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      Effectiveness and optimal dosage of exercise training for chronic non-specific neck pain: A systematic review with a narrative synthesis

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          Abstract

          Background

          Clinical guidelines make vague recommendations as to exercise training (ET) type and dosage to manage chronic non-specific neck pain (CNSNP).

          Objective

          To synthesise evidence on the effectiveness of different ET programmes to reduce CNSNP and associated disability, and whether dosage affects outcomes.

          Methods

          A systematic review and data synthesis was conducted according to a published registered protocol (PROSPERO CRD42018096187). A sensitive topic-based search was conducted of CINAHL, MEDLINE, EMBASE, PEDro, grey literature sources and key journals from inception to 6 th January 2020 for randomised controlled trials, investigating ET for CNSNP or disability. Two reviewers independently completed eligibility screening, data extraction, risk of bias assessment (Cochrane Risk of Bias Tool) and rated the overall strength of evidence using Grading of Recommendations Assessment, Development and Evaluation. Data was tabulated for narrative synthesis and grouped by intervention, outcome and time point to compare across studies.

          Results

          Twenty-six trials from 3990 citations (n = 2288 participants) investigated fifteen ET programmes. High RoB and low sample sizes reduced evidence quality. Clinical heterogeneity prevented meta-analyses. A range of ET programmes reduce pain/disability in the short term (low to moderate evidence). Pillar exercises reduce pain/disability in the intermediate term (low level evidence). Moderate to very large pain reduction is found with ET packages that include motor control + segmental exercises (low to moderate evidence). No high-quality trials investigated long term outcomes. Increased frequency of motor control exercises and progressively increased load of pillar exercise may improve effectiveness.

          Conclusions

          Motor control + segmental exercises are the most effective ET to reduce short term pain/disability, but long-term outcomes have not been investigated. Optimal motor control + segmental exercise variables and dosage is unknown and requires clarification. An adequately powered, low RoB trial is needed to evaluate the effectiveness and optimal dosage of motor control + segmental on long term outcomes.

          Trial registration

          PROSPERO CRD42018096187

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          Most cited references70

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          2015 Updated Method Guideline for Systematic Reviews in the Cochrane Back and Neck Group.

          Method guideline for systematic reviews of trials of interventions for neck and back pain, and related spinal disorders.
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            Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain.

            Exercise therapy encompasses a heterogeneous group of interventions. There continues to be uncertainty about the most effective exercise approach in chronic low back pain. To identify particular exercise intervention characteristics that decrease pain and improve function in adults with nonspecific chronic low back pain. MEDLINE, EMBASE, PsychInfo, CINAHL, and Cochrane Library databases to October 2004 and citation searches and bibliographic reviews of previous systematic reviews. Randomized, controlled trials evaluating exercise therapy in populations with chronic (>12 weeks duration) low back pain. Two reviewers independently extracted data on exercise intervention characteristics: program design (individually designed or standard program), delivery type (independent home exercises, group, or individual supervision), dose or intensity (hours of intervention time), and inclusion of additional conservative interventions. 43 trials of 72 exercise treatment and 31 comparison groups were included. Bayesian multivariable random-effects meta-regression found improved pain scores for individually designed programs (5.4 points [95% credible interval (CrI), 1.3 to 9.5 points]), supervised home exercise (6.1 points [CrI, -0.2 to 12.4 points]), group (4.8 points [CrI, 0.2 to 9.4 points]), and individually supervised programs (5.9 points [CrI, 2.1 to 9.8 points]) compared with home exercises only. High-dose exercise programs fared better than low-dose exercise programs (1.8 points [CrI, -2.1 to 5.5 points]). Interventions that included additional conservative care were better (5.1 points [CrI, 1.8 to 8.4 points]). A model including these most effective intervention characteristics would be expected to demonstrate important improvement in pain (18.1 points [CrI, 11.1 to 25.0 points] compared with no treatment and 13.0 points [CrI, 6.0 to 19.9 points] compared with other conservative treatment) and small improvement in function (5.5 points [CrI, 0.5 to 10.5 points] compared with no treatment and 2.7 points [CrI, -1.7 to 7.1 points] compared with other conservative treatment). Stretching and strengthening demonstrated the largest improvement over comparisons. Limitations of the literature, including low-quality studies with heterogeneous outcome measures and inconsistent and poor reporting; publication bias. Exercise therapy that consists of individually designed programs, including stretching or strengthening, and is delivered with supervision may improve pain and function in chronic nonspecific low back pain. Strategies should be used to encourage adherence. Future studies should test this multivariable model and further assess specific patient-level characteristics and exercise types.
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              Neck Pain: Revision 2017

              The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to neck pain. J Orthop Sports Phys Ther. 2017;47(7):A1-A83. doi:10.2519/jospt.2017.0302.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: MethodologyRole: ValidationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                10 June 2020
                2020
                : 15
                : 6
                : e0234511
                Affiliations
                [1 ] Musculoskeletal Physiotherapy Services, Birmingham Community Healthcare NHS Foundation Trust, Birmingham, England, United Kingdom
                [2 ] Centre of Precision Rehabilitation for Spinal Pain (CPR Spine) School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Birmingham, England, United Kingdom
                [3 ] Edgbaston Physiotherapy Clinic, Birmingham, England, United Kingdom
                EHESP Paris, FRANCE
                Author notes

                Competing Interests: Jonathan Price, Alison Rushton and Nicola R Heneghan declare that they have no competing interests. Isaak Tyros and Vasileios Tyros are employed by the commercial company Edgbaston Physiotherapy Clinic. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                http://orcid.org/0000-0002-5505-1564
                http://orcid.org/0000-0001-8114-7669
                http://orcid.org/0000-0001-7599-3674
                Article
                PONE-D-20-07090
                10.1371/journal.pone.0234511
                7286530
                32520970
                e628835f-6707-4526-9112-8a14fc7deb39
                © 2020 Price et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 11 March 2020
                : 26 May 2020
                Page count
                Figures: 8, Tables: 4, Pages: 32
                Funding
                Funded by: Health Education England/ National Institute for Health Research Pre-Doctoral Clinical Academic Fellowship
                Award ID: ICA-PCAF-2018-01-117
                Award Recipient :
                This work was completed as part of a Clinical Health Research MRes at the University of Birmingham, UK funded by Health Education England and National Institute for Health Research (HEE/ NIHR ICA Programme Pre-doctoral Clinical Academic Fellowship, Mr Jonathan Price, ICA-PCAF-2018-01-117). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. Isaak Tyros and Vasileios Tyros are employed by Edgbaston Physiotherapy Clinic. The funder provided support in the form of salaries for authors IT and VT, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.The specific roles of these authors are articulated in the ‘author contributions’ section.
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