Mueller Et Al 2023 Resistance Motor Control and Mindfulness Based Exercises Are Effective For Treating Chronic

[ literature review ]
JULIANE MUELLER, PhD1a • JONAS WEINIG, BSc1a • DANIEL NIEDERER, PhD2

SARAH TENBERG, MSc1,3 • STEFFEN MUELLER, PhD1
Resistance, Motor Control, and

Mindfulness-Based Exercises Are Effective
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for Treating Chronic Nonspecific Neck Pain:

A Systematic Review With Meta-Analysis
and Dose-Response Meta-Regression
W
ith a 12-month prevalence of 30% to 50%,40 neck pain is Resistance, mindfulness-based (Yoga/
one of the leading causes of disease burden.69 Exercise and Pilates/Tai Chi/Qui Gong), and motor
physiotherapy interventions are effective first-line treatments control exercises were equally effective
Copyright © 2023 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
and the most effective exercise treatments

for relieving neck pain and improving function. 24,37,71
for patients with neck pain.24 Because
these effects were indirectly derived via
U OBJECTIVE: We aimed to analyze the effects −1.27; 95% confidence interval [CI]: −2.26, −0.28; I2 = network meta-analyses, a head-to-head
and dose-response relationship of the most effec- 96%; disability: SMD, −1.76; 95% CI: −3.16, −0.37; I2 = comparison of each treatment would
tive exercises for improving pain and disability in 98%), motor control exercise (pain: SMD, −2.29; 95%
help settle debate about which exercise
people with chronic nonspecific neck pain. CI: −3.82, −0.75; I2 = 98%; disability: SMD, −2.42;
approach has the most beneficial effects
U DESIGN: Intervention systematic review with 95% CI: −3.38, −1.47; I2 = 94%), and Yoga/Pilates/
Tai Chi/Qui Gong exercise (pain: SMD, 1.91; 95% CI: for neck pain.
meta-analysis.
−3.28, −0.55; I2 = 96%; disability: SMD, −0.62; 95% Understanding the potential dose-re-
U LITERATURE SEARCH: We searched the
Journal of Orthopaedic & Sports Physical Therapy®
CI: −0.85, −0.38; I2 = 0%). Yoga/Pilates/Tai Chi/Qui sponse relationship for exercise therapy
PubMed, PEDro, and CENTRAL databases from Gong exercise was more effective than other exercises
their inception to September 30, 2022. would help clinicians because the ideal
(SMD, −0.84; 95% CI: −1.553, −0.13; I2 = 86%) for
U STUDY SELECTION CRITERIA: We included reducing pain. For disability, motor control exercise
dose for people with neck pain remains
randomized controlled trials that involved people was superior to other exercises (SMD, −0.70; 95% CI: unclear.24,37,71 Two analyses were ham-
with chronic neck pain adopting a longitudinal −1.23, −0.17; I2 = 98%). There was no dose-response pered by inadequate data in studying the
exercise intervention and assessed one pain and/ relationship for resistance exercise (R2 = 0.32). effects of different dosages of exercise
or disability outcome. Higher frequencies (estimate = −0.10) and longer for chronic nonspecific neck pain.24,71
U DATA SYNTHESIS: Restricted maximum-likelihood
durations (estimate = −0.11) of motor control exercise
Another found a positive relationship
had larger effects on pain (R2 = 0.72). Longer sessions
random-effects meta-analyses were modeled sepa- between intervention duration and the
(estimate = −0.13) of motor control exercise had
rately for resistance, mindfulness-based, and motor
larger effects on disability (R2 = 0.61). pain-relieving effect of exercise therapy
control exercises; standardized mean differences
(Hedge’s g, standardized mean difference [SMD]) U CONCLUSION: Resistance, mindfulness-based, for chronic neck pain, but no relation-
were effect estimators. Meta-regressions (dependent and motor control exercises were effective for reducing ship between the frequency per week
variable: effect sizes of the interventions; independent neck pain (very low– to moderate-certainty evidence). and the duration of a single training ses-
variables: training dose and control group effects) Higher frequencies and longer duration of sessions sion.70 In general, more weekly exercise
were conducted to explore the dose-response relation- had a significant effect on pain for motor control exer-
therapy sessions were associated with a
ship for therapy success of any exercise type. cise. J Orthop Sports Phys Ther 2023;53(8):420-459.
greater effect on pain.70 However, clear
U RESULTS: We included 68 trials. Compared to Epub: 20 June 2023. doi:10.2519/jospt.2023.11820
U KEY WORDS: CNP, dose-response, motor
dose-response relationships of active in-
true control, effects on pain and disability were
significantly larger for resistance exercise (pain: SMD, control exercise, NP, sensorimotor terventions for chronic nonspecific neck
pain were unclear.
Department of Computer Science, Therapeutic Sciences, Trier University of Applied Sciences, Trier, Germany. 2Department of Sports Medicine and Exercise Physiology, Institute
1
of Occupational, Social and Environmental Medicine, Goethe University Frankfurt, Frankfurt am Main, Germany. 3Department of Sports Medicine and Exercise Physiology, Goethe
University Frankfurt, Frankfurt am Main, Germany. aAuthors equally contributed to the manuscript. This review protocol was preregistered with PROSPERO (registration number
CRD42021289150). No sources of funding were used to assist in the preparation of this article. The authors certify that they have no affiliations with or financial involvement in any
organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr. Juliane Mueller, Department of Computer
Science, Therapeutic Sciences, Trier University of Applied Sciences, Schneidershof, 54293 Trier, Germany. E-mail: ju.mueller@hochschule-trier.de t Copyright ©2023 JOSPT®, Inc
420 | august 2023 | volume 53 | number 8 | journal of orthopaedic & sports physical therapy
Therefore, our systematic review with Qui Gong exercises for patients with including the PERSiST recommendations
meta-analysis and meta-regression had chronic, nonspecific neck pain. for systematic reviews in the sport and ex-
2 aims: ercise medicine fields.8 The review proto-
1. to analyze the effects of resistance, METHODS col was preregistered with PROSPERO
motor control, and Yoga/Pilates/Tai (registration number CRD42021289150).
T
Chi/Qui Gong exercises on pain and his systematic review with meta-
disability in patients with chronic, analysis and meta-regression was Literature Search
nonspecific neck pain, and reported in accordance with the rec- The literature search was performed in
2. to study the potential dose-response ommendations of the Preferred Reporting PubMed (MEDLINE), PEDro, and the
relationship of resistance, motor Items for Systematic Reviews and Meta- Cochrane Library. All databases were
control, and Yoga/Pilates/Tai Chi/ Analysis (PRISMA) 2020 Statement,68 searched from inception to March 31, 2021.
FIGURE 1. Research, selection, and synthesis of included studies. Abbreviations: Eng, English; Ger, German; n, number; WoK, web of knowledge.
journal of orthopaedic & sports physical therapy | volume 53 | number 8 | august 2023 | 421
Study Characteristics (Left Columns) and the Individual Studies’
Results (Right Columns). For Each of the Studies Included,
TABLE 1
the Methodological Aspects, Participants’ Characteristics,
and Key Results Are Displayed
Study Information Population Assessments Outcomes

Measurement
Time Points
Total
(N: Weeks Primary Primary
N Baseline-Pain (If Not, Stated Outcome Outcome
Study Design, Main Inclusion (Total, (Scale, Mean, Otherwise) Pain, Scale, Disability
Citation No. of Study Criterion NP per Group) Age Mean ± SD Sex SD if Not Stated After Cohen’s d, Name, Cohen’s
First Author, Year Number Arms (Time, Other) (SE, C, C2…)) ( years) (f/m) Otherwise) Baseline) (M0-M1) d, , (M0-M1)
Akhter, 2014 1 RCT, 2 CNP ≥ 12 62 23/39 VAS (0-10) 3: 0; 3; 12 VAS (0-10) NDI
Int weeks 31 39.5 (25-45) 12/19 7.6 ± 0.9 E: −5.53 E: −3.10
Ctrl 31 38.1 (23-49) 11/20 7.3 ± 1.1
Akodu, 2021 2 RCT, 3 CNP > 12 45 47.13 ± 8,92 26/19 NPRS (0-10) 2: 0; 8 NPRS (0-10) NDI
Int 1 weeks, 17 47.71 ± 10.02 10/7 6.47 ± 0.94 E: −5.11 E: −1.79
Int 2 intensity ≥ 14 47.43 ± 9.22 9/5 7.43 ± 1.16 E: −3.97 E: −1.84
Int 3 5/10 14 44.93 ± 6.26 7/7 6.71 ± 1.14 E:-2.94 E: −1.85

Albornoz-Cabello, 3 RCT, 2 Nonspecific 49 47 ± 10.95 35/14 NPRS (0-10) 2: 0; 2 NPRS (0-10) NDI
2021 Int neck pain ≥ 24 44.5 ± 12.97 20/4 6.6 ± 1.4 E: −0.93 E: −0.84
Ctrl 12 weeks 25 49.32 ± 8.17 15/10 6.6 ± 1.1
Albornoz-Cabello, 4 RCT, 2 Nonspecific 84 62/22 VAS (0-10), 2: 0; 2 VAS (0-10) NDI
2019 Int mechanical 42 44.5 ± 11.8 33/9 6.2 ± 1.5 E: −0.83 E: −0.79
Ctrl NP 42 49.8 ± 9.5 29/13 6.6 ± 1.3
Andersen, 2014 7 RCT, 2 NP intensity 47 44 ± 12 47/10 NRS (0-9) 2: 0; 2 NRS (0-9)
Int ≥ 3 (0–9 24 44 ± 13 9/5 5.7 ± 1.9 E: −0.97
Ctrl scale; last 23 45 ± 11 18/5 5.4 ± 1.5
month)
Bahat, 2018a 9 RCT, 3 NP ≥ 12 weeks, 90 63/27 VAS (0-100) VAS (0-100 NDI
Int 1 NDI score ≥ 30 48 (Median) 19/11 47.8 ± 20.9 E: −0.80 E: −0.73
Int 2 12%; 30 48 (Median) 21/9 52.5 ± 19.5 E: −0.85 E: −0.40
Ctrl 30 48 (Median) 23/7 45.8 ± 21.5
Bernal-Utrera, 10 RCT, 3 NP ≥ 12 weeks 65 50/15 VAS (0-100) 4: 0; 1; 4; 12 VAS (0-100) NDI
2020 Int 1 + current 23 36.8 ± 2.9 18/5 48.2 ± 3.5 E: −8.70 E: −1.80
Ctrl 1 NP 20 36.9 ± 2.94 15/5 49.8 ± 3.5
Ctrl 2 22 42.9 ± 2.9 17/5 41.9 ± 4.0
Bobos, 2016a 11 RCT, 3 NP ≥ 12 weeks 60 39.5 ± 12.7 47/13 NPRS (0-10 2: 0; 7 NRPS (0-10 NDI
Int 1 + NP ≥ 12 20 38.5 ± 12.7 18/2 N.A. E: −0.75 E: −1.83
Int 2 weeks + 20 40.4 ± 13.5 15/5 N.A. E: −0.36 E: −0.65
Ctrl disability 20 39.5 ± 13.5 14/6 N.A.
score 5/50
NDI
Borisut, 2013a 12 RCT, 4 NP ≥ 24 weeks 100 100/0 VAS (0-100) 2: 0; 12 VAS (0-10) NDI
Int 1 + VAS >30 25 32.7 ± 3.1 25/0 55.0 ± 11.0 E: −1.49 E: −2.43
Int 2 mm (0-100) 25 30.4 ± 3.5 25/0 56.0 ± 22.7 E: −0.57 E: −3.45
Int 3 25 30.2 ± 3.0 25/0 61.5 ± 16.7 E: −2.69 E: −2.57
Ctrl 1 25 29.3 ± 3.1 25/0 59.0 ± 10.5
Bronfort, 2001 13 RCT, 3 NP ≥ 12 weeks 191 44.3 ± 10.6 NPSS (0-100) 6: 0; 5; 11; 12; NPSS (0-100) NDI
Int 63 43.6 ± 10.5 38/25 56.9 ± 14.2 24; 56 E: −2.20 E: −1.38
Ctrl 1 64 45.0 ± 10.5 37/27 56.7 ± 15.6
Ctrl 2 64 44.3 ± 11.0 37/27 56.5 ± 12.8
Table continues on next page.
TABLE 1
and Key Results Are Displayed (continued)

Measurement
Time Points
Total
Cabrera-Martos, 14 RCT, 2 CNP ≥ 12 40 30/10 NPRS (0-10) 2: 0; 4 VAS (0-10) NOOS N.A.
2022 Int weeks, 20 28.84 ± 5.78 16/4 6.25 ± 2.35 E: −0.96
Ctrl intensity ≥ 20 32.5 ± 4.68 4/6 6.16 ± 3.68
3/10
Caputo, 2017a 15 RCT, 2 CNP ≥ 12 35 (Range) 27/8 NRS (0-10) 2: 0, 7 NRS (0-10 NDI
Int 1 weeks 18 41.0 - 45.0 14/4 4.5 ± 2.3 E: −1.09 E: −0.59
Int 2 17 38.5 - 44.0 13/4 6.0 ± 3.0 E: −1.69 E: −0.90

Celenay, 2016a 16 RCT, 2 NP ≥ 12 weeks 102 74/28 VAS (0-10) 2: 0; 4 VAS (0-10) NDI
Int + NDI score 51 44.0 ± 13.0 35/16 4.0 ± 2.9 E: −0.55 E: −0.62
Ctrl 10 points 51 47.0 ± 10.0 39/12 3.8 ± 2.5
Celenay, 2016b 17 RCT, 2 NP ≥ 12 weeks 60 39/21 VAS (0-10) 2: 0; 4 VAS (0-10) NDI
Int + NDI score 30 45.2 ± 11.0 23/7 4.6 ± 3.2 E: −0.83 E: −2.40
Ctrl 10 points 30 50.1 ± 10.3 16/14 3.7 ± 3.3
Cetin, 2022 18 RCT, 2 NP ≥ 24 weeks 34 23/11 VAS (0-10) 2: 0; 6 VAS (0-10) ProFitMap-
Neck
Int1 17 41.94 ± 10.76 11/6 5.77 ± 1.39 E: −2.65 E: −6.13
Int2 17 40.0 ± 11.88 12/5 5.98 ± 1.93 E: −1.26 E: −1.03

Chung, 2018a 19 RCT, 2 CNP ≥ 12 41 21/20 VAS (0-10) 3: 0; 4; 8 VAS (0-10) NDI
Int 1 weeks 22 34.3 ± 8.8 2/10 4.9 ± 1.6 E: −1.37 E: −1.08
Int 2 19 37.4 ± 10.2 9/10 5.3 ± 1.0 E: −1.30 E: −1.07
Cramer, 2013a 21 RCT, 2 Nonspecific 51 47.8 ± 10.4 42/9 VAS (0-100) 2: 0; 9 VAS (0-100) NDI
Int 1 NP ≥ 12 25 46.2 ± 11.2 21/4 44.7 ± 18.8 E: −1.49 E: −1.0
Int 2 weeks + 26 49.5 ± 9.5 21/5 49.3 ± 19.2 E: −0.18 E: 0.04
VAS >40
mm (VAS
0-100)
Dareh-Deh, 2022 22 RCT, 2 NP > 12 weeks 40 24.7 ± 2.1 N.A. VAS (0-10) 2: 0; 8 VAS (0-10)
Int 20 24.9 ± 2.8 N.A. 4.0 ± 1.0 E: −2.3
Ctrl 20 25.3 ± 1.4 N.A. 4.8 ± 0.9
De Araujo Cazotti, 23 RCT, 2 NP ≥ 12 weeks; 64 14/50 NPS (0-10) 4: 0; 6; 13; 26 NPS (0-10) NDI (0-50)
2018 Int NPS: 3-8/10 32 48.6 ± 11.7 6/26 6.4 ± 1.67 E: −3.05 E: −1.39
Ctrl 32 49 ± 12.2 8/24 5.75 ± 1.64
Dunleavy, 2016 25 Quasi-ran- NP NRS ≥ 3/10 56 55.6 ± 9 49/7 NRS (0-10) 4: 0;6;12; 18 NRS (0-10 NDI (0-50)
domized ≥ 12 weeks
parallel
controlled,
3
Int 1 20 2.7 ± 1.7 E: −1.13 E: −1.00
Int 2 19 2.4 ± 1-6 E: −1.53 E: −0.64
Ctrl 17 2.8 ± 1.7
TABLE 1

Measurement
Time Points
Total
Durmus, 2014 26 RCT, 3 NP ≥ 12 weeks, 61 61/0 VAS (0-10) 2: 0;6 VAS (0-10) NPDS (0-
Female 100)
Int 1 20 54.75 ± 8.09 20/0 3.85 ± 1.85 E: −0.59 E: −6.65
Ctrl 1 21 55.71 ± 1.00 21/0 4.5 ± 1.5
Ctrl 2 21 54.15 ± 8.15 21/0 3.95 ± 2.03
Evans, 2012 27 RCT, 3 Mechanical, 270 46.3 ± 10.7 195/75 VAS (0-10) 2: 0; 12 VAS (0-10) NDI (0.50)
Int 1 nonspecific 90 64.0 ± 10.4 65/25 5-5 ± 1.4 E: −1.36 E: −1.02

Int 2 NP ≥ 12 89 48.7 ± 9.6 65/24 5.7 ± 1.3 E: −2.38 E: −1.03
Ctrl weeks; Pain 91 44.1 ± 11.6 65/26 5.6 ± 1.4
≥ 3/10
Falla, 2006a 28 RCT, 2 Female, CNP 58 29 29 58/0 VAS (0-10) 2; 0; 6 VAS (0-10) NDI (0-50):
Int 1 > 12 weeks 37.7 ± 9.9 29/0 3.6 ± 2.0 E: −0.45 E: −1.06
Int 2 NDI ≤ 15/50 38.1 ± 10.7 29/0 4.7 ± 2.0 E: −0.55 E: −0.82
Falla, 2013 29 RCT, 2 Female, NP & 42 42/0 VAS (0-10) 2; 0; 8 VAS (0-10) NDI (0-50)
Exercise disability ≥ 22 39.1 ± 8.7 22/0 5.3 ± 2.8 E: −0.61 E: −0.55
Ctrl 1 year 20 38.6 ± 9.0 20/0 5.1 ± 2.0
Fatima, 2022 30 RCT, 2 CNP ≥ 12 26 N.A. NPRS (0-10) 2: 0; 4 NPRS (0-10) NDI (0-50)
Int weeks, 13 28.64 ± 8.5 N.A. 5.57 ± 0.51 E: −5.49 E: −2.61
Ctrl intensity 13 25.43 ± 7.66 N.A. 5.64 ± 0.49
2-6/10
Galindez-Ibarben- 32 RCT, 2 Female, NP ≥ 27 27/0 VAS (0-100) 2; 0; 1 VAS (0-100) NDI (0-50)
goetxea, 2018 Int 12 weeks 14 34.35 ± 1.71 14/0 53.85 ± 3.64 E: −6.04 E: −5.04
Ctrl VAS at rest 13 32.15 ± 1.87 13/0 48.23 ± 4.30
≥ 30/100
Gallego, 2016a 33 RCT, 2 Nonspecific 28 18/10 VAS (0-10) 4: 0; 0-post; VAS (0-10) NDI (0-50
Int 1 CNP > 12 1 28.43 ± 6.16 3.45 (2.95-4.35) 1; 2 month E: −3.31 E: −1.17
Int 2 weeks NDI 14 29.93 ± 7.34 4.00 (2.66-4.62) (0-post = E: −2.76 E: −1.14
≤ 15/50 post first
session)
Gialanella, 2017 34 RCT, 2 Nonspecific 94 84/10 VAS (0-10) 2: 0; 6 months VAS (0-10) NDI (0-50)
Int CNP > 24 47 65.0 ± 14.0 42/5 6.8 ± 1.3 E: −2.23 E: −1.28
Ctrl weeks 47 60.1 ± 11.0 42/5 6.6 0 ± 1.5
Gimenez-Costa, 35 RCT, 2 CNP ≥ 12 46 46/0 VAS (0-10) 2: 0, 6 VAS (0-10) NDI (0.50)
2022 Int 1 weeks 23 25.1 ± 5.76 23/0 36.73 ± 76.29 E: −0.27 E: −1.80
Int 2 23 26.48 ± 6.52 23/0 37.5 ± 61.77 E: −0.35 E: −1.03
Groisman, 2020 36 RCT, 2 Nonspe- 90 NPRS (0-10) 2: 0; 4 NPRS NDI (0-50)
Int cific CNP 38 42.8 ± 9.8 32/6 5.5 ± 1.6 E: −9.50 E: −0.48
Ctrl ≥ 12 weeks 45 40.2 ± 12-3 42/3 5.7 ± 1.7
NPRS ≥ 2
(0-10) NDI
≥ 10 (0-50)
TABLE 1

Measurement
Time Points
Total
Gupta, 2013a 38 RCT, 2 Dental sur- 30 26 ± 4.28 12/18 VAS (0-10) 2: 0; 4 VAS (0-10) NDI (0-50)
Int 1 geons CNP 15 5.27 ± 0.704 E: −2.09 E: −2.38
Int 2 > 12 weeks 15 5.33 ± 0.724 E: −0.09 E: −0.52
NDI < 24
Iqbal, 2021a 41 RCT, 2 CNP > 5 NPRS 50 25/25 NPRS (0-10) 3: 0; 14; 42 NPRS (0-10) NDI (0-50)
Int 1 25 36.33 ± 6.01 13/12 5.20 ± 0.99 days E: −2.02 E: −1.21
Int 2 25 36.45 ± 5.95 12/13 5.40 ± 0.56 E: −1.61 E: −0.73

Javanshir, 2015a 42 RCT, 2 CNP ≥ 12 60 36 ± 4 40/20 VAS (0-10) 2: 0; 10 VAS (0-10) NDI (0-100)
Int 1 weeks 30 36.8 ± 3.5 4.97 ± 2.39 E: −0.84 E: −1.59
Int 2 30 35.7 ± 5 5.07 ± 2.15 CF: −1.08 CF: −0.94
Javdaneh, 2020 43 RCT, 3 CNP ≥ 12 72 34/38 VAS (0-100) 2: 0; 6 VAS (0-100) N.A.
Int weeks; VAS 24 29 ± 4.37 10/14 56.75 ±8.54 E:-3.32
Ctrl 1 30-70 mm 24 30 ± 6.01 13/11 58.00 ± 7.95
Ctrl 2 24 28 ± 4.77 11/13 57.91 ± 9.94
Javdaneh, 2021a 44 RCT, 3 Nonspecific 72 36/36 VAS (0-100) 2: 0; 6 VAS (0-100) NDI (0-50)
Int CNP, VAS 24 34.58 ± 5.37, 11/13 60.15 ± 6.3 E: −4.38 E: −4.59
Ctrl 1 30-70 24 32.35 ± 8.12, 12/12 62.6 ± 6.15

Ctrl 2 mm, NDI 24 33.41 ± 6.77 13/11 61.4 ± 6.04
15-30/50
Javdaneh, 2021b 45 RCT, 2 CNP ≥ 12 48 22/26 N.A. 2: 0; 6 N.A. NPAD (0-
weeks 100)
Int 24 31.18 ± 6.37 10/14 E. –4.74
Ctrl 24 33.7 ± 8.13 12/12
Jeitler, 2015 46 RCT, 2 CNNP ≥ 12 89 50 ± N.A. 73/16 VAS (0-100) 3: 0, 4, 8 VAS (0-100) NPAD (0-
weeks, VAS 200)
Int ≥ 40 mm 44 49.7 ± 11.2, 35/9 43.8 ± 22.0 E: −0.28 E: −0.56
Ctrl 45 49.6 ± 9.3 38/7 45.5 ± 23.3
Jordan, 1998 47 RCT, 3 CNP ≥ 12 119 Average (range) 88/31 30-point scale 4: 0, 6, 17, 52 30-point 30-point
weeks scale scale
Int 40 33 (23-50), 30/10 12 ± 9.612 E: −0.62 E: N.A.
Ctrl 1 40 36 (21-53), 29/11
Ctrl 2 39 38 (20-58), 29/10
Jull, 2009a 48 RCT, 2 CNP ≥ 12 46 46/0 NRS (0-10) 2: 0, 6 NRS (0-10) NDI (0-50)
Int 1 weeks, 23, 39.6 ± 12.2, 23/0 4.5 ± 1.6 E: −1.06 E: −1.85
Int 2 female 23 37.1 ± 10.3 23/0 4.2 ± 2.1 E: −1.48 E: −1.13
Khan, 2014a 49 RCT, 2 CNP ≥ 12 68 34.4 ± 2.7 41/27 VAS (0-10) 2: 0, 12 VAS (0-10 NPNPQ
weeks till 3 (0-36)
Int 1 years 34 N.A. N.A. 8.6 ± 2.41 E: N.A. E: −3.79
Int 2 34 N.A. N.A. 7.9 ± 1.61 E: −1.04 E: −1.80
TABLE 1

Measurement
Time Points
Total
Khosrokiani, 2022 50 RCT, 3 CNP ≥ 12 113 VAS (0-10) 2: 0; 8 VAS (0-10) NDI (0-100)
Int1 weeks 38 40.0 ± 6.4 23/15 6.0 ± 0.8 E: −4.63 E: −4.06
Int2 37 39.5 ± 6.5 30/7 5.9 ± 1.0 E: −1.33 E: −2.39
Ctrl 38 37.4 ± 2.0 23/15 5.9 ± 0.9
Khosrokiani, 2018 51 RCT, 2 CNP ≥ 12 30 36.5 ± 5.7 30/0 VAS (0-10) 3: 0, 8, 26 VAS (0-10) NDI (0-100)
Int weeks, VAS 15, 36.1 ± 5.6, 15/0 5.3 ± 2.0 E: −1.21 E: −1.55
Ctrl 3-8 15 37.6 ± 5.6 15/0 4.5 ± 2.0

Kim, 2016a 52 RCT, 2 CNP ≥ 12 28 15/13 NRS (0-10) 3: 0, 4, 8 NRS (0-10) NDI (0-50)
Int 1 weeks, NDI 14, 46.7 ± 4.2 8/6 5.2 ± 2.1 E: −0.81 E: −2.90
Int 2 < 15 14 45.4 ± 5.1 7/7 5.1 ± 2.7 E: −0.48 E: −0.40
Lansinger, 2007a 53 RCT, 2 Chronic 122 86/36 VAS (0-100) 4: 0, 12, 24, 48 VAS (0-100) NDI (0-100)
Int 1 nonspecific 60, 44.9 ± 12.3, 44/16 45.0 ± 24.5 E: −0.57 E: −0.15
Int 2 NP ≥ 12 62 42.8 ± 1.4 42/20 39.0 ±18.3 E: −0.93 E: −0.46
weeks, VAS
≥ 20 mm
Lauche, 2016a 54 RCT,3 Chronic 114 49.4 ± 11.7 91/23 VAS (0-100) 2: 0, 12, 24 VAS (0-100) NDI (0-100)
Int 1 nonspecific 38, 52.0 ± 10.9, 28/10, 54.2 ± 20.4 E: −1.07 E: −1.16
Int 2 NP ≥ 12 37, 47.0 ± 12.3, 31/6, 46.2 ± 19.2 E: −1.09 E: −0.76
Ctrl weeks, VAS 39 49.2 ± 11.7 32/7 51.5 ± 21.1
≥ 45 mm
Lee, 2017 55 RCT, 2 CNP > 24 20 9/11 VAS (0-10) 2: 0, 8 VAS (0-10) NDI (0-100)
Int weeks; VAS 11, 27.1 ± 4.8, 6/5 5.2 ± 2.2 E: −1.13 E: −0.99
Ctrl ≥ 3/10 9 27.6 ± 4.7 3/6 4.0 ± 1.8
Lee, 2017 56 RCT, 2 Chronic 18 18/0 VAS (0-10) 2: 0, 2 VAS (0-10) NDI (0-50)
Int nonspecific 9, 58.0 ± 1.6 9/0 4.8 ± 0.4 E: −5.25 E: −2.70
Ctrl NP ≥ 12 9 59.0 ± 2.4 9/0 4.9 ± 0.3
weeks
Lee, 2016a 57 RCT, 3 Chronic 46 N.A. N.A. VAS (0-10) 2: 0, 10 VAS (0-10) NDI (0-100)
Int 1 mechanical 15, 5.1 ± 0.6 E: −4.33 E: −4.85
Int 2 NP, NDI > 15, 5.3 ± 0.6 E: −2.50 E: −1.72
Ctrl 20% 16 5.2 ± 0.6
Letafatkar, 2019 58 RCT, 2 Female, NP ≥ 48 48/0 VAS (0-10) 2: 0; 8 VAS (0-10) NDI (0-100)
Int 12 weeks, 24, 34.3 ± 2.7 24/0 6.5 ± 0.7 E: −3.34 E: −3.52
Ctrl 24 34.6 ± 3.3 24/0 6.0 ± 0.8
Lytras, 2020 59 RCT, 2 Chronic 40 30/10 VAS (0-100) 8: 0; 2; 4; 6; VAS (0-100) NDI (0-50)
Int mechanical 20, 45.8 ± 7.7 15/5 53.7 ± 10.1 10; 14; 22; E: −2.41 E: −1.57
Ctrl NP ≥ 12 20 46.8 ± 8.9 15/5 54.3 ± 8.7 34
weeks
TABLE 1

Measurement
Time Points
Total
Matias, 2019 61 RCT, 2 Chronic 52 43/9 VAS (0-10) 3: 0; 4; 16 VAS (0-10) NDI (0-100)
Int idiopathic 27, 21.3 ± 2.1 21/6 3.2 ± 2.4 E: −0.41 E: −0.78
Ctrl NP ≥ 12 25 20.7 ± 1.9 22/3 3.8 ± 2.3
weeks, min.
2/10 VAS
last week
Mehri, 2020 62 RCT, 2 NP > 12 weeks, 32 32/0 NP and ND scale 2: 0; 8 NP and ND NP and ND
(0-100) scale scale (0-100)
Int 16, 37.8 ± 3.8, 16/0 (0-100)
Ctrl 16 35.5 ± 5.4 16/0 29.6 ± 2.9 E: −1.85
27.9 ± 3.5
Michalsen, 2012a 63 RCT, 2 VAS > 40 (100 77 67/10 VAS (0-100) 3: 0; 4; 10 VAS (0-100) NDI (0-50)
Int 1 mm scale) 38, 48.3 ± 11.0, 35/3 44.3 ± 20.1 E: −1.56 E: −1.35
Int 2 + painful 39 47.5 ± 12.4 32/7 41.9 ± 21.9 E: −0.34 E: −0.24
restriction
of cervical
spine
mobility ≥
12 weeks
Özel, 2022 67 RCT, 3 CNP ≥ 12 66 36.56 ± 13.66 45/21 NPRS (0-10) 3: 0; 2; 4 NPRS (0-10) NDI (0-50)
Int 1 weeks 22 36.23 ± 12.45 16/6 6.77 ± 1.61 E: −2.25 E: −1.43
Int2 22 34.18 ± 13.03 17/5 4.86 ± 1.27 E: −1.91 E: −1.35
Ctrl 22 39.27 ± 15.46 12/10 5.55 ± 1.45
Raju, 2019a 72 RCT, 2 CNP, 70 N.A. N.A. VAS (0-10) 2: 0; 4 VAS (0-10) NDI (0-50)
Int 1 NDI < 15 35, 7.7 ± 0.79 E: −7.97 E: −10.78
Int 2 35 7.3 ± 0.98 E: −3.16 E: −7.25
Ravi, 2016a 73 RCT, 2 Nontraumatic 50 29.7 ± 10.5 32/18 NPRS (0-10) 4: 0, 1, 2, 4 NPRS (0-10) NDI (0-100)
Int 1 NP 25, 6.6 ± 0.5 E: −6.16 E: −0.47
Int 2 25 6.0 ± 0.4 E: −6.86 E: −0.97
Rendant, 2011a 74 RCT, 3 CNP (≥ 24 123 107/15 VAS (0-100) 0; 12; 24 VAS (0-100) NPAD (0-100)
Int 1 weeks-5 42, 44.7 ± 10.8 36/6 57.7 ± 13.5 E: −2.30 E: −1.10
Int 2 years) 39, 44.4 ± 10.9 35/4 57.5 ± 15.5 E: −1.94 E: −0.52
Ctrl 41 47.8 ± 10.3 36/5 53.4 ± 13.2
Rodriguez-Sanz, 75 RCT, 2 CNP ≥ 12 58 49.2 ± 15.9 41/17 NPRS (0-10) 4: 0; 4; 12; 24 NPRS (0-10) N.A.
2021 Int weeks 29 49.72 ± 17.56 22/7 4.28 ± 2.48 E: −0.33
Ctrl 29 48.76 ± 14.53 19/10 4.1 ± 1.7
Sahiner Picak, 76 RCT, 2 CNP ≥ 12 49 44/5 VAS (0-10) 2: 0; 6 VAS (0-10) NDI (0-50)
2022 Int weeks 24 31.54 ± 5.23 21/3 4.28 ± 1.5 E: −1.57 E: −1.00
Ctrl 25 29.4 ± 5.24 23/2 3.74 ± 3.54
Seo, 2022 77 RCT, 2 CNP ≥ 12 26 N.A. NPRS (0-10) 2: 0; 6 NPRS (0-10) NDI (0-100)
Int weeks 13 35.15 ± 5.6 N.A. 4.54 ± 1.35 E: −2.05 E: −1.48
Ctrl 13 36.39 ± 5.17 N.A. 4.92 ± 2.54
TABLE 1

Measurement
Time Points
Total
Shin, 2020 78 RCT, 2 Chronic 38 38/0 VAS (0-10) 2: 0; 3 VAS (0-10) NDI (0-50)
Int nonspecific 19, 66.2 ± 4.7 19/0 4.5 ± 1.4 E: −0.82 E: −0.53
Ctrl NP > 24 19 68.1 ± 4.7 19/0 4.8 ± 1.1
weeks, VAS
> 3/10
Shiravi, 2019a 79 RCT, 3 NP ≥ 12 weeks, 135 145/0 2: 0; 8 VAS (0-10) N.A
Int 1 45, 26.0 ± 1.7 45/0 6.4 ± 0.8 E: −6.79

Int 2 45, 27.6 ± 2.1 45/0 6.9 ± 0.6 E: −5.24
Ctrl 45 25.1 ± 2.0 45/0 6.2 ± 0.7
Soroush, 2022 81 RCT, 3 CNP ≥ 12 102 71.22 ± 5.59 34/68 VAS (0-10) 3: 0; 8; 12 VAS (0-10) NDI (0-100)
Int1 weeks, age 33 72.06 ± 5.91 6/27 6.01 ± 0.47 E: −3.32 E: −3.79
Int 2 between 65 33 72.36 ± 5.30 12/21 6.09 ± 0.48 E: −3.48 E: −3.66
Int 3 and 80 36 69.39 ± 5.20 16/20 6.01 ± 0.47 E: −3.32 E: −5.32
Suvarnnato, 2019 83 RCT, 3 CNP ≥ 12 54 48/6 NPS (0-10) 4: 0; 6; 10; 18 NPS (0-10) NDI (0-100)
Int weeks, NDI 18, 43.5 ± 12.0, 16/2, 4.6 ± 1.7, E: −1.02 E: −0.83
Ctrl 1 ≥ 10/100 18, 43.3 ± 9.7, 17/1, 4.8 ± 1.9,
Ctrl 2 18 42.1 ± 8.5 15/3 4.1 ± 0.9

Tejera, 2020a 84 RCT, 2 Chronic 44 29.7 ± 10.8 21/23 VAS (0-10) 4: 0; 4; 8; 16 VAS (0-10) NDI (0-50)
Int 1 nonspecific 22, 32.7 ± 11.6 11/11 5.0 ± 1.9 E: −1.22 E: −1.02
Int 2 NP 22 26.7 ± 9.2 10/12 4.3 ± 1.3 E: −0.89 E: −0.71
Türel, 2015 85 RCT, 2 Mechanical NP 70 VAS (0-100) 3: 0; 1; 12 VAS (0-100) NPDS (0-100)
≥ 12 weeks,
Int VAS ≥ 5/10 35, 46.5 ±9.7, 30/5, 56.0 ± 7.7, E: −1.82 E: −0.78
Ctrl 35 43.1 ± 9.8 28/7 58.9 ± 8.0
Viljanen, 2003 86 RCT, 3 Female, CNP ≥ 393 393/0 NPRS (0-10) 4: 0; 12; 24; 48 NPRS (0-10) Neck disability
12 weeks scale (0-80)
Int 135, 4.05 ± 6.6, 135/0, 4.8 ± 2.3, E: −0.83
Ctrl 1 128, 43.0 ± 7.3, 128/0, 4.8 ± 2.3, E: −0.91
Ctrl 2 130 44.0 ± 7.4 130/0 4.1 ± 2.2
Yesil, 2018 87 RCT, 3 CNP ≥ 12 81 56/25 VAS (0-10) 3: 0; 6; 12 VAS (0-10) NDI
Int weeks 27, 36.0 ± 7.9, 16/11, 6.9 ± 1.6, E: −1.53 E: −1.19
Ctrl 1 27, 38.6 ± 9.2, 19/8, 6.6 ± 2.1,
Ctrl 2 27 39.7±8.8 21/6 6.0 ± 1.1
Abbreviations: CNP, chronic neck pain; Ctrl, control or comparison group; E, Effect size (Cohen’s d); f, female; Int, Intervention group; m, male; Mx, measure-
ment visit number; N, number; NDI, Neck Disability Index; NP, neck pain; NPRS, numeric pain-rating scale; NPSS, neck pain severity score (0-100); NRS,
numeric rating scale; RCT, randomized controlled trial; SD, standard deviation; T, total; VAS, visual analogue scale.
a
All groups were included into quantitative analysis (meta-regression/meta-analysis).
We updated the search on September search): (neck pain [MeSH Terms]) AND (disability OR function). This
30, 2022, to include the most recent AND (non-specific OR nonspecific OR search syntax was adapted for the other
studies. The following Boolean search chronic) AND (exercise OR strength two databases according to their func-
syntax was applied (for the PubMed OR resistance OR stretch*) AND (pain) tions and requirements.
chrane Collaboration’s Risk of Bias 2
(RoB 2) tool.39,82 We judged risk of bias
in each of the following domains: se-
quence generation, allocation conceal-
ment, blinding (participants, personnel,
and outcome assessment), incomplete
outcome data, selective outcome report-
ing, and other sources of bias. For each

outcome, items were rated as “high risk”,
FIGURE 2. Cochrane risk of bias rating, displayed as a summary bar plot. “low risk,” or “unclear risk” of bias. Any
disagreements were discussed between
the raters (J.M., J.W.). If a decision could
Article Selection Data Extraction not be reached, a third reviewer (D.N.)
Two reviewers (J.M. and J.W.) indepen- Two independent reviewers extracted resolved any conflicts.
dently screened the records retrieved year of publication, study design, popula-
from the bibliographic database search, tion characteristics, assessments, and key Risk of Bias Across the Studies
first the titles and abstracts and, then, outcomes. We also extracted the common The risk of publication bias across all
any full texts of records where eligibil- effect estimators for pre and postpain in- studies was indicated using funnel plots/
ity was unclear. Disagreements were re- tensity and disability from each study. graphs,80 and (statistically) using Egger’s
solved via consensus; if necessary, a third The intervention group baseline-to-post regression and rank correlation tests for
reviewer (D.N.) was asked. We also man- effect sizes (Cohen’s d) were calculated as plot asymmetry. A funnel plot represents
ually searched the reference lists (cross- the change in mean values from baseline the effect size estimate in every study
referencing) of the included articles. to postintervention assessment divided by against an estimate of precision (typically
the baseline standard deviation values for the standard error).80 Funnel plotting and
Selection Criteria the respective scale. Data on training dose testing were performed using the MAJOR
The inclusion and exclusion criteria were and frequency were selected according to package for jamovi (Sydney, Australia).
defined in accordance to population, in- the TIDieR checklist. One author recorded
tervention, control/comparator, and out- all the pertinent data from the included ar- Meta-analysis and Meta-regression
come (PICO). The detailed criteria for ticles and another author independently re- For data pooling, restricted maximum-
both the participants and studies are de- viewed the extracted data for its relevance, likelihood random-effects meta-analyses
tailed in SUPPLEMENTAL TABLE S1. Our search accuracy, and comprehensiveness. We re- were modeled for each major exercise
was limited to full-text availability, publi- solved disagreements via consensus, or a type (resistance exercise, motor con-
cation up to September 30, 2022, and lan- third reviewer (D.N.) if necessary. trol exercise, Yoga/Pilates/Tai Chi/Qui
guage in English or German. We calculated effect estimates for pain Gong). Weighted standardized mean dif-
intensity and disability using either the ferences between the intervention and
Classifying Interventions visual analogue scale (VAS), the numeric control/comparator groups (Hedge’s g)
Studies with exercise interventions fo- rating scale (NRS), or the sum score, in- were used as effect size estimators. For
cused on resistance, motor control, or herent of the scale/assessment tool (0-10, pooled analyses, mean effect sizes and
mindfulness-based exercise (Yoga/Pilates/ 0-24, or 0-100). Only the direction (lower their 95% confidence intervals (CIs) were
Tai Chi/Qui Gong) were included based values mean less pain, less disability) was calculated; summary estimate data were
on the definition of de Zoete et al.24 Re- normalized. For scale-dependent calcu- displayed using forest plots. To test for
sistance exercise included exercises that lations (inverse weighting, calculated as overall effects, Z-statistics at a 5% alpha-
aimed to increase the strength, power, sample size divided by the squared stan- error-probability level were calculated.
or endurance of the cervical muscula- dard deviation of the baseline-to-post dif- Between-effects heterogeneity was as-
ture. Motor control exercise aimed to ference), z-transformed (0-10) variables sessed using the I2- and τ2-statistic. All
increase the control and coordination of were used. Missing standard deviations pooled effects analyses were performed
deep cervical musculature or increase the for the differences were imputed.31 using the MAJOR package for jamovi.
proprioceptive control of head and neck The pooled effects were compared to
movements. Mindfulness-based exercises Risk of Bias Within Studies cutoff values to determine if a potential
followed traditional principles with a The reviewers (J.M. and J.W.) indepen- difference exceeded a minimal clini-
physical component and comprised Yoga/ dently rated the risk of bias for the pain cally relevant difference. Threshold val-
Pilates/Tai Chi/Qui Gong exercises.24 and disability outcomes using the Co- ues were a 5-point change for the Neck
Disability Index60 values and 1.3 points studies retrieved, 68 trials,1–4,7,9–19,21–23,25–30, main results of each trial are displayed
changes for the NRS values.20 published be-
32–36,38,41–59,61–63,67,72–79,81,83–87
in TABLE 1. Overall, data from 4811 par-
The certainty of the evidence was tween 1998 and 2022, were included. ticipants were included in the analysis.
categorized as “very low” (the estimate Baseline pain and effect sizes (Cohen’s
of effect is very uncertain), “low” (fur- Study Characteristics d, exercise therapy group only, used
ther research is likely to change the esti- Sixty-eight trials were included for qual- for the exploratory meta-regressions)
mate), “moderate” (further research may itative synthesis, and 39 for quantitative for pain and disability are presented in
change the estimate), or “high” (further synthesis (FIGURE 1). Characteristics and TABLE 1.
research is very unlikely to change the es-
timate of effect), plus interim values such
as “low to moderate.”5 When judging the
certainty of evidence, we started with the
type of evidence and up-rated or down-
rated based on study limitations, incon-
sistencies, uncertainty about directness,
imprecise data, risk of publication bias
(down-rating items), or large magnitude
of effect, dose-response findings, and
confounder plausibility (up-rating items).
Dose-response analyses were calcu-

lated for effect sizes for the dependent
variables pain and disability. The inde-
pendent variable was the type of exercise
(resistance, motor control, Yoga/Pilates/
Tai Chi/Qui Gong), the effect sizes of the
respective control/comparator group,
as well as the exercise dose (duration
[weeks] and frequency [sessions per
week] of the intervention; the dura-

tion of each training session [minutes];
and where applicable, set duration, set
breaks, and number of repetitions per
exercise). The models were calculated for
the simple pre- to postintervention Co-
hen’s d effect size (dependent variable) to
consider absolute treatment effects. For
the regression models, a syntax for IBM
SPSS was used (David B. Wilson; Meta-
Analysis Modified Weighted Multiple
Regression; MATRIX procedure Version
2005.05.23). Inverse variance-weighted
regression models with random inter-
cepts and fixed slopes were calculated.
Homogeneity analysis (Q and P values),
meta-regression estimates (95% CIs and
P values), and Z-statistics were calculated.
RESULTS
FIGURE 3. Forest plot for the effect sizes of resistance exercises for pain intensity. The plot depicts model
F
IGURE 1 displays the research pro- fit, individual study, and pooled effect size estimates (SMDs and corresponding 95% CIs), separated for the
cedure and the flow of the trial se- different comparators. The size of the boxes corresponds to the respective studies’ (inverse variance) weighting.
Abbreviations: CI: confidence interval; SMD, standardized mean difference.
lection and inclusion. From the 1035
Risk of Bias Within and Across Trials interventions = −1.6 points) and for mo- different from other exercise types (FIGURES
Risk-of-bias ratings are presented in FIG- tor control exercise (mean difference in 3 and 4) for reducing neck pain intensity.
URE 2 and SUPPLEMENTAL FIGURES S1 and S2. the change scores between interventions = Yoga/Pilates/Tai Chi/Qui Gong exercise
Almost all trials had a serious risk of bias −2.0 points). The effects of resistance and was superior to true control (SMD, 1.91;
in at least one domain (SUPPLEMENTAL FIG- motor control exercise were not statisti- 95% CI: −3.28, −0.55; I2 = 96%) and other
URE S1). Eight trials had low to some con- cally significantly nor clinically relevant exercise (SMD, −0.84; 95% CI: −1.553,
cerns of bias. There was a high risk of bias (mean difference in the change scores be- −0.13; I2 = 86%) for reducing pain (FIGURE
due to deviations from intended interven- tween interventions = −0.3 to −0.0 points) 5). Both effects were above the threshold
tions and arising from the randomization
process (FIGURE 2). The funnel plot (SUPPLE-
MENTAL FIGURE S2) highlights publication
bias. For pain (Egger’s regression [Z =
−3.4, P < .001], rank correlation [Kend-
all’s τ = −0.18, P = .01]) and disability (Eg-
ger’s regression [Z = −2.4, P = .02], rank
correlation [Kendall’s τ = −0.14, P = .04]),
tests indicate funnel plot asymmetries.
Risk-of-bias ratings are presented in FIG-
URE 2 and SUPPLEMENTAL FIGURES S1 and S2.
Individual Trials’ Training Characteristics

Twenty-three trials applied resistance
exercise, twenty trials applied motor con-
trol exercise, and 9 trials applied mind-
fulness-based exercise (APPENDIX). The
intervention period ranged between 1 and
26 weeks with a mean of 7.8 ± 4.9 weeks.
Training frequency ranged from 1 to 28
sessions per week with a mean of 5.1 ± 5.1

sessions; 5 trials did not report frequency
data. Mean training time per session was
36.2 ± 18.8 minutes with a range from
2.5 to 90 minutes (17 trials did not report
training time per session). Training vol-
ume ranged from 1 to 5 sets per exercise
practiced with a mean of 2.1 ± 1.2 sets;
32 trials did not report training volume.
Thirty-six trials reported on the number
of repetitions per set per exercise, with a
range of 4 to 20 repetitions (mean: 11.2 ±
4.0 repetitions per set per exercise).
Meta-analyses
The main pooled effect estimates for pain
are displayed in FIGURES 3 to 5. Resistance
(SMD, −1.27; 95% CI: −2.26, −0.28; I2 =
96%) and motor control (SMD, −2.29;
95% CI: −3.82, −0.75; I2 = 98%) exer-
cise was more effective than true control FIGURE 4. Forest plot for the effect sizes of motor control exercises for pain intensity. The plot depicts model
or minimal interventions. The effect was fit, individual study, and pooled effect size estimates (SMDs and corresponding 95% CIs), separated for the
clinically relevant for resistance (mean different comparators. The size of the boxes corresponds to the respective studies’ (inverse variance) weighting.
difference in the change scores between
for clinical relevance (−3.5 in contrast to utes per session. SUPPLEMENTAL TABLE S2 certainty), and mindfulness-based (very
true control and −1.5 when compared to shows the results of dose-response meta- low certainty) exercises. Mindfulness-
other exercises). regression analyses. based exercise was, with low certainty,
The main pooled effect estimates for superior to other exercises regarding pain
disability are displayed in FIGURES 6 to 8. DISCUSSION reduction. For disability, motor control
Resistance exercise was more effective exercises were, with moderate certainty,
C
than true control or minimal interven- ompared to true control, ef- superior to other exercises. There was
tions (SMD, −1.76; 95% CI: −3.16, −0.37; fects on pain and disability were considerable heterogeneity and a high risk
I2 = 98%), but not than other exercise. The larger for resistance (very low cer- of within-study and publication biases.
effect for resistance exercise in contrast to tainty), motor control (low to moderate There was no dose-response relationship
true control or minimal interventions did
not exceed the threshold for a clinically
relevant effect. Motor control exercise was
superior to true control (SMD, −2.42; 95%
CI: −3.38, −1.47; I2 = 94%) or other exer-
cise (SMD, −0.70; 95% CI: −1.23, −0.17;
I2 = 98%) for reducing disability (FIGURE
7). The effects were clinically relevant
(mean between-intervention difference in
change score of −7.6) against true control,

but not when compared to other exercise
(mean between-intervention difference in
change score of −1.6 points). Yoga/Pilates/
Tai Chi/Qui Gong exercises were superior
to true control or minimal intervention
(SMD, −0.62; 95% CI: −0.85, −0.38; I2
= 0%, not clinically relevant difference of
−3.7 points) but no better than other exer-
cise (SMD, −0.52; 95% CI:−1.13, 0.09; I2

= 82%) (FIGURE 8).
Dose-Response Meta-regressions
We did not find an unambiguous dose-
response relationship for resistance exer-
cise. On average, resistance exercise was
applied for 8.3 ± 4.7 weeks with 5.0 ± 4.3
sessions per weeks at 35.4 ± 17.9 minutes
per session. Higher frequencies and lon-
ger durations of motor control exercises
had larger effects on reducing pain. Lon-
ger bouts of motor control exercises had
larger effects on improving disability. On
average, motor control exercises were ap-
plied for 6.5 ± 2.5 weeks with 5.6 ± 4.3 ses-
sions per week at 31.6 ± 9.5 minutes per
session. For the mindfulness-based exer-
cises, no meta-regression could be calcu-
lated as we could not include a sufficient
number of trials of this exercise type. On FIGURE 5. Forest plot for the effect sizes of Yoga/Pilates/Tai Chi/Qui Gong exercise for pain intensity. The plot
average, Yoga/Pilates/Tai Chi/Qui Gong depicts model fit, individual study, and pooled effect size estimates (SMDs and corresponding 95% CIs), separated
was applied for 11.8 ± 5.4 weeks with 1.7 ± for the different comparators. The size of the boxes corresponds to the respective studies’ (inverse variance)
weighting. Abbreviations: CI: confidence interval; SMD, standardized mean difference.
0.9 sessions per week at 49.0 ± 22.6 min-
for resistance exercise. In contrast, higher
frequencies and longer durations of motor
control exercises had a significant effect on
reducing pain. For disability, longer ses-
sions of motor control exercises may lead
to larger effects.
Comparison With Other Evidence

In line with existing evidence,24,71 exer-
cise in the form of resistance, motor con-
trol, and/or mindfulness-based exercises
(Yoga/Pilates/Tai Chi/Qui Gong) was ef-
fective for reducing chronic neck pain and
disability, compared to true control (and/
or other exercises). However, there was a
wide range of effect sizes for pain (range
of Cohen’s d: −0.18 to −9.50) and disabil-
ity (range of Cohen’s d: 0.04 to −10.78).
The dose-response relationship for
motor control exercise on pain supported

a previous analysis70 with a positive re-
lationship between the intervention du-
ration (weeks) and reducing neck pain,
and an association between increased
frequency per week and greater effect
for general pain reduction (although, not
specifically for neck pain). De Zoete et al24
reported a wide intervention period of 5
weeks to 12 months for motor control

exercise programs. The number of treat-
ment sessions per week varied from one
up to daily. This partly covers the results
of our meta-regressions. Nevertheless, a
detailed analysis of the effect of training
characteristics on pain reduction is miss-
ing in the previous review.24 Compared to
results for low back pain,64,65 where the
dose-response relationship is controlled
by duration (weeks) and frequency (ses-
sions/week) for motor control exercise, FIGURE 6. Forest plot for the effect sizes of resistance exercises for disability. The plot depicts model fit,
we could not derive a comparable rela- individual study, and pooled effect size estimates (SMDs and corresponding 95% CIs), separated for the
different comparators. The size of the boxes corresponds to the respective studies’ (inverse variance) weighting.
tionship for motor control exercise in Abbreviations: CI: confidence interval; SMD, standardized mean difference.
patients with neck pain. As no unambig-
uous dose-response relationship could
be identified for resistance training, we O’Riordan et al66 also examined the in combination with other therapeutic
recommend following existing general effect of active interventions in terms of approaches, such as manual therapy, so
evidence on adaptations of the muscu- frequency, intensity, time, and type of the effects achieved cannot necessar-
loskeletal system to resistance training6 training in patients with chronic neck ily and unambiguously be attributed to
when deciding on an appropriate dose. pain. They concluded by providing recom- active therapies. They did not compare
We suggest 2 to 3 sessions per week with mendations for dosing of active interven- the effects of the programs.66 Therefore,
3 sets at 8 to 12 repetitions per exercise tions. However, this work also included dosing recommendations might include
over a minimum of 6 weeks.6 studies that investigated active measures training parameters that are statistically
Recommendations for Clinical Practice
We suggest clinicians consider using re-
sistance, motor control, and mindfulness-
based exercises to reduce pain in patients
with chronic nonspecific neck pain. The
exercise-dose and effect-response re-
lationship between active (resistance,
motor control, and mindfulness-based)

exercise interventions and reducing
chronic nonspecific neck pain is relevant
for policy makers, health insurers, clini-
cians, and the person living with pain.
Our dose-response analysis revealed that
longer duration of sessions (minutes per
session) and higher frequencies (number
of sessions per week) of motor control ex-
ercises had a significant effect on pain. We
recommend motor control exercise pro-
grams of more than 6 weeks duration and
more than 5 sessions per week for people

with chronic, nonspecific neck pain.
Future Research
The minimal clinically relevant dose of
resistance, motor control, or mindful-
ness-based intervention in chronic, non-
specific neck pain remains unclear. This
may define a future area of research in
chronic neck pain. Future original studies

could be designed to prospectively derive
a dose-response relationship.
Limitations: Study and Outcome Level

A common limitation in trials that in-
clude exercise therapies is the limited
ability to blind participants, which is
further compounded by self-assessment
of pain and pain-related function. Self-
reported outcomes may be more vulner-
FIGURE 7. Forest plot for the effect sizes of motor control exercises for disability. The plot depicts model fit,
able to bias.
individual study, and pooled effect size estimates (SMDs and corresponding 95% CIs), separated for the
different comparators. The size of the boxes corresponds to the respective studies’ (inverse variance) weighting. Limitations: Review Level
Abbreviations: CI: confidence interval; SMD, standardized mean difference. The funnel plot analysis revealed an
unclear (albeit low) risk of publication
significant but comparatively less effec- pain. In contrast, a moderate level of bias. Therefore, the mean effect may be
tive. The overall relationship between (the physical activity shows the lowest risk skewed. As a risk for a skewed pooled
amount of) physical activity and neck pain and, therefore, appears to be protective. effect estimate remains, the real mean
remains unclear in contrast to low back It is unclear whether this relationship effect might be slightly different to the
pain, where it is considered U shaped. also needs to be considered for dose plan- effect reported from our meta-analyses.
Both inactivity and extremely high lev- ning of active interventions (resistance, The findings of our (retrospective) me-
els of physical activity (elite sports) may motor control, Yoga/Pilates/Tai Chi/Qui ta-regression should be confirmed by
increase the risk of developing low back Gong) for people with neck pain. prospective meta-analysis.
control (disability) and mindfulness-
based exercises (pain) are superior most
likely to other exercises in patients with
chronic nonspecific neck pain.
IMPLICATIONS: Resistance, motor control,
and mindfulness-based exercises can be
recommended to be adopted for reduc-
ing pain and improving disability in

chronic nonspecific neck pain patients.
Higher frequencies and longer duration
of motor control exercises led to larger
effects on pain reduction.
CAUTION: Certainty of the evidence
ranged from very low to moderate; the
results may change in the presence of
future evidence.
STUDY DETAILS
AUTHOR CONTRIBUTIONS: According to the
definition given by the International

Committee of Medical Journal Editors
(ICMJE), the authors qualify for au-
thorship, based on making one or more
of the substantial contributions to the
intellectual content of (1) conception
and design (J.M., J.W., S.M.) and/or
(2) acquisition of data (J.M., J.W., S.T.)
and/or (3) analysis and interpretation
of data (J.M., J.W., D.N., S.M.) and/or

(4) participation in the drafting of the
manuscript (J.M., J.W., D.N., S.T.) and/
or (5) critical revision of the manuscript
for important intellectual content (J.M.,
J.N., D.N., S.T., S.M.).
DATA SHARING: All data relevant to the
study are included in this article or
available in the supplemental file.
FIGURE 8. Forest plot for the effect sizes of Yoga/Pilates/Tai Chi/Qui Gong exercise for disability. The plot depicts
PATIENT AND PUBLIC INVOLVEMENT: There
model fit, individual study, and pooled effect size estimates (SMDs and corresponding 95% CIs), separated for the was no patient or public involvement in
different comparators. The size of the boxes corresponds to the respective studies’ (inverse variance) weighting. this research.
REFERENCES
CONCLUSIONS Higher frequencies and longer duration of
1. Akhter S, Muhammad K, Ali SS, Soomro RR. Role
sessions had a significant effect on pain re- of manual therapy with exercise regime versus
duction for motor control exercises. t
C
ompared with performing no exercise regime alone in the management of
therapy, active interventions in the non-specific chronic neck pain. Pak J Pharm Sci.
2014;27:2125-2128.
form of resistance, motor control, or KEY POINTS
2. Akodu AK, Nwanne CA, Fapojuwo OA. Efficacy
mindfulness-based exercise was superior for FINDINGS: Resistance, motor control, of neck stabilization and Pilates exercises on
reducing chronic neck pain and improving and mindfulness-based exercises were pain, sleep disturbance and kinesiophobia in
function. We could not establish a dose- superior to true control in patients with patients with non-specific chronic neck pain:
a randomized controlled trial. J Bodyw Mov
response relationship for resistance exercise. chronic nonspecific neck pain. Motor
Ther. 2021;26:411-419. https://doi.org/10.1016/j. endurance training of superficial and deep neck respiratory exercises improves posture, muscle
jbmt.2020.09.008 muscles on muscle activities and pain levels activity, and respiratory pattern of patients with
3. Albornoz-Cabello M, Barrios-Quinta CJ, of females with chronic neck pain. J Phys Ther neck pain: a randomized controlled trial. Sci
Espejo-Antúnez L, Escobio-Prieto I, Sci. 2013;25:1157-1162. https://doi.org/10.1589/ Rep. 2022;12:4149. https://doi.org/10.1038/
Casuso-Holgado MJ, Heredia-Rizo AM. Immediate jpts.25.1157 s41598-022-08128-w
clinical benefits of combining therapeutic exer- 13. Bronfort G, Evans R, Nelson B, Aker PD, 23. de Araujo Cazotti L, Jones A, Roger-Silva D,
cise and interferential therapy in adults with Goldsmith CH, Vernon H. A randomized Ribeiro LHC, Natour J. Effectiveness of the Pilates
chronic neck pain: a randomized controlled trial. clinical trial of exercise and spinal ma- method in the treatment of chronic mechanical
Eur J Phys Rehabil Med. 2021;57:767-774. https:// nipulation for patients with chronic neck neck pain: a randomized controlled trial. Arch
doi.org/10.23736/S1973-9087.21.06688-0 pain. Spine. 2001;26:788-797. https://doi. Phys Med Rehabil. 2018;99:1740-1746. https://
4. Albornoz-Cabello M, Pérez-Mármol JM, org/10.1097/00007632-200104010-00020 doi.org/10.1016/j.apmr.2018.04.018
Barrios Quinta CJ, et al. Effect of adding 14. Cabrera-Martos I, Rodríguez-Torres J, 24. De Zoete RMJ, Armfield NR, McAuley JH, Chen K,
interferential current stimulation to exer- López-López L, Prados-Román E, Sterling M. Comparative effectiveness of physical
cise on outcomes in primary care patients Granados-Santiago M, Valenza MC. Effects of an exercise interventions for chronic non-specific
with chronic neck pain: a randomized active intervention based on myofascial release neck pain: a systematic review with network
controlled trial [with consumer summary]. and neurodynamics in patients with chronic neck meta-analysis of 40 randomised controlled trials.
Clin Rehabil 2019;33:1458-1467. https://doi. pain: a randomized controlled trial. Physiother Br J Sports Med. 2021;55:730-742. https://doi.
org/10.1177/0269215519844554 Theory Pract. 2022;38:1145-1152. https://doi.org org/10.1136/bjsports-2020-102664
5. Alonso-Coello P, Oxman AD, Moberg J, et al. /10.1080/09593985.2020.1821418 25. Dunleavy K, Kava K, Goldberg A, Malek MH,
GRADE evidence to decision (EtD) frameworks: 15. Caputo GM, Di Bari M, Naranjo OJ. Group-based Talley SA, Tutag-Lehr V, Hildreth J. Comparative
a systematic and transparent approach to mak- exercise at workplace: short-term effects of neck effectiveness of Pilates and yoga group exercise
ing well informed healthcare choices. 2: clinical and shoulder resistance training in video display interventions for chronic mechanical neck
practice guidelines. BMJ. 2016;353-353. https:// unit workers with work-related chronic neck pain: quasi-randomised parallel controlled
doi.org/10.1136/bmj.i2089 pain—A pilot randomized trial. Clin Rheumatol. study. Physiotherapy (United Kingdom).
6. American College of Sports Medicine. 2017;36:2325-2333. https://doi.org/10.1007/ 2016;102:236-242. https://doi.org/10.1016/j.
Progression models in resistance train- s10067-017-3629-2 physio.2015.06.002
ing for healthy adults. Med Sci Sport Exerc. 16. Celenay ST, Akbayrak T, Kaya DO. A comparison 26. Durmus D, Alayli G, Tufekci T, Kuru O. A random-
2009;41:687-708. of the effects of stabilization exercises plus ized placebo-controlled clinical trial of phono-
7. Andersen CH, Andersen LL, Zebis MK, Sjøgaard G. manual therapy to those of stabilization exercises phoresis for the treatment of chronic neck pain.
Effect of scapular function training on chronic alone in patients with nonspecific mechanical Rheumatol Int. 2014;34:605-611. https://doi.
pain in the neck/shoulder region: a randomized neck pain: a randomized clinical trial. J Orthop org/10.1007/s00296-013-2928-4
controlled trial. J Occup Rehabil. 2014;24:316-324. Sports Phys Ther. 2016;46:44-55. https://doi. 27. Evans R, Bronfort G, Schulz C, et al. Supervised
https://doi.org/10.1007/s10926-013-9441-1 org/10.2519/jospt.2016.5979 exercise with and without spinal manipulation
8. Ardern CL, Büttner F, Andrade R, et al. 17. Celenay ST, Kaya DO, Akbayrak T. Cervical performs similarly and better than home exercise
Implementing the 27 PRISMA 2020 statement and scapulothoracic stabilization exercises for chronic neck pain: a randomized controlled
items for systematic reviews in the sport and with and without connective tissue massage trial. Spine. 2012;37:903-914. https://doi.
exercise medicine, musculoskeletal rehabilita- for chronic mechanical neck pain: a prospec- org/10.1097/BRS.0b013e31823b3bdf
tion and sports science fields: the PERSiST tive, randomised controlled trial. Man Ther. 28. Falla D, Jull G, Hodges P, Vicenzino B. An
(implementing Prisma in Exercise, Rehabilitation, 2016;21:144-150. https://doi.org/10.1016/j. endurance-strength training regime is effec-
Sport medicine and SporTs science) guidance. math.2015.07.003 tive in reducing myoelectric manifestations
Br J Sports Med. 2022;56:175-195. https://doi. 18. Cetin H, Kose N, Oge HK. Virtual reality and mo- of cervical flexor muscle fatigue in females
org/10.1136/bjsports-2021-103987 tor control exercises to treat chronic neck pain: with chronic neck pain. Clin Neurophysiol.
9. Bahat HS, Croft K, Carter C, Hoddinott A, a randomized controlled trial. Musculoskelet Sci 2006;117:828-837. https://doi.org/10.1016/j.
Sprecher E, Treleaven J. Remote kinematic Pract. 2022;62:102636. https://doi.org/10.1016/j. clinph.2005.12.025
training for patients with chronic neck pain: msksp.2022.102636 29. Falla D, Lindstrom R, Rechter L, Boudreau
a randomised controlled trial. Eur Spine J. 19. Chung S, Jeong YG. Effects of the craniocervical S, Petzke F. Effectiveness of an 8-week exer-
2018;27:1309-1323. https://doi.org/10.1007/ flexion and isometric neck exercise compared cise programme on pain and specificity of
s00586-017-5323-0 in patients with chronic neck pain: a random- neck muscle activity in patients with chronic
10. Bernal-Utrera C, Gonzalez-Gerez JJ, ized controlled trial. Physiother Theory Pract. neck pain: a randomized controlled study.
Anarte-Lazo E, Rodriguez-Blanco C. Manual 2018;34:916-925. https://doi.org/10.1080/ Eur J Pain. 2013;17:1517-1528. https://doi.
therapy versus therapeutic exercise in non- 09593985.2018.1430876 org/10.1002/j.1532-2149.2013.00321.x
specific chronic neck pain: a randomized 20. Cleland JA, Childs JD, Whitman JM. 30. Fatima A, Veqar Z, Zaidi S, Tanwar T. Effects of
controlled trial. Trials. 2020;21:682. https://doi. Psychometric properties of the disability index scapular stabilization and upper limb proprio-
org/10.1186/s13063-020-04610-w and numeric pain rating scale in patients with ception as an adjunct to cervical stabilization in
11. Bobos P, Billis E, Papanikolaou DT, mechanical neck pain. Arch Phys Med Rehabil. chronic neck pain patients: a randomized con-
Koutsojannis C, Macdermid JC. Does deep 2008;89:69-74. https://doi.org/10.1016/ trolled trial. J Bodyw Mov Ther. 2022;29:291-301.
cervical flexor muscle training affect pain j.apmr.2007.08.126 https://doi.org/10.1016/j.jbmt.2021.10.016
pressure thresholds of myofascial trigger 21. Cramer H, Lauche R, Hohmann C, et al. 31. Follmann D, Elliott P, Suh I, Cutler J.
points in patients with chronic neck pain? Randomized-controlled trial comparing yoga and Variance imputation for overviews of clini-
A prospective randomized controlled trial. home-based exercise for chronic neck pain. Clin cal trials with continuous response. J Clin
Rehabil Res Pract. 2016;2016:1-8. https://doi. J Pain. 2013;29:216-223. https://doi.org/10.1097/ Epidemiol. 1992;45:769-773. https://doi.
org/10.1155/2016/6480826 AJP.0b013e318251026c org/10.1016/0895-4356(92)90054-Q
12. Borisut S, Vongsirinavarat M, Vachalathiti 22. Dareh-Deh HR, Hadadnezhad M, Letafatkar 32. Galindez-Ibarbengoetxea X, Setuain I,
R, Sakulsriprasert P. Effects of strength and A, Peolsson A. Therapeutic routine with Ramírez-Velez R, et al. Short-term effects of
manipulative treatment versus a therapeutic different exercise programs on cervical flexor 54. Lauche R, Stumpe C, Fehr J, et al. The effects
home exercise protocol for chronic cervi- muscles dimensions in patients with chronic of tai chi and neck exercises in the treatment
cal pain: a randomized clinical trial. J Back neck pain. J Back Musculoskelet Rehabil. of chronic nonspecific neck pain: a randomized
Musculoskelet Rehabil. 2018;31:133-145. 2015;28:833-840. https://doi.org/10.3233/ controlled trial. J Pain. 2016;17:1013-1027. https://
https://doi.org/10.3233/BMR-169723 BMR-150593 doi.org/10.1016/j.jpain.2016.06.004
33. Gallego Izquierdo T, Pecos-Martin D, 43. Javdaneh N, Letafatkar A, Shojaedin S, 55. Lee J, Lee M, Lim T, et al. Effectiveness of an
Lluch Girbés E, et al. Comparison of cranio- Hadadnezhad M. Scapular exercise combined application-based neck exercise as a pain man-
cervical flexion training versus cervical pro- with cognitive functional therapy is more effective agement tool for office workers with chronic neck
prioception training in patients with chronic at reducing chronic neck pain and kinesiophobia pain and functional disability: a pilot randomized
neck pain: a randomized controlled clinical than scapular exercise alone: a randomized trial. Eur J Integr Med. 2017;12:87-92. https://doi.
trial. J Rehabil Med. 2016;48:48-55. https://doi. controlled trial. Clin Rehabil. 2020;34:1485-1496. org/10.1016/j.eujim.2017.04.012
org/10.2340/16501977-2034 https://doi.org/10.1177/0269215520941910 56. Lee KS, Lee JH. Effect of Maitland mobilization
34. Gialanella B, Ettori T, Faustini S, et al. 44. Javdaneh N, Molayei F, Kamranifraz N. Effect in cervical and thoracic spine and therapeutic
Home-based telemedicine in patients with of adding motor imagery training to neck exercise on functional impairment in individuals
chronic neck pain. Am J Phys Med Rehabil. stabilization exercises on pain, disability and with chronic neck pain. J Phys Ther Sci. 2017;29:
2017;96:327-332. https://doi.org/10.1097/ kinesiophobia in patients with chronic neck pain. 531-535. https://doi.org/10.1589/jpts.29.531
PHM.0000000000000610 Complement Ther Clin Pract. 2021;42:101263. 57. Lee KW, Kim WH. Effect of thoracic manipula-
35. Gimenez-Costa M, Schomacher J, Murillo C, https://doi.org/10.1016/j.ctcp.2020.101263 tion and deep craniocervical flexor training on
Sentandreu T, Falla D, Lluch E. Specific versus 45. Javdaneh N, Saeterbakken AH, Shams A, pain, mobility, strength, and disability of the
non-specific exercises for the neck extensor mus- Barati AH. Pain neuroscience education com- neck of patients with chronic nonspecific neck
cles in women with chronic idiopathic neck pain: bined with therapeutic exercises provides added pain: a randomized clinical trial. J Phys Ther
a randomized controlled trial. Musculoskelet Sci benefit in the treatment of chronic neck pain. Sci. 2016;28:175-180. https://doi.org/10.1589/
Pract. 2022;60:102561. https://doi.org/10.1016/j. Int J Environ Res Public Health. 2021;18:8848. jpts.28.175
msksp.2022.102561 https://doi.org/10.3390/ijerph18168848 58. Letafatkar A, Rabiei P, Alamooti G, et al. Effect

36. Groisman S, Malysz T, Silva de da Souza L, et al. 46. Jeitler M, Brunnhuber S, Meier L, et al. of therapeutic exercise routine on pain, disabil-
Osteopathic manipulative treatment combined Effectiveness of jyoti meditation for patients ity, posture, and health status in dentists with
with exercise improves pain and disability in with chronic neck pain and psychological chronic neck pain: a randomized controlled trial.
individuals with non-specific chronic neck distress–a randomized controlled clinical trial. Int Arch Occup Environ Heal. 2020;93:281-290.
pain: a pragmatic randomized controlled trial. J Pain. 2015;16:77-86. https://doi.org/10.1016/j. https://doi.org/10.1007/s00420-019-01480-x
J Bodyw Mov Ther. 2020;24:189-195. https://doi. jpain.2014.10.009 59. Lytras DE, Sykaras EI, Christoulas KI,
org/10.1016/j.jbmt.2019.11.002 47. Jordan A, Bendix T, Nielsen H, Hansen FR, Myrogiannis IS, Kellis E. Effects of exercise and
37. Gross A, Langevin P, SJ Burnie, et al. Høst D, Winkel A. Intensive training, physiothera- an integrated neuromuscular inhibition technique
Manipulation and mobilisation for neck pain py, or manipulation for patients with chronic neck program in the management of chronic me-
contrasted against an inactive control or an- pain. A prospective, single-blinded, randomized chanical neck pain: a randomized controlled trial.
other active treatment. Cochrane Database clinical trial. Spine. 1998;23:311-318. https://doi. J Manipulative Physiol Ther. 2020;43:100-113.
Syst Rev. 2015;2015:CD004249. https://doi. org/10.1097/00007632-199802010-00005 https://doi.org/10.1016/j.jmpt.2019.03.011
org/10.1002/14651858.CD004249.pub4. 48. Jull GA, Falla D, Vicenzino B, Hodges PW. The 60. Macdelilld JC, Walton DM, Avery S, et al.
38. Gupta B, Aggarwal S, Gupta B, Gupta M, effect of therapeutic exercise on activation of Measurement properties of the neck disability
Gupta N. Effect of deep cervical flexor the deep cervical flexor muscles in people with index: a systematic review. J Orthop Sports Phys
training vs. conventional isometric train- chronic neck pain. Man Ther. 2009;14:696-701. Ther. 2009;39:400-417. https://doi.org/10.2519/
ing on forward head posture, pain, neck https://doi.org/10.1016/j.math.2009.05.004 jospt.2009.2930
disability index in dentists suffering from 49. Khan M, Soomro RR, Ali SS. The effectiveness of 61. Matias BA, Vieira I, Pereira A, Duarte M, Silva AG.
chronic neck pain. J Clin Diagnostic Res. isometric exercises as compared to general exer- Pain neuroscience education plus exercise
2013;7:2261-2264. https://doi.org/10.7860/ cises in the management of chronic non-specific compared with exercise in university students
JCDR/2013/6072.3487 neck pain. Pak J Pharm Sci. 2014;27:1719-1722. with chronic idiopathic neck pain. Int J Ther
39. Higgins JPT, Altman DG, Gøtzsche PC, et al. The 50. Khosrokiani Z, Letafatkar A, Gladin A. Lumbar Rehabil. 2019;26:1-14. https://doi.org/10.12968/
Cochrane Collaboration’s tool for assessing risk motor control training as a complementary ijtr.2018.0084
of bias in randomised trials. BMJ. 2011;343:5928. treatment for chronic neck pain: a randomized 62. Mehri A, Letafatkar A, Khosrokiani Z. Effects
https://doi.org/10.1136/bmj.d5928 controlled trial. Clin Rehabil. 2022;36:99-112. of corrective exercises on posture, pain, and
40. Hogg-Johnson S, Velde van der G, Carroll LJ, https://doi.org/10.1177/02692155211038099 muscle activation of patients with chronic
et al. The burden and determinants of neck pain 51. Khosrokiani Z, Letafatkar A, Sokhanguei Y. Long- neck pain exposed to anterior-posterior
in the general population. Results of the bone term effect of direction-movement control train- perturbation. J Manipulative Physiol Ther.
and joint decade 2000-2010 task force on neck ing on female patients with chronic neck pain. 2020;43:311-324. https://doi.org/10.1016/j.
pain and its associated disorders. J Manipulative J Bodyw Mov Ther. 2018;22:217-224. https://doi. jmpt.2018.11.032
Physiol Ther. 2009;32:S46-S60. https://doi. org/10.1016/j.jbmt.2017.06.004 63. Michalsen A, Traitteur H, Lüdtke R, et al. Yoga for
org/10.1016/j.jmpt.2008.11.010 52. Kim JY, Kwag KI. Clinical effects of deep cervical chronic neck pain: a pilot randomized controlled
41. Iqbal ZA, Alghadir AH, Anwer S. Efficacy of flexor muscle activation in patients with chronic clinical trial. J Pain. 2012;13:1122-1130. https://
deep cervical flexor muscle training on neck neck pain. J Phys Ther Sci. 2016;28:269-273. doi.org/10.1016/j.jpain.2012.08.004
pain, functional disability, and muscle endur- https://doi.org/10.1589/jpts.28.269 64. Mueller J, Niederer D. Dose-response-
ance in school teachers: a clinical trial. Biomed 53. Lansinger B, Larsson E, Persson LC, Carlsson JY. relationship of stabilisation exercises in patients
Res Int. 2021;2021:7190808. https://doi. Qigong and exercise therapy in patients with with chronic non-specific low back pain: a
org/10.1155/2021/7190808 long-term neck pain: a prospective randomized systematic review with meta-regression. Sci
42. Javanshir K, Amiri M, Mohseni Bandpei MA, trial. Spine. 2007;32:2415-2422. https://doi. Rep. 2020;10:16921. https://doi.org/10.1038/
De Las Penas CF, Rezasoltani A. The effect of org/10.1097/BRS.0b013e3181573b4b s41598-020-73954-9
65. Niederer D, Mueller J. Sustainability effects chronic nonspecific neck pain patients. Indian J non-specific neck pain. Work. 2022;71:889-900.
of motor control stabilisation exercises on Physiother Occup Ther. 2016;10:143. https://doi. https://doi.org/10.3233/WOR-213646
pain and function in chronic nonspecific low org/10.5958/0973-5674.2016.00136.2 82. Sterne JAC, Savović J, Page MJ, et al. RoB 2:
back pain patients: a systematic review with 74. Rendant D, Pach D, Lüdtke R, et al. Qigong a revised tool for assessing risk of bias in ran-
meta-analysis and meta-regression. PLOS ONE. versus exercise versus no therapy for domised trials. BMJ. 2019;366:l4898. https://doi.
2020;15:e0227423. https://doi.org/10.1371/jour- patients with chronic neck pain: a random- org/10.1136/bmj.l4898
nal.pone.0227423 ized controlled trial. Spine (Phila Pa 1976). 83. Suvarnnato T, Puntumetakul R, Uthaikhup S,
66. O’Riordan C, Clifford A, Ven Van De P, Nelson J. 2011;36:419-427. https://doi.org/10.1097/ Boucaut R. Effect of specific deep cervical
Chronic neck pain and exercise interventions: fre- BRS.0b013e3181d51fca muscle exercises on functional disability, pain
quency, intensity, time, and type principle. Arch 75. Rodríguez-Sanz J, Malo-Urriés M, Lucha-López MO, intensity, craniovertebral angle, and neck-
Phys Med Rehabil. 2014;95:770-783. https://doi. et al. Comparison of an exercise program with and muscle strength in chronic mechanical neck
org/10.1016/j.apmr.2013.11.015 without manual therapy for patients with chronic pain: a randomized controlled trial. J Pain Res.
67. Özel M, Kaya CP. The effectiveness of neck pain and upper cervical rotation restriction. 2019;12:915-925. https://doi.org/10.2147/JPR.
telerehabilitation-based structured exercise Randomized controlled trial. PeerJ 2021;9:e12546. S190125
therapy for chronic nonspecific neck pain: https://doi.org/10.7717/peerj.12546 84. Tejera DM, Beltran-Alacreu H, Cano-De-la-cuerda
a randomized controlled trial. J Telemed 76. Sahiner Picak G, Yesilyaprak SS. Effects of R, et al. Effects of virtual reality versus exercise
Telecare. 2022;1357633X2210957. https://doi. clinical Pilates exercises in patients with chronic on pain, functional, somatosensory and psycho-
org/10.1177/1357633X221095782 nonspecific neck pain: a randomized clinical trial. social outcomes in patients with non-specific
68. Page MJ, McKenzie JE, Bossuyt PM, et al. The Ir J Med Sci. 2022:1-10. https://doi.org/10.1007/ chronic neck pain: a randomized clinical trial.
PRISMA 2020 statement: an updated guide- s11845-022-03101-y Int J Environ Res Public Health. 2020;17:1-19.
line for reporting systematic reviews. BMJ. 77. Seo J, Song C, Shin D. A single-center study https://doi.org/10.3390/ijerph17165950
2021;372:n71. https://doi.org/10.1136/bmj.n71 comparing the effects of thoracic spine ma- 85. Türel A, Solak Ö, Dündar Ü, et al. Evaluation
69. Plass D, Vos T, Hornberg C, Scheidt-Nave C, nipulation vs mobility exercises in 26 office of the efficacy of spa therapy on pain
Zeeb H, Krämer A. Trends in disease burden in workers with chronic neck pain: a random- and quality of life in patients with chronic
Germany: results, implications and limitations of ized controlled clinical study. Med Sci Monit. mechanical neck pain. Arch Rheumatol.
the global burden of disease study. Dtsch Arztebl 2022;28:e937316. https://doi.org/10.12659/ 2015;30:298-306. https://doi.org/10.5606/
Int. 2014;111:629-638. https://doi.org/10.3238/ MSM.937316 ArchRheumatol.2015.5445
arztebl.2014.0629 78. Shin HJ, Kim SH, Hahm SC, Cho HY. 86. Viljanen M, Malmivaara A, Uitti J, Rinne M,
70. Polaski AM, Phelps AL, Kostek MC, Szucs KA, Thermotherapy plus neck stabilization exercise Palmroos P, Laippala P. Effectiveness of dynamic
Kolber BJ. Exercise-induced hypoalgesia: a meta- for chronic nonspecific neck pain in elderly: a muscle training, relaxation training, or ordinary
analysis of exercise dosing for the treatment single-blinded randomized controlled trial. Int J activity for chronic neck pain: randomised con-
of chronic pain. PLOS ONE. 2019;14:e0210418. Environ Res Public Health. 2020;17:1-12. https:// trolled trial. Br Med J. 2003;327:475-470. https://
https://doi.org/10.1371/journal.pone.0210418 doi.org/10.3390/ijerph17155572 doi.org/10.1136/bmj.327.7413.475
71. Price J, Rushton A, Tyros V, Heneghan NR. Expert 79. Shiravi S, Letafatkar A, Bertozzi L, Pillastrini P, 87. Yesil H, Hepguler S, Dundar U, Taravati S,
Isleten B. Does the use of electrotherapies
consensus on the important chronic non-specific Khaleghi Tazji M. Efficacy of abdominal control
neck pain motor control and segmental exercise feedback and scapula stabilization exercises in increase the effectiveness of neck stabilization
and dosage variables: an international e-Delphi participants with forward head, round shoulder exercises for improving pain, disability, mood,
study. PLOS ONE. 2021;16:e0253523. https://doi. postures and neck movement impairment. and quality of life in chronic neck pain?: a ran-
org/10.1371/journal.pone.0253523 Sports Health. 2019;11:272-279. https://doi. domized, controlled, single-blind study. Spine.
72. Raju AS, Apparao P, Swamy G, Chaturvadi org/10.1177/1941738119835223 2018;43:E1174-E1183. https://doi.org/10.1097/
P, Mounika RG. A comparative study on 80. Simmonds M. Quantifying the risk of er- BRS.0000000000002663
deep cervical flexors training and neck ror when interpreting funnel plots. Syst
stabilization exercises in subjects with Rev. 2015;4:24-27. https://doi.org/10.1186/
chronic neck pain. Indian J Physiother s13643-015-0004-8
Occup Ther. 2019;13:1. https://doi. 81. Soroush S, Arefi MF, Pouya AB, et al. The ef-
@ MORE INFORMATION
org/10.5958/0973-5674.2019.00035.2 fects of neck, core, and combined stabilization
73. Ravi CN, Dibyendunarayan BD, Ramalingam practices on pain, disability, and improvement of
TA. Effectiveness of proprioceptive exercises in the neck range of motion in elderly with chronic WWW.JOSPT.ORG
APPENDIX TABLE
Type Rest
Intervention Coded Training (Between
(Described/ Intervention Frequency Training Sets per
Named by Group (Sessions Duration Sets Repetitions Exercise;
the Authors Assignment Exercises (Number of Training per Week) (Minutes (Number (per Between
First Author, of Each (RE, MCE, Exercises; Description/Name Type Period Scheduled, per per Set, per Exercises
Year Study) YPTQ, Other) of Exercises) Comparator (s) (Weeks) Real Session) Exercise) Exercise) in Seconds)
Akhter, 2014 Strength- Other NA; Set of strengthening Manual therapy 3 2 20 NA 10 NA; NA
ening exercises consisted of with exercise
exercises isometric, concentric, and regime
eccentric exercises with
rest in between and a set
of stretching exercises of
cervical spine; rotation
side to side, lateral flexion
side to side, extension
and sternocleidomastoid
stretches 10 repetitions
each to the left and right;
levator scapulae and pec-

tolaris muscles stretches
10 repetitions each to the
left and right
Akodu, 2021 Neck stabi- MCE NA Dynamic 8 2 30 NA NA NA; NA
lization isometric
exercise exercise
Pilate YPTQ NA Dynamic 8 2 30 NA NA NA; NA
exercise isometric
exercise
Dynamic RE NA Neck stabiliza- 8 2 30 NA NA NA; NA

isometric tion exercise
exercise
Albornoz-Cabel- Therapeutic Other NA; Exercises for stretching Therapeutic 5 2 25-453 3 3-5 NA; NA
lo, 2021 exercise and strengthening of neck exercise plus
and shoulder muscles interferential
(scalene, sternocleido- current
mastoid, levator scapulae therapy
upper trapezius) plus
functional movements
Albornoz-Cabel- Therapeutic Other NA; The supervised exercises Interferential 2 10 20-45 3 3-5 NA; NA
lo, 2019 exercise included (1) ergonomic ad- current
(multi- vice on reducing repetitive therapy plus
modal) motions and/or maintained supervised
positions, and (2) a proto- exercise
col of active physiotherapy
for neck and shoulder
muscles. This protocol
included the following: (2.1)
active stretching exercises,
(2.2) isometric muscle
strengthening exercises,
(2.3) ocular-cervical kinetic
re-education program, and
(2.4) homework including
several exercises detailed
below. The exercises were
performed very slowly.
APPENDIX TABLE (CONTINUED)
Type Rest
Andersen, 2014 Scapular RE 2; Press-up and push-up Passive: not 10 3 20 3-5 10 NA; NA
function plus (have been shown to offered any
training activate the serratus an- physical
terior and lower trapezius training but
muscles to a high extent, was encour-
but with only a low level aged to stay
of activation of the upper active as
trapezius) usual)
Bahat, 2018a Virtual MCE 3; (a) Range of motion exer- No further, 4 28 5 NA NA NA; NA
reality cise; (b) motion velocity ex- both groups
exercise ercise; (c) motion accuracy Exercise
training in smooth head pursuit, or

a combination; during all
3 exercises an avatar was
guided through a virtual
reality world (airplane) by
head movement of the
participant
Exercise MCE 3; (a) Range of motion 4 28 5 NA NA NA; NA
training exercise; (b) motion veloc-
with laser ity exercise; (c) motion
accuracy in smooth head
pursuit, or a combination;
during training participants
wore a head-mounted
laser beam aimed at a 70
× 70 cm poster. Tasks in
the laser group were, eg,
following the line with the
laser, moving quickly from
one circle to another, etc.
Laser training velocity was
not controlled.
Bernal-Uteras, Therapeutic MCE 2-6; CCF in a supine position Sham treatment 3 7 NA 3 10 NA; NA
2020 exercise with a towel in the posterior
area of the neck; CCF sit-
ting; co-contraction of
deep and superficial neck
flexors in supine decubitus;
co-contraction of flexors,
rotators, and lateral flexors;
eccentric for extensors:
the patient seated, he/she
should perform cervical
extension; eccentric for
flexors: patients, placed in
a quadrupedal and neutral
neck position, should
perform neck flexion
Type Rest
Bobos, 2016a Deep cervi- MCE 4; CCFT with air pressure Home exercise 7 2 30-40 NA NA NA; NA
cal flexor biofeedback; nodding from and digital
muscle supine position, nodding video in-
training from pronation position, struction
and nodding from sitting
position close to the wall;
stretching at the end
Superficial RE 4; Posterior head movement Home exercise 7 2 30-40 NA NA NA; NA
muscle from sitting position with and digital
group elastic band, poste- video in-
training rior head movement from struction
supine position, movement

in all directions from pro-
nation position, and “cat-
camel motion exercise”;
stretching at the end
Borisuta 2013 Strength-en- RE NA; Progressive resistance Control 12 7 NA 2 15 60; NA
durance exercise program for the group: not
exercise superficial neck flexor and described
extensor muscles. Neck
flexion and extension were
performed in the supine

and prone positions with
the head supported in
a comfortable resting
position.
Craniocer- MCE NA; Low-load exercise for Control 12 7 NA 1 15 10; NA
vical the craniocervical flexor group: not
flexion muscles. Subjects lay described
exercise supine and slowly moved
the head to the inner range
of craniocervical flexion,
guided by feedback from
an air-filled pressure
sensor placed suboc-
cipitally behind the neck
and inflated to a baseline
pressure of 20 mmHg.
Combined: Other NA; Performed both strength- Control 12 7 NA 2 15 NA; NA
strength- endurance and craniocervi- group: not
endur- cal flexion exercises as described
ance and described above
cranio-
cervical
flexion
exercises
Type Rest
Bronfort, 2001 Strength-en- MCE NA; Stretching, upper-body Spinal manipu- 11 1-2 60 NA 20 NA; NA
durance strengthening, and 15-20 lation (total 20)
exercise min of aerobic exercise us-
ing a dual-action stationary
bike, Dynamic progressive
resistance exercises were
performed for cervical
extensors and rotators
Cabrera-Martos, Self-myo- Other NA; 2 weeks myofascial Booklet with 4 3 50-60 NA NA NA; NA
2022 fascial release of upper cervical information
release spine with foam roller and on neck pain
and upper back, 2 weeks of

neuro- neurodynamic exercises for
dynamic the upper limbs
exercises
Caputo, 2017a Cervical and Other Specific cervical and No further, 7 2 45 3 20 NA; NA
scapulo- scapulo-thoracic exercise both groups
thoracic (recruitment of deep cervi- Exercise
exercises cal muscle, cervical flexion/
extension exercise)
Conven- Other NA; Stretching of deep neck 7 2 45 NA 10 NA; NA
tional extensors, the upper tra-

stretch- pezius, elevator scapulae,
ing and scalene, and pectorals
postural muscles, performed in
exercise supine and sitting position.
Postural re-education in
supine and sitting position,
anterior and posterior
pelvic tilts and cervical
retractions were performed
in the supine, sitting, and
standing positions.
Type Rest
Celenay, 2016a Stabilization Other NA; Cervical exercises: (A) Stabilization 4 3 60 1 8-12 NA; NA
exercise The cervical bracing exercise
technique was performed with manual
in neurodevelopment therapy
stages, and then extremity
range-of-motion exercises
were conducted. (B) Cervi-
cal dynamic isometric
exercises were performed
directly forward, obliquely,
toward right and left, and
directly backward by
maintaining a stable spine
with elastic resistive bands.
(C) Functional training
with elastic resistance and
exercise balls on unstable
surfaces was performed in
combination with cervical
bracing. Scapular thoracic
stabilization exercises: (A)
Scapular adduction and
shoulder external rotation.

(B) Bilateral shoulder
extension with scapular
retraction. (C) Eccentric
scapular retraction. (D)
Brügger’s exercise. (E) For-
ward punch. (F) Dynamic
hug exercise.
Celenay, 2016b Stabilization Other NA; Cervical and scapulotho- Stabilization 4 3 45 1 10 NA; NA
exercise racic stabilization exercise exercise with
connective
tissue mas-
sage
Cetin, 2022 Virtual MCE NA; VR training with VR Motor control 6 3 40 NA 5-10 NA; NA
reality glasses
Motor MCE NA: Craniocervical flexion and Virtual reality 6 3 40 NA 10 NA; NA
control cervical extension exercises
Type Rest
Chung, Craniocer- MCE NA; ACROM performed by No further, 8 3 40 5 10 NA; NA
2018a vical neck flexion-extension, both groups
flexion lateral flexion, and rotation. Exercise
exercise Craniocervical flexion
exercise in the supine posi-
tion performed by holding
progressively increasing
ranges of craniocervical
flexion using an air-filled
pressure sensor.
Neck RE NA; Postural re-education 8 3 40 1 12,5 NA; NA
isometric in all 3 planes (neutral

exercise balance position); neck iso-
metric exercises performed
in the supine and seated
position with maximal
effort by resisting at the
forehead in all 3 planes.
Cramer, Yoga YPTQ 8-11; Each class consisted of No further, 9 1 90 NA NA NA; NA
2013a 8-11 yoga postures chosen both groups
from a pool of 14 stand- Exercise
ing, sitting, and supine

postures, starting with
relatively simple postures
and succeeding to more
complex ones
Exercise Other NA; Seated exercise program 9 7 10 NA NA NA; NA
for the neck and shoulder
region including stretch-
ing and strengthening
exercises
Dareh-Deh, Therapeutic RE 7; Resistance: (1) side-lying Pamphlet with 8 3 45-60 NA: NA: NA; 45
2022 exercise external rotation, (2) prone informa-
horizontal abduction with tion about
external rotation (3), Y-to-I postural
exercise, (4) chin tuck. correction
Stretching: (1) static levator and general
scapulae stretch exercise, health
(2) one-sided unilateral
self-stretch, (3) static ster-
nocleidomastoid stretch
Type Rest
De Araujo Pilates YPTQ NA; Breathing exercises, Control 12 2 60 NA 6-12 NA; NA
Cazotti, 2018 mobility and strengthen-
ing of the shoulder girdle
muscles (first month: basic
exercises; second and
third month: more difficult
exercises) performed on
a mad and on the equip-
ment (Reformer, Cadillac,
Combo, Chair, Spine
Corrector)
Dunleavy, 2016 Pilates YPTQ NA; Pilates exercises were Control 12 1 60 NA NA NA; NA
progressed after 6 sessions
using thoracic flexibility
exercises, light upper-ex-
tremity weights, increased
balance challenge using
foam rollers and upright
seated endurance exercise
Yoga YPTQ NA; Yoga classes began with Control 12 1 60 NA NA NA; NA
mindful focus of breath,
continued with postures

to address alignment,
strength, and flexibility, and
ended with relaxation. The
complexity of yoga poses
was progressed over 12
weeks with increased dura-
tion of holds and linkages
between poses in a “flow.”
Type Rest
Durmus, 2014 Exercise Other 5; Neck exercises (isotonic, Exercise + pho- 6 3 60 NA NA NA; NA
isometric, and stretching); nophoresis
motion flexibility and back
strengthening exercises of
the thoracic and lumbar
spine; stretching of the
erector spine muscle,
hamstring muscles, pelvis
muscles and abdominal
muscles (pelvic tilt, knee
to chest, lower abdominal
exercises, cat and camel,

back extension exercises;
activation of the stabilizing
muscles of the spine
and flexibility exercise of
the lower limb muscles;
functional exercises to
improve postural control,
dynamic body balance and
coordination; progressive
relaxation exercise to
normalize muscle tension

Evans, 2012 Home exer- Other 6; Self-mobilization of the Exercise and 12 7 NA 6-8 (per 5-10 NA; NA
cise and neck and shoulder joints spinal ma- day)
advice (neck retraction, extension, nipulation
flexion, rotation, lateral
bending, and scapular re-
traction)
Exercise RE NA: Neck (extension, flexion Exercise and 12 1-2 60 3 15-25 NA; NA
and rotation) and upper- spinal ma-
body (push-ups and dumb- nipulation
bell shoulder and chest
exercises) strengthening
with individualized intensity
(load and repetitions) +
aerobic warm-up (5 min)
and stretching before and
after strengthening
Type Rest
Falla, 2006 CCF MCE 1; Low-load exercise for the Endurance- 6 14 (twice 10-20 NA NA NA; NA
craniocervical flexor strength per
muscles: perform and training day)
hold progressive, inner
range craniocervical flexion
contraction while trying to
keep the sternocleidomas-
toid and anterior scalene
muscles relaxed 
feedback from an air-filled
pressure sensor
Endurance- RE 1; Training in 2 stages: Stage CCF 6 14 10-20 1-3 12-15 60; NA

strength 1 (2 weeks); Stage 2 (4 (twice per
exercise weeks) with the same day)
exercise:
Lying in supine, with the head
supported in a comfortable
resting position, patients
lifted their head so that
cervical flexion was per-
formed while maintaining
a neutral upper cervical
spine. Patients slowly
moved the head and neck

through full a range of
motion without causing
discomfort or reproducing
their symptoms.
Falla, 2013 Exercise Other Training in 2 stages: Ctrl 8 14 10-20 NA 15 NA; NA
2; Stage 1 (6 weeks): (twice per
incremental craniocervical day)
flexion in a relaxed, supine
lying – perform and hold
progressively inner range
positions  feedback from
a pressure unit; cranio-
cervical extension, flexion,
and rotation in a prone on
elbows position
2; Stage 2 (2 weeks): head lift
exercise for flexors with
load in supine; neck exten-
sion with load in 4-point
kneeling
Fatima, 2022 Cervical sta- RE 11; Flexibility, bracing, resistive Cervical, 4 3 NA 1 NA NA; NA
bilization exercises, and functional scapular
exercises training. See the original stabilization,
paper for a detailed de- and proprio-
scription. ception
Type Rest
Galindez- Home Other NA; General range of motion Manipulation 1 7 10-20 min NA NA NA; NA
Ibarbengoetxea, exercise movements of the neck
2018 (flexion, rotation, side
bending) – 10 times in
each direction
Specific stretching of the
bilateral upper trapezius
(stabilizing of the shoulder,
lateral flexion, rotation
and slight anterior flexion
of the head) and cervical
extensor muscles (head

and neck flexion: hands
were placed at the occipital
bone) – stretch position
was maintained for 30
s and each exercise was
repeated 3 times
CCF; in supine patients
placed a towel under the
neck and then placed one
hand gently on the front
of the neck to feel the

superficial muscles during
the craniocervical flexion
movement (10 repetitions
of 10 s’ duration, with a
10-s rest interval between
each contraction)
Submaximal isometric
exercise: in sitting, the
patients achieved a 5-s
contraction using only
10% effort, 5 times in each
direction (rotation, flexion,
extension, lateral flexion in
both directions)
Gallego, 2016 CCF MCE NA; Low-load training of Proprioception 12 14 (twice ≤10 min max. 5 10 repeti- NA; 3-5
the craniocervical flexor exercise per tions,
muscles with an air-filled day) 10 s
pressure sensor targeting each
the deep flexor muscles
(longus capitis and longus
colli), while aiming to mini-
mize the activation of the
superficial flexor muscles
(sternocleidomastoid and
anterior scalene)
Type Rest
Propriocep- MCE NA; Head relocation: starting CCF 12 14 ≤10 min NA NA NA; NA
tion in a sitting position, with a (twice per
laser attached to a helmet day)
at the apex of their head,
and a target located at eye
level on a wall 90 cm away.
This was established as
the natural head posture.
Subjects then practiced
relocating their head to the
natural head posture after
active neck movements,

first with eyes open using
feedback from the laser
attached to their head,
then with pupillary glasses
preventing pupillary
excursion, and finally with
their eyes closed. All active
movements of the cervical
spine (flexion, extension,
rotation, lateral flexion)
were performed. Oculomo-
tor exercises: eye-follow

(eye movement following a
target located at a comfort-
able distance with the
head stationary and gaze
stability (movements of the
head with visual fixation on
a target. Pupillary glasses
were used to ensure a
steady gaze. Eye-head
coordination: rotation of
the eyes and head to the
same side, both left and
right. After that, patients
practiced following a target
with the eyes first, followed
by the head, ensuring that
they maintained focus on
the target. As a further pro-
gression, the eyes moved
first, and then the head,
to look between 2 targets
positioned horizontally or
vertically, and finally, the
eyes and head rotated in
opposite directions, both
left and right
Type Rest
Gialanella, 2017 Home- Other NA; Before the telerehabilita- Control: recom- 2 + 24 10 NA NA NA NA; NA
based tion the patients performed mendation
tele- 6 stretching exercises for to continue
medicine the neck (forward neck exercising at
(HBT) flexion, backward neck home
extension, neck rotation,
and lateral neck flexion
toward the right and left)
Gimenez-Costa, Lower deep RE 3; 2 isometric and 1 concen- Lower deep 6 14 20-25 3 6-10 60-120; NA
2022 neck tric-eccentric exercise with neck exten-
extensor resistance at C4 sor exercise
exercise
General RE 3; 2 isometric and 1 concen- General neck 6 14 20-25 3 6-10 60-120; NA
neck ex- tric-eccentric exercise with exercise
ercise resistance at occiput
Groisman, 2020 Exercise Other Warm-up followed by Osteopathic 4 3 40-45 3 10 NA; NA
strengthening exercises for treatments +
the neck muscles exercise
Gupta, 2013 DCF training MCE NA Conventional 4 NA NA NA NA NA

isometrics
training
Conven- RE NA DCF training 4 NA NA NA NA NA
tional
iso-
metrics
training
Iqbal, 2021 DCF + con- Other NA; Subjects lay in the Conventional 6 5 NA 3 10 120; NA
ventional crook lying position. A exercises
exercises pressure biofeedback only
unit was placed below the
occiput and inflated up
to a baseline pressure of
20 mmHg. The subjects
were instructed to perform
head-nodding action to
progressively target 5 pres-
sure levels
Conven- Other NA; Nonspecific strengthening DCF + 6 4 <20 min 10 10 s 120; NA
tional of the neck flexor muscles conventional
exercises stretching of the ster- exercises
nocleidomastoid, upper
trapezius, levator scapulae,
suboccipitalis, and pectoral
muscles
Type Rest
Javanshir, 2015a CCF MCE 1; CCF with air-filled pressure No further, 10 3 30 NA 10 NA; NA
sensor both groups
CF RE 1; In supine position, lifting up Exercise 10 3 30 3 12-15 60; NA
the head through full ROM
Javdaneh, 2020 Scapular RE 8; Scapular upward rotation Scapular 6 3 45 1-3 10-15 30; 60
training exercise, wall facing arm training +
lift, backward rocking arm cognitive
lift, arm raise overhead treatment
in line with the lower
trapezius muscle fibres,
shoulder abduction in
the plane of the scapula

above 120°, shoulder
shrug, stretching of levator
scapula, and pectoralis
minor muscle
Javdaneh, 2021a Neck stabi- Other NA; CCF; cervical bracing Control/no 6 3 40-50 1 8-10 NA; NA
lization technique in prone, supine, intervention
exercise bipedal, quadruped;
isometric exercises directly
forward, toward right and
left, obliquely and directly

backward; stretching
Javdaneh, 2021b Therapeutic RE 5; Craniocervical flexion Brochures for 6 3 30-40 1-3 5-15 NA; NA
exercise exercise, cervical isometric proper posi-
exercises, scapular upward tion at work
rotation, backward rocking and home
arm lift, L to Y
Jeitler, 2015 Neck Other 12; NA (muscle stretching and Meditation 8 7 15 NA NA NA; NA
exercise strengthening and joint
mobility)
Jordan, 1998 Intensive Other 4; Isometric: flexion, Manipulative 6 2 60-75 1-3 12 NA; NA
training extension, lateral flexion treatment
to both sides; + stretching
exercises for cervical,
shoulder, neck and scapu-
lar muscles; + strength
training of the shoulder,
scapular, and chest
muscles with handheld
weights
Jull, 2009a CCF MCE 1; CCF training with feedback Strength train- 6 14 10-20 10 NA; NA
from air-filled pressure ing
sensor
Strength RE 1; In supine; lifting the head CCF 6 14 10-20 1-3 10-15 60; NA
training and neck through as full
range of motion
Type Rest
Khan, 2014a isometric RE 4; Isometric training of flexors, No further, 12 3 NA 1 20 NA; NA
exercise extensors, side flexors, and both groups
rotators neck muscles with Exercise
Theraband
general Other 4; Range of movement exer- 12 3 NA 1 20 NA; NA
exercise cises for flexors, extensors,
side flexors, and rotators
neck muscles
Khosrokiani, Direction MCE 13; Thoracic flexion exercise, Postural cor- 24 3 30 NA NA NA; NA
2018 move- horizontal retraction, arm rection and
ment extension exercise, lift ex- lectures on
control ercise, occiput lift exercise, promoting

training nodding; forward head lean general
exercise, cervical extension health
control, lower neck tilt,
upper neck tilt, head turn,
reading text on a cellphone,
writing at a desk, typing
text on a cellphone
Khosrokiani, Combined MCE NA; Deep cervical flexor train- Passive treat- 8 NA 20-30 NA NA NA; NA
2022 deep ing in different positions ment and
cervical plus motor control of lum- education

flexor bar spine with biopressure
motor- feedback in supine and
control standing at a wall
training
and
lumbar
motor
control
exercise
Deep cervi- MCE NA; Deep cervical flexor train- Passive treat- 8 NA 20-30 NA NA NA; NA
cal flexor ing in different positions ment and
motor education
control
training
Kim, 2016a DCF training MCE 1; Deep cervical flexor training No further, 4 3 NA 1 10 NA; NA
with pressure biofeedback both groups
device Exercise
General RE NA; Isometric exercises 4 3 NA 1-3 NA NA; NA
strength- with band and a ball in 4
ening directions, 5 stretching
exercise postures, neck stretching,
neck bending over, neck
bending to both sides, neck
rotation
Type Rest
Lansinger, 2007a Qigong YPTQ 14; Not described in detail No further, 12 1-2 60 NA NA NA; NA
(soft movements, slow both groups
movement sequences with Exercise
breathing techniques and
meditation, relaxation, soft
stretching, self-performed
body massage)
Exercise Other NA; Active movements of the 12 1-2 60 1-3 10-30 NA; NA
therapy cervical and shoulder/
thoracic regions; different
muscle exercises with the
aim to maintain/increase
circulation, endurance,
and strength; stretching
exercises
Lauche, 2016a Tai chi YPTQ NA Wait list 12 Group: 1; Group: NA NA NA; NA
individual: 75-90;
6 indi-
vidual:
≥15
Neck exer- Other 33 (warm-up and cool-down Wait list 12 Group: 1; Group: 1-5 NA NA; NA
cises included); Available in individual: 60-75;

supplementary material of 6 indi-
the original article vidual:
≥15
Lee, 2017 Application- Other 6; Sitting chin tuck, sitting Brochure with 8 2 10-15 1 6 NA; NA
based neck extension, side- postural
exercise bending, neck rotation, corrections
sitting neck flexion, neck
extension and rotation
Lee and Lee, Therapeutic Other NA; Enhancing mobility, stabil- Therapeutic 2 3 60 NA NA NA; NA
2017 exercise ity and muscular strength exercise +
of the neck, improving mobilization
proprioception, performing
reeducation of movement
Lee and Kim, DCF training MCE 3; DCF training with air-filled Thoracic 10 3 35 NA NA NA; NA
2016a pressure sensor, stretching manipulation
of levator scapulae and + DCF +
upper trapezius stretching
ROM Other 4; Neck flexion, extension, Thoracic 10 3 35 NA NA NA; NA
exercise lateral flexion, rotation manipulation
+ DCF +
stretching
Type Rest
Letafatkar, 2019 Therapeutic Other 12; Capital flexion (sitting), Manuscript 8 3 20-30 1-3 12-20 60; NA
exercise capital flexion (supine), with postural
capital flexion with headlift corrections
(supine), strengthening
spine extensors (prone),
strengthening spine
extensors (quadruped),
shoulder abduction lateral
rotation (sitting), shoulder
flexion (sitting), wall slides,
trapezius exercise (side-
lying), combined exercise,

(head, shoulder, pelvis),
combined exercise (head,
shoulder), W to Y
Lytras, 2020 Therapeutic Other 11; Re-education of CCF move- TE + INIT 10 4 45 NA NA NA; NA
exercise ment, training the low level
endurance capacity of the
deep neck flexors, retrain-
ing the cervical flexors
for antigravity function,
extensors of the cervical
spine, co-contraction of the

neck flexors and extensors,
retraining the strength of
the superficial and deep
neck flexor synergy, retrain-
ing scapular orientation
in posture, training the
endurance capacity of
the scapular stabilizers,
retraining scapular control
with arm movement and
load, re-education of pos-
ture + breathing exercise,
and gentle stretching at the
end (15 min)
Matias, 2019 Exercise Other 22; Detailed descriptions. Pain neurosci- 4 1 30 1-2 5/10 NA; NA
See table 1 in the original ence educa-
full text. tion plus
exercise
Type Rest
Mehri, 2020 Corrective Other 12; Capital flexion (sitting), Manuscript: 8 3 30 1 12-15 60
exercise capital flexion (supine), postural
capital flexion with headlift corrections
(supine), strengthening
spine extensors (prone),
strengthening spine
extensors (quadruped),
shoulder abduction lateral
rotation (sitting), shoulder
flexion (sitting), wall slides,
trapezius exercise (side-
lying), combined exercise,

(head, shoulder, pelvis),
combined exercise (head,
shoulder), W to Y
Michalsen, 2012a Yoga YPTQ NA; Available in supplemen- No further, 9 1 in group 90 NA NA NA; NA
tary material in the original both groups (+2-3 (group),
article Exercise home) 10-15
(home)
Exercise Other 12; NA; muscle stretching and 9 3 10-15 NA NA NA; NA
strengthening and joint
mobility
Özel, 2022 Remote su- Other NA; Exercises for stretching, Wait list 4 4 20 1 5-10 NA; NA
pervised strengthening, stabilization,
exercise proprioception
Unsuper- Other NA; Exercises for stretching, Wait list 4 4 20 1 5-10 NA; NA
vised strengthening, stabilization,
exercise proprioception
Raju, 2019a DCF training MCE NA; Deep cervical flexor train- NSE 4 3 NA NA 1 NA; NA
ing with air-filled pressure
sensor
Neck stabi- RE 5; Chin tuck, cervical exten- DCF training 4 3 NA NA NA NA; NA
lization sion, shoulder shrugs,
exercises shoulder rolls, scapular
retraction
Type Rest
Ravi, 2016a Propriocep- Other NA; Isometric neck strength CNE 4 7 NA 1 10 NA; NA
tive exercises in flexion, exten-
exercises sion, rotation; dynamic
exercises for shoulders and
upper extremities by doing
dumbbell shrugs; stretch-
ing of neck, shoulders and
upper-extremity muscles
+ exercises based on the
coordination between eye
and neck motor function
Conven- RE NA; Isometric neck strength PNE + CNE 4 7 NA 1 10 NA; NA

tional exercises in flexion, exten-
exercises sion, rotation; dynamic
exercises for shoulders and
upper extremities by doing
dumbbell shrugs; stretch-
ing of neck, shoulders and
upper-extremity muscles
Rendant, 2011a Qigong YPTQ Up to 12 neck exercises + Waiting list 24 1-2 90 NA NA: NA; NA
9 shoulder exercises +
breathing and moving

exercises (for details, see
fig. 1 in the full text)
Exercise RE NA; Warm up + exercises for Waiting list 24 NA NA NA NA: NA; NA
therapy strengthening and mobility
Rodriguez-Sanz, Deep MCE 3; Deep cervical flexor training Exercise plus 4 7 20 2 10 40; 120
2021 cervical with biopressure feedback manual
flexors supine, deep neck extensor therapy
and training in quadruped
extensors position, deep cervical
training flexors training with lifting
the head supine
Sahiner-Picak, Clinical YPTQ 13; Hundreds, 1 leg stretch, Information and 6 2 60 3 8 NA; NA
2022 Pilates double leg stretch, shoul- brochure
der bridge, swimming,
scissors, 1 leg kick, swan
dive, breast stroke prep,
clam, hip twist, side kick,
arm opening
Type Rest
Seo, 2022 Cervical ex- Other NA; Thoracic extension with Cervical 6 2 25 NA NA NA; NA
ercise + foam roller, thoracic exten- exercise +
thoracic sion with chair, thoracic thoracic ma-
spine flexion in quadruped posi- nipulation
mobility tion, thoracic rotation in
exercises side lying, thoracic rotation
in a kneeling position,
thoracic lateral flexion in
sitting position, cervical
spine isometric exercises
Shin, 2020 Neck stabi- Other 4; Deep neck flexor isometric Neck 5 days 2 per day 40 NA NA NA; NA
lization exercise in supine position, stabilization

exercise Multi-directional isometric exercises +
exercise (cervical flexion, thermo-
extension, rotation, side therapy
bending) in a sitting
position, Upper extrem-
ity movement exercise,
Resistive exercise with
Theraband
Soroush, 2022 Neck stabi- RE NA Combined neck 12 Every other 25-30 NA NA NA; NA
lization and core day

exercise stabilization
exercise
Core stabi- RE NA Combined neck 12 Every other 25-30 NA NA NA; NA
lization and core day
exercise stabilization
exercise
Combined RE NA Core stabiliza- 12 Every other 25-30 NA NA NA; NA
neck and tion exercise day
core sta-
bilization
exercise
Type Rest
Shiravi, 2019a Scapular RE 14; Chin tuck, overhead press, SSE without AF, 6 3 30 NA NA NA; NA
stabiliza- horizontal pull apart, chest active self-
tion press, serratus anterior exercise
exercises punches, retraction plus
with ab- external rotation, scapular
dominal protraction, XY, TYW +
control inferior glide, isometric low
feedback row, dynamic knee push-
up, wall press, wall slide
Scapular RE 9; Chin tuck, overhead press, SSE with AF, 6 3 30 NA NA NA; NA
stabiliza- horizontal pull apart, chest active self-
tion press, serratus anterior exercise

exercises punches, retraction plus
without external rotation, scapular
ab- protraction, XY, TYW
dominal
control
feedback
Suvarnnato, DCF training MCE NA; Deep cervical flexor train- Usual care 6 2 NA NA 10 30; NA
2019 ing with air-filled pressure
sensor
Tejera, 2020a Virtual MCE NA; VR application with 4 No further, 4 2 3 10 30; NA

reality required movements: both groups
start: lateral flexion, later + Exercise
flexion, extension, rotation
Neck exer- MCE 4; Flexion, Extension with 4 2 3 10 30; NA
cises craniocervical flexion, rota-
tion & lateral flexion with
craniocervical flexion
Turel, 2015 Home Other NA; Isometric neck exercises, Exercises com- 2 7 NA 1 10 NA; NA
exercise stretching exercises for the bined with
program muscles of the back and spa therapy
neck (scalene, upper part (total body
of trapezius, pectoralis bath, mas-
minor, interspinous, sage, mud
ligamentum nuchae) therapy)
Viljanen, 2003 Strengthen- RE NA; Dynamic muscle training Ordinary activity 12 3 30 NA NA NA; NA
ing with dumbbells targeting
large muscle groups of
the neck and shoulder,
followed by stretching
Type Rest
Yesil, 2018a (a) Multi- Other 8; Postural re-education, jog- Multimodal 3 5 NA NA NA NA; NA
modal ging, stretching exercises exercise
for cervical, shoulder, chest combined
and scapular muscles, cer- with TENS
vical isometric exercises in
supine, cervical isometric
exercises in sitting, upper
extremity movement exer-
cises, resistive exercises
with Theraband, resistive
exercises with dumbbell
(b) Multi- Other 8; Postural re-education, jog- Multimodal 3 5 NA NA NA NA; NA

modal ging, stretching exercises exercise
for cervical, shoulder, chest combined
and scapular muscles, cer- with IFC
vical isometric exercises in
supine, cervical isometric
exercises in sitting, upper
extremity movement exer-
cises, resistive exercises
with Theraband, resistive
exercises with dumbbell
Abbreviations: ACROM, active cervical range of motion; CCF, craniocervical flexion; CCFT, craniocervical flexion test; CF, cervical flexion; Ctrl, control or
comparison group; DCF, deep cervical flexion; MCE, motor control exercise; NA, not available; Other, otherwise categorized interventions (eg, range of motion,
mixed, multimodal), thus not included in quantitative analyses; RE, resistance exercise; ROM, range of motion; YPTQ, Yoga/Pilates/Tai Chi/Qui Gong.
a
All groups were included into quantitative analysis (meta-regression/meta-analysis).

Mueller Et Al 2023 Resistance Motor Control and Mindfulness Based Exercises Are Effective For Treating Chronic

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Mueller Et Al 2023 Resistance Motor Control and Mindfulness Based Exercises Are Effective For Treating Chronic

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[ literature review ]

JULIANE MUELLER, PhD1a • JONAS WEINIG, BSc1a • DANIEL NIEDERER, PhD2

Resistance, Motor Control, and

for Treating Chronic Nonspecific Neck Pain:

and the most effective exercise treatments

Study Information Population Assessments Outcomes

Int 3 5/10 14 44.93 ± 6.26 7/7 6.71 ± 1.14 E:-2.94 E: −1.85

Study Information Population Assessments Outcomes

Int 2 17 38.5 - 44.0 13/4 6.0 ± 3.0 E: −1.69 E: −0.90

Int2 17 40.0 ± 11.88 12/5 5.98 ± 1.93 E: −1.26 E: −1.03

Study Information Population Assessments Outcomes

Int 1 nonspecific 90 64.0 ± 10.4 65/25 5-5 ± 1.4 E: −1.36 E: −1.02

Study Information Population Assessments Outcomes

Int 2 25 36.45 ± 5.95 12/13 5.40 ± 0.56 E: −1.61 E: −0.73

Ctrl 1 30-70 24 32.35 ± 8.12, 12/12 62.6 ± 6.15

Study Information Population Assessments Outcomes

Ctrl 3-8 15 37.6 ± 5.6 15/0 4.5 ± 2.0

Study Information Population Assessments Outcomes

Study Information Population Assessments Outcomes

Int 1 45, 26.0 ± 1.7 45/0 6.4 ± 0.8 E: −6.79

Ctrl 2 18 42.1 ± 8.5 15/3 4.1 ± 0.9

ing, and other sources of bias. For each

Dose-response analyses were calcu-

week] of the intervention; the dura-

Individual Trials’ Training Characteristics

sessions per week with a mean of 5.1 ± 5.1

change score of −7.6) against true control,

cise (SMD, −0.52; 95% CI:−1.13, 0.09; I2

Comparison With Other Evidence

motor control exercise on pain supported

weeks to 12 months for motor control

motor control, and mindfulness-based)

more than 5 sessions per week for people

chronic neck pain. Future original studies

Limitations: Study and Outcome Level

ing pain and improving disability in

definition given by the International

of data (J.M., J.W., D.N., S.M.) and/or

msksp.2022.102561 https://doi.org/10.3390/ijerph18168848 58. Letafatkar A, Rabiei P, Alamooti G, et al. Effect

levator scapulae and pec-

Dynamic RE NA Neck stabiliza- 8 2 30 NA NA NA; NA

training in smooth head pursuit, or

supine position, movement

performed in the supine

Table continues on next page.

and upper back, 2 weeks of

tional extensors, the upper tra-

shoulder external rotation.

isometric in all 3 planes (neutral

ing, sitting, and supine

continued with postures

exercises, cat and camel,

normalize muscle tension

Endurance- RE 1; Training in 2 stages: Stage CCF 6 14 10-20 1-3 12-15 60; NA

moved the head and neck

extensor muscles (head

of the neck to feel the

active neck movements,

tor exercises: eye-follow

Gupta, 2013 DCF training MCE NA Conventional 4 NA NA NA NA NA

the plane of the scapula

left, obliquely and directly

control ercise, occiput lift exercise, promoting