R.M.J. de Zoete1,2, N.R. Armfield1, J.H. McAuley3, K. Chen1,4, M. Sterling1
1The University of Queensland, RECOVER Injury Research Centre, NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries, Herston, Australia, 2The University of Adelaide, School of Allied Health Science and Practice, Adelaide, Australia, 3University of New South Wales, Neuroscience Research Australia and School of Medical Sciences, Sydney, Australia, 4Geriatric Education and Research Institute, Singapore, Singapore
Background: Following clinical guidelines, physical exercise is the mainstay treatment for chronic nonspecific neck pain. Numerous randomised controlled trials (RCTs) have attempted to investigate the effectiveness of separate exercise interventions, such as strengthening, range of motion, and motor control. The effect sizes found for these interventions, however, are modest at best, and clinicians are required to choose an exercise type that they expect to exert positive effects. Network meta-analysis (NMA) allows for a comparison of direct and indirect evidence from available RCTs, enabling the generation of a hierarchy of intervention effectiveness.
Purpose: To compare the effectiveness of different physical exercise interventions for chronic nonspecific neck pain.
Methods: This study was a systematic review and network meta-analysis. Nine electronic databases were searched: AMED, CINAHL, Cochrane Central Register of Controlled Trials, Embase, MEDLINE, Physiotherapy Evidence Database, PsycINFO, Scopus, and SPORTDiscus. Randomised controlled trials (RCTs) were included if they investigated the effects of any physical exercise intervention in an adult population with chronic nonspecific neck pain. Risk of bias was assessed with the PEDro tool, and the GRADE approach, which has been adapted for NMA, was used to assess study limitations, indirectness and transitivity, statistical heterogeneity and inconsistency, imprecision, and publication bias. Two frequentist NMAs were conducted for pain intensity and pain-related disability, and pairwise effect sizes and 95% confidence intervals were calculated for all possible combinations of interventions in the network. The netmeta package for R was used for all statistical analyses.
Results: Out of 6549 records identified in the electronic database search, 40 studies were included in this NMA. The network for pain intensity included 38 RCTs (total 3151 participants), the disability network included 29 RCTs (2336 participants). Compared to no treatment, three exercise interventions were effective in improving pain intensity and pain-related disability: motor control (Hedges’ g, pain -1.32, 95% CI: -1.99 to -0.65; disability -0.87, -1.45 to -0.29), yoga/Pilates/Tai Chi/Qigong (pain -1.25, -1.85 to -0.65; disability -1.16, -1.75 to -0.57), and strengthening (pain -1.21, -1.63 to -0.78; disability -0.75, -1.28 to -0.22). Uncertain or negligible effects were found for range of motion (-0.98 CI: -2.51 to 0.56), balance (-0.38, CI: -2.10 to 1.33), and multimodal (three or more exercises types combined) (-0.08, CI: -1.70 to 1.53) exercises. The GRADE assessment revealed that the quality of evidence was very low.
Conclusion(s): Compared to ‘no treatment’, we were not able to identify one superior type of exercise for the treatment of chronic nonspecific neck pain. Rather, three exercise interventions (motor control, yoga/Pilates/Tai Chi/Qigong, and strengthening) showed large effect sizes based on relatively large participant numbers for both pain intensity and disability networks. Results should be interpreted with caution as the quality of evidence was very low.
Implications: These findings indicate there is not one superior type of exercise that clinicians should prescribe for chronic nonspecific neck pain. We found three types of exercise to be equally effective in improving pain intensity and pain-related disability. This may assist clinicians in selecting an appropriate treatment for individuals with chronic nonspecific neck pain.
Funding, acknowledgements: None declared.
Keywords: Neck pain, Chronic pain, Systematic review
Topic: Musculoskeletal: spine
Did this work require ethics approval? No
Institution: The University of Queensland
Committee: Human Research Ethics Committee
Reason: Systematic Review
All authors, affiliations and abstracts have been published as submitted.
