Kay TM, Gross A, Santaguida PL, Hoving J, Goldsmith C, Bronfort G, Cervical Overview Group
BACKGROUND: Neck disorders are common, limit function, and are costly to individuals and society. Exercise therapy is a commonly used treatment for neck pain. The effectiveness of exercise therapy remains unclear.
OBJECTIVES: To assess the effectiveness of exercise therapy to relieve pain, or improve function, disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders (MND).
SEARCH STRATEGY: Computerised bibliographic databases including CENTRAL, MEDLINE, EMBASE, MANTIS, CINAHL, and ICL were searched, without language restrictions, from their beginning up to March 2004, and reference lists of articles were scanned.
SELECTION CRITERIA: Selected studies were randomised [RCTs] or quasi-randomised trials and investigated the use of exercise therapy as a treatment in adults with MND with or without headache or radicular signs and symptoms.
DATA COLLECTION AND ANALYSIS: Two reviewers independently conducted citation identification, study selection, data abstraction, and methodological quality assessment. Using a random effects model, relative risk and standardized mean differences were calculated. The reasonableness of combining studies was assessed on clinical and statistical grounds. In the absence of heterogeneity, pooled effect measures were calculated. When trials were considered homogenous, results were summarised using a rating system of five levels of evidence.
MAIN RESULTS: Thirty-one trials were selected, 19% (van Tulder criteria) to 35% (Jadad scale) had high quality. There is limited evidence of benefit that acute range of motion (AROM) may reduce pain in acute MND (whiplash associated disorder (WAD)) in the short term. There is moderateevidence of benefit that neck strengthening exercises reduce pain, improve function and global perceived effect for chronic neck disorder with headache in the short and long term. There is unclear evidence regarding the impact of a stretching and strengthening program on pain, function and global perceived effect for MND. However, when this stretching and strengthening program focuses on the cervical or cervical and shoulder/thoracic region, there is moderate evidence of benefit on pain in chronic MND [pooled SMD -0.42 (95%CI: -0.83 to -0.01)] and neck disorder plus headache, in the short and long term. There is strong evidence of benefit favouring a multimodal care approach of exercise combined with mobilisation or manipulation for subacute and chronic MND with or without headache, in the short and long term. A program of eye fixation or proprioception exercises imbedded in a more complete program shows moderate evidence of benefit for pain [pooled SMD -0.72 (95% CI:-1.12 to -0.32)], function, and global perceived for chronic MND in the short term, and on pain and function for acute and subacute MND with headache or WAD in the long term. There is limited evidence of benefit on pain relief in the short term for a home mobilisation program with other physical modalities over a program of rest then gradual mobilisation for acute MND or WAD. There was evidence of no difference between the different exercise approaches.
AUTHORS’ CONCLUSIONS: The evidence summarised in this systematic review indicates that specific exercises may be effective for the treatment of acute and chronic MND, with or without headache. To be of benefit, a stretching and strengthening exercise program should concentrate on the musculature of the cervical, shoulder-thoracic area, or both. A multimodal care approach of exercise, combined with mobilisation or manipulation for subacute and chronic MND with or without headache, reduced pain, improved function, and global perceived effect in the short and long term. The relative benefit of other treatments (such as physical modalities) compared with exercise or between different exercise programs needs to be explored. The quality of future trials should improve through more effective ‘blinding’ procedures and better control of compliance and co-intervention. Phase II trials would help identify the most effective treatment characteristics and dosages.