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RESEARCH COMMENTARY
Robert J. Fluegel, PT, COMT
MAPS Faculty, Fellow in Training, MAPS Orthopedic Manual Therapy Fellowship

Chris R. Showalter, PT, OCS, COMT, FAAOMPT, Fellowship Program Director

Mobilization combined with Stabilization is SUPERIOR compared to Stabilization alone in Non-Specific Mechanical Neck Pain (NSMNP)


 
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Are Exercises Alone Effective for Mechanical Neck Disorders? Yes, No, and Maybe…

April 21, 2015

April 21, 2015 …RESEARCH COMMENTARY

 

Chris Showalter PT, OCS, COMT, FAAOMPT

MAPS Clinical Director


Are Exercises Alone Effective for Mechanical Neck Disorders?

Yes, No, and Maybe…


Neck pain is common, and the associated pain and disability can significantly affect patients’ lives.  Exercise therapy is a widely used treatment for neck pain. However, the effectiveness of exercises in managing neck pain remains unclear, as demonstrated in a recent Systematic Review (SR) by Anita Gross et al of the Cochrane Collaboration.

 

First some background…

 

The Cochrane Collaboration is an independent, global healthcare research network. Their reviews of studies and journal articles are conducted by teams of experts in a specific field.  Consequently, systematic reviews (SRs) and meta-analyses (MAs) produced by Cochrane are considered robust, unbiased and represent high quality evidence.

 

A recent Cochrane SR entitled “Exercises for Mechanical Neck Disorders” was produced by the Cervical Overview Group (Gross 2015) and is summarized below.

 

Purpose

 

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

 

Selection Criteria

 

The SR included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control group for adults suffering from neck pain with or without cervicogenic headache or radiculopathy.  These RCTs were characterized by the following:

 

  • The inclusion of active exercises (including specific neck and shoulder exercises, stretching, strengthening, postural exercises, breathing, cognitive, functional, and eye-fixation with proprioception exercises) prescribed to, or performed by, the patient in the treatment of neck pain.

     

  • The exclusion of multimodal treatments and exercises that were performed by a trained individual, including studies in which exercise therapy was given as part of a multidisciplinary treatment, multimodal treatment (along with other treatments such as manipulation or ultrasound), or exercises requiring application by a trained individual (such as hold-relax techniques, rhythmic stabilization, and passive techniques).

     

     

    Trials Reviewed

     

    Twenty-seven trials (2,485 analyzed /3,005 randomized participants) met the inclusion criteria.

     

    Results


  • Acute Neck Pain

     

    NO evidence was found for the effectiveness of ANY exercises for Acute Neck Pain.

     

     

  • Chronic Neck Pain

     

    Moderate quality evidence supports the following for the treatment of Chronic Neck Pain:

     

  1. Cervico-scapulothoracic and upper extremity strength training results in improved pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) -0.71 (95% CI: -1.33 to -0.10)] and at short-term follow-up;

     

  2. Scapulothoracic and upper extremity endurance training provided slight beneficial effect on pain at immediate post treatment and short-term follow-up;

     

  3. Combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp -0.33 (95% CI: -0.55 to -0.10)] and up to long-term follow-up and a medium magnitude of effect improving function at both immediate post treatment and at short-term follow-up [SMDp -0.45 (95%CI: -0.72 to -0.18)];

     

  4. Cervico-scapulothoracic strengthening/stabilization exercises to improve pain and function at intermediate term [SMDp -14.90 (95% CI:-22.40 to -7.39)];

     

  5. Mindfulness exercises (Qigong) minimally improved function but not global perceived effect at short term.

     

  6. Low level evidence suggests that the following may not change pain or function at the immediate post treatment to short term follow up:

  • breathing exercises
  • general fitness training
  • stretching alone and
  • feedback exercises combined with pattern synchronization.

    7. Very low quality evidence suggests neuromuscular eye-neck
         coordination/
proprioceptive exercises may improve pain and function at
         short-term follow-
up. 


  • Chronic Cervicogenic Headache

     

  1. Moderate quality evidence supports the effectiveness of static-dynamic cervico-scapulothoracic strengthening/endurance exercises, including pressure biofeedback immediate post treatment and probably improved pain, function and global perceived effect at long-term follow-up.

  2.  Low grade evidence supports effectiveness of patient-performed sustained natural apophyseal glides (SNAG) exercises. 


  • Acute Radiculopathy

     

    Low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilization exercises.

     

     

    AUTHOR’S CONCLUSIONS

     

    Although the SR revealed that moderate and low-level evidence exists to support the use of different exercises for neck pain, no HIGH quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise.

     

  • Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial.

     

  • Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function.

     

  • However, when only stretching exercises were used, no beneficial effects may be expected. 

  • Future research should explore optimal dosage.

     

     

    Take Home Messages 

     

1)  Role for Strengthening Exercises. There appears to be a role for strengthening exercises in the treatment of chronic neck pain, cervicogenic headache and cervical radiculopathy if these exercises are focused on the neck, shoulder and shoulder blade region.  
  • The use of strengthening exercises, combined with endurance or stretching exercises has also been shown to be beneficial.

     

  • There is also some evidence to suggest the beneficial effects of specific exercises (e.g. sustained natural apophyseal glides) with cervicogenic headaches and mindfulness exercises (e.g. Qigong) for chronic mechanical neck pain.

     

2)  Minimal Effect from Stretching or Endurance Exercises Alone.  There appears to be minimal effect on neck pain and function when only stretching or endurance type exercises are used for the neck, shoulder and shoulder blade region.
  • No high quality evidence was found to support the efficacy of only stretching or endurance exercises when performed alone, indicating that there is still uncertainty about the effectiveness of exercise for neck pain.

  • There is limited evidence on optimum dosage requirements for these different types of exercises.

     

3)  Clearly, further research on of the effect of different types of exercises, including optimal dosage, is needed for different specific types of neck pain. 

Cheers and Enjoy

Chris R Showalter

© Chris R. Showalter and Maitland Australian Physiotherapy Seminars

Not to be reproduced, copied or retransmitted in any manner without author’s express written permission

Directing others to the MAPS website (www.ozpt.com) is permissible.

 

Gross et al 2015 Article Follows

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004250.pub5/abstract;jsessionid=944C7A0E4F832ADDC94B565A364EE2F0.f04t01

Background

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

Objectives

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

Search methods

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

Selection criteria

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

Data collection and analysis

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

Main results

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

For acute neck pain only, no evidence was found.

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

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

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

Authors' conclusions

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

There appears to be a role for strengthening exercises in the treatment of chronic neck pain, cervicogenic headache and cervical radiculopathy if these exercises are focused on the neck, shoulder and shoulder blade region.

Furthermore, the use of strengthening exercises, combined with endurance or stretching exercises has also been shown to be beneficial. There is some evidence to suggest the beneficial effects of specific exercises (e.g. sustained natural apophyseal glides) with cervicogenic headaches and mindfulness exercises (e.g. Qigong) for chronic mechanical neck pain. There appears to be minimal effect on neck pain and function when only stretching or endurance type exercises are used for the neck, shoulder and shoulder blade region.


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