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Exercises for mechanical neck disorders

  1. Theresa M Kay1,*,
  2. Anita Gross2,
  3. Charles H Goldsmith3,
  4. Jan L Hoving4,
  5. Gert Brønfort5

Editorial Group: Cochrane Back Group

Published Online: 7 OCT 2009

Assessed as up-to-date: 29 FEB 2004

DOI: 10.1002/14651858.CD004250.pub3

Database Title

Additional Information

How to Cite

Kay TM, Gross A, Goldsmith CH, Hoving JL, Brønfort G. Exercises for mechanical neck disorders. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD004250. DOI: 10.1002/14651858.CD004250.pub3.

Author Information

  1. 1

    Baycrest - Geriatric Health Care System, Clinical Programs and Collaborative Practice, Toronto, ON, Canada

  2. 2

    McMaster University, School of Rehabilitation Science & Dept Clinical Epidemiology and Biostatistics, Hamilton, Ontario, Canada

  3. 3

    McMaster University, Department of Clinical Epidemiology & Biostatistics, Hamilton, Ontario, Canada

  4. 4

    Academic Medical Center, Universiteit van Amsterdam, Coronel Institute of Occupational Health, Amsterdam, Netherlands

  5. 5

    Northwestern Health Sciences University, Wolfe-Harris Center for Clinical Studies, Bloomington, MN, USA

*Theresa M Kay, Clinical Programs and Collaborative Practice, Baycrest - Geriatric Health Care System, 3560 Bathurst Street, Room 283, Brain Health Centre, Toronto, ON, M6A 2E1, Canada. tkay@baycrest.org.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 7 OCT 2009

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ARTICLE TOOLS

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Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

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

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

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

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Criteria for considering studies for this review

 

Types of studies

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

 

Types of participants

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

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

 

Types of interventions

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

 

Types of outcome measures

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

  • pain,
  • measures of function/disability,
  • patient satisfaction, and
  • global perceived effect.

 

Search methods for identification of studies

See: Back Group methods used in reviews.

A research librarian searched computerised bibliographic databases, without language restrictions, for medical, chiropractic and allied health literature. The following databases were searched from their start to March 2004: Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2004), MEDLINE, EMBASE, Manual Alternative and Natural Therapy (MANTIS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Index to Chiropractic literature (ICL), and the Cochrane Back Review Group Trials Register. We also screened references and our personal files, communicated with the Cochrane Back Review Group Co-ordinator and identified content experts. Subject headings (MeSH) and key words included anatomical terms, disorder or syndrome terms, treatment terms and methodological terms. See Appendix 1 for the Search Strategy for MEDLINE.

 

Data collection and analysis

Two reviewers with expertise in medicine, physiotherapy, chiropractic, massage therapy, statistics, or clinical epidemiology independently conducted citation identification, study selection, data abstraction, and assessment of methodological quality. Agreement was assessed for study selection using the quadratic weighted Kappa statistic (Kw), Cicchetti weights (Cicchetti 1976). Disagreements were resolved through consensus, or a third reviewer was consulted if disagreements persisted. Data were extracted on design (RCT or quasi-RCT, number analysed/number randomised, intention-to-treat analysis, power analysis), participants (disorder subtype, duration of disorder), intervention (treatment characteristics for the treatment and comparison group, dosage/ treatment parameters, co-intervention, treatment schedule, duration follow-up), outcome (baseline mean, end of study mean, absolute benefit, reported results, point estimate with 95% confidence interval (95% CI), power, side effects, cost of care). These factors are noted in the Characteristics of included studies.

For continuous data, standardized mean differences (SMD) (95% CI) were calculated using a random effects model. Standard mean difference was selected over weighted mean difference because different interventions were assessed and most interventions used different outcome measures that used different scales. In the absence of clear guidelines on the size of a clinically important effect size, a commonly applied system by Cohen 1988 was used; small (0.20), medium (0.50) and large (0.80). A minimal clinically important difference between treatments for the purpose of the review was 10 points on a 100-point pain intensity scale. A minimal clinically important difference of five neck disability index units or 10% was considered relevant for the neck disability index (Stratford 1999). For continuous outcomes reported as medians, effect sizes were calculated (Kendal 1963; p 237). Relative risks (RR) were calculated for dichotomous outcomes. The number needed to treat and treatment advantages were calculated for primary findings (Gross 2002; see  Table 1). Power analyses were conducted for each article reporting non-significant findings (Dupont 1990). See Characteristics of included studies for details.

Prior to calculation of a pooled effect measure, the reasonableness of pooling was assessed, based on clinical judgement. Using a random effects model, statistical heterogeneity was tested using Chi-squared method between the studies. In the absence of heterogeneity (p > 0.10), a pooled SMD or RR was calculated. Sensitivity analysis or meta-regression for the factors: symptom duration, methodological quality, and subtype of neck disorder were planned but were not carried out because we did not have enough data in one category.

To further summarize our findings, we used the following levels of evidence (Sackett 2000; van Tulder 2003) - of benefit, of no benefit, or of reduced benefit relative to the comparison treatment:

  • Strong evidence - denotes consistent findings in multiple high quality randomised controlled trials
  • Moderate evidence - denotes findings in a single, high quality randomised controlled trial or consistent findings in multiple low quality trials.
  • Limited evidence - indicates a single low quality randomised trial.
  • Unclear evidence - denotes inconsistent or contradictory results in multiple randomised trials.
  • No evidence - means no studies were identified.

The term 'Strong Evidence of No Benefit' was used for trials or meta-analyses large enough to be negative, with a low risk of false-negative conclusions (e.g. power of 80% or greater; sample size of approximately 70 or greater per arm). The required sample size per arm was based on rheumatoid arthritis trial criteria for clinically important change (Goldsmith 1993), since we are aware of no criterion for neck pain trials specifically.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of ongoing studies.

Thirty-one trials were included in this systematic review.

Studies varied in size from 17 to 179 (n analysed), 61% were considered small (less than 70 subjects per intervention arm). Fourteen studies were excluded from the review because they were not RCTs, examined a different type of participant (i.e. cervical root compression, chronic tension headache), tested a different intervention (i.e. not active exercise, the exercise was the same in all groups, or the exercise group could not be separated out), or they did not measure any of the identified primary outcomes.

 

Risk of bias in included studies

Two reviewers independently assessed the methodological quality based on three different scales (see  Table 2): the validated Jadad 1996 criteria (maximum score five, high score greater than two, moderate score two, and low score one; the abbreviated Cochrane collaboration Back Review Group criteria (van Tulder 1997; van Tulder 2000) (maximum score equal 9, high score greater than four) and the Cochrane grading system for concealment of allocation (A to D; see Characteristics of included studies), which refers to how well the allocation to treatment group was concealed.

The methodological quality scores for each trial are listed in  Table 3 (Jadad criteria) and  Table 4 (van Tulder criteria). Of the 31 selected trials, 19% (van Tulder scale) to 35% (Jadad scale) were rated as high quality. Common methodological weaknesses included failure to describe or use appropriate concealment of allocation (48%) and lack of effective "blinding" procedures - the minimum expectation being blinding of the outcome assessor (65%). Compliance was monitored in only 25%, and co-intervention was not avoided in 71% of trials. Methodological quality did not appear to influence the end results of the review, as both high and low quality studies had similar outcome directions. This relationship between methodological quality and end results of the review was not formally tested using sensitivity analysis/meta-regression, because there were not enough data in any one disorder and treatment category.

 

Effects of interventions

A quick summary of various forms of exercises compared to a control can be found in  Table 5. Formal sensitivity analysis was not conducted, as there were not enough trials in each subgroup.

 

Active Range-of-Motion Exercises

Active range-of-motion (AROM) exercises consisted of any exercises done by the individual patient/subject that included active movement without resistance. Exercises could be gentle, active, small range, and amplitude movements (Rosenfeld 2000) or end range sustained stretches (Hanten 2000). Three trials assessed the effects of AROM exercises, two trials measured pain in patients with MND/WAD of acute duration (Rosenfeld 2000, McKinney 1989 and one trial MND of unspecified duration (Hanten 2000). When physiotherapy (heat, cold, SWD, hydrotherapy, traction, and exercises) was compared with a control of rest for 10 to 14 days followed by general advice to mobilise, in a single high quality trial, there was limited evidence of benefit for pain in the short term (six weeks of treatment) that did not persist in the long term (six weeks of treatment and 104 weeks follow-up) in acute WAD (McKinney 1989). When a trial of moderate quality compared a program of early and delayed education, there was limited evidence of benefit on pain relief in the short and long term (four treatment sessions (average) and 24 weeks follow-up) for acute WAD (Rosenfeld 2000). To understand the effectiveness of different subtypes of exercises, or the impact of the timing of exercises, comparisons evaluating one exercise type against another were examined. In a moderate quality study there was limited evidence of no difference in pain relief when neck AROM exercises were compared with ischemic pressure and stretching neck and upper back muscles in the short term (five days) for MND (disorder duration not specified) (Hanten 2000). In a trial of moderate quality, there was limited evidence of benefit for pain relief when early exercise was compared with delayed exercise in the short and long term (four treatment sessions (average) and 24 weeks follow-up) for acute WAD (Rosenfeld 2000).

In summary, there are few comparisons for AROM. There is limited evidenced of benefit that AROM may reduce pain in acute WAD in the short term.

 

Strengthening Exercises

Strengthening exercises consist of any exercise done by the individual/patient that includes resistance, for example isometric, isokinetic or isotonic. It could include strength training with machines (Waling 2002), free weights, or low load endurance exercises to train muscle control (Jull 2002). Of five trials assessing strengthening exercises, four compared strengthening to a placebo or control, two of chronic MND (Goldie 1970, Waling 2002), one chronic NDH (Jull 2002), and one mixture of subacute MND/NDR/NDH (Kogstad 1978). In a moderate quality trial, there was no evidence of benefit for pain or function when strength or endurance training through the arms was compared with a control in the short (ten weeks of treatment and two weeks follow-up) or long term (ten weeks of treatment and 144 weeks follow-up) in chronic MND (Waling 2002). However, there was evidence of benefit on global perceived effect in a low quality trial, when strengthening through the neck was compared with a (treatment) control in the short term (three weeks of treatment and three weeks follow-up) for chronic MND (Goldie 1970). In a high quality trial, when strengthening through the neck was compared with a control, there was limited evidence of benefit in the short (seven weeks of treatment and long term (seven weeks of treatment and 45 weeks follow-up) for headaches (intensity and frequency), disability and global perceived effect for chronic NDH (Jull 2002). When manual therapy was added to this exercise treatment, there was an additional benefit for headache duration (Jull 2002). In a low quality trial, when a conventional approach (heat, soft tissue massage, traction) including exercise (isometric) was compared with a placebo treatment (placebo tablets plus education and ergonomics) there was no evidence of difference in global perceived effect in the short term (five weeks of treatment) in all disorder types of subacute duration (Kogstad 1978). Three trials compared strengthening exercises to other treatments (Goldie 1970; Jull 2002; Kogstad 1978). In a low quality trial, a comparison of strengthening and traction showed evidence of no difference on global perceived effect in the short term (three weeks of treatment and three weeks follow-up) for chronic MND (Goldie 1970). In a high quality trial comparing neck strengthening with manual therapy, there was evidence of no difference for pain, function or global perceived effect in the short (seven weeks of treatment) or long term (seven weeks of treatment and 45 weeks follow-up) for chronic NDH (Jull 2002). When exercise was added to a program of physical medicine methods (including soft tissue massage and traction) and compared with manual therapy, there was no evidence of difference on global perceived effect in the short (five weeks of treatment) and long term (five weeks of treatment and 18 months follow-up) for subacute MND, NDH and NDR (Kogstad 1978). Two additional trials (one of moderate quality and one high quality) showed no evidence of difference on pain (Waling 2002, Hagberg 2000) or function (Waling 2002) when strengthening of the arms was compared with endurance or coordination (balance and postural stability) exercises in the short (five or 10 weeks of treatment with two weeks follow-up) and long term (five or 10 weeks of treatment and 18 or 144 weeks follow-up) in chronic MND.

These conflicting results for strengthening exercises, when compared with a placebo, control or another treatment, may be in part from the different control groups (for example: (a) stress management; (b) drug therapies; (c) placebo tablets, education, and ergonomics), but it may also have occurred from the different types of exercises [for example: (a) neck or shoulder exercises; (b) singular (isometric) exercises; (c) multiple exercise approaches (endurance, postural, isometric, proprioception)]. When the exercise focused on strengthening the shoulder/thoracic region, the trials showed no effect (Waling 2002), however, when the strengthening focused on the neck areas, the trials showed a positive effect for exercise (Goldie 1970; Jull 2002).

In summary, there is moderate evidence of benefit for neck strengthening exercises for pain, function and global perceived effect for chronic NDH in the short and long term. There is unclear evidence for strengthening exercises for chronic MND for pain relief in the short and long term; this may be confounded by the location of focus of the strengthening exercises (neck or shoulders/upper back). The difference in benefit between an exercise approach and physical medicine methods or manual therapy, or between a strengthening or endurance exercise program is unclear.

 

Stretching and strengthening exercises

A combination of stretching and strengthening was used by 16 trials with multiple comparisons.

 

Stretching and strengthening exercises compared with a control treatment

Six studies compared stretching and strengthening exercises to a control treatment, four included chronic MND (Allison 2002; Gam 1998; Lundblad 1999; Ylinen 2003), one trial was MND of unspecified duration (Takala 1994) and one trail was NDH of unspecified duration (Karlberg 1996). A high quality trial of stretching and strengthening (cervical and shoulder region) compared a program of ultrasound, massage and exercise with a no treatment control. There was evidence of benefit on pain in the short term (four weeks of treatment), however, when sham ultrasound was used as the control, there was evidence of no difference for pain in the short term (four weeks of treatment) for chronic MND (Gam 1998). In another moderate quality trial comparing either a strengthening or endurance program of the neck and shoulder with a control of recreation activities, there was limited evidence of benefit for pain relief in the long term (52 weeks of treatment) in chronic MND (Ylinen 2003). Two trials, one chronic MND of low quality (Allison 2002) and one MND (duration not specified) of moderate quality (Takala 1994) compared a shoulder/thoracic exercise program with a no treatment control; there was no evidence of benefit for pain in the short term (eight to 10 weeks of treatment) (Allison 2002; Takala 1994). There was unclear evidence on function as one study showed evidence of benefit for function, and a positive effect on overall handicap and interference with work in the short term (10 weeks of treatment) for MND of unspecified duration (Takala 1994), and another no effect on function (Northwick Park Questionnaire) in the short term (at eight weeks of treatment) for chronic MND (Allison 2002). One trial of moderate quality that did not specify the targeted muscles as either neck or shoulder/trunk showed no evidence of benefit for exercises over a no treatment control group for pain and function in the long term (16 weeks of treatment and 52 weeks follow-up) in chronic MND (Lundblad 1999). Two studies comparing strengthening exercises to a control could be pooled on the basis of outcome (pain), duration (four and eight weeks of treatment) and disorder type (chronic MND). There is moderate evidence of benefit on pain [pooled SMD -0.42 (95%CI Random: -0.83 to -0.01)] (Allison 2002; Gam 1998). One trial of moderate quality showed limited evidence of benefit on pain in the short term (13 weeks of treatment) when stretching and strengthening plus mobilizations, NSAID, and education was compared to a wait period control for subacute NDH (Karlberg 1996). A complete review of the benefits of a multimodal approach has already been published by our group in Gross 2004. Overall, there was strong evidence of benefit favouring multimodal care for pain reduction [pooled SMD -0.85 (95%CI:-1.20 to -0.50)], improvement in function [pooled SMD -0.57 (95%CI: -0.94 to -0.21)] and global perceived effect [SMD -2.73 (95%CI:-3.30 to -2.16)] for subacute and chronic MND with or without headache. The common elements in this care strategy were mobilisation or manipulation plus exercise ( Table 1).

In summary, there is strong evidence of benefit favouring a multimodal care approach of exercise combined with mobilizations or manipulations for subacute and chronic MND with or without headache for pain reduction, improved function, and high global perceived effect in the short and long term, moderate evidence of benefit favouring a stretching and strengthening program in the cervical or cervical and shoulder/trunk region on pain in chronic MND with or without headache in the short and long term, and limited evidence of benefit favouring a multimodal approach of care on pain in the short term for subacute NDH. There is evidence of no difference for a stretching and strengthening program focusing on shoulder musculature or when the focus of exercise is not specified on pain or function in the short or long term. There was no evidence available for NDR.

 

Stretching and strengthening exercises compared with another treatment

Four trials compared a treatment including trunk/shoulder and neck stretching and strengthening exercises with another treatment (Bronfort 2001; Jordan 1998; Persson 2001; Hoving 2002). Two trials of high quality compared an intensive neck and shoulder exercise program with manual therapy techniques in chronic MND (Bronfort: MedX v SMT; Jordan 1998). Both trials showed evidence of no difference on pain, disability or global perceived effect in the short term (six to 11 weeks of treatment) or the long term (six to 11 weeks of treatment and 46 to 52 weeks follow-up). When an exercise program was compared with manual treatments in acute/subacute/chronic duration of MND/NDH, there was no evidence of difference for pain in the short term, and global perceived effect in the short and long term (six weeks of treatment and 46 weeks follow-up). However, there was evidence of benefit in improvement in the main functional limitation in the long term (six weeks of treatment and 46 weeks follow-up) (Hoving 2002: PT v MT). In a high quality trial comparing an exercise program (neck and shoulder) with a program of education, medication and home exercises, there was evidence of no difference for pain, and global perceived effect in the short or long term (six weeks of treatment and 46 weeks follow-up) for MND/NDH of acute, subacute, or chronic duration (Hoving 2002: PT v GP). In a high quality trial of chronic NDH, a program including manual techniques, modalities and exercise (neck and shoulder) was compared with surgery; there was limited evidence of benefit for pain relief for the surgical treatment in the short term (12 weeks of treatment), however, this did not persist long term (12 weeks of treatment and 52 weeks follow-up) (Persson 2001:PTvsurg). When this same exercise treatment was compared with constant collar use, there was evidence of no difference in pain relief in the short or long term (12 weeks of treatment and 52 weeks follow-up) (Persson 2001:PTv col).

In summary, there is unclear evidence on the relative benefit of stretching and strengthening exercises over other treatments such as a manual therapy approach or a program of education, medication and home exercises in MND (either acute, subacute, or chronic duration) for all outcomes (pain, function, and global perceived effect) in the short or long term. In the long term, surgical intervention was no better than a program of modalities plus exercise for NDR.

 

One form of exercise compared with another

Nine trials compared one form of exercise with another (Allison 2002; Bronfort 2001; Levoska 1993; Lundblad 1999; Randlov 1998; Soderlund 2000; Soderlund 2001; Vasseljen 1995; Ylinen 2003). When an active stretching muscle training of neck and shoulder was compared against a program consisting of passive modalities and light stretching and exercising (neck and shoulder) there was evidence of benefit in the short term (five weeks of treatment) on pain relief (decreased occurrence of cephalalgy or neck and shoulder pain) in a moderate quality trial of MND (duration not specified) (Levoska 1993). In a high quality trial comparing neck and shoulder exercises with no resistance with shoulder exercises with resistance, there was evidence of no difference in patient satisfaction in the short and long term (12 weeks of treatment and 52 weeks follow-up) in chronic MND (Randlov 1998). In a high quality trial, comparing a program of spinal manipulation and neck and upper body stretching and strengthening exercises with a stretching and strengthening program (intensive using machines), there was evidence of no difference for pain or function, however there was evidence of benefit for patient satisfaction in the long term (11 weeks of treatment and 52 weeks follow-up) for chronic MND (Bronfort 2001). There was no evidence of difference when a general exercise program was compared with a Feldenkrais program (less intense) on pain intensity, disability during work/leisure time or sick leave in the long term (16 weeks of treatment and 52 weeks follow-up) for chronic MND (Lundblad 1999). When an articular based program with neck exercises was compared with a neural focus treatment with neck exercises there was no evidence of difference on pain and disability in the short term (eight weeks of treatment) in a low quality trial of chronic MND (Allison 2002). When an exercise program for the neck and shoulders was compared with an endurance program, there was no evidence of difference on pain relief in the long term (52 weeks of treatment) in chronic MND (Ylinen 2003). In a high quality trial comparing eye-fixation/proprioception exercises with another exercise program, there was evidence of benefit on function in the short term for chronic MND/WAD (Fitz-Ritson 1995). When a strategy to address coping and self-efficacy was added to an exercise program, there was no evidence of difference on pain intensity and pain disability index in the short term (12 sessions and 12 weeks follow-up), however, there was evidence of benefit for global perceived effect in the short term (12 sessions and 12 weeks follow-up) in a moderate quality trial of chronic MND/WAD (Soderlund 2001).

In summary, there was evidence of no difference between the different exercise approaches, therefore the relative benefit of different exercise approaches appear similar.

 

Eye-fixation/proprioception exercises

Trials classified as dizziness or proprioception exercises used eye-fixation or neck proprioception exercises as a treatment strategy. All studies (except Provinciali 1996) used the term proprioceptive training or discussed affecting proprioception through training. Provinciali 1996 refers to cervicoencephalic syndrome. Generally, the purpose of these trials was to affect sensory integration or sensory and coordination of reflex control rather than mobility and strength. The purpose was to restore coordinated movement or cervicoencephalic kinaesthesia utilizing visual training techniques.

 

Eye-fixation/proprioception exercises compared with a control

Four trials assessed the effect of eye-fixation/proprioception exercises (Taimela 2000; Fitz-Ritson 1995; Revel 1994; Provinciali 1996). When eye-fixation/proprioception exercises were compared with a control in two moderate quality trials of chronic MND, there was limited evidence of benefit for pain relief in the short term (eight to 12 weeks of treatment and two weeks follow-up) with a pooled SMD -0.72 (95% CI Random: -1.12 to -0.32) (Taimela 2000; Revel 1994), however this did not persist in the long term (12 weeks of treatment and 36 weeks follow-up) (Taimela 2000). In the same two trials, there was limited evidence of benefit for functional improvement in the short term (Revel 1994) and on global perceived effect in the short and long term (Taimela 2000).

 

Eye-fixation exercises compared with other treatments

When eye-fixation exercises were compared with other treatments in a moderate quality trial of acute and subacute WAD with or without headache, there was limited evidence of benefit on pain and return to work in the long term (two weeks of treatment and 24 weeks follow-up) (Provinciali 1996). When eye-fixation/proprioception exercises were compared with another exercise program, there was evidence of no benefit for pain relief in the short and long term, however, there was limited evidence of benefit on global perceived effect in the short and long term (12 weeks of treatment and 36 weeks follow-up) (Taimela 2000). In one high quality trial for chronic WAD, there was limited evidence of benefit on function in the short term (eight weeks of treatment) (Fitz-Ritson 1995). In summary, program of eye-fixation/proprioception exercises imbedded in a more complete program showed moderate evidence of benefit for pain, function, and global perceived for chronic mechanical neck disorder in short term and on pain and function for acute/subacute neck disorder with headache/whiplash associated disorder in the long term.

 

Home Exercises

Home exercises consist of any exercises given to do at home. The individual may be given instructions (written or verbal) and training but the exercises are not supervised on a continued basis. Studies were not included if the same home exercises were given in the treatment and comparison groups. Ten trials assessed the effects of a home exercise program.

 

Home exercises compared to either a placebo or control group

Six trials compared home exercises to either a placebo (detuned SWD and US) (Koes 1992: GP v pl)] or control group (no treatment, rest with or without collar then general mobilisation or mock therapy of superficial massage, manual traction, electrical stimulation, medication and education) (Allison 2002:AT v CG; McKinney 1989: 3 v 1; Mealy 1986; Pennie 1990; Brodin 1985: 2 v 1). In two high quality trials, there was limited evidence of benefit for pain relief in the short term (four to eight weeks of treatment) (McKinney 1989: 3 v 1; Mealy 1986), however, there was evidence of no difference on global perceived effect in the short term (six to 8 weeks of treatment) (Pennie 1990) for acute WAD when a program of exercises plus other physical modalities was compared with general advise to rest (10 to 14 days with or without a collar), followed by general mobilisation. There was evidence of no benefit for pain in one low quality trial (Allison 2002:AT v CG), one high quality trial (Koes 1992: GP v pl) and moderate quality trial (Brodin 1985: 2 v 1) and for function in one low quality (Allison 2002:AT v CG) and one high quality trial (Koes 1992: GP v pl) for chronic MND in the short term (three to 8 weeks of treatment and one week follow-up). In summary, there is limited evidence of benefit on pain relief in the short term for a mobilisation program with other physical modalities, over a program of rest then gradual mobilisation for acute WAD.

 

Home exercises compared with other treatments

When home exercises were compared with other treatments in two high quality trials of chronic MND and acute, subacute, and chronic MND and NDH, there was evidence of no difference for pain, physical functioning, and global perceived effect in the short term, when treatment by the general practitioner (medication, advice about posture, home exercises and other treatment modalities) was compared with a manual therapy treatment (manipulation and mobilisation) (Koes 1992: GP v MT; Hoving 2002: GP v MT). The manual therapy group was favoured for pain relief and global perceived effect in the short term (six weeks of treatment and one to 7 weeks follow-up) (Hoving 2002: GP v MT), and physical functioning in the short term (nine weeks of treatment and three weeks follow-up) (Koes 1992: GP v MT). In summary, there is evidence of no benefit when home exercises are compared with other treatments in the short term and long term and there appears to be some benefit for using manual therapy program over a general practitioner or home based approach.

 

One home exercise approach compared with another

Two trials of moderate quality assessed different types of home exercise approaches (Taimela 2000; Rosenfeld 2000). One moderate trial of acute MND (Rosenfeld 2000) and one moderate trial of chronic MND (Taimela 2000) favoured an individual training program with education (written and verbal) to an education program for pain relief in the short term (12 to 24 weeks of treatment) (Taimela 2000; Rosenfeld 2000) and patient satisfaction in the short and long term (12 weeks of treatment and 36 weeks follow-up) (Taimela 2000). A home program of ischemic pressure plus stretching exercises was compared with a home program of active ROM exercises in MND (disorder duration not specified) there was evidence of no difference for pain in the short term (five days of treatment) (Hanten 2000). In summary, there is limited evidence of benefit for individualised instruction over written information alone for pain in the short term and patient satisfaction in the short and long term for acute and chronic MND.

 

Adverse Events

Side effects were reported by 12% of the trials. They were benign, of short duration and included headache, arm pain, pins and needles, dizziness and worsening of symptoms.

 

Cost of Care

There was moderate evidence favouring reduced costs for multimodal manual therapy and exercise care over physiotherapy, exercise, or general practitioner practice (Hoving 2002; Provinciali 1996).

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Study Selection

The validity of a systematic review is dependent on the selection of all relevant studies. Although studies published in any language were accepted, many scientific journals in non-English languages are not indexed in MEDLINE and EMBASE. We did not search non-English databases, which may introduce 'language bias' in the review. Multiple sources of literature including writing to authors and institutions was not undertaken due to the lack of productivity of these methods in the last review (Gross 1996). Therefore 'publication bias' was not guarded against in this update.

 

Methodological Quality

Two of the 31 studies met the criterion of double-blinding (blind patients and care providers) (Gam 1998; Goldie 1970), a methodological issue inherent to the nature of exercise therapy. It is therefore very important to have blinded assessment of outcome and analysis; 11 of the 31 trials reported blinding of the observer. This may be challenging for the primary outcomes of pain, function, satisfaction and global perceived effect. Further, it is important for future studies to ensure the treatments are equally credible and acceptable to patients, and patients have limited experience or expectations for either treatment to minimize expectation bias. Another issue that is important in exercise therapy is that of compliance, co-intervention and contamination, which are not commonly monitored during the trial or dealt with through the study design. These have an important impact on "dosage" and an understanding of dose response to exercise.

 

Effectiveness of Exercise Therapy

In our previous systematic review (Gross 1996), results were inconclusive, and there was no ability to look at subgroups of exercise due to the small number of trials and their low power. Since then, 15 randomised clinical trials have been added to the current review. In general, these new trials utilize larger sample sizes and more consistent outcomes.

  • Strong evidence : There is strong evidence of benefit favouring a multimodal care approach of exercise combined with mobilisations or manipulations for subacute and chronic MND with or without headache in the short and long term.
  • Moderate evidence : When the stretching and strengthening program focuses on the cervical or cervical and shoulder/thoracic region, there is moderate evidence of benefit on pain in chronic MND [pooled SMD -0.42 (95%CI: -0.83 to -0.01)] and NDH in the short and long term. A program of eye-fixation/proprioception exercises imbedded in a more complete program shows moderate evidence of benefit for pain, function, and global perceived effect for chronic MND in short term and on pain and function for acute and subacute WAD with or without headache in the long term.
  • Limited evidence: The current results point to limited evidence of benefit that AROM may reduce pain in acute WAD in the short term. There is limited evidence of benefit that neck strengthening exercises will reduce pain, improve function and global perceived effect for chronic NDH in the short and long term. There is limited evidence of benefit on pain relief in the short term for a home mobilisation program with other physical modalities over a program of rest then gradual mobilisation for acute WAD. In the long term, surgical intervention was no better than a program of modalities plus exercise for NDR based on limited evidence.
  • Unclear evidence : There is unclear evidence regarding the impact of a stretching and strengthening program on pain, function and global perceived effect for MND. It is unclear if exercise therapy is more effective than other types of treatment (manual therapies or modalities) and it is impossible to identify the effective components of these multimodal treatments. There was evidence of no difference between the different exercise approaches.

 

Adverse Events and Cost of Care

Adverse events were reported in five of the randomised trials in this review and were benign and of short duration (Jull 2002; Brodin 1985; Bronfort 2001; Hoving 2002; Jordan 1998). More consistent reporting over many trials is required to understand the type and severity of side effects from exercise therapy. Only two trials reported on the cost of care (Hoving 2002; Provinciali 1996). To better understand the direct and indirect costs, better reporting is required by each study.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

 

Implications for practice

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

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

 
Implications for research

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

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

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

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
Download statistical data

 
Comparison 1. ACTIVE RANGE OF MOTION [AROM] / STRETCHING
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Exercise [+ modalities, traction, manual therapy] v Control [rest then gentle movement]: Pain Intensity [VAS]1Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    1.1 MND/WAD: Acute Short term [4 w of treatment]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
 2 Exercise [early/delayed] v Comparison [Education early/delayed]: Pain Intensity [low/no]4Risk Ratio (M-H, Random, 95% CI)Totals not selected
    2.1 MND/WAD: Acute Short term [24 w of treatment]
4Risk Ratio (M-H, Random, 95% CI)Not estimable

 
Comparison 2. STRENGTHENING
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Exercise [strength +/- endurance] v Control [+/- stress management]: Pain Intensity [VAS]5Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    1.1 MND: Chronic Short term [10w of treatment + 2 w follow-up]
3Std. Mean Difference (IV, Random, 95% CI)Not estimable
    1.2 MND: Chronic Long term [10 w of treatment + 144 w follow-up]
3Std. Mean Difference (IV, Random, 95% CI)Not estimable
    1.3 NDH: Chronic Short term [7 w of treatment]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
    1.4 NDH: Chronic Long Term [7w of treatment 45 w follow-up]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
 2 Exercise [strength + endurance] v Control: Function2Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    2.1 NDH: Chronic Short term [7 w of treatment]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
    2.2 NDH: Chronic Long term [7 w of treatment + 45 w follow-up]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
 3 Exercise [strength + endurance] v Control: Global Perceived Effect2Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    3.1 NDH: Chronic Short term [7 w of treatment]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
    3.2 NDH: Chronic Long term [7 w of treatment + 45 w follow-up]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
 4 Exercise [+/-ED +/-analgesics +/- traction /- massage] v Control [+ED +/- analgesics]: Global Perceived Effect2Risk Ratio (M-H, Random, 95% CI)Totals not selected
    4.1 MND: Chronic Short term [3 w treatment + 3 w follow-up]
1Risk Ratio (M-H, Random, 95% CI)Not estimable
    4.2 MND/NDH/NDR Subacute Short term [5 w of treatment]
1Risk Ratio (M-H, Random, 95% CI)Not estimable
    4.3 MND/NDH/NDR Subacute Long term [5w of treatment + 18 w follow-up]
1Risk Ratio (M-H, Random, 95% CI)Not estimable
 5 Exercise [strength + endurance] v Comparison [Manual Therapy]: Pain Intensity [VAS]2Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    5.1 NDH Chronic Short term [7 w of treatment]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
    5.2 NDH: Chronic Long term [7 w of treatment + 45 w follow-up]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
 6 Exercise [strength + endurance] v Comparison [Manual Therapy]: Function2Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    6.1 NDH: Chronic Short term [7 w of treatment]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
    6.2 NDH: Chronic Long term [7 w of treatment + 45 w follow-up]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
 7 Exercise [strength + endurance] v Comparison [Manual Therapy]: Global Perceived Effect2Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    7.1 NDH: Chronic Short term [7 w of treatment]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
    7.2 NDH: Chronic Long term [7 w of treatment + 45 w follow-up]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
 8 Exercise [+ED +analgesics] v Comparison [traction+ ED+ analgesics or manual therapy]: Global Perceived Effect2Risk Ratio (M-H, Random, 95% CI)Totals not selected
    8.1 MND: Chronic Short term [3 w treatment + 3 w follow-up]
1Risk Ratio (M-H, Random, 95% CI)Not estimable
    8.2 MND/NDH/NDR Subacute Short term [5 w of treatment]
1Risk Ratio (M-H, Random, 95% CI)Not estimable
    8.3 MND/NDH/NDR Subacute Long term [5 w of treatment + 18 w follow-up]
1Risk Ratio (M-H, Random, 95% CI)Not estimable

 
Comparison 3. STRETCHING AND STRENGTHENING
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Exercise [+ manual treatment +/- US] v Control [no treatment]: Pain Intensity5Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    1.1 MND: Chronic Short term [4-8 w of treatment]
3Std. Mean Difference (IV, Random, 95% CI)Not estimable
    1.2 NDH: Subacute Short term [after median 13 w [8 w for control] of treatment]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
    1.3 MND: Chronic Long term [16 w treatment + 52 w follow-up]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
 2 Exercise [+ behavioural approach] v Control [recreation]: Pain [considerable or complete]2Risk Ratio (M-H, Random, 95% CI)Totals not selected
    2.1 MND: Chronic Long term [52 w treatment]
2Risk Ratio (M-H, Random, 95% CI)Not estimable
 3 Exercise [+ manual therapy] v Control [no treatment]: Function2Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    3.1 MND: Chronic Short term [8 w of treatment]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
    3.2 MND: Chronic Long term [16 w of treatment + 52 w follow-up]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
 4 Exercise v Comparison [manual therapy or ED + medication]: Pain Intensity3Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    4.1 MND: Chronic Short term [11 w of treatment]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
    4.2 MND: Chronic Long term [11 w of treatment + 52 w follow-up]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
    4.3 MND/NDH: Acute/subacute/chronic Short term [6 w of treatment + 1 w follow-up]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
    4.4 MND/NDH: Acute/subacute/chronic Short term [6 w of treatment + 46 w follow-up]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
 5 Exercise v Comparison [manual therapy or ED + medication]: Function3Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    5.1 MND: Chronic Short term [11 w of treatment]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
    5.2 MND: Chronic Long term [11 w of treatment + 52 w follow-up]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
    5.3 MND/NDH: Acute/subacute/chronic Short term [6 w of treatment + 1 w follow-up]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
    5.4 MND/NDH: Acute/subacute/chronic Long term [6 w of treatment + 46 w follow-up]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
 6 Exercise v Comparison [manual therapy or ED + medication]: Global Perceived Effect3Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    6.1 MND: Chronic Short term [11 w of treatment]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
    6.2 MND: Chronic Long term [11 w of treatment + 52 w follow-up]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
    6.3 MND/NDH: Acute/subacute/chronic Short term [6 w of treatment + 1 w follow-up]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
    6.4 MND/NDH: Acute/subacute/chronic Long term [6 w of treatment + 46 w follow-up]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable

 
Comparison 4. DIZZINESS/VERTIGO EXERCISES
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Exercise [+ ED or analgesics] v Control [ED or analgesics]: Pain Intensity2Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    1.1 MND: Chronic Short term [8-12 w of treatment + 0-2 w follow-up]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
    1.2 MND: Chronic Short term [8 w of treatment + 2 w follow-up]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
    1.3 MND: Chronic Long term [12 w of treatment + 36 w follow-up]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
 2 Exercise [+ analgesics] v Control [analgesics]: Function1Risk Ratio (M-H, Random, 95% CI)Totals not selected
    2.1 MND: Chronic Short term [8 w of treatment + 2 w follow-up]
1Risk Ratio (M-H, Random, 95% CI)Not estimable
 3 Exercise [+ ED] v Control [ED]: Global Perceived Effect [Patient satisfaction]1Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    3.1 MND: Chronic Short term [12 w of treatment]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
    3.2 MND: Chronic Long term [12 w of treatment + 36 w follow-up]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
 4 Exercise [+ manual therapy + ED] v Comparison [modalities]: Pain Intensity1Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    4.1 NDH/WAD: Acute/subacute Long term [2 w of treatment + 24 w follow-up]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable
 5 Exercise [+ manual therapy + ED] v Comparison [modalities]: Global Perceived Effect [Return to Work]1Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    5.1 NDH/WAD Acute/subacute Long term [2 w of treatment + 24 w follow-up]
1Std. Mean Difference (IV, Random, 95% CI)Not estimable

 
Comparison 5. HOME EXERCISES
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
 1 Exercise [+ manual therapy or modailites] v Control [no/sham treatment or rest + mobilisation]: Pain Intensity4Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    1.1 MND: Acute Short term [6-8 w of treatment]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
    1.2 MND: Chronic Short term [6-8 w of treatment]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
 2 Exercise [mock therapy + neck school + analgesics]v Control [analgesics]: Pain Intensity [pain present]1Risk Ratio (M-H, Random, 95% CI)Totals not selected
    2.1 MND/NDR: Subacute/Chronic Short term [3 w of treatment + 1 w follow-up]
1Risk Ratio (M-H, Random, 95% CI)Not estimable
 3 Exercise [manual therapy or analgesics + advice] v Control [no/sham treatment]: Function2Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    3.1 MND: Chronic Short term [6-8 w of treatment]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
 4 Exercise [+ traction] v Control [rest then active ex]: Global Perceived Effect1Risk Ratio (M-H, Random, 95% CI)Totals not selected
    4.1 MND/WAD: Acute Short Term [6-8 w of treatment]
1Risk Ratio (M-H, Random, 95% CI)Not estimable
 5 Exercise [+ ED + analgesics] v Comparison [manual therapy]: Pain Intensity2Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    5.1 MND/NDH+/- NDR: Acute/Subacute/Chronic Short term [6 w of treatment +/- 1 w follow-up]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
 6 Exercise [+ED + analgesics] v Comparison [manual therapy]: Function2Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    6.1 MND/NDH+/-NDR Acute/Subacute/Chronic Short term [6 w of treatment +/- 1 w follow-up]
2Std. Mean Difference (IV, Random, 95% CI)Not estimable
 7 Exercise [+ ED + analgesics] v Comparison [manual therapy]: Global Perceived Effect1Std. Mean Difference (IV, Random, 95% CI)Totals not selected
    7.1 MND/NDH: Acute/Subacute/Chronic Short term [6 w of treatment + 1 w follow-up] manual therapy
1Std. Mean Difference (IV, Random, 95% CI)Not estimable

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Appendix 1. MEDLINE search strategy

1. neck/ or neck muscles/ or exp cervical plexus/ or exp cervical vertebrae/ or Atlanto-Axial Joint/ or atlanto-occipital joint/ or axis/ or atlas/ or spinal nerve roots/ or exp brachial plexus/
2. (odontoid or cervical or occip: or atlant:).tw.
3. 1 or 2
4. exp arthritis/ or exp myofascial pain syndromes/ or fibromyalgia/ or spondylitis/ or exp spinal osteophytosis/ or spondylolisthesis/
5. exp headache/ and cervic:.tw.
6. whiplash injuries/ or cervical rib syndrome/ or torticollis/ or cervico-brachial neuralgia.ti,ab,sh. or exp radiculitis/ or polyradiculitis/ or polyradiculoneuritis/ or thoracic outlet syndrome/
7. (monoradicul: or monoradicl:).tw.
8. 4 or 5 or 6 or 7
9. random:.ti,ab,sh.
10. randomised controlled trial.pt.
11. double-blind method/
12. single blind method/
13. placebos/
14. clinical trial.pt.
15. exp clinical trials/
16. controlled clinical trial.pt.
17. (clin$ adj25 trial$).ti,ab.
18. ((singl$ or doubl$ or trebl$) adj25 (blind$ or mask$)).ti,ab.
19. placebo$.ti,ab.
20. or/9-19
21. exp arthritis/rh,th or exp myofascial pain syndromes/rh,th or fibromyalgia/rh,th or spondylitis/rh,th or exp spinal osteophytosis/rh,th or spondylosis/rh,th or spondylolisthesis/rh,th
22. exp headache/rh,th and cervic:.tw.
23. whiplash injuries/rh,th or cervical rib syndrome/rh,th or thoracic outlet syndrome/rh,th or torticollis/rh,th or cervico-brachial neuralgia/rh,th or exp radiculitis/rh,th or polyradiculitis/rh,th or polyradiculoneuritis/rh,th
24. or/21-23
25. exp alternative medicine/ or Chiropractic/
26. (chiropract: or kinesiology or massage or traditional medicine or relaxation or therapeutic touch).tw.
27. or/25-26
28. 3 and 24
29. 3 and 8 and 27
30. 28 or 29
31. 20 and 30

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Last assessed as up-to-date: 29 February 2004.

DateEventDescription
12 August 2009Amendedcontact details for authors updated


 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Protocol first published: Issue 2, 2003
Review first published: Issue 3, 2005

DateEventDescription
25 June 2008AmendedConverted to new review format.
6 June 2005AmendedJune 2005 -- we changed the order of the authors, reduced the length of the abstract; made some edits to the text for clarification; corrected the format in some of the references.
30 April 2005New citation required and conclusions have changedSubstantive amendment


 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

This is one review of a series conducted by the Cervical Overview Group: Aker P, Bronfort G, Eady A, Goldsmith C, Graham N, Gross A, Haines T, Haraldsson B, Houghton P, Kay T, Kroeling P, Peloso P, Radylovick Z, Santaguida PL, Trinh K

Primary Reviewers - Kay T, Gross A , Santaguida PL, Hoving J, Goldsmith C, Bronfort G
Statistician - Goldsmith C
Methodological Quality Assessment - Goldsmith C, Aker P, Trinh K, Haines T, Peloso P
Study Identification and Selection - Kay T, Santiguida PL, Hoving J, Gross A, Haraldson B, Houghton P
Research Librarian - Eady A
Data Abstraction, Synthesis, Manuscript Preparation, Public Responsibility, Grants, Administration - primary reviewers
Final Synthesis - full Cervical Overview Group

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

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

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Internal sources

  • Sunnybrook & Women's College Health Sciences Centre, Canada.
  • University of Toronto, Department of Rehabilitation Medicine, Canada.
  • McMaster University, Department of Clinical Epidemiology and Biostatistics, School of Rehabilitation Science, Occupational Health Program, Canada.
  • Monash University, Department of Epidemiology and Preventative Medicine, Australia.
  • Northwestern Health Sciences University, USA.

 

External sources

  • Hamilton Health Sciences Corporation, Chedoke-McMaster Foundation (1997), Canada.
  • University of Saskatchewan, Clinical Teaching and Research Award (1997), Canada.
  • Hamilton Hospital Assessment Centre (2002), Canada.
  • Consortial Center for Chiropractic Research - National Institutes of Health, Bethesda, MD (2002), USA.
  • Hamilton District Research Grant (2000), Canada.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to ongoing studies
  21. Additional references
  22. References to other published versions of this review
Allison 2002 {published data only}
Allison 2002:AT v CG {published data only}
  • refer to Allison 2002.
Allison 2002:AT v NT {published data only}
  • refer to Allison 2002.
Brodin 1985 {published data only}
Brodin 1985: 2 v 1 {published data only}
  • refer to Brodin 1985.
Brodin 1985: 3 v 1 {published data only}
  • refer to Brodin 1985.
Brodin 1985: 3 v 2 {published data only}
  • refer to Brodin 1985.
Bronfort 2001 {published data only}
  • Bronfort G, Aker PD, Evans R, Goldsmith CH, Nelson B, Vernon H. A randomized controlled clinical trial of rehabilitative exercise and chiropractic spinal manipulation for chronic neck pain. Spine 2001;26(7):788-99.
  • Bronfort G, Evan R, Nelson B. Aker PD, Goldsmith CH, Vernon H. A randomized controlled clinical trial of spinal manipulation and exercise for chronic neck pain: A report on neck performance outcomes after 11 weeks and long-term effects on patient-rated outcomes. Proceedings of the Scientific symposium, 1997 World Chiropractic Congress. 1998:62-8. [: {CO97:65}]
  • Bronfort G, Evans R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A randomized controlled clinical trial of rehabilitative exercise and spinal manipulation for chronic neck pain. Effects on neck pain and disability, functional health status, biomechanical neck dysfunction, and somato-visceral symptoms. Proceedings of the 1998 International Conference of Spinal Manipulation. 1998:67-70. [: {CO97:310}]
Bronfort: MedX v SMT {published data only}
  • refer to Bronfort 2001.
Bronfort:SMT/ExvMedX {published data only}
  • refer to Bronfort 2001.
Brontfort:SMT/ExvSMT {published data only}
  • refer to Bronfort 2001.
Fitz-Ritson 1995 {published data only}
Gam 1998 {published data only}
  • Gam AN, Warming S, Larsen LH, Jensen B, Hoydalsmo O, Allon I, et al. Treatment of myofascial trigger-points with ultrasound combined with massage and exercise - a randomised controlled trial. Pain 1998;77:73-9. [: CO2002]
Gam SUSvsCG {published data only}
  • refer to Gam 1998.
Gam USvCG {published data only}
  • refer to Gam 1998.
Geibel 1997 {published data only}
  • Giebel GD, Edelmann M, Huser R. Die distorsion der halswirbelsaule: Fruhfunktionalle vs. ruhigstellende behandlung. Zentralbl Chir 1997;122:517-21.
Goldie 1970 {published data only}
  • Goldie I, Landquist A. Evaluation of the effects of different forms of physiotherapy in cervical pain. Scand J Rehab Med 1970;2-3:117-21.
Goldie: ex v cnt {published data only}
  • refer to Goldie 1970.
Goldie: ex v trac {published data only}
  • refer to Goldie 1970.
Hagberg 2000 {published data only}
  • Hagberg M, Harms-Ringdahl K, Nisell R, Hjelm EW. Rehabilitation of neck-shoulder pain in women industrial workers: A randomized trial comparing isometric shoulder endurance training with isometric shoulder strength training. Arch Phys Med Rehabil 2000;81:1051-8.
Hanten 2000 {published data only}
  • Hanten WP, Olson SL, Butts NL, Nowicki AL. Effectiveness of a home program of ischemic pressure followed by sustained stretch for treatment of myofascial trigger points. Physical Therapy 2000;80(10):997-1003.
Hoving 2002 {published data only}
  • Hoving JL, de Vet HCW, Koes BW, van Mameren H, Deville WJLM, van der Windt DAWM, et al. Manual therapy, physical therapy, or continued care by the general practitioner for patients with neck pain: long-term results from a pragmatic randomized trial. In: Hoving JL editor(s). 1st Edition. Wageningen: Pons & Looijen bv, 2001:59-73. [: CO97]
  • Hoving JL, Koes BW, de Vet HCW, van der Windt DAWM, Assendelft WJJ, van Mameren H, et al. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. Annals of Internal Medicine 2002;136(10):713-22. [: CO2002]
  • Korthals-de Bos IBC, Hoving JL, van Tulder MW, Rutten-van Molken MPMH, Ader HJ, de Vet HCW, et al. Manual therapy is more cost-effective than physical therapy and GP care for patients with neck pain. In: Hoving JL editor(s). 1st Edition. Wageningen: Pons & Looijen bv, 2001:75-90. [: CO97]
Hoving 2002: GP v MT {published data only}
  • refer to Hoving 2002.
Hoving 2002: PT v GP {published data only}
  • refer to Hoving 2002.
Hoving 2002: PT v MT {published data only}
  • refer to Hoving 2002.
Jordan 1998 {published data only}
  • Jordan A, Bendix T, Nielsen H, Hansen FR, Host D, Winkel A. Intensive training, physiotherapy, or manipulation for patients with chronic neck pain: A prospective single-blind randomized clinical trial. Spine 1998;23(3):311-9.
  • Jordan A, Bendix T, Nielsen H, Hansen FR, Host D, Winkel A. Intensive training, physiotherapy, or manipulation for patients with chronic neck pain. A prospective single-blind randomized clinical trial.. Proceedings of the 1996 International conference on spinal manipulation. 1996.
Jordan 1998: Int vCH {published data only}
  • refer to Jordan 1998.
Jordan 1998:CHvPT {published data only}
  • refer to Jordan 1998.
Jordan 1998:Int v PT {published data only}
  • refer to Jordan 1998.
Jull 2002 {published data only}
  • Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;27(17):1835-43. [: CO2002]
Jull 2002:ExT v Cntl {published data only}
  • refer to Jull 2002.
Jull 2002:ExT v MT {published data only}
  • refer to Jull 2002.
Jull 2002:MTExT v MT {published data only}
  • refer to Jull 2002.
Jull 2002:MTExT vExT {published data only}
  • refer to Jull 2002.
Jull 2002:MTExTvCntl {published data only}
  • refer to Jull 2002.
Karlberg 1996 {published data only}
  • Karlberg M, Magnusson M, Eva-Maj M, Melander A, Moritz U. Postural and symptomatic improvement after physiotherapy in patients with dizziness of suspected cervical origin. Archives of Physical Medicine and Rehabilitation 1996;77:874-82. [: {CO97:262}]
Koes 1992 {published data only}
  • Koes B. A randomized clinical trial of manual therapy and physiotherapy for persistent back and neck complaints. Subgroup analysis and relationship between outcomes measure. Journal of Manipulative and Physiological Therapeutics 1993;16(4):211-9. [: {CO97:2320}]
  • Koes B, Bouter LM, Knipshild PG. The effectiveness of manual therapy, physiotherapy and continued treatment by general practitioner for chronic nonspecific back and neck complaints. Journal of Manipulative and Physiological Therapeutics 1991;14(9):498-502. [: {C097:3285}]
  • Koes BW. Efficacy of manual therapy and physiotherapy for back and neck complaints (Thesis). den Haag: Cip-Gegevens Koninklijke Bibliotheek, 1992a. [: {CO97:124}]
  • Koes BW, Bouter LM, van Mameren H, Esser AH, Verstegen GH, Hofhuizen DM, et al. Randomized clinical trial of manual therapy and physiotherapy for persistent back and neck complaints. Manual Therapy in the Netherlands 1992d, (1):7-12. [: {CO97:128}]
  • Koes BW, Bouter LM, van Mameren H, Esser AH, Verstegen GM, Hofhuizen DM, et al. A blind randomized clinical trial of manual therapy and physiotherapy for chronic back and neck complaints: Physical outcome measures. J Manipulative Physiol Ther 1992e;15(1):16-23. [: {CO97:126}]
  • Koes BW, Bouter LM, van Mameren H, Esser AH, Verstegen GM, Hofhuizen DM, et al. Randomized clinical trial of manipulative therapy and physiotherapy for persistent back and neck complaints: results of one year follow up. BMJ 1992b;304(6827):601-5. [: {CO97:127}]
  • Koes BW, Bouter LM, van Mameren H, Essers AH, Verstegen GM, Hofhuizen DM, et al. The effectiveness of manual therapy, physiotherapy, and treatment by the general practitioner for nonspecific back and neck complaints. Spine 1992c;17(1):28-35. [: {CO97:129}]
Koes 1992: GP v MT {published data only}
  • refer to Koes 1992.
Koes 1992: GP v pl {published data only}
  • refer to Koes 1992.
Koes 1992: PT v GP {published data only}
  • refer to Koes 1992.
Koes 1992: PT v pl {published data only}
  • refer to Koes 1992.
Koes 1992:PT v MT {published data only}
  • refer to Koes 1992.
Kogstad 1978 {published data only}
  • Kogstad OA, Karterud S, Gudmundsen J. Cervicobrachialgia. A controlled trial with conventional treatment and manipulation. Tidiskr Nor Loegeforen 1978;98(16):845-8. [: CO2002:]
Kogstad 1978:CT v MT {published data only}
  • refer to Kogstad 1978.
Kogstad 1978:CT v Pl {published data only}
  • refer to Kogstad 1978.
Levoska 1993 {published data only}
  • Levoska S, Keinanen-Kiukaanneimi S. Active or passive physiotherapy for occupational cervicobrachial disorders? A comparison of two treatment methods with a 1-year follow-up. Arch Phys Med Rehabil 1993;74:425-30.
Lundblad 1999 {published data only}
  • Lundblad I, Elert J, Gerdle B. Randomized Controlled Trial of Physiotherapy and Feldenkrais Interventions in Female Workers with Neck-Shoulder Complaints. Journal of Occupational Rehabilitation 1999;9(3):179-94.
Lundblad 1999: PTvCG {published data only}
  • refer to Lundblad 1999.
Lundblad 1999: PTvFG {published data only}
  • refer to Lundblad 1999.
McKinney 1989 {published data only}
McKinney 1989: 2 v 1 {published data only}
  • refer to McKinney 1989.
McKinney 1989: 2 v 3 {published data only}
  • refer to McKinney 1989.
McKinney 1989: 3 v 1 {published data only}
  • refer to McKinney 1989.
Mealy 1986 {published data only}
  • Mealy K, Brennan H, Fenelon GC. Early mobilisation of acute whiplash injuries. British Medical Journal 1986;92:656-7.
Pennie 1990 {published data only}
Persson 2001 {published data only}
  • Persson L, Karlberg M, Magnusson M. Effects of different treatments on postural performance in patients with cervical root compression. A randomized prospective study assessing the importance of the neck in postural control. Journal of Vestibular Research 1996;6(6):439-53. [: CO2002]
  • Persson LCG, Carlsson CA, Carlsson JY. Long-lasting cervical radicular pain managed with surgery, physiotherapy, or a cervical collar. A prospective, randomized study. Spine 1997;22(7):751-8. [: CO97: 324]
  • Persson LCG, Lilja A. Pain, coping, emotional state and physical function in patients with chronic radicular neck pain. A comparison between patients treated with surgery, physiotherapy or neck collar - a blinded, prospective randomized study. Disability and Rehabilitation 2001;23(8):325-35. [: CO2002:2809]
  • Persson LCG, Moritz U, Brandt L, Carlsson CA. Cervical radiculopathy: pain, muscle weakness and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy or cervical collar. A prospective, controlled study. Eur Spine J 1997;6(4):256-66. [: CO97: 1493]
Persson 2001:PTv col {published data only}
  • refer to Persson 2001.
Persson 2001:PTvsurg {published data only}
  • refer to Persson 2001.
Provinciali 1996 {published data only}
  • Provinciali L, Baroni M, Illuminati L, Ceravolo MG. Multimodal treatment to prevent the late whiplash syndrome. Scandinavian Journal of Rehabilitation Medicine 1996;28:105-11.
Randlov 1998 {published data only}
  • Randlov A, Ostergaard M, Manniche C, Kryger P, Jordan A, Heegaard S, Holm B. Intensive dynamic training for females with chronic neck/shoulder pain. A randomized controlled trial. Clin Rehabil 1998;12(3):200-10.
Revel 1994 {published data only}
  • Revel M, Minguet M, Gergoy P, Vaillant J, Manuel JL. Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck apin: a randomized controlled study. Archives of Physical Medicine Rehabilitation 1994;75:895-9.
Rosenfeld 2000 {published data only}
Rosenfeld:DExvDED {published data only}
  • refer to Rosenfeld 2000.
Rosenfeld:DExvEED {published data only}
  • refer to Rosenfeld 2000.
Rosenfeld:EExvDED {published data only}
  • refer to Rosenfeld 2000.
Rosenfeld:EExvDEx {published data only}
  • refer to Rosenfeld 2000.
Rosenfeld:EExvEED {published data only}
  • refer to Rosenfeld 2000.
Soderlund 2000 {published data only}
  • Soderlund A, Lindberg P. Acute whiplash-associated disorders (WAD): the effects of early mobilization and prognostic factors in long-term symptomatology. Clinical Rehabilitation 2000;14:457-67. [: CO2002]
Soderlund 2001 {published data only}
  • Soderlund A, Lindberg P. Cognitive Behavioural Components in Physiotherapy Management of Chronic Whiplash Associated Disorders (WAD) - A Randomised Group Study. Physiotherapy Theory and Practice 2001;17:229-38.
Taimela 2000 {published data only}
Taimela:Activevcontr {published data only}
  • refer to Taimela 2000.
Taimela:Activevhome {published data only}
  • refer to Taimela 2000.
Taimela:Homevcontrol {published data only}
  • refer to Taimela 2000.
Takala 1994 {published data only}
  • Takala EP, Viikari-Juntura E, Tynkkynen EM. Does group gymnastics at the workplace help in neck pain? A controlled study. Scandinavian Journal of Rehabilitation Medicine 1994;26:17-20.
Vasseljen 1995 {published data only}
  • Vasseljen O, Johansen BM, Westgaard RH. The effect of pain reduction on perceived tension and EMG-recoded trapezius muscle activity in workers with shoulder and neck pain. 1995; 27:243-252. Scandinavian Journal of Rehabilitation Medicine 1995;27:243-52.
Waling 2002 {published data only}
Waling 2002:Co v C {published data only}
  • refer to Waling 2002.
Waling 2002:EvC {published data only}
  • refer to Waling 2002.
Waling 2002:SvC {published data only}
  • refer to Waling 2002.
Ylinen 2003 {published data only}
Ylinen 2003: EvC {published data only}
  • refer to Ylinen 2003.
Ylinen 2003: SvC {published data only}
  • refer to Ylinen 2003.

References to studies excluded from this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to ongoing studies
  21. Additional references
  22. References to other published versions of this review
Bissett 1985 {published data only}
  • Bissett A, Mitchell KR, Major G. The cervico-brachial pain syndrome: Muscle activity and pain relief. Behaviour Change 1985;2(2):129-35.
Brewerton 1966 {published data only}
  • Brewerton DA. Pain in the neck and arm: a multicentre trial of the effects of physiotherapy: Arranged by the British Association of Physical Medicine. BMJ 1966;1:253-8.
Carlsson 1990 {published data only}
  • Carlsson J, Fahlcrantz A, Augustinsson L. Muscle tenderness in tension headache treated with acupuncture or physiotherapy. Cephalgia 1990;10(3):131-41.
    Direct Link:
Foley-Nolan 1992 {published data only}
  • Foley-Nolan D, Moore K, Codd M, Barry C, O'Connor P, Coughlan RJ. Low energy high frequency pulsed electromagnetic therapy for acute whiplash injuries: A double blind randomized controlled study. Scandinavian Journal of Rehabilitation Medicine 1992;24:51-9. [: CO97;61]
Friedrich 1996 {published data only}
  • Friedrich M, Cermak T, Maderbacher P. The effect of brochure use versus therapist teaching on patients performing therapeutic exercise and on changes in impairment status. Physical Therapy 1996;76(10):1082-8.
Hanten 1997 {published data only}
  • Hanten WP, Barrett M, Gillespie-Plesko M, Jump KA, Olson SL. Effects of active head retraction with retraction/extension and occipital release on the pressure pain threshold of cervical and scapular trigger points. Physiotherapy Theory and Practice 1997;13:285-91. [: CO2002]
Herring 1992 {published data only}
  • Herring C. The effects of controlled passive mobilization and controlled passive stretch on cervical intersegmental hypermobility in acute cervical strain/sprain injuries. Transactions of the consortium for chiropractic research. 1992:28.
Highland 1992 {published data only}
  • Highland TR, Dreisinger TE, Vie LL, Russell GS. Changes in isometric strength and range of motion of the isolated cervical spine after eight weeks of clinical rehabilitation. Spine 1992;17(6):S77-S82.
Hurwitz 2002 {published data only}
  • Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F, Adams AH. A Randomized Trial of Chiropractic Manipulation and Mobilization for Patients With Neck Pain: Clinical Outcomes From the UCLA Neck-Pain Study. Research and Practice 2002;92(10):1634-41. [: CO2002:]
Kamwendo 1991 {published data only}
  • Kamwendo K, Linton SJ. A controlled study of the effect of neck school in medical secretaries. Scandinavian Journal of Rehabilitation Medicine 1991;23:143-52. [: CO97;119]
Linton 2001a {published data only}
Nordemar 1981 {published data only}
Rundcrantz 1991 {published data only}
  • Rundcrantz B, Johnsson B, Moritz U, Roxendal G. Cervico-brachial disorders in dentists: A comparison between two kinds of physiotherapeutic interventions. Scandinavian Journal of Rehabilitation Medicine 1991;23:11-7.
Skargren 1997 {published data only}
  • Skargren EI, Carlsson PG, Oberg BE. One-year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as primary management for back pain. Spine 1998;23(17):1875-84. [: CO97;CO2002]
  • Skargren EI, Oberg BE, Carlsson PG, Gade M. Cost and effectiveness analysis of chiropractic and physiotherapy treatment for low back and neck pain: Six-month follow-up. Spine 1997;22(18):2167-71. [: CO2002;CO97]

References to ongoing studies

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to ongoing studies
  21. Additional references
  22. References to other published versions of this review
Guerriero 1997 {published data only}
  • Guerriero D. Comparative effects of manipulation and physical therapy on motion in the cervical spine. Proceedings of the International Conference on Spinal Manipulation. 1991.
Gurumoorthy 2000 {published data only}
  • Gurumoorthy D, Twomey L.T, Batalin N.J. A prospective study of acute whiplash injury and its clinical management. Internation Federation of Manipulation Therapy, 7th Scientific Conference. November 2000:Abstract 78. [: CO2002]
Reginiussen 2000 {published data only}
  • Reginiussen T, Johnsen R, Torstensen TA. Efficiency of manual therapy on patients with cervicogenic headache. A randomized single blinded controlled trial. Internation Federation of Manipulation Therapy, 7th Scientific Conference. November 2000:Abstract 105.
Stokke 1995 {published data only}
  • Stokke O. A randomized comparison of chiropractic and physiotherapy treatment of neck pain of functional (Mechanical) Origins: A controlled clinical trial. Conference Proceedings of the Chiropractic Centennial Foundation. 1995:372-3.

Additional references

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to ongoing studies
  21. Additional references
  22. References to other published versions of this review
Australian Guideline 2003
  • Australian Acute Musculoskeletal Pain Guidelines Group, Australian National Health and Medical Research Council. Evidence-Based Management of Acute Musculoskeletal Pain. Brisbane: Australian Academic Press (www.australianacademicpress.com.au), December 2003.
Borghouts 1998
Borghouts 1999
Bronfort 2004
  • Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation mobilisation for low back pain and neck pain: a systematic review and best evidence synthesis. Spine Journal 2004;4:335-56.
Cicchetti 1976
Cohen 1968
Cohen 1988
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Côté 1998
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Dupont 1990
Goldsmith 1993
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Goldsmith 1999
  • Goldsmith CH. Estimating the horizon of a literature search. In: Canadian Cochrane Symposium. Canadian Cochrane Symposium, Hamilton. Nov, 19 1999.
Gross 2002
Gross 2002b
  • Gross A, Kay T, Kennedy C, Gasner D, Hurley L, Yardley K, et al. Clinical practice guideline on the use of manipulation or mobilization in the treatment of adults with mechanical neck disorder. Manual Therapy 2002;7(4):193-205.
Gross 2004
  • Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, et al. Manipulation and mobilisation for mechanical neck disorders. Cochrane Database of Systematic Reviews 2004, Issue 1. [Art. No.: CD004249. DOI: ]
Jadad 1994
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Jadad 1996
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Jensen 1986
Kendal 1963
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Koes 1991
Lamberts 1987
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Linton 1998
Linton 2001
Makela 1991
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Olesen 1988
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Olesen 1997
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Rajala 1995
Sackett 2000
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Schumacher 1993
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Sjaastad 1990
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Spitzer 1987
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Spitzer 1995
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Stratford 1999
  • Stratford PW, Riddle DL, Binkley JM, Spadoni G, Westaway MD, Padfield B. Using the Neck Disability Index to Make Decisions Concerning Individual Patients. Physiotherapy Canada 1999;Spring:107-19.
Takala 1982
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van Tulder 1997
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van Tulder 2000
  • van Tulder M, Malmivaara A, Esmail R, Koes B. Exercise therapy for low back pain. A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000;25(21):2784-2796.
van Tulder 2003
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Verhagen 2004
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Vernon 1988
  • Vernon H (editor). Upper cervical syndrome: Chiropractic diagnosis and treatment. Baltimore: Williams & Williams, 1988.
Vernon 1991a
Vernon 1991b
Waalen 1994
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References to other published versions of this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to ongoing studies
  21. Additional references
  22. References to other published versions of this review
Aker 1996
Gross 1996
  • Gross AR, Aker PD, Goldsmith CH, Peloso P. Conservative management of mechanical neck disorders: A meta-analysis. Online J Curr Clin Trials 1996 July 30;5:Doc No 200-1.
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