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SEARCH FLOW CHART Records identified through NCBI searching “chronic non – specific neck pain” ( N=17) Additional records identified through other sources (n=14) Records Screened by Title (n= 31) Full -text articles assessed for eligibility (n=17) Studies included in Critical Appraisal (n=4) Full Text articles Excluded, with reasons (n=) -Outcomes not of interest (n=12) -Poor quality Study (n=1) -Manual Interventions Performed (n= 2) – Records excluded (n=14) CHARACTERISTICS OF RESEARCH STUDIES TABLE 1 STUDY AUTHORS CHARAC TERISTI CS Nazari et al.

(2018) Park& Lee (2020). Saeterbakken et al. (2020) Suvarnnato et al. (2019) TITLE Nazari, G., Bobos, P., Billis, E., & MacDermid, J.

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C. (2018).

Cervical flexor muscle training reduces pain, anxiety, and depression levels in patients with chronic neck Park, S. H., & Lee, M. M. (2020).

Effects of lower trapezius strengthening exercises on pain, dysfunction, posture alignment, muscle thickness and contraction rate in patients with neck pain; Randomized controlled trial. Saeterbakken, A. H., Makrygiannis, P., Stien, N., Solstad, T., Shaw, M., Andersen, V., & Pede rsen, H. (2020). Dose -response of resistance training for neck -and shoulder pain relief: a workplace intervention study.

BMC Sports Science, Medicine & Rehabilitation, 12 (8). https://doi.org/10.1 186/s13102 – 020 -0158 -0 Suvarnnato, T., Puntumetakul, R., Uthaikhup, S., & Boucaut, R. (2019).

Effect of specific deep cervical muscle exercises on functional disability, pain intensity, craniovertebral angle, and neck -muscle strength in chronic mechanical n eck pain: a randomized controlled trial.

Journal of Pain Research , 12 . 915 –925. pain by a clinically important amount: A prospective cohort study.

Physiotherapy Resear ch International, 23 (3), 1. Medical Science Monitor:

Internatio nal Medical Journal of Experimental and Clinical Research , 26, e920208.

https://doi.org/10.12 659/MSM.920208 https://doi.org/10.2147/JPR.S 190125 Participan ts (test subjects with relevant variables) 60 patients: 12 male, 48 female 39.47+ – 12.67 years, 0 attrition 53 initially recruited, 13 were excluded for a total of 40 participants. 11 men & 9 women per group, pain 3 -6 months. 30, 23 women, 7 men. 8 withdrew along the course of the study for a tota l of 22 participants. All “office workers.” 54, 18/group with 0 drop outs. 5 men, 49 women Inclusion/ Exclusio n Criteria Inclusion: 18 – 65 yo , neck pain 3+ months and, score of 5/50 on Neck Disability index (Greek Version). Exclusion: a history of neck surgery or cervical Inclusion: midline of the outer ear is shifted > 2.5 cm from the midline of the acromion, cranio -vertebral angle (CVA) of less than 53°, score of 3 or greater in visual analogue scale (VAS), &no congenital Inclusion: mild to moderate pain (10 – 60 mm) on VAS in the neck and/or shoulder region for 3+ months and work on the computer or low -intensity isometric contraction during work (i.e. dentist, hairdresser). Exclusion: People with considerable pain (> 60 mm VAS) or that Inclusion: neck -pain symptoms > 3 months, a score ≥10/100 on the Thai Version of the Neck Disability Index (NDI -TH) questionnaire, 18 –60 years old. Mechanical neck pain defined as pain in the neck or shoulder/neck area provoked by mechanical characteristics: including radiculopathy, systemic diseases, diagnosed with any SNC pathological conditions or involved in PT program in the last 6 m onths deformity. Exclusion: X-ray orthopedic c ondition diagnosis, traumatic neck injury, history of spine or thoracic surgery, or participation in < 70% of the study interventions. received treatment in last 6m by healthcare professional. sustained neck postures, cervical movement, or manual palpation of the cervical musculature. Localized pain must me specific to the dor sal part of the neck, area limited by a horizontal line through the inferior portion of the occipital region and a horizontal line through the spinous process of the first thoracic vertebra. Exclusion: 1) diagnosis of cervical radiculopathy or myelopathy 2) history of cervical and thoracic spine fracture and/or dislocation; 3) history of surgery of the cervical and/or thoracic spine; 4) history of spinal osteoporosis, spinal infection, or fibromyalgia syndrome, and 5) history of whiplash injury and/or head /neck injuries. Outcome Measures Primary Variable: Pain Intensity level measured by Variables : Pain on visual analog scale (VAS), neck disability index Variables : general & worst pain on visual analog scale (VAS) 2x/wk and 0 -100 rating for health -related quality of Primary Variable: Thai version of the Neck Disability Index (NDI) NPRS (0 -10) Secondary Variables:

Anxiety & depression levels measured by HADS – GREEK version (14 Q, 4 point scale) Measured at baseline & at end (7wks) (NDI), postural alignment, muscle thickness and contraction rate by ultrasound Measured at baseline & at end life. And 2 max volunary isometric contraction exercises:shrugs & seated row 16 total weeks: measured at end of 8 wk control, end of 8wk training period(mid), and end of post -training period Secondary Variables: Numeric pain scale (NPS), CV angle, and neck -muscle strength Measured at baseline, immediate ly after 6 weeks of training, and at 1 – and 3 – month follow -up. Interventi on Investigat ed 3 Groups: A (deep neck flexor +home based exercise) B (superficial muscle + home based exercise) C (home -based exercise only) 2 Groups: Both received scapula & thoracic stabalization settings from Cool et al.

(2007). 3×10 for 20s +20s rest between sets. Intervention every 4 wks, 3x/wk @ 35 min/ session, with the frequency and intensity applied individually according to the participant’s ne eds. Control Group 2 groups: one (TG10) or two (TG20) times/day .

5days/wk, for 8 wks , 10 min/session. Personal trainer (PT) present for the first week of each group, then the participants worked independently. For the first week (5 sessions), a personal trainer was present. PT visited every week to supervise, & weekly questionnaire (wors t & general pain, health -related quality of life & training attendance Extensor training (ET): 3×10, 10s iso hold . 30s rest between sets. Each subject performed this exercise twice per week over a 6 -week period with the physical therapist. The exercise was performe d as tolerated without provocation of neck pain. Deep Flexor Training (FT): 10 reps/ set, with a short rest.

30s rest between sets. With researcher 2x/wk, at home without air -filled pressure sensor 2x/day. Control G (CG): general Experimental Group : also received lower trapeziums strengthening exercise program. 3×10 s for 10s + 20s break between sets. Intervention every 4 wks, 3x/wk @ 30 min/ session, with the frequency and intensity applied individually accord ing to the participant’s needs. The TG20 group were encouraged to train at the beginning and end of the working day whilst the TG10 group trained at the time that best suited them. The TG10 and TG20 groups reporte d to perform 89 and 87% of the training sessio ns respectively. misc treatment, form manu al therapy to exercise, as based on routine, in or outpatient care. Results Group A did better at both primary and secondary outcomes measures. Largest v smallest dif in Primary between baseline and posttreatment: A 4.75 + – 1.74 NPRS C 1.00 +_ 1.10 No significant difference between groups. Significant difference in Ex group muscle thickness and contraction rate during contraction but not at rest. Differences in muscle thickness & contraction rate between groups No differences between groups for any measured variables.

Between mid and post -testing: 25% reduction in gene ral pain, 43% reduction in worst pain, 10.6% improvement in quality of life. No dose -response relationship was observed NDI: improvement between experimental groups was statistically significant, but likely not clinically significant. NPS: Decreased more in ET over DT group at all points measured, and both over CT, but not statistically significant over CT at 1 & 3 months NPRS showed a significant increase in the experimental group than the control group Evidence Quality Score STROBE:

21/22 SORT: B PEDro: 8/10 SORT: A STROBE: 21/22 SORT: A PEDro: 7/10 SORT: A Support for Answer YES. YES YES YES

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