Tuesday, February 10, 2015 'Moderate'-Quality Evidence Supports Strengthening, Stretching Exercises for Chronic Neck Pain According to results of a new systematic review, moderate-grade evidence seems to support strengthening and stretching exercises to help ease chronic neck pain, while the use of endurance and stretching exercises alone don't seem to make much of a difference. But the real takeaway of the recently published Cochrane review is that much more work needs to be done to better classify this type of pain and to better track exercise dosage information. The review, published on January 28, examined 27 trials (2,485 participants) aimed at identifying whether exercise reduced neck pain and disability, improved function, and increased patient satisfaction and reported quality of life. The trials included studies that compared an exercise treatment with no treatment or a placebo, as well as those that combined exercise with another intervention such as manipulation, massage, education, heat, or medications. Reviewers excluded trials that included exercise as part of a multidisciplinary or multimodal treatment and those that "required application by a trained individual." While none of the studies produced what reviewers classified as strong evidence, authors pointed to "moderate"-level evidence that "there appears to be a role for strengthening exercises" in treatment of not only chronic neck pain, but cervicogenic headache and cervical radiculopathy, "if these exercises are focused on the neck, shoulder, and shoulder blade region." As for specific exercises and approaches, reviewers also found limited evidence that sustained natural apophyseal glides seemed to be among the more effective exercises for treatment of cervicogenic headaches, and "mindfulness exercises" such as Qigong possibly beneficial for mechanical neck pain, though the improvement may be slight. Among other findings in the review: Moderate-quality evidence suggests that individuals experiencing cervicogenic headaches can benefit from static and dynamic cervical scapulothoracic strengthening and endurance exercises including pressure biofeedback. Moderate-grade evidence supports the idea that cervical, scapulothoracic, and upper extremity stretching and endurance training have little to no effect on chronic neck pain and function. Low-grade evidence points to "little to no difference" in chronic neck pain and function through the use of breathing exercises, general fitness training, cervical spine stretches, or range-of-motion exercises. The lack of strong evidence overall points not only to a need for more rigorously constructed research, but for more agreement on some fundamentals around neck pain and exercise interventions, according to the review authors. "To date, there is no standardized definition of mechanical neck pain even if it has evolved over the last three decades," authors write. Given the variability of the group identified as experiencing neck pain, they write, "subgrouping based on diagnosis, treatment, or prognosis system classification would be useful to increase homogeneity for research and clinical applicability." Another impediment to strong research in this area: exercise classification and dosage requirements. Authors of the review advocate for a classification system that describes "the physiological effect of exercise on the body rather than describing the types of activity used to produce that effect" and "allow[s] … researchers to classify exercises into a specific category by recognizing their mechanisms of actions." Additionally, authors of the review assert that "in general, there is also limited evidence on optimal dosage requirements … for exercise therapies and other modalities used to treat neck disorders." Until more solid research is produced, providers should take a careful approach when considering evidence to date, authors state. "The level of evidence of these studies varied from low to moderate," authors write. "Thus clinicians should not underestimate their clinical judgment in the choice of optimal treatment modality for client needs." APTA members can access the full text via the Cochrane Database of Systematic Reviews in PTNow ArticleSearch; nonmembers can access the abstract only for free via PubMed. Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.