What therapeutic exercises should be prescribed for a patient with neck pain?

Therapeutic Exercises for Neck Pain

For chronic neck pain, prescribe a structured program of cervico-scapulothoracic strengthening and stretching exercises performed 2-3 times per week, as this approach provides moderate to large pain reduction and functional improvement superior to general exercise or stretching alone. 1, 2

Exercise Program Structure

Core Components (Perform 2-3 days/week on non-consecutive days)

Cervical and scapulothoracic strengthening exercises are the cornerstone of treatment, with specific neck strengthening showing superior short- to medium-term pain relief compared to general exercise programs. 1

• Strengthening exercises: Begin with low resistance (40-60% of 1-repetition maximum) and higher repetitions (10-15 reps), performing 1 set of 8-12 repetitions 1
• Scapulothoracic strengthening: Focus on rotator cuff and posterior shoulder girdle muscles, as scapular dysfunction frequently accompanies neck pain 1, 3
• Deep cervical flexor training: This specific approach improves range of motion and disability more than conventional treatment alone 4
• Core stabilization exercises: When combined with neck exercises, these provide superior pain and posture improvement 4

Execution Guidelines

• Perform exercises in a rhythmical manner at moderate to slow controlled speed through full range of motion 1
• Exhale during contraction/exertion phase and inhale during relaxation to prevent Valsalva maneuver 1
• Use pain threshold as intensity guide: discontinue if pain lasts more than one hour after exercise 1

Evidence-Based Exercise Types by Effectiveness

Moderate Quality Evidence (Most Effective)

Combined cervical, shoulder and scapulothoracic strengthening and stretching exercises provide small to large magnitude beneficial effects on pain immediately post-treatment and up to long-term follow-up, with medium magnitude effects improving function. 2

• Cervico-scapulothoracic and upper extremity strength training: Provides moderate to large pain reduction immediately post-treatment (pooled SMD -0.71) and at short-term follow-up 2
• Scapulothoracic and upper extremity endurance training: Provides slight beneficial effect on pain at immediate post-treatment and short-term follow-up 2
• Cervico-scapulothoracic strengthening/stabilization exercises: Improves pain and function at intermediate term (SMD -14.90) 2

Additional Effective Modalities

• Stretching exercises (neck and shoulder): When performed 2 times/day, 5 days/week for 4 weeks, significantly reduces pain (VAS improvement -1.4) and improves neck function (NPQ improvement -4.8) compared to ergonomic advice alone 5
• Iyengar yoga: More effective than home exercise for persistent neck pain 6
• Qigong: More effective than wait list for persistent neck pain 6

Adjunctive Measures

• Apply local heat before exercise to improve tissue elasticity and reduce pain, as heat has higher strength of recommendation than ultrasound 1, 3
• Low-level laser therapy: Provides moderate improvement in short-term function and pain 3
• Massage: Shows small improvements in short-term function and pain 3

Critical Contraindications and Pitfalls

Never prescribe overhead pulley exercises, as these encourage uncontrolled abduction and have the highest incidence of developing shoulder pain. 1

• Avoid vigorous, repetitive exercises and explosive movements that stress cervical structures 1
• Do not prescribe passive range-of-motion exercises performed aggressively or improperly, as these cause more harm than benefit 1
• Stretching alone without strengthening shows no beneficial effects and should not be used as monotherapy 2

Dosage and Frequency Considerations

Patients who exercise ≥3 times/week achieve significantly greater improvement in neck function and quality of life compared to those exercising <3 times/week. 5

• Exercise programs should be applied for at least 4 weeks, 3 days per week minimum 4, 5
• Regular adherence is critical: a 4-week program with consistent compliance decreases pain by clinically meaningful amounts (VAS reduction >1.4 points) 5

Home Exercise Program Design

• Provide education on strategies for reducing load on the shoulder during daily activities and proper positioning 1
• Cognitive behavioral therapy, distraction, mindfulness, relaxation, and guided imagery can be incorporated as adjunctive psychological interventions 1, 3
• Breathing exercises and relaxation training may be useful as supportive measures 3

Expected Outcomes

Combined strengthening and stretching programs provide moderate magnitude effects (approximately 10 points on a 100-point scale for pain improvement), with effects on function generally smaller than effects on pain. 3, 7

• Osteopathic manipulative treatment combined with exercises reduces pain and improves functional disability more than exercise alone 8
• Most studies report small effect sizes, suggesting a small clinical effect can be expected with exercise alone, emphasizing the importance of combining multiple modalities 6