Phasic exercises for cervical rehabilitation after "whiplash" trauma. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. A feasibility study assessing manual therapies to different regions of the spine for patients with subacute or chronic neck pain. A pilot randomized clinical trial on the relative effect of instrumental (MFMA) versus manual (HVLA) manipulation in the treatment of cervical spine dysfunction. Neck/shoulder exercise for neck pain in air force helicopter pilots: a randomized controlled trial. A randomised controlled trial of preventive spinal manipulation with and without a home exercise program for patients with chronic neck pain. Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial. Immediate effects of inhibitive distraction on active range of cervical flexion in patients with neck pain: a pilot study. Immediate effects on neck pain and active range of motion after a single cervical high-velocity low-amplitude manipulation in subjects presenting with mechanical neck pain: a randomized controlled trial.
To assess whether "phasic" exercises, including rapid eye-head-neck-arm movements, can benefit patients with chronic cervical injuries.
                A randomized, controlled, double blind study involving 30 chronic patients, who were allocated to either group 1 or group 2. The study period was for 8 wk.
                The study was conducted in a private practice.
                Thirty chronic motor vehicle accident patients who continued to experience increased pain/soreness/stiffness of the cervical musculature with sports/activities requiring rapid head neck movements were selected for the study.
                Group 1 patients (n = 15) had standard exercises (stretching/isometric/isokinetic) and chiropractic therapy. Group 2 patients (n = 15) had "phasic" exercises and chiropractic therapy. Patients in both groups exercised for a minimum of four times weekly, for 8 wk.
                Pre and Post Pain and Disability Index was administered to both groups.
                Group 1, which had standard exercises and chiropractic therapy, improved by 7.4% (p > .05). Group 2, which had "phasic" exercises and chiropractic therapy, improved by 48.3% (p > .001). Confounders were identified, which explains the minimal improvement of group 1 and the remarkable results of group 2.
                It would appear that any rehabilitation program for chronic neck-injured patients should involve exercises that address the following: eye-head-neck-arm coordinated movements, coordination of the entire vertebral column,/ and return the "phasic" component of the musculature to functional levels. Additional studies will address the effect of these exercises on the strength, range of motion and pain improvement of the cervical spine in normal, acute and chronic patients. A multicenter, randomized controlled trial with unblinded treatment and blinded outcome assessment was conducted. The treatment period was 6 weeks with follow-up assessment after treatment, then at 3, 6, and 12 months.
                To determine the effectiveness of manipulative therapy and a low-load exercise program for cervicogenic headache when used alone and in combination, as compared with a control group.
                Headaches arising from cervical musculoskeletal disorders are common. Conservative therapies are recommended as the first treatment of choice. Evidence for the effectiveness of manipulative therapy is inconclusive and available only for the short term. There is no evidence for exercise, and no study has investigated the effect of combined therapies for cervicogenic headache.
                In this study, 200 participants who met the diagnostic criteria for cervicogenic headache were randomized into four groups: manipulative therapy group, exercise therapy group, combined therapy group, and a control group. The primary outcome was a change in headache frequency. Other outcomes included changes in headache intensity and duration, the Northwick Park Neck Pain Index, medication intake, and patient satisfaction. Physical outcomes included pain on neck movement, upper cervical joint tenderness, a craniocervical flexion muscle test, and a photographic measure of posture.
                There were no differences in headache-related and demographic characteristics between the groups at baseline. The loss to follow-up evaluation was 3.5%. At the 12-month follow-up assessment, both manipulative therapy and specific exercise had significantly reduced headache frequency and intensity, and the neck pain and effects were maintained (P < 0.05 for all). The combined therapies was not significantly superior to either therapy alone, but 10% more patients gained relief with the combination. Effect sizes were at least moderate and clinically relevant.
                Manipulative therapy and exercise can reduce the symptoms of cervicogenic headache, and the effects are maintained. The purpose of this project was to develop and test protocols for a randomized clinical trial of a combined therapeutic approach (thoracic spine and sacroiliac joint high-velocity, low-amplitude spinal manipulation [HVLA SM] + cervical spine postisometric relaxation) and cervical spine HVLA SM for patients with subacute or chronic neck pain.
                Patients were recruited in the Quad Cities in Iowa and Illinois. After a baseline assessment visit, eligible patients were randomly assigned to cervical spine HVLA SM or to the combined therapeutic approach for 4 treatment visits over 2 weeks. Outcome assessments included the Neck Disability Index, visual analog scale, and posttreatment response questionnaire. Patient outcomes were not aggregated or compared by treatment group.
                It took approximately 8 months of planning, which included the development of forms and protocols, pretesting the forms, and training staff and clinicians in the standardized protocols. Twelve participants were screened, and 6 patients were enrolled and randomly allocated to care over a 6-week period. All patients completed 5 visits. Five of 6 patients had an improvement on the Neck Disability Index. On the visual analog scale, 2 patients improved at 2 weeks, whereas the other 4 got worse. Five patients completed the posttreatment response questionnaire; 2 of the 5 indicated they experienced discomfort or an unpleasant reaction from the study treatments.
                Designing a successful feasibility randomized clinical trial requires considerable planning, development and pretesting of the forms and protocols, and training clinicians and staff for standardized protocols. Patients were willing to be randomized, follow treatment protocols, complete baseline and outcome assessments, and return 83% of the follow-up questionnaires. To determine the relative effect of instrument-delivered thrust cervical manipulations in comparison with traditional manual-delivered thrust cervical manipulations in the treatment of cervical spine dysfunction.
                Prospective, randomized, comparative clinical trial.
                Outpatient chiropractic clinic, Technikon Natal, South Africa.
                Thirty patients diagnosed with neck pain and restricted cervical spine range of motion without complicating pathosis for at least 1 month were included in the study.
                The patients were randomized into 2 groups. Those in one group received mechanical force, manually assisted (MFMA) manipulation to the cervical spine, delivered by means of a hand-held instrument (Activator II Adjusting Instrument). Those in the other group received specific contact high-velocity, low-amplitude (HVLA) manipulation consisting of standard Diversified rotary/lateral break techniques to the cervical spine. Each group received only the specific therapeutic intervention, no other treatment modalities or interventions (including medication) being used, until asymptomatic status was achieved or a maximum of 8 treatments had been received. Main Outcome Measures: Both treatment groups were assessed through use of subjective (Numerical Pain Rating Scale 101, McGill Short-Form Pain Questionnaire, and Neck Disability Index) and objective (goniometer cervical range of motion) measurement parameters at specific intervals during the treatment period and at 1-month follow-up. The data were assessed through use of 2-tailed nonparametric paired and unpaired analysis, descriptive statistics, and power analysis of the data.
                The results indicate that both treatment methods had a positive effect on the subjective and objective clinical outcome measures, no significant difference being observed between the 2 groups (P < .025). The subjective data from all 3 questionnaires showed statistically significant changes from initial to final consultations as well as from initial consultation to 1-month follow-up (P < .025). The objective range of motion measures showed statistically significant changes in the MFMA group for left and right rotation and left and right lateral flexion from initial consultation to final consultations and for right rotation and right lateral flexion from initial consultation to 1-month follow-up. The HVLA group showed only the change in left rotation from initial to final consultations and from initial consultation to 1-month follow-up to be statistically significant.
                The results of this clinical trial indicate that both instrumental (MFMA) manipulation and manual (HVLA) manipulation have beneficial effects associated with reducing pain and disability and improving cervical range of motion in this patient population. A randomized, controlled clinical trial in a similar patient base with a larger sample size is necessary to verify the clinical relevance of these findings. The study was a randomized, controlled trial with blinded outcome assessment. A 6-week intervention was followed up directly afterwards and after 12 months.
                The purpose was to evaluate the preventive efficacy of a neck/shoulder exercise regimen for neck pain in air force helicopter pilots.
                Neck pain is a significant medical problem in modern military aviation. Research shows neck-muscle dysfunction in subjects with various neck disorders. So far, evidence for neck exercise as prevention or early intervention is sparse, and few trials use randomized controlled design.
                Sixty-eight helicopter pilots on active flying duty with or without neck pain were randomly assigned to a supervised neck/shoulder exercise regimen or a control group receiving no such regimen. The key outcome was change in the prevalence of neck pain cases at the 12-month follow-up, rated for the previous week and the previous 3 months. Secondary outcomes included neck-flexor surface electromyographic activity during active craniocervical flexion and pain-related fear regarding physical activity. In addition, a secondary regression analysis included preintervention predictors that may be associated with change in prevalence of neck-pain cases at the 12-month follow-up.
                Eighty-two percent (56/68) of the participants assigned at random completed the intervention and provided data at month 12. Regression analysis showed a reduction in the prevalence of neck pain cases in the exercise group, which was significant for pain ratings during the previous week, OR = 3.2 (95% CI = 1.3-7.8), and previous 3 months, OR = 1.9 (95% CI = 1.2-3.2). Electromyographic activity at the highest contraction level was significantly reduced in the exercise group, P < 0.05, whereas no between-groups effect emerged for pain-related fear. Results from the secondary analysis showed that general strength training for more than 1 hour per week before the intervention predicted reduction in prevalence of pain at follow-up.
                A supervised neck/shoulder exercise regimen was effective in reducing neck pain cases in air force helicopter pilots. This was supported by improvement in neck-flexor function postintervention in regimen members. However, no effect emerged for pain-related fear. General strength training before the intervention predicted reduction in prevalence of pain at follow-up. Evidence indicates that supervised home exercises, combined or not with manual therapy, can be beneficial for patients with non-specific chronic neck pain (NCNP). The objective of the study is to investigate the efficacy of preventive spinal manipulative therapy (SMT) compared to a no treatment group in NCNP patients. Another objective is to assess the efficacy of SMT with and without a home exercise program.
                Ninety-eight patients underwent a short symptomatic phase of treatment before being randomly allocated to either an attention-group (n = 29), a SMT group (n = 36) or a SMT + exercise group (n = 33). The preventive phase of treatment, which lasted for 10 months, consisted of meeting with a chiropractor every two months to evaluate and discuss symptoms (attention-control group), 1 monthly SMT session (SMT group) or 1 monthly SMT session combined with a home exercise program (SMT + exercise group). The primary and secondary outcome measures were represented by scores on a 10-cm visual analog scale (VAS), active cervical ranges of motion (cROM), the neck disability index (NDI) and the Bournemouth questionnaire (BQ). Exploratory outcome measures were scored on the Fear-avoidance Behaviour Questionnaire (FABQ) and the SF-12 Questionnaire.
                Our results show that, in the preventive phase of the trial, all 3 groups showed primary and secondary outcomes scores similar to those obtain following the non-randomised, symptomatic phase. No group difference was observed for the primary, secondary and exploratory variables. Significant improvements in FABQ scores were noted in all groups during the preventive phase of the trial. However, no significant change in health related quality of life (HRQL) was associated with the preventive phase.
                This study hypothesised that participants in the combined intervention group would have less pain and disability and better function than participants from the 2 other groups during the preventive phase of the trial. This hypothesis was not supported by the study results. Lack of a treatment specific effect is discussed in relation to the placebo and patient provider interactions in manual therapies. Further research is needed to delineate the specific and non-specific effects of treatment modalities to prevent unnecessary disability and to minimise morbidity related to NCNP. Additional investigation is also required to identify the best strategies for secondary and tertiary prevention of NCNP.
                ClinicalTrials.gov: NCT00566930. Active physical training is commonly recommended for patients with chronic neck pain; however, its efficacy has not been demonstrated in randomized studies.
                To evaluate the efficacy of intensive isometric neck strength training and lighter endurance training of neck muscles on pain and disability in women with chronic, nonspecific neck pain.
                Examiner-blinded randomized controlled trial conducted between February 2000 and March 2002.
                Participants were recruited from occupational health care systems in southern and eastern Finland.
                A total of 180 female office workers between the ages of 25 and 53 years with chronic, nonspecific neck pain.
                Patients were randomly assigned to either 2 training groups or to a control group, with 60 patients in each group. The endurance training group performed dynamic neck exercises, which included lifting the head up from the supine and prone positions. The strength training group performed high-intensity isometric neck strengthening and stabilization exercises with an elastic band. Both training groups performed dynamic exercises for the shoulders and upper extremities with dumbbells. All groups were advised to do aerobic and stretching exercises regularly 3 times a week.
                Neck pain and disability were assessed by a visual analog scale, the neck and shoulder pain and disability index, and the Vernon neck disability index. Intermediate outcome measures included mood assessed by a short depression inventory and by maximal isometric neck strength and range of motion measures.
                At the 12-month follow-up visit, both neck pain and disability had decreased in both training groups compared with the control group (P<.001). Maximal isometric neck strength had improved flexion by 110%, rotation by 76%, and extension by 69% in the strength training group. The respective improvements in the endurance training group were 28%, 29%, and 16% and in the control group were 10%, 10%, and 7%. Range of motion had also improved statistically significantly in both training groups compared with the control group in rotation, but only the strength training group had statistically significant improvements in lateral flexion and in flexion and extension.
                Both strength and endurance training for 12 months were effective methods for decreasing pain and disability in women with chronic, nonspecific neck pain. Stretching and fitness training are commonly advised for patients with chronic neck pain, but stretching and aerobic exercising alone proved to be a much less effective form of training than strength training. The purpose of this pilot study was to examine the immediate effects of a manual therapy technique called Inhibitive Distraction (ID) on active range of motion (AROM) for cervical flexion in patients with neck pain with or without concomitant headache. A secondary objective of this study was to see whether patient subgroups could be identified who might benefit more from ID by studying variables such as age, pain intensity, presence of headache, or pre-intervention AROM. We also looked at patients' ability to identify pre- to post-intervention changes in their ability to actively move through a range of motion. Forty subjects (mean age 34.7 years; range 16-48 years) referred to a physical therapy clinic due to discomfort in the neck region were randomly assigned to an experimental and a control group. We used the CROM goniometer to measure pre- and post-intervention cervical flexion AROM in the sagittal plane within a single treatment session. The between-group difference in AROM increase was not statistically significant at P<0.05 with a mean post-intervention increase in ROM of 2.4 degrees (SD 6.2 degrees ) for the experimental group and 1.2 degrees (SD 5.8 degrees ) for the placebo group. We were also unable to identify potential subgroups more likely to respond to ID, although a trend emerged for greater improvement in chronic patients with headaches, lower pain levels, and less pre-intervention AROM. In the experimental group and in both groups combined, subjects noting increased AROM indeed had a significantly greater increase in AROM than those subjects not noting improvement. In conclusion, this study did not confirm immediate effects of ID on cervical flexion AROM but did provide indications for potential subgroups likely to benefit from this technique. Recommendations are provided with regard to future research and clinical use of the technique studied. The objective of this study is to analyze the immediate effects on neck pain and active cervical range of motion after a single cervical high-velocity low-amplitude (HVLA) manipulation or a control mobilization procedure in mechanical neck pain subjects. In addition, we assessed the possible correlation between neck pain and neck mobility.
                Seventy patients with mechanical neck pain (25 males and 45 females, aged 20-55 years) participated in this study. The lateral gliding test was used to establish the presence of an intervertebral joint dysfunction at the C3 through C4 or C4 through C5 levels. Subjects were divided randomly into either an experimental group, which received an HVLA thrust, or a control group, which received a manual mobilization procedure. The outcome measures were active cervical range of motion and neck pain at rest assessed pretreatment and 5 minutes posttreatment by an assessor blinded to the treatment allocation of the patient. Intragroup and intergroup comparisons were made with parametric tests. Within-group effect sizes were calculated using Cohen's d coefficient.
                Within-group changes showed a significant improvement in neck pain at rest and mobility after application of the manipulation (P < .001). The control group also showed a significant improvement in neck pain at rest (P < .01), flexion (P < .01), extension (P < .05), and both lateral flexions (P < .01), but not in rotation. Pre-post effect sizes were large for all the outcomes in the experimental group (d > 1), but were small to medium in the control mobilization group (0.2 < d < 0.6). The intergroup comparison showed that the experimental group obtained a greater improvement than the control group in all the outcome measures (P < .001). Decreased neck pain and increased range of motion were negatively associated for all cervical motions: the greater the increase in neck mobility, the less the pain at rest.
                Our results suggest that a single cervical HVLA manipulation was more effective in reducing neck pain at rest and in increasing active cervical range of motion than a control mobilization procedure in subjects suffering from mechanical neck pain.
Low to moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain immediately post treatment and intermediate term, and cervicogenic headaches in the long term. Low to moderate evidence suggests no benefit for some upper extremity stretching and strengthening exercises or a general exercise program.  Future trials should consider using an exercise classification system to establish similarity between protocols and adequate sample sizes. Factorial trials would help determine the active treatment agent within a treatment regimen where a standardized representation of dosage is essential. Standardized reporting of adverse events is needed for balancing the likelihood of treatment benefits over potential harms.