333: Exercise therapy for chronic neck pain: A network meta‑analysis

Topic: Clinical Science
Subtopic: Pain category (ICD-11), Chronic primary musculoskeletal pain, Pharmacological treatments, Physiotherapy (e.g. exercise, rehab), Treatment/management

Background and Aims: Neck pain is a common and globally impactful condition.[1] Clinical guidelines recommend conservative approaches, with exercise therapy as a central strategy.[1] Programs may include strengthening, stretching, and mobility exercises to improve function, reduce pain, and prevent recurrence.[2,3] While manual therapy, education, and medications are also used, evidence suggests structured exercise offers long-term benefits with fewer risks.[4,5] However, the optimal type, intensity, and duration of exercise remain unclear. This Network Meta-analysis (NMA) aims to determine which form of exercise, alone or in combination, is most effective for reducing pain in individuals with chronic neck pain.

Methods: A systematic review with NMA of randomized controlled trials (RCTs) that included adults with chronic neck pain who received any type of exercise compared with other treatments or no intervention. The primary outcome was pain intensity. Five databases were used to conduct the literature search. Risk of bias was assessed using the RoB-2 tool. Bayesian random-effects models were used to estimate treatment effects (standardized mean differences (SMDs)) with 95% credible intervals. “No intervention” served as the reference group, with an SMD < 0 indicating a favorable effect. Interventions were ranked using SUCRA, with higher values indicating greater overall effectiveness.

Results: Searches identified 17,258 studies, and 1,118 full texts were assessed; 725 were deemed eligible, including 439 with chronic non-specific neck pain. Based on prioritization, 243 RCTs were included for data extraction and RoB assessment. 156 RCTs (11,741 participants), including exercise, with 56 different nodes were included in the NMA. The three highest-ranked interventions by SUCRA (96.6%, 90.1%, 85.5%, respectively) were exercise plus kinesiotape (SMD: -2.84; 95%CrI: -4.17, -0.97), exercise plus needle-based (SMD: -2.28; 95%CrI: -3.62, -0.97), multimodal exercise plus medication (SMD: -1.98; 95%CrI: -3.30, -0.66). High between-trial heterogeneity was observed, but no evidence of incoherence.

Conclusions: Our NMA suggests that the most effective strategies for chronic neck pain involve multimodal approaches that combine exercise with other therapies, such as kinesiotape, needle-based interventions, or medications. These interventions consistently ranked highly and showed a strong likelihood of being more effective than no treatment. However, the evidence is limited by small sample sizes and substantial heterogeneity across studies, which reduces confidence in the results. To strengthen the evidence base, larger, well-designed, and rigorously conducted randomized trials are needed to confirm the effectiveness of these exercise-based combinations and establish clear clinical recommendations.

References: 1. Blanpied, P.R., et al., Neck pain: revision 2017: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 2017. 47(7): p. A1-A83.
2. Currier, B.S., et al., Resistance training prescription for muscle strength and hypertrophy in healthy adults: a systematic review and Bayesian network meta-analysis. British Journal of Sports Medicine, 2023. 57(18): p. 1211-1220.
3. Xie, J., et al., Comparative efficacy of exercise versus passive physical therapy in improving nonspecific neck pain: a multilevel network meta-analysis and dose-response analysis. The Spine Journal, 2025.
4. de Oliveira-Souza, A.I.S., et al., Comparative effectiveness of manual therapy, pharmacological treatment, exercise therapy, and education for neck pain (COMPETE study): protocol of a systematic review with network meta-analysis. Systematic Reviews, 2025. 14(1): p. 30.
5. Gao, Q., et al., Comparative Efficacy of Mind–Body Exercise for Treating Chronic Non-Specific Neck Pain: A Systematic Review and Network Meta-Analysis. Current Pain and Headache Reports, 2024. 28(6): p. 507-523.

Presenting Author: Dr. Ana Izabela Sobral de Oliveira Souza
Submitting Author: Ana Izabela Oliveira-Souza

Senior Author: Prof. Dr. Susan Armijo-Olivo

IASP 2026 Global Year theme of Neuropathic Pain: No

• Jordana Barbosa da Silva - Hochschule Osnabrück - University of Applied Sciences
• Tiago da Veiga Pereira - University of Oxford
• Javier Munoz Laguna - Musculoskeletal Epidemiology Research Group, Epidemiology, Biostatistics and Prevention Institute, University of Zurich
• Liz Dennett - Geoffrey and Robyn Sperber Health Sciences Library, University of Alberta, Edmonton, Alberta, Canada
• Nathalie M. Schweyckart - Musculoskeletal Epidemiology Research Group, University of Zurich, Zurich, Switzerland,
• Dorothea Charlotte Zimmerman - ZHAW- Zürcher Hochschule für Angewandte Wissenschaften
• Haliton A. de Oliveira Junior - Health Technology Assessment unit. A Beneficência Portuguesa de São Paulo.
• Henry Dan Kiyomoto - Instituto de Pesquisa e Ensino em Avaliação de Tecnologia em Saúde
• Clara Gisele Lopes - Musculoskeletal Epidemiology Research Group, Epidemiology, Biostatistics and Prevention Institute, University of Zurich
• Cristian Justribo-Manion - Universidad Abat Oliba – CEU, CEU Universities; Barcelona, Spain
• Cesar A. Hincapié - Musculoskeletal Epidemiology Research Group, Epidemiology, Biostatistics and Prevention Institute, University of Zurich
• Matthias Schürmann - Musculoskeletal Epidemiology Research Group, Epidemiology, Biostatistics and Prevention Institute, University of Zurich
• Nikolaus Ballenberger - Hochschule Osnabrück - University of Applied Sciences
• Bruno R. da Costa - Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, UK; Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
• Douglas Paul Gross - University of Alberta / Department of Physical Therapy
• Susan Armijo-Olivo - Hochschule Osnabrück - University of Applied Sciences / Faculty of Rehabilitation Medicine/Faculty of Medicine and Dentistry