Neck Pain Tool-kit: Step 3

This page is part of the 'Manual Therapy & Exercise for Neck Pain: Clinical Treatment Tool-kit' resource for clinical decision making, which provides evidence, techniques, and dosages for the use of manual therapy and exercise in the treatment of neck pain. Please see the main project page for further information, or to return to Step 1 to identify your patient. Otherwise, proceed to Step 3 below to inform your technique.

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The techniques utilized in the positive trials investigating the use of manual therapy and exercise for the treatment of neck pain are presented below, organized by patient characteristics

Once you have found the techniques most applicable to your patient, click on Step 4: consider dosage to see the techniques utilized in the positive studies for that patient population

Contents

3.1 Neck pain alone (non-specific)

Acute/subacute neck pain

Thoracic manipulation

Cleland 2005[1]

  • upper thoracic spine thrust manipulation targeting T1-T4(a)
    • patient laces hands behind his/her neck
    • therapist uses the patients elbow to flex spine down to the upper thoracic levels
    • therapist stabilizes the inferior vertebrae using his/her manipulative hand and uses his/her chest to provide the thrust manipulation. If no pop is heard, a second attempt is made
  • middle thoracic spine thrust manipulation targeting T5-T8 (b)
    • patient clasps hands on opposite shoulder
    • therapist flexes spine down to the target levels using the patients arms
    • therapist provides the thrust manipulation through his/her chest. If no pop is heard, a second attempt is made
(a) Upper thoracic thrust manipulation
(b) Middle thoracic thrust manipulation
  • Advice to maintain usual activities within the limits of pain
  • Advice to maintain current medications
  • Adjunct exercise
    • place fingers over manubrium and place chin on the fingers
    • rotate the head and neck as far as possible to alternating sides
    • start using 5 fingers and progress to 4, 3, 2, and 1 finger as mobility improves
    • 10 repetitions to each side, 3-4 times/day

Gonzalez-Iglesias 2009[2] 

  • seated distraction manipulation (c)
    • patient seated with arms crossed over the chest and one hand over opposite shoulder and one hand over rib cage
    • therapist places his/her upper chest at the level of the patient’s middle thoracic spine
    • therapist grasps the patient’s elbows and flexes the thoracic spine until tension is felt
    • a distraction manipulation was applied in an upward direction
    • if no pop was heard, a second attempt was made
  • adjunct electrothermal therapy
(c) Seated thoracic distraction manipulation

Subacute/chronic neck pain

Manual therapy and exercise

Bronfort 2001[3]

  • Spinal manipulation to the cervical and thoracic spine (Haldeman 1991[4]) with light soft-tissue massage as indicated to facilitate the spinal manipulative therapy
  • Warm-up on a stationary bike with arm levers
  • Light stretching as part of warm-up (a-c)
  • Upper-body strengthening exercises (Dyrssen 1989[5])
    • Push-ups (d)
    • Dumbbell shoulder exercises (e-k)
  • Dynamic neck exercises lying on table with headgear attached to a simple pulley system
    • extension (l)
    • flexion (m)
    • rotation (n)
(a) Upper fibres of trapezius stretch
(b) Levator scapulae stretch
(c) Scalene stretch
(d) Push-ups
(e) Shoulder press
(f) Shrugs
(g) Front raise
(h) Reverse flyes
(i) Curls
(j) Bent-over rows
(k) Pullovers
(l) Neck extension with pulley
(m) Flexion with pulley
(n) Rotation with pulley

Hoving 2002[6]

  • An eclectic approach to manual therapy including several techniques used in western Europe, North America, and Australia, including those described by Cyriax, Kaltenborn, Maitland, and Mennel (Basmajian 1993[7]; Cookson 1979[8]; Gross 1996[9]).
  • Techniques included:
    • “hands-on” muscular mobilization techniques (aimed at improving soft tissue function)
    • specific articular mobilization techniques (to improve overall joint function and decrease any restrictions in movement at single or multiple segmental levels in the cervical spine) (o-oo)
    • coordination or stabilization techniques (to improve postural control, coordination, and movement patterns by using the stabilizing cervical musculature) (Van der 1993[10]) (pp-rr)
(o) Lateral glide described by Cyriax
(p) AP described by Cyriax
(q) Traction described by Cyriax

(r) Cervical traction described by Kaltenborn
(s) Upper thoracic traction described by Kaltenborn

(t) Mid thoracic traction described by Kaltenborn
(u) PA described by Kaltenborn
(v) AP described by Kaltenborn
(w) Rotation described by Kaltenborn

(x) Lateral glide described by Kaltenborn

(y) Rotation in sitting described by Maitland
(z) Side flexion in sitting described Maitland
(aa) Flexion in sitting described by Maitland

(bb) Extension in sitting described by Maitland
(cc) Rotation in lying described by Maitland
(dd) Side flexion in lying described by Maitland
(ee) Flexion in lying described by Maitland

(ff) Extension in lying described by Maitland
(gg) Bilateral AP described by Maitland
(hh) Bilateral PA described by Maitland
(ii) Unilateral PA described by Maitland

(jj) Unilateral AP described by Maitland
(kk) Transverse mobilization described by Maitland
(ll) AP described by Mennel
(mm) Side glide described by Mennel

(nn) Rotation described by Mennel
(oo) Side tilting described by Mennel
(pp) Deep neck flexor activation
(qq) Deep neck flexor activation with pressure biofeedback

(rr) Chin tuck and head lift from supine

Jull 2002[11]

  • Manipulative therapy at the therapist’s discretion (Maitland 2000[12])(y-kk)
    • low-velocity cervical joint mobilization techniques (in which the cervical segment is moved passively with rhythmical movements)
    • high-velocity manipulation techniques
  • Low load endurance exercises to train muscle control of the cervicoscapular region (Jull 1997[13])
  • The subjects were first taught to perform a slow and controlled craniocervical flexion action aimed to target the deep neck flexor muscles (pp)
  • They then trained to be able to hold progressively increasing ranges of craniocervical flexion using feedback from an air-filled pressure sensor placed behind the neck (qq).
  • The muscles of the scapula, particularly the serratus anterior and lower trapezius, were trained using inner range holding exercises of scapular adduction and retraction, practiced initially in the prone lying position (ss)
  • Training of these neck and scapular muscles also was incorporated into postural correction exercises performed regularly throughout the day in the sitting position. The subjects were trained to sit with a natural lumbar lordosis while gently retracting and adducting their scapulas and gently elongating their cervical spine to facilitate the longus colli (tt)
  • Subsequently, isometric exercises using a low level of rotatory resistance were used to train the cocontraction of the neck flexors and extensors (uu)
  • They also could be taught muscle lengthening exercises to address any muscle tightness assessed to be present (a-c)
(ss) Prone scapular retraction
(tt) Posture incorporating deep neck flexors and scapular retraction
(uu) Isometric rotation

Skargren 1998[14]

  • Each patient's treatment was at the discretion of the individual physiotherapist
    • None of the physiotherapists was a specialist in manipulation.

Ylinen 2003[15]

Endurance training group

  • Neck flexor exercise performed by lifting the head up from the supine position (qq)
  • Dynamic exercises for shoulders and upper extremities using dumbbells(2 sets of 20 repetitions with 2kg dumbbells)
    • presses (e)
    • shrugs (f)
    • flyes (h)
    • curls (i)
    • bent-over rows (j)
    • pullovers (k)
  • Exercises for trunk and leg muscles against body weight
    • squats (vv)
    • sit-ups (ww)
    • back extensions (xx)
  • Stretching for neck, shoulder, and upper limb muscles (a-c, yy-ccc)
  • Advice to perform aerobic exercise 3 times a week for a half hour (ddd,eee)
  • A common multimodal rehabilitation program, including aspects commonly associated with traditional treatment: relaxation training, aerobic training, behavioral support to reduce fear of pain and improve exercise motivation, and lectures and practical exercises in ergonomics
  • 4 sessions of physical therapy, which consisted mainly of massage and mobilization to alleviate neck pain and to enable those with severe neck pain to perform active physical exercises
  • Every other session was performed at only half intensity to avoid excessive loading

Strength training group

  • Neck exercises with an elastic rubber band performed in a sitting position at 80% of maximum isometric strength recorded at baseline and follow-up visits
    • directly forward (fff)
    • obliquely toward right and left (ggg)
    • directly backward (hhh)
  • Dynamic exercises for shoulders and upper extremities using dumbbells (1set of 15 repetitions with highest load possible)
    • presses (e)
    • shrugs (f)
    • flyes (h)
    • curls (i)
    • bent-over rows (j)
    • pullovers (k)
  • Exercises for trunk and leg muscles against body weight
    • squats (vv)
    • sit-ups (ww)
    • back extensions (xx)
  • Stretching for neck, shoulder, and upper limb muscles (a-c, yy-ccc)
  • Advice to perform aerobic exercise 3 times a week for a half hour (ddd, eee)
  • A common multimodal rehabilitation program, including aspects commonly associated with traditional treatment: relaxation training, aerobic training, behavioral support to reduce fear of pain and improve exercise motivation, and lectures and practical exercises in ergonomics
  • 4 sessions of physical therapy, which consisted mainly of massage and mobilization to alleviate neck pain and to enable those with severe neck pain to perform active physical exercises
  • Every other session was performed at only half intensity to avoid excessive loading
(vv) Squats

(ww) Sit-ups
(xx) Back extensions
(yy) Shoulder retraction stretch
(zz) Shoulder protraction stretch

(aaa) Shoulder elevation stretch
(bbb) Posterior shoulder stretch
(ccc) Doorframe stretch
(ddd) Aerobic exercise performed on recumbent Stationary bike

(eee) Aerobic exercise performed on treadmill
(fff) Flexion directly forward

(ggg) Oblique flexion
(hhh) Extension

Allison 2002[16]

Neural treatment (Elvey 1997[17]). The treating physiotherapist could use any or all of the following interventions at his/her discretion.

  • Cervical lateral glide (iii)
    • The subject was positioned in supine, the shoulder slightly abducted with a few degrees of medial rotation, and the elbow flexed to approximately 90 such that the hands were resting on the subject’s chest or abdomen
    • The physiotherapist gently supported the shoulder over the acromial region with one hand while holding and supporting the head and neck
    • The technique involved a gentle controlled lateral glide to the contralateral side of pain in a slow oscillating manner up to a point in range where the first perception of resistance was felt by the therapist (and before the onset of pain).
  • Shoulder girdle oscillation (jjj)
    • The subject was positioned prone with the involved arm comfortably supported by the physiotherapist towards a position of hand behind the back.
    • The physiotherapist placed the other hand over the acromial area.
    • The technique involved a gentle oscillation of the shoulder girdle in a caudad cephalad direction. The range of oscillation was governed by the onset of first resistance perceived by the therapist in the caudad direction.
    • The technique was progressed by performing the oscillation in gradually increased amounts of hand behind the back position.
  • Muscle re-education
    • Contract-relax techniques were performed into shoulder abduction and external rotation.
    • This was progressed from a shoulder position of flexion/ adduction towards a position of abduction/external rotation comparable to a quadrant position in the scapular plane (Elvey and Hall, 1997).
  • Home mobilisation
    • Cervical spine side flexion was performed contralateral to the painful side with the shoulder in a position of abduction, and elbow resting on a table in a flexed position
    • Active movements of shoulder abduction and/or external rotation in the same starting position as above was carried out if appropriate (kkk)
(iii) Cervical lateral glide
(jjj) Shoulder girdle oscillation
(kkk) Abduction/External rotation of shoulder

Brodin 1985[18]

  • superficial massage
  • slight and relaxing traction (q)
  • electrical stimulation
  • 'cervical mobilization (Stoddard 1959[19]) (lll-rrr)
  • ‘cervical school’
    • education on anatomy and mechanical problems
    • how to deal with practical problems such as lifting, carrying, and relaxation
    • movements with the aim of improving muscular control of the cervical spine and shoulder girdle
(lll) Rotation described by Stoddard
(mmm) Side flexion described by Stoddard
(nnn) Extension described by Stoddard
(ooo) Flexion described by Stoddard
(ppp) AA rotation described by Stoddard
(qqq) Side flexion toward, and rotation away manipulation described by Stoddard
(rrr) CT side bend described by Stoddard

Karlberg 1996[20]

  • Physiotherapy methods were chosen by the therapist based on analysis of different functions such as mobility, stability, muscle tension and tone, postural alignment and body awareness (Feldenkrais 1987[21]; Jacobsen 1938[22]; Kaltenborn 1993[23]; Lewit 1991[24])
  • The purpose of the treatment was to reduce cervical discomfort, and it included soft tissue treatment, stabilization exercises of the trunk and cervical spine (pp,qq), passive (u-ff) and active mobilization (sss-vvv), relaxation techniques (www), home training programs and minor ergonomic changes at work
  • The majority of the patients underwent several treatment modalities, depending on findings from the analysis mentioned above
(sss) Active flexion
(ttt) Active extension
(uuu) Active side flexion
(vvv) Active rotation
(www) Relaxation with diaphragmatic breathing

Palmgren 2006[25]

  • Patients received information regarding basic anatomy and physiology of the spine, principles of ergonomics for neck pain patients, and basic instructions on how to exercise and cope with the pain. The clinical findings were explained and potential causes of pain were clarified
  • The patients were told that neck pain generally has a benign, self-limiting natural course and that the healing process could be accelerated by simple, regular exercises and by avoiding immobility
  • The choice of therapy and modality was pragmatic and based on the analysis of different functions such as mobility, muscle tension and tone, and each patient’s symptoms, but might include:
    • high-velocity and low-amplitude techniques
    • myofascial techniques
    • spine-stabilizing exercises targeted toward hypomobile zygapophyseal joints in the cervical region and the cervicothoracic junction
  • The spine stabilizing exercises consisted of:
    • 4-5 minutes of jogging for a warm-up was performed (eee)
    • Stretching of cervical and shoulder region (a-c, yy-ccc)
    • Cervical isometrics in supine and seated (xxx-ffff)
(xxx) Isometric rotation in sitting
(yyy) Isometric side flexion in sitting
(zzz) Isometric side flexion and rotation
(aaaa) Isometric extension
(bbbb) Isometric flexion
(cccc) Isometric rotation in supine
(dddd) Isometric flexion in supine
(eeee) Isometric flexion in supine
(ffff) Isometric extension in supine

Strengthening exercise

Chiu 2005[26]

  • An intensive neck exercise program using the Multi Cervical Rehabilitation Unit (MCRU) (Pollock 1993[27]) and the exercise protocol of (Jull 1999[28])
  • Activation of the deep neck muscles aimed to enhance their ability for active stabilization for warm-up (a)
  • Flexion and extension of neck using the MCRU as a warm-up exercise for the superficial neck muscles using resistance equal to approximately 20% of the peak isometric muscle strength as warm-up (b)
  • Full flexion and extension within pain tolerance (b)
    • The dynamic weight load was calculated to be about 30% of the peak isometric muscle strength
    • The weight load was increased by approximately 5%, when a set of 12 or more repetitions had been achieved.
  • Activation of the deep neck flexor muscles (c)
    • the patient lay down in the supine position with the weight of the head and the cervical spine supported by towels under the occiput in a neutral position
    • An air-filled pressure sensor (Stablizer, Chattanooga South Pacific, Australia) was used to monitor the subtle flattening of the cervical lordosis that was expected to occur with contraction of deep neck flexors.
    • The sensor was placed suboccipitally behind the neck and inflated to 20 mmHg
    • The patient was instructed to slowly nod the head in an action indicating 'yes', so as to raise the pressure to a level that could be held steadily for 10 seconds
    • A 15 second break was given between each 10 second hold and this pattern was repeated for 10 minutes or until patient was unable to hold the contraction
(a) Activation of deep neck flexion muscles in supine
(b) MCRU
(c) Deep neck flexor activation with pressure biofeedback

Bronfort 2001[3]

  • Stretching for warm-up (d-f)
  • Aerobic exercise using dual action stationary bike for warm-up
  • Strengthening of shoulders and upper back using MedX variable resistance equipment (g)
    • Patients were stabilized with torso restraints to isolate and specifically exercise the cervical musculature.
    • They were encouraged to perform repetitions to volitional muscle fatigue (maximum 20 reps) even if pain was exacerbated, and resistance was increased periodically (Highland 1992[29]; Nelson 1999[30]).
(d) Scalene stretch
(e) Upper fibres of trapezius stretch
(f) Levator scapulae stretch
(g) MedX 4-way neck exercise equipment

Franca 2008[31]

Strengthening exercise (Hall 1999[32])

  • Stretching exercise of the muscles of the neck and upper limbs regions (d-f, h-l)
  • Recruitment exercise of the deep cervical flexion muscles (wave movement of the head) (a)
  • Strengthening exercise of the deep cervical flexion muscles (c)
  • Strengthening of upper limbs (o-r)
(h) Doorframe stretch
(i) Shoulder retraction stretch
(j) Shoulder protraction stretch
(k) Shoulder elevation stretch
(l) Posterior shoulder stretch
(m) Shoulder press
(n) Shrugs
(o) Front raise
(p) Reverse flyes
(q) Curls
(r) Bent-over rows

Martel 2011[33]

  • Advised to perform a home exercise program 3 times/week
  • All participants were instructed in the same routine
  • Exercise volume was tailored to each participant’s strength, flexibility and ability to complete the routine with minimal neck pain
  • Each patient received a written copy of the program and exercises were checked every 2 months by a kinesiologist
  • Exercises included
    • Range of motion exercises (Manual therapy and exercise figures sss-vvv)
    • 4 stretching/mobilisation exercises (d-f)
    • 4 strengthening exercises (concentric and isometric contractions) of the cervical and upper thoracic spine (primarily flexion, extension, lateral flexion and rotation of the cervical spine) (Manual therapy and exercise figures xxx-bbbb).

Qigong exercises

Rendant 2011[34]

  • 12 neck exercises including ROM and imagery
    • Turn head (a)
    • Tilt head (b)
    • Bow head (c)
    • Roll head gently (or rotate head)(d)
    • Bend neck like an immortal crane
    • Gently rock head like an old sage
    • While nodding turn head from side to side (e)
    • Imagine a huge dragon was twisting your neck
    • Rub the base of your skill (described as gallbladder 20) (f)
    • Rub your neck (g)
    • Knead your neck (h)
    • Let your arms hang loose and swing (i)
  • 7 Shoulder exercises
    • Massage shoulders(j)
    • Move shoulders in a circular motion (k)
    • Move shoulders as if you were rowing(l)
    • Raise shoulders (m)
    • Open and close shoulders (Expander-exercises) (n-o)
    • Tap on shoulders, tap the kidneys(p-q)
    • Jia Ji Gong
  • 7 moving exercises
    • Uplift clear thoughts, let troubled thoughts subside
    • Push the boot against the current
    • Be at one with the universe from within
    • The spring breeze caresses the weeping willow
    • The older the tree, the deeper the roots
    • Stretch up toward the sky
    • Stand on one leg like a golden hen
(a) Turn head
(b) Tilt head
(c) Bow head
(d) Roll head gently
(e) While nodding, turn head from side to side
(f) Rub the base of your skull
(g) Rub your neck
(h) knead your neck
(i) Let your arms hang loose and swing
(j) massage your shoulders
(k) move your shoulders in a circular motion
(l) Move shoulder as if you were rowing
(m) Raise shoulders
(n) Shoulder closed position
(o) shoulder open position
(p) Tap on shoulders
(q) Tap on kidneys

von Trott 2009[35]

  • 10 minutes of typical qigong "opening" exercises with 10-12 specific exercises: hip, legs, shoulders, arms and the head are moved in a qigong specific way (Wiedemann 2008[36])
  • Up to 4 exercises of Dantian Qigong (Wiedemann 2008[36])
    • Opening and closing of the Dantian(r-t)
    • Embracing the waterpot (u-w)
    • Bringing fire below the waterpot (x-aa)
    • Uniting the three Dantian (bb-hh)
  • 10 minutes of "closing" exercises (e.g. striking the meridians, circles over the lower Dantian and rubbing the kidney region (Wiedemann 2008[37])
(r) Opening and closing of the Dantian
(s) Opening and closing of the Dantian
(t) Opening and closing of the Dantian
(u) Embracing the waterpot
(v) Embracing the waterpot
(w) Embracing the waterpot
(x) Bringing fire under the waterpot
(y) Bringing fire under the waterpot
(z) Bringing fire under the waterpot
(aa) Bringing fire under the waterpot
(bb) Uniting the three Dantian
(cc) Uniting the three Dantian
(dd) Uniting the three Dantian
(ee) Uniting the three Dantian
(ff) Uniting the three Dantian
(gg) Uniting the three Dantian
(hh) Uniting the three Dantian

Cervical range of motion and strengthening exercises

Rendant 2011[34]

  • Warming up with a soft ball
    • Practice standing upright
    • Pass the ball around the body at shoulder height
    • Throw and catch the ball
  • Main exercises with theraband
    • Stretch the theraband (a)
    • Rowing movements with theraband (b)
    • Move as if climbing a ladder (c)
    • Hold band in front of body (d)
    • Hold band behind your head (e)
    • With your arms above your head, grip your hands (as if picking fruit) (f)
    • With arms stretched out at shoulder height, turn head (g)
    • Swing arms (h)
    • With head bowed, stretch out arms (i)
    • Place band under your feet and pull it tight (j)
    • Standing opposite a partner with two bands stretched out beween each pair, pull it backwards and forwards (like a train piston) (k)
  • Closing exercises
    • Move head slowly from left to right (l)
    • Move head backwards and forwards (m-n)
    • Bow head and stretch arms to the floor (o)
    • With arms outstretched, turn head (p)
    • Swing arms (q)
    • While sitting, roll your body into a ball and then straighten out (r-s)
(a) Stretch the theraband
(b) Rowing movement with theraband
(c) Move as if climbing a ladder
(d) Hold band in front of body
(e) Hold band behind your head
(f) With your arms above your head, grip your hands
(g) With arms stretched out at shoulder height, turn head
(h) swing arms
(i) With head bowed, stretch out arms
(j) place band under your feet and pull tight
(k) Moving like a train piston
(l) Neck rotation
(m) Neck flexion
(n) Neck extension
(o) Bow head and stretch out arms
(p) With arms outstretched, turn head
(q) Swing arms
(r) Roll body into a ball and then straighten out
(s) Mobilizing and stabilizing the whole vertebrae

von Trott 2009[35]

  • Exercise therapy was based on a standardized program for computer and workplace related neck pain (Wiedemann 2008[36])
    • Mobilizing and stabilizing the whole vertebrae (s-t)
    • Strengthening the dorsal neck muscles (u)
    • Softening the atlanto-axial and upper vertebra joints (v-w)
    • Strengthening the lateral neck muscles (x)
    • Strengthening the ventral neck muscles (y)
(t) Mobilizing and stabilizing the whole vertebrae
(u) Strengthen dorsal neck muscles
(v) Softening the atlanto-axial and upper vertebra joints
(w) Softening the atlanto-axial and upper vertebra joints
(x) Strengthen the lateral neck muscles
(y) Strengthen ventral neck muscles

Isometric strengthening exercise

Helewa 2007[38]

  • Adjunct moist hot or cold pack according to patient preference, applied for 20 minutes to the neck and upper scapular area and instruction for home use
  • Adjunct effleurage massage consisted of soothing rhythmic superficial strokes lasting 5 minutes.
  • Adjunct neck support pillow to be used during sleep
  • Participants received a neck support pillow to be used during sleep
    • Two types of pillows were randomly assigned equally in each arm: Shape of Sleep and the Sissel Design AB Swedish foam pillow (Sissel Design AB, Svedala, Sweden)
  • Sitting posture taught and reinforced by mirror feedback, was a relaxed mid-position, with the shoulders neither retracted nor protracted. Viewed from the side, the head is held with the ear above the shoulder (a)
  • Manually resisted isometric exercises involved muscle groups acting on the head, neck, and shoulder girdles. Contraction of one muscle group was followed slowly and rhythmically by a contraction of its antagonist (b-e)
a) Sitting posture with mirror feedback
b) Manually resisted isometric rotation
c) Manually resisted isometric side flexion
d) Manually resisted isometric flexion
e) Manually resisted isometric extension

Goldie 1970[39]

  • different cervical movments against the physiotherapist’s gentle pressure to the maximum ability under the pain threshold (b-e)
  • 10 minutes rest in supine on a low pillow following treatment

Eye-neck coordination exercises

Revel 1994[40]

  • slow passive motions of head in supine while patient maintains gaze on a fixed target (a)
  • active head movement (mainly rotation) in standing with restricted gaze (0.5mm) following a mobile target (b)
  • gaze on a fixed target with restricted gaze while the physiotherapist passively moves the trunk (c)
  • fix a target for a few seconds, remember the position, then close eyes and maximally rotate the head and try to find the initial position (d)
  • following a mobile target with free eye neck coupling alternating between slow pursuits and saccadic movement (e)
(a) Passive movements while fixed on a target
(b) Restricted gaze following a mobile target
(c) Fixed gaze, therapist rotates body
(d) Return to the original position with eyes closed
(e) Following a mobile target

Cervical Manipulation

Bitterli 1977[41]

  • Manipulation (Maigne 1972a[42]; Maigne 1972b[43]; Maigne 1972c[44]) (a-d)
(a) Thoracic distraction manipulation described by Maigne
(b) Cervicothoracic manipulation described by Maigne
(c) Cervicothoracic manipulation described by Maigne
(d) Lying cervicothoracic manipulation (Mandoline) described by Maigne

Howe 1983[45]

  • Manipulation (Bourdillon 1975[46]) (e-g)
    • Move the joint as far as comfortably possible and then apply a quick thrust of moderate force in the same direction
  • Injection of either methylprednisonlone or mixture of lignocaine and hydrocortisone to the dorsum of the appropriate apophyseal joint in two patients whose necks were too painful to manipulate
(e) AO thrust manipulation for side flexion restriction described by Bourdillon
(f) AA thrust manipulation for rotation restriction described by Bourdillon
(g) Side flexion/ contra-lateral rotation manipulation described by Bourdillon, Gibbons, Matthews, Vernon

Martinez-Segura 2006[47]

  • Manipulation (Gibbons 2000[48]) (g)
    • The patient was supine with the cervical spine in a neutral position
    • The index finger of the therapist applied contact over the posterior lateral aspect of the articular pillar at the dysfunctional side of the identified vertebra (assessed by the lateral gliding test).
    • The therapist’s other hand cradled the patient’s head
    • Gentle ipsilateral side flexion and contralateral rotation were introduced from the restricted side until slight tension was palpated in the tissues at the contact point
    • A high velocity, low amplitude thrust was directed upward and medially in the direction of the patient’s contralateral eye

Sloop 1982[49]

Manipulation performed by a rheumatologist (Cyriax 1971[50]; Maigne 1972a[42],b[43],c[44]; Maitland 1968[51]; Matthews 1972[52]) (a-d), h-s)

(h) Forced rotation manipulation described by Cyriax
(i) Side flexion manip. described by Cyriax
(j) Traction described by Cyriax
(k) Rotation described by Maitland
(l) Side flexion described by Maitland
(m) Flexion described by Maitland
(n) Extension described by Maitland
(o) Bilateral AP described by Maitland
(p) Bilateral PA described by Maitland
(q) Unilateral PA described by Maitland
(r) Unilateral AP described by Maitland
(s) Transverse mobilization described by Maitland

Vernon 1990[53]

Rotational thrust manipulation (g)

Thoracic manipulation

Cleland 2005[1]

  • Thoracic thrust manipulation to each level with an identified segmental mobility restriction (a-b)
    • The stabilizing hand was placed at the level immediately caudal to the restricted segment using a ‘‘pistol grip’’
    • Once the pre-manipulative position was achieved the patient was instructed to take a deep inhalation and exhale
    • During the exhalation the treating clinician performed a high velocity, small amplitude thrust in a direction to facilitate relative closing or opening of the respective facet joint as indicated by the segmental examination
    • If an audible cavitation was heard during the first manipulation attempt, the treating clinician proceeded to the next segment
    • If no audible cavitation was heard, the patient was repositioned, and the manipulation intervention was repeated
    • If no audible cavitation was noted after two attempts, the physical therapist manipulated the next segmental restriction
(a)Thoracic thrust manipulation
(b) Mid thoracic thrust manipulation

Unspecified/mixed duration neck pain

Strengthening exercise

Andersen 2008[54]

  • High intensity strength training for neck and shoulder muscles
    • Arm row (a)
    • Shoulder abduction (b)
    • Shoulder elevation (c)
    • Reverse flies (d)
    • Upright row (e)
(a) Arm row
(b) Shoulder abduction
(c) Shoulder elevation
(d) Reverse flies
(e) Upright row

3.2 Neck pain with cervicogenic headache

Acute/subacute neck pain with cervicogenic headache

Manual therapy, relaxation and eye fixation exercise

Provinciali 1996[55]

  • Relaxation training using diaphragmatic breathing in supine (a)
  • Active reduction of cervical and lumbar lordosis based on Neck School recommendations (Sweeney 1992[56]) (b)
  • Psychological support to reduce anxiety and emotional influence (Radanov 1991[57])
  • Eye fixation exercises to prevent dizziness (Shutty 1991[58]) (c)
  • Massage and mobilization of cervical spine (Mealy 1986[59]) (d-k)
(a) Relaxation with diaphragmatic breathing
(b) Active reduction of cervical and lumbar lordosis
NeckPainToolkit Step3 Acute ManTherRelax C.jpg
(d) Traction and thoracic mobilization through arms/axilla
(e) Rotation in sitting described by Maitland
(f) Side flexion in sitting described Maitland
(g) Flexion in sitting described by Mdescribed by
(h) Extension in sitting described by Maitland
(i) Rotation in lying described by Maitland
(j) Side flexion in lying described by Maitland
(k) Flexion in lying described by Maitland
(l) Extension in lying described by Maitland

Self SNAG exercise

Hall 2007[60]

  • Self sustained neurophysiological apophyseal glide (SNAG) exercise (Mulligan, 2004) (a)
    • A thin, rubber-covered strap was positioned on the posterior arch of C1 and drawn horizontally forward across the face to facilitate rotation of at C1-C2 in the same direction as found to be limited.
    • The subject applied forward pressure on the strap and turned the head toward the restricted side of rotation, sustaining end range for 3 seconds (in a symptom free range)
    • The therapist assisted with positioning of the strap and applied end range overpressure in rotation.
    • Subjects given 3 trials to gain familiarity with the treatment before 2 repetitions were performed.
(a) C1/2 self SNAG

Chronic neck pain with cervicogenic headache

Manual therapy and exercise

Jull 2002[11]

  • Manipulative therapy at the therapist’s discretion (Maitland 2000[12])(a-h)
    • low-velocity cervical joint mobilization techniques (in which the cervical segment is moved passively with rhythmical movements)
    • high-velocity manipulation techniques
  • Lowload endurance exercises to train muscle control of the cervicoscapular region (Jull 1997[13])
  • The subjects were first taught to perform a slow and controlled craniocervical flexion action aimed to target the deep neck flexor muscles (i)
  • They then trained to be able to hold progressively increasing ranges of craniocervical flexion using feedback from an airfilled pressure sensor placed behind the neck (j)
  • The muscles of the scapula, particularly the serratus anterior and lower trapezius, were trained using inner range holding exercises of scapular adduction and retraction, practiced initially in the prone lying position (k)
  • Training of these neck and scapular muscles also was incorporated into postural correction exercises performed regularly throughout the day in the sitting position. The subjects were trained to sit with a natural lumbar lordosis while gently retracting and adducting their scapulas and gently elongating their cervical spine to facilitate the longus colli (l)
  • Subsequently, isometric exercises using a low level of rotatory resistance were used to train the cocontraction of the neck flexors and extensors (m)
  • They also could be taught muscle lengthening exercises to address any muscle tightness assessed to be present (n-p)
(a) Rotation in sitting described by Maitland
(b) Side flexion in sitting described Maitland
(c) Flexion in sitting described by Maitland
(d) Extension in sitting described by Maitland
(e) Rotation in lying described by Maitland
(f) Side flexion in lying described by Maitland
(g) Flexion in lying described by Maitland
(h) Extension in lying
(i) Deep neck flexor activation
(j) Deep neck flexor activation with pressure biofeedback
(k) Prone scapular retraction
(l) Posture incorporating deep neck flexors and
(m) Isometric rotation
(n) Scalene stretch
(o) Upper fibres of trapezius stretch
(p) Levator scapulae stretch

Exercise

Jull 2002[11]

  • Lowload endurance exercises to train muscle control of the cervicoscapular region (Jull 1997[13])
  • The subjects were first taught to perform a slow and controlled craniocervical flexion action aimed to target the deep neck flexor muscles (a)
  • They then trained to be able to hold progressively increasing ranges of craniocervical flexion using feedback from an airfilled pressure sensor placed behind the neck (b).
  • The muscles of the scapula, particularly the serratus anterior and lower trapezius, were trained using inner range holding exercises of scapular adduction and retraction, practiced initially in the prone lying position (c)
  • Training of these neck and scapular muscles also was incorporated into postural correction exercises performed regularly throughout the day in the sitting position. The subjects were trained to sit with a natural lumbar lordosis while gently retracting and adducting their scapulas and gently elongating their cervical spine to facilitate the longus colli (d)
  • Subsequently, isometric exercises using a low level of rotatory resistance were used to train the cocontraction of the neck flexors and extensors (e)
  • They also could be taught muscle lengthening exercises to address any muscle tightness assessed to be present (f-h)
(a) Deep neck flexor activation
(b) Deep neck flexor activation with pressure biofeedback
(c) Prone scapular retraction
(d) Posture incorporating deep neck flexors and
(e) Isometric rotation
(f) Scalene stretch
(g) Upper fibres of trapezius stretch
(h) Levator scapulae stretch

Cervical manipulation

Haas 2004[61]

  • The principal therapy was high-velocity, low-amplitude spinal manipulation (Bergmann 1993[62]) (a,b)
  • Discretional therapy included the administration of up to 2 physical modalities selected from the following: heat and soft tissue therapy including massage (Nicholson 1989[63]) and trigger point therapy (Travell 1983[64])
  • Treating chiropractors were also at liberty to recommend modification of daily activities and rehabilitative exercises
(a) Manipulation as described by Bergmann
(b) Manipulation described by Bergmann

Chen 2007[65]

Cervical manipulation (Biondi 2005[66])

3.3 Whiplash associated disorder

Acute/subacute whiplash associated disorder

Manual therapy and exercise

Giebel 1997[67]

  • AROM in lying (a-d)
  • AROM in sitting (Mealy 1986[59]) (e-h)
  • Contract/relax and hold/relax in lying (week 1) for upper fibres of trapezius (i), levator scapulae (j), scalenes (k)
  • Contract/relax and hold/relax in sitting (week 2) for upper fibres of trapezius (l), levator scapulae (m), scalene (n)
  • Light traction with mobilization (through arms/axilla) of thoracic spine (o)
  • Individualized segmental mobilization (p-bb)
(a) AROM rotation in lying
(b) AROM side flexion in lying
(c) AROM flexion in lying
(d) AROM extension in lying
(e) AROM rotation in sitting
(f) AROM side flexion in sitting
(g) AROM flexion in sitting
(h)AROM extension in sitting
(i) Contract-relax upper fibres of trapezius (UFT) in lying
(j) Contract-relax levator scapulae (LS) in lying
(k) Contract-relax scalenes in lying
(l) Contract-relax UFT in sitting
(m) Contract-relax LS in sitting
(n) Contract-relax scalenes in sitting
(o) Traction + thoracic mobilization through arms/axilla
(p) Rotation in lying
(q) Side flexion in lying
(r) Flexion in lying
(s) Extension in lying
(t) Rotation in sitting
(u) Side flexion in sitting
(v) Flexion in sitting
(w) Extension in sitting
(x) Bilateral AP described by Maitland
(y) Bilateral PA described by Maitland
(z) Unilateral AP described by Maitland
(aa) Unilateral PA described by Maitland
(bb) Transverse mobilization described by Maitland

Mealy 1986[59]

  • mobilization using smaller amplitude for pain and spasm, larger amplitude for stiffness (Maitland) (p-bb)
  • daily exercises of cervical spine at home every hour within the limits of pain (a-h)

Bonk 2000[68]

  • Mobilization through full ROM in supine (week 1) (p-s)
  • Mobilization through full ROM in sitting (week 2/3) (t-w)
  • Active mobilization in supine (week 1) (a-d)
  • Active mobilization in sitting (week 2/3) (Mealy et al, 1986) (e-h)
  • Strengthening and isometric exercise in supine (week 1) (cc-ff)
  • Strengthening and isometric exercise in sitting(week 2/3) (gg-ii)
  • Interscapular strengthening (added in week 3) (ll-nn)
(cc) Isometric rotation in supine

(dd) Isometric side flexion in supine
(ee) Isometric flexion in supine
(ff) Isometric extension in supine
(gg) Isometric rotation in sitting
(hh) Isometric side flexion in sitting
(ii) Isometric extension
(jj) Isometric flexion
(kk) Scapular retraction in prone
(ll) ‘I’
(mm)’Y’
(nn) ‘T’

McKinney 1989[69]

  • Manual therapy (Maitland; McKenzie) (t-cc)
  • ROM exercise (Mealy 1986[59]) (a-h)
  • Isometric neck exercise (dd-jj)
  • Interscapular strengthening (kk-nn)
  • Click to continue to Step 4: Consider dosage for acute/subacute whiplash associated disorder

Thoracic manipulation

Fernandez-de-las-Penas 2004[70]

  • Thoracic manipulation (Gibbons 2000[48]) (a)
    • patient lying supine with arms crossed over the chest and hands around shoulders
    • the hand of the therapist contacts with a neutral hand position over the spinous process of T4
    • the other hand stabilizes the head, neck and upper thoracic spine of the patient
    • the thoracic spine is gently flexed until slight tension is palpated in the tissues at your contact point
    • the thrust is applied downward and in a cephalad direction
  • Adjunct physiotherapy (Gam 1998[71]; McKinney 1989[69]; Croft 1995[72]; Soderland 2000[73]; Provinciali 1996[55]; Still 1992[74])
(a) Thoracic thrust manipulation

Chronic whiplash associated disorder

Manual therapy and exercise

Jull 2007[75]

  • The multimodal physical therapy program that was purposefully low load in nature to avoid provocation of symptoms in this pain group of chronic whiplash. The program has proven effective for patients with idiopathic neck pain (Jull 2002[11]) and it is described in full elsewhere (Jull 2004[76])
  • It included specific low load exercises aimed to re-educate muscle control of the neck flexor and extensor muscles and those of the scapular region as well as their incorporation into posture and functional activities (a-f)
  • Subjects also undertook exercises aimed to retrain kinaesthetic sense (Revel 1994[40]) (g-k)
  • The manipulative therapy included only low velocity mobilizing techniques (Maitland 2005[77]) (l-x)
  • Education and assurance was provided including ergonomic advice on activities of daily living, correct work practices and work environment. Subjects were encouraged to continue exercises at home and completed an exercise compliance diary. 
(a) Deep neck flexor DNF activation
(b) DNF activation with pressure biofeedback
(c) Chin tuck and head lift from supine
(d) Prone scapular retraction
(e) Posture incorporating deep neck flexors and scapular retraction
(f) Isometric rotation
(g) Passive movements with fixed gaze
(h) Restricted gaze following a mobile target
(i) Fixed gaze, therapist rotates body
(j) Return to the original position with eyes closed
(k) Following a mobile target
(l) Rotation in sitting described by Maitland
(m) Side flexion in sitting described Maitland
(n) Flexion in sitting described by Mdescribed by
(o) Extension in sitting described by Maitland
(p) Rotation in lying described by Maitland
(q) Side flexion in lying described by Maitland
(r) Flexion in lying described by Maitland
(s) Extension in lying described by Maitland
(t) Bilateral AP described by Maitland
(u) Bilateral PA described by Maitland
(v) Unilateral PA described by Maitland
(w) Unilateral AP described by Maitland
(x) Transverse mobilization described by Maitland

3.4 Neck pain with radiculopathy

Acute neck pain with radiculopathy

Mobilizing and stabilizing exercise

Kuijper 2009

Physiotherapy protocol

  • Exercise 1: Chest Press, sitting position (Technogym©) (a)
  • Exercise 2: Lateral Pull-down, sitting position (Technogym©) (b)
  • Exercise 3: Low-back flies (c)
    • Dumbbells in each hand and make ‘flying movements’, bent forward standing position or in roman chair
  • Exercise 4: Neck-press (d)
    • Push dumbbells from the shoulder above the head, standing position
  • Exercise 5: Front-raises (e)
    • Elevate dumbbells forwards to shoulder height, standing position
  • Exercise 6: Upright row (f)
    • ‘Rowing up’ bar with weights; elbows finish above shoulder height and wrists finish at shoulder height, standing position
  • Exercise 7: Weight rotation (g)
    • In standing position, keep bar with weights on top in vertical position, bottom part stays on the ground, with stretched arms and rotate to left and right
(a) Seated chest press
(b) Seated lat pulldown
(c) Reverse flye
(d) Shoulder press
(e) Front raise
(f) Upright row
(g) Weight rotation

Home exercises for physiotherapy group performed once/day

  • Exercise 1- Standing position, in neutral position: withdraw chin.(h)
  • Exercise 2 - Lying on the back, withdraw chin while keeping head on the ground (i)
  • Exercise 3 - Standing, withdraw chin and turn head to one side as far as possible. Repeat in the opposite direction. (j)
  • Exercise 4 - standing position, withdraw chin, place the palm of the hand against the head (left or right side of the forehead), and give resistance against the hand with the head (do not allow any movements of the head). (k)
  • Exercise 5 - Standing position, place right hand against the head behind the right ear, left hand on the left side of the forehead. Rotate the head to the right against the resistance of the hands. Reverse hand positions and repeat to the left. No movements of the head. (l)
  • Exercise 6 - Standing position, withdraw chin, place both hands on the back of the head, and push the head against the hands. No movement of the head allowed. (m)
  • Exercise 7 - Standing position, withdraw chin, place the right hand on the right side of the head and move the head to the right against resistance. Repeat to the left. (n)
  • Exercise 8 - Lying on the back, lift the head a little from the ground and move the chin just a little bit towards the chest. (o)
  • Exercise 9 - Lying on the back, lift the head a little from the ground and turn the head to the right. Repeat to the left. (p)
  • Exercise 10 - Sitting on a chair, keep both arms down, pull back the shoulders and relax again. (q)
(h) Standing chin tuck
(i) Supine chin tuck
(j) Standing chin tuck + neck rotation
(k) Isometric rotation/side flexion
(l) Isometric rotation
(m) Isometric extension
(n) Isometric side flexion
(o) Chin tuck + head lift
(p) Chin tuck + head lift + rotation
(q) scapula retraction in sitting

References

References will automatically be added here, see adding references tutorial.

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