Neck Pain in Adults _________________________________________________________________________
Evidence of Efficacy Strengthening tailored to individual patients with neck pain is superior to generalized strengthening [227]. A 2016 practice guideline stated that supervised qigong, Iyengar yoga, and programs that combined strengthening, range of motion, and flexibility were effective in persistent neck pain; exercise alone had minimal benefit [229]. Exercise combined with any blend of manipulation, mobilization, muscle energy, and stretching is more effective in reducing neck pain and disability than any single approach used alone [103]. A systematic review of exercise efficacy in neck pain disorders concluded that use of strengthening and endurance exercises for the cervico-scapulothoracic region and shoulder may be beneficial in reducing pain and improving function; and that stretching exercises alone are not beneficial [230]. In acute radiculopathy, cervical stretch, strengthening, and stabilization exercises show a small benefit in pain reduction. For chronic neck pain, the authors identified five modalities with some evidence of efficacy for neck pain [230]: • Cervico-scapulothoracic and upper extremity strength training: Moderate to large improvements in pain at short-term follow-up • Scapulothoracic and upper extremity endurance training: Smaller beneficial effect on pain at short- term follow-up • Combined cervical, shoulder, and scapulothoracic strengthening and stretching exercises: Smaller to large-magnitude benefit on pain from post-treatment to long-term follow-up, and a medium magnitude of effect on improved function at short-term follow-up • Cervico-scapulothoracic strengthening/stabilization exercises: Improved pain and function at intermediate-term follow-up • Mindfulness exercises and qigong: Minimally improved function at short term The study also determined that weak evidence suggested minimal-to-no short-term benefit on pain or function with breathing exercises, general fitness training, stretching alone, and feedback exercises with pattern synchronization. Very weak evidence suggests neuromuscular eye-neck coordination and proprioceptive exercises may improve pain and function short-term [230]. In patients with chronic cervicogenic headache, static-dynamic cervico-scapulothoracic strengthening/endurance exercises (including pressure biofeedback) were found to improve pain, function, and global perceived effect at post-treatment and probably at long-term follow-up [230]. Low-grade evidence supports sustained natural apophyseal glide exercises in this patient population.
Two randomized controlled trials compared the outcomes of patients with chronic nonspecific neck pain after four weeks of stabilization exercises alone or combined with a manual therapy. In the first trial, patients receiving cervical and scapulothoracic stabilization exercises plus manual therapy showed significantly greater improvements in pressure pain threshold, disability, pain intensity at night, cervical rotation motion, and quality of life than patients receiving exercises alone [231]. The second trial compared cervical and scapulothoracic stabilization exercises alone or plus connective tissue massage. Both decreased pain intensity and anxiety levels, but combination therapy led to significantly greater improvements in pain intensity at night, pressure pain threshold, state anxiety, and mental health than exercises alone [232]. At six-month follow-up, patients with chronic nonspecific neck pain showed significantly greater reductions in pain and disability from global postural re-education than manual therapy (nine 1-hour sessions for both) [233]. The Alexander technique is an educational approach to modify dysfunctional posture, movement, and thinking patterns associated with musculoskeletal disorders. In patients with chronic nonspecific neck pain, the Alexander technique did not differ from local heat application in pain reduction after both were delivered weekly for five weeks [234]. Consensus indicates that exercise therapy is beneficial for chronic pain, but the lack of endogenous analgesia in some chronic pain disorders should not be ignored and clinicians should account for this when treating patients with chronic pain [235]. General exercise is frequently recommended for WADs. In contrast to other musculoskeletal pain conditions, a review of high-quality studies concluded general exercise does not reduce pain or disability in patients with WAD [228]. Exercise-induced hypoalgesia describes the desired effect of reduced pain sensitivity following exercise. The effect of acute exercise on pain sensitivity in chronic pain conditions is controversial, because hypoalgesia, unchanged pain sensitivity, and hyperalgesia (impaired exercise-induced hypoalgesia) have all been reported. Evidence suggests impaired exercise-induced hypoalgesia is evident in WAD following aerobic exercise [236]. In patients with chronic WAD, exercise-induced hypoalgesia responses to isometric (3-minute wall squat) or aerobic (30 minute bicycling) exercise were compared by recording neck and leg pressure pain thresholds before and after exercises. Pressure pain threshold increases were found at both areas after isometric, but not aerobic, exercise. Isometric exercises directed at non-painful muscles may reduce local and remote pain sensitivity in patients with chronic WAD and mild-to- moderate neck pain and disability [237].
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