Article Text

Comparative effectiveness of physical exercise interventions for chronic non-specific neck pain: a systematic review with network meta-analysis of 40 randomised controlled trials
  1. Rutger MJ de Zoete1,2,
  2. Nigel R Armfield1,
  3. James H McAuley3,
  4. Kenneth Chen1,4,
  5. Michele Sterling1
  1. 1 RECOVER Injury Research Centre, NHMRC Centre of Research Excellence in Recovery Following Road Traffic Injuries, The University of Queensland, Herston, Queensland, Australia
  2. 2 School of Allied Health Science and Practice, The University of Adelaide, Adelaide, South Australia, Australia
  3. 3 Neuroscience Research Australia and School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
  4. 4 Geriatric Education and Research Institute, Singapore
  1. Correspondence to Dr Rutger MJ de Zoete, School of Allied Health Science and Practice, The University of Adelaide, Adelaide, South Australia, Australia; rutger.dezoete{at}


Objective To compare the effectiveness of different physical exercise interventions for chronic non-specific neck pain.

Design Systematic review and network meta-analysis.

Data sources Electronic databases: AMED, CINAHL, Cochrane Central Register of Controlled Trials, Embase, MEDLINE, Physiotherapy Evidence Database, PsycINFO, Scopus and SPORTDiscus.

Eligibility criteria Randomised controlled trials (RCTs) describing the effects of any physical exercise intervention in adults with chronic non-specific neck pain.

Results The search returned 6549 records, 40 studies were included. Two networks of pairwise comparisons were constructed, one for pain intensity (n=38 RCTs, n=3151 participants) and one for disability (n=29 RCTs, n=2336 participants), and direct and indirect evidence was obtained. Compared with no treatment, three exercise interventions were found to be effective for pain and disability: motor control (Hedges’ g, pain −1.32, 95% CI: −1.99 to −0.65; disability −0.87, 95% CI: –1.45 o −0.29), yoga/Pilates/Tai Chi/Qigong (pain −1.25, 95% CI: –1.85 to −0.65; disability –1.16, 95% CI: –1.75 to −0.57) and strengthening (pain –1.21, 95% CI: –1.63 to −0.78; disability –0.75, 95% CI: –1.28 to −0.22). Other interventions, including range of motion (pain −0.98 CI: −2.51 to 0.56), balance (pain −0.38, 95% CI: −2.10 to 1.33) and multimodal (three or more exercises types combined) (pain −0.08, 95% CI: −1.70 to 1.53) exercises showed uncertain or negligible effects. The quality of evidence was very low according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.

Conclusion There is not one superior type of physical exercise for people with chronic non-specific neck pain. Rather, there is very low quality evidence that motor control, yoga/Pilates/Tai Chi/Qigong and strengthening exercises are equally effective. These findings may assist clinicians to select exercises for people with chronic non-specific neck pain.

PROSPERO registration number CRD42019126523.

  • neck
  • meta-analysis
  • exercise
  • chronic

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Twitter @DrRdeZoete, @MicheleSterlin7

  • Contributors RMJdZ conceived the content, wrote the paper and approved the final version. RMJdZ and NRA conducted the analyses. NRA, JM and KC contributed and approved the final version of the paper. MS conceived the design of the study, contributed to writing the paper and approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.