the comparative effectiveness of exercise interventions for the management of neck pain. Therefore, the true impact of exercise alone could not be determined with strong evidence. Although there was some evidence of benefit as noted above, it became clear that categorizing exercises into a classification system according to their elements was essential in differentiating the intended effect that different types of exercises may have had. Exploring the dosage and mode of delivery of recommended exercises is essential in future reviews.

In the current update, our objective was to adapt a therapeutic model for exercise and sub‐classify the different exercises. This allowed us to link the specific aims of the exercise activity to its anatomical rationale. As a result, we gained a better perspective on the intended aim of the specific exercise, which allowed us to clarify some of the reporting variances and the variance in exercise types that may have been affecting the estimates of effect size. We wanted to determine the more accurate effect of exercises, which have clinical implications in patients with neck pain.

Objectives

This systematic review assessed the short‐ to long‐term effect of exercise therapy on pain, function, patient satisfaction, quality of life, and global perceived effect in adults experiencing mechanical neck pain with or without cervicogenic headache or radiculopathy. Where appropriate, the influence of risk of bias, duration of the disorder and subtypes of neck disorder on the treatment effect was assessed.

Methods

Criteria for considering studies for this review

Types of studies

We included any published or unpublished randomized controlled trials (RCTs) in any language. We excluded quasi‐RCTs and clinical controlled trials (CCTs).

Types of participants

Participants included in the review were adults (males or females aged 18 years or older) with acute (less than 30 days), subacute (30 days to 90 days) or chronic (greater than 90 days) neck disorders categorized as:

We excluded studies if they investigated neck disorders with definitive or possible long tract signs (e.g. myelopathies); neck pain caused by other pathological entities (Schumacher 1993); headache associated with the neck, but not of cervical origin; co‐existing headache, when either neck pain was not dominant or the headache was not provoked by neck movements or sustained neck postures; and 'mixed' headache.

Types of interventions

We included studies that used one or more type of exercise therapy specified in the Therapeutic Exercise Intervention Model to sub‐classify exercise (Sahrmann 2002) prescribed or performed in the treatment of neck pain. For the purposes of this review, we excluded studies in which exercise therapy was given as part of a multidisciplinary treatment, multimodal treatment (e.g. manual therapy plus exercise), or exercises that required manual therapy techniques by a trained individual (such as hold‐relax techniques, rhythmic stabilization, and passive techniques).

Types of comparisons

We contrasted interventions against the following comparisons:

  • sham or placebo,

  • no treatment or wait list, and

  • exercise plus another intervention versus that same intervention (for example, exercise plus manual therapy versus manual therapy).

We excluded all other comparisons.

Types of outcome measures

A study was included if it used at least one of the four primary outcome measures of interest:

  • pain,

  • measures of function/disability (including, but not limited to, neck disability index, activities of daily living, return to work, and sick leave),

  • patient satisfaction, and

  • global perceived effect/quality of life.

We extracted information on adverse events and costs of care when available.

We defined the duration of follow‐up as:

  • immediately post treatment (≤ one day),

  • short‐term follow‐up (one day to three months),

  • intermediate‐term follow‐up (three months up to, but not including, one year), and

  • long‐term follow‐up (one year or longer).

Search methods for identification of studies

A research librarian searched computerized bibliographic databases, without language restrictions, for medical, chiropractic and allied health literature. Subject headings (MeSH) and key words included anatomical terms, disorder or syndrome terms, treatment terms and methodological terms.

Electronic searches

We searched the following databases from their inception up to between January and May 2014:

  • Cochrane Central Register of Controlled Trials (CENTRAL, which includes the CBRG Trials Register; Ovid, 21 May 2014),

  • MEDLINE(Ovid, 1950 to April 2014 week 4),

  • Embase (Ovid, 1980 to April 21, 2014),

  • Manual Alternative and Natural Therapy (MANTIS; Ovid, 1980 to May 2014),

  • Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO, 1982 to March 2014),

  • Index to Chiropractic literature (ICL; Jan 2014), and

  • ClinicalTrials.gov (May 2014).

See Appendix 1 for the search strategies used for CENTRAL, MEDLINE, Embase, MANTIS, CINAHL, and ICL.

Searching other resources

We also screened references of all retrieved full‐text articles, identified content experts and searched conference proceedings from the World Confederation of Physical Therapist (WCPT 2007; WCPT 2011, International Federation of Orthopaedic and Manipulative Therapists IFOMPT 2012; IFOMPT 2008 ‐ hardcopy used), World Federation of Chiropractic (WFC 2013 ‐ CD copy used), and searched personal files up to May 2014 for grey literature.

Data collection and analysis

For continuous data, standardized mean differences (SMD) with 95% confidence intervals (CI) were calculated using a random‐effects model. Standard mean difference was selected over mean difference (WMD) because different types of exercises were assessed and most interventions used different outcome measures that used different scales.

Selection of studies

Two review authors with expertise in medicine, physiotherapy, chiropractic, massage therapy, statistics, or clinical epidemiology independently conducted citation identification and study selection using pre‐piloted forms. The assembled group did not author any of the primary trials. We assessed agreement for study selection using the quadratic weighted Kappa statistic (Kw), Cicchetti weights (Cicchetti 1976). We resolved disagreements through consensus and consultation with a third party if required.

Data extraction and management

Two review authors independently conducted data abstraction on pre‐piloted forms. We resolved disagreements through consensus. We consulted a neutral third party if consensus was not reached. We contacted study authors for missing information and data clarification. We extracted data on design (RCT, number analyzed/number randomized, intention‐to‐treat analysis, power analysis), participants (disorder subtype, duration of disorder), intervention (treatment characteristics for the treatment and comparison group, dosage/treatment parameters, co‐intervention, treatment schedule, duration of follow‐up), and outcomes (baseline mean, end of study mean, absolute benefit, reported results, point estimate with 95% CI, power, side effects, cost of care, and adverse events). These factors are noted in the Characteristics of included studies table.

Assessment of risk of bias in included studies

Two review authors independently conducted assessment of risk of bias in included studies using pre‐piloted forms. Disagreements were resolved through consensus (Graham 2011). The Cervical Overview Group used a calibrated team of assessors and at least two assessors independently assessed the risk of bias. 'Risk of bias' tables were presented and discussed by the broader validity assessment team to maximize inter‐rater reliability (Graham 2011), and consensus was reached on final 'Risk of bias' assessments. We did not exclude studies from this review on the basis of the 'Risk of bias' assessment results. The following biases were assessed: selection bias (random sequence generation, allocation concealment, groups similarity at baseline); performance bias (blinding of personnel/care providers, co‐intervention, and compliance); detection bias (blinding of outcome assessor); attrition bias (incomplete outcome data); reporting bias (selective reporting) (see Appendix 2 for the 'Risk of bias' criteria recommended by the Cochrane Back Review Group (Furlan 2009)). We rated each 'Risk of bias' item as low, high, or unclear and entered it into the 'Risk of bias' table for each included study.

Measures of treatment effect

We used primarily SMD with 95% CIs for continuous data. There are two summary statistics used for meta‐analysis of continuous data, the mean difference (MD) and the standard mean difference (SMD). The selection of the summary statistic was determined by whether all studies in a homogenous meta‐analysis group reported an outcome using the same scale (pooled MD) or using a different scale (pooled SMD). The estimation of minimal clinically important difference (MCID) for pain, function and disability were in accordance with the Cochrane Back Group recommendations (Furlan 2009). For the purpose of the review, the MCID for pain was 10 on a 100‐point pain intensity scale (Farrar 2001; Felson 1995; Goldsmith 1993). To assign some descriptors on the size of the difference between the treatment group and control groups, we considered the effect to be small when it was less than 10% of the visual analogue scale (VAS) scale, medium when it was between 10% and 20% of the VAS scale, and large when it was 20% to 30% of the VAS scale. For the neck disability index (NDI), we used a MCID of 7/50 neck disability index units (MacDermid 2009). It is noted that the minimal detectable change varies from 5/50 for non‐complicated neck pain to 10/50 for cervical radiculopathy (MacDermid 2009). For other outcomes (i.e. global perceived effect and quality of life), where there was an absence of clear guidance on the size of clinically important effect sizes, we used the common hierarchy of Cohen 1988: small (0.20), medium (0.50) or large (0.80). Risk ratios (RR) were calculated for dichotomous outcomes. When neither continuous nor dichotomous data were available, we extracted the findings and the statistical significance as reported by the author(s) in the original study.

Dealing with missing data

Where data were not extractable, we contacted the primary authors. For continuous outcomes reported as medians, we calculated effect sizes (Kendal 1963; p 237).

Assessment of heterogeneity

Prior to calculation of a pooled effect measure, the reasonableness of pooling was assessed, based on clinical judgement. Using a random‐effects model, statistical heterogeneity was tested using the Chi2 method between the studies. In the absence of heterogeneity (P > 0.10), we calculated a pooled SMD, MD or RR.

Assessment of reporting biases

We planned to assess reporting bias using sensitivity analysis but this was not possible due to a paucity of trials in any one category. Assessment of publication bias included use of the graphical aide funnel plot.

Data synthesis

We assessed the quality of the body of the evidence using the GRADE approach (Guyatt 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 generalizable), 5) imprecision (insufficient data), other factors (e.g. reporting bias) (Higgins 2009). The quality of the evidence was adjusted by a level based on the performance of the studies against the five domains. All plausible confounding factors were considered, as were their effects on the demonstrated treatment effects and their impact on the dose‐response gradient (Atkins 2004).

Levels of evidence were defined as follows.

  • High quality evidence: Further research is very unlikely to change our confidence in the estimate of effect. There are consistent findings among 75% of RCTs, with low risk of bias, that generalize to the population in question. There are sufficient data, with narrow confidence intervals. There are no known or suspected reporting biases (all of the domains are met).

  • Moderate quality evidence: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate (one of the domains is not met).

  • Low quality evidence: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate (two of the domains are not met).

  • Very low quality evidence: We are very uncertain about the estimate (three of the domains are not met).

  • No evidence: No RCTs were identified that measured this outcome.

We used the Cochrane GRADE approach and considered a number of additional factors (adverse events, costs, temporality, plausibility, dose response, strength of association, and clinical applicability) to place the results into a larger context. The number needed to treat to benefit (NNTB) and treatment advantages were calculated to communicate the magnitude of effect for main findings (Gross 2002).

Subgroup analysis and investigation of heterogeneity

Not conducted due to lack of data.

Sensitivity analysis

Sensitivity analysis or meta‐regression for the factors: symptom duration, methodological quality and subtype of neck disorder were planned but were not carried out because we did not have enough data in any one category.

Results

Description of studies

Results of the search

Considering all sources, we identified 5614 records through database searches and we found 44 records from other sources searched from start up to November 2013. Following screening of 201 full text articles, 192 were assessed for eligibility, (agreement on selection showed weighted kappa 0.94, SE 0.02). After further application of the eligibility criteria, we found 27 trials that used exercise treatment for non‐specific subacute and chronic neck pain, and selected them for this review; Figure 1 describes the flow of included, excluded, and ongoing, as well as those awaiting classification.


Study flow diagram (PRISMA).

Study flow diagram (PRISMA).

Included studies

Twenty‐seven trials [(2485/3005) analyzed at end of study /randomized participants] were selected for this review.

  • Three studies described different aspects of the same study population under additional publications: Andersen 2008 ‐ one trial, two publications; Bronfort 2001 ‐ one trial, four publications; Stewart 2007 ‐ one trial, three publications.

  • Two trials investigated cervicogenic headache, one subacute (Hall 2007) and the other chronic (Jull 2002).

  • One trial investigated acute radiculopathy (Kuijper 2009).

Studies varied in sample size from 16 to 340 (n analyzed), and 27 of 28 trials were considered small (less than 70 participants per intervention arm).

Excluded studies

Studies (n=130 primary papers and 30 companion paper) were excluded for the following reasons: two used a quasi‐RCT design, one used a prospective observational design, 12 examined a different type of participant (e.g. chronic tension headache, cervical dystonia), one reported on a subgroup of the included population, 96 tested a different intervention (e.g. not active exercise, the exercise was the same in all groups, or the exercise group could not be separated out from a multimodal intervention), 11 used a comparison group and seven did not measure any of the identified primary outcomes. See Characteristics of excluded studies tables for more details.

Risk of bias in included studies

We used the quadratic weighted Kappa (Kw) statistic to assess agreement on a per question basis (Kw 0.23 to 1.00). Each 'Risk of Bias' item is presented as a percentage across all included studies Figure 2. Common methodological weaknesses included each of the criteria listed below (see 'Risk of Bias' tables). Methodological quality did not appear to influence the end results of the reviews; both high and low quality studies had similar outcome directions. Albeit, limited data were available to analyze for publication bias; Figure 3 suggests that we cannot rule out publication bias. This relationship between risk of bias and end results of the review was not formally tested using sensitivity analysis or meta‐regression, as there were not enough trials in any one meta‐analysis.


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

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


Funnel plot of comparison: 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, outcome: 7.2 Pain Intensity: 10 to 20 weeks of treatment.

Funnel plot of comparison: 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, outcome: 7.2 Pain Intensity: 10 to 20 weeks of treatment.

Allocation

There was failure to describe or use appropriate concealment of allocation in 42.9% of studies.

Blinding

There was a lack of effective "blinding" procedures in 92.9% of trials ‐ the minimum expectation being blinding of the outcome assessor.

Incomplete outcome data

There were incomplete outcome data provided by 28.6% of the trials.

Selective reporting

There was selective reporting bias with 78.6% of the trials.

Other potential sources of bias

Compliance was monitored and acceptable in only 42.9% of trials, and co‐intervention was either not avoided or not described in 71.4% of trials. The funnel plot (Figure 3) has the classic small negative trial missing that may suggest publication bias (language bias); we did not search non‐English databases. Alternatively, it could reflect the poor methodological quality leading to inflated effects in smaller trials.

Effects of interventions

See: Summary of findings for the main comparison Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION compared to THAT SAME INTERVENTION; Summary of findings 2 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization compared to WAIT LIST; Summary of findings 3 Chronic MND: Qigong Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) compared to WAIT LIST; Summary of findings 4 Acute Radiculopathy: Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST; Summary of findings 5 Acute to subacute CGH: Cervical stretch/ROM vs SHAM; Summary of findings 6 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION; Summary of findings 7 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization + Manual Therapy vs Manual Therapy; Summary of findings 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM; Summary of findings 9 Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM; Summary of findings 10 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST; Summary of findings 11 Acute to Chronic MND: Scapulothoracic/UE Endurance Training vs CONTROL; Summary of findings 12 Subacute to Chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT; Summary of findings 13 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL

Chronic Mechanical Neck Pain

1. Support Element 
a) Breathing Exercises
Diaphragmatic Breathing Exercises versus Control

One trial Hallman 2011 compared diaphragmatic breathing with a no treatment control. This latter group took part in the breathing protocol in sessions 1 and 10, without any prescribed treatment in between.

  • Pain Intensity outcomes

No difference in pain between groups immediately post treatment (Figure 4).


Forest plot of comparison: 1 Chronic MND: Breathing Patterns vs CONTROL, outcome: 1.1 Pain Intensity (Borg 0 to 10): 10 weeks of treatment vs Control.

Forest plot of comparison: 1 Chronic MND: Breathing Patterns vs CONTROL, outcome: 1.1 Pain Intensity (Borg 0 to 10): 10 weeks of treatment vs Control.

  • Function outcomes

No difference in function between groups immediately post treatment.

  • Quality of Life outcomes

No difference in quality of life between groups immediately post treatment.

Conclusion: There is low quality evidence (one trial, 24 participants, Hallman 2011) that diaphragmatic breathing may have no effect on pain, function and quality of life when compared to a no treatment control for chronic mechanical neck pain immediately post treatment (50 sessions over 10 weeks).

b) Cardiovascular/Aerobic Training
General Fitness Training versus Control

One trial with two publications (Andersen 2008) compared a general exercise program with a no treatment control (general health information) intervention.

  • Pain Intensity Outcomes

No difference in pain between both (see above: general exercise versus control) groups immediately post treatment (Figure 5).


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

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

Conclusion: There is low quality evidence (one trial with two publications, 24 participants, Andersen 2008) that general fitness training exercises may have no difference in pain when compared with a reference intervention for (sub)acute/chronic neck pain immediately post treatment.

2. Base Element
a) Stretching
Cervical Stretch/range of motion (ROM) Exercises + Another Intervention versus That Same Intervention

One trial (Allan 2003) evaluated neck stretching either before or after manipulation compared with manipulation alone.

  • Pain Intensity Outcomes

No difference in pain between all groups immediately post treatment.

  • Function Outcomes

No difference in function between all groups immediately post treatment.

Conclusion: There is low quality evidence (one trial, 16 participants, Allan 2003) that 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. Manipulation was the control group in both arms of the trial and therefore, the contribution of the base element of stretching could be factored out.

Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization versus Sham

One trial (Kjellman 2002) compared cervical movement exercises (McKenzie protocol) with sham ultrasound.

  • Pain Intensity Outcomes 

There is no evidence of benefit on pain immediately post treatment, at intermediate‐term or long‐term follow‐up (Figure 6).


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

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

  • Function Outcomes

There was no evidence of benefit on function immediately post treatment, at intermediate‐term or long‐term follow‐up.

Conclusion: Low quality evidence (one trial, 50 participants, Kjellman 2002) shows no difference for pain relief and function immediately post intervention, at six‐ and 12‐month follow‐up using Cervical Stretch/ROM Exercise + Dynamic Cervical Stabilization for chronic MND.

b) Strengthening
Static Cervical Strengthening + Static Stabilization versus No Intervention or Wait List

One trials (two comparisons) studying chronic neck pain compared either manually (1) resisted isometric neck exercise plus postural training with mirror feedback to a control, or (2) these same isometric neck exercises and the use of an orthopaedic pillow were compared with the use of an orthopaedic pillow (Helewa 2007).

  • Pain Intensity Outcomes 

Of the two comparisons, one showed no evidence of benefit (exercise versus control) while the other showed evidence of benefit (exercise + an intervention versus that same intervention) on function immediately post treatment and at short‐term follow‐up. (Helewa 2007).

  • Function Outcomes

Of the two comparisons, one showed no evidence of benefit (exercise versus control) while the other showed evidence of benefit (exercise + an intervention versus that same intervention) on function immediately post treatment and at short‐term follow‐up. (Helewa 2007).

  • Quality of Life

In two comparisons (exercise versus control, exercise + an intervention versus that same intervention), there was no evidence of benefit immediately post treatment and at short‐term follow‐up on quality of life (Helewa 2007), albeit there may be a clinically important effect favouring exercise + pillow versus pillow alone.

Conclusion : Evidence exists from two trials (three comparisons) where data are not combinable. Low quality evidence from one trial (two independent comparisons, 50 participants, Helewa 2007) gives varying results. Evidence of benefit showed people may improve slightly when exercise was added to a pillow versus a pillow alone (NNTB = 9). However, this was not observed when isometric exercise alone was evaluated for function and quality of life, from immediately post treatment to short‐term follow‐up.

Postural Exercise versus Control

One trial Beer 2012 compared sitting postural exercises versus control.

  • Pain Intensity Outcomes:

No difference in pain between groups immediately post treatment.

  • Physical Function outcomes

No difference in physical function between groups immediately post treatment.

Conclusion: We are uncertain whether postural exercises improve pain or function. There is very low quality evidence (one trial, 20 participants, Beer 2012) that postural exercises have no difference on pain and function when compared to control for chronic mechanical neck pain immediately post treatment (two‐week intervention).

Scapulothoracic + Upper Extremity (UE) Strengthening versus Control

Three trials (Andersen 2008; Andersen Ch 2012; Dellve 2011), each with different dosages compared specific strength training of the scapulothoracic region and upper extremity with a reference intervention.

  • Pain Intensity Outcomes

No difference in pain at four weeks of treatment. There is a moderate to large difference in pain reduction between groups at 10 to 20 weeks of treatment, [SMD pooled ‐0.71 (95%CI:‐1.33 to ‐0.10); Figure 7]. Additionally one and nine weekly sessions were no different when contrasted with the reference group.


Forest plot of comparison for (sub)Acute/Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, outcome: Pain Intensity: 10 to 20 weeks of treatment.

Forest plot of comparison for (sub)Acute/Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, outcome: Pain Intensity: 10 to 20 weeks of treatment.

  • Physical Function Outcomes

No statistical difference in physical function between groups immediately post treatment, but may achieve a minimal clinically important difference at short‐term follow‐up.

Conclusion: There is moderate quality evidence (three trials, 157 participants, Andersen 2008; Andersen Ch 2012; Dellve 2011) that scapulothoracic and UE strength training probably improves pain a moderate to large amount immediately post treatment and at short‐term follow‐up. It may improve functional outcomes when compared to control at short‐term follow‐up (10 to 20 weeks of intervention).

c) Stretch and Strengthening
Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization versus Placebo or Sham

One trial (Kjellman 2002) compared general exercises including neck and shoulder ROM, active neck endurance and strength exercises with sham ultrasound.

  • Pain Intensity Outcomes

There was no evidence of benefit immediately post treatment, at intermediate‐term and long‐term follow‐up.

  • Physical Function Outcomes

There was no evidence of benefit immediately post treatment, at intermediate‐term and long‐term follow‐up.

Conclusion: Low quality evidence (one trial, 50 participants, Kjellman 2002) shows no difference for pain relief and function immediately post intervention, at six and 12 months follow‐up using Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization for chronic MND.

Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization versus Wait List

Two trials (Rendant 2011; von Trott 2009) compared a standardized exercise program for neck pain including repeated active cervical rotations, strength and flexibility exercises to a wait list. The two trials appeared clinically similar and were pooled.

  • Pain Intensity Outcomes

When two studies (Rendant 2011; von Trott 2009) were pooled, there was a significant difference, moderate clinically important 15‐point change post treatment [Heterogeneity: Chi² = 0.74, df = 1 (P = 0.39); I² = 0% MD pooled ‐14.90 (CI 95% ‐22.40 to ‐7.39), NNTB =4]. This reduced to a small difference of [pooled MD ‐10.94 (CI 95% ‐18.81 to ‐3.08)] at short‐term follow‐up (Figure 8).


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

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

  • Function Outcomes

One trial (Rendant 2011), showed evidence of benefit for function post treatment. One trial (von Trott 2009) showed no significant difference immediately post treatment and at short‐term follow‐up. When the two studies were pooled, there was a significantly different, clinically important, moderate change in function. [Heterogeneity: Tau² = 0.09; Chi² = 2.63, df = 1 (P = 0.10); I² = 62% SMD pooled:‐0.50 (CI 95% ‐1.04 to 0.03), NNTB = 5 (Analysis 10.3)]. At short‐term follow‐up (24 weeks of treatment), pooled SMD: ‐0.40 (CI 95% ‐0.74 to ‐0.06) (Analysis 10.4).

  • Global Perceived Effect

No significant difference in global perceived effect was found at any time points.

  • Quality of Life

When the two trials were pooled, no significant difference in quality of life was found at any time point. [Heterogeneity: Tau² = 0.00; Chi² = 0.95, df = 1 (P = 0.33); I² = 0% MD pooled at 12 weeks ‐2.22 (CI 95% ‐5.17 to 0.72) (Analysis 10.7), at short‐term follow‐up pooled MD 0.01 (CI 95% ‐0.47 to 0.49) (Analysis 10.8)].

Conclusion : Moderate quality evidence (two trials, 147 participants, Rendant 2011; von Trott 2009) shows cervical stretch/ROM exercises + cervical/scapulothoracic strengthening + static/dynamic cervical/shoulder stabilization probably has moderate benefit for pain and function, but not global perceived effect and quality of life immediately post treatment and at short‐term follow‐up. A clinician may need to treat four people to achieve a moderate degree of pain relief and five to achieve moderate functional benefit in one patient.

Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic +/‐UE Strengthening + Dynamic/Static Cervical Stabilization + Another Intervention versus That Same Intervention

Four trials studying chronic neck pain compared the following exercise interventions with a control group:

  1. deep neck flexor retraining with pressure biofeedback and resisted neck flexion/extension strengthening using multicervical rehabilitation unit (Chiu 2005);

  2. 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 2001);

  3. muscle stretching and strengthening exercises of the neck and upper limb regions including strengthening of the deep cervical flexor muscles (Franca 2008); and

  4. a home exercise program of ROM, stretching/mobilization and strengthening exercises of the cervical and upper thoracic spine (Martel 2011).

Both treatment arms of all groups received another intervention and were compared with that same intervention combined with exercise. We considered the exercise protocols to be clinically similar; that is, they all contained an exercise component, which applied a resistance force directly to the cervicoscapular region. Other similar clinical elements included the dosage and duration of care. We judged these exercise trials to be both clinically and statistically homogeneous (P = 0.67, I2= 0%).

  • Pain Intensity Outcomes

When data were pooled into a summary estimate, we found consistent evidence of reduced pain from immediately post treatment pooled SMD ‐0.33 (95% CI:‐0.55 to ‐0.10) (Analysis 9.1; Bronfort 2001; Chiu 2005; Franca 2008; Martel 2011) to intermediate‐term (Analysis 9.3) and long‐term follow‐up (Bronfort 2001). This suggests an initial small‐ to longer‐term large treatment benefit. The number needed to treat for one patient to benefit varies from six to 18.

  • Function Outcomes

There was evidence of benefit in function immediately post treatment pooled SMD ‐0.25 (95% CI: ‐0.48 to ‐0.01), intermediate‐term pooled SMD ‐0.45 (95% CI: ‐0.72, to ‐0.18) (Figure 9; Bronfort 2001; Chiu 2005; Franca 2008) and long‐term follow‐up (Bronfort 2001). The latter represents the largest improvement. The number needed to treat for one patient to benefit varies from four to 13.


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

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

  • Global Perceived Effect and Quality of Life

There was a statistically important difference in global perceived effect noted immediately post treatment (Analysis 9.9) and at long‐term follow‐up (Bronfort 2001; Martel 2011).

  • Patient Satisfaction

There were statistically and clinically important differences for patient satisfaction noted at all time points (Bronfort 2001).

Conclusion : Moderate quality evidence (four trials, 341 participants, Bronfort 2001; Chiu 2005; Franca 2008; Martel 2011) 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 benefit. Moderate quality evidence (one trial, 101 participants) demonstrates patients are very satisfied with their care. Changes in quality of life are suggestive of benefit but not conclusive. Changes in global perceived effect measures indicate a difference immediately post treatment and at long‐term follow‐up.

d) Stretching and Endurance Training
Cervical/Scapulothoracic/UE Stretch + UE Endurance Training versus No Intervention

One trial (Viljanen 2003) compared dynamic muscle training with free weights with ordinary activity.

  • Pain Intensity Outcomes

There was no significant pain relief immediately post treatment and at short‐term or long‐term follow‐up.

  • Function Outcomes

There was no significant change in function at the same three time points.

Conclusion : Moderate quality evidence (one trial, 393 participants, Viljanen 2003), shows little to no difference for UE stretching and endurance training for chronic neck pain and function immediately post treatment, at short‐term and long‐term follow‐up.

e) Strengthening and Endurance Training
Cervical/Scapulothoracic Strengthening + Endurance Training versus Control

One trial (Ang 2009) compared non‐postural and postural strengthening exercises and endurance‐strength exercises versus a control group.

  • Pain Prevalence Outcomes

There was no significant decrease in pain prevalence immediately post treatment or at long‐term follow‐up.

Conclusion: Very low quality evidence (one trial, 68 participants, Ang 2009) shows we are uncertain whether cervical/scapulothoracic strengthening and endurance‐strength exercises improves the prevalence of neck pain in chronic neck pain at immediately post treatment and at long‐term follow‐up.

Pattern synchronization and Cervical/Scapulothoracic Strengthening and Scapulothoracic Endurance versus Control

One trial Lange 2013 compared deep neck flexor recruitment combined with upper extremity strengthening/endurance exercises versus control.

  • Pain Intensity Outcomes

There was evidence of a very small change in pain intensity immediately post treatment (24 weeks of treatment).

Conclusion: Low quality evidence due to floor effect (one trial, 55 participants, Lange 2013) shows deep neck flexor recruitment combined with UE strengthening/endurance exercises may have little difference in pain immediately post treatment.

f) Endurance Training
Scapulothoracic/UE Endurance Training versus Control

One trial (Andersen 2011) with two comparisons compared shoulder abduction endurance training for two minutes or 12 minutes with a control group.

  • Pain Intensity Outcomes

There was evidence of benefit immediately post treatment for pain for both the two‐minute and 12‐minute training programs.

Conclusion: Moderate quality evidence (one trial, 198 participants, Andersen 2011) shows moderate benefit for pain relief immediately post intervention using scapulothoracic/UE endurance training for (sub)acute/chronic MND. A clinician may need to treat four people to achieve this type of pain relief.

3. Modulator Elements
Neuromuscular Exercise (eye‐neck co‐ordination/proprioception) + Another Intervention versus That Same Intervention

One trial (Revel 1994) compared eye‐neck co‐ordination exercises and analgesic/anti‐inflammatory medication with that same medication only for chronic neck pain.

  • Pain Intensity

There was evidence of benefit on pain at short‐term follow‐up. The number needed to treat for one patient to benefit is four.

  • Function

There was evidence of benefit on function at short‐term follow‐up. The number needed to treat for one patient to benefit is three.

Conclusion: We are uncertain whether eye‐neck co‐ordination exercises improve pain or function. Very low quality evidence (one trial, 60 participants, Revel 1994) 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 benefit in one person.

Patterns synchronization + Feedforward/feedback exercises for co‐ordinating the neck, eyes and upper limbs versus No Intervention

One trial (Humphreys 2002) compared eye‐neck‐upper limb co‐ordination exercises versus no intervention in patients with chronic neck pain.

  • Pain Intensity

No difference in pain between groups immediately post treatment.

Conclusion : Low quality evidence (one trial, 56 participants, Humphreys 2002) shows eye‐neck‐upper limb exercises show little or no difference in pain immediately post treatment.

Patterns synchronization + Feedforward/feedback: vestibular rehabilitation (balance on unstable surfaces and walking with head movements and eyes closed) vs No Intervention

One trial (Hansson 2013) compared vestibular rehabilitation program vs no intervention in patients with chronic neck pain.

  • Pain Intensity

No difference in pain between groups immediately post treatment or at short‐term follow‐up.

Conclusion: Low quality evidence (one trial, 29 participants, Hansson 2013) shows vestibular rehabilitation type exercises may have little or no difference in neck pain both immediately post treatment and at short‐term follow‐up.

4. Base + Modulator Elements + Support
Trunk and Extremity Stretch + Pattern/Synchronization: Balance Co‐ordination + Cardiovascular/Aerobic versus No Intervention

One trial (Takala 1994) with unspecified duration of neck pain at baseline, compared a group of whole body exercise program, which included aerobic training and shoulder/thoracic exercises, with no treatment.

  • Pain Intensity

There was no evidence of benefit for pain reduction immediately post treatment.

Conclusion: Low quality evidence (one trial, 44 participants,Takala 1994) shows little to no difference for pain reduction immediately post treatment in patients with neck pain of unspecified duration when treated with group exercise that combined extensibility and co‐ordination exercises with cardiovascular training.

General Endurance Training + Dynamic/Static Lowback/pelvic Stabilization + General Stretching + Neuromuscular/body Mechanics Movement Training versus No Intervention

One trial (Lundblad 1999) compared lumbopelvic stabilization, ergonomic exercises, endurance, general strengthening, and co‐ordination exercises with no treatment.

  • Pain Intensity

There was no evidence of benefit for pain reduction at short‐term follow‐up.

Conclusion: Low quality evidence (one trial, 38 participants, Lundblad 1999) shows little to no difference for pain reduction with a combined exercise approach of stabilization of the low back and pelvis, posture awareness, ergonomic training, and strength, co‐ordination, endurance, flexibility/smoothness and rhythm exercises when compared to no intervention or a wait list control in chronic neck pain at short‐term follow‐up.

5. Base + Cognitive/Affective Element
Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) versus Wait List

Two trials (Rendant 2011; von Trott 2009) compared a program of Qigong exercises (Dantian Qigong) including relaxation of mind and body, conscious breathing and movement exercises of the hip, legs, shoulders, arms and head with a wait list.

  • Pain Intensity

When data were pooled into a summary estimate, there was evidence of reduced pain post treatment at 12 weeks [pooled MD ‐13.28 (‐20.98 to ‐5.58)] (Analysis 18.1) and 24 weeks [pooled MD ‐7.82 (‐14.57, ‐1.07)] (Analysis 18.2) of treatment (Rendant 2011; von Trott 2009).

  • Function

When data were pooled into a summary estimate, there was evidence of reduced function post treatment at 12 weeks [pooled SMD ‐0.36 (‐0.68 to ‐0.03); Analysis 18.3] and 24 weeks [pooled SMD ‐0.28 (‐0.68 to 0.11); Analysis 18.4] of treatment (Rendant 2011; von Trott 2009)

  • Global Perceived Effect

There was no evidence of benefit for global perceived effect immediately post treatment and at short‐term follow‐up.

  • Quality of Life

There was evidence of benefit for SF36 physical component immediately post 12 weeks of treatment [pooled MD ‐2.72 (95% CI: ‐5.42 to ‐0.01); Analysis 18.7]; but not at short‐term follow‐up of 24 weeks [pooled MD ‐1.88 (95%CI: ‐5.80 to 2.04); Analysis 18.8] (Rendant 2011; von Trott 2009).

Conclusion: Moderate quality evidence (two trials, 191 participants, Rendant 2011; von Trott 2009) shows Qigong exercises (Dantian Qigong) 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 benefit at immediate and short‐term follow‐up on quality of life and global perceived effect. A clinician may need to treat four to six people to achieve this type of pain relief, five to eight people to achieve this functional benefit, and seven to 10 people for this improvement in quality of life.

6. Base + Modular + Cognitive Affective + Support
Stretch/ROM + Strength and Endurance Training (trunk and limb) + Pattern/Synchronization: Balance Co‐ordination + Cardiovascular/Aerobic + Cognitive (Coaching + Motivational) versus that Same Intervention

One trial (Stewart 2007) compared an individualized, progressive submaximal program, which included aerobic training, trunk and limb exercises and advice compared with advice alone.

  • Pain Intensity

There was evidence of small benefit on pain post treatment but not at long‐term follow‐up.

  • Function

There was evidence of small benefit on function post treatment and at long‐term follow‐up.

  • Global Perceived Effect

There was evidence of small benefit on global perceived effect post treatment but not at long‐term follow‐up.

  • Quality of Life

There was evidence of small benefit on quality of life post treatment but not at long‐term follow‐up.

Conclusion: Low quality evidence (one trial, 132 participants, Stewart 2007) shows small benefits for pain relief, function,global perceived effect and quality of life immediately post treatment and small benefit at 12‐month follow‐up for function using Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Co‐ordination + Cardiovascular/Aerobic + Cognitive (CBT) + another treatment for Subacute/chronic WAD.

Cervicogenic Headache

1. Base Element
Stretch/ROM exercises versus Sham

One trial (Hall 2007) investigated patients with subacute cervicogenic headache; this trial compared C1‐C2 self‐sustained natural apophyseal glide (SNAG) exercises with a sham mobilization.

  • Pain Intensity Outcomes 

There was pain reduction at both short‐ and long‐term follow‐up. The number needed to treat for one patient to benefit is three.

Conclusion:  Low quality evidence (one trial, 32 participants, Hall 2007) shows people may improve a large amount for pain reduction 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.

2. Base and Modular Element
Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization versus No Intervention

One trial (Jull 2002) studied chronic cervicogenic headache and compared endurance exercises including pressure biofeedback for the cervicoscapular region with no treatment.

  • Pain Intensity

When compared with no treatment, there was evidence of a large benefit post treatment and a moderate size benefit at long‐term follow‐up ( Analysis 21.2) for pain relief. The number needed to treat for one patient to benefit is six.

  • Function

When compared with no treatment, there was evidence of a moderate degree of benefit at post treatment and at long‐term follow‐up (Analysis 21.4) on function. The number needed to treat for one patient to benefit is six.

  • Global Perceived Effect

When compared with no treatment, there was evidence of a large benefit post treatment and at long‐term follow‐up ( Analysis 21.6) on global perceived effect.

Conclusion : Moderate quality evidence (one trial, 97 participants, Jull 2002) shows cervicoscapular strengthening and endurance exercises including pressure biofeedback probably improve pain, function and global perceived effect for chronic cervicogenic headaches at long‐term follow‐up when compared to no treatment. A clinician may need to treat six people to achieve this type (medium to large amount) of pain relief and functional benefit in one patient.

Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization + Manual Therapy versus Manual Therapy

One trial (Jull 2002) studied chronic cervicogenic headache and compared endurance exercises including pressure biofeedback plus manual therapy for the cervicoscapular region with manual therapy.

  • Pain Intensity

When compared with manual therapy, there was evidence of no difference post treatment and at long‐term follow‐up for pain relief.

  • Function

When compared with manual therapy, there was evidence of no difference post treatment and at long‐term follow‐up on function.

  • Global Perceived Effect

When compared with manual therapy, there was evidence of no difference post treatment and at long‐term follow‐up on global perceived effect. However, we believe there may be a clinically important but not statistical difference at long‐term follow‐up.

Conclusion : Moderate quality evidence (one trial, 96 participants, Jull 2002) shows when exercise combined with manual therapy contrasted with manual therapy alone there is probably no difference in pain, function and global perceived effect for chronic cervicogenic headaches at long‐term follow‐up.

Acute Radiculopathy

1. Base Element
a) Stretching and Strengthening
Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization versus Wait List

One trial (Kuijper 2009) studying acute cervical radiculopathy compared cervical mobilizing and stabilizing exercises with a wait list control.

  • Pain Intensity

There was a significant difference in reduction of pain immediately post treatment but no difference at intermediate‐term follow‐up.

  • Function

There was no statistical significant difference in improved function immediately post treatment and at intermediate‐term follow‐up.

  • Patient Satisfaction

There was no difference between groups in patient satisfaction at immediate post treatment follow‐up.

Conclusion : There is low quality evidence (one trial, 133 participants, Kuijper 2009) showing cervical mobilization and stabilization exercises may improve pain slightly, but may make no difference in function and patient satisfaction when compared immediately post treatment with a control for acute cervical radiculopathy. However, there may be no difference in pain and functional improvement at intermediate‐term follow‐up.

Adverse Events

Fifteen of the 27 trials did not report on adverse events (Andersen 2008; Andersen Ch 2012; Ang 2009; Beer 2012; Dellve 2011; Hall 2007; Hallman 2011; Hansson 2013; Humphreys 2002; Kjellman 2002; Kuijper 2009; Lundblad 1999; Revel 1994; Takala 1994; Viljanen 2003); six trials found patients did not report any adverse events (Allan 2003; Chiu 2005; Franca 2008; Helewa 2007; Lange 2013; Martel 2011; six studies reported self‐limiting side effects such as headache, neck, shoulder or thoracic pain or worsening of symptoms (Andersen 2011; Bronfort 2001; Jull 2002; Rendant 2011; Stewart 2007; von Trott 2009).

Discussion

Summary of main results

Limiting the eligible trials to those with single interventions that compared exercise with a control or comparative group maximized the opportunity to evaluate the treatment effect of exercise interventions. Moreover, having selected a priori an exercise classification system allowed us to use a clinical rationale for selecting studies with similar interventions for interpretation and inclusion within meta‐analyses, particularly for the outcomes of pain and function. Although there were only 28 studies eligible for this systematic review, these two new strategies provided greater clarity in our conclusions about the effectiveness of exercise therapy. In summary, for moderate quality evidence there is still uncertainty about the effectiveness of exercise for neck pain. Further research is likely to have an important impact on the effect estimate. Furthermore, for low quality evidence further research is very likely to have an important impact on the effect estimate. The reader should take these limitations into account when interpreting the following evidence statements.

  • Moderate to low quality evidence suggests there can be small to large beneficial effects on chronic mechanical neck pain when combining the use of cervical, shoulder/scapulothoracic strengthening and stretching exercises immediately post treatment and at short‐ and long‐term follow‐up. There may also be a small to moderate beneficial effect on function when combining the use of cervical, shoulder/scapulothoracic strengthening and stretching exercises immediately post treatment and at short‐ to long‐term follow‐up.

  • Moderate grade evidence suggests there may be a slight beneficial effect on chronic mechanical neck pain with the use of scapulothoracic and upper extremity endurance training immediately post treatment.

  • Moderate quality evidence suggests there may be a slight improvement in chronic mechanical neck pain and function with the use of Qigong (stretch, endurance, dynamic stabilization exercises combined with cognitive exercises emphasizing mindfulness and emotion) immediately post treatment and at short‐term follow‐up. There may be little to no difference in quality of life and general perceived effect measures with the use of qigong exercises.

  • Low quality evidence suggests there may be a large beneficial effect in cervicogenic headaches with the use of craniovertebral stretch and range of motion exercises (C1‐C2 Self‐SNAG) both at short‐ and long‐term follow‐up.

  • Moderate quality evidence suggests there is a large beneficial effect on pain in cervicogenic headaches when combining the use of static and dynamic cervical, scapulothoracic strengthening and endurance exercises including pressure biofeedback immediately post treatment and probably improves pain moderately in cervicogenic headaches at long‐term follow‐up. There was also a moderate beneficial effect on function immediately post treatment and at long‐term follow‐up.

  • Low quality evidence suggest that there is a slight beneficial effect on pain with acute cervical radiculopathy when combining the use of static and dynamic cervical, scapulothoracic and upper extremity stretching and strengthening immediately post treatment but not at intermediate‐term follow‐up. There was little to no difference in function.

  • Low grade evidence suggests there is little to no difference in chronic mechanical neck pain and function with respect to the use of breathing exercises or general fitness training

  • Low grade evidence suggests there is little to no difference in chronic mechanical neck pain and function with respect to the use of cervical spine stretches and range of motion exercises.

  • Moderate grade evidence suggests there is little to 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.

  • Low quality evidence suggests that there is little to no difference in chronic mechanical neck pain when combining the use of trunk and upper extremity stretching, balance exercises and aerobic training immediately post treatment.

  • Low quality evidence suggests that there is little to no difference in chronic mechanical neck pain when combining the use of endurance, general stretching, body mechanics and lumbar stabilization exercises at short‐term follow‐up.

Knowledge of key multimodal approaches like exercise and manual therapy is still needed as this model of combined care is commonly used in clinical practice.

Overall completeness and applicability of evidence

Our group looked at the clinical applicability of 28 trials associated with neck disorders versus control: 25 studies were interested in neck pain, two in cervicogenic headache and one in cervical radiculopathy. The level of evidence ranged from low to moderate. Most studies adequately described the study population. Three studies did not specify the duration of neck pain. Radicular signs and symptoms were present in 14% of the studies, absent in 29% and not specified in 57%. Of the 28 studies in this update, 36% provided sufficient details for the treatment protocol to be replicated and 18 studies omitted important details about the treatment administration or included insufficient description of the qualifications of the treatment provider.

The outcomes were as follow: 96% of the studies reported pain, 64% reported function and 36% reported quality of life or patient satisfaction. Of the ones that reported pain, function and quality of life, benefit was shown in respectively 81%, 89% and 80%, but no study reached the minimal clinically important difference for any outcome. These results can be applied to an adult population suffering from acute, subacute and chronic mechanical neck pain.

Follow‐up was reported at immediate or short term in 54% of the studies and the remaining trials (46%) had intermediate‐ or long‐term measurement timing. Minor and short lasting adverse events were reported in 25% of the studies, their occurrence was not specified in 57%, and no adverse events happened in the remaining studies (18%). Drop‐outs occurred in 68% of the studies and none evaluated the cost of care. To better understand the direct and indirect costs of the different treatments and make decisions regarding the most effective and efficient type of care, attempts to evaluate and report cost‐related outcomes are required.

The clinical applicability was evaluated in 28 studies contrasting the use of exercise for neck pain compared with a control group. Sample population was adequately described in 82% of the trials. Treatment protocol was adequately described in 36% of the trials; the remaining studies omitted information about treatment providers and exercise dosage, which hinders reproducibility. The magnitude of effect and clinical applicability showed benefits that outweigh any transient and minor side effects. The level of evidence of these studies varied from low to moderate; thus clinicians should not underestimate their clinical judgement in the choice of optimal treatment modality for client needs.

The stage of the pathology, commonly described as acute, subacute and chronic, can certainly affect the effect size of an intervention such as exercise. For instance, in regards to pain, none of the included trials reached the minimal clinically important difference of 2.0 points (NPRS) or 20 mm (VAS); this could be related to the low to moderate pain levels experienced by the chronic neck pain population with lesser room for improvement compared to an acute neck pain population with high initial levels of pain. Thus, according to the stage of the pathology, it could respectively under or overestimate the size effect of a specific exercise.

To date, there is no standardized definition of mechanical neck pain even if it has evolved over the last three decades. Spitzer 1987 defined mechanical neck pain as complaints of pain, stiffness, and tenderness with or without referral to proximal extremity. Merskey 1994 proposed the following definition: “pain perceived as arising from anywhere within the region bounded superiorly by the superior nuchal line through the tip of the first thoracic spinous process, and laterally by the sagittal plane tangential to the lateral borders of the neck.” More recently, other authors suggested different definitions such as generalized neck and/or shoulder pain with mechanical characteristics including: symptoms provoked by maintained neck postures or by movement, or by palpation of the cervical muscles (Fernandez‐de‐las‐Penas 2007). Thus, considering that mechanical neck pain is a heterogeneous group, subgrouping based on diagnosis, treatment or prognosis system classification would be useful to increase homogeneity for research and clinical applicability.

Exercise classification is also of utmost importance when interested in the nature of the intervention. The model implemented in this review, proposed by Sahrmann 2002, reveals the interaction between dosage, elements of movement system and activity by describing the physiological effect of exercise on the body rather than describing the types of activity used to produce that effect. Using this kind of model would allow practitioners and researchers to classify exercises into a specific category by recognizing their mechanisms of actions. It also allows placement of similar exercise interventions from different trials into more homogeneous subgroups enabling meta‐analyses. Thus, by a better understanding and classification of the physical impairments, exercise interventions and stage or type of pathology, accuracy in the clinical applicability of results could be improved.

In general, there is also limited evidence on optimal dosage requirements (Bronfort 2001; Jull 2002) for exercise therapies, and other modalities used to treat neck disorders. To address questions regarding the dose of therapies used to treat the neck, researchers (Gross 2007) have recommended using factorial designs and studying only single interventions (Carroll 2008b; Helewa 2007). Subsequently, dosage comparisons of similar types of exercises (or exercises that address the same element) can be made; these comparisons can be used to evaluate the impact of dosage variation of the exercise element on the magnitude of treatment outcomes. Specific dosage information is clinically relevant and specific therapeutic recommendations can be drawn from such clinical trials.

Different control interventions have been used in the reference group, but were absent in the experimental group in eight trials of this review. A study design comparing exercise and another intervention with the same intervention was used in four trials. No intervention or wait list as a control intervention was used in the remaining 12 studies. Using different control interventions could lead to underestimation of the effect of exercise if that intervention also shows beneficial effects. Using the same intervention in both exercise and control group may provide a better idea of adding exercise to a treatment plan, but an interaction of effect is also possible and could lead to overestimation of the effect of exercise.

Self‐reported outcome measures of function are popular in the literature to evaluate the effectiveness of treatment in a patient’s everyday life. The Neck Disability Index (NDI) is well accepted in the current literature and is one of the most used tools to assess patient’s functional capacities. However, the NDI recently showed an insufficient unidimensionality ( Ailliet 2013;Hung 2014 ; van der Velde 2009) and a very large floor effect. Its use in research in regards to construct validity is now questioned.

The use of only self‐reported outcome measures may bias the effect estimate. More objective and performance‐based measures of functional tasks should be used in conjunction with subjective measures and questionnaires to establish a complete picture of the results. Such tools need to be developed and integrated into future research.

The timing of outcome measurement has been well reported in all trials. However, most studies did not specify if participants continued their exercises program at home after the end of the intervention period. Knowing the instructions given for the continuation or cessation of the exercise before follow‐up would improve the accuracy of their effectiveness according to how long they were performed. This information could lead to conclusions about carry‐over effect of the exercise program.

Quality of the evidence

One of the major methodological difficulties inherent to studies evaluating exercise interventions is blinding of therapists and patients. None of the trials in this review blinded the care provider, as this is not possible in an exercise trial. Patient blinding can minimize expectation bias by ensuring the treatments are equally credible and acceptable to patients; patients have limited experience or expectations for either the index treatment or control intervention. However, the nature of exercise interventions makes it difficult to blind the patient and care provider. Therefore, it is very important to control for measurement bias by blinding the outcome assessor and the data analyst. A caveat to this is that the use of self‐reported outcome measures de facto 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 that are important in studies evaluating exercise therapy are that of compliance (reducing the treatment effect), co‐intervention (increasing the treatment effect and reducing the magnitude of effect if it occurs in the control group) and contamination (reducing the magnitude of effect). The intervention requires patient motivation and therefore strategies to support behavior changes (Teixeira 2012). Twelve of the 28 studies had acceptable compliance, and eight of 28 studies monitored co‐interventions. This provides greater confidence that the outcome is due to the exercise intervention and that the dosage is consistent between individual participants and treatment groups.

Adequate randomization is a crucial component for a randomized controlled trial. However, adequate sequence generation was evident in only 46% (13/28) of the trials included in this review. Greater care should be taken to ensure the method of randomization is adequate and clearly reported.

Ninety‐six per cent (27/28) of the clinical trials contained small sample sizes (<70 per arm analyzed). Risk of random error will of course be reduced with increased precision or increased sample size. Request for larger trials is a challenge on a per site basis. A co‐ordinated multi‐centre trial is one answer but recruiting and retaining is the challenge. For this it is helpful to identify the motivation factors for participation. First, motivation for clinical study participation has been linked to types of personal benefit, including financial and therapeutic (Nappo 2013). Although financial incentives are important in recruiting healthy volunteers, their motivations are not limited to financial gains (Stunkel 2011). It has been proposed that altruism should be the main reason for a person's decision to participate in a research study (Grady 2001). Ideally, the volunteer is capable of making decisions based on the information provided about the proposed study, and understands the purpose, risks, benefits, alternatives and requirements of the study. After receiving this information, the volunteer is able to decide to participate, free from coercion or improper influences (Grady 2001). Second, clinician recruitment may be difficult. Technology has the potential to facilitate this task. With the emerging presence of electronic medical charting, data sharing has become a point of interest. By training clinicians around the world, patients could be screened on a global scale. A standardized protocol could then be applied in a standardized setting to those who meet the inclusion criteria. As a result, valid and reliable objective measures with low risk of bias could be gathered and accessed by researchers internationally. Finally, it is imperative for investigators to clearly articulate the relevance of the study to the appropriate stakeholders: the neck pain patients who will allocate a significant amount of time to the trial and the clinicians who will contribute patients to the study and, in the process, upset their usual routine and suffer some financial loss. The relevance of the study needs to emphasize the possible benefits to present and future patients, to the healthcare system and to society in general.

This being said, the overarching feature to low precision resides in the subclassification of control trials and restriction of their use. What first must be done is to establish a firm foundation of the effect of (x type of) exercise in clinical control trials and not include head‐to‐head exercise comparison trials. We believe once sound evidence has been formed, the next step is to do comparison trials to establish the superiority of different variations of similar exercises.

Potential biases in the review process

The validity of any systematic review is dependent on the selection of all relevant studies. Although studies published in any language were accepted, many scientific journals in non‐English languages are not indexed in MEDLINE and Embase. We did not search non‐English databases, which may have introduced 'language bias' in the review. Studies without a control or comparative group were excluded so that exercise treatment effectiveness and efficacy could be properly ascertained (Carroll 2008b). This review contains only published studies therefore 'publication bias' was not guarded against.

Agreements and disagreements with other studies or reviews

This review has provided more detailed informations with respect to the degree of evidence and the types of exercise that have an impact on neck pain.

There were no new trials added to our update with respect to acute whiplash associated disorders (WAD) that compared exercise with a control.

For chronic neck pain, Leaver 2010 showed evidence supporting stretching/range of motion (ROM) exercises for pain relief immediately post treatment but no change in the intermediate and long term for pain and function. Our review disagreed with these findings while using the same evidence. We found low quality evidence that neck stretching or ROM had no benefit relative to a control treatment for chronic neck pain and function from immediately post treatment up to long‐term follow‐up.

Three reviews included Qigong (an approach encompassing stretching, strengthening, endurance training, balance/co‐ordination, cardiovascular and cognitive/affective elements). Lee 2009 showed no evidence of benefit in the short term while Southerst 2014 and Teasell 2010c found Qigong exercise effective on pain in the short term for chronic WAD. Although our review supported the latter findings, there was only a very small magnitude of effect on pain and function, but not on global perceived effect and quality of life immediately post treatment. Additionally, a non‐significant effect of a three‐point change on NDI (zero to 50 scale) for function was noted at long‐term follow‐up. For cervico‐scapulothoracic and upper extremity stretching and strengthening, Bertozzi 2013, similarly to our data, suggested that it may improve pain immediately post treatment and at short‐term follow‐up. A meta‐analysis of four studies (Bronfort 2001; Chiu 2005; Franca 2008; Martel 2011) of moderate quality evidence showed medium pain relief and function improvement at immediately post treatment and long‐term follow‐up. Changes in global perceived effect measures indicated a difference immediately post treatment and at long‐term follow‐up. Finally, for stretching and strengthening, two new reviews (Bertozzi 2013; Southerst 2014) showed evidence of benefit on pain and function in long‐term follow‐up. Our review concurred with these reviews. The studies showed moderate quality evidence and two trials (Rendant 2011; von Trott 2009) showed cervico‐scapulothoracic and shoulder stretching, strengthening and stabilization exercises probably have medium benefit for pain and function, but not global perceived effect and quality of life at immediately post treatment and at short‐term follow‐up.

Neuromuscular exercises (Leaver 2010; Teasell 2010b) showed evidence of benefit for subacute/chronic neck pain with or without WAD in the short term for pain and function. This review found very low quality evidence (Revel 1994) for a moderate reduction in pain and function improvement in the short term for eye‐neck co‐ordination exercises.

Salt 2011 found a multimodal exercise approach favoured exercise in acute radiculopathy. There was inconclusive evidence for the effect of non‐invasive management. We found low quality evidence (Kuijper 2009) showing cervical mobilization and specific stabilization exercises may improve pain slightly, but may make no difference in function and patient satisfaction when compared immediately post treatment with a control. There may be no difference in pain and functional improvement at intermediate‐term follow‐up. The challenge in acute radiculopathy is to determine the utility of exercises that provide immediate relief but not longer‐term benefit.

Our review is in agreement with 1) The reports by Racicki 2012, Bronfort 2009, and Hurwitz 2008, suggesting evidence of benefit for exercise in subacute/chronic cervicogenic headache and 2) Bertozzi 2013 about cardiovascular/aerobic training. There is low quality evidence (Andersen 2008) that 3) general fitness training may have no difference in pain when compared with a reference intervention for (sub)acute/chronic neck pain immediately post treatment.

Study flow diagram (PRISMA).
Figures and Tables -
Figure 1

Study flow diagram (PRISMA).

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 2

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

Funnel plot of comparison: 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, outcome: 7.2 Pain Intensity: 10 to 20 weeks of treatment.
Figures and Tables -
Figure 3

Funnel plot of comparison: 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, outcome: 7.2 Pain Intensity: 10 to 20 weeks of treatment.

Forest plot of comparison: 1 Chronic MND: Breathing Patterns vs CONTROL, outcome: 1.1 Pain Intensity (Borg 0 to 10): 10 weeks of treatment vs Control.
Figures and Tables -
Figure 4

Forest plot of comparison: 1 Chronic MND: Breathing Patterns vs CONTROL, outcome: 1.1 Pain Intensity (Borg 0 to 10): 10 weeks of treatment vs Control.

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

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

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

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

Forest plot of comparison for (sub)Acute/Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, outcome: Pain Intensity: 10 to 20 weeks of treatment.
Figures and Tables -
Figure 7

Forest plot of comparison for (sub)Acute/Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, outcome: Pain Intensity: 10 to 20 weeks of treatment.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Study

Stretch before Manip v Manip alone

Allan 2003

Although the stretch before manipulation group had 30% (n = 2) greater decrease in intra‐group pain by the end of the study than those who received maniplation alone, inter‐group analysis using the Kruskal‐Wallis test found no statistical signifance between the groups (X2 = 2.447, d.f. = 2, P = 0.294)

There was no statistically significant difference in pain between the stretch before manipulation group and the control group of manipulation alone

There was no statistically significant difference between the stretch before manipulation vs stretch after manipulation

Stretch after Manip v Manip alone

Allan 2003

Although the manipulation then stretch group had 26% (n = 2) greater decrease in intra‐group pain by the end of the study than those who received maniplation alone, inter‐group analysis using the Kruskal‐Wallis test found no statistical signifance between the groups (X2 = 2.447, d.f. = 2, P = 0.294).

There was no statistically significant difference in pain between the stretch after manipulation group from the control group of manipulation alone

There was no statistically significant difference between the stretch before manipulation vs stretch after manipulation

Figures and Tables -
Analysis 3.1

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

Study

Stretch before Manip v Manip alone

Allan 2003

There was no statistically significant difference in function between the stretch before manipulation and the control group of manipulation alone

There was no statistically significant difference in function between stretch before manipulation vs stretch after manipulation

Stretch after Manip v Manip alone

Allan 2003

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

no statistically significant difference in function between stretch before manipulation vs stretch after manipulation

Figures and Tables -
Analysis 3.2

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 1 Pain Intensity (NPS): 4 weeks of treatment.
Figures and Tables -
Analysis 7.1

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

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

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

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

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

Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 4 Pain Intensity (VAS): 10 weeks of treatment + 10 weeks follow‐up.
Figures and Tables -
Analysis 7.4

Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 4 Pain Intensity (VAS): 10 weeks of treatment + 10 weeks follow‐up.

Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 5 Function: 4 weeks of treatment.
Figures and Tables -
Analysis 7.5

Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 5 Function: 4 weeks of treatment.

Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 6 Function: 20 weeks of treatment.
Figures and Tables -
Analysis 7.6

Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 6 Function: 20 weeks of treatment.

Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 7 Function: 12 to 20 weeks of treatment/follow‐up.
Figures and Tables -
Analysis 7.7

Comparison 7 Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL, Outcome 7 Function: 12 to 20 weeks of treatment/follow‐up.

Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 1 Pain Intensity (VAS): 8 weeks of treatment.
Figures and Tables -
Analysis 8.1

Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 1 Pain Intensity (VAS): 8 weeks of treatment.

Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 2 Pain Intensity (VAS): 8 weeks of treatment + 6 month follow‐up.
Figures and Tables -
Analysis 8.2

Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 2 Pain Intensity (VAS): 8 weeks of treatment + 6 month follow‐up.

Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 3 Pain Intensity (VAS): 8 weeks of treatment + 12 month follow‐up.
Figures and Tables -
Analysis 8.3

Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 3 Pain Intensity (VAS): 8 weeks of treatment + 12 month follow‐up.

Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 4 Function (NDI): 8 weeks of treatment.
Figures and Tables -
Analysis 8.4

Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 4 Function (NDI): 8 weeks of treatment.

Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 5 Function (NDI): 8 weeks of treatment + 6 month follow‐up.
Figures and Tables -
Analysis 8.5

Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 5 Function (NDI): 8 weeks of treatment + 6 month follow‐up.

Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 6 Function (NDI): 8 weeks treatment + 12 month follow‐up.
Figures and Tables -
Analysis 8.6

Comparison 8 Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM, Outcome 6 Function (NDI): 8 weeks treatment + 12 month follow‐up.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 1 Pain Intensity: Immediate Post Treatment (<11w of treatment).
Figures and Tables -
Analysis 9.1

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 1 Pain Intensity: Immediate Post Treatment (<11w of treatment).

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 2 Pain Intensity: 11 w of treatment + 3 month follow‐up.
Figures and Tables -
Analysis 9.2

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 2 Pain Intensity: 11 w of treatment + 3 month follow‐up.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 3 Pain Intensity: Treatment + IT follow‐up (11 weeks of treatment + 6 month follow‐up.
Figures and Tables -
Analysis 9.3

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 3 Pain Intensity: Treatment + IT follow‐up (11 weeks of treatment + 6 month follow‐up.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 4 Pain Intensity: Treatment + LT follow‐up.
Figures and Tables -
Analysis 9.4

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 4 Pain Intensity: Treatment + LT follow‐up.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 5 Function: Immediate Post treatment.
Figures and Tables -
Analysis 9.5

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 5 Function: Immediate Post treatment.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 6 Function: Treatment + ST follow‐up.
Figures and Tables -
Analysis 9.6

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 6 Function: Treatment + ST follow‐up.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 7 Function: Treatment + IT follow‐up.
Figures and Tables -
Analysis 9.7

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 7 Function: Treatment + IT follow‐up.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 8 Function: Treatment + LT follow‐up.
Figures and Tables -
Analysis 9.8

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 8 Function: Treatment + LT follow‐up.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 9 Quality of Life: Immediate Post Treatment.
Figures and Tables -
Analysis 9.9

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 9 Quality of Life: Immediate Post Treatment.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 10 Quality of Life: Treatment + ST follow‐up.
Figures and Tables -
Analysis 9.10

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 10 Quality of Life: Treatment + ST follow‐up.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 11 Quality of Life: Treatment + IT follow‐up.
Figures and Tables -
Analysis 9.11

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 11 Quality of Life: Treatment + IT follow‐up.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 12 Quality of Life: Treatment + LT follow‐up.
Figures and Tables -
Analysis 9.12

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 12 Quality of Life: Treatment + LT follow‐up.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 13 Patient Satisfaction: Immediate Post Treatment.
Figures and Tables -
Analysis 9.13

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 13 Patient Satisfaction: Immediate Post Treatment.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 14 Patient Satisfaction: Treatment + ST follow‐up.
Figures and Tables -
Analysis 9.14

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 14 Patient Satisfaction: Treatment + ST follow‐up.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 15 Patient Satisfaction: Treatment + IT follow‐up.
Figures and Tables -
Analysis 9.15

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 15 Patient Satisfaction: Treatment + IT follow‐up.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 16 Patient Satisfaction: Treatment + LT follow‐up.
Figures and Tables -
Analysis 9.16

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 16 Patient Satisfaction: Treatment + LT follow‐up.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 17 Global Perceived Effect: Immediate Post Treatment.
Figures and Tables -
Analysis 9.17

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 17 Global Perceived Effect: Immediate Post Treatment.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 18 Global Perceived Effect: Treatment + ST follow‐up.
Figures and Tables -
Analysis 9.18

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 18 Global Perceived Effect: Treatment + ST follow‐up.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 19 Global Perceived Effect: Treatment + IT follow‐up.
Figures and Tables -
Analysis 9.19

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 19 Global Perceived Effect: Treatment + IT follow‐up.

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 20 Global Perceived Effect: Treatment + LT follow‐up.
Figures and Tables -
Analysis 9.20

Comparison 9 Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION, Outcome 20 Global Perceived Effect: Treatment + LT follow‐up.

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 1 Pain Intensity (VAS): 12 weeks of treatment.
Figures and Tables -
Analysis 10.1

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 1 Pain Intensity (VAS): 12 weeks of treatment.

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 2 Pain Intensity (VAS): 24 weeks of treatment.
Figures and Tables -
Analysis 10.2

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 2 Pain Intensity (VAS): 24 weeks of treatment.

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 3 Function: 12 weeks of treatment.
Figures and Tables -
Analysis 10.3

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 3 Function: 12 weeks of treatment.

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 4 Function: 24 weeks of treatment.
Figures and Tables -
Analysis 10.4

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 4 Function: 24 weeks of treatment.

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 5 Global Perceived Effect (General Health Perception): 12 weeks of treatment.
Figures and Tables -
Analysis 10.5

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 5 Global Perceived Effect (General Health Perception): 12 weeks of treatment.

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 6 Global Perceived Effect (General Health Perception): 12 weeks of treatment + 12 weeks follow‐up.
Figures and Tables -
Analysis 10.6

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 6 Global Perceived Effect (General Health Perception): 12 weeks of treatment + 12 weeks follow‐up.

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 7 Quality of Life (SF‐36): 12 weeks of treatment.
Figures and Tables -
Analysis 10.7

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 7 Quality of Life (SF‐36): 12 weeks of treatment.

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 8 Quality of Life (SF‐36): 24 weeks of treatment.
Figures and Tables -
Analysis 10.8

Comparison 10 Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST, Outcome 8 Quality of Life (SF‐36): 24 weeks of treatment.

Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST, Outcome 1 Pain Intensity (VAS): 12 weeks of treatment.
Figures and Tables -
Analysis 11.1

Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST, Outcome 1 Pain Intensity (VAS): 12 weeks of treatment.

Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST, Outcome 2 Pain Intensity (VAS): 12 weeks of treatment + 3 month follow‐up.
Figures and Tables -
Analysis 11.2

Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST, Outcome 2 Pain Intensity (VAS): 12 weeks of treatment + 3 month follow‐up.

Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST, Outcome 3 Pain Intensity (VAS): 12 weeks of treatment + 9 month follow‐up.
Figures and Tables -
Analysis 11.3

Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST, Outcome 3 Pain Intensity (VAS): 12 weeks of treatment + 9 month follow‐up.

Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST, Outcome 4 Function (Neck Disability 0‐80): 12 weeks of treatment.
Figures and Tables -
Analysis 11.4

Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST, Outcome 4 Function (Neck Disability 0‐80): 12 weeks of treatment.

Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST, Outcome 5 Function (Neck Disability 0‐80): 12 weeks of treatment + 3 month follow‐up.
Figures and Tables -
Analysis 11.5

Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST, Outcome 5 Function (Neck Disability 0‐80): 12 weeks of treatment + 3 month follow‐up.

Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST, Outcome 6 Function (Neck Disability 0‐80): 12 weeks of treatment + 9 month follow‐up.
Figures and Tables -
Analysis 11.6

Comparison 11 Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST, Outcome 6 Function (Neck Disability 0‐80): 12 weeks of treatment + 9 month follow‐up.

Comparison 12 Acute to Chronic MND: Pattern synchronization + cervical/scapulothoracic strengthening + scapulothoracic endurance vs NO INTERVENTION, Outcome 1 Pain Intensity (VAS 0 to 10): 24 weeks of treatment.
Figures and Tables -
Analysis 12.1

Comparison 12 Acute to Chronic MND: Pattern synchronization + cervical/scapulothoracic strengthening + scapulothoracic endurance vs NO INTERVENTION, Outcome 1 Pain Intensity (VAS 0 to 10): 24 weeks of treatment.

Comparison 13 Chronic MND: Cervical/Scapulothoracic Strengthening + Cervical/Scapulothoracic Endurance Training, Outcome 1 Pain Prevelance during previous week: 6 weeks of treatment + 46 weeks follow‐up.
Figures and Tables -
Analysis 13.1

Comparison 13 Chronic MND: Cervical/Scapulothoracic Strengthening + Cervical/Scapulothoracic Endurance Training, Outcome 1 Pain Prevelance during previous week: 6 weeks of treatment + 46 weeks follow‐up.

Comparison 14 Acute to Chronic MND: Scapulothoracic/UE Endurance Training vs CONTROL, Outcome 1 Pain Intensity (VAS): 10 weeks treatment.
Figures and Tables -
Analysis 14.1

Comparison 14 Acute to Chronic MND: Scapulothoracic/UE Endurance Training vs CONTROL, Outcome 1 Pain Intensity (VAS): 10 weeks treatment.

Comparison 15 Chronic MND: Neuromuscular Education (eye neck coordination/proprioception) + ANOTHER INTERVENTION VS THAT SAME INTERVENTION, Outcome 1 Pain Intensity (VAS): 8 weeks treatment + 10 weeks follow‐up.
Figures and Tables -
Analysis 15.1

Comparison 15 Chronic MND: Neuromuscular Education (eye neck coordination/proprioception) + ANOTHER INTERVENTION VS THAT SAME INTERVENTION, Outcome 1 Pain Intensity (VAS): 8 weeks treatment + 10 weeks follow‐up.

Comparison 15 Chronic MND: Neuromuscular Education (eye neck coordination/proprioception) + ANOTHER INTERVENTION VS THAT SAME INTERVENTION, Outcome 2 Function (pt's assessment of functional improvement): 8 weeks treatment + 10 weeks follow‐up.
Figures and Tables -
Analysis 15.2

Comparison 15 Chronic MND: Neuromuscular Education (eye neck coordination/proprioception) + ANOTHER INTERVENTION VS THAT SAME INTERVENTION, Outcome 2 Function (pt's assessment of functional improvement): 8 weeks treatment + 10 weeks follow‐up.

Comparison 16 Chronic MND:Trunk/Extremity Stretch + Pattern/Synchronization: Balance and Coordination + Cardiovascular/Aerobic vs NO TREATMENT, Outcome 1 Pain Intensity (VAS): 10 weeks of treatment.
Figures and Tables -
Analysis 16.1

Comparison 16 Chronic MND:Trunk/Extremity Stretch + Pattern/Synchronization: Balance and Coordination + Cardiovascular/Aerobic vs NO TREATMENT, Outcome 1 Pain Intensity (VAS): 10 weeks of treatment.

Comparison 17 Chronic MND:General Endurance Training + Dynamic/Static Lowback/pelvic Stabilization + General Stretching + Neuromuscular/body Mechanics Movement Training vs NO INTERVENTION OR WAIT LIST, Outcome 1 Pain Intensity (VAS): 16 weeks treatment + 6 weeks follow‐up.
Figures and Tables -
Analysis 17.1

Comparison 17 Chronic MND:General Endurance Training + Dynamic/Static Lowback/pelvic Stabilization + General Stretching + Neuromuscular/body Mechanics Movement Training vs NO INTERVENTION OR WAIT LIST, Outcome 1 Pain Intensity (VAS): 16 weeks treatment + 6 weeks follow‐up.

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 1 Pain Intensity (VAS): 12 weeks of treatment.
Figures and Tables -
Analysis 18.1

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 1 Pain Intensity (VAS): 12 weeks of treatment.

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 2 Pain Intensity (VAS): 24 weeks of treatment.
Figures and Tables -
Analysis 18.2

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 2 Pain Intensity (VAS): 24 weeks of treatment.

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 3 Function: 12 weeks of treatment.
Figures and Tables -
Analysis 18.3

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 3 Function: 12 weeks of treatment.

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 4 Function: 24 weeks of treatment.
Figures and Tables -
Analysis 18.4

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 4 Function: 24 weeks of treatment.

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 5 Global Perceived Effect (General Health Perception): 12 weeks of treatment.
Figures and Tables -
Analysis 18.5

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 5 Global Perceived Effect (General Health Perception): 12 weeks of treatment.

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 6 Global Perceived Effect (General Health Perception): 12 weeks of treatment + 12 weeks Follow‐up.
Figures and Tables -
Analysis 18.6

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 6 Global Perceived Effect (General Health Perception): 12 weeks of treatment + 12 weeks Follow‐up.

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 7 Quality of Life (SF‐36 physical component): 12 weeks of treatment.
Figures and Tables -
Analysis 18.7

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 7 Quality of Life (SF‐36 physical component): 12 weeks of treatment.

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 8 Quality of Life: 24 weeks of treatment.
Figures and Tables -
Analysis 18.8

Comparison 18 Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST, Outcome 8 Quality of Life: 24 weeks of treatment.

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 1 Pain Intensity: (0‐10 box scale): 6 weeks of treatment.
Figures and Tables -
Analysis 19.1

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 1 Pain Intensity: (0‐10 box scale): 6 weeks of treatment.

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 2 Pain Intensity (0‐10 box scale): 6 weeks treatment + 12 month follow‐up.
Figures and Tables -
Analysis 19.2

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 2 Pain Intensity (0‐10 box scale): 6 weeks treatment + 12 month follow‐up.

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 3 Function (NDI): 6 weeks of treatment.
Figures and Tables -
Analysis 19.3

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 3 Function (NDI): 6 weeks of treatment.

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 4 Function (NDI): 6 weeks of treatment + 12 month follow‐up.
Figures and Tables -
Analysis 19.4

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 4 Function (NDI): 6 weeks of treatment + 12 month follow‐up.

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 5 Global Perceived Effect (‐5 to 5 scale): 6 weeks of treatment.
Figures and Tables -
Analysis 19.5

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 5 Global Perceived Effect (‐5 to 5 scale): 6 weeks of treatment.

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 6 Global Perceived Effect (‐5 to 5 scale): 6 weeks of treatment + 12 month follow‐up.
Figures and Tables -
Analysis 19.6

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 6 Global Perceived Effect (‐5 to 5 scale): 6 weeks of treatment + 12 month follow‐up.

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 7 Quality of Life (SF‐36): 6 weeks of treatment.
Figures and Tables -
Analysis 19.7

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 7 Quality of Life (SF‐36): 6 weeks of treatment.

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 8 Quality of Life (SF‐36): 6 weeks of treatment + 12 month follow‐up.
Figures and Tables -
Analysis 19.8

Comparison 19 Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT, Outcome 8 Quality of Life (SF‐36): 6 weeks of treatment + 12 month follow‐up.

Comparison 20 Acute to Subacute CGH: Cervical Stretch/ROM vs SHAM, Outcome 1 Pain Intensity (Headache Questionnaire): Treatment + 4 weeks follow‐up.
Figures and Tables -
Analysis 20.1

Comparison 20 Acute to Subacute CGH: Cervical Stretch/ROM vs SHAM, Outcome 1 Pain Intensity (Headache Questionnaire): Treatment + 4 weeks follow‐up.

Comparison 20 Acute to Subacute CGH: Cervical Stretch/ROM vs SHAM, Outcome 2 Pain Intensity (Headache Questionnaire): Treatment + 12 month follow‐up.
Figures and Tables -
Analysis 20.2

Comparison 20 Acute to Subacute CGH: Cervical Stretch/ROM vs SHAM, Outcome 2 Pain Intensity (Headache Questionnaire): Treatment + 12 month follow‐up.

Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST, Outcome 1 Headache Intensity (VAS 0‐10): 6 weeks of treatment.
Figures and Tables -
Analysis 21.1

Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST, Outcome 1 Headache Intensity (VAS 0‐10): 6 weeks of treatment.

Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST, Outcome 2 Headache Intensity (VAS 0‐10): 6 weeks treatment + 12 month follow‐up.
Figures and Tables -
Analysis 21.2

Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST, Outcome 2 Headache Intensity (VAS 0‐10): 6 weeks treatment + 12 month follow‐up.

Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST, Outcome 3 Function (NPNPQ 0‐36): 6 weeks treatment.
Figures and Tables -
Analysis 21.3

Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST, Outcome 3 Function (NPNPQ 0‐36): 6 weeks treatment.

Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST, Outcome 4 Function (NPNPQ 0‐36): 6 weeks treatment + 12 month follow‐up.
Figures and Tables -
Analysis 21.4

Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST, Outcome 4 Function (NPNPQ 0‐36): 6 weeks treatment + 12 month follow‐up.

Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST, Outcome 5 Global Perceived Effect (VAS): 6 weeks treatment.
Figures and Tables -
Analysis 21.5

Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST, Outcome 5 Global Perceived Effect (VAS): 6 weeks treatment.

Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST, Outcome 6 Global Perceived Effect (VAS): 6 weeks treatment + 12 month follow‐up.
Figures and Tables -
Analysis 21.6

Comparison 21 Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST, Outcome 6 Global Perceived Effect (VAS): 6 weeks treatment + 12 month follow‐up.

Comparison 22 Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST, Outcome 1 Pain Intensity (VAS): 6 weeks treatment.
Figures and Tables -
Analysis 22.1

Comparison 22 Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST, Outcome 1 Pain Intensity (VAS): 6 weeks treatment.

Comparison 22 Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST, Outcome 2 Pain Intensity (VAS): 6 weeks treatment + 6 month follow‐up.
Figures and Tables -
Analysis 22.2

Comparison 22 Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST, Outcome 2 Pain Intensity (VAS): 6 weeks treatment + 6 month follow‐up.

Comparison 22 Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST, Outcome 3 Function (NDI): 6 weeks treatment.
Figures and Tables -
Analysis 22.3

Comparison 22 Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST, Outcome 3 Function (NDI): 6 weeks treatment.

Comparison 22 Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST, Outcome 4 Function (NDI): 6 weeks treatment + 6 month follow‐up.
Figures and Tables -
Analysis 22.4

Comparison 22 Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST, Outcome 4 Function (NDI): 6 weeks treatment + 6 month follow‐up.

Comparison 22 Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST, Outcome 5 Satisfaction (5 point scale): 6 weeks treatment.
Figures and Tables -
Analysis 22.5

Comparison 22 Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST, Outcome 5 Satisfaction (5 point scale): 6 weeks treatment.

Comparison 23 Chronic MND: Patterns synchronization + Feedforward/feedback: vestibular rehabilitation (balance on unstable surfaces and walking with head movements and eyes closed) vs NO INTERVENTION, Outcome 1 Pain Intensity (VAS) 6 weeks vs Control.
Figures and Tables -
Analysis 23.1

Comparison 23 Chronic MND: Patterns synchronization + Feedforward/feedback: vestibular rehabilitation (balance on unstable surfaces and walking with head movements and eyes closed) vs NO INTERVENTION, Outcome 1 Pain Intensity (VAS) 6 weeks vs Control.

Comparison 23 Chronic MND: Patterns synchronization + Feedforward/feedback: vestibular rehabilitation (balance on unstable surfaces and walking with head movements and eyes closed) vs NO INTERVENTION, Outcome 2 Pain Intensity (VAS) 3 months vs control.
Figures and Tables -
Analysis 23.2

Comparison 23 Chronic MND: Patterns synchronization + Feedforward/feedback: vestibular rehabilitation (balance on unstable surfaces and walking with head movements and eyes closed) vs NO INTERVENTION, Outcome 2 Pain Intensity (VAS) 3 months vs control.

Comparison 24 Chronic MND: Patterns synchronization + Feedforward/feedback: exercises for coordinating the neck, eyes and upper limbs vs NO INTERVENTION, Outcome 1 Pain intensity (VAS) 4 weeks vs Control.
Figures and Tables -
Analysis 24.1

Comparison 24 Chronic MND: Patterns synchronization + Feedforward/feedback: exercises for coordinating the neck, eyes and upper limbs vs NO INTERVENTION, Outcome 1 Pain intensity (VAS) 4 weeks vs Control.

Summary of findings for the main comparison. Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION compared to THAT SAME INTERVENTION

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

Patient or population: patients with mechanical neck disorders
Settings: ambulatory care clinic
Intervention: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION
Comparison: THAT SAME INTERVENTION

Outcomes

Effects

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 10 worst pain

(follow‐up: 6 months)

Three trials showed a small reduction in pain.

Pooled scores estimated using a mean difference of ‐0.67 (‐1.32 to ‐0.02)

241
(3 studies: Bronfort 2011, Chiu 2005, Franca 2008)

⊕⊕⊕⊝
moderate1

Function: NDI 0 no disability to 50 maximum disability (follow‐up: 6 months)

Three trials showed a small to moderate improvement in function.

Pooled scores estimated using a mean difference of ‐2.80 (‐6.36 to 0.76)

241
(3 studies: Bronfort 2011, Chiu 2005, Franca 2008)

⊕⊕⊕⊝
moderate1

Quality of Life: SF‐36 (physical component) 0 worse to 100 better, SF‐12.

(follow‐up: Immediate post treatment)

Two trials showed no significant difference

Pooled scores estimated using a standard mean difference of ‐0.18 (‐0.48 to 0.13)

165

(2 studies: Bronfort 2001, Martel 2011)

⊕⊕⊝⊝
low1

Patient Satisfaction: 1 to 7; completely satisfied to completely dissatisfied

(follow‐up: 24 months)

One trial showed moderate improvement in satisfaction

Scores estimated using a standard mean difference of ‐0.93 (‐1.35 to ‐0.52)

101

(1 study: Bronfort 2001)

⊕⊕⊕⊝
moderate

Global Perceived Effect: Patient‐ Rated Improvement 1 more improvement to 9 less improvement

(follow‐up: 24 months)

One trial showed a small to moderate improvement in global perceived effect

Scores estimated using a standard mean difference of ‐0.42 (‐0.81 to ‐0.03)

101

(1 study: Bronfort 2001)

⊕⊕⊕⊝
moderate

Adverse Effects

One study reported increased neck or headache pain: Intervention group (n = 8), comparison group (n = 6); increased radicular pain intervention group (n = 1); severe thoracic pain comparison group (n = 1); all cases self‐limiting and no permanent injuries (Bronfort 2001). 3 trials reported no complications or serious adverse events (Chiu 2005, Franca 2008, Martel 2011)

Moderate quality evidence: (4 trials, 341 participants, Bronfort 2001; Chiu 2005; Franca 2008; Martel 2011) 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 6 to18 people to achieve this type of pain relief and 4 to 13 to achieve this functional benefit. Moderate quality evidence (one trial, 101 participants; Bronfort 2001) demonstrates patients are very satisfied with their care. Changes in quality of life are suggestive of benefit but not conclusive. Changes in global perceived effect measures indicate a difference immediately post treatment and at long‐term follow‐up.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Two of the pooled studies had high risk of bias scores (Franca 4/12 and Martel 5/12). That is, the studies met fewer than 6 of the 12 criteria, indicating high risk of bias.

Figures and Tables -
Summary of findings for the main comparison. Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION compared to THAT SAME INTERVENTION
Summary of findings 2. Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization compared to WAIT LIST

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

Patient or population: patients with chronic mechanical neck disorders
Settings: residential community
Intervention: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization
Comparison: WAIT LIST

Outcomes

Effects

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 100 worst pain; (follow‐up: immediate post treatment)

a. 12 weeks of treatment

b. 24 weeks of treatment or 12 weeks of treatment+ 12 weeks follow‐up

Two trials showed a medium reduction in pain.

a. Pooled mean difference ‐14.90 (‐22.40 to ‐7.39)

b. Pooled mean difference ‐10.94 (‐18.81 to ‐3.08)

147
(2 studies: Rendant 2011, von Trott 2009)

⊕⊕⊕⊝
moderate1,2

Function: NPDI or NDI 0 no disability to 100 maximum disability; (follow‐up: immediate post treatment)
a. 12 weeks of treatment

b. 24 weeks of treatment or 12 weeks treatment + 12 weeks follow‐up

Two trials showed a medium improvement in function.

a. Pooled SMD ‐0.50 (‐1.04 to 0.03)

b. Pooled SMD ‐0.40 (‐0.74 to ‐0.06)

147
(2 studies: Rendant 2011, von Trott 2009)

⊕⊕⊕⊝
moderate1,2

Quality of Life: SF‐36 (physical component) 0 worse to 100 better; (follow‐up: immediate post treatment)

a. 12 weeks of treatment

b. 24 weeks of treatment or 12 weeks treatment + 12 weeks follow‐up

Two trials showed no significant difference in quality of life scores

a. Pooled mean difference ‐2.22 (‐5.17 to 0.72)

b. Pooled mean difference 0.06 (‐4.06 to 4.17)

143
(2 studies: Rendant 2011, von Trott 2009)

⊕⊕⊕⊝
moderate1,2

Global Perceived Effect: General Health Perception 0 worse to 100 better (follow‐up: immediate post treatment)

a. 12 weeks of treatment

b. 24 weeks of treatment

One trial showed no significant difference in GPE.

70

(1 study: von Trott 2009)

⊕⊕⊕⊝
moderate2

Adverse Effects

Reported by 18 patients in exercise group: muscle soreness (n = 15), 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) , nausea (n = 1), muscle tensions (n = 2)

Moderate quality evidence (two trials, 147 participants, von Trott 2009; Rendant 2011) shows cervical stretch/ROM exercises + cervical/scapulothoracic strengthening + static/dynamic cervical/shoulder stabilization probably has moderate benefit for pain and function, but not GPE and QoL at immediate post treatment and short‐term follow‐up. A clinician may need to treat four people to achieve moderate degree of pain relief and five to achieve moderate functional benefit in one patient.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 One of the studies (Rendant 2011) scored 6/12 on 'Risk of bias' assessment.That is, the study met 6 or fewer than 6 of the 12 criteria, indicating high risk of bias.
2 Small studies

Figures and Tables -
Summary of findings 2. Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization compared to WAIT LIST
Summary of findings 3. Chronic MND: Qigong Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) compared to WAIT LIST

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

Patient or population: patients with chronic mechanical neck disorders
Settings: residential community
Intervention: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance)
Comparison: WAIT LIST

Outcomes

Effects

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 100 worst pain (follow‐up: immediate post treatment)

a. 12 weeks of treatment

b. 24 weeks of treatment or 12 treatments + 12 weeks follow‐up

Two trials showed a moderate reduction in pain

Pooled scores estimated using a

a. Mean difference of ‐13.28 (‐20.98 to ‐5.58)

b. Mean difference of ‐7.82 (‐14.57 to ‐1.07)

148
(2 studies: Rendant 2011, von Trott 2009)

⊕⊕⊕⊝
moderate1

Function: NPDI 0 no disability to 100 maximum disability (follow‐up: immediate post treatment)

a. 12 weeks of treatment

b. 24 weeks of treatment or 12 weeks treatment + 12 weeks follow‐up

Two trials showed a small improvement in function

Pooled scores estimated using a

a. Standard mean difference of ‐0.36 (‐0.68 to ‐0.03)

b. Standard mean difference of ‐0.28 (‐0.68 to 0.11)

148
(2 studies: Rendant 2011, von Trott 2009)

⊕⊕⊕⊝
moderate1

Quality of Life: SF‐36 (physical component) 0 worse to 100 better (follow‐up: immediate post treatment)

a. 12 weeks of treatment

b. 24 weeks of treatment or 12 weeks treatment + 12 weeks follow‐up

Two trials showed little to no difference in quality of life

Pooled scores estimated using a

a. Mean difference of ‐2.72 (‐5.42 to ‐0.01)

b. Mean difference of ‐1.88 (‐5.80 to 2.04)

148
(2 studies: Rendant 2011, von Trott 2009)

⊕⊕⊕⊝1
moderate

Global Perceived Effect: General Health Perception 0 worse to 100 better (follow‐up immediate post treatment and short‐term)

One trial showed no significant difference in GPE.

70

(1 study: von Trott 2009)

⊕⊕⊕⊝
moderate1,2

Adverse Effects

Reported by 23 patients in qigong group including: muscle soreness (n = 17), 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), nausea (n = 2), muscle tension (n = 1)

Moderate quality evidence: (2 trials, 148 participants, Rendant 2011; von Trott 2009) shows Qigong exercises (Dantian Qigong) 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 benefit at immediate and short‐term follow‐up on quality of life and global perceived effect. A clinician may need to treat four to six people to achieve this type of pain relief, five to eight people to achieve this functional benefit, and seven to 10 people for this improvement in quality of life.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 One included study (Rendant 2011) scored 6/12 on risk of bias assessment.That is, the study met 6 or fewer than 6 of the 12 criteria, indicating high risk of bias.
2 Small studies.

Figures and Tables -
Summary of findings 3. Chronic MND: Qigong Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) compared to WAIT LIST
Summary of findings 4. Acute Radiculopathy: Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST

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

Patient or population: patients with acute radiculopathy

Settings: Three hospitals in Netherlands

Intervention: Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization

Comparison: Wait list

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 10 worst pain

(follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up period after treatment)

b. 6 months

One trial showed a small reduction in pain immediately post treatment and no benefit at 6 months follow‐up.

a. Standard mean difference are ‐0.47 (‐0.81 to ‐0.12) post intervention

b. Standard mean difference are 0.16 (‐0.19 to 0.51) at 6 months follow‐up.

133 participants
(1 study: Kuijper 2009)

⊕⊕⊝⊝1,2
low

Function: NDI 0 no disability to 50 maximum disability (follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up period after treatment)

b. 6 months

One trial showed a small reduction in functional disability immediately post treatment and no benefit at 6 months follow‐up.

a. Standard mean difference are ‐0.11 (‐0.45 to 0.23) post intervention.

b. Standard mean difference are 0.06 (‐0.29 to 0.40) at 6 month follow‐up.

133 participants
(1 study: Kuijper 2009)

⊕⊕⊝⊝1,2
low

Patient Satisfaction: 5‐point scale, 1 to 5; very satisfied to unsatisfied

(follow‐up: immediate post treatment)

a. 6 weeks of treatment

a. One trial showed no difference in patient satisfaction immediately post treatment. relative risk ratio are 0.92 (0.62 to 1.37) post intervention.

129 participants
(1 study: Kuijper 2009)

⊕⊕⊝⊝1,2
low

Adverse Effects

Not reported

Low quality evidence: (one trial, 133 participants, Kuijper 2009) Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization may improve pain slightly, but may make no difference in function and patient satisfaction when compared immediately post treatment with a control for acute cervical radiculopathy. However, there may be no difference in pain and functional improvement at intermediate‐term follow‐up.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 One included study (Kuijper 2009) scored 4/12 on risk of bias assessment.That is, the study met 6 or fewer than 6 of the 12 criteria, indicating high risk of bias.
2 Small study.

Figures and Tables -
Summary of findings 4. Acute Radiculopathy: Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST
Summary of findings 5. Acute to subacute CGH: Cervical stretch/ROM vs SHAM

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

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

Settings: Physiotherapy Private Practice

Intervention: Cervical stretch/ROM

Comparison: SHAM INTERVENTION

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 100 worst pain

(follow‐up: immediate post treatment )

a. 4 weeks of treatment

(follow‐up period after treatment)

b. 12 months

One trial showed a small reduction in pain

a. Standard mean difference are ‐1.58 (‐2.38 to ‐0.77) at 4 weeks

b. Standard mean difference are ‐1.74 (‐2.57 to ‐0.91) at 12 months.

32

(1 study: Hall 2007)

⊕⊕⊝⊝
low1,2

Adverse effects

Not reported

Low quality evidence: (one trial, 32 participants, Hall 2007 ) shows Cervical stretch/ROM may improve a large amount for pain reduction at short‐ and long‐term follow‐up with the use of C1 to 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.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Percision: Small study (n=16 per arm).

2 Reporting bias: due to trial size and single outcome, future research is likely to influence the direction of reported effect. Replication in a second trial is needed.

Figures and Tables -
Summary of findings 5. Acute to subacute CGH: Cervical stretch/ROM vs SHAM
Summary of findings 6. Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION

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

Patient or population: patients with chronic CGH

Settings: multiple trial centres

Intervention: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization

Comparison: NO INTERVENTION

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 10 worst pain

(follow‐up: immediate post treatment)

a. 6 weeks

(follow‐up period after treatment)

b. 12 months

One trial showed a large reduction in pain at 6 weeks and 12 months follow up.

a. Standard mean difference are ‐0.75 (‐1.16 to ‐0.34) at 6 weeks

b. Standard mean difference are ‐0.59 (‐1.00 to ‐0.18) at 12 months follow‐up.

97

(1 study: Jull 2002)

⊕⊕⊕⊝
moderate1

Function: NPNPQ 0% no disability to 100% maximum disability

(follow‐up: immediate post treatment)

a. 6 weeks

(follow‐up period after treatment)

b. 12 months

One trial showed a moderate reduction in functional disability

a. Standard mean difference are ‐0.56 (‐0.96 to ‐0.15) at 6 weeks

b. Standard mean difference are ‐0.70 (‐1.11 to 0.29) at 12 months follow‐up.

97

(1 study: Jull 2002)

⊕⊕⊕⊝
moderate1

Global Perceived Effect: VAS 0 to 100

(follow‐up: immediate post treatment)

a. 6 weeks

(follow‐up period after treatment)

b. 12 months

One trial showed a large benefit in global perceived effect

a. Standard mean difference are ‐2.96 (‐3.55 to ‐2.38) at 6 weeks.

b. Standard mean difference are ‐2.51 (‐3.05 to ‐1.97) at 12 months follow‐up.

97

(1 study: Jull 2002)

⊕⊕⊕⊝
moderate1

Adverse effects

Minor and temporary adverse effects were noted: 6.7% of headaches were provoked by treatment

Moderate quality evidence: (one trial, 97 participants, Jull 2002) shows cervicoscapular strengthening and endurance exercises including pressure biofeedback probably improves pain, function and global perceived effect for chronic cervicogenic headaches at long term follow‐up when compared to no treatment. A clinician may need to treat six people to achieve this type of pain relief and functional benefit in one patient.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Percision: Although small study, consistent findings are noted across multiple outcomes at long term follow‐up.

Figures and Tables -
Summary of findings 6. Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION
Summary of findings 7. Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization + Manual Therapy vs Manual Therapy

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

Patient or population: patients with Chronic CGH

Settings: multiple trial centres

Intervention: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization + Manual Therapy

Comparison: MANUAL THERAPY

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: 6 weeks treatment VAS 0 no pain to 10 worst pain

(follow‐up: immediate post treatment)

a. 6 weeks

(follow‐up period after treatment)

b. 12 months

One trial showed a small reduction in pain

a. Standard mean difference are ‐0.11 (‐0.50 to 0.29) at 6 weeks

b. Standard mean difference are ‐0.17 (‐0.57 to 0.23) at 12 months follow‐up.

96

(1 study: Jull 2002)

⊕⊕⊕⊝
moderate1

Function: NPNPQ 0% no disability to 100% maximum disability

(follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up period after treatment)

b. 12 months

One trial showed a small reduction in functional disability

a. Standard mean difference are ‐0.11 (‐0.51 to 0.28) at 6 weeks

b. Standard mean difference are ‐0.23 (‐0.63 to 0.17) at 12 months follow‐up.

96

(1 study: Jull 2002)

⊕⊕⊕⊝
moderate1

Global Perceived Effect: VAS 0 to 100 (follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up period after treatment)

b. 12 months

One trial showed a small benefit in global perceived effect

a. Standard mean difference are ‐0.29 (‐0.68 to 0.11) at 6 weeks

b. Standard mean difference ‐0.30 (‐0.70 to 0.10) at 12 months follow‐up.

96

(1 study: Jull 2002)

⊕⊕⊕⊝
moderate1

Adverse effects

Minor and temporary adverse effects were noted: 6.7% of headaches were provoked by treatment

Moderate quality evidence (one trial, 96 participants, Jull 2002) shows when exercise combined with manual therapy contrasted with manual therapy alone there is probably no difference in pain, function and global perceived effect for chronic cervicogenic headaches at long‐term follow‐up.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Percision: Although small study, consistent findings are noted across multiple outcomes at long term follow‐up.

Figures and Tables -
Summary of findings 7. Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization + Manual Therapy vs Manual Therapy
Summary of findings 8. Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM

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

Patient or population: patients with chronic MND

Settings: Primary care physical therapy and private physical therapy practices

Intervention: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization

Comparison: PLACEBO or SHAM

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 100 worst pain

(follow‐up: immediate post treatment)

a. 2 months of treatment

(follow‐up period after treatment)

b. 6 months

c. 12 months

One trial showed no difference in pain immediately post intervention and at 6 and 12 months follow‐up.

a. Standard mean difference 0.26 (‐0.33 to 0.85) immediately 2 months post intervention.

b. Standard mean difference ‐0.16 (‐0.75 to 0.43) at 6 months follow‐up.

c. Standard mean difference ‐0.19 (‐0.40 to 0.78) at 12 months follow‐up.

77

(1 study: Kjellman 2002)

⊕⊕⊝⊝
low1,2

Function: 2 months treatment NDI 0 no disability to 50 maximum disability

(follow‐up: immediate post treatment)

a. 2 months of treatment

(follow‐up period after treatment )

b. 6 months

c. 12 months

One trial showed no difference in function immediately post intervention and at 6 and 12 months follow‐up.

a. Standard mean difference are 0.14 (‐0.45 to 0.73) immediately post 2 months intervention.

b. Standard mean difference ‐0.06 (‐0.66 to 0.53) at 6 months follow‐up.

c. Standard mean difference 0.12 (‐0.47 to 0.72) at 12 months follow‐up.

77

(1 study: Kjellman 2002)

⊕⊕⊝⊝
low1,2

Adverse effects

Not reported

Low quality evidence: (One trial, 77 participants, Kjellman 2002) No difference for pain relief and function immediately post intervention, at 6 and 12 months follow‐up using Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization for chronic MND.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 One of the studies (Kjellman 2002)) scored 5/12 on 'Risk of bias' assessment.That is, the study met 6 or fewer than 6 of the 12 criteria, indicating high risk of bias.
2 Small studies

Figures and Tables -
Summary of findings 8. Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM
Summary of findings 9. Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM

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

Patient or population: patients with chronic MND

Settings: Primary care physical therapy and private physical therapy practices

Intervention: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization

Comparison: PLACEBO or SHAM

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 100 worst pain (follow‐up: immediate post treatment)

a. 2 months of treatment

(follow‐up period after treatment)

b. 6 months

c. 12 months

One trial showed no difference in pain immediately post intervention and at 6 and 12 months follow‐up.

a. Standard mean difference are ‐0.10 (‐0.66 to 0.45) immediately post 2 months intervention.

b. Standard mean difference ‐0.29 (‐0.85 to 0.27) at 6 months follow‐up.

c. Standard mean difference 0.04 (‐0.51 to 0.60) at 12 months follow‐up.

50

(1 study: Kjellman 2002)

⊕⊕⊝⊝
low1,2

Function: NDI 0 no disability to 50 maximum disability (follow‐up: immediate post treatment)

a. 2 months of treatment

(follow‐up period after treatment )

b. 6 months

c. 12 months

One trial showed no difference in function immediately post intervention and at 6 and 12 months follow‐up.

a. Standard mean difference are ‐0.24 (‐0.79 to 0.32) immediately post 2 month intervention.

b. Standard mean difference ‐0.22 (‐0.79 to 0.36) at 6 months follow‐up

c. Standard mean difference 0.14 (‐0.44 to 0.71) at 12 months follow‐up.

50

(1 study: Kjellman 2002)

⊕⊕⊝⊝
low1,2

Adverse effects

Not reported

Low quality evidence: (One trial, 50 participants, Kjellman 2002) No difference for pain relief and function immediately post intervention, at 6 and 12 month follow‐up using Cervical Stretch/ROM Exercise + Dynamic Cervical Stabilization for chronic MND.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 One of the studies (Kjellman 2002) scored 5/12 on 'Risk of bias' assessment.That is, the study met 6 or fewer than 6 of the 12 criteria, indicating high risk of bias.
2 Small studies

Figures and Tables -
Summary of findings 9. Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM
Summary of findings 10. Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST

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

Patient or population: patients with chronic MND

Settings: office workers

Intervention: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training

Comparison: NO INTERVENTION or WAIT LIST

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 100 worst pain

(follow‐up: immediate post treatment)

a. 12 weeks of treatment

(follow‐up period after treatment)

b. 3 months

c. 9 months

One trial showed no difference in pain immediately post intervention and at 3 and 9 months follow‐up.

a. Standard mean difference are 0.08 (‐0.16 to 0.32) immediately post 12 weeks intervention.

b. Standard mean difference 0.00 (‐0.24 to 0.24) at 3 months follow‐up.

c. Standard mean difference ‐0.04 (‐0.28 to 0.20) at 9 months follow‐up.

393

(1 study: Viljanen 2003)

⊕⊕⊕⊝
moderate1

Function: NDI 0 no disability to 50 maximum disability

(follow‐up: immediate post treatment)

a. 12 weeks of treatment

(follow‐up period after treatment)

b. 3 months

c. 9 months

One trial showed no difference in function immediately post intervention and at 3 and 9 months follow up.

a. Standard mean difference 0.07 (‐0.17 to 0.31) immediately post 12 weeks intervention.

b. Standard mean difference 0.07 (‐0.17 to 0.31) at 3 months follow‐up.

c. Standard mean difference 0.14 (‐0.11 to 0.38) at 9 months follow‐up.

393

(1 study: Viljanen 2003)

⊕⊕⊕⊝
moderate1

Adverse effects

Not reported

Moderate quality evidence: (one trial, 393 participants, Viljanen 2003) Little to no difference for pain relief and function immediately post intervention, at 3 and 9 months follow‐up using Cervical/Scapulothoracic/UE Stretch + UE Endurance Training for chronic MND.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Percision: high drop out rate (14%); reason for dropout not described.

Figures and Tables -
Summary of findings 10. Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST
Summary of findings 11. Acute to Chronic MND: Scapulothoracic/UE Endurance Training vs CONTROL

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

Patient or population: patients with Acute to Chronic MND

Settings: two large withe collar organizations

Intervention: Scapulothoracic/UE Endurance Training

Comparison: CONTROL

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 10 worst pain (follow‐up: immediate post 10 weeks treatment)

a. 2‐minute training group

b. 12‐minute training group

One trial showed moderate pain relief immediately post intervention.

a. Standard mean difference for the 2 minute training group ‐0.66 (‐1.02 to ‐0.30).

b. Standard mean difference for the 12 minute training group ‐0.59 (‐0.94 to ‐0.23).

198

(1 study: Andersen 2011)

⊕⊕⊕⊝
moderate1

Adverse effects

Reported worsening of neck muscle tension during and/or in the days after training (2‐minute n = 1, 12‐minute n = 4), shoulder joint pain during training (2‐minute n = 1, 12‐minute n = 4), pain in the upper arm during training (2‐minute n = 1, 12‐minute n = 1), pain of the forearm/wrist during training (12‐minute n = 2), worsening of headache after training (2‐minute n = 1, 12‐minute n = 1). No long‐lasting or major complications resulted from the training program.

Moderate quality evidence: (one trial, 198 participants, Andersen 2011) Moderate benefit for pain relief immediately post intervention using Scapulothoracic/UE Endurance Training for (sub)Acute/Chronic MND. A clinician may need to treat four people to achieve this type of pain relief.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Percision: small sample (n = 63 or 64 per Arm) measured at Immediate post treatment.

Figures and Tables -
Summary of findings 11. Acute to Chronic MND: Scapulothoracic/UE Endurance Training vs CONTROL
Summary of findings 12. Subacute to Chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT

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

Patient or population: patients with subacute/chronic WAD

Settings: two physiotherapy clinics

Intervention: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT

Comparison: THAT SAME OTHER TREATMENT

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 10 worst pain

(follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up period after treatment)

b. 12 months

One trial showed small pain relief immediately post intervention and no difference at 12 months follow‐up.

a. Standard mean difference ‐0.46 (‐0.81 to ‐0.12) immediately post 6 weeks intervention.

b. Standard mean difference ‐0.12 (‐0.47 to 0.23) at 12 months follow‐up.

132

(1 study: Stewart 2007)

⊕⊕⊝⊝
low1,2

Function: NDI 0 no disability to 50 maximum disability

(follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up period after treatment)

b. 12 months

One trial showed small benefit in function immediately post intervention and at 12 months follow‐up.

a. Standard mean difference ‐0.50 (‐0.85 to ‐0.15) immediately post 6 weeks intervention.

b. Standard mean difference ‐0.39 (‐0.74 to ‐0.03) at 12 months follow‐up.

132

(1 study: Stewart 2007)

⊕⊕⊝⊝
low1,2

Global perceived effect: ‐5 to 5 scale; vastly worse to completely recovered

(follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up after treatment)

b. 12 months

One trial showed small benefit in global perceived effect immediately post intervention and no difference at 12 months follow‐up.

a. Standard mean difference ‐0.46 (‐0.80 to ‐0.11) immediately post 6 weeks intervention.

b. Standard mean difference ‐0.18 (‐0.54 to 0.17) at 12 months follow‐up.

132

(1 study: Stewart 2007)

⊕⊕⊝⊝
low1,2

Quality of Life: SF‐36 0 high disability to 100 no disability (follow‐up: immediate post treatment)

a. 6 weeks of treatment

(follow‐up after treatment)

b. 12 months

One trial showed small benefit in global perceived effect immediately post intervention and no difference at 12 month follow‐up.

a. Standard mean difference ‐0.35 (‐0.69 to ‐0.01) immediately post 6 weeks intervention.

b. Standard mean difference ‐0.15 (‐0.50 to 0.20) at 12 month follow‐up.

132

(1 study: Stewart 2007)

⊕⊕⊝⊝
low1,2

Adverse effects

Reported; The main complaint in this group was muscle pain with exercise (3) followed
by knee pain (2) and lumbar spine pain (2).

Low quality evidence: (one trial, 132 participants, Stewart 2007) Small benefit for pain relief, function, global perceived effect and quality of life immediately post treatment and small benefit at 12 month follow up for function using Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT for Subacute/chronic WAD.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 One of the studies (Stewart 2007) scored 6/12 on 'Risk of bias' assessment.That is, the study met 6 or fewer than 6 of the 12 criteria, indicating high risk of bias.
2 Small studies

Figures and Tables -
Summary of findings 12. Subacute to Chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT
Summary of findings 13. Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL

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

Patient or population: patients with Acute to Chronic MND

Settings: Seven workplaces

Intervention: Scapulothoracic + UE Strengthening

Comparison: CONTROL

Outcomes

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Pain Intensity: VAS 0 no pain to 100 worst pain (follow‐up: immediate post 10 to 20 weeks of treatment)

Three trials showed a moderate reduction in pain. Pooled scores estimated using a standard mean difference ‐0.71 (‐1.33 to ‐0.10).

157

(3 studies: Andesen 2008, Andersen CH 2012, Dellve 2011)

⊕⊕⊕⊝
moderate

Pain Intensity: VAS 0 no pain to 100 worst pain (follow‐up: immediate post 20 weeks of treatment)

a. 1 weekly session

b. 9 weekly sessions

One trial (two comparisons) showed no difference in pain relief immediately post intervention.

a. One weekly session of 60 minutes, scores using a standard mean difference ‐0.20 (‐0.63 to 0.22).

b. Nine weekly sessions of seven minutes, scores using a standard mean difference ‐0.13 (‐0.61 to 0.34).

163

(1 study: three groups, Andersen CH 2012)

⊝⊝⊝⊝
very low1

Pain Intensity: VAS 0 no pain to 100 worst pain (follow‐up: immediate post 10 weeks of treatment)

One trial showed moderate reduction in pain 10 weeks post intervention. Scores using a standard mean difference ‐0.89 (‐1.76 to ‐0.01) at 10 week follow‐up.

26

(1 study: Andersen 2008)

⊕⊕⊝⊝
low

Function: DASH 20% no difficulty to 100% fully unable (follow‐up: immediate post 20 weeks of treatment).

a. 1 weekly session

b. 9 weekly sessions

One trial showed no difference in function immediately post intervention.

a. Standard mean difference ‐0.17 (‐0.58 to 0.24) immediately post intervention for one weekly session of 60 minutes

b. Standard mean difference ‐0.06 (‐0.53 to 0.41) for nine weekly sessions of seven minutes.

163

(1 study: Andersen CH 2012)

⊝⊝⊝⊝
very low1

Work ability index: 7 poor ability to 49 excellent ability treatment (follow‐up: immediate post 20 weeks treatment)

One trial showed a small improvement in work ability immediately post intervention. Standard mean difference ‐0.23 (‐0.66 to 0.19) immediately post 20 weeks intervention.

88

(1 study: Dellve 2011)

⊕⊕⊝⊝
low

Adverse effects

Not reported

Moderate quality evidence: (3 trials, 157 participants, Andersen 2008, Andersen Ch 2012, Dellve 2011) that scapulothoracic and upper extremity strength training probably improves pain. It probably functional outcomes when compared to control for chronic mechanical neck pain immediately post treatment (10 or 20 week interventions). However low quality evidence suggests that scapulothoracic and upper extremity strength training may improve pain slightly.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Design: 0, Limitations: ‐1, Inconsistency: 0, Indirectness: 0, Imprecision: ‐1, Other: ‐1 subgroup analysis.

Figures and Tables -
Summary of findings 13. Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL
Comparison 1. Chronic MND: Breathing Patterns vs CONTROL

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (Borg 0 to 10): 10 weeks of treatment vs Control Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 Practice paced breathing vs Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2 Function (NDI 0 to 100): 10 weeks of treatment vs Control Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

2.1 Practice paced breathing vs Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3 SF‐36 (physical function): 10 weeks of treatment vs Control Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

Figures and Tables -
Comparison 1. Chronic MND: Breathing Patterns vs CONTROL
Comparison 2. Acute to Chronic MND: General Fitness Training vs CONTROL

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (VAS): 10 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 General Fitness Training v Reference Intervention

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2 Pain Intensity (VAS): 10 weeks of treatment + 10 weeks follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

2.1 General Fitness Training v Reference Intervention

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 2. Acute to Chronic MND: General Fitness Training vs CONTROL
Comparison 3. Chronic MND: Cervical Stretch/ROM Exercises + ANOTHER INTERVENTION vs THAT SAME INTERVENTION

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (NRS‐101): 4 weeks of treatment Show forest plot

Other data

No numeric data

1.1 Stretch before Manip v Manip alone

Other data

No numeric data

1.2 Stretch after Manip v Manip alone

Other data

No numeric data

2 Function (NDI): 4 weeks of treatment Show forest plot

Other data

No numeric data

2.1 Stretch before Manip v Manip alone

Other data

No numeric data

2.2 Stretch after Manip v Manip alone

Other data

No numeric data

Figures and Tables -
Comparison 3. Chronic MND: Cervical Stretch/ROM Exercises + ANOTHER INTERVENTION vs THAT SAME INTERVENTION
Comparison 4. Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (VAS): 8 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 McKenzie Treatment v Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2 Pain Intensity (VAS): 8 weeks of treatment + 6 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

2.1 McKenzie Treatment v Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3 Pain Intensity (VAS): 8 weeks of treatment + 12 months follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

3.1 McKenzie Treatment v Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4 Function (NDI): 8 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

4.1 McKenzie Treatment v Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

5 Function (NDI): 8 weeks of treatment + 6 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

5.1 McKenzie Treatment v Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

6 Function (NDI): 8 weeks of treatment + 12 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

6.1 McKenzie Treatment v Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 4. Chronic MND: Cervical Stretch/ROM Exercises + Dynamic Cervical Stabilization vs SHAM
Comparison 5. Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO INTERVENTION OR WAIT LIST

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (VAS): 6 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 Isometric neck exercises +/‐ pillow vs control or pillow

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2 Pain Intensity (VAS): 6 weeks of treatment + 6 weeks follow‐up Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

2.1 Isometric neck exercises +/‐ pillow vs pillow or placebo

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3 Function (NPQ): 6 weeks of treatment Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

3.1 Isometric neck exercises +/‐ pillow vs pillow or placebo

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4 Function (NPQ): 6 weeks of treatment + 6 weeks follow‐up Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

4.1 Isometric neck exercises +/‐ pillow vs pillow or placebo

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

5 Global Perceived Effect Treatment (patients assessment): 3 weeks of treatment

0

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

5.1 Isometric exercises vs no intervention

0

Risk Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

6 Quality of Life (SF‐36): 6 weeks of treatment + 6 w follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

6.1 Isometric neck exercises +/‐ pillow vs pillow or placebo

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 5. Chronic MND: Static Cervical Strengthening + Static Stabilization vs NO INTERVENTION OR WAIT LIST
Comparison 6. Chronic MND: Pattern synchronization (sitting posture) vs CONTROL

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain intensity (VAS) 2 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 Postural Exercise vs Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2 Function (NDI): 2 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

2.1 Postural Exercise vs Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 6. Chronic MND: Pattern synchronization (sitting posture) vs CONTROL
Comparison 7. Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (NPS): 4 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 Muscle strength training vs CONTROL

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2 Pain Intensity: 10 to 20 weeks of treatment Show forest plot

3

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

2.1 Strength Specific Training vs Reference Group

3

157

Std. Mean Difference (IV, Random, 95% CI)

‐0.71 [‐1.33, ‐0.10]

3 Pain Intensity: 20 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

3.1 Strength Specific Training vs Reference Group

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4 Pain Intensity (VAS): 10 weeks of treatment + 10 weeks follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

4.1 Strength Specific Training vs Reference Group

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

5 Function: 4 weeks of treatment Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

5.1 Intensive muscular strength training vs CONTROL

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

6 Function: 20 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

6.1 Specific strength training vs Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

7 Function: 12 to 20 weeks of treatment/follow‐up Show forest plot

2

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

7.1 Muscle strength training vs CONTROL

2

128

Std. Mean Difference (IV, Random, 95% CI)

‐0.28 [‐0.63, 0.07]

Figures and Tables -
Comparison 7. Acute to Chronic MND: Scapulothoracic + UE Strengthening vs CONTROL
Comparison 8. Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (VAS): 8 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 General Exercise vs Sham US

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2 Pain Intensity (VAS): 8 weeks of treatment + 6 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

2.1 General Exercise vs Sham US

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3 Pain Intensity (VAS): 8 weeks of treatment + 12 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

3.1 General Exercise vs Sham US

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4 Function (NDI): 8 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

4.1 General Exercise vs Sham US

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

5 Function (NDI): 8 weeks of treatment + 6 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

5.1 General Exercise vs Sham US

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

6 Function (NDI): 8 weeks treatment + 12 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

6.1 General Exercise vs Sham US

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 8. Chronic MND: Cervical/UE Stretch/ROM Exercise + Cervical/UE Strengthening + Dynamic Cervical Stabilization vs PLACEBO or SHAM
Comparison 9. Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity: Immediate Post Treatment (<11w of treatment) Show forest plot

4

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 Exercise +/‐ Infrared +/‐ SMT +/‐ Acupuncture vs Infrared or SMT or Acupuncture

4

317

Mean Difference (IV, Random, 95% CI)

‐0.66 [‐1.28, ‐0.03]

2 Pain Intensity: 11 w of treatment + 3 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

2.1 SMT + Rehab Exercises vs SMT

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3 Pain Intensity: Treatment + IT follow‐up (11 weeks of treatment + 6 month follow‐up Show forest plot

3

Mean Difference (IV, Random, 95% CI)

Subtotals only

3.1 <11w of treatment + 6 month follow‐up

3

241

Mean Difference (IV, Random, 95% CI)

‐0.67 [‐1.32, ‐0.02]

4 Pain Intensity: Treatment + LT follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

4.1 <11w of treatment + 24 month follow‐up

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

5 Function: Immediate Post treatment Show forest plot

4

Mean Difference (IV, Random, 95% CI)

Subtotals only

5.1 <11w of treatment

4

317

Mean Difference (IV, Random, 95% CI)

‐1.91 [‐4.65, 0.83]

6 Function: Treatment + ST follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

6.1 <11w of treatment + 3 month follow‐up

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

7 Function: Treatment + IT follow‐up Show forest plot

3

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

7.1 <11w of treatment + 6 month follow‐up

3

241

Std. Mean Difference (IV, Random, 95% CI)

‐0.45 [‐0.72, ‐0.18]

8 Function: Treatment + LT follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

8.1 <11w of treatment + 24 month follow‐up

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

9 Quality of Life: Immediate Post Treatment Show forest plot

2

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

9.1 <11w of treatment

2

165

Std. Mean Difference (IV, Random, 95% CI)

‐0.18 [‐0.48, 0.13]

10 Quality of Life: Treatment + ST follow‐up Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

10.1 11w of treatment + 3 month follow‐up

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

11 Quality of Life: Treatment + IT follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

11.1 11w of treatment + 6 month follow‐up

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

12 Quality of Life: Treatment + LT follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

12.1 11w of treatment + 24 month follow‐up

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

13 Patient Satisfaction: Immediate Post Treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

13.1 11>w of treatment

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

14 Patient Satisfaction: Treatment + ST follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

14.1 11w of treatment + 3 month follow‐up

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

15 Patient Satisfaction: Treatment + IT follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

15.1 11w of treatment + 6 month follow‐up

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

16 Patient Satisfaction: Treatment + LT follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

16.1 11w of treatment + 24 month follow‐up

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

17 Global Perceived Effect: Immediate Post Treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

17.1 11w of treatment

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

18 Global Perceived Effect: Treatment + ST follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

18.1 11w of treatment + 3 month follow‐up

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

19 Global Perceived Effect: Treatment + IT follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

19.1 11w of treatment + 6 month follow‐up

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

20 Global Perceived Effect: Treatment + LT follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

20.1 11w of treatment + 24 month follow‐up

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 9. Chronic MND: Cervical/UE Stretch/ROM Exercises + Cervical/Scapulothoracic+/‐UE Strengthening + Dynamic/Static Cervical Stabilization + ANOTHER INTERVENTION vs THAT SAME INTERVENTION
Comparison 10. Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (VAS): 12 weeks of treatment Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 Exercise Therapy vs No Treatment

2

147

Mean Difference (IV, Random, 95% CI)

‐14.90 [‐22.40, ‐7.39]

2 Pain Intensity (VAS): 24 weeks of treatment Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

2.1 Exercise Therapy vs No Treatment

2

140

Mean Difference (IV, Random, 95% CI)

‐10.94 [‐18.81, ‐3.08]

3 Function: 12 weeks of treatment Show forest plot

2

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

3.1 Exercise Therapy vs No Treatment

2

147

Std. Mean Difference (IV, Random, 95% CI)

‐0.50 [‐1.04, 0.03]

4 Function: 24 weeks of treatment Show forest plot

2

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

4.1 Exercise Therapy vs No Treatment

2

140

Std. Mean Difference (IV, Random, 95% CI)

‐0.40 [‐0.74, ‐0.06]

5 Global Perceived Effect (General Health Perception): 12 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

5.1 Exercise Therapy vs No Treatment

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

6 Global Perceived Effect (General Health Perception): 12 weeks of treatment + 12 weeks follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

6.1 Exercise Therapy vs No Treatment

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

7 Quality of Life (SF‐36): 12 weeks of treatment Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

7.1 Exercise Therapy vs No Treatment

2

143

Mean Difference (IV, Random, 95% CI)

‐2.22 [‐5.17, 0.72]

8 Quality of Life (SF‐36): 24 weeks of treatment Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

8.1 Exercise Therapy vs No Treatment

2

144

Mean Difference (IV, Random, 95% CI)

0.06 [‐4.06, 4.17]

Figures and Tables -
Comparison 10. Chronic MND: Cervical Stretch/ROM Exercises + Cervical/Scapulothoracic Strengthening + Static/Dynamic Cervical/Shoulder Stabilization vs WAIT LIST
Comparison 11. Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (VAS): 12 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 Dynamic muscle training vs control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2 Pain Intensity (VAS): 12 weeks of treatment + 3 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

2.1 Dynamic muscle training vs control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3 Pain Intensity (VAS): 12 weeks of treatment + 9 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

3.1 Dynamic muscle training vs control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4 Function (Neck Disability 0‐80): 12 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

4.1 Dynamic muscle training vs control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

5 Function (Neck Disability 0‐80): 12 weeks of treatment + 3 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Fixed, 95% CI)

Totals not selected

5.1 Dynamic muscle training vs control

1

Std. Mean Difference (IV, Fixed, 95% CI)

0.0 [0.0, 0.0]

6 Function (Neck Disability 0‐80): 12 weeks of treatment + 9 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

6.1 Dynamic muscle training vs control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 11. Chronic MND: Cervical/Scapulothoracic/UE Stretch + UE Endurance Training vs NO INTERVENTION or WAIT LIST
Comparison 12. Acute to Chronic MND: Pattern synchronization + cervical/scapulothoracic strengthening + scapulothoracic endurance vs NO INTERVENTION

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (VAS 0 to 10): 24 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 Training group vs control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 12. Acute to Chronic MND: Pattern synchronization + cervical/scapulothoracic strengthening + scapulothoracic endurance vs NO INTERVENTION
Comparison 13. Chronic MND: Cervical/Scapulothoracic Strengthening + Cervical/Scapulothoracic Endurance Training

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Prevelance during previous week: 6 weeks of treatment + 46 weeks follow‐up Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

1.1 Exercise Regimen vs control group

1

Risk Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 13. Chronic MND: Cervical/Scapulothoracic Strengthening + Cervical/Scapulothoracic Endurance Training
Comparison 14. Acute to Chronic MND: Scapulothoracic/UE Endurance Training vs CONTROL

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (VAS): 10 weeks treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 2 minute training group vs Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

1.2 12 minute training group vs Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 14. Acute to Chronic MND: Scapulothoracic/UE Endurance Training vs CONTROL
Comparison 15. Chronic MND: Neuromuscular Education (eye neck coordination/proprioception) + ANOTHER INTERVENTION VS THAT SAME INTERVENTION

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (VAS): 8 weeks treatment + 10 weeks follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 Rehabilitation Group vs Control Group

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2 Function (pt's assessment of functional improvement): 8 weeks treatment + 10 weeks follow‐up Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

2.1 Rehabilitation Group vs Control Group

1

Risk Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 15. Chronic MND: Neuromuscular Education (eye neck coordination/proprioception) + ANOTHER INTERVENTION VS THAT SAME INTERVENTION
Comparison 16. Chronic MND:Trunk/Extremity Stretch + Pattern/Synchronization: Balance and Coordination + Cardiovascular/Aerobic vs NO TREATMENT

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (VAS): 10 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 Group Gymnastics vs Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 16. Chronic MND:Trunk/Extremity Stretch + Pattern/Synchronization: Balance and Coordination + Cardiovascular/Aerobic vs NO TREATMENT
Comparison 17. Chronic MND:General Endurance Training + Dynamic/Static Lowback/pelvic Stabilization + General Stretching + Neuromuscular/body Mechanics Movement Training vs NO INTERVENTION OR WAIT LIST

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (VAS): 16 weeks treatment + 6 weeks follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 Physiotherapy Group vs Control Group

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 17. Chronic MND:General Endurance Training + Dynamic/Static Lowback/pelvic Stabilization + General Stretching + Neuromuscular/body Mechanics Movement Training vs NO INTERVENTION OR WAIT LIST
Comparison 18. Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (VAS): 12 weeks of treatment Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 Qigong vs No Treatment

2

148

Mean Difference (IV, Random, 95% CI)

‐13.28 [‐20.98, ‐5.58]

2 Pain Intensity (VAS): 24 weeks of treatment Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

2.1 Qigong vs No Treatment

2

137

Mean Difference (IV, Random, 95% CI)

‐7.82 [‐14.57, ‐1.07]

3 Function: 12 weeks of treatment Show forest plot

2

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

3.1 Qigong vs No Treatment

2

148

Std. Mean Difference (IV, Random, 95% CI)

‐0.36 [‐0.68, ‐0.03]

4 Function: 24 weeks of treatment Show forest plot

2

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

4.1 Qigong vs No Treatment

2

137

Std. Mean Difference (IV, Random, 95% CI)

‐0.28 [‐0.68, 0.11]

5 Global Perceived Effect (General Health Perception): 12 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

5.1 Qigong vs No Treatment

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

6 Global Perceived Effect (General Health Perception): 12 weeks of treatment + 12 weeks Follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

6.1 Qigong vs No Treatment

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

7 Quality of Life (SF‐36 physical component): 12 weeks of treatment Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

7.1 Qigong vs No Treatment

2

148

Mean Difference (IV, Random, 95% CI)

‐2.72 [‐5.42, ‐0.01]

8 Quality of Life: 24 weeks of treatment Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

8.1 Qigong vs No Treatment

2

137

Mean Difference (IV, Random, 95% CI)

‐1.88 [‐5.80, 2.04]

Figures and Tables -
Comparison 18. Chronic MND: Stretch/ROM + Endurance Training + Dynamic Stabilization + Cognitive (mindfulness & emotional balance) vs WAIT LIST
Comparison 19. Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity: (0‐10 box scale): 6 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 Exercise + Advice vs Advice

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2 Pain Intensity (0‐10 box scale): 6 weeks treatment + 12 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

2.1 Exercise + Advice vs Advice

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3 Function (NDI): 6 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

3.1 Exercise + Advice vs Advice

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4 Function (NDI): 6 weeks of treatment + 12 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

4.1 Exercise + Advice vs Advice

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

5 Global Perceived Effect (‐5 to 5 scale): 6 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

5.1 Exercise + Advice vs Advice

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

6 Global Perceived Effect (‐5 to 5 scale): 6 weeks of treatment + 12 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

6.1 Exercise + Advice vs Advice

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

7 Quality of Life (SF‐36): 6 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

7.1 Exercise + Advice vs Advice

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

8 Quality of Life (SF‐36): 6 weeks of treatment + 12 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

8.1 Exercise + Advice vs Advice

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 19. Subacute to chronic WAD: Trunk/Extremity Stretch/ROM + Trunk/Extremity Strengthening + Trunk/Extremity Endurance Training + Pattern/Synchronization: Coordination + Cardiovascular/Aerobic + Cognitive (CBT) + ANOTHER TREATMENT vs THAT SAME OTHER TREATMENT
Comparison 20. Acute to Subacute CGH: Cervical Stretch/ROM vs SHAM

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (Headache Questionnaire): Treatment + 4 weeks follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 C1‐C2 Self Snag vs Placebo Group

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2 Pain Intensity (Headache Questionnaire): Treatment + 12 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

2.1 C1‐C2 Self Snag vs Placebo Group

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 20. Acute to Subacute CGH: Cervical Stretch/ROM vs SHAM
Comparison 21. Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Headache Intensity (VAS 0‐10): 6 weeks of treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 Therapeutic Exercise +/‐ Manip vs Control Group or Manip

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2 Headache Intensity (VAS 0‐10): 6 weeks treatment + 12 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

2.1 Therapeutic Exercise +/‐ Manip vs Control Group or Manip

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3 Function (NPNPQ 0‐36): 6 weeks treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

3.1 Therapeutic Exercise +/‐ Manip vs Control Group or Manip

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4 Function (NPNPQ 0‐36): 6 weeks treatment + 12 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

4.1 Therapeutic Exercise +/‐ Manip vs Control Group or Manip

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

5 Global Perceived Effect (VAS): 6 weeks treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

5.1 Therapeutic Exercise +/‐ Manip vs Control Group or Manip

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

6 Global Perceived Effect (VAS): 6 weeks treatment + 12 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

6.1 Therapeutic Exercise +/‐ Manip vs Control Group or Manip

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 21. Chronic CGH: Cervical/Scapulothoracic Strengthening with Endurance Training + Craniocervical Pressure Biofeedback + Dynamic Cervical Stabilization vs NO INTERVENTION or WAIT LIST
Comparison 22. Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (VAS): 6 weeks treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

1.1 Physiotherapy vs Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

2 Pain Intensity (VAS): 6 weeks treatment + 6 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

2.1 Physiotherapy vs Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

3 Function (NDI): 6 weeks treatment Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

3.1 Physiotherapy vs Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4 Function (NDI): 6 weeks treatment + 6 month follow‐up Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

4.1 Physiotherapy vs Control

1

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

5 Satisfaction (5 point scale): 6 weeks treatment Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

5.1 Physiotherapy vs Control

1

Risk Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 22. Acute Radiculopathy (NDR): Cervical Stretch/ROM + Cervical/Scapulothoracic/UE Strengthening + Static/Dynamic Cervical Stabilization vs WAIT LIST
Comparison 23. Chronic MND: Patterns synchronization + Feedforward/feedback: vestibular rehabilitation (balance on unstable surfaces and walking with head movements and eyes closed) vs NO INTERVENTION

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain Intensity (VAS) 6 weeks vs Control Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

2 Pain Intensity (VAS) 3 months vs control Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

Figures and Tables -
Comparison 23. Chronic MND: Patterns synchronization + Feedforward/feedback: vestibular rehabilitation (balance on unstable surfaces and walking with head movements and eyes closed) vs NO INTERVENTION
Comparison 24. Chronic MND: Patterns synchronization + Feedforward/feedback: exercises for coordinating the neck, eyes and upper limbs vs NO INTERVENTION

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain intensity (VAS) 4 weeks vs Control Show forest plot

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

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