Chronic neck pain (CNP) is common and costly, and the effect of physiotherapeutic interventions on the condition is unclear. We reviewed the literature for evidence of effect of physiotherapy interventions on patients with CNP. Five bibliographic databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, and PEDro) were systematically searched. Randomised, placebo and active-treatment-controlled trials including physiotherapy interventions for adults with CNP were selected. Data were extracted primary outcome was pain. Risk of bias was appraised. Effect of an intervention was assessed, weighted to risk of bias. 42 trials reporting on randomised comparisons of various physiotherapy interventions and control conditions were eligible for inclusion involving 3919 patients with CNP. Out of these, 23 were unclear or at high risk of bias, and their results were considered moderate- or low-quality evidence. Nineteen were at low risk of bias, and here eight trials found effect on pain of a physiotherapy intervention. Only exercise therapy, focusing on strength and endurance training, and multimodal physiotherapy, cognitive-behavioural interventions, massage, manipulations, laser therapy, and to some extent also TNS appear to have an effect on CNP. However, sufficient evidence for application of a specific physiotherapy modality or aiming at a specific patient subgroup is not available.
Musculoskeletal disorders are threatening quality of life by having the potential to restrict daily activities, cause absence from work, and result in a change or discontinuation in employment. These disorders are expensive for society and for patients and are responsible for the highest number of healthy years lost [
According to a Dutch study, 44% of patients with chronic neck pain visited their general practitioner (GP) with the condition during a twelve-month period; 51% of these were referred to physiotherapy treatment [
The Cochrane Collaboration has provided systematic reviews on the effect of massage for mechanical neck disorders [
However, none of these reviews have covered the majority of commonly used physiotherapy modalities in one in order to get an overview of the subject. Besides, the effect of specific physiotherapy treatments in specific subgroups of chronic pain patients is an important topic which has not yet been examined. Clinicians and policy makers need evidence from research to inform and guide clinical practice and policy. Patients and researchers also need such information to support shared decisions and to set priorities for future research.
The aim of this study was to review the literature systematically and discuss the quality of evidence of commonly used physiotherapy interventions (exercise, manual therapy, and electrotherapy) aimed at improving outcomes (on pain, function, and quality of life) important for patients with chronic neck pain [
We performed a systematic review of all available randomised controlled trials on the subject of physiotherapy for neck pain to determine the effects of physiotherapy interventions on pain, function, and quality of life in neck-pain patients and to explore whether beneficial effects could be explained by biases affecting individual trials [
We searched five bibliographic databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, and PEDro) from January 1990 to January 2012 with a structured, pre-defined, search strategy [
Reference lists of review articles and included studies were searched to identify other potentially eligible studies. An additional search was conducted via the scientific search machine
Studies were included if participants were older than 18 years of age and had chronic neck pain for more than three months (therefore considered chronic). Chronic neck pain was defined as (i) chronic whiplash-associated disorders (WAD); (ii) chronic non-specific neck pain, including work-related neck pain, myofascial neck pain, upper trapezius myalgia, chronic neck pain associated with degenerative findings with or without radicular findings, or other surrogate terms.
Eligible interventions were physiotherapy interventions commonly used in the treatment of musculoskeletal pain: (i) exercise therapy, including specific types of exercises, for example, neuromuscular training, strength training, and endurance training; (ii) manual therapy, for example, massage, manipulations, and mobilisations; (iii) electrotherapy, for example, TENS, low-level laser, or other surrogate terms. Acupuncture was not considered a physiotherapy technique since this technique is not part of physiotherapy in all countries. Comparison of the therapy had to be made with no treatment (e.g., waiting list controls), or other conservative active therapies called “care as usual,” or sham therapy. Anticipating that only a limited number of trials available used placebo/sham control, we decided also to include trials in which an active control was used as a cointervention.
To be eligible for inclusion, a study must apply at least one pain measurement prior to and following the intervention, which was an outcome considered to be of major importance to the patients. Self-reported function and disability [
We created a reliable process through consequently two reviewers who independently conducted the study selection and assessment of eligibility criteria. Similarly, two reviewers independently conducted data abstraction and assessed the risk of bias. Disagreements were resolved through consensus with a third reviewer being consulted if there was disagreement.
Data regarding publication status, trial design, patient characteristics, treatment regimens, outcome methods, results, and funding were extracted on a standardised form using a custom-made Microsoft Excel spreadsheet.
We assessed the risk of bias by using the Cochrane Collaboration’s tool for assessing risk of bias as presented in [
Due to the limited number of studies investigating each of the specific interventions, it was decided that both meta-analytical and level of evidence approaches would be inappropriate. Therefore, a narrative approach where we evaluated the study and results between groups within a trial was used to summarise the findings. To formulate conclusions, only results from trials at low risk were considered as evidence for an intervention.
The literature search identified 4921 relevant studies (1110 from EMBASE, 1568 from MEDLINE, 1239 from CINAHL, and 491 from PEDro), of which 3685 were duplicates, leaving 1236 potentially eligible studies to be screened (see Figure
Flow diagram of the selection process of included studies.
Study characteristics and study results are presented under the categories exercise therapy (25 trials, 18 regarding chronic non-specific neck pain, and seven regarding chronic neck pain related to whiplash); manual therapy (six trials, all related to chronic non-specific neck pain); and electrotherapy (11 trials, all related to chronic non-specific neck pain) in Appendix
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. [ |
Women, aged 35–60, with diagnosed primary mechanical myogenous or arthrogenous, neck pain lasting > 12 wks ( |
(1) GPR group ( |
VAS, ROM, SF-36 | There were no statistically significant differences in effect between groups after treatment and at 6 wk followup |
| ||||
Dellve et al. [ |
Women, aged 35–60, with work disability (at least 50%) and pain in the neck (diagnosed cervicobrachial pain syndrome) for at least 1 year ( |
(1) Myofeedback training ( |
Work ability index (WAI) |
There were no statistically significant differences in effect between groups after 1 mth and at followup after 3 mths |
| ||||
Falla et al. [ |
Patients with chronic nonsevere neck pain (>3 mths), score < 16 (out of possible 50) in NDI ( |
(1) Endurance-strength training of the cervical spine flexor muscles ( |
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. [ |
Chronic neck pain (diagnosed spondylosis, whiplash, nonspecific neck pain, and discogenic pain), age 18 and over ( |
(1) Specific neck stabilisation exercises ( |
NPDS, NPQ, VAS** | There were no significant between-group differences in the NPDS at either 6 wks or 6 mths |
| ||||
Gustavsson et al. [ |
Patients with musculoskeletal tension-type neck pain of persistent duration (>3 mths), age 18–65 ( |
(1) Multicomponent pain and stress self-management group intervention (PASS) ( |
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 ( |
| ||||
Häkkinen et al. [ |
Nonspecific neck pain of more than 6 mths, age 25–53, pain > 29 mm on VAS ( |
(1) Strength training and stretching ( |
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. [ |
Patients with chronic neck pain (>3 mths), nonradicular extremity pain was permitted, age 20–60 ( |
(1) Intensive training of the neck and shoulder musculature ( |
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. [ |
Females with chronic neck pain of idiopathic or traumatic origin and abnormal measures of joint position sense ( |
(1) Proprioceptive exercise intervention ( |
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. [ |
Females with chronic, nonsevere neck pain (>3 mths), score < 15/50 on NDI ( |
(1) Craniocervical spine flexion training ( |
(NDI, NRS)**, |
There were no statistically significant differences in effect between groups measured in the week immediately after intervention (week 7) |
| ||||
O’Leary et al. [ |
Females with chronic neck pain (>3 mths), having in the higher end of mild to moderate pain and disability, score > 4/50 on NDI ( |
(1) Cranio-cervical spine flexion coordination exercise (CCF) ( |
VAS | There were no statistically significant differences between groups on VAS |
| ||||
Randløv et al. [ |
Females with chronic neck/shoulder pain (>6 mths), age 18–65 ( |
(1) Light training ( |
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. [ |
Patients with chronic neck pain (>3 mths), age > 15 ( |
(1) Rehabilitation group ( |
Head repositioning accuracy, VAS, medication intake, ROM | Significant difference between groups for the rehabilitation group on VAS pain ( |
| ||||
Taimela et al. [ |
Patients with chronic, nonspecific neck pain (>3 mths), half had local pain and half referred pain below the elbow, age 30–60 ( |
(1) Active treatment ( |
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) ( |
| ||||
Viljanen et al. [ |
Female office workers with chronic non-specific neck pain (>12 wks), age 30–60 ( |
(1) Dynamic muscle training ( |
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. [ |
Patients with chronic non-specific neck pain (>3 mths), age 18–70 ( |
(1) Behaviour graded activity programme ( |
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. [ |
Women with chronic work-related trapezius myalgia (>1 ye), not on sick leave more than 1 mth during last year, age < 45 ye ( |
(1) Strength training group ( |
VAS, three scales: pain-in-general, pain-at-worst, pain-at-present. |
Significant effect of strength training and endurance training VAS pain-at-worst after 10 wks ( |
| ||||
Ylinen et al. [ |
Female office worker, age 25–53, with constant or frequently occurring neck pain of more than 6 mths. Motivated to continue working and rehabilitation ( |
(1) Endurance group ( |
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 ( |
| ||||
Ylinen et al. [ |
Female, age 25–53, with constant or frequently occurring neck pain of more than 6 mths duration, pain > 44 mm on VAS ( |
Crossover trial, after 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 |
**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.
Exercise therapy—patients with chronic whiplash-associated disorder.
Author | Participants | Interventions | Main outcome measures | Study results on effect* of intervention on pain |
---|---|---|---|---|
Ehrenborg and Archenholtz [ |
Patients, aged 17–58, with pain after whiplash injury (>3 mths), and referred to the pain unit for outpatient-based, interdisciplinary rehabilitation ( |
(1) Biofeedback training ( |
Canadian occupational performance measure, Multidimensional Pain Inventory, Swedish version | There were no statistically significant differences in effect between groups at 6 mths followup |
| ||||
Fitz-Ritson [ |
Patients with chronic pain in cervical spine musculature following motor vehicle accident (WAD), age 19–57, still having symptoms after receiving chiropractic treatments and rehabilitation exercises for > 12 mths ( |
(1) Continued chiropractic treatments and standard rehabilitation exercises ( |
NPDI | The authors do not report any data on statistically significant differences between groups after 8 wk |
| ||||
Jull et al. [ |
Patients with chronic whiplash-associated disorder (>3 mths, <2 yrs), classified WADII, age 18–65 ( |
(1) Multimodal physiotherapy programme (MPT) ( |
NPI, VAS** | The MPT group attained a statistically significant greater reduction in reported neck pain and disability (NPI) ( |
| ||||
Pato et al. [ |
Patients with whiplash injury grade I or II (Quebec Task Force Classification), with persistent neck pain or headache 6–12 mths after the accident ( |
(1) Local anesthetic infiltration of tender points in the neck 2 × a wk, in 8 wks, ( |
Subjective outcome rating (free of symptoms, improved, unchanged, worse), McGill pain questionnaire, VAS), working capacity | There were no statistically significant differences between the 3 different treatment groups measured at 8 wk and at 6 mths followup. There was a statistically significant effect in the short term in female patients in the groups with additional CBT ( |
| ||||
Ryan [ |
Patients with chronic WAD, duration of pain not reported ( |
(1) Strength training group ( |
VAS, SF-36, strength | There were no statistically significant differences between groups posttreatment |
| ||||
Söderlund and Lindberg [ |
Patients with chronic WAD, (>3 mths after injury), age 18–60 ( |
(1) Physiotherapy with cognitive behavioural components, learning and application of basic physical and psychological skills in everyday activities, besides physiotherapy as in group 2 ( |
PDI, NRS, physical measures of pain, disability, coping and self-efficacy | Results revealed no statistically significant differences between groups in self-ratings of disability or pain intensity post treatment or at 3 mths followup |
| ||||
Stewart et al. [ |
Patients with chronic WAD (>3 mths, <12 mths), classified WAD I–III, having significant pain or disability ( |
(1) Advice alone group ( |
Pain intensity and pain bothersomeness rated on a 0–10 box scale, PSFC | Exercise and advice were more effective than advice alone at 6 wks for all primary outcomes but not at 12 months. The effect of exercise on the 0–10 pain intensity scale was −1.1 (95% CI −1.8 to −0.3, |
**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.
Manual therapy—patients with chronic nonspecific neck pain.
Author | Participants | Interventions | Main outcome measures | Study results on effect* of intervention between groups |
---|---|---|---|---|
Bronfort et al. [ |
Patients with mechanical neck pain lasting > 12 wks, age 20–65 ( |
(1) Spinal manipulation and low-technology rehabilitative neck exercise ( |
Pain rating scale (0–10), NDI, SF-36, global improvement of satisfaction with care, medication use | No statistically significant differences between groups in patient rated outcomes at 11 wk and at 12 mth followup |
| ||||
Lau et al. [ |
Patients with a diagnosis of chronic mechanical neck pain (>3 mths), age 18–55 ( |
(1) Thoracic manipulations TM, anterior-posterior approach in supine lying ( |
NPRS, NPQ, SF-36, cervical ROM, craniovertebral angle | Statistically significant differences in favour of TM post-treatment on pain intensity ( |
| ||||
Martel et al. [ |
Patients with pain of mechanical origin located in the anatomical region of the neck, with or without radiation to the head, trunk, or limbs > 12 wks; between 18 and 60 yrs ( |
All: spinal manipulation 10–15 treatments in 5-6 wk (symptomatic phase) after that 3 different interventions (preventive phase). |
VAS, cervical ROM, NPDI, Bournemouth questionnaire, SF-12 questionnaire, fear-avoidance behaviour questionnaire | No statistically significant differences were found between groups |
| ||||
Sherman et al. [ |
Patients with chronic neck pain (>3 mths), age 20–64 ( |
(1) Therapeutic neck massage ( |
NDI, NRS | Statistically significant effect on massage after four wks measured by NDI, −2.1 (−4.00–0.03) ( |
| ||||
Sillevis et al. [ |
Patients between 18 and 65 from outpatients physiotherapy clinic with non-specific pain in the cervical and cervicothoracic region down to T4, provoked with neck movements, present for at least 3 mths ( |
(1) One time thrust manipulation at T3-T4 ( |
VAS, pupil diameter | No statistically significant differences between groups immediately after the treatment |
| ||||
Yaǧci et al. [ |
Patients with chronic cervical myofascial pain syndrome (>6 mths), age 21–44 ( |
(1) Spray-stretch technique ( |
VAS, pain threshold, ROM, strength, endurance | No statistically significant differences between groups were found on pain posttreatment |
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.
Electrotherapy—patients with chronic nonspecific neck pain.
Author | Participants | Interventions | Main outcome measures | Study results on effect* of intervention on pain |
---|---|---|---|---|
Altan et al. [ |
Patients with chronic cervical myofascial pain syndrome (>3 mths), having tender points ( |
(1) Laser treatment ( |
VAS, algometric measurements, ROM | There were no significant differences between groups immediately after (wk 2) and at 12 wks followup |
| ||||
Chiu et al. [ |
Patients with chronic intermittent neck pain (>3 mths), age 20–70 ( |
(1) TENS group ( |
VNPS, NPQ, NPI, strength | There were no statistically significant differences between the three groups on VNPS pain after 6 wk and at 6 mths followup, but the TENS group and the exercise group had a significantly better improvement in NPQ than that of the control group ( |
| ||||
Chow et al. [ |
Patients with chronic neck pain (>3 mths), age > 18 ( |
(1) Laser treatment ( |
VAS | The improvement in raw VAS was statistically significantly greater in the laser-treatment group than in the sham laser treatment group (−2.7 compared with +0.3, |
| ||||
Dundar et al. [ |
Patients with chronic cervical myofascial pain, having spot tenderness along taut band, age 20–60 ( |
(1) Laser treatment ( |
VAS, ROM, NDI | There were no statistically significant differences between groups after 4 wks |
| ||||
Esenyel et al. [ |
Patients with chronic myofascial trigger points (duration 6 months to 7 yrs) in one side of the upper trapezius muscles ( |
(1) Ultrasound therapy ( |
VAS, PPT, ROM | Statistically significant and equal reduction in VAS pain from ultrasound and injection groups compared with controls ( |
| ||||
Gam et al. [ |
Patients with chronic trigger points in the neck and with an intensity disturbing normal daily activity, age 18–60 ( |
(1) Ultrasound, massage, exercise ( |
VAS, measure of trigger points | There were no significant differences between groups post treatment and at 6 mth followup |
| ||||
Gur et al. [ |
Patients with chronic myofascial pain syndrome in the neck (>1 yr), affecting quality of life, with 1–10 tender points in shoulder girdle ( |
(1) Laser treatment ( |
NPDS, VAS | Statistically significant difference on pain in favour of laser treatment at 2nd wk and 3rd wk on pain VAS (2nd wk: VAS pain at rest 3.11 ± 2.29, |
| ||||
Özdemir et al. [ |
Patients with chronic neck pain related to osteoarthritis ( |
(1) Low-level laser therapy ( |
VAS, physician assessment of pressure pain, angle of lordosis, ROM, NPDS | The authors did not report any data on statistically significant differences on pain between groups after treatment |
| ||||
Seidel and Uhlemann [ |
Patients with chronic cervical pain syndrome (>6 mths) ( |
(1) Placebo, sham laser treatment ( |
VAS, PPT, ROM | The authors did not report any data on statistically significant differences on pain between groups after 4 wk |
| ||||
Smania et al. [ |
Patients with chronic myofascial pain syndrome of the superior trapezius muscle (and in no other muscle), age 18–80 ( |
(1) Repetitive magnetic stimulation (rMS) ( |
NPDVAS, VAS, PPT, ROM | The rMS group and the TENS group showed a statistically significant improvement in the NPDVAS compared to the placebo group: differences to placebo group in NPDVAS, rMS group: pre-post |
| ||||
Thorsen et al. [ |
Female laboratory workers with chronic pain (>1 yr) from neck and shoulder girdle, pain affecting the quality of work or daily living, 1–10 tender points, age 18–65 yrs ( |
Crossover study, 6 sessions over 2 wks followed by one wk pause before 6 new treatment sessions over 2 wks in other group. |
VAS | There were no statistically significant differences between groups post treatment |
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.
The trials covered the following intervention topics: (i) exercise therapy: various types of dynamic and isometric exercises, general aerobic exercises, exercises with a focus on strength, endurance, proprioception and coordination, specific neck stabilising exercises, craniocervical-flexion exercises, posture, behavioural graded activity, relaxation, body awareness, myo-feedback training, and multimodal physiotherapy; (ii) manual therapy: massage, manipulation, and traction; (iii) electrotherapy: laser, transcutaneous nerve stimulation (TENS), ultrasound, and repetitive magnetic stimulation (rMS).
Sham therapy or waiting list controls were used as control groups in 12 trials; 10 trials used a control group consisting of a self-management book, health-counselling, or other interventions, clearly distinguished from the active intervention group; six trials used active-treatment control reported as “treatment as usual”; active-treatment control was used in 14 trials.
Primary outcome measures were self-reported pain and/or self-reported pain and disability in 41 trials; when primary outcome measures were not reported, all outcome measures were considered. One trial had an objective test as primary outcome, yet pain was included in the secondary outcome measures.
Risk of bias is presented in Appendix
(a) Exercise therapy, (b) manual therapy, and (c) electrotherapy.
Author | Agenda | Sequence generation | Allocation concealment | Blinding of participants, personnel, and outcome assessors | Incomplete outcome data | Selective outcome reporting | Other sources of bias | Result of summary assessment of risk of bias |
---|---|---|---|---|---|---|---|---|
Cunha et al. [ |
Global posture reeducation + stretching | Adequate | Unclear | Inadequate | Inadequate | Unclear | Unclear | High |
Dellve et al. [ |
Myofeedback training + intensive strength training | Unclear | Unclear | Unclear | Inadequate | Unclear | Unclear | Unclear |
Ehrenborg and Archenholtz [ |
Biofeedback training + interdisciplinary rehabilitation | Adequate | Adequate | Inadequate | Adequate | Unclear | Unclear | Low |
Falla et al. [ |
Endurance-strength exercise | Adequate | Unclear | Inadequate | Adequate | Unclear | Adequate | Unclear |
Fitz-Ritson [ |
Proprioception, eye-head-neck coordination | Inadequate | Inadequate | Inadequate | Inadequate | Unclear | Unclear | High |
Griffiths et al. [ |
Specific neck stabilisation exercises + general exercises | Adequate | Adequate | Inadequate | Adequate | Unclear | Adequate | Low |
Gustavsson et al. [ |
Multicomponent pain and stress self-management group intervention + individual physiotherapy | Adequate | Adequate | Inadequate | Adequate | Unclear | Adequate | Low |
Häkkinen et al. [ |
Strength training + stretching | Adequate | Adequate | Inadequate | Adequate | Unclear | Adequate | Low |
Jordan et al. [ |
Intensive training + physiotherapy + chiropractic manipulation | Adequate | Adequate | Inadequate | Unclear | Unclear | Adequate | Low |
Jull et al. [ |
Proprioception, eye-head coordination + cranio-cervical flexion | Adequate | Adequate | Inadequate | Inadequate | Unclear | Adequate | Low |
Jull et al. [ |
Multimodal physiotherapy programme | Adequate | Adequate | Inadequate | Adequate | Unclear | Adequate | Low |
Jull et al. [ |
Cranio-cervical flexion exercise + strength exercises | Adequate | Unclear | Inadequate | Adequate | Unclear | Adequate | Low |
O’Leary et al. [ |
Cranio-cervical flexion + cervical flexion endurance training | Unclear | Unclear | Inadequate | Unclear | Unclear | Adequate | Unclear |
Pato et al. [ |
Cognitive behavioural therapy + multimodal physiotherapy + infiltration + medication | Unclear | Unclear | Inadequate | Inadequate | Unclear | Unclear | Unclear |
Randløv et al. [ |
Intensive training + light training | Adequate | Unclear | Inadequate | Unclear | Unclear | Adequate | Unclear |
Revel et al. [ |
Proprioception, eye-head-neck coordination | Unclear | Unclear | Inadequate | Inadequate | Unclear | Adequate | Unclear |
Ryan [ |
Strength training + endurance training | Unclear | Unclear | Inadequate | Inadequate | Unclear | Unclear | High |
Söderlund and Lindberg [ |
Cognitive behavioural programme | Unclear | Unclear | Inadequate | Adequate | Unclear | Adequate | Unclear |
Stewart et al. [ |
Exercise | Adequate | Adequate | Inadequate | Adequate | Adequate | Adequate | Low |
Taimela et al. [ |
Multimodal proprioceptive training + home exercises | Unclear | Unclear | Inadequate | Adequate | Unclear | Adequate | Unclear |
Viljanen et al. [ |
Dynamic muscle training + relaxation training | Adequate | Unclear | Inadequate | Adequate | Unclear | Adequate | Unclear |
Vonk et al. [ |
Behavioural graded activity + exercise | Adequate | Adequate | Inadequate | Adequate | Unclear | Adequate | Low |
Waling et al. [ |
Strength + endurance + coordination training | Unclear | Unclear | Inadequate | Inadequate | Unclear | Adequate | High |
Ylinen et al. [ |
Intensive strength training + lighter endurance training | Adequate | Adequate | Inadequate | Adequate | Unclear | Adequate | Low |
Ylinen et al. [ |
Stretching exercises + manual therapy | Adequate | Adequate | Inadequate | Adequate | Unclear | Adequate | Low |
Author | Agenda | Sequence generation | Allocation concealment | Blinding of participants, personnel, and outcome assessors | Incomplete outcome data | Selective outcome reporting | Other sources of bias | Result of summary assessment of risk of bias |
---|---|---|---|---|---|---|---|---|
Bronfort et al. [ |
Manipulation + exercise | Adequate | Adequate | Inadequate | Adequate | Unclear | Adequate | Low |
Lau et al. [ |
Thoracic manipulation | Adequate | Adequate | Inadequate | Adequate | Unclear | Unclear | Low |
Martel et al. [ |
Spinal manipulation + home exercise | Adequate | Adequate | Inadequate | Adequate | Adequate | Adequate | Low |
Sherman et al. [ |
Massage | Adequate | Adequate | Inadequate | Adequate | Unclear | Adequate | Low |
Sillevis et al. [ |
Thoracic manipulation | Adequate | Adequate | Inadequate | Adequate | Unclear | unclear | Low |
Yaǧci et al. [ |
Connective tissue massage + spray-stretch technique | Unclear | Unclear | Inadequate | Unclear | Unclear | Unclear | Unclear |
Author | Agenda | Sequence generation | Allocation concealment | Blinding of participants, personnel, and outcome assessors | Incomplete outcome data | Selective outcome reporting | Other sources of bias | Result of summary assessment of risk of bias |
---|---|---|---|---|---|---|---|---|
Altan et al. [ |
Laser | Unclear | Unclear | Adequate | Inadequate | Unclear | Unclear | Unclear |
Chiu et al. [ |
TENS | Adequate | Adequate | Inadequate | Adequate | Unclear | Adequate | Low |
Chow et al. [ |
Laser | Adequate | Adequate | Adequate | Adequate | Unclear | Unclear | Low |
Dundar et al. [ |
Laser | Adequate | Unclear | Inadequate | Adequate | Unclear | Unclear | Unclear |
Esenyel et al. [ |
Ultrasound | Unclear | Unclear | Inadequate | Unclear | Unclear | Unclear | Unclear |
Gam et al. [ |
Ultrasound | Adequate | Unclear | Adequate | Inadequate | Unclear | Adequate | Unclear |
Gur et al. [ |
Laser | Adequate | Unclear | Inadequate | Unclear | Unclear | Unclear | Unclear |
Özdemiret al. [ |
Laser | Unclear | Unclear | Unclear | Unclear | Unclear | Unclear | Unclear |
Seidel and Uhlemann [ |
Laser | Adequate | Unclear | Inadequate | Unclear | Unclear | Unclear | Unclear |
Smania et al. [ |
rMS + TENS | Adequate | Unclear | Inadequate | Unclear | Adequate | Unclear | Unclear |
Thorsen et al. [ |
Laser | Unclear | Unclear | Adequate | Inadequate | Unclear | Adequate | Unclear |
Overall, the quality of reporting on methodological issues varied. Table
The summary assessment of risk of bias revealed 19 trials at low risk of bias [
All studies are described in detail in Appendix
Gustavsson et al. [ Ylinen et al. [
No trials with low risk of bias supported single use of proprioception exercises (eye-head co-ordination), cranio-cervical flexion exercises (C-CF), or neck stabilisation exercises for pain. No trials with low risk of bias support the use of stretching.
Jull et al. [ Stewart et al. [
No trials at low risk of bias support the use of EMG biofeedback.
Lau et al. [ Sherman et al. [
No trials at low risk of bias support the use of traction.
Chiu et al. [ Chow et al. [
No trials at low risk of bias support the use of ultrasound therapy. No trials at low risk of bias support the use of rMS.
In this review, we assessed the effect of various interventions for the treatment of chronic neck pain and evaluated the methodological quality of the trials. Our findings emphasise the importance of taking the risk of bias into consideration when evaluating the evidence of an intervention.
Trials varied substantially regarding their internal validity, although the methodological quality of the RCTs in general appeared to be somewhat low with an unclear or high risk of bias. We identified various methodological flaws that may have implications for the internal validity of the trials and consequently may result in biased outcomes. Key domains in this context were randomisation, blinding, and incomplete outcome data.
Our evaluation also exposes a widespread use of within-group analyses, claiming statistically nonsignificant results to be beneficial. Results were frequently analysed and reported as if they were uncontrolled within-group studies, which consequently led to misinterpretation of results. To some extent this may be due to the absence of a control group in many trials, and the use of an active treatment as a comparative group makes the “proof” of a truly statistically significant effect more difficult to find. We believe that attention should be paid to inadequate interpretation of a trial result when authors inadequately interpret lack of difference in terms of efficacy [
Overall, the evidence of effect of physiotherapy for chronic neck pain is strengthened. Yet, for some of the treatments offered, no definite effect and clinical usefulness can be shown. This does not necessarily implicate that these treatments have no effect, only that the present evidence is not sufficient.
Physiotherapy interventions for chronic neck pain showing the strongest support for an effect on pain are strength and endurance training (supported by two trials by Stewart et al. [
When looking deeper into the actual components of the various interventions in the above-mentioned trials, four of them—despite the differences, diversity, and individual features of the interventions—seem to have several characteristics in common: The interventions can be considered to be rehabilitative interventions of multimodal physiotherapy with a focus on exercise, including cognitive-behavioural components. This is based on (1) the trial by Stewart et al. [
Our review adds new knowledge regarding the evidence for use of massage. Our findings are in discrepancy to a Cochrane Review by Haraldsson et al. [
To our knowledge, this is the first systematic review on interventions for chronic neck pain addressing the majority of commonly used physiotherapeutic modalities in one study, in order to get an overview of the subject area.
The search strategy and selection criteria we used were quite strict and easy to apply and according to normal procedures for conducting systematic reviews [
The quality assessment was presented in a reproducible manner. However, the results may be affected by our emphases during filtering methods for synthesis evidence. We might have chosen to exclude all trials with insufficient reporting on allocation sequence and allocation concealment. However, we chose not to, since this would have left us with very few trials to assess. We assessed risk of bias, requiring a convincing mechanism to be described in order for a trial to be classified as “adequate.” Our approach to this problem was to assume that the quality was inadequate unless information on the contrary was provided, and in doing so, we might have misclassified well-conducted but badly reported trials.
The present review succeeded in a subgroup assessment of physiotherapy treatment for chronic non-specific neck pain and for chronic WAD. Yet the first group was very wide due to the mixed conditions in the group of participants. The various interventions were considered to be complex, multifaceted, and with various cointerventions, and by classifying them into intervention groups according to—what we believed to be—the trial’s agenda, we may have misclassified some. On the other hand, the often used combined therapies also highlight a fundamental problem when assessing effect of specific and single physiotherapy modalities. Another issue is the quality of the intervention since the interventions were administered in different ways and in different settings. It is reasonable to expect that the way in which they were administered including the dose-response relationship could have influenced the outcome. It would have been interesting and very relevant to examine this. Herbert and Bo [
We need to know which patients will benefit from which intervention, built on well-conducted and well-reported trials, considering subgroups of patients with chronic neck pain, in order to support recommended evidence-based decisions and to set priorities for future research. We also request future trial investigators to consider to what extent cointerventions are valuable, in addition to possible confounders. Another issue to consider is the extent to which the control groups ought to be given care and attention to the same extent as the intervention groups.
See Tables
See Table
The authors report no conflict of interests.
P. Damgaard contributed to the conception, design, and writing of the study protocol and the design of search strategies; she located and obtained trial reports, helped to select and assess trials, conducted the data analysis, and drafted and approved the final paper. E. M. Bartels contributed to the conception of the study protocol and the design of search strategies; she helped to locate and obtain trial reports, and revised and approved the final paper. I. Ris helped to select and assess trials, contributed to the data analysis, and revised and approved the final paper. R. Christensen contributed to the conception, design, and writing of the study protocol, conducted data analysis, and revised and approved the final paper. All authors acted as guarantors for the paper. B. Juul-Kristensen contributed to the conception, design, and writing of the study protocol and the design of search strategies; she helped to select and assess trials and revised and approved the final paper.
The funding organisations had no role in any aspect of the study, the paper, or the decision to publish.
The authors have completed ICMJE's the Unified Competing Interest form at (available on request from the corresponding author) and want to acknowledge. The financial support for the submitted work by grants from The Danish Association for Physiotherapists, the Research Fund of the Region of Southern Denmark, the patient organization PTU-Danish Society of Polio and Accident Victims and from The Research Unit for Musculoskeletal Function and Physiotherapy at The University of Southern Denmark, and the Parker Institute, Musculoskeletal Statistics Unit, which is supported by grants from The Oak Foundation, The Danish Rheumatism Association, and Frederiksberg Hospital. The authors also declare. No financial relationships with commercial entities that might have an interest in the submitted work; no spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; and no nonfinancial interests that may be relevant to the submitted work.