Neck Pain Patient Decision Aid: Step 2

This page is part of the 'Should I receive manual therapy and exercise for my neck pain?: A patient decision aid' resource for patients. Please see the main project page for further information, or proceed to Step 2 below to understand the evidence.


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Neck pain alone for less than 6 weeks

There is low quality evidence available. Definitive recommendations cannot be made from this research.

Neck pain with headache for less than 6 weeks

There is low quality evidence available. Definitive recommendations cannot be made from this research.

Neck pain after whiplash injury for less than 6 weeks

Neck mobilizations and range of motion exercises performed frequently within your limits of pain provide greater pain relief in the short-term when compared to using analgesic medication and collar.[1][2]

Outcome Follow-up Number of people experiencing greater change with manual therapy and exercise in comparison to analgesic medication and collar treatment Average difference in improvement between groups
Pain Short-term NeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Half.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

[1 out of 4 to 5]

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Neck pain alone for more than 6 weeks

Neck exercises plus mobilization with or without manipulations or massage can help you in the short- and long-term. Moderate to high quality evidence suggests:

  • Greater short-term pain relief than exercise alone, but no long-term difference in pain, function, or quality of life (QoL)[3][4][5].
Outcome Follow-up Number of people experiencing greater change with manual therapy and exercise in comparison to exercise alone Average difference in improvement between groups
Pain Short-term

NeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Half.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

[1 out of 6]


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Small moderate large

Pain Long-term NeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

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Small moderate large

Function Long-term NeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

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Small moderate large

Quality of life Long-term NeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

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  • Greater short- and long-term improvements in pain and quality of life with manual therapy and exercise in comparison to manual therapy alone[3][6]
Outcome Follow-up Number of people experiencing greater change with manual therapy and exercise in comparison to manual therapy alone Average difference in improvement between groups
Pain Long-term

NeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

[1 out of 8 to 9]

NeckPainPatientAid Step2 Whiplash-12weeks SmallBar.pngSmall moderate large

Quality of life Long-term

NeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

[1 out of 9 to 52]

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  • Greater long-term improvements in pain and function in comparison to advice[7]
Outcome Follow-up Number of people experiencing greater change with manual therapy and exercise in comparison to advice Average difference in improvement between groups
Pain Long-term

NeckPainPatientAid YellowSmiley Half.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

[1 out of 18]

NeckPainPatientAid Step2 Whiplash-12weeks Mod-LargeBar.png Small moderate large

Function Long-term

NeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Half.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

[1 out of 4]

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  • Similar benefit to advice and care from your doctor a year after the pain is started[4][8]
Outcome Follow-up Number of people experiencing greater change with manual therapy and exercise in comparison to general practitioner care Average difference in improvement between groups
Pain Long-term NeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

NeckPainPatientAid Step2 Whiplash-12weeks NoBar.png

Small moderate large

Function Long-term NeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

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Small moderate large


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Manipulation and mobilization appear to have similar effects for improving pain and function in the intermediate-term[9] |

Outcome Follow-up Number of people experiencing greater change with manual therapy and exercise in comparison to general practitioner care Average difference in improvement between groups
Pain Intermediate-term NeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png NeckPainPatientAid Step2 Whiplash-12weeks NoBar.png

Small moderate large

Function Intermediate-term NeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png NeckPainPatientAid Step2 Whiplash-12weeks NoBar.png

Small moderate large


NeckPainPatientAid Step2 NeckPain-12weeks 9.jpg
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Exercise alone is also effective in the short- and long-term

  • Neck and upper back range of motion and low-load strengthening exercises provide reductions in pain, improvements in function, and patient satisfaction. There is no difference in global perceived effect or quality of life[3][10][11][12]
Outcome Follow-up Number of people experiencing greater change with exercise in comparison to other treatments Average difference in improvement between groups
Pain Intermediate-term

NeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

[1 out of 6 to 18]

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Small moderate large

Function Intermediate-term

NeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

[1 out of 4 to 13]

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Small moderate large

Quality of life Long-term NeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

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  • Upper extremity stretching, strengthening and endurance training do not provide any additional benefit to normal activities in terms of neck pain and function[13]
Outcome Follow-up Number of people experiencing greater change with upper extremity exercise in comparison to a control group Average difference in improvement between groups
Pain Short-term NeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png NeckPainPatientAid Step2 Whiplash-12weeks NoBar.png

Small moderate large

Function Short-term NeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png NeckPainPatientAid Step2 Whiplash-12weeks NoBar.png

Small moderate large


  • Qigong exercises are more effective than being on a wait-list for that treatment[14][15]
Outcome Follow-up Number of people experiencing greater change with upper extremity exercise in comparison to a control group Average difference in improvement between groups
Pain Immediately following treatment period

NeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

1 out of 4 to 6

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Small moderate large

Function Immediately following treatment

NeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

1 out of 5 to 19

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Small moderate large

Quality of life Immediately following treatment

NeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

1 out of 7 to 10

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Small moderate large


NeckPainPatientAid Step2 NeckPain-12weeks 11.jpg
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Neck pain with headache for more than 6 weeks

Manual therapy and exercise provide greater short and long-term improvements in pain and function compared to no treatment[5] 

Outcome Follow-up Number of people experiencing greater change with manual therapy and exercise in comparison to no treatment Average difference in improvement between groups
Pain Long-term

NeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

[1 out of 5] 

NeckPainPatientAid Step2 Whiplash-6weeks LargeBar.png

Small moderate large

Function Long-term

NeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Half.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

[1 out of 6]

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Small moderate large


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NeckPainPatientAid Step2 WhiplashHeadache-12weeks 3.jpg
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NeckPainPatientAid Step2 NeckPain-12weeks 13.jpg
NeckPainPatientAid Step2 NeckPain-12weeks 14.jpg
NeckPainPatientAid Step2 WhiplashHeadache-12weeks 11.jpg
NeckPainPatientAid Step2 WhiplashHeadache-12weeks 12.jpg


Exercise also provides greater short and long-term improvements in pain and function compared to no treatment[5] 

Outcome Follow-up Number of people experiencing greater change with manual therapy and exercise in comparison to no treatment Average difference in improvement between groups
Pain Long-term

NeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Half.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

[1 out of 6]

NeckPainPatientAid Step2 Whiplash-6weeks LargeBar.png

Small moderate large

Function Long-term NeckPainPatientAid YellowSmiley Full.pngNeckPainPatientAid YellowSmiley Half.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.pngNeckPainPatientAid YellowSmiley Frown.png

[1 out of 6]

NeckPainPatientAid Step2 Whiplash-12weeks ModBar.png

Small moderate large


NeckPainPatientAid Step2 NeckPain-12weeks 13.jpg
NeckPainPatientAid Step2 NeckPain-12weeks 14.jpg
NeckPainPatientAid Step2 WhiplashHeadache-12weeks 11.jpg
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Neck pain after whiplash injury for more than 6 weeks

There is low quality evidence available. Definitive recommendations cannot be made from this research.

Neck pain with pain numbness and tingling down your arm

There is low quality evidence available. Definitive recommendations cannot be made from this research.

References

  1. Giebel GD, Edelmann M, Huser R. Diedistorsionderhalswirbelsaule: Fruhfunk-tionalle vs.ruhigstellendebehandlung. Zentralbibliotak Chiropractic 1997;122:517-21.
  2. Mealy K, Brennan H, Fenelon GC. Early mobilisation of acute whiplash injuries. Br Med J 1986;92:656-7.
  3. 3.0 3.1 3.2 Bronfort G, Evan R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine 2001;26(7):788-99.
  4. 4.0 4.1 Hoving JL, Koes BW, deVet HCW,vanderWindt DAWM, Assendelft WJJ, van Mameren H, et al. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. A randomized controlled trial. Ann Int Med 2002;136:713-22.
  5. 5.0 5.1 5.2 Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2001;27(17):1835-43.
  6. Skargren EI, Oberg BE. Predictive factors for 1-year outcome of low-back and neck pain in patients treated in primary care: comparison between the treatment strategies chiropractic and physiotherapy. Pain 1998;77:201-7.
  7. Ylinen J, Takala EP, Nykanen M, Hakkinen A, Malkia E, Pohjolainen T, et al. Active neck muscle training in the treatment of chronic neck pain in women. JAMA 2003;289(19):2509-16.
  8. Walker MJ, Boyles RE, Young BA, Strunce JB, Garber MB, Whitman JM, et al. The effectiveness of manual physical therapy and exercise for mechanical neck pain. Spine 2008;33(22):2371-8.
  9. Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F, Adams AH. A Randomized Trial of Chiropractic Manipulation and Mobilization for Patients With Neck Pain: Clinical Outcomes From the UCLA Neck-Pain Study. Research and Practice 2002;92(10):1634-41.
  10. Chiu TTW, Hui-chan CWY, Cheing G. A randomized clinical trial of TENS and exercise for patients with chronic neck pain. Clin Rehabil 2005;19:850-60.
  11. Franca DLM., Senna-Fernades V., Martins Cortez C., Jackson MN., Bernardo-Filho M., and Guimaraes MAM. Tension neck syndrome treated by acupuncture combined with physiotherapy: A comparative clinical trial (pilot study).. Complementary Therapies in Medicine 2008;16:268-277.
  12. Martel J., Dugas C., Dubois JD., Descarreaux M.. A randomised controlled trial of preventive spinal manipulation with and without a home exercise program for patients with chronic neck pain. BMC Musculoskeletal Disorders 2011;12:41-54.
  13. Viljanen M, Malmivaara A, Uitti J, Rinne M, Palmroos P, Laippala P. Effectiveness of dynamic muscle training, relaxation training, or ordinary activity for chronic neck pain: randomized controlled trial. BMJ. 2003;327:475-479.
  14. von Trott P., Wiedemann A, Ludtke R., reibhauer A., Willich ST., and Witt CM.. Qigong and exercise therapy for elderly patients with chronic neck pain (QIBANE): A randomized controlled study. J Pain 2009;10(5):501-508.
  15. Rendant D, Pach D, Ludtke R, Reishauer A, Mietzner A, Willich SN, Witt CM. Qigong versus exercise versus no therapy for patients with chronic neck pain. Spine 2011;36(6):419-29.