Evidence of Physiotherapy Interventions for Patients with Chronic Neck Pain: A Systematic Review of Randomised Controlled Trials

Table 1

Exercise therapy—patients with chronic nonspecific neck pain.

Author	Participants	Interventions	Main outcome measures	Study results on effect* of intervention on pain
Cunha et al. [31]	Women, aged 35–60, with diagnosed primary mechanical myogenous or arthrogenous, neck pain lasting > 12 wks (𝑁=33)	(1) GPR group (𝑛=15), manual therapy for stretching fasciae for 30 min, muscle stretching in the form of global posture reeducation (GPR) for 30 min; (2) Conventional stretching group (𝑛=16), manual therapy for stretching fasciae for 30 min, muscle stretching through conventional stretching exercises for 30 min; All: two weekly physiotherapy sessions during a 6 wk period	VAS, ROM, SF-36	There were no statistically significant differences in effect between groups after treatment and at 6 wk followup
Dellve et al. [32]	Women, aged 35–60, with work disability (at least 50%) and pain in the neck (diagnosed cervicobrachial pain syndrome) for at least 1 year (𝑁=60)	(1) Myofeedback training (𝑛=20), min 8 hours/wk, registered the muscle activity (EMG) of upper trapezius muscles and gave alarm if the preset level of muscular rest was not reached. Personal visit once/wk from a physiotherapist browsing EMG profiles with reference to diary entries; (2) Intensive muscular strength training (𝑛=20), a structured 5–10 min program to be performed twice a day for 6 days/wk. A physiotherapist coached by two personal visits and additional phone calls twice/wk.; (3) Control group (𝑛=20); All: kept a diary 6 days/wk recording activities, discomfort, pain, and sleeping disturbances. All interventions lasted 1 mth	Work ability index (WAI); Single item on work ability, working degree, changed work ability; Pain, NRS; Copenhagen Psychosocial Questionnaire; Cutlery wiping performance test, dexterity, max. grip strength	There were no statistically significant differences in effect between groups after 1 mth and at followup after 3 mths
Falla et al. [33]	Patients with chronic nonsevere neck pain (>3 mths), score < 16 (out of possible 50) in NDI (𝑁=58)	(1) Endurance-strength training of the cervical spine flexor muscles (𝑛=29); (2) Referent exercise intervention, low-load craniocervical exercise (𝑛=29); All: instruction and supervision once a wk for 6 wk, supplied with an exercise diary	EMG measures of maximum voluntary contraction force of sternocleidomastoid and anterior scalene muscle, NRS**, NDI**	There were no statistically significant differences between groups for change in pain (NRS) or disability (NDI) measured in the week immediately after intervention (week 7)
Griffiths et al. [34]	Chronic neck pain (diagnosed spondylosis, whiplash, nonspecific neck pain, and discogenic pain), age 18 and over (𝑁=74)	(1) Specific neck stabilisation exercises (𝑛=37) in addition to the same programme as group 2; (2) General neck exercise programme (𝑛=37), posture correction technique, and active range of movement exercise; All: max. four 30 min treatment sessions within the first 6 wks, advice to perform exercises 5–10 times daily, written sheets, after 6 wks the therapist could discharge the patient or continue	NPDS, NPQ, VAS**	There were no significant between-group differences in the NPDS at either 6 wks or 6 mths
Gustavsson et al. [35]	Patients with musculoskeletal tension-type neck pain of persistent duration (>3 mths), age 18–65 (𝑁=156)	(1) Multicomponent pain and stress self-management group intervention (PASS) (𝑛=77), relaxation training, body awareness exercises, lectures and group discussions, seven 1.5 h sessions over a 7 wk period, and a booster session after 20 wks; (2) Control group receiving individually administered physiotherapy (IAPT) (𝑛=79)	Questionnaire comprising the self-efficacy scale, NDI, coping strategies questionnaire, hospital and depression scale, fear-avoidance beliefs questionnaire, and questions regarding neck pain, analgesics, and utilisation of health care	There was a statistically significant effect on ability to control pain (𝑃<0.001), and on neck related disability (NDI) (𝑃<0.001) in favour of PASS at the 20 wks followup
Häkkinen et al. [36]	Nonspecific neck pain of more than 6 mths, age 25–53, pain > 29 mm on VAS (𝑁=101)	(1) Strength training and stretching (𝑛=49). Sessions once a wk for 6 wks and thereafter one session every second mth for 12 mths; (2) Stretching group (𝑛=52) in a single group session instructions; All: encouraged to perform home training regimen three times a wk and to keep weekly exercise diary	VAS, neck and shoulder disability index, NDI, ROM, isometric strength	There were no statistically significant differences in effect between groups after two and 12 months measured with VAS and NDI
Jordan et al. [37]	Patients with chronic neck pain (>3 mths), nonradicular extremity pain was permitted, age 20–60 (𝑁=119)	(1) Intensive training of the neck and shoulder musculature (𝑛=40); (2) Individual physiotherapy treatment (𝑛=39); (3) High-velocity, low-amplitude spinal manipulation performed by a chiropractor (𝑛=40); All: above training/treatment sessions twice a wk for 6 wks, besides a single neck school group session	Self-reported disability and pain on 11-point box scales, medication use, patients perceived effect, physicians global assessment	There were no statistically significant differences in effect between groups at 4 and 12 mths followup
Jull et al. [38]	Females with chronic neck pain of idiopathic or traumatic origin and abnormal measures of joint position sense (𝑁=64)	(1) Proprioceptive exercise intervention (𝑛=28); (2) Craniocervical spine flexion exercise intervention (𝑛=30); All: personal instruction and supervision once a wk for 6 wks	Joint position error, NDI, NRS	There were no statistically significant differences in effect between groups measured in the week immediately after intervention (week 7)
Jull et al. [39]	Females with chronic, nonsevere neck pain (>3 mths), score < 15/50 on NDI (𝑁=46)	(1) Craniocervical spine flexion training (𝑛=23), low load; (2) Strength training (𝑛=23); All: personal instruction and supervision once a wk for 6 wks	(NDI, NRS)**,; EMG amplitude of deep cervical spine flexor muscles, sternocleidomastoid and anterior scalene muscle and ROM	There were no statistically significant differences in effect between groups measured in the week immediately after intervention (week 7)
O’Leary et al. [40]	Females with chronic neck pain (>3 mths), having in the higher end of mild to moderate pain and disability, score > 4/50 on NDI (𝑁=48)	(1) Cranio-cervical spine flexion coordination exercise (CCF) (𝑛=24); (2) Cervical spine flexion endurance exercise (CF) (𝑛=24); All: one experimental session	VAS	There were no statistically significant differences between groups on VAS
Randløv et al. [41]	Females with chronic neck/shoulder pain (>6 mths), age 18–65 (𝑁=77)	(1) Light training (𝑛=41); (2) Intensive training (𝑛=36); All: three times per wk, in total 36 sessions	Pain measures with two 11-point box scales, activities of daily living, strength, endurance	There were no statistically significant differences in effect between groups after six and twelve mths followup
Revel et al. [42]	Patients with chronic neck pain (>3 mths), age > 15 (𝑁=60)	(1) Rehabilitation group (𝑛=30), receiving common symptomatic treatment, besides eye-head exercises improving neck proprioception in individual exercise sessions twice a wk for 8 wks; (2) Control group (𝑛=30), receiving only symptomatic treatment without rehabilitation	Head repositioning accuracy, VAS, medication intake, ROM	Significant difference between groups for the rehabilitation group on VAS pain (−21.8±25.2) (𝑃=0.04) at 10 wk followup
Taimela et al. [43]	Patients with chronic, nonspecific neck pain (>3 mths), half had local pain and half referred pain below the elbow, age 30–60 (𝑁=76)	(1) Active treatment (𝑛=25), proprioceptive exercises, relaxation and behavioural support, 24 sessions; (2) Home regimen (𝑛=25), neck lecture and two sessions of practical training for home exercises and instructions for maintaining a diary; (3) Control group (𝑛=26), a lecture regarding care of the neck with a recommendation to exercise	VAS, ROM, PPT	The VAS scores after the intervention at 3 mths were significantly lower in the active treatment (22 mm) and home regimen (23 mm) groups than in the control group (39 mm) (𝑃=0.018) after 3 mths. No statistically significant differences between the groups were noted at 12 mths
Viljanen et al. [44]	Female office workers with chronic non-specific neck pain (>12 wks), age 30–60 (𝑁=393)	(1) Dynamic muscle training (𝑛=135); (2) Relaxation training (𝑛=128); (3) Control group, ordinary activity (𝑛=130); Groups 1 and 2 were instructed and trained 3 times a wk for 12 wks followed by one wk of reinforcement 6 mths after randomisation	Pain rated on a scale 0 (no pain)–10 (unbearable pain), pain questionnaire	There were no statistically significant differences in effect between groups at 3, 6, and 12 mths followup
Vonk et al. [45]	Patients with chronic non-specific neck pain (>3 mths), age 18–70 (𝑁=139)	(1) Behaviour graded activity programme (𝑛=68), biopsychosocial model guided by the patient’s functional abilities; (2) Conventional exercise (𝑛=71), reflected usual care, exercises, massage and mobilisation and traction; All: treatment period 9 wks	Global perceived effect, NDI, NRS	There were no statistically significant differences in effect between groups at 4, 9, 26, and 52 wks
Waling et al. [46]	Women with chronic work-related trapezius myalgia (>1 ye), not on sick leave more than 1 mth during last year, age < 45 ye (𝑁=103)	(1) Strength training group (𝑛=29), loaded to allow 12 rep. maximum (RM); (2) Endurance training group (𝑛=28), arm-cycling intensity light (11)—somewhat hard (13) on RPE alternating with exercises loaded to 30–35 RM; (3) Coordination training (𝑛=25). Body-awareness therapy and training.; (4) Control group: nontraining. Group stress and bodily reactions due to stress were studied. Two-hour sessions once a wk for 10 wks; Groups 1–3: one-hour sessions, three times a wk for 10 wks	VAS, three scales: pain-in-general, pain-at-worst, pain-at-present.; Pain threshold	Significant effect of strength training and endurance training VAS pain-at-worst after 10 wks (𝑃<0.05). But no difference on VAS pain-at-present or at VAS pain-at-general
Ylinen et al. [47]	Female office worker, age 25–53, with constant or frequently occurring neck pain of more than 6 mths. Motivated to continue working and rehabilitation (𝑁=180)	(1) Endurance group (𝑛=60), endurance training, dynamic neck exercises; (2) Strength group (𝑛=60), strength training, high-intensity isometric neck strengthening and stabilisation exercises; Groups 1 and 2: 12-day institutional rehabilitation programme with training lessons, behavioural support, 4 sessions of physical manual therapy, advice to continue exercise 3 times a wk at home; (3) Control group (𝑛=60): 3-day institutional rehabilitation programme with recreational activities; All: advice to perform aerobic exercise 3 times a wk for half an hour at home	VAS, neck and shoulder pain and disability index, vernon neck disability index	At the 12 mth followup, both neck pain and disability had decreased in both training groups compared with the control group (𝑃<0.01). Decrease Pain VAS in the endurance group: −35 ((−42)–(−28)); in the strength group: −40 ((−48)–(−32))
Ylinen et al. [48]	Female, age 25–53, with constant or frequently occurring neck pain of more than 6 mths duration, pain > 44 mm on VAS (𝑁=125)	Crossover trial, after 4 wks; (1) Manual therapy group (𝑛=62), low-velocity osteopathic-type mobilisation of cervical joints, traditional massage, passive stretching, two treatments a wk for 4 wks; (2) Stretching exercises group (𝑛=63) consisted of instruction to perform neck stretching exercises at home for 4 wks	VAS, neck and shoulder pain and disability index, NDI,	There were no statistically significant differences in effect between groups at the one- and three-year followup

^∗In order to show an effect of an intervention and hereby support the intervention, it requires showing statistical significant difference between groups.
**Secondary outcome measure.
VAS: visual analogue scale; NRS: numerical rating scale; VNPS: verbal numeric pain scale; NPQ: Northwick Park neck pain questionnaire; NDI: neck disability index; NPDI: neck pain and disability index; NPDS: neck pain and disability scale; NPDVAS: neck pain and disability visual analogue scale; PSFS: patient specific functional scale; NPI: Northwick Park neck pain index; SF-36: short-form 36; PPT: pressure pain threshold; ROM: range of movement; RPE: rating of perceived exertion; EMG: electromyographic, HRQoL: health-related quality of life.