WHICH EXERCISE FOR NECK PAIN: A COCHRANE REVIEW UPDATE AND SUBGROUP ANALYSES

A.R Gross1,2, D. Bertani2, N. Mahoney2, H. Thakker2, Y. Sharma2, N. Chacko1, C.H Goldsmith3,4, G. Gelley5, M. Forget6, S.J Burnie7
1McMaster University, Rehabilitation Sciences, Hamilton, Canada, 2Western University, Physical Therapy, London, Canada, 3McMaster University, Health Research Methods, Evidence and Impact, Hamilton, Canada, 4Simon Fraser University, Faculty of Health Sciences, Burnaby, Canada, 5University of Manitoba, College of Rehabilitation Science, Winnipeg, Canada, 6National Defence, Government of Canada, Canadian Forces Health Services Group, Kingston, Canada, 7Canadian Memorial Chiropractic College, Department of Clinical Education, Toronto, Canada

Background: Neck pain is common, disabling, costly and treated with exercise.

Purpose: To do subgroup analysis on exercise elements in a Cochrane review update on the effectiveness of exercise for neck pain with or without radiculopathy or cervicogenic headache in adults.

Methods: We searched MEDLINE, CINAHL, EMBASE and ClinicalTrials.gov up to March 2020. We included randomised controlled trials comparing exercise with a control or as an adjuvant to conservative care for adults with neck pain. Standard Cochrane review methodology following MECIR guidelines was conducted. Pairs of independent reviewers conducted the study selection, data extraction and risk of bias assessment. The quality of evidence was determined using GRADE (high/moderate/low/very low). Meta-analyses used mean differences (MDp) at immediate-post (IP), short-term (ST) and long-term (LT). The test for subgroup difference by exercise element was analyzed.

Results: Seventy-five studies (n=11032 participants randomised; 32% low risk of bias) compared exercise against a control or as an adjuvant. Participants (mean age 36.5, pain severity 4.55/10) from primary (n=40) to tertiary care (n=30) were treated over a mean of 10-weeks. The quality of evidence was low (range: very low to moderate). The test for subgroup differences by exercise element noted improved pain and function-disability:

 Pain (MD VAS 0-100, 95% CI):
  • strengthening
    IP: MDp -9.26 (-15.99 to -2.53); participants 354; studies 7; I2=53%
    ST: MDp -12.64 (-19.13 to -6.16); participants 107; studies 3; I2=0%
  • stretch-ROM
    LT: MD -20.00 (-27.75 to -12.25); participants 32; study 1
  • strength-endurance
    IP: MDp -12.81 (-24.75 to -0.87); participants 81; studies 2; I2=82%
    ST: MD -14.00, (-19.69 to -8.31); participants 26; study 1;
    Source of inconsistency: participant fighter pilot or chronic WAD, outcome ceiling effect
  • strength-endurance with pattern synchronization & feedback-feedforward
    ST: MD -14.00 (-19.69 to -8.31); participants 26; study 1
  • strengthening & stretching
    IP: MDp -14.82 (-25.15 to -4.49); participants 755; studies 8; I2=91%;
    Sources of inconsistency: treatment duration, exercise protocol.
  • strengthening with feedback-feedforward  
    IP: MDp -28.40 (-49.66 to -7.14); participants 184; studies 2; I2=96%
    LT: MD -14.10 (-23.95 to -4.25); participants 97; study 1;
    Sources of inconsistency: route of exercise.
  • pattern synchronization (posture training)
    ST: MD -19.80 (-36.48 to -3.12); participants 27; study 1
  • cognitive affective (mind-body balance)
    IP: MDp -8.35 (-14.12 to -2.58); participants 209; studies 3; I2=0%;
  • cognitive affective with pattern synchronization (TMJ-coordination) & feedback-feedforward
    ST: MD -20.00 (-37.60 to -2.40); participants 26; study 1
Function-disability (MD NDI 0-100, 95% CI):
  • strength-endurance with feedback-feedforward
    IP: MD -8.41 (-14.02 to -2.80); participants 97; study 1;
    LT: MD -10.32 (-20.17 to -0.47); participants 97; study 1
  • pattern synchronization (posture training)
    ST: MD -15.20 (-28.96 to -1.44); participants 27; study 1.
When exercise was added to standard care, results were comparable. Subgroup analysis favoured exercise supervision and route. Transient side-effects (low-quality, RD 0.00, 95% CI -0.01 to 0.01; participants 554; studies 5; I2=0%) include soreness, muscle tension, vertigo.

Conclusion(s): Moderate to low-quality evidence suggests using of exercises for neck pain. Monitoring adherence in large trials with dose analysis and LT follow-up is needed.

Implications: Identification of which exercise elements may impact translation of exercise research to clinical practice.

Funding, acknowledgements: Canadian Academy of Manipulative Physiotherapy Research Fund

Keywords: Exercise, neck pain, Cochrane systematic review

Topic: Musculoskeletal: spine

Did this work require ethics approval? No
Institution: McMaster University
Committee: HiREB Student Research Committee
Reason: This is a systematic review. There are no human subjects.


All authors, affiliations and abstracts have been published as submitted.

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