[ CLINICAL COMMENTARY ]

ANITA R. GROSS, MSc¹šJ;:>7?D;I"MSc²š9>7HB?;>$=EB:IC?J>"PhD³šB?D7I7DJ7=K?:7"PhD4šB7KH?;C$C9B7K=>B?D"DSc5

F7KBF;BEIE"MSc6šIJ;F>;D8KHD?;"MSc7š@7D>EL?D="PhD8š9;HL?97BEL;HL?;M=HEKF9E=9

Knowledge to Action:
A Challenge for Neck Pain Treatment
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eck pain causes significant impairment, second only to to 1% of the 2004 gross domestic prod-

N low back pain.84,110 In a recent best-evidence synthesis,49

the 12-month prevalence of neck pain varied from 30% to
50%,20,104 lifetime prevalence was approximately 70%, point
prevalence was 22%,8 and the estimated incidence was 213 per 1000
uct.79 Given the burden of neck disorders
for society and individuals, it is impor-
tant to maximize effective strategies to
treat and prevent neck pain. Equally im-
portant is for health providers to make
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

person years. Sedentary lifestyles are contributing to the prevalence of evidence-based treatment decisions to
neck pain.25 Occupational factors play a large role in the development optimize their delivery of care. There is
a wide spectrum of treatments available
of neck pain as one of the most frequent musculoskeletal disease seen by rheuma- to people with neck pain, not all of which
causes of long-term sickness absence.21 tologists17 relate to neck pain. Combined, are equally effective.
Some 25% of visits to chiropractors,20 low back pain and neck pain have cost Clinical practice guidelines are de-
15% to hospital-based physiotherapists,43 an estimated $90 billion per year in the fined as “systematically developed state-
2% to family physicians,76 and 75% of United States, a figure roughly equivalent ments to assist practitioner and patient
decisions about appropriate healthcare
Journal of Orthopaedic & Sports Physical Therapy®

T SYNOPSIS: For clinicians, systematic reviews
can enhance incorporation into practice of the
large volumes of information emerging from
research on effectiveness and risks. But we believe
that these reviews are most useful with simplified
tools to facilitate translation of this knowledge
into practice. We provide a “Neck Care Tool Kit”
that gives a diagrammatic approach to prioritiz-
ing intervention. The evidence from a series of 11
systematic reviews by the Cervical Overview Group
is depicted in decision flow-charts and tables to
enhance clinical interpretation of the overview
findings. On simple visual inspection of symbols
in a table, the reader can establish where there is
evidence of benefit or no benefit, the strength of
the recommendation, and if these data represent
short- or long-term findings. Where possible, we
guide clinicians to dosage of specific treatment
methods. There is no consensus as to which
outcome measures to prioritize among the large
number in use. This clinical commentary guides
clinicians to view the evidence in enough detail to
integrate it into their clinical practice environment.
We conclude by delineating research gaps and
proposing future research directions.
TB;L;BE<;L?:;D9;0 Therapy, level 5.
J Orthop Sports Phys Ther 2009;39(5):351-363.
doi:10.2519/jospt.2009.2831
TA;OMEH:I0 cervical spine, exercise, guide-
lines, systematic reviews
for specific circumstances.”48 Ideally, they
serve as a “knowledge translation tool” to
move the best evidence into clinical prac-
tice. However, some guidelines are not
based on high-quality evidence, such as
that found in systematic reviews. System-
atic reviews facilitate clinicians’ ability to
stay current, as they compile high-qual-
ity, synthesized data. Further, guidelines
commonly exhibit discrepancies3,83 and
may not be evidence based.95 The onus is
on the clinician to judiciously interpret
and integrate the information provided.
To make evidence-based clinical prac-
tice guidelines and systematic reviews

1
Associate Clinical Professor, School of Rehabilitation Science, McMaster University, Hamilton, Canada. 2 Associate Professor, Program in Occupational Health and Environmental
Medicine, McMaster University, Hamilton, Canada. 3 Emeritus Professor of Biostatistics, Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada. 4 Co-
associate Director of Evidence-Based Practice Unit, Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada. 5 Clinical Associate, School of Rehabilitation
Science, McMaster University, Hamilton, Canada. 6 Development, Clinical Immunology, Analgesia, Anemia and Urology, MRL, Merck & Co, Inc, Rahway, NJ. 7 Chiropractor,
private practice, Toronto, Canada. 8 Senior Research Fellow, Coronel Institute of Occupational Health, Academic Medical Center, Universiteit van Amsterdam, The Netherlands;
Department of Epidemiology and Preventive Medicine, Monash University, Australia. 9 An interdisciplinary, internationally-based working group interested in the conducting and
maintaining of systematic reviews on conservative management for mechanical neck disorders: Theresa Kay, Peter Kroeling, Nadine Graham, Bohdi Haraldsson, Angela Eady,
Kein Trinh, Janette Ezzo, Anne Morien, Elaine Wang, Ian Cameron, Roger White, Lothar Lilge, Lenora Perry, Carl Hildebrand. Address correspondence to Anita Gross, McMaster
University, School of Rehabilitation Sciences, IAHS 4th floor, 1400 Main St W, Hamilton, ON, CANADA, L8S 1C7. E-mail: grossa@mcmaster.ca

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 351
 [ CLINICAL COMMENTARY ]
COG
1992 to 2004

Physical
Medicine Manual Therapy Patient Education
Medicine Methods

Medication Exercise Manipulation

Injection Electrotherapy Mobilization

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Low-level laser Massage

Heat and cold

Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Sonic agents

Traction

Acupuncture
Journal of Orthopaedic & Sports Physical Therapy®

Orthosis

<?=KH;'$Categories of neck care reviewed by the Cervical Overview Group.

more useful to clinicians, we provide a
supplementary “tool kit,” with simpli-
fied summaries and practical application
tips to help translate this knowledge into
practice. Our purpose in this commen-
tary, as clinicians, is to supply an applied
clinical discussion of the findings of the
Cervical Overview Group (COG). We pro-
vide the following “Neck Care Tool Kit”
for application of the evidence on neck
(<?=KH;(), (3) summary-of-findings tables
(J78B;'), (4) summary of outcome mea-
sures (J78B;(), (5) evidence-based home
exercise program (J78B; ) and 7FF;D:?N
7L7?B78B;EDB?D;).
EL;HL?;ME<9E=
H;L?;M<?D:?D=I
findings, consistent with the evidence
available up to September 2004. Note
that it is not the intent of this commen-
tary to update our overview but rather
to help guide and assist in translating
this volume of evidence into clinical
practice.
The following clinical questions are the
focus of our series of reviews, completed
within the framework of the Cochrane

pain treatment into practice, through
presentation and discussion of simple
figures, as well as tables, showing a dia-
grammatic approach to prioritizing treat-
ments: (1) categories of neck care (<?=KH;
1), (2) evidence-based neck care algorithm
S
ince first publishing our over-
view in 1996,1,37 COG has completed
11 systematic reviews on conserva-
tive management of mechanical neck
disorders (<?=KH; ').24,36,41,42,40,44,38,64,74,75,86,
87,110,111
One of our recent overview publi-
cations39 serves to summarize the group’s
Collaboration systematic review process-
es (<?=KH; )). Do conservative manage-
ment strategies have positive effects on
neck pain, function/disability, return to
work, time lost from work, patient-per-
ceived effects, or patient satisfaction? Do

352 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
 Evidence-Based Neck Care
Cervical Overview Group 2007
(Gross et al 2007)

Chronic neck pain with Chronic myofascial Chronic neck pain with
Chronic neck pain Acute whiplash
cervicogenic headache neck pain radicular findings

COMBINED CARE: Exercise: Use NOT SUPPORTED: Exercise: Use NOT SUPPORTED:
exercise AROM education, strengthen and stretch IM anesthetic low-level laser therapy Intermittent traction
mobilization/manipulation home exercise advise rest craniocervical flexion injection at specified dosage
(with or without medication, education)

Exercise: IV glucocorticoid Use NOT SUPPORTED:

strengthen and stretch continuous use of
for short-term pain relief and Epidural injection
proprioceptive soft collar
eye fixation intermediate-term sick leave Repetitive
magnetic stimulation

Low-level laser therapy Pulsed electromagnetic Acupuncture

for associated field for short-term
for short-term pain relief
degenerative changes pain relief
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Acupuncture Use NOT SUPPORTED:

for short-term pain relief botulinium-A injection
as sole intervention for pain

Pulsed electromagnetic Use NOT SUPPORTED:

field for short-term unsupervised home exercise
pain relief as sole intervention
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Repetitive
magnetic stimulation

<?=KH;($Evidence-based neck care algorithm. Algorithm findings from the Cervical Overview Group 2004 update by disorder subtype. The grading of the strength of the
evidence utilized the categories recommended by the Cochrane Back Group. We depict the strength of the evidence by shape. Key: rectangle with bold letters, strong evidence
of benefit; rectangle with plain text, moderate evidence of benefit; triangle, limited evidence of benefit; octagon, evidence suggests not beneficial. Gross AR, Goldsmith C,
Hoving JL et al. Conservative management of mechanical neck disorders: a systematic review. Adapted with permission from J Rheumatol. 2007;34(3):1083-1102.

trial factors, such as study quality, neck signs and symptoms (NDR), (4) neck dis- Trials comparing one treatment to anoth-
Journal of Orthopaedic & Sports Physical Therapy®

pain chronicity, neck pain subtype, or order associated with whiplash (WAD), er were excluded from this commentary.
dose of intervention influence treatment (5) neck disorders associated with degen-
effects? What are the costs and adverse erative changes (DC), and (6) neck disor- EkjYec[i
effects associated with the treatments? ders with associated myofascial pain. Pain, function/disability, work-related
Our review methods meet the guidelines outcomes, patient satisfaction, or patient-
for systematic reviews published by the ?dj[hl[dj_edi perceived effect.
Cochrane Collaboration Back Group.113 We include studies using manual therapy, To inform clinicians on the risk of bias
We include clinical trials if they meet the medicinal and injection therapies, physi- inherent in our review’s findings, we use
following criteria. cal medicine methods, or patient educa- both the shorter 5-item methodological
tion. We do not include trials addressing quality criteria list by Jadad et al,58 as well
:[i_]di numerous complementary/alternative, as the more comprehensive van Tulder et
Randomized controlled trial (RCT) or herbal, and homeopathic therapies, or al113 11-item criteria, because the latter is
quasi-RCT. interventions that are principally psy- recommended by the Cochrane Back Pain
chology based. subgroup. We have found these 2 criteria
FWhj_Y_fWdji lists to have moderate correlation of their
Acute, subacute, or chronic neck pain 9ecfWh_iedi total scores (estimate rho, 0.65; 95% CI:
with or without cervicogenic headache (1) Placebo (eg, mobilization versus 0.43 to 0.86) and significant agreement
or radicular findings. We have used the mock/sham mobilization; mobilization on the classification of studies as high- or
following terms to categorize neck pain: versus another sham treatment [sham low-quality (estimated kappa, 0.53; SD,
(1) mechanical neck disorder (MND) to transcutaneous electrical nerve stimula- 0.17) across our series of reviews and, as
depict “non-specific” neck pain, (2) neck tion (TENS)]); (2) other treatment (eg, such, we have chosen to report the short-
disorder with cervicogenic headache mobilization and ultrasound versus ultra- er Jadad results primarily.
(NDH), (3) neck disorder with radicular sound), and (3) wait list or no treatment. To aid clinicians’ judgments on the

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 353
 [ CLINICAL COMMENTARY ]
J78B;' Summary of Findings*

Rx Jh[Wjc[djJof[ FW_d <kdYj_ed =F; IWj_i\WYj_ed

Evidence of Benefit
Multimodal Multimodal: stretching and strengthening exercise, mobilization, gggg (M-A) gggg (M-A) gggg
and manipulation for subacute/chronic MND/NDH/NDR7,11,12,60,62
Exercise Strengthening and stretching of neck region for chronic MND
a. MEDX high-load weight training (20 ses/11 wk)13,23 vv/vvvv vv/vvvv vv/vvvv vv/vvvv
b. 6 strengthening and stretching exercises (8 ses/4 wk)32 vv
c. Feldenkrais and home exercise (32 ses/16 wk)78 vvvv vvvv
d. Endurance training neck flexors, scapular/upper extremity, vvvv
and home exercise (12 ses/2.5 wk)121
e. High-load strength training neck flexors, scapular/upper extremity vvvv
and home exercise (12 ses/2.5 wk)121
Strengthening and stretching of neck region for chronic NDH
a. Craniocervical flexion, cervicoscapular and postural exercise vvvv vvvv vvvv
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(12 ses/6 wk)60

Strengthening and stretching of shoulder region plus total body
conditioning for chronic MND
a. Group exercise class (gymnastics) at work105 vv vv
b. Feldenkrais intervention and home exercises78 vv/vvvv vv/vvvv
AROM or stretch exercise for acute WAD80,81 vv
Cervical proprioceptive training and eye fixation exercises
for chronic MND
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

a. Proprioceptive rehabilitation program, eye-neck vv vv

coordination (6 ses/8 wk)92
b. Eye fixation and cervicothoracic endurance exercises, vv/vvvv vv vv/vvvv
posture (24 ses/12 wk)105
Home exercise for acute WAD
a. Active and passive repeated movement; McKenzie and Maitland80,81 vv
b. Exercise within limit of pain, Maitland mobilization82 vv
Medicine Intravenous glucocorticoid for acute WAD90 vv vvv Sick leave
Epidural injections with methylprednisolone and lidocaine for vv/vvvv vv/vvvv
chronic neck disorder with radiation103
Intramuscular injection local anesthetic for chronic MND VVV
(myofascial neck pain)22
Journal of Orthopaedic & Sports Physical Therapy®

Massage Traditional Chinese therapeutic massage for chronic MND16 V

Electrotherapy Pulsed electromagnetic field (PEMF) for acute MND/WAD and
chronic DC
a. Extremely low frequency112 vv vv vv
b. Low frequency
1. PEMF system (4 ses/2 wk)112 v
2. ELF (low-frequency electromagnetic field) (15 ses/3 wk)94,109 v
c. High frequency
2-3 wk Rx for chronic MND28 v
2-3 wk Rx for acute WAD29 v
4-6 wk Rx for chronic MND28 v
4-6 wk Rx for acute WAD29 v
12 wk Rx for acute WAD29 v
2. Therapeutic application musically modulated electromagnetic v
field (4 ses/2 wk)93
Repetitive magnetic stimulation (RMT) for chronic myofascial VV
pain (10 ses/2 wk)100
Laser Low-level laser therapy (LLLT) for chronic MND/DC (OA)15,85,106,102 v/vvv v
Traction Intermittent traction for chronic MND, NDR, DC35,122 vv vv
Orthosis Orthopaedic pillow for chronic MND59 vv vv
Acupuncture Acupuncture vv (M-A)
a. Traditional Chinese medicine for chronic MND, NDR19,56 v/vv
b. Japan style for subacute/chronic MND and WAD4 vv
c. Electroacupuncture for chronic MND and DC120 v
d. Western for chronic MND119 v/vv/vvv/vvvv vv/vvv/vvvv
e. Local standard points for chronic NDR89 v
f. Local standard points for chronic MND88 vv
g. Dry needling over ear trigger point for chronic MND57 vv/vvv
h. Traditional Chinese medicine (dry needling trigger point) for v
chronic MND56

354 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
 J78B;' Summary of Findings* (continued)

Rx Jh[Wjc[djJof[ FW_d <kdYj_ed =F; IWj_i\WYj_ed

Evidence of No Benefit
Medicine Botulinum-A injection for chronic MND with or without radiculopathy vv (M-A)
or headache18,96,30,31,117,118
Intracutaneous injection of sterile water for NDH94 vv
Subcutaneous injection of a vasodilator for chronic MND10 v
Melatonin for chronic WAD, MND114 v
Morphin added to epidural injection (triaminalone, lidocaine) for V/VVVV
chronic NDR14
Exercise Home exercise for chronic MND and NDR
a. Mobilization, home exercise (stretches, Thera-Band vv vv
strengthening) (unknown ses/8 wk)7
b. Home exercises, medication (1 ses)66-72 vv vv
c. Mock therapy included superficial massage, manual traction, vv
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electrical stimulation, analgesics, education (neck school

including exercise)11,12
d. Education on “how program fits with every day life” vvvv vvvv
and exercise51
Manual therapy Manipulation alone
a. 1 ses for acute, subacute, chronic MND99 vv
b. 3-4 ses/3 wk for chronic NDR/NDH5 vv
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Manipulation, mobilization, and modalities for chronic NDR/DC11,12,73 vv vvvv

Massage alone
a. Ischemic compression for chronic myofascial neck pain and MND47,52 v/vv
b. Occipital release for MND46 v
c. Western massage for subacute MND57 v
Thermal and sonic agents Ultrasound for chronic MND (myofascial neck pain)
a. At 8 ses/4 wk, 3 W/cm2, 3 min per trigger point32 v v v
b. At 10 ses/2 wk, 1.5 W/cm2, 6 min per trigger point22 v/vvv
Ultrasound for acute WAD27 v
Hot pack for chronic MND55 vvvv vvvv vvvv
Infrared light for subacute/chronic MND/DC77 vv
Journal of Orthopaedic & Sports Physical Therapy®

Infrared light for myofascial neck pain4 vv

Spray and stretch for chronic MND (myofascial neck pain)52,101 v (M-A)
Electrotherapy Modulated galvanic current (diadynamic) for chronic NDR/NDH78 V v
Iontophoresis for acute WAD26 V
Magnetic necklace (static magnet) for chronic MND50 V
Electrical muscle stimulation for chronic MND, NDR, NDH53,75 vvvv vvvv vvvv
Laser Low-level laser therapy (gallium arsenide, 830 nm)
for subacute/chronic MND (myofascial neck pain)107 vv
for chronic MND (myofascial neck pain)98,108 vv
LLLT (helium neon, 632.8 nm) for chronic MND (myalgia)116 V
Orthosis Oral splint for chronic MND, NDH63 vv/vvv
Soft collar for acute WAD or NDH
a. Soft collar intermittent use (2 wk)33 vv
b. Soft collar intermittent use (2 wk)6 vvv vvv sick leave vvv
c. Soft collar continuous use (2 wk)80,81,82 vv (M-A)
Education Advice to be active for subacute/chronic MND34,61,66-72 vv/vvv
Advice to rest for acute WAD
a. Short-term follow-up80,81,82 vv (M-A)
b. Intermediate-term follow-up5 vvv vvv sick leave vvv
Advice on pain and stress coping skills for chronic MND51 VVVV
Neck school for acute/subacute/chronic MND61 VV
Traction Static traction for acute to chronic MND, NDR, DC9,65,122 vv vv
Key: strong evidence, diamonds (gg); moderate evidence, circles (vv); limited evidence, triangles (VV); the solid diamond, circle, or triangle (gvV) shows
evidence of benefit; the open diamond, circle, or triangle (gvV) shows evidence of no benefit; long-term follow-up (4 symbols); intermediate-term follow-up (3
symbols); short-term follow-up (2 symbols); posttreatment follow-up (1 symbol).
Abbreviations: DC, degenerative changes; GPE, global perceived effect; M-A, results based on a meta-analysis; MND, mechanical neck disorder; NDH, neck
disorder with headache; NDR, neck disorder with radicular findings; neg, negative results; Rx, treatment; ses, session; WAD, whiplash-associated disorder.
*Overview findings subdivided by intervention and outcome measures depict the direction of the evidence by solid (beneficial) and open (not beneficial) sym-
bols. The strength of the evidence is depicted by symbol type, and the duration of follow-up by the number of symbols. Meta-analyses (M-A) are also noted.

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 355
 [ CLINICAL COMMENTARY ]
strength of the evidence, our group uses
Summary of Outcome Measures Noted the approach recommended by the Co-
J78B;( in our Overview Are Diverse With chrane Back Group on the levels of evi-
No Obvious Standardization dence. These categories are as follows and
are reported in J78B;' and <?=KH;I( and 4:
LWh_WXb[ C[Wikh[c[dj strong evidence (consistent findings from
FW_d š '&Yc"'&&ccL7I multiple high-quality RCTs); moderate
 š L7IWYj_l_jo&je'&Yc evidence (findings from a single, high-
 š L7I&je'&&"h[YehZ[Z*j_c[i%Z1jejWbcWha_d]i"cc%ma quality RCT or consistent findings from
 š DHI#'&'eh''#XeniYWb[ multiple low-quality RCTs); limited evi-
 š 7l[hW][fW_dZkh_d]fh[l_ekim[[a"ceiji[l[h[fW_d"DHI&je'& dence (findings from a single low-quality
 š D[YafW_dceZ_Ó[ZledAeh÷iYWb["Wl[hW][)iYWb[i&je'&& RCT); and unclear evidence (inconsistent
 š C_bb_ediYWb[i&je'&&cc results from multiple RCTs).
 š &#je#)fe_djiYWb[ We are careful to point out where there
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 š &#je#+fe_djiYWb[ is an absence of evidence, where there

 š /#fe_djb_d[WhiYWb[ is unclear (inconsistent) evidence, and
 š 9ecX_d[ZiYeh[i\eh^[WZWY^["d[Ya"i^ekbZ[hL7I&je'& where there is evidence of no effect. In
 š IYejj#>kia_iiedj[ij"L7I future updates our group will also utilize
 š CY=_bbFW_dGk[ij_eddW_h[ the GRADE system,97 as endorsed by the
 š M>OCF?'&#fe_djiYWb[ Cochrane Collaboration, to broaden the
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

 š FW_dYekdj"d[Ya%i^ekbZ[h%Whc%^WdZfW_dWdZ^[WZWY^[fh[i[dj reporting on the strength of evidence.

 š J_c[jeh[jkhdZje+&e\fh[jh[Wjc[djfW_d A frequent criticism of Cochrane re-
 š :W_boWdWb][i_Yki[ views and other systematic reviews is
 š H[Ykhh[dY[e\fW_d that, in spite of their methodological
<kdYj_ed"Z_iWX_b_jo š D[Ya:_iWX_b_jo?dZ[n&je+&"&je'&& rigor, they fail to provide clear clinical
 š Dehj^m_YaFWhaD[YaFW_dGk[ij_eddW_h[&je),"&je'&& answers or lack appropriate translation
 š D[YaFW_dWdZ:_iWX_b_joIYWb[
of the evidence into the realities of clini-
 š 9ef[d^W][dD[Ya<kdYj_edWb:_iWX_b_joIYWb[
cal practice. It is common to read in re-
 š D[YaZ_iWX_b_joceZ_Ó[ZledAeh÷iYWb["Wl[hW][)iYWb[i&je'&&
views that “the methodological quality of
Journal of Orthopaedic & Sports Physical Therapy®

 š ''#fe_djiYWb[e\CEFE<hW][dXe][di^eki[^ebZWYj_l_jo"f^oi_YWbWYj_l_jo"
the evidence is limited, there are too few
activity of daily living, social activity, neck mobility)
studies of merit, and there are no clear
 š I[b\#h[fehjZ_iWX_b_jo_dZ[ncWn_ckciYeh[)&
evidence-based answers.” This criticism
 š AWhde\iao<kdYj_edIYWb[
is also valid of “the conservative manage-
 š F^oi_YWb\kdYj_ed_d]"'&#fe_djiYWb[
ment of mechanical neck disorders” sys-
tematic reviews. Others have struggled
Meha#h[bWj[ZekjYec[i š J_c[e÷mehaZ
with this issue, as exemplified in a recent
 š I_YaZWoi
best-evidence synthesis by Hurwitz et
=beXWbf[hY[_l[Z[÷[Yj š '#je#+fe_djiYWb[
al.54 While best-evidence synthesis has
 š I[b\#h[fehj[Z_cfhel[c[dj
some methodological differences from
 š F[hY[_l[Zh[Yel[ho
the Cochrane reviews, such as design cri-
 š I[b\#Wii[iic[dje\ekjYec["ehZ_dWbiYWb[Å)je!)
teria for selection of studies and criteria
FWj_[djiWj_i\WYj_ed š '#je#-iYWb["Yecfb[j[boiWj_iÓ[ZjeYecfb[j[boZ_iiWj_iÓ[Z
for methodological quality, its numerous
 š '#je#+iYWb[
findings overlap substantially with those
 š '&#je#+&iYWb[
of the COG. However, these publications
GkWb_joe\b_\[ š I<#),Gk[ij_eddW_h[
have not been prepared in a manner that
 š I<#'(F9I
allows ready uptake by clinicians.
 š ;khe#G&je'&&
Disappointingly, over the past decade,
 š =[d[hWb>[Wbj^Gk[ij_eddW_h[(.
there has been no improvement in the
 š Dejj_d]^Wc>[Wbj^FheÓb[&je).
methodological quality of controlled tri-
IkccWhoiYeh[ š 9kckbWj_l[WZlWdjW][\eh,fWj_[dj#eh_[dj[ZekjYec[i
als conducted for neck disorders (<?=KH;
Abbreviations: VAS, visual analogue scale; NRS, numeric rating scale; WHYMPI, West Haven-Yale
Multidimensional Pain Inventory; SF-36, Short Form-36 item; Euro-Q, Euro Quality of Life.
5), in spite of the strong recommenda-
tions on conduct and reporting of clinical

356 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
 Content of a Home Exercise Training Program From Cervical
J78B;) Overview Group 2004 Update for HaNSA Clinics Based on
Ylinen et al 121 and Jull et al 60 Clinical Trials

;n[hY_i[ ;gk_fc[djKi[Z BeWZFW_d#<h[[ehBemFW_d H[f I[j <h[gk[dYo :khWj_ed

Specific neck
Craniocervical flexors Pressure biofeedback 3 levels mmHg 10 1 3/wk 5 min
4 isometric Head weight/self-resist Pain-free range 20 3 15 min
 *_iejed_Y HkXX[hjkX_d] O[bbem%h[Z&$+#'$&a] (& )  (&c_d
Postural/upper extremity
Isotonic Rubber tubing Green/blue (2 kg) 20 3 3/wk 12 min
Trunk
Isotonic Body weight 20 3 3/wk 12 min
Stretch
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Specific neck 5 N/A N/A 3 1 Daily 10 min

Scapulothoracic 2 N/A N/A 3 1 Daily 5 min
Abbreviation: HaNSA, Head and Neck, Shoulder, Arm Research Group; N/A, not applicable.

trials from the Consolidated Standards of

Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Reporting Trials (CONSORT) group and

its resulting guidelines.7 Practitioners, Literature search
however, often have to make practice
decisions in the absence of research data
of optimal quality. Our team is mindful
to highlight the best available evidence,
even though it may not be based on opti-
Identification criteria,
mal methodological rigor, in an attempt
selection criteria
to rationally guide clinical practice.
Journal of Orthopaedic & Sports Physical Therapy®

We have developed 2 simple clinical

guides that are complementary (J78B;'"
<?=KH;I ( and 4). We have not included Validity assessment,
Data abstraction
the actual magnitude of effects here, but risk of bias
this information is available to interested
practitioners in the original trials and in
our more recent publication.39 The mag-
nitude of expected benefit can be im- Analysis:
portant to patients, third-party payers, effect measure
and policymakers. It can be represented
test of homogeneity
in clinical trials as the absolute benefit
as well as the number-needed-to-treat
(NNT). The NNT adjusts expected ben-
Sensitivity analysis
efits by subtracting the absolute effect on
synthesis
placebo from the absolute effect on active
therapy. It demonstrates the number of
people who would need to be treated for
1 person to benefit by the desired amount.
For example, an approach that includes Conclusions
exercise and mobilization/manipulation recommendations
is compatible with a 28% to 70% treat-
ment advantage over a placebo/control
<?=KH;)$The framework of the Cochrane Collaboration systematic review processes.
group, and a long-term absolute benefit

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 357

Chronic neck nain
COMBINED CARE:
exercise
mobilization/manipulation
(with or without medication, education)
Pulsed electromagnetic
field for short-term
pain relief
Downloaded from www.jospt.org at on December 15, 2017. For personal use only. No other uses without permission.
<?=KH;*$An algorithm of findings from the Cervical Overview Group 1996 update by disorder subtype. The grading of the strength of the evidence utilized the categories
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
recommended by the Cochrane Back Group. Key: rectangle with bold letters, strong evidence of benefit; rectangle, moderate evidence of benefit; octagon, evidence suggests
not beneficial.
in pain reduction of 25 mm on a numeric
rating scale (0-100 mm) from baseline.
In terms of NNT, between 2 to 5 patients
with subacute or chronic mechanical
neck disorders (with or without head-
ache) would need to be treated for 1 pa-
Journal of Orthopaedic & Sports Physical Therapy®
tient to substantially benefit. NNTs in the
range of 2 to 5 are generally considered to
indicate important treatment effects.
The algorithms in <?=KH;I( and 4 may
serve as the most straightforward clinical
treatment guide for the disorders encom-
passed by the term “neck pain.” They depict
both the evidence in terms of its direction
(evidence for its use, or against its use), as
well as its evolution over the past 12 years,
as new data have become available.
9B?D?97B7FFB?97J?ED
M
hich treatments have the
strongest evidence of benefit? The
following is based on our 2004 re-
view, which will be continually updated as
the evidence base expands. Our challenge
to clinicians is to look into each therapy
category in greater depth and go further
into the specifics of clinical application. It
is not correct to assume that simply be-
358 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
[ CLINICAL COMMENTARY
Evidence-Based Neck Care
Cervical Overview Group 1996
(Aker et al 1996)
Chronic neck pain with
Acute whiplash
cervicogenic headache
Use NOT SUPPORTED: Use NOT SUPPORTED:
education, low-level laser therapy
advise rest at specified dosage
Use NOT SUPPORTED:
continuous use of
soft collar
Pulsed electromagnetic
field for short-term
pain relief
cause one is applying, for example, exer-
cise, manual therapy, or laser, that one is
practicing an evidence-based therapy. For
instance, which of these therapies would
you use to change pain versus change
function? Consider <?=KH;' and J78B;' to
help guide some of these decisions. The
following is a brief description of treat-
ment approaches that have the best cur-
rent evidence: exercise, manual therapies,
medication (parenteral use of corticoster-
oids or local anesthetics), acupuncture,
laser, traction, patient education.
Exercise is a key component of most
multimodal care programs. Direct
strengthening and stabilization of the
cervicothoracic region (postural mus-
cles), including endurance training com-
bined with neuromuscular re-education
exercises and stretches, are a prominent
feature for the treatment of chronic neck
pain with or without cervicogenic head-
ache.13,23,32,60,121 Active range-of-motion
and stretching exercises are especially
important for individuals with acute
WAD.80,81,82 For specific patient circum-
stances, approaches that are likely to be
useful may include proprioceptive/ver-
tigo exercises, 92,105 progressive goal at-
]
Chronic myofascial Chronic neck pain with
neck pain radicular findings
Intermittent traction
Acupuncture
for short-term pain relief
tainment strategies to increase function,
and adaptation of exercise programs to
ergonomic features of work. There is
evidence that unsupervised home pro-
grams are not beneficial for individuals
with chronic MND and NDR.2,11,12,51,66-72
Although the optimal dosage for exercise
could not be determined from the liter-
ature, it may well be higher than most
practitioners suspect. One high-quality
research trial assessed a dose of 3 sets of
20 repetitions for craniocervical flexion
routines.60 For strength or endurance
training, a similar dose conclusion ap-
pears rational.121 Findings such as these
have guided us to create an evidence-
based exercise routine for individuals
with subacute and chronic MND (with or
without cervicogenic headache and asso-
ciated degenerative changes) and related
dosage recommendations (J78B;)"7FF;D#
:?N7L7?B78B;EDB?D;). We challenge clini-
cians to look closely at the details of the
data presented in the literature to pre-
scribe evidence-based exercise. Clearly,
exercises are judiciously tailored to the
individual patient’s needs and circum-
stances; this depiction of exercise is not
intended to be a prescriptive formula.
 5
study requires replication and no stud-
ies have yet been reported on the use of
oral glucocorticoids for their short-term
4
anti-inflammatory effects. In individuals
with chronic NDR, a single trial of epi-
Jadad Criteria

3 dural methylprednisolone and lidocaine

improved function and pain in the short
2 and long term.103 Replication of these
promising treatment options is required
1 as is proper evaluation of commonly used
medications, as they have known side ef-
fects but no established evidence of bene-
0
fit. For instance, there is no evidence that
<1990 1990 to <2000
2000 nonsteroidal anti-inflammatory drugs are
Downloaded from www.jospt.org at on December 15, 2017. For personal use only. No other uses without permission.

effective in the treatment of neck pain.86

10
Our summaries of the evidence suggest
that the use of botulinum toxin alone is
ineffective.18,30,31,96,117,118 It has not been
8
studied in combination with other thera-
van Tulder Criteria

pies such as mobilization and exercise, a

6
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

context in which some clinicians believe

there may be promise.
4
Acupuncture, using varied methods,
has been shown to offer pain relief in the
2
short term,19,43,56,57,89,119,120 while the longer-
term studies57,119 have not demonstrated
0 persistence of the effects; there was little
<1990 1990 to <2000
2000 impact of this treatment approach on
function.119
Journal of Orthopaedic & Sports Physical Therapy®

DT PM PE MT Low-level laser therapy has demon-

strated benefit in the short and interme-
diate term for pain and function for neck
<?=KH;+$Over the past decade, methodological quality of controlled trials has shown poor progress in spite of
strong recommendations from Consolidated Standards of Reporting Trials (CONSORT) group. Abbreviations: DT, disorders with associated degenerative
drug therapy; PM, physical medicine methods; PE, patient education; MT, manual therapy. changes15,85,102,106; however, benefit of la-
ser has not been shown for pain believed
There are a large number of techniques to 3 weeks for individuals with subacute/ to arise from myofascial structures.98,107,108
for mobilization and manipulation. The chronic MND.40 Laser therapy appears to be effective for
evidence does not show superiority of In spite of the widespread use of many 1 disorder subtype: chronic neck disorder
any specific technique.40 Therefore, de- medications for neck pain, such as non- with associated degenerative changes.
picting techniques for this commentary steroidal anti-inflammatory drugs, acet- Dosage parameters are diverse across
is not reasonable. Overall, the research aminophen, and opiates, the evidentiary trials. Clinicians need to return to the
indicates that mobilization or manipu- database is inadequate, with many of individual publications to establish the
lation is most effective when used as an these medications simply not reported dosage characteristics needed for clini-
adjunct to exercise.2,11,12,60,62 That is, in as tested in controlled trials in neck cal application. The effective dosage
the absence of an underlying support- pain.86 The evidence suggests that par- parameters need to be scientifically de-
ing exercise, mobilization/manipulation enteral routes of administration are ef- termined. The evidence does not support
showed less impressive benefits.5,11,12,73,99 fective. Use of corticosteroids and local widespread use in all neck disorders, as it
The most effective dose of mobilization/ anesthetic agents has shown intermedi- may not be superior to placebo in many
manipulation across different neck pain ate- to long-term benefit for both pain subtype disorders for neck pain.
subtypes remains to be clarified. The lit- and function.90,103 For acute WAD, in- Intermittent cervical mechanical trac-
erature reports a large range of effective travenous glucocorticoids reduced work tion has been found to be useful for pain
“doses,” including up to 20 sessions over 1 disability at 1 year.90 However, this single and the patient’s global perceived effect

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 359
 [ CLINICAL COMMENTARY
of treatment for individuals with chronic
neck disorder (with or without radicular
features),35,122 while continuous traction
has not.9,65,122 Intermittent traction holds
promise for the treatment of individuals
with chronic neck disorder with associat-
ed radicular findings based on 1 RCT and
2 quasi-RCTs. The value of other forms of
traction remains somewhat unclear and
further high-quality studies are required.
No educational interventions have
demonstrated benefit when offered as a
standalone treatment.6,51,61,80,81,82 However,
advice to “stay active,” when considered
Downloaded from www.jospt.org at on December 15, 2017. For personal use only. No other uses without permission.
broadly, does seem to have an influence
on pain for individuals with subacute and
chronic MND.34,61,66-72
ADEMB;:=;=7FI
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
P
ractice can be based on the use
of the interventions we have out-
lined as having beneficial effects.
For many interventions, there are limita-
tions to consider, methodological limita-
tions related to the conduct of the trials,
limited exploration of the appropriate
dosage, and limited considerations of
which subgroups of patients might most
Journal of Orthopaedic & Sports Physical Therapy®
derive benefit. In addition, there are no
accepted standards for the collection of
functional or disability outcomes in in-
dividuals with neck pain, nor are there
validated, accepted cut-offs for clinically
meaningful changes in many of the out-
comes that are used. We found a great
diversity of outcome measures listed in
use across randomized trials (J78B; ().
Reading through this list brings forward
more questions than answers. The chal-
lenge this poses to clinicians is great:
which instrument is most reliable, valid,
and responsive to change? What are the
related clinically important differences?
Although numerous self-report scales,
like the Neck Disability Index (NDI)
and Patient Specific Functional Scales
(PSFS), are commonly used both in ran-
domized trials and promoted for use in
clinical practice, observer-based func-
tional performance measures are oddly
absent. Are there new measures that
360 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
need to be developed that address such
gaps? Finally, there are insufficient links
translating the evidence into practice and
policymaking. The list below highlights
some of the priority areas, based on our
series of reviews:
 Attention to the heterogeneity of par-
ticipants is needed. There is a need
to clearly identify the patient types
entered into trials and to examine ef-
fects of therapy by patient subgroups
and prognostic modulators.
 Standardized outcomes need to be em-
ployed across trials and clinical prac-
tice. Our group has focused on pain,
functional assessment, the patient’s
self-report of response to therapy, and
impact on ability to work. There needs
to be consensus across investigators
on not only whether these are the
most important outcomes, but also
what instruments are best to measure
them. We need an international forum
to establish consensus on primary out-
comes needed in trials as well as those
of most benefit to clinical practice.
 Identification of clinically meaningful
outcomes is a related concept. Empiri-
cal research is needed to identify im-
portant changes in the variables that
are chosen.
 Increased use of factorial designs is
required. For instance, we have stated
that combination therapies appear to
be most beneficial. However, it is im-
portant to understand the contribu-
tion of each individual intervention
to the overall benefit, and to under-
stand whether there is synergy. This
is best accomplished through factorial
designs that allow assessment of the
combined intervention, as well as the
individual parts.
 Greater attention to conduct and re-
porting requirements is needed. Such
requirements have been detailed by
CONSORT to increase the method-
ological quality of trials.
 There needs to be attention to dosage ef-
fects. This can be accomplished through
trials testing a single therapy, but at
several intensities, such as number of
]
sessions in a defined period, as well as
number of days or weeks of therapy.
Too often therapies are contrasted
when it is not established what the op-
timal implementation of either therapy
is (cart before the horse model).
 There needs to be an exploration
of patient self-report against other
performance-based outcomes. One
such example is a comparison of self-
reported exercise tolerance against
measures of exercise tolerance (VO2)
versus job role function in patients
with neck pain.
 Exploring the key “underpinning bi-
ologies” is important to future treat-
ment development. Our direct link
with Head and Neck, Shoulder, Arm
Research Group (HaNSA) assists in
addressing gaps in current trial data
and helps to shape biological under-
standing, performance-based mea-
surement development, as well as
future trial designs.
 Researchers must also work with cli-
nician educators and policymakers to
translate research results into action.
There is a need to move toward clearly
identifying those guidelines that are
evidence based and establishing inter-
national-consensus-based guidelines.
 Clinician educators and policymak-
ers must also work with researchers to
ensure clinical relevance. The research
needs to be relevant to clinical prac-
tice and policy.
M>7J?I?DJ>;<KJKH;57
9HOIJ7B87BB7D:M?I>B?IJ
M
e have 3 suggestions or “wish-
es” emerging from our crystal
ball. First, a series of internation-
al meetings with all relevant stakeholder
groups should be established to reach
agreement on commonly used outcome
measures, acceptable measurement meth-
ods, and the size of minimum clinically
important differences for these instru-
ments for trials as well as individual pa-
tients (see Standardization of Outcomes
at www.trialsjournal.com for an example).
 The results of trials should not only re-
port the measurement on these agreed
outcome measures, but also provide an
estimate of the percentage of patients who
were at least improved by the minimum
clinically important differences in each of
the trial groups as well comparisons be-
tween the groups. Next, we suggest that
trials that contain multiple interventions
should make more use of factorial designs
to be able to disentangle the effects of in-
dividual, as well as combinations of the
different interventions. Establishing an
effective dosage range for many interven-
Downloaded from www.jospt.org at on December 15, 2017. For personal use only. No other uses without permission.
tions could be concurrently established
using a factorial design methodology.
Characterizing the responders to the vari-
ous therapeutic interventions, which may
require us to return to the underpinning
“biologies” of the disorder subtype, should
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
be an additional feature in the design of
future trials. Finally, we believe that more
attention should be paid to the rigor of the
trials by including methodologists such
as epidemiologists, biostatisticians, and
health economists on the research teams
to help with better planning, design, con-
duct, analysis and relevant reporting of
trial results. T
Journal of Orthopaedic & Sports Physical Therapy®
ACKNOWLEDGEMENTS: We thank Mr Averill Le-
han, photographer, for donating his expertise
and skill in producing the photographs for the
exercise series.
H;<;H;D9;I
1. Aker PD, Gross AR, Goldsmith CH, Peloso P.
Conservative management of mechanical neck
pain: systematic overview and meta-analysis.
BMJ. 1996;313:1291-1296.
2. Allison GT, Nagy BM, Hall T. A randomized
clinical trial of manual therapy for cervico-
brachial pain syndrome: a pilot study. Man Ther.
2002;7:95-102.
3. Australian Acute Musculoskeletal Pain Guide-
lines Group. Evidence-Based Management of
Acute Musculoskeletal Pain. Australian Aca-
Z[c_YFh[iiFJOBjZ1(&&)$
4. Birch S, Jamison RN. Controlled trial of Japa-
nese acupuncture for chronic myofascial neck
pain: assessment of specific and nonspecific ef-
fects of treatment. Clin J Pain. 1998;14:248-255.
5. Bitterli J, Graf R, Robert F, Adler R, Mumenthaler
journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 361
M. [Objective criteria for the evaluation of chi-
ropractic treatment of spondylotic headache].
Nervenarzt. 1977;48:159-162.
6. Borchgrevink GE, Kaasa A, McDonagh D, Stiles
TC, Haraldseth O, Lereim I. Acute treatment of
whiplash neck sprain injuries. A randomized
trial of treatment during the first 14 days after a
car accident. Spine. 1998;23:25-31.
7. Boutron I, Moher D, Altman DG, Schulz KF,
Ravaud P. Extending the CONSORT statement to
randomized trials of nonpharmacologic treat-
ment: explanation and elaboration. Ann Intern
Med. 2008;148:295-309.
8. Bovim G, Schrader H, Sand T. Neck pain in the
general population. Spine. 1994;19:1307-1309.
9. British Association of Physical Medicine. Pain
in the neck and arm: a multicentre trial of the
effects of physiotherapy, arranged by the Brit-
ish Association of Physical Medicine. BMJ.
1966;1:253-258.
10. Brockow T, Dillner A, Franke A, Resch KL. An-
algesic effectiveness of subcutaneous carbon-
dioxide insufflations as an adjunct treatment
in patients with non-specific neck or low back
pain. Complement Ther Med. 2001;9:68-76.
http://dx.doi.org/10.1054/ctim.2001.0434
11. Brodin H. Cervical pain and mobilization. Int J
Rehabil Res. 1984;7:190-191.
12. Brodin H. Cervical pain and mobilization. Man
Med. 1985;2:18-22.
13. Bronfort G, Evans R, Nelson B, Aker PD, Gold-
ic_j^9>"L[hded>$7hWdZec_p[ZYb_d_YWbjh_Wb
of exercise and spinal manipulation for patients
with chronic neck pain. Spine. 2001;26:788-797;
discussion 798-789.
14.9WijW]d[hWB"CWkh[jj[F"Fe_dj_bbWhjL"L_jWb@C"
Erny P, Senegas J. Long-term results of cervical
epidural steroid injection with and without mor-
phine in chronic cervical radicular pain. Pain.
1994;58:239-243.
15. Ceccherelli F, Altafini L, Lo Castro G, Avila A,
Ambrosio F, Giron GP. Diode laser in cervical
myofascial pain: a double-blind study versus
placebo. Clin J Pain. 1989;5:301-304.
16.9[dIO"BeoI<"Ib[jj[d;="CYbW_d[7$J^[[÷[Yj
of traditional Chinese therapeutic massage on
individuals with neck pain. Clin Acup Orient
Med. 2003;4:88-93.
17.9^[hhoDC"C[o[h@:"9^[dO">ebj:B"CY:ed-
ald JC. The reported incidence of work-related
musculoskeletal disease in the UK: MOSS 1997-
2000. Occup Med (Lond). 2001;51:450-455.
18. Cheshire WP, Abashian SW, Mann JD. Botulinum
toxin in the treatment of myofascial pain syn-
drome. Pain. 1994;59:65-69.
19. Coan RM, Wong G, Coan PL. The acupuncture
treatment of neck pain: a randomized controlled
study. Am J Chin Med. 1981;9:326-332.
20. Cote P, Cassidy JD, Carroll L. The Saskatchewan
Health and Back Pain Survey. The prevalence
of neck pain and related disability in Saskatch-
ewan adults. Spine. 1998;23:1689-1698.
21. Employers’ Organisation. Sickness Absence in
Local Government 2004/2005. Available at:
http://www.lga.gov.uk/lga/aio/1096796. Local
Government Employers; 2005.
22. Esenyel M, Caglar N, Aldemir T. Treatment
of myofascial pain. Am J Phys Med Rehabil.
2000;79:48-52.
23. Evans R, Bronfort G, Nelson B, Goldsmith CH.
Two-year follow-up of a randomized clinical
trial of spinal manipulation and two types of
exercise for patients with chronic neck pain.
Spine. 2002;27:2383-2389. http://dx.doi.
org/10.1097/01.BRS.0000030192.39326.FF
24. Ezzo J, Haraldsson BG, Gross AR, et al. Massage
for mechanical neck disorders: a systematic
review. Spine. 2007;32:353-362. http://dx.doi.
org/10.1097/01.brs.0000254099.07294.21
25. Falla DL. Unravelling the complexity of muscle
impairment in chronic neck pain. Man Ther.
2004;9:125-133.
26.<_WbaWL"Fh[_i_d][h;"8e^b[h7$QF^oi_YWbZ_W]-
nosis and physical therapy of whiplash injury]. Z
Phys Med Baln Med Klim. 1989;18:390-397.
27. Flynn T. A comparative study between ultra-reiz
and ultra sound in the treatment for relief of
pain in whiplash injuries. Physiotherapy Ireland.
1987;8:11-14.
28. Foley-Nolan D, Barry C, Coughlan RJ, O’Connor
P, Roden D. Pulsed high frequency (27MHz)
electromagnetic therapy for persistent neck
pain. A double blind, placebo-controlled study
of 20 patients. Orthopedics. 1990;13:445-451.
29. Foley-Nolan D, Moore K, Codd M, Barry C,
O’Connor P, Coughlan RJ. Low energy high
frequency pulsed electromagnetic therapy for
acute whiplash injuries. A double blind random-
ized controlled study. Scand J Rehabil Med.
1992;24:51-59.
30. Freund BJ, Schwartz M. Treatment of chronic cer-
vical-associated headache with botulinum toxin
A: a pilot study. Headache. 2000;40:231-236.
31. Freund BJ, Schwartz M. Treatment of whiplash
associated neck pain with botulinum toxin-A: a
pilot study. J Rheumatol. 2000;27:481-484.
32. Gam AN, Warming S, Larsen LH, et al. Treat-
ment of myofascial trigger-points with ultra-
sound combined with massage and exercise: a
randomised controlled trial. Pain. 1998;77:73-79.
33. Gennis P, Miller L, Gallagher EJ, Giglio J, Carter
W, Nathanson N. The effect of soft cervical collars
on persistent neck pain in patients with whiplash
injury. Acad Emerg Med. 1996;3:568-573.
34. Glossop ES, Goldenberg E, Smith DS, Williams
IM. Patient compliance in back and neck pain.
Physiotherapy. 1982;68:225-226.
35. Goldie I, Landquist A. Evaluation of the effects of
different forms of physiotherapy in cervical pain.
Scand J Rehabil Med. 1970;2:117-121.
36. Graham N, Gross AR, Goldsmith C. Mechanical
traction for mechanical neck disorders: a sys-
tematic review. J Rehabil Med. 2006;38:145-152.
http://dx.doi.org/10.1080/16501970600583029
37. Gross AR, Aker PD, Goldsmith CH, Peloso P. Con-
servative management of mechanical neck disor-
ders. A systematic overview and meta-analysis.
Online J Curr Clin Trials. 1996;Doc No 200-201.
38. Gross AR, Aker PD, Goldsmith CH, Peloso P.
Patient education for mechanical neck disorders
 [ CLINICAL COMMENTARY
[withdrawn]. Cochrane Database Syst Rev.
2007;18(2):CD000962.
39. Gross AR, Goldsmith C, Hoving JL, et al. Con-
servative management of mechanical neck
disorders: a systematic review. J Rheumatol.
2007;34:1083-1102.
40. Gross AR, Hoving JL, Haines TA, et al. A Co-
chrane review of manipulation and mobiliza-
tion for mechanical neck disorders. Spine.
2004;29:1541-1548.
41. Gross AR, Kay T, Peloso P, Goldsmith C, Haines
T. Laser therapy for mechanical neck disorder:
a Cochrane review [abstract]. Arthritis Rheum.
2002;46:S237, Suppl.
42. Gross A, Kay T, Peloso PM, Haines T, Kroeling P.
Thermal agents for mechanical neck disorders:
a Cochrane review [abstract]. Arthritis Rheum.
2002;46 Suppl:S237.
Downloaded from www.jospt.org at on December 15, 2017. For personal use only. No other uses without permission.
43. Hackett GI, Hudson MF, Wylie JB, et al. Evalua-
tion of the efficacy and acceptability to patients
of a physiotherapist working in a health centre.
Br Med J (Clin Res Ed). 1987;294:24-26.
44. Haines T, Gross A, Goldsmith CH, Perry
L. Patient education for neck pain with or
without radiculopathy. Cochrane Database
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Syst Rev. 2008;CD005106. http://dx.doi.
org/10.1002/14651858.CD005106.pub2
45. Haldeman S, Kohlbeck FJ, McGregor M. Stroke,
cerebral artery dissection, and cervical spine ma-
nipulation therapy. J Neurol. 2002;249:1098-1104.
http://dx.doi.org/10.1007/s00415-002-0783-4
46. Hanten WP, Barrett M, Gillespie-Plesko M, Jump
KA, Olson SL. Effects of active head retraction
with retraction/extensiona dn occipital release
on the pressure pain threshold of cirvical and
scapular trigger points. Physiother Theory
Journal of Orthopaedic & Sports Physical Therapy®
Pract. 1997;13:285-291.
47. Hanten WP, Olson SL, Butts NL, Nowicki AL.
Effectiveness of a home program of ischemic
pressure followed by sustained stretch for treat-
ment of myofascial trigger points. Phys Ther.
2000;80:997-1003.
48. Hasenfeld R, Shekelle PG. Is the methodological
quality of guidelines declining in the US? Com-
parison of the quality of US Agency for Health
Care Policy and Research (AHCPR) guidelines
with those published subsequently. Qual Saf
Health Care. 2003;12:428-434.
49.>e]]#@e^diedI"lWdZ[hL[bZ[="9WhhebbB@"[j
al. The burden and determinants of neck pain
in the general population: results of the Bone
and Joint Decade 2000-2010 Task Force on
Neck Pain and Its Associated Disorders. Spine.
2008;33:S39-51. http://dx.doi.org/10.1097/
BRS.0b013e31816454c8
50. Hong CZ, Lin JC, Bender LF, Schaeffer JN,
Meltzer RJ, Causin P. Magnetic necklace: its
therapeutic effectiveness on neck and shoulder
pain. Arch Phys Med Rehabil. 1982;63:462-466.
51. Horneij E, Hemborg B, Jensen I, Ekdahl C. No
significant differences between intervention pro-
grammes on neck, shoulder and low back pain:
a prospective randomized study among home-
care personnel. J Rehabil Med. 2001;33:170-176.
52. Hou CR, Tsai LC, Cheng KF, Chung KC, Hong CZ.
362 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
Immediate effects of various physical therapeu-
tic modalities on cervical myofascial pain and
trigger-point sensitivity. Arch Phys Med Rehabil.
2002;83:1406-1414.
53. Hsueh TC, Cheng PT, Kuan TS, Hong CZ. The
immediate effectiveness of electrical nerve
stimulation and electrical muscle stimulation
on myofascial trigger points. Am J Phys Med
Rehabil. 1997;76:471-476.
54.>khm_jp;B"9WhhW][[;@"lWdZ[hL[bZ[="
et al. Treatment of neck pain: noninvasive
interventions: results of the Bone and Joint
Decade 2000-2010 Task Force on Neck
Pain and Its Associated Disorders. Spine.
2008;33:S123-152. http://dx.doi.org/10.1097/
BRS.0b013e3181644b1d
55. Hurwitz EL, Morgenstern H, Harber P, Komin-
ia_=<"Ok<"7ZWci7>$7hWdZec_p[Zjh_Wbe\
chiropractic manipulation and mobilization for
patients with neck pain: clinical outcomes from
the UCLA neck-pain study. Am J Public Health.
2002;92:1634-1641.
56. Irnich D, Behrens N, Gleditsch JM, et al. Im-
mediate effects of dry needling and acupuncture
at distant points in chronic neck pain: results of
a randomized, double-blind, sham-controlled
crossover trial. Pain. 2002;99:83-89.
57. Irnich D, Behrens N, Molzen H, et al. Ran-
domised trial of acupuncture compared with
conventional massage and “sham” laser acu-
puncture for treatment of chronic neck pain.
BMJ. 2001;322:1574-1578.
58. Jadad AR, Moore RA, Carroll D, et al. Assessing
the quality of reports of randomized clinical
trials: is blinding necessary? Control Clin Trials.
1996;17:1-12.
59.@eY^[ciE"LehjcWd8":[hZ[C$=[hWdZec_i-
eerd onderzoek naar het effect van The Pillow
op de nachtrust, pijn en voorkeur van patienten
met klachten van de nek—en schouderregio.
Ned Tijdschr Fysiother. 1997;107:159-163.
60. Jull G, Trott P, Potter H, et al. A randomized
controlled trial of exercise and manipulative
therapy for cervicogenic headache. Spine.
2002;27:1835-1843; discussion 1843.
61. Kamwendo K, Linton SJ. A controlled study of
the effect of neck school in medical secretaries.
Scand J Rehabil Med. 1991;23:143-152.
62. Karlberg M, Magnusson M, Malmstrom EM, Me-
lander A, Moritz U. Postural and symptomatic
improvement after physiotherapy in patients
with dizziness of suspected cervical origin. Arch
Phys Med Rehabil. 1996;77:874-882.
63. Karppinen K, Eklund S, Suoninen E, Eskelin M,
Kirveskari P. Adjustment of dental occlusion in
treatment of chronic cervicobrachial pain and
headache. J Oral Rehabil. 1999;26:715-721.
64. Kay TM, Gross A, Goldsmith C, Santaguida
PL, Hoving J, Bronfort G. Exercises for me-
chanical neck disorders. Cochrane Database
Syst Rev. 2005;CD004250. http://dx.doi.
org/10.1002/14651858.CD004250.pub3
65. Klaber Moffett JA, Hughes GI, Griffiths P.
An investigation of the effects of cervi-
cal traction part 1: clinical effectiveness.
]
Clinic Rehab. 1990;4:205-211. http://dx.doi.
org/10.1177/026921559000400304
66. Koes BW, Bouter LM, Knipshild PG, et al. The
effectiveness of manual therapy, physiotherapy
and continued treatment by the general prac-
titioner for chronic nonspecific back and neck
complaints: design of a randomized clinical trial.
J Manipulative Physiol Ther. 1991;14:498-502.
67. Koes BW, Bouter LM, van Mameren H, et al.
Randomized clinical trial of manual therapy
and physiotherapy for persistent back and neck
complaints. Man Ther Netherlands. 1992;1:7-12.
68. Koes BW, Bouter LM, van Mameren H, et al. A
randomized clinical trial of manual therapy and
physiotherapy for persistent back and neck
complaints: subgroup analysis and relationship
between outcome measures. J Manipulative
Physiol Ther. 1993;16:211-219.
69. Koes BW, Bouter LM, van Mameren H, et al.
A blinded randomized clinical trial of manual
therapy and physiotherapy for chronic back and
neck complaints: physical outcome measures. J
Manipulative Physiol Ther. 1992;15:16-23.
70. Koes BW, Bouter LM, van Mameren H, et al. The
effectiveness of manual therapy, physiotherapy,
and treatment by the general practitioner for
nonspecific back and neck complaints. A ran-
domized clinical trial. Spine. 1992;17:28-35.
71. Koes BW, Bouter LM, van Mameren H, et al. Ran-
domised clinical trial of manipulative therapy
and physiotherapy for persistent back and neck
complaints: results of one year follow up. BMJ.
1992;304:601-605.
72. Koes BW. Efficacy of Manual Therapy and Phys-
iotherapy for Back and Neck Complaints [the-
sis]. den Haag, The Netherlands: Cip-Gegevens
Koninklijke Bibliotheek; 1992.
73. Kogstad OA, Karterud S, Gudmundsen J. [Cer-
vicobrachialgia. A controlled trial with conven-
tional therapy and manipulation]. Tidsskr Nor
Laegeforen. 1978;98:845-848.
74. Kroeling P, Gross A, Houghton PE. Electro-
therapy for neck disorders. Cochrane Database
Syst Rev. 2005;CD004251. http://dx.doi.
org/10.1002/14651858.CD004251.pub3
75. Kroeling P, Gross AR, Goldsmith CH. A Cochrane
review of electrotherapy for mechanical neck
disorders. Spine. 2005;30:E641-648.
76. Lamberts H, Brouwer H, Groen AJM, Huisman
H. Het transitiemodel in de huisartspraktijk.
Huisarts en Wetenschap. 1987;30:105-130.
77. Lewith GT, Machin D. A randomised trial to
evaluate the effect of infra-red stimulation of
local trigger points, versus placebo, on the pain
caused by cervical osteoarthrosis. Acupunct
Electrother Res. 1981;6:277-284.
78. Lundblad I, Elert J, Gerdle B. Randomized con-
trolled trial of physiotherapy and Feldenkrais in-
terventions in female workers with neck-shoulder
complaints. J Occupat Rehab. 1999;9:179-194.
79. Luo X, Pietrobon R, Sun SX, Liu GG, Hey
L. Estimates and patterns of direct health
care expenditures among individuals with
back pain in the United States. Spine.
2004;29:79-86. http://dx.doi.org/10.1097/01.
 BRS.0000105527.13866.0F
80. McKinney LA. Early mobilisation and outcome in
acute sprains of the neck. BMJ. 1989;299:1006-
1008.
81. McKinney LA, Dornan JO, Ryan M. The role of
physiotherapy in the management of acute neck
sprains following road-traffic accidents. Arch
Emerg Med. 1989;6:27-33.
82. Mealy K, Brennan H, Fenelon GC. Early mobili-
zation of acute whiplash injuries. Br Med J (Clin
Res Ed). 1986;292:656-657.
83. Whiplash Guidelines. Available at: http://www.
maa.nsw.gov.au/default.aspx?MenuID=95#415.
New South Wales Government, Motor Accidents
Authority. Accessed January 30, 2008.
84. Nachemson A, Waddell G, Norlund AI. Epidemi-
ology of neck and low back pain. In: Nachemson
A, Jonsson E, eds. Neck and Back Pain: The
Downloaded from www.jospt.org at on December 15, 2017. For personal use only. No other uses without permission.
Scientific Evidence of Causes, Diagnosis and
Treatment. Philadelphia, PA: Lippincott Williams
& Wilkins; 2000:165-187.
85. Ozdemir F, Birtane M, Kokino S. The clinical
efficacy of low-power laser therapy on pain and
function in cervical osteoarthritis. Clin Rheuma-
tol. 2001;20:181-184.
86. Peloso P, Gross A, Haines T, Trinh K, Goldsmith
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
CH, Aker P. Medicinal and injection therapies
for mechanical neck disorders. Cochrane Data-
base Syst Rev. 2005;CD000319. http://dx.doi.
org/10.1002/14651858.CD000319.pub3
87. Peloso PM, Gross AR, Haines TA, Trinh K, Gold-
smith CH, Aker P. Medicinal and injection thera-
pies for mechanical neck disorders: a Cochrane
systematic review. J Rheumatol. 2006;33:957-967.
88. Petrie JP, Hazleman BL. A controlled study of
acupuncture in neck pain. Br J Rheumatol.
1986;25:271-275.
Journal of Orthopaedic & Sports Physical Therapy®
89. Petrie JP, Langley GB. Acupuncture in the treat-
ment of chronic cervical pain. A pilot study. Clin
Exp Rheumatol. 1983;1:333-336.
90. Pettersson K, Toolanen G. High-dose methyl-
prednisolone prevents extensive sick leave after
whiplash injury. A prospective, randomized,
double-blind study. Spine. 1998;23:984-989.
91.F^_b_fiedJ">WW][di[dD"BWkcWddL"D_[i
M, Thorup K, Hansen TI. [The effect of diady-
namic current on chronic soft-tissue pain in
the neck and shoulder girdle]. Ugeskr Laeger.
1983;145:479-481.
92.H[l[bC"C_d]k[jC"=h[]eoF"LW_bbWdj@"CWdk[b
JL. Changes in cervicocephalic kinesthesia after
a proprioceptive rehabilitation program in pa-
tients with neck pain: a randomized controlled
study. Arch Phys Med Rehabil. 1994;75:895-899.
93. Rigato M, Battisti E, Fortunato M, Giordano
N. Comparison between the analgesic and
therapeutic effects of a musically modulated
electromagnetic field (TAMMEF) and those
of a 100 Hz electromagnetic field: blind ex-
periment on patients suffering from cervical
spondylosis or shoulder periarthritis. J Med
Eng Technol. 2002;26:253-258. http://dx.doi.
org/10.1080/0309190021000025873
94. Sand T, Bovim G, Helde G. Intracutaneous
sterile water injections do not relieve pain in
journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | 363
cervicogenic headache. Acta Neurol Scand.
1992;86:526-528.
95.IWjkhdeF@"C[Z_dW<"LWb[hW<"Cedj_bbW@";iYe-
bWhF"=WiYed@@$LWb_Z_joWdZh[b_WX_b_joe\]k_Z[-
lines for neck pain treatment in primary health
care. A nationwide empirical analysis in Spain.
Int J Qual Health Care. 2003;15:487-493.
96.IY^d_Z[hF"CehWhk;"L_]bC"[jWb$Foi_YWb
therapy and adjunctive botulinum toxin type A
in the treatment of cervical headache: a double-
blind, randomised, placebo-controlled study. J
Headache Pain. 2002;3:93-99.
97. Schunemann HJ, Jaeschke R, Cook DJ, et al. An
official ATS statement: grading the quality of evi-
dence and strength of recommendations in ATS
guidelines and recommendations. Am J Respir
Crit Care Med. 2006;174:605-614. http://dx.doi.
org/10.1164/rccm.200602-197ST
98. Seidel U, Uhlemann C. [Therapy of cervical
tendomyosis: a randomised controlled double-
blind trial comparing dosed lasertherapy on
acupuncture points and classical acupuncture].
Dt Ztschr f Akup. 2002;4:258-269. http://dx.doi.
org/10.1055/s-2002-36555
99. Sloop PR, Smith DS, Goldenberg E, Dore C. Ma-
nipulation for chronic neck pain. A double-blind
controlled study. Spine. 1982;7:532-535.
100. Smania N, Corato E, Fiaschi A, Pietropoli P,
Aglioti SM, Tinazzi M. Therapeutic effects of
peripheral repetitive magnetic stimulation on
myofascial pain syndrome. Clin Neurophysiol.
2003;114:350-358.
101.Idem9@"7l[iMeeZH":em^efebkaL"[jWb$
Randomized controlled clinical trial of spray
and stretch for relief of back and neck myofas-
cial pain. Phyiother Canada. 1992;44:8.
102. Soriano FS, Rios R, Pedrola M, Giangnorio J,
Battagliotti CR. Acute cervical pain is relieved with
Gallium Arsenide (GaAs) Laser, a double-blind
preliminary study. Laser Ther. 1996;8:149-154.
103. Stav A, Ovadia L, Sternberg A, Kaadan M,
Weksler N. Cervical epidural steroid injection for
cervicobrachialgia. Acta Anaesthesiol Scand.
1993;37:562-566.
104. Strine TW, Hootman JM. US national prevalence
and correlates of low back and neck pain
among adults. Arthritis Rheum. 2007;57:656-
665. http://dx.doi.org/10.1002/art.22684
105.JWaWbW;F"L__aWh_#@kdjkhW;"Jodaaod[d;C$
Does group gymnastics at the workplace help in
neck pain? A controlled study. Scand J Rehabil
Med. 1994;26:17-20.
106. Taverna E, Parrini M, Cabitza P. Laser therapy
versus placebo in the treatment of some bone
and joint pathology. Minerva Ortopedica Trau-
matologica. 1990;48:251-256.
107. Thorsen H, Gam AN, Jensen H, Hojmark L, Wahl-
strom L. [Low energy laser treatment--effect in
localized fibromyalgia in the neck and shoulder
regions]. Ugeskr Laeger. 1991;153:1801-1804.
108. Thorsen H, Gam AN, Svensson BH, et al. Low
level laser therapy for myofascial pain in the
neck and shoulder girdle. A double-blind, cross-
over study. Scand J Rheumatol. 1992;21:139-141.
109. Thuile C, Walzl M. Evaluation of electromagnetic
fields in the treatment of pain in patients with
lumbar radiculopathy or the whiplash syn-
drome. NeuroRehabilitation. 2002;17:63-67.
110. Trinh K, Graham N, Gross A, et al. Acu-
puncture for neck disorders. Spine.
2007;32:236-243. http://dx.doi.org/10.1097/01.
brs.0000252100.61002.d4
111.Jh_d^AL"=hW^WcD"=heii7H"[jWb$7YkfkdY-
ture for neck disorders. Cochrane Database
Syst Rev. 2006;3:CD004870. http://dx.doi.
org/10.1002/14651858.CD004870.pub3
112. Trock DH, Bollet AJ, Markoll R. The effect of
pulsed electromagnetic fields in the treatment
of osteoarthritis of the knee and cervical spine.
Report of randomized, double blind, placebo
controlled trials. J Rheumatol. 1994;21:1903-1911.
113. van Tulder M, Furlan A, Bombardier C, Bouter L.
Updated method guidelines for systematic re-
views in the cochrane collaboration back review
group. Spine. 2003;28:1290-1299. http://dx.doi.
org/10.1097/01.BRS.0000065484.95996.AF
114. van Wieringen S, Jansen T, Smits MG, Nagtegaal
JE, Coenen AML. Melatonin for chronic whip-
lash syndrome with delayed meloatonin onset:
randomised, placebo-controlled trial. Clin Drug
Investigation. 2001;21:813-820.
115. Waalen DP, White TP, Waalen JK. Demographic
and clinical characteristics of chiropractic
patients: a five year study of patients treated at
the Canadian Memorial Chiropractic College. J
Can Chiropr Assoc. 1994;38:75-82.
116. Waylonis GW, Wilke S, O’Toole D, Waylonis DA,
Waylonis DB. Chronic myofascial pain: manage-
ment by low-output helium-neon laser therapy.
Arch Phys Med Rehabil. 1988;69:1017-1020.
117. Wheeler AH, Goolkasian P, Gretz SS. Botulinum
toxin A for the treatment of chronic neck pain.
Pain. 2001;94:255-260.
118. Wheeler AH, Goolkasian P, Gretz SS. A random-
ized, double-blind, prospective pilot study of
botulinum toxin injection for refractory, unilat-
eral, cervicothoracic, paraspinal, myofascial
pain syndrome. Spine. 1998;23:1662-1666;
discussion 1667.
119. White P, Lewith G, Prescott P, Conway J. Acupunc-
ture versus placebo for the treatment of chronic
mechanical neck pain: a randomized, controlled
trial. Ann Intern Med. 2004;141:911-919.
120.M^_j[F<"9hW_]M<"LWa^Wh_W7I"=^edWc[;"
Ahmed HE, Hamza MA. Percutaneous neu-
romodulation therapy: does the location of
electrical stimulation effect the acute analgesic
response? Anesth Analg. 2000;91:949-954.
121.Ob_d[d@"JWaWbW;F"DoaWd[dC"[jWb$7Yj_l[
neck muscle training in the treatment of chronic
neck pain in women: a randomized controlled
trial. JAMA. 2003;289:2509-2516.
122. Zylbergold RS, Piper MC. Cervical spine disor-
ders. A comparison of three types of traction.
Spine. 1985;10:867-871.
@ CEH;?D<EHC7J?ED
WWW.JOSPT.ORG
 [ CLINICAL COMMENTARY ]
APPENDIX

EVIDENCE-BASED HOME NECK CARE EXERCISE PROGRAM, PHASE 1

These therapeutic neck exercises are from clinical trials noted in TABLE 1 for individuals with chronic neck pain and select exercises are for the acute phase. The
exercises should be judiciously tailored to individual circumstances and applied as indicated based on a clinical examination. Phases 1 to 3 depict a progressive
dose of exercises detailed in TABLE 3.
1. Craniocervical flexion
Start with pressure biofeedback inflated to 20 mmHg. Make sure your chin and forehead are lined up. Nod your
head, keeping the large neck muscles soft and bringing the reading up to 22 mmHg. Work up to ten 10-second
holds. Then progress to 24, 26, and 28 mmHg.
Sets___ Reps___
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Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

2. Neck active range of motion

Start with your head in neutral, then
A. Tilt backward
B. Bend forward
C. Tilt side to side
D. Turn side to side
Sets___ Reps___
Journal of Orthopaedic & Sports Physical Therapy®

3. Resisted shoulder extension with elbow flexed

“Set” your cervical spine, abdominals and scapulae, then extend your arm with elbows bent backward.
Sets___ Reps___

A1 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
 4. Resisted shoulder extension with elbow straight
“Set” your cervical spine, abdominals, and scapulae, then extend your arm backward.
Sets___ Reps___

5. Resisted shoulder shrug

“Set” your cervical spine, abdominals, and scapulae, then slightly abduct arms and minimally shrug shoulders.
Sets___ Reps___
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Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

6. Resisted elbow exercise

Journal of Orthopaedic & Sports Physical Therapy®

“Set” your cervical spine, abdominals, and scapulae, then

A. Bend
B. Straighten level 1
C. Straighten level 2
your elbows.
Sets___ Reps___

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | A2
 [ CLINICAL COMMENTARY ]
EVIDENCE-BASED HOME NECK CARE EXERCISE PROGRAM, PHASE 2
These therapeutic exercises should be tailored to the individual based on sound clinical decision making. Phases 1 to 3 depict a progressive
dose of exercise detailed in TABLE 3.
1. Head lift
Start with your head in neutral (chin and forehead lined up), do a chin nod and lift your head, while maintaining
your chin tucked. Hold for a count of 5 to 10 seconds and return smoothly with your chin still tucked.
Sets___ Reps___
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2. Isometric neck strength

Place your hand on your head and resist
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

A. Bending
B. Tilting backward
C. Tilting sideways
D. Turning your head
Hold for a count of 5 to 10 seconds.
Sets___ Reps___
Journal of Orthopaedic & Sports Physical Therapy®

3. Shoulder stretches
“Set” your cervical spine, abdominals, and scapulae,
A. Clasp your hands behind your back and squeeze your scapulae together
B. Hold your arms out in front of you and reach forward feeling a stretch between your scapulae
C. Reach your arms overhead
Hold for 20 seconds.
Sets___ Reps___

4. Shoulder stretches
“Set” your cervical spine, abdominals, and scapulae
A. With elbows at shoulder level, lean into a corner to feel a stretch in the front of your chest
B. With elbows at eye level lean into a corner to feel a stretch
Hold for 20 seconds.
Sets___ Reps___

A3 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
 5. Transverse abdominus
A. Tense your lower abdomen by imagining drawing your hip bones together (or apart if that works better), hold
for 10 seconds
B. Then let the 1 leg fall out over a 10-second count
Sets___ Reps___
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6. Wall sit
“Set” cervical spine, transverse abdominus, and scapulae, then slide down the wall into a semi-squat position.
Hold for as long as you can, working up to 2 minutes.
Sets___ Reps___
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | A4
 [ CLINICAL COMMENTARY ]
EVIDENCE-BASED HOME NECK CARE EXERCISE PROGRAM, PHASE 3
The therapeutic exercises depicted in phase 3 are of higher intensity and should be tailored to individuals based on a clinical exam.

1. Shoulder strength
“Set” cervical spine, abdominals, and scapulae then “hug a tree.”
Sets___ Reps___
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2. Shoulder strengthen
“Set” cervical spine, abdominals, and scapulae, then elevate arms into a “reverse fly.”
Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Sets___ Reps___
Journal of Orthopaedic & Sports Physical Therapy®

3. Resisted neck: craniocervical flexion and oblique flexion

“Set” cervical spine, abdominals, and scapulae, then
A. Nod head
B. Nod head at a slight oblique angle
Sets___ Reps___

@ MORE INFORMATION
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A5 | may 2009 | volume 39 | number 5 | journal of orthopaedic & sports physical therapy
 4. Resisted neck extension
“Set” cervical spine, abdominals, and scapulae,
A. First nod your head
B. Then tilt your head backward
The focus of extension is in the lower neck.
Sets___ Reps___

5. Resisted neck side flexion

“Set” cervical spine, abdominals, and scapulae, then tilt head to the side.
Sets___ Reps___
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Copyright © 2009 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

6. Resisted neck rotation

“Set” cervical spine, transverse abdominus, and scapulae, then rotate head.
Sets___ Reps___
Journal of Orthopaedic & Sports Physical Therapy®

journal of orthopaedic & sports physical therapy | volume 39 | number 5 | may 2009 | A6