Exercises for mechanical neck disorders

 

Characteristics of included studies [ordered by study ID]

Allison 2002

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Methods	Type of Trial: RCT crossover design Number Analysed/Randomised: 36/40 Intension-to-treat Analysis: conducted Power Analysis: NR
Participants	Chronic MND (cervical brachial pain syndrome)
Interventions	INDEX TREATMENT Articular Treatment (AT): thoracic and glenohumeral mobilisation, home exercise (stretches, theraband strengthening) COMPARISON TREATMENTS Neural treatment (NT): neural tissue techniques, mobilisation, neuromuscular techniques, home mobilisation exercise techniques (10 repetitions, 1 to 3 times/day] Control Group (CG): no treatment, allowed to seek treatment from a non-physiotherapy health care provider COINTERVENTION: NR Treatment Schedule: 8 weeks, ? session Duration of Follow-up: none
Outcomes	PAIN (VAS, 0 to 10) Baseline Median: NT 4.6, AT 5.1, CG 3.3 Reported Results: significant favouring NT SMD(AT v CG): -0.15(95%CI:-1.05 to 0.75) [power %] SMD(AT v NT): 0.63(95%CI: -0.20 to 1.46) FUNCTION (Northwick Park Questionnaire, 0 to 36) Baseline Median: NT 12, AT 12.5, CG 12.5 Reported Results: not significant SMD(AT v CG): -0.10(95%CI:-1.00 to 0.80) [power %] SMD(AT v NT): 0.24(95%CI: -0.57 to 1.56) power %] SIDE EFFECT: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Allison 2002:AT v CG

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Methods	[Refer to Allison 2002 for details; author described articular treatment v control group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Allison 2002:AT v NT

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Methods	[Refer to Allison 2002 for details; author described articular group v neural group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Brodin 1985

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Methods	Type of Trial: RCT Number Analysed/Randomised: 63/71 Intention-to-treat Analysis: NR Power Analysis: NR
Participants	Chronic MND (25% of N had NDR or lower cervical degenerative changes)
Interventions	INDEX TREATMENT Group 3 (G3): mobilisation (passive) described by Stoddard, massage, manual traction, superficial heat, analgesics, education (neck school including exercise, 3 hours), 3 sessions/week COMPARISON TREATMENTS Group 1(G1): analgesic Group 2 (G2): Mock Therapy included superficial massage, manual traction, electrical stimulation, analgesics, education (neck school including exercise, 3 hours), 3 sessions/week COINTERVENTION: NR Treatment Schedule: 3 weeks, 9 sessions Duration of Follow-up: 1 week
Outcomes	PAIN (9 point linear scale): Baseline: NR Reported Results: significant difference favouring G3 RR(3 v 1): 0.67(95%CI:0.43 to 1.04) [power 18%] RR(3 v 2): 0.59(95%CI:9.39 to 0.91) SIDE EFFECTS: 10 in G1; G2 reported discomfort, usually small complaints; RR: 9.22(95%CI:0.61 to 14.30); note one subject dropped out due to acute cerebral disease (n=1), others dropped out for the following reasons: acute abdominal pain (n=1); ; vacation and infection (n=1); acute pain in several joints (n=1); incapable of following planned treatment (n=4) COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Brodin 1985: 2 v 1

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Methods	[Refer to Brodin 1985 for details; author described group 2 v 1]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Brodin 1985: 3 v 1

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Methods	[Refer to Brodin 1985 for details; author described group 3 v 1]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Brodin 1985: 3 v 2

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Methods	[Refer to Brodin 1985 for details; author described group 3 v 2]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Bronfort 2001

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Methods	Type of Trial: RCT Number Randomised: 191 Number Analysed: 158 to 160 Intention-to-treat Analysis: NR Power Analysis: NR
Participants	Chronic MND
Interventions	INDEX TREATMENT MedX Exercise (MedX): high technology exercise, medically supervised rehabilitative exercise, 20 sessions over 3 months Manipulation and low tech Exercise (SMT/Ex): chiropractic manipulation, supervised low technology rehabilitative exercise, 20 sessions over 3 months COMPARISON TREATMENT Spinal Manipulative (SMT): chiropractic manipulation, 20 sessions over 3 months COINTERVENTION: NR Treatment Schedule: 11 weeks, 20 session Duration of Follow-up: 12 months
Outcomes	CUMULATIVE ADVANTAGE for six patient-oriented outcomes Reported Results: favours SMT/Ex over SMT; MONOVA value yielded a significant group difference [Wilk's Lambda=0.85, F(12,302)=2.2, p<0.01] PAIN (11-box scale, 0 to 10) Baseline Mean: SMT 56.6, MedX 57.1, SMT/Ex 56.0 Reported Results: group difference in patient-rated pain ANOVA [F(2,156)=4.2, p=0.02] favours the two exercise groups SMD(MedX v SMT): -0.31(95%CI: -0.68 to 0.06) [power 29%] SMD(SMT v SMT/Ex): 0.24(95%CI:-0.14 to 0.61) [power 28%] SMD(SMT/Ex v MedX): 0.06(95%CI:-0.33 to 0.44) [power 28%] FUNCTION (Neck Disability Index, 0 to 50) Reported Results: no significant group differences were found ANOVA: F[2, 156] = 2.04, p = 0.13 SMD(MedX v SMT): -0.33(-0.70 to 0.05) [power 23%] SMD(SMT v SMT/Ex): 0.31(-0.06 to 0.68) [power 28%] SMD(SMT/Ex v MedX): 0.31(-0.06 to 0.68) [power 25%] PATIENT SATISFACTION (1 to 7; completely satisfied to completely dissatisfied) Reported Results: A clinically worthwhile cumulative advantage was reported favouring manipulation/exercise [low tech] group over exercise [high tech] and manipulation alone ANOVA: F[2, 158] = 6.7, p = 0.002 SMD(MedX v SMT): -0.26(-0.63 to 0.12) [power 49%] SMD(SMT v SMT/Ex): 0.71(0.33 to 1.10) SMD(SMT/Ex v MedX): -0.44(-0.83 to -0.05) PATIENT RATED IMPROVEMENT (1 to 9) Reported Results: substantial improvement over time, ANOVA: F[2, 174] = 1.7, p = 0.18 SMD(MedX v SMT):-0.29(-0.67 to 0.10) [power 44%] SMD(SMT v SMT/Ex): 0.29(-0.08 to 0.67) [power 44%] SMD(SMT/Ex v MedX): 0.01(-0.37 to 0.39) [power 38%] SIDE EFFECTS: increase neck or headache pain 8 SMT/Ex, 9 MedX, 6 SMT; increased radicular pain 1 SMT/Ex; severe thoracic pain 1 SMT; all cases self-limiting and no permanent injuries; RR(SMT/Ex v MedX): 0.81(95%CI:0.23 to 1.55) RR(SMT v MedX): 0.61(95%CI:0.23 to 1.55) COST OF CARE: NR
Notes	Source of Reference: Personal File Publication Type: Abstract from conference proceedings Peer Reviewed: can't tell Source of Funding: not specified Funding Agency has a Peer Review Mechanism: can't tell Country: USA, Canada
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Bronfort: MedX v SMT

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Methods	[Refer to Bronfort 2001 for details; author described MedX v SMT]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Bronfort:SMT/ExvMedX

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Methods	[Refer to Bronfort 2001 for details; author described SMT and exercise v MedX]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Brontfort:SMT/ExvSMT

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Methods	[Refer to Bronfort 2001 for details; author described SMT and exercise v SMT]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Fitz-Ritson 1995

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Methods	Type of Trial: RCT Number Randomised: 30 Number Analysed: 30 Intension-to-treat Analysis: not applicable Power Analysis: NR
Participants	Chronic WAD
Interventions	INDEX TREATMENT Group 1 (G1), Chiropractic and Exercises (standard rehabilitation): a. chiropractic b. exercises: standard rehabilitative exercises with 4 levels (10 exercises each), each level done for 2 weeks [levels include: a. range of motion b. stretching c. isometric-toning d. isokinetic strengthening] e. frequency = 5 days per week COMPARISON TREATMENT: Group 2 (G2), Chiropractic and Exercises (phasic neck): a. chiropractic b. exercises: phasic exercises of 2 levels (8 exercises each); each level done for 4 weeks; frequency = 5 days per week COINTERVENTION: NR Treatment Schedule: 8 weeks, 40 sessions Duration of Follow-up: none
Outcomes	NECK PAIN & DISABILITY INDEX Baseline mean: G1 59.5, G2 60 Reported Results: significant favouring G2 SIDE EFFECTS: NR COST OF CARE: NR
Notes	Source: Publication Type: journal Peer Reviewed: yes Funding Agency has Peer Review Mechanism: can't tell Country: Canada
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Gam 1998

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Methods	Type of Trial: RCT Number Randomised: 67 Number Analysed: 58 Intension-to-treat Analysis: NR Power Analysis: 10%
Participants	Chronic MND
Interventions	INDEX TREATMENT Group A (US): a. exercise (six exercises focusing on strength and mobility for neck and shoulder region) First 2 session 30 minutes, following 3 weeks 15 minutes, instructed to do 1 time/week at home b. ultrasound to a maximum of 5 most tender trigger points (frequency 100Hz, pulse=2:8, intensity 3 W/cm2, treatment time 3 minutes per sound head, radiation area 0.8cm squared, maximum treatment time 15 minutes) c. massage (transverse friction on the MTrP followed by myofascial technique applied on involved muscle groups, maximal duration 10 minutes) frequency: 4 weeks, 2 sessions/week COMPARISON Group B (SUS): a. Sham ultrasound b. massage (same as Group A) c. exercise (same as Group A) Group C (CG): control group, no treatment COINTERVENTION: NR Treatment Schedule: 4 weeks, 8 sessions Duration of Follow-up: 6 months
Outcomes	PAIN AT REST (VAS, 0 to 10) Baseline Median: US 2.6, SUS 3.7, CG 2 Reported Results: no significant differences were found between groups at any time SMD (SUS v CG): -0.26(95% CI:-0.89 to 0.36) SMD (US v CG): -0.75(95% CI:-1.42, -0.07) FUNCTION (Pain on Function; VAS, 0 to 10) Baseline Median: US 5.4, SUS 4.5, CG 4.5 Reported Results: no significant differences between groups ANALGESIC USE Baseline Median: US 4, SUS 2, CG 4 Reported Results: no significant difference between groups INDEX SCORE Baseline Median: US 11.5, SUS 10, CG 12.5 Reported Results: significant reduction in index score for US and SUS at end of study compared to CG [p<0.05] SIDE EFFECTS: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Gam SUSvsCG

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Methods	[Refer to Gam 1998 for details; author described sham ultrasound v control group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Gam USvCG

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Methods	[Refer to Gam 1998 for details; author described ultrasound v control group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Geibel 1997

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Methods	Type of Trial: RCT Number Analysed/Randomised: 97/103 Intention-to-treat Analysis: NR Power Analysis: NR
Participants	Acute WAD, NDH
Interventions	INDEX TREATMENT Group 1 (G1): a. exercise: active movement seated, hold-relax/contract-relax technique to scaleni, levator scapula and trapezius in sitting, strengthening of interscapular muscles, further parameters = not specified b. mobilisation (passive, neuromuscular): for individual segments active-assisted followed by passive movements under light traction; proprioceptive neuromuscular facilitation: active, hold-relax/contract-relax technique to scaleni, levator scapula and trapezius in sitting; light traction with mobilisation c. medication: analgesic, antiinflammatory COMPARISON TREATMENT Group 2 (G2): a. advised no exercise b. collar: worn continuously, take off at night c. medication: analgesic, antiinflammatory COINTERVENTION: analgesics and antiinflammatories allowed in both groups Treatment Schedule: 3 weeks Duration of Follow-up: 9 weeks
Outcomes	PAIN (NRS101) Baseline Mean: G1 46.70, G2 49.20 Reported Results: Physiotherapy has a clear advantage over collars SMD@2w treatment: -1.04(95%CI:-1.46 to -0.61) SMD@3w treatment and 9 weeks follow-up: -4.88(95%CI:-5.68 to -4.07) NOTE that the large effect estimate for pain intensity in Giebel's trial is an artifact of both groups markedly improving from baseline to almost no pain. Clinically this benefit translates to a 5.5% treatment advantage for the multimodal treatment. FUNCTION [household activity, physical activity, activity of daily living, social activity, neck mobility (11 point scale of MOPO Fragenbogens)] Baseline: NR Reported Results: significant favour G1 SMD: 0.23(95%CI:-0.17 to 0.63) (a positive sign denotes advantage of the first group in the contrast) [power 100%] SIDE EFFECT: NR COST OF CARE: cost of direct care: G1 155DEM (78USD), G2 113DEM (57USD) sick days [number patients x days off work]: G1 187, G2 330 Reported Results: G1 treatment economically favoured
Notes	Source of Reference: COCH Publication Type: journal Peer Reviewed: can't tell Source of Funding: not specified Funding Agency has a Peer Review Mechanism: not specified Country: Germany
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Goldie 1970

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Methods	Type of Trial: CCT Number Randomised: 73 Number Analysed: 73 Intention-to-treat: not applicable Power Analysis: NR
Participants	Chronic MND with possible NDR (radiation down either of the upper extremities following a segmental pattern, paraesthesiae was uncommon, paresis was absent)
Interventions	INDEX TREATMENT: Isometric Group: isometric exercise against therapist manual pressure to a maximum of the patients' ability under the pain threshold in cervical movement directions, patient either in sitting or supine position, rest for 10 minutes post treatment in lying position, 3 times per week for 10 sessions just over 3 weeks; analgesic; muscle relaxant; education (advice to rest) COMPARISON TREATMENTS: Traction Group: a. traction b. medication: analgesic, muscle relaxant, c. education (advice to rest) No-treatment Group: a. medication: analgesic, muscle relaxant COINTERVENTION: avoided in trial Treatment Schedule: 3 weeks, 10 sessions Duration Follow-up: 3 weeks (assessment), 24 week (letter)
Outcomes	PATIENT GLOBAL PERCEIVED EFFECT (3 point scale) Baseline: NR Reported Results: A slight tendency favouring traction RR (exercise v no treatment): 0.42(95%C: 0.21,0.83) RR (exercise v traction): 0.84(95%CI: 0.37,1.91) [power %] SIDE EFFECTS: patient rated as not improved or worse traction 9 of 26; exercise 7 of 24; no treatment 16 of 23 COST OF CARE: NR
Notes	Source of Reference: ref from letter Publication Type: journal Peer Reviewed: yes Funding Agency has a Peer Review Mechanism: can't tell Country: Scandinavia [Sweden]
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	No	C - Inadequate

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Goldie: ex v cnt

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Methods	[Refer to Goldie 1970 for details; author described isometric group v non-treated group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	No	C - Inadequate

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Goldie: ex v trac

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Methods	[Refer to Goldie 1970 for details; author described isometric group v traction group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	No	C - Inadequate

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Hagberg 2000

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Methods	Type of Trial: RCT Number Randomised 77 Number Analysed: 69 Intention-to-treat Analysis: NR Power analysis: calculated; using the variance of the pain measurements (pain right now = 21 mm on VAS) a power analysis showed 604 patients needed to detect a significant (0.10) 5 mm difference on pain rating between 2 programs with a 90% probability
Participants	Chronic MND (ICD-10)
Interventions	INDEX TREATMENT Isometric Shoulder Endurance Training: a. goal to improve endurance in the upper part of the trapezius muscle. b. Position: In a sitting posture, the patient had to lift the arm to 90 degrees of forward flexion with straight arm and the forearm semipronated. c. Intensity: Subject to hold this position for 2 minutes. The exercise was done 4 times with 2 minutes of rest in between, 3 time/week for 12 weeks. d. This exercise corresponds to a contraction level of about 20% to 30% of maximal shoulder joint torque, and approximately the same contraction for the upper part of the trapezius. COMPARISON TREATMENT: Isometric Shoulder Strength Training: a. goal to improve strength in the upper part of the trapezius, and mainly involved the type 2 muscle fibres b. position: sitting posture with the arms in 90 degrees of forward flexion and the forearm semipronated. A sling from the floor was attached to the arms just proximal to the elbow joint. c. intensity: the training contraction was performed as a maximal contraction held for 5 seconds followed by a rest for 2 minutes. The exercise was done as 10 contractions with 2-minute rests in between for 12 weeks COINTERVENTION: NSAID Treatment Schedule: 12 weeks Duration of Follow-up: 12 weeks
Outcomes	NECK-SHOULDER PAIN WORST OF PRECEDING WEEK (VAS, 0 to 100)] Baseline Mean: Endurance 43, Strength 35 Reported Results: no significant difference PRESENT PAIN (VAS, 0 to 100) Baseline Mean: Endurance 42, Strength 34 Reported Results: no significant difference SICK LEAVE Reported Results: substantially the same for both groups RATING OF PERCEIVED EXERTION AT WORK (BORG, 0 to 10) Baseline Mean: Endurance 6.2, Strength 6.4 Reported Results: no significant difference SHOULDER FUNCTION [arm motion performance test, seconds] Baseline Mean: Right Endurance 10.7, Strength 13.4 Left Endurance 10.9, Strength 12.0 Reported Results: significant difference on the right favoured the isometric shoulder strength training group SIDE EFFECT: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

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Hanten 2000

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Methods	Type of Trial: RCT Number Randomised: 40 Number Analysed: 40 Intention-to-treat analysis: not applicable Power analysis: NR
Participants	MND, disorder duration NR (myofascial trigger points in neck or upper back)
Interventions	INDEX TREATMENT Group 1 (G1): a. sustained stretching for the neck and upper back musculature holding each for 30 to 60 seconds at least 2 times/day for 5 days; b. written and verbal instructions, rationale, and a demonstration on performing Ischaemic pressure using a Thera Cane in sitting with muscle in lengthened position applying gradually increasing pressure to the TP and holding until a release was felt. Repeated the process until no further release was obtained. Frequency: primary TP at least 2 times/day for 5 days; c. time to practice the Ischaemic pressure applications and sustained stretches, ask questions, and receive feedback; d. subjects were asked to perform no treatment on days 6 and 7 COMPARISON TREATMENT: Group 2 (G2): a. verbal and written instructions, rationale, and a demonstration on performing active neck flexion, neck lateral flexion and neck rotation while seated near the edge of an armless chair with both feet planted on the floor, 10 times each exercise, at least 2 times/day for 5 days; b. returned on day 2 for a session with examiner who assessed technique and answered questions; c. subjects were asked to perform no treatment on days 6 and 7 COINTERVENTION: NR Treatment Schedule: 5 days Duration of Follow-up: 8 days
Outcomes	PAIN INTENSITY (VAS, 0 to 100) Baseline mean: G1 25.7, G2 26.6 Reported Results: significant difference favouring G1 PERCENTAGE OF TIME IN PAIN Baseline mean: G1 25.1, G2 28.7 Reported Results: do difference between groups PRESSURE PAIN THRESHOLD [pressure algometer] Baseline mean: G1 4.5, G2 3.7 SIDE EFFECTS: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

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Hoving 2002

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Methods	Type of Trial: RCT Number Analysed/Randomised: 178/183 Intention-to-treat Analysis: conducted Power Analysis: conducted
Participants	Acute, subacute, chronic MND and NDH
Interventions	INDEX TREATMENT Physical Therapy (PT): a. active exercise therapies: strengthening, stretching (ROM), postural/ relaxation/ functional exercise b. optional modalities: manual traction, massage, interferential, heat; excluded specific mobilisations techniques, median 9 (IQR 7-12) sessions COMPARISON TREATMENTS Manual Therapy (MT): a. muscular and articular mobilisation techniques, low velocity passive movements within or at the limit of joint range; excluded manipulation b. coordination and stabilisation techniques c. 45 minute sessions, one session per week for a maximum of 6 sessions [median 6 (IQR5-6)] Continued Care by General Practitioner (GP): a. education: advice on prognosis, psychosocial issues, self care (heat, home exercise), ergonomics (pillow, work position), await further recovery; booklet (ergonomics, home exercise); b. medication: paracetamol, NSAID c. 10 minute follow-up every 2 weeks was optional; excluded referral for other treatment, median 2 (IQR1-4) treatments COINTERVENTION: analgesics and antiinflammatories allowed in both groups, home exercise for all three groups Treatment Schedule: 6 weeks, 6 sessions Duration of Follow-up: 52 weeks
Outcomes	PAIN (NRS, 0 to 10) Baseline Mean: MT 5.9, PT 5.7, GP 6.3 Reported Results: significant favouring MT over PT SMD (PT v MT): 0.41(95%CI: 0.04 to 0.78) [power %] SMD (PT v GP): 0.34(95%CI: -0.02 to 0.70) [power 96%] FUNCTION (Neck Disability Index, 0-50) Baseline: MT 13.6, PT 13.9, GP 15.9 Reported Results: significant favouring MT over PT SMD (PT v GP): 0.28(95% CI:-0.08 to 0.64) [power %] SMD (PT v MT): 0.12(95% CI:-0.25 to 0.48) [power 17%] GLOBAL PERCEIVED EFFECT (perceived recovery, %) Reported Results: significant favouring MT over PT and GP SMD (PT v GP): 0.30(95% CI:-0.05 to 0.66) [power 21%] SMD (PT v MT): 0.42(95% CI:0.05 to 0.78) [power 14%] SIDE EFFECT: benign and transient increased neck pain > 2 days RR(MT v GP): 3.91(95%CI: 1.15 to 13.34) RR(MT v PT): 2.70(95%CI: 0.91 to 8.01) RR(PT v GP): 1.45(95%CI: 0.34 to 6.19) increased headache RR(MT v GP): 1.65(95%CI: 0.84 to 3.23) RR(MT v PT): 0.88(95%CI: 0.51 to 1.52) RR(PT v GP): 1.87(95%CI: 0.98 to 3.60) arm pain/pins&needles RR(MT v GP): 2.13(95%CI: 0.68 to 6.72) RR(MT v PT): 0.87(95%CI: 0.36 to 2.11) RR(PT v GP): 2.44(95%CI: 0.79 to 7.51) dizziness RR(MT v GP): 1.60(95%CI: 0.47 to 5.39) RR(MT v PT): 0.84(95%CI: 0.30 to 2.36) RR(PT v GP): 1.90(95%CI: 0.59 to 6.16) COST OF CARE: favours MT total costs Results: not significant SMD(MT v GP):-0.41(95%CI:-0.77 to -0.05) SMD(MT v PT): -0.34(95%CI:-0.70 to 0.02) SMD(PT v GP):-0.02(95%CI:-0.3 to 0.33) total direct costs Results: significant favours MT v PT SMD(MT v GP):-0.28(95%CI:-0.64 to 0.07) SMD(MT v PT): -0.49(95%CI:-0.85 to -0.17) SMD(PT v GP):0.21(95%CI:-0.15 to 0.56) total indirect costs Results: significant favour MT v GP SMD(MT v GP):-0.40(95%CI:-0.75 to -0.04) SMD(MT v PT): -0.28(95%CI:-0.64 to 0.08) SMD(PT v GP):-0.07(95%CI:-0.43 to 0.28) duration off work Results: significant favour MT v GP SMD(MT v GP):-0.43(95%CI:-0.85 to -0.01) SMD(MT v PT): -0.29(95%CI:-0.71 to 0.12) SMD(PT v GP):-0.10(95%CI:-0.51 to 0.32)
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Hoving 2002: GP v MT

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Methods	[Refer to Hoving 2002 for details; author described continued care by general practitioner v manual therapy]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Hoving 2002: PT v GP

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Methods	[Refer to Hoving 2002 for details; author described physical therapy v continued care by general practitioner]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Hoving 2002: PT v MT

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Methods	[Refer to Hoving 2002 for details; author described physical therapy v manual therapy]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Jordan 1998

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Methods	Type of Trial: RCT Number Randomised: 119 Number Analysed: 102 Intention-to-treat Analysis: NR Power Analysis: NR
Participants	chronic MND without radicular signs and symptoms
Interventions	INDEX TREATMENT Intensive Training Group (Int ): a. exercise: group sessions of 4 to 5 patients, under the guidance of a physiotherapist; stationary bicycle, 5 to 6 minutes; stretching, 10 minutes; intensive training of neck muscles on a Neck Exercise Unit [Follo, Norway] including isometric strengthening measures in flexion, extension, left and right lateral flexion, followed by strengthening programs initiated at 30% of maximum obtained values, one series of 12 reps for flexion, three series of 12 reps each in extension and lateral flexion; rest and stretching between series; new isometric measures every 14 days and dosage modified accordingly; strength training of shoulder, scapular and chest muscles with hand-held weights; shoulder pull-down machine to strengthen the latissimus dorsi muscles; at conclusion, 5 to 6 minutes bicycle (cool down) b. massage; traction (manual) c. hot pack, ultrasound d. proprioceptive neuromuscular facilitation e. neck school f. 2 sessions/week COMPARISON TREATMENT Physiotherapy Group (PT): a. proprioceptive neuromuscular facilitation b. mobilisation (passive), massage, traction (manual) c. hot pack, ultrasound d. neck school e. 2 sessions/week Chiropractic Group (CH): a. manipulation: high velocity, low-amplitude thrust to cervical, traction (manual), manual treatment: given to tender muscles and trigger points b. neck school c. 2 sessions/week CO-INTERVENTION: NR Treatment Schedule: 6 weeks, 12 sessions Duration of Follow-up: 46 weeks
Outcomes	PAIN (headache intensity, three 11 point box scale, maximum score 30) Baseline: NR Reported Results: no significant difference SMD(PT v Int): 0.00(95%CI:-0.47 to 0.47) [power 11%] SMD(PT v CH and Int v CH): 0.00(95%CI:-0.48 to 0.48) [power 11%] FUNCTION (self-report disability index, maximum score 30) SMD(Int v PT): 0.25(95%CI: -0.22 to 0.73) [power 18%] SMD(PT v CH): 0.00(95%CI:-0.48 to 0.48) [power 11%] SMD(Int V CH): 0.36(95%CI:-0.12 to 0.84) [power 11%] GLOBAL PERCEIVED EFFECT (patient perceived effect, 6 point scale) SMD(PT V CH and Int V CH): 0.00(95%CI:-0.48 to 0.48) [power 11%] SIDE EFFECT: CH: persistent acute pain (n = 1) COST OF CARE: NR
Notes	Source of Reference: Personal Files Publication Type: journal Peer Reviewed: yes Source of Funding: Danish Medical Research Council, Danish Arthritic Association, Medical Research Fund for Copenhagen, Faroe Islands and Greenland, Foundation for Chiropractic Education and Research, The Fund to Promote Chiropractic Research and Postgraduate Education Funding Agency has a Peer Review Mechanism: yes Country: Denmark
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Jordan 1998: Int vCH

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Methods	[Refer to Jordan 1998 for details; author described Intensive training V chiropractic]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Jordan 1998:CHvPT

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Methods	[Refer to Jordan 1998 for details; author described chiropractic v physiotherapy]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Jordan 1998:Int v PT

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Methods	[Refer to Jordan 1998 for details; author described Intensive training v physiotherapy]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Jull 2002

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Methods	Type of Trial: RCT Number Analysed/Randomised: 193/200 Intention-to-treat Analysis: calculated Power Analysis: NR
Participants	Chronic NDH
Interventions	INDEX TREATMENT Exercise Therapy (ExT): therapeutic low load exercise to cervical-scapular region: craniocervical flexor training with pressure biofeedback, scapular muscle training, postural correction, exercise performed throughout the day, isometric strengthening with co contraction of neck flexion and extension, stretching as needed, 30 minute session duration, two sessions/weeks, 8 to 12 sessions total Combined Therapy (MT/ExT): a. manipulation, mobilisation b. exercise c. 30 minute session duration, two sessions/weeks, 8 to 12 sessions total COMPARISON TREATMENT Manipulative Therapy (MT): manipulation: high velocity, low-amplitude manipulation described by Maitland; mobilisation (low velocity), 30 minute session duration, 2 sessions/week, 8 to 12 sessions total Control Group (Cntl): no treatment COINTERVENTION: NR Treatment Schedule: 6 weeks, 8 to 12 sessions Duration of Follow-up: 52 weeks
Outcomes	PAIN (headache intensity change score; VAS, 0 to 10) Baseline Mean: MT 4.8, ExT 5.4, MT/ExT 5.1, Cntl 5.3 Reported Results: significant favouring MT and ExT SMD(ExT v Cntl):-0.59(95%CI:-1.00, -0.18) SMD(Ext v MT): 0.21(95%CI:-0.18 to 0.61) [power 96%] SMD(MT/ExT v ExT): 0.06(95%CI:-0.35, 0.46) [power 98%] SMD(MT/ExT v Cntl):-0.58(95%CI:-1.00,-0.17) FUNCTION (Northwick Park neck pain questionnaire change score, 0 to 36) Baseline Mean: MT 27.5, ExT 29.6, MT/ExT 29.7, Cntl 30.7 Reported Results: significant favouring MT or MT/ExT over control; no significant difference between MT, ExT and MT/ExT comparisons SMD(ExT v Cntl):-0.59(95%CI:-1.00,-0.18) SMD(ExT v MT):-0.32(95%CI:-0.72, 0.08) [power 100%] SMD(MT/ExT v ExT): 0.11(95%CI:-0.29, 0.50) [power 59%] SMD(MT/ExT v Cntl):-0.64(95%CI:-1.06,-0.23) GLOBAL PERCEIVED EFFECT (participant perceived effect; VAS, 0 to 100) Reported Results: significant favouring MT and MT/ExT over control, not significant for MT or MT/ExT when compared to ExT SMD(ExT v Cntl):-2.51(95%CI:-3.05,-1.97) SMD(ExT v MT): -0.29(95%CI:-0.69, 0.10) [power 81%] SMD(MT/ExT v ExT): 0.01(95%CI:-0.38, 0.40) [power 59%] SMD(MT/ExT v Cntl):-2.73(95%CI:-3.30,-2.16) SIDE EFFECT: minor and temporary, 6.7% of headaches were provoked by treatment COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Jull 2002:ExT v Cntl

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Methods	[Refer to Jull 2002 for details; author described exercise treatment v control group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

---

Jull 2002:ExT v MT

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Methods	[Refer to Jull 2002 for details; author described exercise treatment v manual therapy group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

---

Jull 2002:MTExT v MT

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Methods	[Refer to Jull 2002 for details; author described manual therapy and exercise treatment v manual therapy group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

---

Jull 2002:MTExT vExT

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Methods	[Refer to Jull 2002 for details; author described manual therapy and exercise treatment v exercise treatment]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

---

Jull 2002:MTExTvCntl

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Methods	[Refer to Jull 2002 for details; author described manual therapy and exercise treatment v control group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

---

Karlberg 1996

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Methods	Type of Trial: RCT Number Analysed/Randomised: 17/17 Intention-to-treat Analysis: conducted Power Analysis: NR
Participants	Subacute NDH
Interventions	INDEX TREATMENT Physiotherapy Group (PT): a. mobilisation (passive, neuromuscular): technique described by Kaltenborn and Lewit, soft tissue treatment b. physiotherapy treatment: stabilization exercise described by Feldenkrais, relaxation techniques described by Jacobson c. NSAID d. education e. median 13 sessions (range: 5 to 23) over 8 to 9 weeks COMPARISON TREATMENT Delayed Treatment Group (D): wait period 8 weeks without treatment COINTERVENTION: NR Treatment Schedule: median 8 to 9 weeks, 13 sessions Duration of Follow-up: none
Outcomes	PAIN (headache intensity; VAS, 0 to 100) Baseline Mean: PT 54, D 56 Reported Results: significant favouring PT SMD: -1.47(95% CI:-2.58, -0.36) SIDE EFFECTS: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Koes 1992

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Methods	Type of Trial: RCT Number Randomised: 64 Number Analysed: 58/64, not specified for 6 month and 1 year follow-up for neck only group Intention-to-treat Analysis: calculated (see chapter 5, table 6) Power Analysis: calculated, 50 subjects per group
Participants	Subacute, chronic MND
Interventions	INDEX TREATMENT General Practitioner Group (GP): a. home exercises b. medication: analgesics, NSAID c. education: posture, participation in sports, bed rest and other treatment modalities; 1 session Physical Therapy Group (PT): a. massage b. exercise c. heat d. electrotherapy (10% received exercise/massage; 44% heat/ exercise/massage; 12% electrotherapy/exercise/massage; 9% electrotherapy/ heat/ exercise/ massage; 3% exercise only; 9% exercise/heat; 5% electrotherapy/exercise; 5% massage only; 3% massage/heat), exercise, heat, electrotherapy mean 14.7 (SD: 14) sessions/7.8 weeks) COMPARISON TREATMENT Manual Therapy Group (MT): a. manipulation and mobilisation: described by Dutch Society of Manual Therapy, [Note: all therapists except for placebo therapists were free to choose from their usual therapeutic domain within explicitly formulated limits, e.g. no manipulative techniques were performed by the physio]; mean 5.4 (SD: 6) sessions/8.9 weeks Placebo Treatment (Pl): a. de-tuned short wave diathermy & US; 2 times/week, mean 11.1 (SD: 12) sessions/5.8 weeks COINTERVENTION: detailed in chapter 6, table 5 Treatment Schedule: varied from 1 to 9 weeks Duration of Follow-up: 9 weeks of treatment + 3 weeks follow-up Note: 6 & 12 months data not reported due to extensive cross over of care
Outcomes	PAIN (WHYMPI: 10 point scale) Baseline: NR Reported Results: better results favouring MT at 9 weeks treatment and 3 weeks follow-up SMD(GP v MT): 0.61(95% CI: -0.18 to 1.40) [power %] SMD(GP v pl): 0.44(95% CI:-0.36 to 1.23) [power %] SMD(MT v PT): -0.64(95% CI:-1.35 to 0.08) [power 14%] FUNCTION (physical functioning,10 point scale) Baseline Mean: MT 6.11, PT 5.6, GP 5.29, Pl 5.71 Reported Results: significant favouring MT @ 9 weeks treatment and 3 weeks follow-up: SMD(GP v MT): 0.31(95% CI:-0.48 to 1.10) [power %] SMD(MT v PT): -0.75(95% CI:-1.50 to 0.00) [power 17%] GLOBAL PERCEIVED EFFECT: Reported Results: not significant between groups SMD(GP v pl): 0.38(-0.41 to 1.18) [power %] SIDE EFFECTS: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

---

Koes 1992: GP v MT

---

Methods	[Refer to Koes 1992 for details; author described general practitioner [GP] v manual therapy [MT] group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

---

Koes 1992: GP v pl

---

Methods	[Refer to Koes 1992 for details; author described general practitioner (GP) group v placebo (pl) group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

---

Koes 1992: PT v GP

---

Methods	[Refer to Koes 1992 for details; author described physical therapy (PT) group v general practitioner (GP) group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

---

Koes 1992: PT v pl

---

Methods	[Refer to Koes 1992 for details; author described physical therapy (PT) group v placebo (pl) group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

---

Koes 1992:PT v MT

---

Methods	[Refer to Koes 1992 for details; author described physical therapy (PT) group versus manual therapy (MT) group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

---

Kogstad 1978

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Methods	Type of Trial: quasi-RCT Number Analysed/Randomised: 50/50 Intention-to-treat Analysis: NR Power Analysis: NR
Participants	NDR, disorder duration NR
Interventions	INDEX TREATMENT Conventional Therapy Group (CT): a. isometric exercises, home exercises b. heat c. soft tissue massage d. 15 minutes intermittent mechanical traction e. 60-minute sessions, 3 sessions/week for 5 weeks COMPARISON TREATMENT Placebo Group (Pl): placebo tablets 3 times/day for 5 weeks Manual Therapy Group (MT): a. manipulation (described by Brodin) b. heat c. soft tissue massage d. 40-minute sessions, 2 sessions/week for 4 weeks CO-INTERVENTION: 3 patients in placebo group received conventional treatment or manual therapy during 18 month follow-up period Treatment Schedule: 5 weeks, 8 sessions for MT; 12 sessions for CT Duration of Follow-up: 18 months
Outcomes	GLOBAL PERCIEVED EFFECT (objective and subjective findings) Reported Results: not significant RR (CT v Pl): 0.43(95%CI: 0.15 to 1.20) RR (CT v MT): 1.30(95%CI: 0.28 to 6.11) SIDE EFFECTS: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	No	C - Inadequate

---

Kogstad 1978:CT v MT

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Methods	[Refer to Kogstad 1978 for details; author described conventional therapy v manual therapy]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	No	C - Inadequate

---

Kogstad 1978:CT v Pl

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Methods	[Refer to Kogstad 1978 for details; author described conventional therapy v placebo]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	No	C - Inadequate

---

Levoska 1993

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Methods	Type of Trial: comparison trial Number Analysed/Randomised: 44/47 Intention-to-treat Analysis: NR Power Analysis: NR
Participants	MND, disorder duration NR
Interventions	INDEX TREATMENT: Active Exercise Group (AE): a. exercise: resistance based on assessment of endurance force; 60 minutes of omnikinetic training machine or dumbbells (one to 10 kg), movement lasted from 30 to 60 seconds followed by a 60 second pause; resistance was increased as performance improved; b. mean visits 13 (min 7, max 15) COMPARISON TREATMENT: Passive Exercise Group (PE): a. exercise: physical exercising of muscles of the neck and shoulder for 20 minutes; no home exercise program b. manual therapy: massage for 20 minute with slight stretches c. heat: 20 minutes d. mean visits attended 10.9 (min 10, max 15) COINTERVENTION: NR Treatment Schedule: 5 weeks, PE mean 10.9 sessions; AE mean 13 sessions Duration of Follow-up: 52 weeks
Outcomes	PAIN (occurrence of pain symptoms): Baseline: NR Reported Results: significant (p < 0.01) favouring active exercise RR: 0.50(95%CI: 0.18 to 1.42) SIDE EFFECT: NR COST OF CARE: NR
Notes	Source of Reference: MEDLINE Publication Type: journal Peer Reviewed: yes Source of Funding: not specified Training of Primary Author: unknown Country: Scandinavia
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	No	C - Inadequate

---

Lundblad 1999

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Methods	Type of Trial: RCT Number Analysed/Randomised: 58/97 Intention-to-treat Analysis: NR Power Analysis: NR
Participants	Chronic MND
Interventions	INDEX TREATMENT Feldenkrais Intervention (F) a. education: Individualised (functional integration) teacher guides through movement sequences; Group (awareness through movement) verbally guided through exercises for neck-shoulder complaints b. home exercises c. 50 minutes per week; individually 4 times and in group (7 to 8 subjects) 12 times; required 50% participation in both segments of program Physiotherapy Intervention (PT) a. stabilisation exercises for low back and pelvis, isolated and relaxed shoulder movements b. education: use of body emphasising self-directed control and responsibility for body, ability to cope with pain, muscle tension, and complaints c. awareness of body posture d. practice work-related lift and movement techniques e. exercise program of strength, coordination, endurance, flexibility/smoothness and rhythm f. home exercises g. 50 minutes; 2 times/weeks for 16 weeks in group of 5 to 8 subjects; Required 50% participation in the exercises COMPARISON GROUP Control Regime (C): no treatment Treatment Schedule: 16 weeks, 32 sessions Duration of Follow-up: 52 weeks
Outcomes	PAIN (VAS, 0 to 10) Baseline Mean: VAS - usually PT 1.2, F 1.5, C 2.0 VAS - worst PT 4.1, F 4.4, C 5.5 Reported Results: no significant differences DISABILITY (work and leisure, 4 point scale) Baseline Mean: Disability - work PT 1.3, F 1.2, C 1.3 Disability - leisure PT 0.6, F 0.9, C 0.6 Sick leave (days) PT 12.7, F 12.0, C 11.5 Sick leave (%) PT 6.5, F 5.8, C 5.9 Reported Results: no significant differences SMD: 0.09(95%CI:-0.56 to 0.74) [power %] SIDE EFFECTS: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

---

Lundblad 1999: PTvCG

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Methods	[Refer to Lundblad 1999 for details; author described PT group v C group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

---

Lundblad 1999: PTvFG

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Methods	[Refer to Lundblad 1999 for details; author described PT group v F group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

---

McKinney 1989

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Methods	Type of Trial: RCT Number Analysed/Randomised: 170/247 Intention-to-treat Analysis: NR Power Analysis: NR
Participants	Acute WAD
Interventions	INDEX TREATMENT Group 2 (G2): a. mobilisation described as active and passive repetitive movements using principles of Maitland and McKenzie b. heat/cold application, short wave diathermy, hydrotherapy c. traction d. "the full gamut of physiotherapeutic aids was available as deemed appropriate" e. education: posture and exercise to perform at home f. standard analgesic g. collar: fitted with soft collar, intermittent use h. three 40 minute sessions/weeks for 6 weeks COMPARISON TREATMENT Group 1 (G1): a. education: mobilisation after an initial 10 to 14 day rest period, general advice b. analgesics c. collar: fitted with soft collar, continuous use Group 3 (G3): a. education: posture correction b. collar: restricted to very short periods in situations where their neck was vulnerable to sudden jolting, if collar worn exercise should be performed immediately after c. heat d. medication: muscle relaxation, analgesics e. encouraged to perform demonstrated mobilisation exercises COINTERVENTION: NR Treatment Schedule: 6 weeks, 24 sessions Duration of Follow-up: 2 weeks
Outcomes	PAIN (VAS, 0 to 10) Baseline Median: G1 5.6, G2 5.3, G3 5.3 Reported Results: significantly better than rest (G1) SMD(2 v 1): -0.77(95% CI: -1.20,-0.35) SMD(2 v 3): 0.50(95% CI:-0.28, 0.39) [power 16%] SIDE EFFECTS: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

McKinney 1989: 2 v 1

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Methods	[Refer to McKinney 1989 for details; author described group 2 v 1]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

McKinney 1989: 2 v 3

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Methods	[Refer to McKinney 1989 for details; author described group 2 v 3]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

McKinney 1989: 3 v 1

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Methods	[Refer to McKinney 1989 for details; author described group 3 v 1]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Mealy 1986

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Methods	Type of Trial: RCT Number Analysed/Randomised: 51/61 Intention-to-treat Analysis: NR Power Analysis: NR
Participants	Acute WAD
Interventions	INDEX TREATMENT Active Group (A): a. exercise: within the limits of pain, daily, every hour at home b. mobilisation (passive): technique described by Maitland c. heat; ice d. analgesics COMPARISON TREATMENT: Standard Group (S): a. soft cervical collar, worn for two weeks b. rest for two weeks before beginning gradual mobilisation c. analgesics COINTERVENTION: NR Duration of Therapy Period: 8 weeks Duration of Follow-up: none
Outcomes	PAIN (pain intensity, 0 to 10) Baseline Mean: A 5.71, S 6.44 Reported Results: significant favouring active group SMD: -0.86(95% CI:-1.44 to -0.29) SIDE EFFECTS: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Pennie 1990

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Methods	Type of Trial: CCT Number Analysed/Randomised: 128/135 Intention-to-treat Analysis: NR Power Analysis: NR
Participants	Acute WAD
Interventions	INDEX TREATMENT: Traction Group: a. education: advice on simple neck and shoulder exercises, neck care, sleep posture b. intermittent halter traction for 10 minutes COMPARISON TREATMENT: Collar Group: a. collar: 2 weeks rest in a soft collar or moulded one of thermoplastic polyethylene foam b. exercise: taught program of active (home) exercises COINTERVENTION: not avoided for collar group after 6-8 weeks of treatment referred for physiotherapy if not improved or deteriorated Treatment Schedule: 6 to 8 weeks [2 times per week for traction and education (exercise, posture) group] Duration Follow-up: 12 weeks
Outcomes	PAIN INTENSITY (VAS, 0 to 100) Baseline: NR Reported Results: not significant DAYS OFF WORK Baseline: NR Reported Results: not significant RR 1.02(95%CI: 0.43 to 2.38) GLOBAL PERCEIVED EFFECT (4 point scale) Baseline: NR RR 1.02(95%CI: 0.43 to 2.38) SIDE EFFECTS: NR COST OF CARE: NR
Notes	Source of Reference: manual search Publication Type: journal Peer Reviewed: yes Funding Agency has Peer Review Mechanism: can't tell Country: UK
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	No	C - Inadequate

---

Persson 2001

---

Methods	Type of Trial: RCT Number Analysed/Randomised: 79/81 Intention-to-treat Analysis: NR Power Analysis: NR
Participants	Chronic NDR
Interventions	INDEX TREATMENT PT Group: physiotherapy decided by the physiotherapist according to patient's symptoms and individual preferences [manual therapies (massage, manual traction, gentle mobilisation); modalities for pain relief like TENS, application of heat or cold (moist, ultrasound); exercise (relaxation exercises; active stretching, strengthening, endurance exercises, postural correction); ergonomic instruction]; 15 sessions of 30-45 minutes COMPARISON TREATMENTS: Surgery Group: surgery [anterior cervical discectomy technique described by Cloward (1958); mobilisation on the 1st postoperative day; cervical collar use for 1-2 days post-operatively ] Collar Group: cervical collar (rigid collars during day; soft collar at night) COINTERVENTION: Surgery group: 8 patients had 2nd operation, 11 patients received physiotherapy PT group: 1 patient had surgery Collar group: 5 patients had surgery, 12 patients received physiotherapy Treatment Schedule: 12 weeks,15 sessions Duration of Follow-up: 56 weeks
Outcomes	PAIN INTENSITY (VAS, 0 to 100) Baseline Mean: surgery 47, PT 50, collar 49 Reported Results: not significant SMD(PT v collar): 0.16(95%CI:-0.38, 0.70) SMD(PT v surgery): 0.33(95%CI:-0.21, 0.87) WORST PAIN (VAS, 0 to 100) Baseline Mean: surgery 72, PT 70, collar 68 Reported Results: not significant SMD(PT v collar): 0.04(95%CI: -0.50, 0.57) SMD(PT v surgery): 0.28(95%CI: -0.27, 0.82) Side Effects: NR Cost of Care: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Persson 2001:PTv col

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Methods	[Refer to Persson 2001 for details; author described Physiotherapy v cervical collar]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Persson 2001:PTvsurg

---

Methods	[Refer to Persson 2001 for details; author described Physiotherapy v surgery]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Provinciali 1996

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Methods	Type of Trial: RCT Number Analysed/Randomised: 60/60 Intention-to-treat Analysis: conducted Power Analysis: NR
Participants	Acute, subacute WAD, NDH (cervico-encephalic syndrome = fatigue, dizziness, poor concentration, disturbed accommodation and impaired adaptation to light intensity)
Interventions	INDEX TREATMENT Group A: a. exercise (eye fixation): described by Shutty to alter dizziness b. mobilisation (passive): technique described by Mealy; massage: technique described by Mealy c. neck school described by Sweeney, relaxation training based on diaphragmatic breathing in supine position according to Shutty, active reduction of cervical and lumbar lordosis based on suggestion provided by Neck School according to Sweeney d. psychological support to reduce anxiety and limit emotional influence described by Radanov; 10 one-hour sessions/2 week COMPARISON TREATMENT Group B: TENS, pulsed electromagnetic field therapy, US, 10 one-hour sessions/2 week CO-INTERVENTION: NR Treatment Schedule: 2 weeks, 10 sessions Duration of Follow-up: 24 weeks
Outcomes	PAIN (neck pain intensity, VAS 0 to 10) Baseline Median: A 6.8, B 7.4 Reported Results: significant favouring group A SMD: -0.79(95%CI:-1.32 to -0.26) FUNCTION (Return to Work) Reported Results: significant favouring group A SMD: -1.05(95%CI:-1.59 to -0.26) GLOBAL PERCEIVED EFFECT (self assessment of outcome, ordinal scale -3 to +3) Reported Result: significant favouring group A, p < 0.001 SIDE EFFECTS: NR COST OF CARE: a. return to work Results: significant difference favours Group A, a treatment advantage of 16 days SMD: -1.05(95%CI:-1.59 to -0.51) b. sick days saved Results: 143 days saved favouring Group A
Notes	Source of Reference: Personal Files, COCH Publication Type: journal Peer Reviewed: yes Source of Funding: not specified Funding Agency has a Peer Review Mechanism: can't tell Country: Italy
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Randlov 1998

---

Methods	Type of Trial: RCT Number Analysed/Randomised:52/77 Intention-to-treat: NR Power Analysis: NR
Participants	Chronic MND
Interventions	INDEX TREATMENT Group A (Light Training) a. stationary bicycling and six stretches for neck and shoulder muscles, carried out once each session including 20 repetitions each for 15 minutes b. hot packs for 14 minutes COMPARISON TREATMENT: Group B (Intensive Training) a. bicycling and stretching of seven exercises of the neck and shoulder area for 10 minutes b. seven exercises for the neck and shoulder, 20 repetitions per round and five rounds were carried out in each session. c. Additionally, shoulder exercises were carried out with increasing resistance COINTERVENTION: pain relieving medication Treatment Schedule: 12 weeks Duration of Follow-up: none
Outcomes	PAIN (at moment and average, 0 to 20 points) Baseline Median: A 12 , B 12 Reported Results: not significant FUNCTION (ADL Scale, 0 to 40 points) Baseline Median: A 16, B 16 Reported Results: not significant PATIENT SATISFACTION (5 points) Reported Results: not significant RR 0.95 (95%CI: 0.52 to 1.74) SIDE EFFECTS: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

---

Revel 1994

---

Methods	Type of Trial: RCT Number Analysed/Randomised: 60/60 Intention-to-treat: NA Power analysis: NR
Participants	Chronic MND (osteoarthritic changes 27 of 30)
Interventions	INDEX TREATMENT Rehabilitation Group (RG) a. proprioceptive rehabilitation program: purpose to improve neck proprioception; 15 minute individualised exercise session; exercises were mainly concerned with eye-neck coordination including; i. slow passive motions of the head with gaze on a fixed target, ii. active movements of the head, automatic movements of the neck with passive trunk movements and head position relocation exercises, iii. exercises in a wide range of motion with free eye-head coupling [author description well detailed in Rehabilitation Procedure page 896]; 2 times per week; 30 to 40 minute sessions b. medication: analgesics, antiinflammatory COMPARISON TREATMENT Control Group (CG) a. medication: analgesic, antiinflammatory typical dosage was indomethacin 100mg; aspirin, 3000 mg; diclofenac, 150 mg; naproxen, 1000 mg COINTERVENTION: NR Treatment Schedule: 8 weeks Duration of Follow-up: 2 weeks
Outcomes	PAIN INTENSITY (VAS, 0 to 100) Baseline Mean: RG 50.5, CG 45.9 Reported Results: significant favouring RG SMD:-0.77(95% CI: -1.29 to -0.24) DAILY INTAKE OF NSAID / ANAGESICS Baseline Mean: RG 2.0/1.8, CG 2.3/1.6 Reported Results: not significant SELF ASSESSED FUNCTIONAL IMPROVEMENT (5 point scale) Reported Results: significant favouring RG SIDE EFFECTS: NR COST OF CARE: NR
Notes	Source of Reference: Publication Type: journal Peer Reviewed: not specified Source of Funding: not specified Funding Agency has a Peer Review Mechanism: can't tell Country: Europe [France]
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Rosenfeld 2000

---

Methods	Type of Trial: RCT Number Analysed/Randomised: 88/97 Intention-to-treat Analysis: NR Power Analysis: NR
Participants	Acute MND (WAD)
Interventions	INDEX TREATMENT Early Exercise (EEx): Active treatment within 96 hours after MVA; active range of motion (small range an amplitude to end of comfort rotation 10 times each waking hour), education (warning signs of recurrence or exacerbation), if symptoms persisted after 20 days individual was assessed and given an individualised program with additional exercises which could include cervical retraction, extension, flexion, rotation, lateral flexion or a combination COMPARISON TREATMENT Early Education (EED): Standard treatment within 96 hours after MVA; education (injury mechanism, rest, advice, posture correction), active range of motion 2 to 3 times/day a few weeks after injury including shoulder elevation, shoulder blade retraction, torso rotation, lateral head flexion, and rotation with flexion Delayed Exercise (DEx): Active treatment same as EEx Group with a delay of 14 days after trauma Delayed Education (DED): Standard Treatment same as EED with a delay of 14 days after trauma COINTERVENTION: reported to not differ statistically Treatment Schedule: 6 months (in active treatment groups 2 patients needed one instruction and treatment session, 13 needed 2 sessions, and 10 needed 3 sessions, 18 required more than 3 sessions). Symptoms persisted more than 20 days in 27/43 (63%) in active treatment groups Duration of Follow-up: none
Outcomes	PAIN (VAS, 0 to 100) Baseline Mean: EEx 43, EED 34, DEx 40, DED 42 Reported Results: the reduction in pain was greater for those receiving active treatment than in those receiving standard treatment (p>0.001) SMD (DEx v DED): 0.47(95% CI: 0.28 to 0.80) SMD (DEx v EED): 0.78(95%CI: 0.41 to 1.48) SMD (EEx v DED): 0.11(95% CI: 0.03 to 0.42) SMD (EEx v EED): 0.18(95% CI: 0.05 to 0.72) SIDE EFFECT: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Rosenfeld:DExvDED

---

Methods	[Refer to Rosenfeld 2000 for details; author described delayed exercise v delayed education]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Rosenfeld:DExvEED

---

Methods	[Refer to Rosenfeld 2000 for details; author described delayed exercise v early education]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Rosenfeld:EExvDED

---

Methods	[Refer to Rosenfeld 2000 for details; author described early exercise v delayed education]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Rosenfeld:EExvDEx

---

Methods	[Refer to Rosenfeld 2000 for details; author described early exercise v delayed exercise]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Rosenfeld:EExvEED

---

Methods	[Refer to Rosenfeld 2000 for details; author described early exercise v early education]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Soderlund 2000

---

Methods	Type of Trial: RCT Number Analysed/Randomised: 53/66 Intention-to-treat: NR Power Analysis: NR
Participants	Subacute, chronic WAD II and III (NDR)
Interventions	INDEX TREATMENT Additional exercise treatment (AT): a. additional exercises (isometric neck extension) b. instruction (same as RT group) c. exercise (same as RT group) COMPARISON TREATMENTS Regular Treatment (RT): a. exercise (active range of motion in neck rotation, and shoulder flexion) b. instruction (alternating rest with activities and posture) COINTERVENTION: NR Treatment Schedule: 6 weeks, 6 sessions, booster session at 6 weeks to encourage patients to continue the exercises, as well as at 3 and 6 months follow-up Duration of Follow-up: 6 months
Outcomes	PAIN (NRS, 0 to 10) Baseline Mean: AT 4.3, RT 3.7 Reported Results: significant positive effects for merged (AT& RT) group over time regarding pain intensity (p<0.001) SELF EFFICACY SCALE (0 to 200) Baseline Mean: AT 140.6, RT 152.0 Reported Results: significant positive effects for merged (AT & RT) group over time regarding self-efficacy (p<0.001) FUNCTION (Physical Disability Index, 0 to 70] Baseline Mean: AT 26.4, RT 21.5 Reported Results: significant positive effects for merged (AT & RT) group over time regarding pain disability index (p<0.001) SIDE EFFECTS: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Soderlund 2001

---

Methods	Type of Trial: RCT Number Analysed/Randomised: 32/33 Power Analysis: NR
Participants	chronic WAD (grade 1 to 3)
Interventions	INDEX TREATMENT Experimental Treatment [Exp]: a. learning basic skills - relaxation training and reeducation of a balanced cervicothoracic posture based on cervicothoracic muscular stabilisation techniques (Sweeney 1992) b. exercises aimed to increase neck ROM, coordination and endurance of neck muscles and reeducation of normal humeroscapular rhythm c. application of basic skills - basic skills integrated with the everyday activities derived from the functional behavioural analysis d. generalisation of basic skills - basic skills integrated with the everyday activities derived from the functional behavioural analysis e. maintenance of basic skills - repetition of key components of last session, written summary of the program f. Individualised for each patient; all skills training was done at home; treatment completed by the experimenter; Duration: maximum 12 appointments Median =11 COMPARISON TREATMENT: Comparison Treatment (Cntl): a. exercises: muscular stabilisation of neck; neck and shoulder mobility with stretching and coordination of head movements; maintain the body posture and arm muscle strength b. given oral or written information (or both) and were expected to practice exercises at home or at the physiotherapy departments' gym (or both) c. treatment could also include pain-relieving methods like relaxation, transcutaneous electric nerve stimulation, acupuncture and heat, given in the physiotherapy department COINTERVENTION: NR Treatment Schedule: treatments were individualised for each patient; Duration: maximised to appointments, median = 6 sessions Duration of Follow-up: 12 weeks
Outcomes	PAIN INTENSITY (NRS, 0 to 10) Baseline Mean: Exp 4.2, Cntl 3.6 Reported Results: no significant difference between groups SMD: 0.12(95%CI:-0.57 to 0.82) [power %] FUNCTION (Physical Disability Index, 0 to 70) Baseline Mean: Exp 31.1, Cntl 25.9 Reported Results: no significant difference between groups SMD: 0.36(95%CI:-0.34 to 1.06) [power %] SIDE EFFECTS: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

---

Taimela 2000

---

Methods	Type of Trial: RCT Number Analysed/Randomised: 61/76 Intension-to-treat Analysis: calculated Power Analysis: NR
Participants	Chronic MND (non-specific)
Interventions	INDEX TREATMENT Active (A) Treatment: a. exercises: cervicothoracic endurance exercises, eye fixation exercises, posture control exercise b. relaxation training, behavioral support c. education: lecture about neck pain and its consequences d. written information regarding home exercises COMPARISON TREATMENTS Home (H) Group: a. practical training for home exercises with daily diary b. education: lecture about neck pain and its consequences c. written information regarding home exercises Control (Cntl) Group: a. education: lecture about neck pain and its consequences b. written information regarding home exercises COINTERVENTION: Avoided in trial design [47% used anti-inflammatories, 8% reported use of drugs affecting central nervous system; no statistical discernable difference for use of medication between groups] Treatment Schedule: Active: 12 weeks, 24 sessions 2 sessions/ 1 week; Home: 2 sessions/2 week; Control: 1 session Duration of Follow-up: 12 months
Outcomes	PAIN INTENSITY (VAS, 0 to 100) Baseline Mean: H 38, A 49, Cntl 51 Reported Results: significantly lower in Active group at 3 months , no significant difference at 12 months SMD (H v Cntl): 0.24(95%CI:-0.36 to 0.84) [power %] SMD (A v Cntl):-0.51(95%CI:-1.13 to 0.12) [power %] SELF REPORTED WORKING ABILITY Reported Results: an improvement in favour of the Active treatment was seen at 3 months (p=0.004) and this difference remained at 12 month follow-up (p=0.01) SELF EXPERIENCED BENEFITS OF TREATMENT (-1 to 5) Reported Results: significantly different favouring Active treatment (p<0.001) SIDE EFFECTS: Active Group: 2/22 had dizziness and muscle pain Control Group: no side effects COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Taimela:Activevcontr

---

Methods	[Refer to Taimela 2000 for details; author described Active group v Control group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Taimela:Activevhome

---

Methods	[Refer to Taimela 2000 for details; author described Active group v Home group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Taimela:Homevcontrol

---

Methods	[Refer to Taimela 2000 for details; author described Home group v Control group]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Takala 1994

---

Methods	Type of Trial: RCT Number Analysed/Randomised: 44/45 Intention-to-treat: NR Power Analysis: NR
Participants	MND, disorder duration NR
Interventions	INDEX TREATMENT Group A: Group gymnastic, instructional type = group; setting = work; treatment characteristics = exercise planned to train whole body a) aerobic dynamic exercise [10 minutes walking or stepping], b) relaxation, c) stretching of muscles of the trunk and extremities and dynamic exercises [10 minutes]; schedule 10 minutes walking/stepping, 10 minutes stretch/dynamic exercises, 5 minutes walking/stepping, 10 minutes dynamic and coordination exercises, 10 minutes stretch and relaxation; duration of session = 45 minutes; frequency = 1 time per week COMPARISON TREATMENT: Group B: no treatment COINTERVENTION: NR Treatment Schedule: 10 weeks, 10 sessions of treatment in the spring session (crossover of placebo group occurred in autumn, the groups were reversed) Duration of Follow-up: none
Outcomes	PAIN (VAS, 0 to 100) Baseline Median: A 40, B 50 Reported Results: no significant difference PRESSURE PAIN SENSITIVITY [algometer (pressure pain threshold on upper trapezius, levator scapulae, rhomboid, infraspinatus) mean score of 8 measures] Baseline Mean: A 45.2, B 44.8 Reported Results: no significant difference SIDE EFFECTS: NR COST OF CARE: NR
Notes	Source of Reference: Publication Type: journal Peer Reviewed: yes Funding Agency has Peer Review Mechanism: can't tell Country: Scandinavia [Finland]
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Vasseljen 1995

---

Methods	Type of Trial: RCT [for Groups 1 and 2; Group 3 not randomised] Number Analysed/Randomised: 24/24 Intention-to-treat Analysis: not applicable Power Analysis: NR
Participants	Chronic MND
Interventions	INDEX TREATMENT Group 1 (G1): a. mobilisation (passive): provided when indicated; massage: 5 to 10 minutes b. exercise: strength on weight training apparatus, 5-10 minutes & stretching 3 to 4 minutes, total 20-30 minutes c. education: ergonomic principles d. home exercise on postural control, strength and flexibility training of the shoulder/neck region; e. two one hour sessions/week for 10 sessions COMPARISON TREATMENT Group 2 (G2): a. exercise: adopted from Dyrssen, 1.1kg dumbbells in both hands, 4 arm exercises each performed 10 times, cycle repeated 3 times; load adjusted for 10 repetitions, abdominal and back exercises; breathing techniques; 5 minutes stretching exercise to shoulder/neck b. education: same as Group 1 c. three 30 minute session/week for 6 weeks COINTERVENTION: NR Treatment Schedule: 5 to 6 weeks, 10 to 18 sessions Duration of Follow-up: 24 weeks; mailed questionnaire
Outcomes	PAIN (VAS, 0 to 10) Baseline Mean: G14.2, G2 4.2 Reported Result: not significant SMD: 0.09 (95%CI:-0.71, 0.89) [power 9%] RR: 0.29 (95% CI: 0.07, 1.10) SIDE EFFECTS: NR COST OF CARE: NR
Notes	Source of Reference: Personal Files, MANTIS Publication Type: journal Peer Reviewed: yes Source of Funding: The Norwegian Fund for Postgraduate Education in Physiotherapy and The Norwegian Research Council Funding Agency has Peer Review Mechanism: can't tell Country: Norway
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

---

Waling 2002

---

Methods	Type of Trial: CCT Number Analysed/Randomised: 103/103 Intention-to-treat Analysis: calculated Power Analysis: calculated [power to detect 20 mm reduction on the VAS scale for pain in general was 90%, power to detect a reduction of 10 mm was lower than 50%]
Participants	chronic MND [work related trapezius myalgia]
Interventions	INDEX TREATMENT Strength Training Group (S): a. with machines giving resistance in the concentric part of the movement (air machines) b. four different exercises for the neck and shoulder muscles (latissimus pull down, triceps press, shoulder flexion and scapular retraction) c. load individualised to 10 to 12 maximal voluntary contractions in 3 sets, increased as strength was gained d. during short pauses while waiting for a special machine exercises for abdominal and back muscles were done Endurance Training Group (E): a. arm cycling on an arm ergometer for 3 minutes alternated with 3 minutes of arm exercises using rubber expanders b. resistance on arm cycling set so a hear rate around 110 to 120 beats per minute was achieved c. expanders were loaded individually to allow 30 concentric contractions of each exercise d. for variation exercises for abdominal and back muscles were included Co-ordination training Group (Co-ord): Body awareness training was the concept for co-ordination training a. exercises aimed in getting a better understanding and awareness of the body regarding muscular tension and relaxation in movements b. most of program consisted of exercises from the Body Awareness Therapy introduced by Roxendal (1985) c. attention is focused on balance and postural stability d. emphasis on mental awareness on the performance and a minimum use of force in movements to achieve a better muscular co-ordination and overall function COMPARISON TREATMENT Control group (C): a. studied and discussed stress management b. duration 2 hours at a time, frequency 1 time/week for 10 weeks c. led by an occupational nurse d. no exercises were performed in this group e. Frequency: 3 times/week COINTERVENTION: analgesics Treatment Schedule: 10 weeks, 30 sessions Duration of Follow-up: 3 years
Outcomes	PAIN (in general; VAS, 0 to 100) Baseline Mean: S 39, E 40, Co-ord 41, C 43 Reported Results: pain same in all 4 groups SMD(E v C): 0.48(-0.03, 0.89) [power %] SMD(S v C): 0.58(0.07, 1.10) SMD(Co-ord v C): 0.45(-0.07, 0.97) [power %] PAIN (at worst; VAS, 0 to 100) Baseline Mean: S 74, E 70, Co-ord 77, C 75 Reported Results: pain same in all 4 groups PAIN (at present; VAS, 0 to 100) Baseline Mean: S 26, E 28, Co-ord 33, C 37 Reported Results: pain same in all 4 groups EXTENT OF BODY AREA MARKED AS PAINFUL (PPD%) Baseline Mean: S 5.4, E 4.6, Co-ord 4.8, C 6.9 Reported Results: pain same in all 4 groups FREQUENT NECK-SHOULDER PAIN (%) Baseline Mean: S 90, E 96, Co-ord 96, C 91 Reported Results: pain same in all 4 groups WORRIED ABOUT NECK-SHOULDER PAIN (%) Baseline mean [SD]: S 76 [75], E 57 [59], Co-ord 56 [58], C 35 [44] SIDE EFFECTS: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

---

Waling 2002:Co v C

---

Methods
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

---

Waling 2002:EvC

---

Methods	[Refer to Waling 2002 for details; author described endurance v control]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

---

Waling 2002:SvC

---

Methods	[Refer to Waling 2002 for details; author described strength v control]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

---

Ylinen 2003

---

Methods	Type of Trial: RCT Number Analysed/Randomized: 179/180 Intention-to-treat Analysis: calculated Power Analysis: calculated, expecting endurance and control to improve 15% in pain measured by VAS, strength would have to improve 50% to be better than the other 2 groups. A beta of 0.05 with 95% power and assuming a uniform drop-out of 5%, 60 patients in each group would be sufficient
Participants	Chronic MND
Interventions	INDEX TREATMENT Endurance (E) Group: a. 12 day institutional rehabilitation program b. exercises [neck flexor muscles by lifting the head up from the supine position in 3 series of 20 repetitions; 5 sessions per week; 45 minutes for 12 days b. dynamic exercises for the shoulders and upper extremities by doing dumbbell shrugs, presses, curls, bent-over rows, flyes, and pullovers performing 3 sets of 20 repetitions for each exercise with a pair of dumbbells each weighing 2 kg. c. exercises for the trunk and leg muscles against their individual body weights by doing a single series of squats, sit-ups, and back extension exercises d. each training session concluded with stretching exercises for the neck, shoulder, and upper limb muscles for 20 minutes e. also advised to perform aerobic exercise 3 times/week for 30 minutes f. received written information about the exercises to be practiced at home 3 times/week g. multimodal rehabilitation program, including aspects commonly associated with traditional treatment: relaxation training, aerobic training, behavioral support to reduce fear of pain and improve exercise motivation, and lectures and practical exercises in ergonomics h. during the rehabilitation course, each patient received 4 sessions of physical therapy, which consisted mainly of massage and mobilisation to alleviate neck pain and to enable those with severe neck pain to perform active physical exercises Strength (S) Group: a. 12 day institutional rehabilitation program b. exercise used elastic rubber band to train the neck flexor muscles in each session performed in sitting, a single series of 15 repetitions directly forward, obliquely toward right and left, and directly backward c. aim to maintain the level of resistance at 80% of the participant's maximum isometric strength re coded at the baseline and at follow-up visits d. load was checked with a handheld isometric strength testing device during the training sessions e. dynamic exercises for the shoulders and upper extremities by doing dumbbell shrugs, presses, curls, bent-over rows, flyes, and pullovers with individually adjusted single dumbbell, 1 set for each exercise with the highest load possible to perform 15 repetitions f. dynamic exercises for the shoulders and upper extremities by doing dumbbell shrugs, presses, curls, bent-over rows, flyes, and pullovers performing 3 sets of 20 repetitions for each exercise with a pair of dumbbells each weighing 2 kg. g. exercises for the trunk and leg muscles against their individual body weights by doing a single series of squats, sit-ups, and back extension exercises h. each training session concluded with stretching exercises for the neck, shoulder, and upper limb muscles for 20 minutes i. also advised to perform aerobic exercise 3 times/week for 30 minutes j. received written information about the exercises to be practiced at home 3 times/week k. multimodal rehabilitation program, including aspects commonly associated with traditional treatment: relaxation training, aerobic training, behavioral support to reduce fear of pain and improve exercise motivation, and lectures and practical exercises in ergonomics l. during the rehabilitation course, each patient received 4 sessions of physical therapy, which consisted mainly of massage and mobilisation to alleviate neck pain and to enable those with severe neck pain to perform active physical exercises COMPARISON TREATMENT 3. Control (C) Group: a. 3 days at rehabilitation centre for tests and recreational activities b. advised to perform aerobic exercise 3 times/week for 30 minutes c. written information about stretching exercises to practice at home 3 times/week for 20 minutes per day COINTERVENTION: analgesics; 80% of Control group, 49% of Endurance group, and 57% of the Strength group used additional therapists as follows: massage and stretching about 65%; hot and ice packs, electrotherapy, acupuncture, traction, and zone therapy from between 5 to7% Treatment Schedule: 12 months Duration of Follow-up: 12 months
Outcomes	NECK PAIN (VAS, 0 to 100) Baseline Median: E 57, S 58, C 58 Reported Results: pain was at the same level in the 3 groups RR (E v C): 0.52(95%CI: 0.37, 0.73) RR (S v C): 0.34(95%CI: 0.22, 0.53) MODIFIED NECK & SHOULDER PAIN DISABILITY INDEX (0 to 100) Baseline Median: E 36, S 35, C 38 Reported Results: pain and disability index was at the same level in the 3 groups VERNON NECK DISABILITY INDEX (NDI, 0 to 50) Baseline Median: E 22, S 21, C 22 Reported Results: disability index was a the same level in the 3 groups USE OF ANALGESICS Baseline Number: None E 13, S 10, C 11 Occasionally S 37, S 41, C 41 Daily E 9, S 9, C 8 SIDE EFFECTS: NR COST OF CARE: NR
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

---

Ylinen 2003: EvC

---

Methods	[Refer to Ylinen 2003 for details; author described endurance v control]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

---

Ylinen 2003: SvC

---

Methods	[Refer to Ylinen 2003 for details; author described strength v control]
Participants
Interventions
Outcomes
Notes
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

---

 1.0 Definitions of terms
1.1 Acute = <30 days [1 month, 4 weeks]
Subacute = 30 days [1 month, 4 weeks] to 90 days [3 months, 12 weeks]
Chronic = > 90 days [3 months, 12 weeks]
1.2 short term follow-up <6 months
longer term follow-up > or = 6 months
2.0 Short forms commonly used in text:
2.1 Clinical terms
MT = manual therapy
PMM = physical medicine methods
ED = education
DT = drug therapy
TENS = transcutaneous electrical nerve stimulation
PEMT = pulsed electromagnetic therapy
US = ultrasound
AROM = active range of motion
PROM = passive range of motion
2.2 Outcome measures
WHYMPI = West Haven-Yale Multidimensional Pain Inventory [sub scale pain severity]
SF-36 = short-form 36 [short-form with 36 questions yielding an 8-scale health profile]
NDI = neck disability index
VAS = visual analogue scale
NRS-101 = numeric rating scale 101 [0 to 100 point scale]
PPT = pain pressure threshold [measured by algometre]
2.3 Other
v = versus
w = weeks
m = months
y = years

 

Characteristics of excluded studies [ordered by study ID]

---

Study	Reason for exclusion
Bissett 1985	1. Intervention: EMB biofeedback mediated muscle relaxation not active exercise
Brewerton 1966	1. Population: Cervical root compression
Carlsson 1990	1. Population: chronic tension headache (either occipital, temporal and/or frontal)
Foley-Nolan 1992	1. Intervention: not exercise
Friedrich 1996	1. Intervention: Education comparison, exercise is the same in all 3 groups
Hanten 1997	1. Outcome Measure: did not use any of the identified outcome measures (only Pain pressure threshold as a proxy for pain)
Herring 1992	1. Design: not RCT/CCT 2. Outcome Measure: did not use at least one outcome measure
Highland 1992	1. Design = Not RCT or CCT
Hurwitz 2002	1. Intervention: No active exercise
Kamwendo 1991	1. Intervention: Exercises not specified
Linton 2001a	1. Intervention: Unable to seperate exercise group within treatment as usual comparison group
Nordemar 1981	1. Intervention: passive exercise
Rundcrantz 1991	1. Intervention: This was a quasi-RCT, treatment was individualized and unable to specify exercise.
Skargren 1997	1. Intervention: Unable to seperate data for exercise group (unclear if McKenzie treatment mobilisation or exercise)

---

 

Characteristics of ongoing studies [ordered by study ID]

Guerriero 1997

---

Trial name or title	Comparative effects of manipulation and physical therapy on motion in the cervical spine
Methods
Participants	chronic neck pain
Interventions	cervical spine manipulation v sham treatment v cervical spine manipulation, ischemic compression of myofascial trigger points , PNF, interferential therapy
Outcomes	cervical ROM
Starting date
Contact information	Palmer Institute of Graduate Studies and Research, Davenport, Iowa.
Notes

---

Gurumoorthy 2000

---

Trial name or title	A prospective study of acute whiplash injury and its clinical management
Methods
Participants	acute neck injury (whiplash associated disorder)
Interventions	early immobilisation v early active mobilisation
Outcomes	pain, cervical ROM, neck muscle strength, time to return to normal duties
Starting date
Contact information	Curtin University of Technology, Perth, Australia
Notes

---

Reginiussen 2000

---

Trial name or title	Efficiency of manual therapy on patients with cervicogenic headache. A randomized single blinded controlled trial
Methods
Participants	cervicogenic headache
Interventions	manual therapy (soft tissue methods, stretching/massage, mobilising and thrust techniques) v standardised physiotherapy treatment consisting of SWD, exercises and stretching
Outcomes	headache, neck pain, function, use of drugs, patient satisfaction
Starting date
Contact information	Institut of Manual Therapy, Alta, Norway
Notes

---

Stokke 1995

---

Trial name or title	A randomised comparison of chiropractic and physiotherapy treatment for neck pain of functional (mechanical) origins. A controlled clinical trial
Methods
Participants	neck pain, neck and head pain, neck and shoulder pain
Interventions	chiropractic spinal manipulation v physiotherapy v medication
Outcomes	NDI, pain intensity VAS
Starting date
Contact information	Institute of Community Medicine, School of Medicine, Uniersity of Tramso, 9037 Tromso, Norway.
Notes

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Comparison 1. ACTIVE RANGE OF MOTION [AROM] / STRETCHING

---

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

---

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

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

---

1.1 MND/WAD: Acute Short term [4 w of treatment]

1

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

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

4

Risk Ratio (M-H, Random, 95% CI)

Totals not selected

---

2.1 MND/WAD: Acute Short term [24 w of treatment]

4

Risk Ratio (M-H, Random, 95% CI)

Not estimable

---

 

Comparison 2. STRENGTHENING

---

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

---

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

5

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

---

1.1 MND: Chronic Short term [10w of treatment + 2 w follow-up]

3

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

1.2 MND: Chronic Long term [10 w of treatment + 144 w follow-up]

3

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

1.3 NDH: Chronic Short term [7 w of treatment]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

1.4 NDH: Chronic Long Term [7w of treatment 45 w follow-up]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

 2 Exercise [strength + endurance] v Control: Function

2

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

---

2.1 NDH: Chronic Short term [7 w of treatment]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

2.2 NDH: Chronic Long term [7 w of treatment + 45 w follow-up]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

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

2

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

---

3.1 NDH: Chronic Short term [7 w of treatment]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

3.2 NDH: Chronic Long term [7 w of treatment + 45 w follow-up]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

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

2

Risk Ratio (M-H, Random, 95% CI)

Totals not selected

---

4.1 MND: Chronic Short term [3 w treatment + 3 w follow-up]

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

---

4.2 MND/NDH/NDR Subacute Short term [5 w of treatment]

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

---

4.3 MND/NDH/NDR Subacute Long term [5w of treatment + 18 w follow-up]

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

---

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

2

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

---

5.1 NDH Chronic Short term [7 w of treatment]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

5.2 NDH: Chronic Long term [7 w of treatment + 45 w follow-up]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

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

2

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

---

6.1 NDH: Chronic Short term [7 w of treatment]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

6.2 NDH: Chronic Long term [7 w of treatment + 45 w follow-up]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

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

2

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

---

7.1 NDH: Chronic Short term [7 w of treatment]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

7.2 NDH: Chronic Long term [7 w of treatment + 45 w follow-up]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

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

2

Risk Ratio (M-H, Random, 95% CI)

Totals not selected

---

8.1 MND: Chronic Short term [3 w treatment + 3 w follow-up]

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

---

8.2 MND/NDH/NDR Subacute Short term [5 w of treatment]

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

---

8.3 MND/NDH/NDR Subacute Long term [5 w of treatment + 18 w follow-up]

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

---

 

Comparison 3. STRETCHING AND STRENGTHENING

---

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

---

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

5

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

---

1.1 MND: Chronic Short term [4-8 w of treatment]

3

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

1.2 NDH: Subacute Short term [after median 13 w [8 w for control] of treatment]

1

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

1.3 MND: Chronic Long term [16 w treatment + 52 w follow-up]

1

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

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

2

Risk Ratio (M-H, Random, 95% CI)

Totals not selected

---

2.1 MND: Chronic Long term [52 w treatment]

2

Risk Ratio (M-H, Random, 95% CI)

Not estimable

---

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

2

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

---

3.1 MND: Chronic Short term [8 w of treatment]

1

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

3.2 MND: Chronic Long term [16 w of treatment + 52 w follow-up]

1

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

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

3

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

---

4.1 MND: Chronic Short term [11 w of treatment]

1

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

4.2 MND: Chronic Long term [11 w of treatment + 52 w follow-up]

1

Std. 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]

2

Std. 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]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

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

3

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

---

5.1 MND: Chronic Short term [11 w of treatment]

1

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

5.2 MND: Chronic Long term [11 w of treatment + 52 w follow-up]

1

Std. 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]

2

Std. 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]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

 6 Exercise v Comparison [manual therapy or ED + medication]: Global Perceived Effect

3

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

---

6.1 MND: Chronic Short term [11 w of treatment]

1

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

6.2 MND: Chronic Long term [11 w of treatment + 52 w follow-up]

1

Std. 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]

2

Std. 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]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

 

Comparison 4. DIZZINESS/VERTIGO EXERCISES

---

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

---

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

2

Std. 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]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

1.2 MND: Chronic Short term [8 w of treatment + 2 w follow-up]

1

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

1.3 MND: Chronic Long term [12 w of treatment + 36 w follow-up]

1

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

 2 Exercise [+ analgesics] v Control [analgesics]: Function

1

Risk Ratio (M-H, Random, 95% CI)

Totals not selected

---

2.1 MND: Chronic Short term [8 w of treatment + 2 w follow-up]

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

---

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

1

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

---

3.1 MND: Chronic Short term [12 w of treatment]

1

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

3.2 MND: Chronic Long term [12 w of treatment + 36 w follow-up]

1

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

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

1

Std. 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]

1

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

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

1

Std. 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]

1

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

 

Comparison 5. HOME EXERCISES

---

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

---

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

4

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

---

1.1 MND: Acute Short term [6-8 w of treatment]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

1.2 MND: Chronic Short term [6-8 w of treatment]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

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

1

Risk 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]

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

---

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

2

Std. Mean Difference (IV, Random, 95% CI)

Totals not selected

---

3.1 MND: Chronic Short term [6-8 w of treatment]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

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

1

Risk Ratio (M-H, Random, 95% CI)

Totals not selected

---

4.1 MND/WAD: Acute Short Term [6-8 w of treatment]

1

Risk Ratio (M-H, Random, 95% CI)

Not estimable

---

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

2

Std. 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]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

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

2

Std. 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]

2

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

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

1

Std. 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

1

Std. Mean Difference (IV, Random, 95% CI)

Not estimable

---

 

Table 1. NNT & Treatment Advantage: Pain Relief with Multimodal Care

---

Author/Comparison	NNT	Advantage (%)
Jull 2002:MT/ExT v Cntl	5 [clinically important pain reduction]	40.8%
Rosenfeld 2000	5 [clinically important pain reduction]	38%
Skargren 1997; Skargren 1998	4 [clinically important pain reduction]	26.1%

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Table 2. Methodological Quality Criteria

---

Criteria

---

The Jadad et al. 1996 Criteria and scores
1a. Was the study described as randomised? (Score 1 if yes)
1b and 1c. Was the method of randomisation described and appropriate to conceal allocation (Score 1 if appropriate and -1 if not appropriate);
2a. Was the study described as double-blinded? (Score 1 if yes);
2b and 2c. Was the method of double blinding described and appropriate to maintain double blinding (Score 1 if appropriate and -1 if not appropriate);
3. Was there a description of how withdrawals and dropouts were handled? (Score 1 if yes)

---

The van Tulder et al. 2003 Criteria (Score: 1 if yes, 0 if no or don't know)
A. Was the method of randomisation adequate?  A random (unpredictable) assignment sequence. Examples of adequate methods are computer-generated random numbers table and use of sealed opaque envelopes. Methods of allocation using date of birth, date of admission, hospital numbers, or alternation should not be regarded as appropriate.
B. Was the treatment allocation concealed?  Assignment generated by an independent person not responsible for determining the eligibility of the patients. This person has no information about the persons included in the trial and has no influence on the assignment sequence or on the decision about eligibility of the patient.
C. Were the groups similar at baseline regarding the most important prognostic indicators? In order to receive a "yes," groups have to be similar at baseline regarding demographic factors, duration and severity of complaints, percentage of patients with neurological symptoms, and value of main outcome measure(s).
D. Was the patient blinded to the intervention? The review author determines if enough information about the blinding is given in order to score a "yes."
E. Was the care provider blinded to the intervention? The review author determines if enough information about the blinding is given in order to score a "yes."
F. Was the outcome assessor blinded to the intervention? The review author determines if enough information about the blinding is given in order to score a "yes."
G. Were co-interventions avoided or similar? Co-interventions should either be avoided in the trial design or be similar between the index and control groups.
H. Was the compliance acceptable in all groups? The review author determines if the compliance to the interventions is acceptable, based on the reported intensity, duration, number and frequency of sessions for both the index intervention and control intervention(s).
I. Was the withdrawal/drop-out rate described and acceptable? The number of participants who were included in the study but did not complete the observation period or were not included in the analysis must be described and reasons given. If the percentage of withdrawals and drop-outs does not exceed 20% for immediate and short-term follow-ups, 30% for intermediate and long-term follow-ups and does not lead to substantial bias a "yes" is scored.
J. Was the timing of the outcome assessment in all groups similar? Timing of outcome assessment should be identical for all intervention groups and for all important outcome assessments.
K. Did the analysis include an intention-to-treat analysis? All randomized patients are reported/analyzed in the group to which they were allocated by randomization for the most important moments of effect measurement (minus missing values), irrespective of noncompliance and co-interventions.

---

The Cochrane Grading System for Quality of Allocation Concealment
A. Adequate concealment of allocation
B. Uncertainty about whether the allocation was adequately concealed
C. The allocation was definitely not adequately concealed
D. The score was not assigned

---

 

Table 3. Methodological Quality: Jadad criteria

---

Author (Year)	1a-Randomized	1b-Appropriate	1c-Inadequate	2a-Double Blind	2b-Appropriate	2c-Inadequate	3-Withdrawals	Total Score
Allison 2002	1	0	0	0	0	0	0	1/5
Brodin 1984	1	0	0	0	0	0	1	2/5
Brodin 1985	1	1	0	0	0	0	1	3/5
Bronfort 2001	1	1	0	0	0	0	1	3/5
Fitz-Ritson 1995	1	0	0	1	0	0	1	3/5
Gam 1998	1	1	0	1	1	0	1	5/5
Geibel 1997	1	0	0	0	0	0	1	2/5
Goldie 1970	1	0	1	0	0	0	1	1/5
Hagberg 2000	1	1	0	0	0	0	1	3/5
Hanten 2000	1	0	0	0	0	0	1	2/5
Hoving 2002	1	1	0	0	0	0	1	3/5
Hoving 2001a	1	1	0	0	0	0	1	3/5
Hoving 2001b	1	1	0	0	0	0	1	3/5
Jordan 1996	1	1	0	0	0	0	1	3/5
Jordan 1998	1	1	0	0	0	0	1	3/5
Jull 2002	1	1	0	0	0	0	1	3/5
Karlberg 1996	1	0	0	0	0	0	1	2/5
Koes 1991	1	1	0	0	0	0	0	2/5
Koes 1992a	1	1	0	1	0	0	1	4/5
Koes 1992b	1	1	0	0	0	0	1	3/5
Koes 1992c	1	1	0	1	0	0	1	4/5
Koes 1992d	1	1	0	0	0	0	1	3/5
Koes 1992e	1	1	0	0	0	0	1	3/5
Koes 1993	1	1	0	0	0	0	1	3/5
Kogstad 2002	1	0	0	0	0	0	1	2/5
Levoska 1993	1	0	0	0	0	0	1	2/5
Lundblad 1999	1	0	0	0	0	0	1	2/5
McKinney 1989a	1	1	0	0	0	0	1	3/5
McKinney 1998b	1	1	0	0	0	0	0	2/5
Mealy 1986	1	1	0	1	0	0	1	4/5
Pennie 1990	1	0	1	0	0	0	1	1/5
Persson 2001	1	1	0	0	0	0	1	3/5
Provinciali 1996	1	0	0	0	0	0	1	2/5
Randlov 1998	1	1	0	0	0	0	1	3/5
Revel 1994	1	0	0	0	0	0	1	2/5
Rosenfeld 2000	1	0	0	0	0	0	1	2/5
Soderlund 2000	1	0	0	0	0	0	1	2/5
Soderlund 2001
Taimela 2000	1	0	0	0	0	0	1	2/5
Takala 1994	1	0	0	0	0	0	1	2/5
Vasseljen 1995	1	0	0	0	0	0	1	2/5
Waling 2002	1	0	0	0	0	0	1	2/5
Ylinen 2003	1	0	0	0	0	0	1	2/5

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Table 4. Methodological Score: van Tulder criteria

---

Author	A	B	C	D	E	F	G	H	I
Allison 2002	0	1	0	0	1	1	0	0	0
Brodin 1984	0	1	0	0	0	0	0	0	0
Brodin 1985	1	1	0	0	0	0	0	1	0
Bronfort 2001	1	1	1	0	1	1	0	1	0
Fitz-Ritson 1995	1	1	0	1	0	0	0	0	0
Gam 1998	1	1	1	1	1	0	0	0	1
Giebel 1997	0	1	1	0	1	0	0	1	0
Goldie 1970	1	0	1	1	0	0	1	0	1
Hagberg 2000	1	1	0	0	0	0	0	1	0
Hanten 2000	0	1	1	0	1	1	1	0	0
Hoving 2002	1	1	1	0	1	1	1	1	0
Hoving 2001a Hoving 2001b	1	1	0	0	1	1	0	0	0
Jordan 1996	1	1	0	0	0	0	0	0	0
Jordan 1998	1	1	1	0	0	0	1	1	0
Jull 2002	1	1	0	0	1	1	1	1	0
Karlberg 1996	0	1	0	0	0	1	0	1	0
Koes 1991	1	1	0	0	1	1	0	0	0
Koes 1992a	1	1	0	0	1	1	0	1	0
Koes 1992b	1	1	0	0	1	1	0	1	0
Koes 1992c	1	1	0	0	1	1	0	1	0
Koes 1992d	1	0	0	0	1	1	0	1	0
Koes 1992e	1	1	0	0	1	1	0	1	0
Koes 1993	1	0	0	0	1	1	0	1	0
Kogstad 1978	0	1	0	0	0	1	1	1	0
Levoska 1993	1	1	1	1	0	0	0	0	0
Lundblad 1999	0	0	1	0	0	0	1	1	0
McKinney 1989a	1	0	0	0	1	0	0	1	0
McKinney 1989b	1	0	0	0	1	0	0	1	0
Mealy 1986	1	1	0	0	1	0	0	1	0
Pennie 1990	1	0	0	1	0	0	0	0	0
Persson 2001	1	1	0	0	0	1	0	1	0
Provinciali 1996	0	1	0	0	1	1	0	1	0
Randlov 2000	1	0	1	0	1	0	0	1	1
Revel 1994	1	1	1	1	0	0	0	0	0
Rosenfeld 2000	0	1	0	0	0	1	1	1	0
Soderlund 2000 Soderlund 2001	0	1	0	0	0	1	1	1	0
Taimela 2000	0	1	0	0	1	1	0	0	0
Takala 1994	1	1	1	1	0	0	0	0	0
Vasseljen 1995	0	1	0	0	0	1	1	1	0
Waling 2002	0	1	0	0	0	0	1	1	0
Ylinen 2003	0	1	1	0	0	1	1	1	0

---

 

Table 5. Quick Summary: Exercise vs Control

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Exercise Method	Acute WAD	Chronic MND	MND (NR)	NDH (NR)	Chronic NDH	Sub MND/NDR/NDH*	Sub/chr MND/NDR	Sub/chr MND/NDH
Active ROM	+ pain ST
Strengthening		- pain ST/LT - function ST/LT + GPE ST/LT			+ pain ST/LT + function ST/LT + GPE ST/LT	- GPE ST
Stretching & Strengthening (multimodal)		- pain ST + pain LT - function ST	+ function ST	+ pain ST				+ pain (multimodal) ST/LT + function (multimodal) ST/LT + GPE (multimodal) ST/LT
Eye Fixation Exercise		+ pain ST + function ST + GPE ST/LT
Home Exercise	+ pain ST - GPE ST	- pain ST - function ST					- pain ST
KEY:	- = negative results + = positive results Sub = subacute chr = chronic * = with brachialgia	ST = short term results LT = long term results GPE = global perceived effect NR = duration not reported

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