Archives of Physical Medicine and Rehabilitation

journal homepage: www.archives-pmr.org

Archives of Physical Medicine and Rehabilitation 2014;95:770-83

REVIEW ARTICLE (META-ANALYSES)

Chronic Neck Pain and Exercise Interventions:

Frequency, Intensity, Time, and Type Principle
Cliona O’Riordan, BSc,a Amanda Clifford, PhD,a Pepijn Van De Ven, PhD,b
John Nelson, PhDb
From the aDepartment of Clinical Therapies and bDepartment of Electronic and Computer Engineering, University of Limerick, Limerick, Ireland.

Abstract
Objective: To identify the most effective components in an active exercise physiotherapy treatment intervention for chronic neck pain based on
the frequency, intensity, time, and type (FITT) exercise method of tailoring physical activity recommendations to the individual needs and goals of
patients.
Data Sources: Databases, including the Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health,
MEDLINE, SPORTDiscus, Biomedical Reference Collection, and Academic Search Premier, were searched for relevant articles.
Study Selection: Quantitative design studies that included active exercise as part of a multimodal or stand-alone approach were selected. Only studies
scoring 6 on the Physiotherapy Evidence Database Scale were included in the review because this reflected a good level of evidence.
Data Extraction: Study methodologies and relevant outcome measures, including isometric strength, Neck Disability Index scores, and pain
scores, were extracted from relevant articles and grouped together for appraisal and synthesis.
Data Synthesis: Evidence from selected articles was synthesized according to the FITT exercise principal to determine the most effective
exercise type, frequency, and intensity in the treatment of chronic neck pain.
Conclusions: Physiotherapy interventions using a multimodal approach appear to produce more beneficial outcomes in terms of increased strength,
improved function, and health-related quality of life and reduced pain scores. Active strengthening exercises appear to be beneficial for all of these
outcomes; the inclusion of additional stretching and aerobic exercise components appear to enhance the benefits of an exercise intervention.
Archives of Physical Medicine and Rehabilitation 2014;95:770-83
ª 2014 by the American Congress of Rehabilitation Medicine

Hudson and Ryan1 report that neck pain is one of the most prevalent
and costly musculoskeletal conditions in Western society. It is
estimated that up to 67% of adults will experience neck pain at some
stage in their lives.2 In European populations, between 15% and
19% of cases will develop into a chronic state.3 Worldwide, this
figure is up to 20% of the population reporting chronic neck prob-
lems at any one time.4 Those experiencing chronic pain are twice as
likely to present to health care services compared with the general
population.5 Compensation, health care service provision, and loss
of productivity because of sick leave days accumulate to large
amounts of money for states each year.2 Epidemiologic studies of
chronic neck pain prevalence are limited in Ireland. A study by
Raftery et al6 found that of the 13% of the population who suffer
from chronic pain, 29.4% also suffered from neck pain. In 2008, an
No commercial party having a direct financial interest in the results of the research supporting
this article has conferred or will confer a benefit on the authors or on any organization with which
the authors are associated.
estimated V5.34 billion or 2.86% of the gross domestic product was
spent on chronic pain in Ireland; second to lower back pain, chronic
neck pain accounts for a large proportion of this expenditure. Data
from the United States indicates that 14.3% of the population is
experiencing chronic neck pain. Similar to this are Australian fig-
ures, which indicate that approximately 640,000 Australians expe-
rience chronic neck pain, costing the state almost $1.14 billion
annually in associated health care.7 National figures from The
Netherlands indicated that $686 million was spent in 1996 on
chronic neck pain.8 Data from the United Kingdom suggest that
costs for private physiotherapy care for chronic neck pain amount to
an approximated £296 per individual, with figures reaching upward
of £1911 when referred to >1 service (eg, pain clinic and physio-
therapy), which is commonly the case in chronic pain.9
For the purpose of this review, chronic pain is defined in accor-
dance with the International Association for the Study of Pain and the
American Pain Society as pain that persists beyond normative tissue
healing time, which is defined as 3 months.10 Chronic neck pain for

0003-9993/14/$36 - see front matter ª 2014 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2013.11.015

Downloaded for Anonymous User (n/a) at Chilean Security Association from ClinicalKey.com by Elsevier on May 11, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
Frequency, intensity, time, and type of exercise and neck pain 771

the purpose of this review includes pain experienced in the anatomic
region of the cervical spine between C1 and C7 and surrounding
musculature only, excluding the shoulders. Pain of insidious onset is
discussed only because whiplash-associated disorders were
excluded as a result of the psychosocial and medicolegal implica-
tions in such conditions.11 Mechanisms for the development of
chronic pain are not fully understood; however, it is known that pain
can become more complex in its pathophysiology than that of the
original insult or injury.12 Chronic musculoskeletal pain usually
develops as a result of an injury or insult followed by neurogenic
inflammation, hyperalgesia, and allodynia.11 The transmission of
repeated pain signals produces functional and structural changes in
the nervous system and central sensitization occurs, followed by a
loss of nociceptive control.13,14
Evidence suggests that being a woman, white, and middle-aged
increases the risks of neck pain becoming chronic.3,15-17 Ylinen,18
Webb,16 Guez,19 and colleagues report that the incidence of
chronic neck pain in women ranges from 7% to 22% compared with
5% to 16% in men. A history of previous neck pain or, similarly, a
whiplash-associated accident can increase the chances of developing
chronic neck pain.20 However, personal societal and environmental
factors can influence the development of a whiplash-associated
disorder. Although a weaker correlation exists, occupation is a risk
factor in the development of chronic neck pain.21 Sedentary life-
styles, office-based workplaces, and an ever-increasing reliance on
technology has increased the prevalence of neck pain in recent
years.22 Additionally, Manchikanti et al3 found that industrial
workers and manual laborers were at an increased risk of developing/
experiencing chronic pain; statistics indicate that 16% of manual
laborers and 74% of crane operators experienced chronic neck pain.
With an increasing prevalence of chronic neck pain,22 it is
important to determine physiotherapy treatment interventions that
are cost effective, time efficient, and patient appropriate.20 A range
of strategies to tackle chronic neck pain have been examined from
single modalities to combination interventions.20 Single modality
treatment approaches are deemed to be an inaccurate representation
of clinical or best practice for individual patients.23 A large variety of
physiotherapeutic interventions are available for the treatment of
chronic neck pain, including manual therapy, spinal manipulations,
passive therapies, relaxation techniques, electrotherapy and stress
management, and active exercise.23-25 In 2008, a set of clinical
guidelines published by the American Physical Therapy Association
for the treatment of neck pain advocated participation in active ex-
ercise.25 Guidelines by Scholten-Peeters et al26 also recommend
education and exercise therapy as key components of any multi-
modal treatment approach to encourage greater autonomy in man-
aging pain and inhibiting pain transmission.
Active exercise is proposed to target the muscles that may be
damaged during injury; resultant strains and tears of the stabilizing
systems (including the deep muscles and ligaments) can result in
dysfunctional movement patterns because of a lack of motor control
at the cervical spine.22 Superficial neck muscles replace the actions
of the deep muscles, resulting in early fatigue, overactivity, and pain;
therefore, active exercise can work effectively to rehabilitate the
injured musculoskeletal structures and correct movement patterns.22
List of abbreviations:
FITT frequency, intensity, time, and type
MVC maximal voluntary contraction
PEDro Physiotherapy Evidence Database
In the same way as medication is prescribed in required dosages,
applying a similar degree of precision to prescriptions of physical
activity is required; hence the development of the frequency, in-
tensity, time, and type (FITT) format. Despite the high incidence of
chronic neck pain and the resounding evidence for the benefits of
active exercise for the treatment of associated symptoms, there is a
paucity of evidence to recommend a definitive FITT principle in this
population. Through this method, exercise may be tailored to an
individual’s needs according to various aspects of activitydfor
example the type of exercise undertaken, at what level of exertion
(intensity), how often, and for what duration.27
Therefore, it is the aim of this review to evaluate and present
the research for active exercise in the treatment of chronic neck
pain in an FITT format to identify which exercise interventions are
associated with the most optimal outcomes and which other
treatment modalities the exercise complements. We will also
identify what further research may still be warranted for devel-
oping an effective intervention in a chronic neck pain population.
Methods
The following databases were searched between April and
November 2012 for relevant articles: the Allied and Comple-
mentary Medicine Database, Cumulative Index to Nursing and
Allied Health, MEDLINE, SPORTDiscus, Biomedical Reference
Collection, and Academic Search Premier. Keywords search terms
included chronic, neck, pain, and exercise as single words and in
combinations. This identified 256 articles. Further studies were
sourced via reference lists of appropriate articles. See the
Preferred Reporting Items for Systematic Reviews and Meta-
Analyses flow diagram in figure 1 for full details.
The abstracts were read to ascertain relevance based on the
following inclusion criteria: (1) published material; (2) research
conducted between 2000 and 2012; (3) research examining the
effects of active (where active was defined as an exercise in which
the participant actively engages muscles of an affected limb/area
to create motion or movement in direct contrast with a passive
approach where a patient relies on an external stimulus to move a
limb or limb segment) exercise in a chronic neck pain population
where chronic neck pain was defined as the presence of pain for at
least 3 months; (4) exercise that was used as part of a stand-alone
or multimodal treatment approach to chronic neck pain to include
advice/education as a component of treatment; (5) research that
took the format of a randomized controlled trial, controlled trial,
cross-sectional study, or pilot/feasibility trial; and (6) research that
examined the effects of exercise on >1 outcome measure (eg,
strength, pain, disability, health-related quality of life).
Articles were excluded if they were not published in English as
a primary language, no form of active treatment was given, and
there was no control or alternative therapy group for comparison.
Results
This search strategy identified 16 studies for inclusion in this
literature review. Details of the included studies have been given in
tabular form. Table 1 details the appraisal of evidence using the
Physiotherapy Evidence Database (PEDro) Scale for each of the
studies reviewed. The PEDro Scale is available online (http://www.
pedro.org.au/english/downloads/pedro-scale/). Table 2 provides a
description on the demographic details of included studies. Table 3
demonstrates the individual components of the exercise regimens

www.archives-pmr.org

Downloaded for Anonymous User (n/a) at Chilean Security Association from ClinicalKey.com by Elsevier on May 11, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
772 C. O’Riordan et al

Fig 1 Article retrieval process.

used in each of the studies reviewed, and table 4 outlines the
methodologic design and results of each of the studies reviewed.
Discussion
Research in the 1990s24 found inconclusive evidence for the ef-
fects of exercise on mechanical neck pain; this has been refuted by
research over the last decade with resounding evidence for the
benefits of active exercise in the treatment intervention above
passive alternatives.4,20,28 For the purpose of this review, the
studies included will be discussed in terms of the frequency with
which the active exercise is undertaken, the intensity at which the
exercise is conducted, the time spent exercising, and the type of
exercise undertaken (the FITT principle).

www.archives-pmr.org

Downloaded for Anonymous User (n/a) at Chilean Security Association from ClinicalKey.com by Elsevier on May 11, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
 www.archives-pmr.org

Frequency, intensity, time, and type of exercise and neck pain

Downloaded for Anonymous User (n/a) at Chilean Security Association from ClinicalKey.com by Elsevier on May 11, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.

Table 1 Included studies assessed using the PEDro Scale

Measure of
Received Between at Least 1
Groups Treatment/ Group Outcome Point Measure Level of
Similar Control or Stats for From 85% of of Variability Evidence
Concealed at Blinded Blinded Blinded Intention- at Least 1 Original for at Least PEDro (Oxford
Study Randomized Allocation Baseline (participants) (assessors) (therapists) to-Treat Outcome Group 1 Key Outcome Score Scale)
Falla et al31 Yes No Yes No No No Yes Yes Yes Yes 6 2
Hudson and Ryan1 Yes No Yes No Yes No Yes Yes Yes Yes 7 2
Häkkinen et al30 Yes No Yes No No No Yes Yes Yes Yes 6 2
Evans et al32 Yes No Yes No No No Yes Yes Yes Yes 6 2
Ylinen et al5 Yes No Yes No Yes No Yes Yes Yes Yes 7 2
Viljanen et al2 Yes No Yes No Yes No Yes Yes Yes Yes 7 2
Chiu et al43 Yes No Yes No No No Yes Yes Yes Yes 6 2
Stewart et al34 Yes No Yes No Yes No Yes Yes Yes Yes 7 2
Taimela et al44 Yes No Yes No Yes Yes Yes Yes Yes Yes 7 1
Salo et al29 Yes No Yes No Yes Yes Yes Yes Yes Yes 7 1
Jull et al45 Yes No No No No No Yes Yes Yes Yes 5 2
Ylinen16 Yes No Yes No No No Yes Yes Yes Yes 6 2
Waling et al39 Yes No Yes No No No Yes Yes Yes Yes 6 2
Chiu et al33 Yes No Yes No No No Yes Yes Yes Yes 6 2
Andersen et al35 Yes No Yes No No No Yes Yes Yes Yes 6 2
Bronfort et al4 Yes No Yes No No No Yes Yes Yes Yes 6 2

773
774 C. O’Riordan et al

Table 2 Participant demographics for included studies

Sex Distribution
Study Sample Size (n) Symptom Duration (% female) Age (y)
31
Falla et al 58 7.906.40y 100.00 37.9010.20
Hudson and Ryan1 12 7.005.70y 66.66 42.70
Häkkinen et al30 101 5.802.40y 100.00 40.00
Evans et al32 270 9.409.10y 77.00 46.3010.70
Ylinen et al5 180 9.006.00y 100.00 46.006.00
Viljanen et al2 393 11.005.70y 100.00 45.006.60
Chiu et al42 218 1y 66.70 44.319.77
Stewart et al34 134 9.002.40y 89.00 43.3014.70
Taimela et al44 76 >3mo 73.00 47.0016.80
Salo et al29 101 5.8y 90.00 41.009.00
Jull et al45 46 10.1010.60y 100.00 9.6012.20
Ylinen18 180 9.006.00y 100.00 46.006.00
Waling et al39 103 6.753.51 100.00 38.106.10
Chiu et al 200533 218 >1y 68.00 45.006.00
Andersen et al35 198 >3mo 12.12 44.0011.00
Bronfort et al4 191 5y 59.20 45.0010.50
NOTE. Values are mean  SD or as otherwise indicated.

Frequency expected figures. Salo et al29 also reported significant benefits in

Exercise frequency varied among studies included in this review (see
table 3) with interventions typically ranging from 3 sessions a week
to daily sessions with benefits visible from all frequencies.1,5,29-36
Positive outcomes were reported for pain intensity, isometric
strength, health-related quality of life, and perceived disability in
trials incorporating 3 exercise sessions a week.5,18,33,35,37,38
Studies demonstrating significant increases in isometric
strength used an exercise frequency of between 3 and 5 times a
week.5,31,39 Programs that involved daily exercise over a 10-week
period demonstrated beneficial effects for a reduction in neck pain
and an increase in isometric strength.35 Falla et al31 found statis-
tically significant increases of 10.117.3N in their endurance
strength training group, whereas there were gains of 1.8N identified
in participants of the low-load craniocervical flexor muscle group
for the same frequency and intervention duration. Interventions of
at least 3 sessions weekly produced gains in strength, which is in
agreement with known resistance training benefits and its effects as
established by the American College of Sports Medicine guide-
lines.40 Hudson,1 Evans,32 and colleagues reported beneficial
outcomes; the most notable outcomes included reductions in pain
intensity and perceived reductions in disability from lower-
frequency exercise interventions (ie, 1e2 sessions/wk). Häkkinen
et al30 reported statistically and clinically significant reductions in
pain (37mm [51%] on a visual analog scale in the strengthening
and stretching group and 32mm [42%] in a stretching group) from
exercising 2.1 times a week and as little as 1.1 times in the fourth
quarter of a 12-month intervention. Additionally, significant range
of motion and isometric strength gains were visible in both groups
for flexion-extension and lateral flexion. For further information,
please see the PEDro Scale website (http://www.pedro.org.au/
english/downloads/pedro-scale/).
Although an exercise frequency was determined per the study
design (eg, 3 times/wk), adherence to the exercise protocol
appeared to vary quite substantially.1,5,31 Although exercise fre-
quency was, on average, 3 times a week, many studies, such as
that of Viljanen et al,2 found that over a 12-week period, training
adherence only ever reached approximately 39% (1.7 times/wk) of
health-related quality of life and an associated decrease in pain
intensity from exercising as little as twice a week. Participation in
an active exercise intervention appears to have positive effects on
pain intensity and isometric strength, even when desired fre-
quencies are not adhered to. This suggests that undertaking ex-
ercise as little as twice a week is beneficial, given the known
benefits of exercise on general health and well-being in a chronic
pain population.23 Many of the studies included in this review,
such as Salo,29 Evans,32 and colleagues, incorporated education
(see table 2) into their interventions as part of a multimodal
approach; as such, it cannot be assumed that benefits seen were
because of exercise alone because benefits may also be attribut-
able to this. High-frequency exercise interventions are not deemed
appropriate for a population with chronic neck pain because of
adherence barriers. According to patient reports, training fre-
quency decreased after the initial intervention had ended, with
some decreasing from an expected 3 times a week to 1.9 times a
week by the end of the first year.29
Findings, therefore, suggest that the most beneficial frequency
of exercise to target pain, weakness, and quality of life in a
population of people with chronic neck population with a varying
age range is 3 times a week.
Intensity
Training intensity varied depending on the type of exercise being
investigated, that is, resistance or endurance. Resistance regimens
usually conducted exercises based on percentage values ranging
between 20% and 70% of an individual’s maximal voluntary
contraction (MVC) (see table 3). For strength or resistance
training, baseline measurements of MVC were determined using
manual muscle testing methods with handheld dynamometers or
purpose-built fixed-frame dynamometers, or as commonly seen, 1
repetition or 12 repetition maximums.5 Endurance training per-
taining to the training of a larger group of muscles, that is, deep or
superficial cervical muscles or larger shoulder muscles to increase
muscular stamina, can be influenced by the ability of the

www.archives-pmr.org

Downloaded for Anonymous User (n/a) at Chilean Security Association from ClinicalKey.com by Elsevier on May 11, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
 www.archives-pmr.org

Frequency, intensity, time, and type of exercise and neck pain

Table 3 Individual study characteristics using the FITT principle
Results (effects on strength,
Study Frequency Intensity Time Type pain, disability, other) Format
Falla et al 31
Twice daily 12 repetition 10e20min daily over 6wk Strengthening/ EG Y 1.1cm VAS Individual
maximum resistance LLEG Y 0.9cm VAS
EG [ MVC 10.117.3N
Downloaded for Anonymous User (n/a) at Chilean Security Association from ClinicalKey.com by Elsevier on May 11, 2020.

LLEG [ 1.810.6N
P values not specified
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.

Hudson 1d/wk for 1h with Undisclosed 1h/wk for 6wk EG: strengthening/ Statistically significant improvements in pain and Individual
and Ryan1 physiotherapy (MG) resistance disability (P<.01) pre- to postintervention, not
20-min session with statistically significant between groups (pain:
physiotherapy PZ.67, disability: PZ.84). Pain: MG and UC Y
5e8 times (UC) 5/10 VAS
NDI score Y 12.3% (MG) and 7.4% (UC)
Häkkinen 3t/w Strength group: 12mo Strengthening/ Pain (VAS) Y by 37mm in strength and stretching Group
et al30 80% of MVC resistance groups (95% CI, e44 to e30). Stretching only
group Y e32mm (95% CI, e39 to e25mm).
Complete pain relief by 51% of strength and
stretch group, 42% of other. Insignificant change
(PZ.88; 95% CI, e7 to 7)
NDI score significantly lower at 12mo (P<.001), no
discernible difference in change between 2 training
groups
Isometric neck strength mean difference at 12mo,
strength and stretch group increase of 9N (95%
CI, 3e14), stretch only 9N (95% CI, 3e14,
PZ.88)
Evans et al32 2t/wk (supervised or Partially individualized Hourly sessions for a 12wk Strengthening Y Pain (11 Box Numerical Rating Scale). Mean Supervised
independent (load and repetitions) treatment period (follow- differences at 12wk from baseline. group and
sessions) according to abilities up at 12mo) Exercise vs exercise and manual therapy: e.19 individual
of individual (eg, (95% CI, e.89 to .51; PZ1)
baseline 3 sets Exercise and manual therapy vs home exercise
of 15e25 repetitions program: e1.27cm (95% CI, e1.96 to .58;
using variable head PZ.001)
weights of 1.25e10lb Exercise vs home exercise program: e1.07cm
[0.5e4.5kg]) (95% CI, e1.77 to .38; PZ.001)
Y NDI scores. Mean differences at 12 wk.
Exercise and manual therapy vs exercise: e2.26
(95% CI, e5.43 to .92; PZ.265)
Exercise and manual therapy vs home exercise
program: e4.66 (95% CI, e7.8 to e1.52;
PZ.001)
Exercise vs home exercise program: e2.4 (95%

775
CI, e5.56 to .76; PZ.001)
(continued on next page)
 776
Table 3 (continued )
Results (effects on strength,
Study Frequency Intensity Time Type pain, disability, other) Format
Ylinen et al 5
3e5t/wk Strengthening group 12mo intervention Strengthening Y Neck pain VAS Individual
80% of MVC and endurance Controls: Y e16mm (95% CI, e22 to e9)
Downloaded for Anonymous User (n/a) at Chilean Security Association from ClinicalKey.com by Elsevier on May 11, 2020.

(individual) Endurance group: e35mm (95% CI, e42 to e28)

Gravity for endurance Strength group: e40mm (95% CI, e48 to e32)
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.

group P.001 (endurance vs control, strength vs control)

Y NDI score
Control: e12 (95% CI, e15 to e81)
Endurance group: e22 (95% CI, e26 to e19)
Strength group: e23 (95% CI, e27 to e20)
P.001 (endurance vs control, strength vs control)
[ Isometric strength
Strength group [ MVC 110% (flexion), 76%
(rotation), 69% (extension)
Endurance group [ MVC 28% (flexion), 29%
(rotation), 16% (extension)
Controls [MVC 10% (flexion), 10% (rotation),
7% (extension)
Viljanen 3 exercise sessions Low-load intensity 12wk treatment Dynamic or Mean difference in pain reports as per VAS Individual
et al2 a week or intervention relaxation At 3mo follow-up dynamic group vs control: .20
5 relaxation 12mo follow-up period therapy (95% CI, e.40 to 0.7)
sessions a week Exercise sessions 30min At 12mo: 0.5 (95% CI, e7.6 to 0.3)
in duration Mean difference in dynamic muscle strength
At 3mo DyG vs control: 0.1 (95% CI, e2.2 to 2.5)
At 12mo: e0.6 (95% CI, e3.2 to 2.1)
Mean difference in disability as per NDI score
At 3mo follow-up DyG vs control: 0.8 (95%
CI, e1.9 to 3.6)
At 12mo: e0.1 (95% CI, e3 to 2.9)
P values are not given
Chiu et al43 2t/wk 20% of 12 repetition 6wk treatment intervention 6wk treatment Pain: VPNS mean difference Individual
maximum 6mo follow-up period, 6mo Control: .302.48 (.475), TENS group: .602.54
Exercise sessions 45min follow-up (.027), exercise: 1.572.67 (<.001)
duration Disability NPQ mean difference
Control: .23.63 (.003), TENS: .38.60 (<.001),
www.archives-pmr.org

exercise: .39.62 (<.001)

Neck muscle strength (N)

C. O’Riordan et al
Control: 1.253.94 (.03), TENS: 1.423.9 (.02),
exercise: 2.284.22 (<.001)
Control group differences were not maintained
at 6mo follow-up
(continued on next page)
 www.archives-pmr.org

Frequency, intensity, time, and type of exercise and neck pain

Table 3 (continued )
Results (effects on strength,
Study Frequency Intensity Time Type pain, disability, other) Format
Stewart et al34 2t/wk Described in text as 6wk intervention, 1h Combination Y Pain: VAS combination therapy vs advice/ Individual
individualized, exercise sessions therapy, control: e1.1 (95% CI, e1.8 to 0.3; PZ.005). Not
progressive, and strengthening, significant at 12mo (PZ.59)
Downloaded for Anonymous User (n/a) at Chilean Security Association from ClinicalKey.com by Elsevier on May 11, 2020.

submaximal endurance, NDI score

coordination CombG vs advice: e2.7 (95% CI, e4.5 to .09;
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.

Aerobic PZ.004). Not significant at 12mo (PZ.08)

Taimela et al44 1t/wk Low load and low 12wk intervention Relaxation therapy, Pain as per VAS Individual
progression Follow-up at 12mo proprioceptive At baseline 5521mm for both active exercise
1h sessions exercise, group and home exercise group (control group)
education At 6wk, active mean VAS 22mm, home 23mm,
control 39mm (PZ.018)
No statistically significant difference between
groups noted at 12mo follow-up; tendency in
favor of home exercise group
Salo et al29 1e2t/wk 80% of MVC of neck 12mo exercise Strengthening/ Statistically significant improvements in 5 out of Individual
musculature intervention resistance, the 8 health-related quality of life dimensions
stretching in the combined strengthening and stretching
group, namely physical and social functioning,
bodily pain and health perceptions, and role
physical; for the strengthening group,
improvements were seen in 4 of 8 of these
dimensions
Bodily pain decreases increased week exercise
adherence in the combined therapy group
(PZ.05; 95% CI, .00e.27)
Physical functioning improvements in the
strengthening group resulted in increased weekly
exercise adherence (PZ.03; 95% CI, .03e.42)
Jull et al45 7t/wk Low load: against gravity 6wk exercise intervention CCF training, Y EMG activity in superficial neck flexors in CCF Individual
Strengthening group: (1h/wk with physio- proprioceptive training group (P<.001). Increase in deep neck
individualized 12 therapy) and 10e20min training flexor electromyographic activity in CCF group
repetition maximum, of daily exercise (PZ.05)
progressions based on Y Pain scores as measured on VAS: CCF group
50% of 10 repetition (P<.001), strength group (P<.05). CCF group
maximum, 75% of 10 Y e2.8cm, proprioception training group Y e1.9cm
repetition maximum, NDI score
10 repetition maximum CCF group e5.04.2, strength group e3.52.3
load PZ.05
(continued on next page)

777
 778
Table 3 (continued )
Results (effects on strength,
Study Frequency Intensity Time Type pain, disability, other) Format
18
Ylinen 3e5t/wk Strengthening group 12mo intervention 3y follow-up from Median VAS at 3y follow-up: 14 (95% CI, 4e39; Individual
80% of MVC initial 2003 study PZ.069)
Downloaded for Anonymous User (n/a) at Chilean Security Association from ClinicalKey.com by Elsevier on May 11, 2020.

(individual) Median NDI score value at 3y follow-up: 12 (95%

Gravity for endurance CI, 4e22; PZ.072)
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.

group
Chiu et al33 2t/wk EG: 8e12 repetition 6wk exercise intervention Strengthening/ Pain scores as per VPNS after 6wk intervention Individual
maximum or 30% 6mo follow-up resistance Mean difference control vs exercise: 1 (95%
of MVC and increased Education/advice CI, 0.2e1.7; PZ.01)
by 5% when a set NPQ
of 12 was achieved Mean difference control vs exercise: 0.2 (95%
CI, 0.0e0.4; PZ.03)
Isometric strength
Significant increase (95% CI, 26.1e45.7; P<.01)
in all 6 directions
At 6wk, significantly better improvements (mean
difference: 0.4e2.2lb (0.5e1kg); PZ.57e.00) in
the exercise group compared with control group. Not
significant at 6mo follow-up
Andersen et al35 5t/wk Moderate to high based 10wk exercise intervention Strengthening/ NDI score (0–10) between group differences after 10wk Individual
on elastic exercise 2e12min exercise resistance 2min exercise group vs control: e1.4 (95% CI, e2.0
band coloring red, sessions (total between (elastic exercise to .07; P<.001)
green, and blue 10 and 60min of band training) 12min exercise group vs control: e1.9 (95% CI,
(red elastic exercise exercise a week) e2.5 to e1.2; P<.001)
bandZmoderate for 2min vs 12min exercise groups: 0.5 (95% CI, e0.3
women, greenZ to 1.3; PZ.12)
moderate for men etc) [ Muscle strength (Nm)
2min exercise vs control: 2 (95% CI, 0.5e3.5;
PZ.008)
12min vs control: 1.7 (95% CI, 0.2e3.3; PZ.02)
2min vs 12min exercise group: 0.3 (95% CI, e1.3
to 1.8; PZ.74)
Bronfort et al4 1 t/wk Low load individualized 12wk exercise intervention NA Pain scores baseline to 11wk Individual
12mo follow-up Spinal manipulation and exercise (group 1):
Maximum 45min exercise 5615 to 23.618
www.archives-pmr.org

session duration MED X group (group 2): 57.115 to 24.119.7

Spinal manipulation (group 3): 56.612.8 to

C. O’Riordan et al
31.321.8
Group 1 vs group 2: effect size, .03; 95% CI, .41e.35
Group 1 vs group 3: effect size, e.25; 95%
CI, e.12 to e.61
(continued on next page)
Frequency, intensity, time, and type of exercise and neck pain 779

cardiovascular system to provide oxygen rich blood to the area

exercise supervision with physical therapist that included stretching, upper body strengthening, aerobic exercise, and dynamic progressive resistance exercises; MG, multimodal group; NA, not applicable; NDI,
Abbreviations: CCF, craniocervical flexion; CI, confidence interval; CombG, combination group; DyG, dynamic group; EG, exercise group; LLEG, low-load exercise group; MED X exercise group, one-to-one
being exercised. These interventions were based on a lower in-
Format tensity and primarily based on gravity, intending to increase
physical muscular endurance.41 The mean age of participants
across the studies in this review was mid-40s with age ranges
spanning between 18 and 63 years. Therefore, to target the

neck disability index; VPNS, verbal pain numerical scale; NPQ, Northwich Pain Questionnaire; TENS, transcutaneous electrical nerve stimulation; UC, usual care; VAS, visual analog scale.
training needs of individual participants, exercise prescriptions
were predominantly individualized. Minimum intensity thresholds
were set at or above that at which participants were expected to
Group 2 vs group 3: effect size, e.28; 95%

Group 1 vs group 3: effect size, e.14; 95%

Group 2 vs group 3: effect size, e.27; 95%

Group 1 vs group 2: effect size, .16; 95% work to induce strength benefits.5,31,33,37 In a study by Ylinen
et al,5 the resistance training group conducted multidirectional
strengthening exercises (eg, flexion, lateral flexion, and rotation)
Group 3: 27.810.3 to 15.812.3
Group 2: 26.710.4 to 12.49.9
Group 1: 26.48.5 to 14.18.7

using elastic exercise bands, whereas an endurance group con-

ducted lower-intensity exercises against gravity. Both groups
Results (effects on strength,

showed significant gains in strength (see table 3). Observed

NDI score baseline to 11wk

baseline levels of strength were so low in the sample population

pain, disability, other)

(such that 5 of the participants in the endurance training group

CI, .10 to e.66

CI, .54 to e.22

CI, .22 to e.57

struggled to lift their head from the bed) that strength gains were
CI, .10e.65

visible from exercising at an intensity as low as working against

gravity. This finding strengthens the recommendation for indi-
vidually tailoring exercise interventions; low-intensity exercise is
defined as against gravity, and medium- to high-intensity exercise
is defined as against gravity with further added resistance.35
In an attempt to combat adverse effects of training, such as
delayed onset muscle soreness or an increase in pain, which may
impact end results, a variety of studies reviewed here (see table 3)
incorporated lower-intensity resistance training for some exercise
sessions. For example, in a study by Ylinen et al,42 participants
conducted exercise sessions at the prescribed intensity on day 1 of
Type

the exercise intervention; in the following exercise session, par-

ticipants were only required to work at half that prescribed in-
tensity. This was a measure taken to reduce excessive loading on
musculoskeletal systems and aerobic endurance.
Progressive intensities are required to avoid plateauing and
enable continued training gains.32,43 For example, Chiu et al33
commenced training at 20% of MVC values; exercise intensity
progressed in increments of 5% when an individual was able to
conduct a set of 12 repetitions of flexion strengthening exercises (see
Time

table 3). Falla et al31 used an alternative approach by conducting a 2-

phase strengthening program. Phase 1 consisted of a 12-repetition
set (prescribed weight based on 12 repetition maximum weight)
for the first 2 weeks. The remaining 4 weeks of the 6-week exercise
intervention were then spent executing 15 repetitions per set.
Because both had positive results, designing an exercise protocol
that allows participants to become accustomed to an exercise before
Intensity

increasing the intensity is beneficial and positively effects outcomes.

Although high-dose/intensity exercise programs were seen to
lead to reduction in neck pain,32 low-dose or low-load endurance
exercise programs were still seen to have advantageous results.31 For
endurance interventions, intensity was based on gravity, for example
supine lying and lifting head against gravity.5 This surprising result
has been hypothesized to be the result of the learning effect involved
in the movement and the low-strength baseline values of participants.
Frequency

Therefore, from collating and reviewing the evidence, training in-

tensity in a chronic neck pain population should be individually
Table 3 (continued )

tailored based on baseline abilities as defined by their MVC values.

Bronfort et al4
(continued)

Time
Study

The time spent exercising in an individual exercise session and the

length of time the intervention lasted varied in length between

www.archives-pmr.org

Downloaded for Anonymous User (n/a) at Chilean Security Association from ClinicalKey.com by Elsevier on May 11, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
780 C. O’Riordan et al

Table 4 Components of study exercise interventions

Resistance/ Manual Proprioception/
Study Strengthening Endurance Dynamic Stretching Therapy Other Training Postural
Falla et al31 O O X X X X X
Hudson and Ryan1 O O X X O Education X
Häkkinen et al30 O X X O X X X
Evans et al32 O X X X O Education X
Ylinen et al5 O O X O X Aerobic exercise (controls) X
Viljanen et al2 X O X O X Relaxation techniques X
Chiu et al33 O X O X X Infrared irradiation X
Stewart et al34 O X X X X Aerobic exercise, advice/education X
Taimela et al44 X O X X X Advice, education, behavioral O
support, relaxation techniques
Miller et al38 O O X O O X X
Salo et al29 O O X O X X X
Jull et al45 X X X X X Craniocervical Flexion O
Ylinen18 O O X O X X X
Chiu et al43 O X X X X Transcutaneous electrical nerve X
stimulation
Andersen et al35 O X X X X Advice/education X
Bronfort et al4 O X X X O Aerobic exercise X
Waling et al39 O O X X X Advice, coordination training X
Abbreviations: O, yes; X, no.

studies (see table 3). It is difficult to ascertain the actual cumu-
lative time spent exercising over the course of an intervention
because of a lack of adherence by participants once an initial
supervised exercise intervention was completed.18,30,32,35 Single
exercise bouts ranged from 10 minutes to 1 hour in duration in the
studies reviewed; however, exercise interventions usually
ranged from 6 to 12 weeks with follow-up at 3, 6, and 12
months.1,5,29-35,43 Benefits were seen from exercising for as little
as 10 minutes a day 3 times a week.29,33,36 Because exercising a
specific muscle group for an hour at a time may not be desirable
for this particular population, a regimen which provides clinically
significant results in the least time spent exercising should be
used, that is between 2 and 20 minutes per session.32
The duration of exercise interventions varied with effective
interventions ranging from 6 weeks to 3 years. Generally, in-
terventions ranged between 6 to 12 weeks with follow-up occur-
ring over a year-long period. Short duration interventions have
been shown to produce immediate benefits in isometric strength,
pain intensity, and perceived disability; however, long-term
follow-up shows that if exercise is not conducted after the initial
intervention is over, benefits are lost.2,5,18,30,32 Outcomes found to
be statistically significantly different immediately after an inter-
vention were not found to be so 1 year later in most studies that
conducted such follow-ups.2,32-34 Therefore, it is important to take
overall findings, including long-term benefits of exercise in-
terventions, into consideration when formulating an optimal ex-
ercise intervention. Because episodes of chronic pain may be
transient, it is important to maintain exercise levels beyond that of
the initial scope of the study to maintain long-term benefits.4,32
Strength or resistance training interventions need to be of a
minimum 6-weeks duration to ensure there is sufficient opportu-
nity for muscle hypertrophy to occur.5,35,43 Although interventions
seen in this review were scheduled for a similar length in duration,
the actual cumulative time spent exercising may have differed
greatly. For example, Evans et al32 conducted an exercise inter-
vention that lasted 12 months; however, during that time only 20
hours of supervised exercise were conducted. Salo et al29 provided
an intervention of the same length of time but with a desired
accumulative exercise duration of 156 hours over the course of the
year (see table 3). Both methodologies had significantly desirable
outcomes in their respective interventions; one must consider how
likely an individual is to adhere fully to a year- long program or to
attend 20 supervised physiotherapy sessions when formulating an
optimally effective intervention. Salo29 aimed to have an accu-
mulative exercise duration of approximately 156 hours over the
course a year; however, according to exercise diaries kept by
patients, the reality showed that by the final quarter of the trial
period, approximately 1 hour of exercise, opposed to the desired 3
hours, was being performed by participants over a weekly period.
Therefore, when examining the time spent exercising and the
duration of an exercise intervention to provide the most optimal
results, it is recommended that interventions must last at least
6 weeks for physiological benefits to occur. Exercising between
12 and 45 minutes produces the best results with 30 to 45
minutes being a reasonable and largely attainable exercise ses-
sion duration.
Type
Clinical guidelines by the orthopedic section of the American
Physical Therapy Association25 detail that exercise should be part
of a treatment intervention for chronic neck pain. Along with
stretching, coordination, centralization procedures, nerve mobili-
zations, traction, manual therapy, patient education, and coun-
seling, active exercise in the form of strengthening and/or
endurance exercise are advocated. Though these guidelines
formed similar conclusions to this review, the novelty of providing

www.archives-pmr.org

Downloaded for Anonymous User (n/a) at Chilean Security Association from ClinicalKey.com by Elsevier on May 11, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
Frequency, intensity, time, and type of exercise and neck pain
an exercise prescription in an FITT format makes this review
clinically applicable.25
Although there has been much debate as to which form of
exercise is most beneficial, a combination of both resistance and
endurance exercise and stretching reaps the greatest benefits for
participants.5,29,34,38 These studies showed immediate and some
long-term benefits in increased isometric strength, a desirable
outcome from a physiotherapy perspective because it is widely
postulated that the deep cervical flexor is substantially weaker in
those with chronic neck pain. Endurance exercises are also of
benefit; the stabilizing role of the deep neck flexors at the cervical
spine is commonly affected in chronic neck pain, and these ex-
ercises help build the endurance required to maintain head pos-
tures over an extended period of time.22
Evaluation of the studies in this review demonstrate that resis-
tance exercise made up approximately 50% of the interventions
with the remainder being devoted to stretching, aerobic exercise,
and/or education in order to target the known weaknesses that may
occur in the cervical musculoskeletal system.1,5,32
It was rarely observed that both resistance and endurance ex-
ercise were part of the same exercise program; rather, the indi-
vidual types of exercises were compared directly for their
effectiveness. This may be because of the study methodology and
aim to determine the benefits of any 1 active exercise form in a
chronic neck pain population before combining different forms of
exercise. According to this review and clinical guidelines, there is
evidence for the beneficial effects of both forms of exercise. A
combination of strengthening, stretching, and aerobic exercise
appears to have the most beneficial effects on isometric strength
and a reduction in pain intensity and disability with an overall
increase in perceived well-being.25
The integration of aerobic exercise into many of the studies
reviewed here5,29,32,34 resulted in increased positive health-related
quality of life perceptions29 and patient satisfaction and global
perceived benefit.33 Though not commonly investigated, potential
benefits from proprioceptive exercises and joint position training
as studied by Jull et al45 found that joint position error was sta-
tistically significantly improved. There were also advantageous
results seen for reduced pain and disability scores in the same
training group when compared with a craniocervical flexion
training regimen. Therefore, including 1 of these in an exercise
intervention could produce favorable outcomes.1,5
Barriers to exercise (adherence, adjuncts, delivery)
The importance of education in a chronic pain population has long
been established, primarily in a chronic back pain population.12
Fear avoidance and a lack of understanding of exercise benefits
are characteristics of those with chronic pain.24 These characteris-
tics are postulated to be causative factors in the development of a
chronic pain state.12 Studies in table 2 that included education as a
component of a multimodal approach had beneficial results, such as
reduced perceived levels of disability. A Cochrane review by Gross
et al21 found evidence of varying quality, which suggests that ed-
ucation in chronic neck pain is beneficial for improvements in pain,
function, quality of life, and exercise adherence; these results are
further mirrored by studies in this review (see table 2).29 Thera-
peutic patient education should emphasize a patient-centered
approach to specifically fit the needs of a patient.23
Adherence is predominantly only a superficially measured
outcome in chronic pain population studies.32 The type of delivery
www.archives-pmr.org
Downloaded for Anonymous User (n/a) at Chilean Security Association from ClinicalKey.com by Elsevier on May 11, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
781
of an intervention appears to affect adherence to a program, and
designing what is perceived to be an optimal exercise intervention
for a chronic neck pain population is of little significance if it is
not going to be adhered to. Though it may be suggested that
conducting exercise in a group setting would encourage partici-
pation because of the socialization and group dynamic factors, in
fact, supervised group sessions offered little additional benefits
from individual sessions.32
Exercise interventions reviewed here were largely conducted in
home settings, community centers, or hospital settings; therefore, cost
effectiveness must also be considered in the development and de-
livery of an optimal program. Viljanen2 attempted to reproduce the
beneficial effects found by Ylinen5 in a more cost-effective home-
based setting. Though results were not of statistical or clinical sig-
nificance, the availability for patients to conduct exercise in a more
cost-effective manner than being supervised by a health professional
is an important factor, particularly in current economic climates.
According to Ylinen,5 the potential barriers to adherence
include the seasonal variation of symptoms. Pain is exacerbated in
the autumn with some relief in the spring; therefore, the timing of
an intervention may have a bearing on observed results. Studies in
this review did not declare the time of year the interventions were
undertaken, making it impossible to draw conclusions on
what intervention had the best outcome based on time of
year conducted.
Psychosocial factors, including depression and anxiety, are
reported to affect between 20% to 50% of people with chronic
pain.14 Experiencing such symptoms can effect a patient’s ability
to participate in their own self-care and pose difficulties in
modulating pain because of altered neurotransmitter balance.14
The presence of such symptoms must be acknowledged when
developing a treatment intervention for this population. Inclusion
of psychosocial or counseling components as part of an inter-
vention in parallel with education may be beneficial in increasing
adherence in future studies.
Study limitations
Methodologic bias
Articles included and discussed in this review were critically
appraised for their study methodology and resultant findings.
Literature searches, article selection, data extraction, and synthesis
were conducted by only 1 reviewer; this potentially creates a se-
lection bias and should be considered when interpreting the con-
clusions drawn from this review. Articles retrieved were applied to
previously outlined inclusion and exclusion criteria to determine
suitability and were also assessed using the PEDro Scale to
determine levels of evidence. Most studies reviewed were of good
(score of 6 or 7) and not excellent (score 10) methodologic
quality. Exercise interventions are difficult to blind from the
participants because of the study nature. Therefore, it is possible
that results seen in this review may have been biased. Therapist
and assessor blinding, though not commonly seen in the studies
here (see table 3), can strengthen findings and eliminate bias.6,31
Multimodal approach
Many of the studies reviewed here were of multimodal approach;
education or manual therapies were always given in conjunction
with exercise. Therefore, it is important to consider this when
interpreting the findings and recommendations outlined in this
article because confounding variables cannot be ruled out.
782
Outcome assessment
Some studies discussed in this review (see table 3) used subjective
outcomes as their primary evaluation method. Self-assessment can
lead to bias and may not be a true indication of the results of an
intervention. Objective measures are always more accurate.
Conclusions
The findings of the review are in agreement with the current
guidelines for a chronic neck pain population, which state that
programs should be multimodal to include active exercise and
education. Exercising a minimum of 3 times a week for approx-
imately 30 to 60 minutes at an intensity reaching up to 80% of
MVC to induce strength gains and reduce pain and disability is
recommended. Resistance exercises to increase isometric strength
of the deep cervical flexors are warranted to ensure correct muscle
recruitment and function.22 Endurance exercises incorporated into
a regimen that uses gravity as resistance can increase the postural
functioning of the deeper cervical muscles, which may reduce
pain in a chronic neck pain population.46 Aerobic exercises can
help induce an increased perceived feeling of global well-being
and health-related quality of life.29 Effective interventions
should last between 6 and 12 weeks with encouragement to
continue life-long exercise to maintain long-term benefits and the
longevity of alleviated pain-related symptoms. A combination of
group and home-based exercises is optimal for increasing adher-
ence and long-term motivation. Every effort should be made to
make exercise facilities readily available for this population to aid
adherence and ensure permanence of exercise benefits.
Clinical implications
This review has provided clinicians with an immediately clinically
applicable physiotherapy intervention for a chronic neck pain
population through the use of the FITT principle. It would be
beneficial to incorporate or devise a future intervention trial for
this clinical population using this proposed FITT principle and
assess its effectiveness for outcomes, such as isometric strength,
pain, neck disability, and health-related quality of life, to cement
the findings of this review and further the level and scope of ev-
idence for active exercise in a chronic neck pain population.
Keywords
Exercise; Neck pain; Physical therapy modalities; Rehabilitation
Corresponding author
Cliona O’Riordan, BSc, Clinical Therapies Department, Univer-
sity of Limerick, Limerick, Ireland. E-mail address: Cliona.
ORiordan@ul.ie.
References
1. Hudson JS, Ryan CG. Multimodal group rehabilitation compared to
usual care for patients with chronic neck pain: a pilot study. Man Ther
2010;15:552-6.
2. Viljanen M, Malmivaara A, Uitti J, Rinne M, Palmroos P, Laippala P.
Effectiveness of dynamic muscle training, relaxation training, or
Downloaded for Anonymous User (n/a) at Chilean Security Association from ClinicalKey.com by Elsevier on May 11, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
C. O’Riordan et al
ordinary activity for chronic neck pain: randomised controlled trial.
BMJ 2003;327:475.
3. Manchikanti L, Singh V, Datta S, Cohen SP, Hirsch JA; American
Society of Interventional Pain Physicians. Comprehensive review of
epidemiology, scope and impact of spinal pain. Pain Physician 2009;
12:E35-70.
4. Bronfort G, Evans R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A
randomized clinical trial of exercise and spinal manipulation for pa-
tients with chronic neck pain. Spine (Phila Pa 1976) 2001;26:788-97;
discussion 798-9.
5. Ylinen J, Takala EP, Nykänen M, et al. Active neck muscle training in
the treatment of chronic neck pain in women: a randomized controlled
trial. JAMA 2003;289:2509-16.
6. Raftery MN, Sarma K, Murphy AW, De la Harpe D, Normand C,
McGuire BE. Chronic pain in the Republic of Irelanddcommunity
prevalence, psychosocial profile and predictors of pain-related
disability: results from the Prevalence, Impact and Cost of Chronic
Pain (PRIME) study, part 1. Pain 2011;152:1096-103.
7. Researchers get a handle on neck pain. HealthCanal - Health News.
Available at http://www.healthcanal.com/disorders-conditions/17408-
researchers-get-a-handle-on-neck-pain.html. Accessed February 4,
2013.
8. Borghouts JA, Koes BW, Vondeling H, Bouter LM. Cost-of-illness of
neck pain in the The Netherlands in 1996. Pain 1999;80:629-36.
9. Carnes D, Gallagher J, Herne S, Munday E, Ritchie S, Underwood M.
Mapping care pathways and estimating the number and cost of muscu-
loskeletal chronic pain patients to inform the development and imple-
mentation of a new service. Prim Health Care Res Dev 2008;9:241-7.
10. Kindler L, Jones K, Perrin N, Bennett R. Risk factors predicting the
development of widespread pain from chronic back and neck pain.
J Pain 2010;11:1320-8.
11. Sheather-Reid RB, Cohen ML. Psychophysical evidence for a
neuropathic component of chronic neck pain. Pain 1998;75:341-7.
12. O’Sullivan P. Diagnosis and classification of chronic low back pain
disorders: maladaptive movement and motor control impairments as
underlying mechanism. Man Ther 2005;10:242-55.
13. Moseley GL, Flor H. Targeting cortical representations in the treat-
ment of chronic pain: a review. Neurorehabil Neural Repair 2012;26:
646-52.
14. Whitten CE, Donovan M, Cristobal K. Treating chronic pain: new
knowledge, more choices. Perm J 2005;9:9-18.
15. Goode AP, Freburger J, Carey T. Prevalence, practice patterns, and
evidence for chronic neck pain. Arthritis Care Res (Hoboken) 2010;
62:1594-601.
16. Webb R, Brammah T, Lunt M, Urwin M, Allison T, Symmons D.
Prevalence and predictors of intense, chronic and disabling neck and
back pain in the UK general population. Spine (Phila Pa 1976) 2003;
28:1195-202.
17. Guez M. Chronic neck pain. An epidemiological, psychological and
SPECT study with emphasis on whiplash-associated disorders. Acta
Orthop Suppl 2006;77. preceding 1, 3-33.
18. Ylinen J. Physical exercises and functional rehabilitation for the
management of chronic neck pain. Eura Medicophys 2007;43:119-32.
19. Guez M, Hildingsson C, Nilsson M, Toolanen G. The prevalence of
neck pain: a population-based study from northern Sweden. Acta
Orthop Scand 2002;73:455-9.
20. Verhagen AP, Scholten-Peeters GG, van Wijngaarden S, de Bie RA,
Bierma-Zeinstra SM. Conservative treatments for whiplash. Cochrane
Database Syst Rev 2007(2):CD003338.
21. Croft PR, Lewis M, Papageorgiou AC, et al. Risk factors for
neck pain: a longitudinal study in the general population. Pain 2001;
93:317-25.
22. Falla D. Unravelling the complexity of muscle impairment in chronic
neck pain. Man Ther 2004;9:125-33.
23. Gross A, Forget M, St George K, et al. Patient education for neck pain.
Cochrane Database Syst Rev 2012;3:CD005106.
24. Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J,
Bronfort G; Cervical Overview Group. Exercises for mechanical
www.archives-pmr.org
Frequency, intensity, time, and type of exercise and neck pain
neck disorders: a review. Cochrane Database Syst Rev 2005 (3):
CD004250.
25. Childs JD, Cleland JA, Elliott JM, et al. Neck pain: clinical practice
guidelines linked to the International Classification of Functioning,
Disability, and Health from the Orthopedic Section of the American
Physical Therapy Association. J Orthop Sports Phys Ther 2008;38:A1-34.
26. Scholten-Peeters GG, Bekkering GE, Verhagen AP, et al. Clinical
practice guidelines for the physiotherapy in patients with whiplash-
associated disorders. Spine (Phila Pa 1976) 2002;27:412-22.
27. Oberg E. Physical activity prescription: our best medicine. Integrative
Medicine 2007;6:18-22.
28. Gross AR, Hoving JL, Haines TA, et al. Manipulation and mobi-
lisation for mechanical neck disorder. Cochrane Database Syst Rev
2004 (1):CD004249.
29. Salo P, Ylönen-Käyrä N, Häkkinen A, Kautiainen H, Mälkiä E,
Ylinen J. Effects of long-term home-based exercise on health-related
quality of life in patients with chronic neck pain: a randomized
study with a 1-year follow-up. Disabil Rehabil 2012;34:1971-7.
30. Häkkinen A, Kautiainen H, Hannonen P, Ylinen J. Strength training
and stretching versus stretching only in the treatment of patients with
chronic neck pain: a randomized one-year follow-up study. Clin
Rehabil 2008;22:592-600.
31. Falla D, Jull G, Hodges P, Vicenzino B. An endurance-strength
training regime is effective in reducing myoelectric manifiestations
of cervical flexor muscle fatigue in females with chronic neck pain.
Clin Neurophysiol 2006;117:828-37.
32. Evans R, Bronfort G, Schulz C, et al. Supervised exercise with and
without spinal manipulation performs similarly and better than home
exercise for chronic neck pain: a randomized controlled trial. Spine
(Phila Pa 1976) 2012;37:903-14.
33. Chiu TT, Lam TH, Hedley AJ. A randomized controlled trial on the
efficacy of exercise for patients with chronic neck pain. Spine (Phila
Pa 1976) 2005;30:E1-7.
34. Stewart MJ, Maher CG, Refshauge KM, Herbert RD, Bogduk N,
Nicholas M. Randomised controlled trial of exercises for chronic
whiplash-associated disorders. Pain 2007;128:59-68.
www.archives-pmr.org
Downloaded for Anonymous User (n/a) at Chilean Security Association from ClinicalKey.com by Elsevier on May 11, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
783
35. Andersen LL, Saervoll CA, Mortensen OS, Poulsen OM, Hannerz H,
Zebis MK. Effectiveness of small daily amounts of progressive
resistance training for frequent neck/shoulder pain: randomised
controlled trial. Pain 2011;152:440-6.
36. Sarig-Bahat H. Evidence for exercise therapy in mechanical neck
disorders. Man Ther 2003;8:10-20.
37. Häkkinen A, Salo P, Tarvainen U, Wirén K, Ylinen J. Effect of manual
therapy and stretching on neck muscle strength and mobility in
chronic neck pain. J Rehabil Med 2007;39:575-9.
38. Miller J, Gross A, D’Sylva J, et al. Manual therapy and exercise for
neck pain: a systematic review. Man Ther 2010;15:334-54.
39. Waling K, Sundelin G, Ahlgren C, Järvholm B. Perceived pain before
and after three exercise programsea controlled trial of women with
work-related trap myalgia. Pain 2000;85:201-7.
40. http://www.acsm.org Recommendations for Resistance Training Ex-
ercise (ACSM 1995).
41. Helgerud J, Engen LC, Wisloff U, Hoff J. Aerobic endurance
training improves soccer performance. Med Sci Sports Exerc 2001;
33:1925-31.
42. Ylinen JJ, Takala EP, Nykänen MJ, Kautiainen HJ, Häkkinen AH,
Airaksinen OV. Effects of twelve-month strength training subsequent
to twelve-month stretching exercise in treatment of chronic neck pain.
J Strength Cond Res 2006;20:304-8.
43. Chiu TT, Hui-Chan CW, Chein G. A randomized clinical trial of
TENS and exercise for patients with chronic neck pain. Clin Rehabil
2005;19:850-60.
44. Taimela S, Takala EP, Asklöf T, Seppälä K, Parviainen S. Active
treatment of chronic neck pain: a prospective randomized intervention.
Spine (Phila Pa 1976) 2000;25:1021-7.
45. Jull GA, Falla D, Vicenzino B, Hodges PW. The effect of therapeutic
exercise on activation of the deep cervical flexor muscles in people
with chronic neck pain. Man Ther 2009;14:696-701.
46. Falla D, Bilenkij G, Jull G. Patients with chronic neck pain
demonstrate altered patterns of muscle activation during perfor-
mance of a functional upper limb task. Spine (Phila Pa 1976) 2004;
29:1436-40.