Elsevier

The Spine Journal

Volume 16, Issue 12, December 2016, Pages 1503-1523
The Spine Journal

Review Article
Is exercise effective for the management of neck pain and associated disorders or whiplash-associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

https://doi.org/10.1016/j.spinee.2014.02.014Get rights and content

Abstract

Background context

In 2008, the Neck Pain Task Force (NPTF) recommended exercise for the management of neck pain and whiplash-associated disorders (WAD). However, no evidence was available on the effectiveness of exercise for Grade III neck pain or WAD. Moreover, limited evidence was available to contrast the effectiveness of various types of exercises.

Purpose

To update the findings of the NPTF on the effectiveness of exercise for the management of neck pain and WAD grades I to III.

Study design/setting

Systematic review and best evidence synthesis.

Sample

Studies comparing the effectiveness of exercise to other conservative interventions or no intervention.

Outcome measures

Outcomes of interest included self-rated recovery, functional recovery, pain intensity, health-related quality of life, psychological outcomes, and/or adverse events.

Methods

We searched eight electronic databases from 2000 to 2013. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. The results of scientifically admissible studies were synthesized following best-evidence synthesis principles.

Results

We retrieved 4,761 articles, and 21 randomized controlled trials (RCTs) were critically appraised. Ten RCTs were scientifically admissible: nine investigated neck pain and one addressed WAD. For the management of recent neck pain Grade I/II, unsupervised range-of-motion exercises, nonsteroidal anti-inflammatory drugs and acetaminophen, or manual therapy lead to similar outcomes. For recent neck pain Grade III, supervised graded strengthening is more effective than advice but leads to similar short-term outcomes as a cervical collar. For persistent neck pain and WAD Grade I/II, supervised qigong and combined strengthening, range-of-motion, and flexibility exercises are more effective than wait list. Additionally, supervised Iyengar yoga is more effective than home exercise. Finally, supervised high-dose strengthening is not superior to home exercises or advice.

Conclusions

We found evidence that supervised qigong, Iyengar yoga, and combined programs including strengthening, range of motion, and flexibility are effective for the management of persistent neck pain. We did not find evidence that one supervised exercise program is superior to another. Overall, most studies reported small effect sizes suggesting that a small clinical effect can be expected with the use of exercise alone.

Introduction

Neck pain is common in the general population with 30% to 50% of adults experiencing neck pain annually [1]. In the United States, neck pain is the fourth leading cause of morbidity and chronic disability [2]. In 2008, The 2000 to 2010 Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders (NPTF) reported that 50% to 75% of individuals with neck pain report pain 1 to 5 years later [3]. The episodic nature of neck pain also poses a clinical management challenge as few interventions have been identified as effective and treatment effects are often small and short lived [3], [4].

Clinical practice guidelines promote exercise for the management of neck pain and associated disorders (herein referred to as neck pain) and whiplash-associated disorders (WAD) [5], [6] (Jessica J. Wong, Pierre Côté, Heather M. Shearer, et al. unpublished data, 2013). Moreover, evidence from population-based surveys suggests that it is commonly prescribed by health-care providers [7]. However, guidelines lack consistency in the type, intensity (frequency, duration), and mode of delivery of recommended exercises.

In 2008, the NPTF synthesized evidence on the effectiveness of exercise for the management of neck pain and WAD. Two trials focused on persistent Grade I/II neck pain and compared exercise interventions with other conservative interventions. One trial [8], [9] demonstrated that exercise (aerobic exercise, stretching, progressive upper body strengthening, and dynamic resistance exercises for the neck) with or without spinal manipulative therapy resulted in greater long-term improvements in pain and disability than spinal manipulative therapy alone. In another trial by Chiu et al. [10], [11], both exercise (activation of deep neck flexors and progressive dynamic flexion/extension resistance training) and Transcutaneous electrical nerve stimulation (TENS) led to similar outcomes in patients with persistent neck pain. Both interventions resulted in greater reductions in neck pain and disability compared with infrared irradiation. The NPTF found three trials that focused on female office workers with persistent neck pain. Two trials [12], [13], [14] demonstrated that strengthening and endurance exercises for the neck flexors and upper extremities, either alone or when added to a multimodal physical therapy program, yield similar outcomes with respect to pain and disability. In one trial [15], group exercises (dynamic resistance training for the neck and shoulder) resulted in similar long-term clinical outcomes as group-based relaxation training or advice to continue usual activities. The Task Force found only one trial on exercise for the management of WAD. In a trial by Rosenfeld et al. [16], home-based range-of-motion exercises resulted in greater pain reduction and diminished need for sick leave compared with written information and advice for patients recently exposed to whiplash trauma. The NPTF did not find evidence related to exercise for the management of Grade III neck pain or WAD.

Since the publication of the NPTF, three systematic reviews have commented on the effectiveness of exercise for the management of neck pain [17], [18], [19]. However, all reviews had important limitations. First, their synthesis of results included both high- and low-quality studies [17], [18], [19]. Second, two of the three reviews only commented on the statistical significance of results, without reference to clinical significance [18], [19]. These methodological limitations may have led to biased recommendations. Moreover, the reviews had a limited scope. Two reviews focused on the subpopulations: workers [18] and those injured in motor vehicle collisions [19]. In the third review, studies that compared exercise with alternative nonexercise interventions were excluded [17]. This limits our ability to understand the comparative effectiveness of exercise interventions for the management of neck pain.

The purpose of our systematic review is to update the work of the NPTF on the effectiveness of exercise compared with other interventions, placebo/sham interventions, or no intervention for the management of adults or children with Grade I, II, or III neck pain or WAD.

Section snippets

Registration

This review protocol was registered with the International Prospective Register of Systematic Reviews on January 23, 2013 (CRD42013003717).

Population

Our review targeted studies of adults or children with neck pain Grade I, II, or III or WAD Grade I, II, or III. We excluded studies of neck pain caused by major structural pathology (eg, fractures, dislocations, spinal cord injury, infection, neoplasms, or systemic disease). We defined neck pain according to the definition proposed by the NPTF (Table 1) [20]

Study selection

Our search retrieved 4,761 articles. We removed 1,035 duplicates and screened 3,726 articles for eligibility (Figure). After screening, 3,705 articles did not meet our selection criteria, whereas 21 studies were critically appraised. The interrater agreement for the screening of articles was k=0.92 (95% CI 0.88–0.97). We accepted 11 articles as scientifically admissible. One of the scientifically admissible articles [41] was a secondary analysis of another admissible study [42].

Study characteristics

All 10

Summary of evidence

Our systematic review suggests that patients with recent neck pain Grade I/II have similar outcomes whether they are managed with home exercises, multimodal manual therapy, or medication (ie, NSAIDs or acetaminophen). However, the risk of mild transient adverse events is higher for those who receive NSAIDs or acetaminophen [48]. We also found evidence that supervised graded strengthening exercises are more effective than advice to continue daily activities but lead to similar outcomes as a

Acknowledgment

This research was undertaken, in part, thanks to funding from the Canada Research Chairs program. The authors acknowledge the invaluable contributions to this review from Angela Verven, Arthur Ameis, Carlo Ammendolia, David Cassidy, Doug Gross, Gail Lindsay, John Stapleton, Maja Stupar, Mike Paulden, Murray Krahn, Patrick Loisel, Poonam Cardoso, and Roger Salhany. The authors also thank Trish Johns-Wilson at the University of Ontario Institute of Technology for her review of the search strategy.

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    Author disclosures: DS: Consulting: Appraisal of guidelines for the Ontario Chiropractic Association. The appraisals were used to prepare a report to be submitted for consideration by the Workplace Safety and Insurance Board, Canada (A, estimated). MCN: Support for travel to meetings for the study or other purposes (B); Royalties: Wolters Kluwer (B); Speaking/Teaching Arrangements: EuroSpine (B); Trips/Travel: (B); Scientific Advisory Board/Other Office: Palladian Healthcare (B). PC: Grant: Ontario Ministry of Finance—Finance Services Commission of Ontario (I CDN, Paid directly to institution). HMS: Nothing to disclose. SV: Nothing to disclose. HY: Nothing to disclose. JJW: Nothing to disclose. DAS: Nothing to disclose. KAR: Nothing to disclose. GMvdV: Nothing to disclose. SAM: Consulting fee or honorarium: Member of the Guideline Expert Panel; MIG Project (B). LJC: Support for travel to meetings for the study or other purposes: Guideline Expert Panel Meetings (A, Paid directly to institution); Consulting: Government of Alberta Department of Finance (Insurance Branch) (A); Grants: WCB Manitoba Scientific Research Competition endMS Research and Training Network (F, Paid directly to institution), Eurospine (D, Paid directly to institution), WCB Manitoba Scientific Research Competition (F, Paid directly to institution), CIHR (E, Paid directly to institution). CLJ: Nothing to disclose. ALT-V: Nothing to disclose.

    The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.

    Funding: This study was funded by the Ontario Ministry of Finance and the Financial Services Commission of Ontario (RFP#: No.: OSS_00267175). The funding agency was not involved in the collection of data, data analysis, interpretation of the data, or drafting of the article.

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