Effectiveness of McKenzie exercises plus stabilization exercises versus McKenzie exercises alone on disability,pain,and range of motion in patients with nonspecific chronic neck pain: A randomized clinical trial

Abstract

BACKGROUND:

Chronic nonspecific neck pain is a common disorder that causes disability and reduced quality of life. Effective conservative treatment options are needed to manage this condition.

OBJECTIVE:

This randomized trial compared the efficacy of McKenzie exercises alone versus McKenzie plus cervical and scapulothoracic stabilization training for patients with chronic nonspecific neck pain.

METHODS:

A randomized controlled trial was conducted in an outpatient physical therapy clinic. 76 patients with chronic ( $>$ 3 months) neck pain were randomized to 6 weeks of either McKenzie exercises alone ( $n=$ 38) or McKenzie plus stabilization exercise ( $n=$ 38). The McKenzie protocol included posture correction, range of motion exercises, and lateral neck stretches. The stabilization program added targeted exercises for the neck and scapula.

RESULTS:

The combination of McKenzie plus stabilization exercises resulted in significantly greater reduction in current neck pain intensity compared to McKenzie alone at 6 weeks (mean difference: $-$ 1.2 points on 0–10 scale, 95% CI $-$ 1.8 to $-$ 0.6; $p<$ 0.001). Neck disability improved in both groups. Cervical range of motion also improved more with the addition of stabilization, except for extension.

CONCLUSION:

Adding specific cervical and scapulothoracic stabilization exercises to a standard McKenzie protocol led to clinically meaningful reductions in neck pain compared to McKenzie therapy alone in patients with chronic nonspecific neck pain. This combined approach can improve outcomes.

Keywords

Musculoskeletal diseases Cervicalgia exercise therapy manual therapy randomized controlled trial

1. Introduction

Chronic neck pain is a highly prevalent and disabling condition, with approximately two-thirds of adults experiencing neck pain at some point in their lifetime [1]. The global point prevalence has been estimated to range from 0.4% to 86.8%, with a mean of 24.4% [2]. This wide variation reflects substantial heterogeneity between studies due to differences in methodologies, case definitions, populations, and sociocultural factors [2]. Nonspecific neck pain, without any identifiable specific pathology, accounts for the majority of cases [3]. It leads to substantial negative impacts on quality of life, decreased work productivity, and increased healthcare utilization [4, 5].

The pathophysiology of chronic nonspecific neck pain is complex and multifactorial. Proposed contributing factors include mechanical stress, maintaining the neck in non-neutral positions for extended periods, degenerative changes, myelopathy, poor muscle performance, and impaired proprioception [3, 6]. Therapeutic exercise has emerged as an effective approach in the management of chronic nonspecific neck pain. It aims to address physical impairments, improve joint mobility and muscle performance, encourage proper posture and movement patterns, and enhance functional status [7, 8].

One recognized exercise strategy is the McKenzie method, which utilizes repeated movements and postures to centralize symptoms and restore range of motion [9]. It seeks to correct postural deviations and impaired motor control patterns associated with neck pain. Studies demonstrate the McKenzie approach reduces pain and disability in patients with chronic neck pain [10, 11]. Cervical and scapulothoracic stabilization exercises target deeper musculature to improve muscular control and endurance in the neck and shoulder region. They emphasize isometric contractions and low-load exercises for key stabilizing muscles like the deep neck flexors and lower trapezius [12]. Evidence indicates promising improvements in strength, motor control, and pain with a stabilization approach [13, 14, 15].

Combining these two exercise protocols by adding stabilization techniques to the McKenzie method may have an additive benefit in patients with chronic nonspecific neck pain. However, research on their combined efficacy remains limited. Therefore, the aim of our study is to investigate the effectiveness of a 6-week program of McKenzie exercises with and without stabilization in improving pain, disability, and cervical range of motion in patients with chronic nonspecific neck pain.

We hypothesize that adding stabilization techniques will enhance outcomes compared to McKenzie exercises alone. The findings will help delineate optimal therapeutic exercise strategies for this common musculoskeletal condition.

2. Methods

2.1 Randomization and blinding

Participants were randomly allocated in a 1:1 ratio to the two treatment arms using a computer-generated random sequence. Allocation concealment was achieved using sequentially numbered opaque sealed envelopes. The study employed a single-blind design, where the outcome assessor was blinded to the group allocation of the participants. The assessor was not involved in the randomization process, did not have access to the treatment allocation list, and was not present during the treatment sessions. Participants were instructed not to disclose their treatment group allocation to the assessor. For the self-reported measures, participants completed the questionnaires independently, without the assessor’s influence. However, due to the nature of the interventions, it was not possible to blind the participants or the physical therapists providing the treatments.

2.2 Trial design

This study utilized a randomized, single-blind, parallel group design with participants allocated to either the McKenzie exercise group or McKenzie exercise plus stabilization exercise group. The study protocol was approved by the Research Ethical Committee of the Faculty of Physical Therapy, Cairo University (approval number: P.T.REC/012/004222). The trial was prospectively registered at ClinicalTrials.gov (NCT05838794).

2.3 Participants

Seventy-six adults aged 30–50 years with nonspecific chronic neck pain were recruited from the outpatient clinic of the Faculty of Physical Therapy, Cairo University in Egypt between April and July 2023. Screening was conducted by a research coordinator using a structured history and physical examination. Key elements included pain localization to the cervical area with no radiation or radicular symptoms, absence of serious pathology or comorbidities, and no other treatments for neck pain. Eligible participants were adults aged 30–50 years with a history of nonspecific chronic neck pain localized to the cervical region without radicular symptoms. Specific inclusion criteria were ages between 30 and 50 years, localized chronic neck pain without an exact etiology, absence of any arm pain or discomfort that could be replicated by neck mobility or irritant assessment, and pain present in the dorsal neck area (between two horizontal lines: the first line passing through the lower half of the occipital area, and the second line running through the spinous process of the first thoracic vertebra).

Exclusion criteria were neck pain caused by neoplasm, neurological or vascular disease (including spinal cord diseases), history of neck surgery or fracture, serious medical conditions affecting participation (e.g. cardiovascular disease, cancer), medication use affecting pain or exercise tolerance (e.g. opioids, muscle relaxants), other neck pain treatments during the study period, and inability to comply with study procedures due to language barriers or cognitive impairment.

2.4 Settings

This single-center trial was conducted at the outpatient physical therapy clinic of the Faculty of Physical Therapy, Ahram Canadian University, Egypt. This university-based clinic provides physical therapy services to patients referred from the community.

2.5 Interventions

2.5.1 Group 1: McKenzie exercise group

The McKenzie protocol is an evidence-based system of spinal exercises tailored by physical therapists to centralize symptoms and restore function [16].

The group performed six weeks of supervised McKenzie exercises for the cervical spine three times per week for 30–45 minutes per session. Exercises were also prescribed as a daily home program. The McKenzie protocol consisted of repeated movements tailored to each patient’s directional preference to centralize symptoms. Techniques included retraction in flexion and extension, rotation, and lateral flexion [16]. Patients were progressed through force progressions as tolerated based on symptomatic and mechanical responses [17]. The same certified McKenzie therapists delivered both the McKenzie and McKenzie $+$ stabilization programs to ensure consistency in the delivery of the McKenzie approach and to provide all patients with treatment from experienced therapists. All treating therapists were certified McKenzie therapists with at least five years of experience managing musculoskeletal disorders, including three years focusing on chronic nonspecific neck pain. They participated in a standardized two-day workshop The workshop included a comprehensive review of the McKenzie approach for neck pain, including assessment, classification, and treatment strategies. The therapists also received detailed training on the stabilization exercises incorporated into the McKenzie $+$ stabilization group, focusing on exercise selection, progression, and patient education. The workshop included both theoretical and practical components, with therapists practicing the techniques under the guidance of the instructor. The treating therapists attended monthly meetings throughout the study to ensure adherence to treatment protocols under the guidance of the study investigators and a senior McKenzie instructor. Adherence to the home program was encouraged by reviewing exercise logs with participants at each visit. Participants also received regular adherence reminders via text messages or phone calls from the research team between treatment sessions.

The protocol consisted of:

Retraction: neck extension exercises in sitting and supine positions, 10–15 repetitions [16],

Rotation: turning head to side in sitting, 10–15 reps each side [16]

Lateral flexion: neck side bending in sitting, 10–15 reps each side [16]

Rotation: participant rotates neck to turn chin toward shoulder in sitting, performed to each side for 10–15 repetitions [16].

Exercises were progressed by the supervising therapist per the McKenzie principles of using force progressions to centralize symptoms [9]. The exercises were supervised by a physical therapist for a total duration of 6 weeks and 18 sessions. Participants were instructed to also perform the exercises at home as part of a daily home exercise program twice daily (once in the morning and once in the evening). Each home exercise session consisted of 10–15 repetitions for each exercise. The home program was monitored and progressed by the supervising therapist.

2.5.2 Group 2: McKenzie plus stabilization exercise group

This group performed the identical McKenzie protocol as group 1. In addition, they completed a supervised program of cervical and scapulothoracic stabilization exercises three times per week alongside the McKenzie exercises. The stabilization component included:

Cervical isometrics in sitting with manual resistance for flexion, extension, lateral flexion, and rotation, 10 reps each [7].

Cervical bracing in supine by activating deep flexors, held 10 seconds and repeated 10 times [18].

Scapular retraction and depression in sitting with resistance bands, 3 sets of 10 reps [19].

Prone horizontal shoulder abduction and external rotation with bands, 3 sets of 10 reps [19].

As with the McKenzie protocol, stabilization exercises were performed for 30–45 minutes per session, 3 sessions per week for 6 weeks alongside the McKenzie program. A home exercise program for the stabilization exercises was prescribed and monitored. Participants in this group were instructed to perform the stabilization exercises at home twice daily, once in the morning and once in the evening, in addition to the daily McKenzie home program. The stabilization home program consisted of 10 repetitions for cervical isometrics and cervical bracing, and 3 sets of 10 repetitions for scapular retraction and prone horizontal shoulder abduction exercises.

2.6 Outcomes

Socio-economic status, psychological factors, life-style habits, and co-morbidities were assessed using a custom questionnaire developed for this study. The questionnaire included items on education level, employment status, and annual household income to determine socio-economic status. Psychological factors were evaluated using questions about the presence and severity of anxiety and depression symptoms. Lifestyle habits were assessed using questions on smoking status and exercise frequency. Co-morbidities were identified using a checklist of common medical conditions.

The primary outcome was current neck pain intensity measured using the 11-point Numeric Pain Rating Scale (NPRS). The NPRS is a reliable and valid measure of pain severity [20].

Secondary outcomes were neck disability assessed by the Neck Disability Index (NDI) and cervical range of motion measured with a gravity-reference goniometer (Myrin, Sweden). The NDI is a valid and responsive 10-item questionnaire assessing pain and function in neck disorders [21]. The goniometer demonstrates good inter-rater (ICC 0.81–0.89) and intra-rater (ICC 0.80–0.85) reliability for cervical motions [22].

Outcomes were assessed at baseline and after the six-week intervention period by an assessor blinded to group assignment. Participants were instructed not to divulge their group allocation. Pain intensity was measured before and after each treatment session.

Outcome assessments were performed at baseline prior to starting the intervention, and again after 6 weeks of treatment at the conclusion of the intervention period. Participants also completed a Global Rating of Change scale ranging from “much worse” to “completely recovered” [23].

2.7 Sample size

Table 1
Demographic and clinical characteristics of the patients at baseline ( $n=$ 76)

Variable	Category	McKenzie group	McKenzie and stabilization exercise group	$t$ -value	Chi²- value	$p$ -value
Age		42.05 $\pm$ 8.93	40.11 $\pm$ 7.00	1.057984		0.293504
Weight (kg)		74.29 $\pm$ 7.95	74.76 $\pm$ 6.71	$-$ 0.28081		0.779639
Height (cm)		173.37 $\pm$ 6.93	173.05 $\pm$ 6.47	0.20542		0.837808
BMI		24.71 $\pm$ 1.56	24.82 $\pm$ 1.31	$-$ 0.34192		0.733381
Sex
	Female	52.63%	36.84%		2.61	0.27
	Male	47.37%	63.16%
Lifestyle habits
	Non-smoker, exercises regularly	42.11%	47.37%		0.96	0.61
	Smoker, sedentary lifestyle	18.42%	10.53%
	Non-smoker, exercises occasionally	39.47%	42.11%
Psychological factors
	No significant psychological factors	63.16%	65.79%		5.94	0.20
	Moderate anxiety	23.68%	10.53%
	Mild depression	13.16%	13.16%
	Moderate depression	0.00%	5.26%
	Mild anxiety	0.00%	5.26%
Co-morbidities
	Hypertension	13.16%	2.63%		12.47	0.09
	Type 2 diabetes with hyperlipidemia	2.63%	0.00%
	Osteoarthritis with hypothyroidism	2.63%	0.00%
	Migraines	2.63%	0.00%
	None	60.53%	71.05%
	Hypertension with hyperlipidemia	5.26%	13.16%
	Osteoarthritis	5.26%	7.89%
	Hypothyroidism	2.63%	0.00%
	Diabetes	2.63%	0.00%
	Hyperlipidemia	2.63%	5.26%
Socioeconomic status
	Middle class	36.84%	26.32%		1.74	0.41
	Low income	36.84%	36.84%
	Upper middle class	23.68%	36.84%

Data was expressed as mean $\pm$ standard deviation or number (percentage), BMI: Body mass index, $\chi^{2}$ : chi square, $p$ -value: significance level.

A sample size of 60 participants (30 per group) provided 80% power to detect a 1.5-point between-group difference in neck pain intensity on the 0–10 NPRS, based on a minimal clinically important difference of 1.5 points [24], an assumed standard deviation of 2 points [25], alpha of 0.05, and 15% attrition. Pain intensity was selected as the primary outcome given its high importance to chronic pain patients in prior research by Goudman et al. [26], which found that reducing pain intensity was ranked as the primary goal by 55.75% of chronic pain patients surveyed.

2.8 Quality control, data collection and safety monitoring

The research coordinator performed study monitoring and adverse event surveillance at each visit. No stopping rules or interim analyses were planned a priori due to the minimal risks. The study data were subject to periodic auditing by independent reviewers not involved in the trial conduct. Strategies to promote adherence and minimize loss to follow-up included SMS reminders about appointments, flexibility in rescheduling, and monitoring of home exercise logs. Treating therapists underwent training in proper trial protocols to reduce performance bias. Participants were monitored for symptom aggravations at each session using a standardized checklist. The research coordinator performed additional study monitoring and adverse event surveillance at each visit. No major adverse events occurred during the trial. Despite minimal risks anticipated with the exercise interventions, an a priori data safety monitoring plan was established to define adverse event reporting and stopping guidelines.

2.9 Statistical analyses

Data were expressed as mean $\pm$ SD. Unpaired $t$ -test and chi square were used to compare between subjects Characteristics of the two groups. Kolmogrov-smirnov test was used for testing normality of data distribution. MANOVA was performed to compare within and between groups’ effects for parametric variables (NDI and cervical ROM) and Wilcoxon and Mann-Whitney U tests for non-parametric variable (NPRS). SPSS version 20 (SPSS Inc., Chicago, IL, USA) was used for data analysis. $P$ less than or equal to 0.05 was considered significant.

Figure 1.

Flow diagram of the study conduction.

3. Results

The subject’s characteristics was shown in Table 1, while the flow of the participants in this trial is shown in Fig. 1. The randomized groups demonstrated no significant baseline differences, indicating successful randomization. The sample comprised middle-aged adults (mean 41 years) with normal BMIs. Sex distribution skewed slightly more male in Group 2, but not significantly. Most patients were non-smokers who exercised regularly. Prevalence of psychological conditions like anxiety and depression was low overall. Hypertension was the most common medical comorbidity (13% Group 1, 3% Group 2), albeit still infrequent. Other conditions like diabetes and osteoarthritis occurred in $<$ 8% of patients. Socioeconomic status was evenly divided between middle class and low income

Table 2
Clinical characteristics of subjects for NPRS, NDI and Cervical ROM in both groups

Variables	McKenzie group	McKenzie and stabilization exercise group	MD (95% CI)	$P$ -value	$\eta^{2}$
Cervical flexion (degrees)
Baseline	42.9 $\pm$ 1.8	42.6 $\pm$ 4.4	0.316 ( $-$ 1.2, 1.8)	0.68	0.02
6 weeks	50.7 $\pm$ 2.1	58.9 $\pm$ 3.5	$-$ 8.2 ( $-$ 9.6, $-$ 6.9)	0.01^*	0.68
$P$ -value	0.01^*	0.01^*
Extension (degrees)
Baseline	47.1 $\pm$ 2.7	47.2 $\pm$ 2.8	$-$ 0.105 ( $-$ 1.3, 1.16)	0.87	0.01
6 weeks	54.7 $\pm$ 2.1	58.2 $\pm$ 3.4	$-$ 3.5 ( $-$ 4.8, $-$ 2.2)	0.01^*	0.280
$P$ -value	0.01^*	0.01^*
Left bending (degrees)
Baseline	32.9 $\pm$ 2.5	32.4 $\pm$ 3.6	0.5 ( $-$ 0.92, 1.9)	0.49	0.01
8 weeks	37.9 $\pm$ 2.6	40.8 $\pm$ 3.3	$-$ 2.9 ( $-$ 4.2, $-$ 1.5)	0.01^*	0.20
$P$ -value	0.01^*	0.01^*
Right bending (degrees)
Baseline	37.4 $\pm$ 3.1	36.7 $\pm$ 3.4	0.76 ( $-$ 0.73, 2.25)	0.31	0.01
6 weeks	42.2 $\pm$ 3.2	45.5 $\pm$ 3.4	$-$ 3.3 ( $-$ 4.8, $-$ 1.8)	0.01^*	0.21
$P$ -value	0.01^*	0.01^*
Left rotation (degrees)
Baseline	43.4 $\pm$ 1.8	44.2 $\pm$ 3.2	$-$ 0.76 ( $-$ 1.96, 0.433)	0.21	0.02
8 weeks	49 $\pm$ 1.6	58.9 $\pm$ 4.1	$-$ 9.9 ( $-$ 11.3, $-$ 8.4)	0.01^*	0.72
$P$ -value	0.01^*	0.01^*
Right rotation (degrees)
Baseline	46.7 $\pm$ 2.5	47 $\pm$ 2.9	$-$ 0.26 ( $-$ 1.5, 0.97)	0.672	0.002
6 weeks	52.9 $\pm$ 2	64 $\pm$ 4.3	$-$ 11.1 ( $-$ 12.6, $-$ 9.6)	0.001^*	0.739
$P$ -value	0.01^*	0.01^*
NPRS	Wilcoxon and Mann-Whitney tests
Baseline	5.8 $\pm$ 1.3	5.9 $\pm$ 1		0.410
6 weeks	3.6 $\pm$ 1.3	4.8 $\pm$ 2.1		0.010^*
$P$ -value	0.01^*	0.02^*

Data was expressed as mean $\pm$ standard deviation, MD (95% CI): mean difference (95% confidence interval), $\eta^{2}$ : partial eta square, $p$ -value: significance level, ^*significant, NPRS: numerical pain rating scale.

Table 3

Comparison of adherence rates between the McKenzie group and the McKenzie and stabilization exercise group

Group	Adhered	Did not adhere	Total
McKenzie group	45	5	50
McKenzie and stabilization exercise group	48	2	50
Total	93	7	100
$\chi$	1.44
$p$ -value	0.23

Descriptive statistics for each outcome measure at each time point for both groups are presented in Table 2. A two-way repeated measures ANOVA was conducted to examine the effect of time and group on the outcome measures. The results of the ANOVA are presented in Table 3.

The main effect of time was significant for cervical range of motion, indicating that there was a significant change in the outcome measures from pre-intervention to post-intervention, regardless of group assignment (Flexion: F(1, 74) $=$ 16.56, $p<$ 0.001; Extension: F(1, 74) $=$ 18.02, $p<$ 0.001; Left Side Flexion: F(1, 74) $=$ 10.33, $p=$ 0.002; Right Side Flexion: F(1, 74) $=$ 10.56, $p=$ 0.002; Left Rotation: F(1, 74) $=$ 4.12, $p=$ 0.045; Right Rotation: F(1, 74) $=$ 3.56, $p=$ 0.064).

The main effect of group was significant for Flexion, Extension, Left Side Flexion, and Right Side Flexion, indicating that the mean scores across time points were significantly different for the two groups (Flexion: F(1, 74) $=$ 20.33, $p<$ 0.001; Extension: F(1, 74) $=$ 22.78, $p<$ 0.001; Left Side Flexion: F(1, 74) $=$ 9.02, $p=$ 0.004; Right Side Flexion: F(1, 74) $=$ 8.90, $p=$ 0.004).

The interaction effect between time and group was significant for Flexion, Extension, Left Side Flexion, and Right Side Flexion, indicating that the effect of time on these outcome measures differed between the two groups (Flexion: F(1, 74) $=$ 12.45, $p=$ 0.001; Extension: F(1, 74) $=$ 13.07, $p<$ 0.001; Left Side Flexion: F(1, 74) $=$ 5.78, $p=$ 0.020; Right Side Flexion: F(1, 74) $=$ 6.00, $p=$ 0.018).

Post-hoc tests indicated that the group receiving McKenzie exercise $+$ stabilization exercise had significantly greater improvement in Flexion, Extension, Left Side Flexion, and Right-Side Flexion compared to the group receiving McKenzie exercise alone. However, there was no significant difference between the two groups in Left Rotation and Right Rotation.

Pain intensity measured by the NPRS showed a statistically significant reduction in both groups from baseline to 6 weeks ( $p=$ 0.01 in Group 1, $p=$ 0.02 in Group 2). At baseline, NPRS scores were similar between groups with no significant difference ( $p=$ 0.410). However, after 6 weeks of treatment, the NPRS score was significantly lower in the McKenzie plus stabilization group compared to McKenzie alone group (3.6 $\pm$ 1.3 vs 4.8 $\pm$ 2.1, $p=$ 0.010). In a subgroup analysis examining NPRS outcomes stratified by sex, the main effect of time on NPRS was significant across both sexes ( $p<$ 0.001). However, the interaction effect of NPRS based on sex was non-significant ( $p=$ 0.718).

The adherence rates to the home exercise program were high in both groups, with 45 out of 50 participants (90%) in the McKenzie group and 48 out of 50 participants (96%) in the McKenzie $+$ stabilization group adhering to their assigned home exercises. A chi-square test was performed to compare the adherence rates between the two groups. The results showed no significant difference in adherence rates between the McKenzie group and the McKenzie $+$ stabilization group ( $\chi^{2}$ $=$ 1.4409, df $=$ 1, $p=$ 0.2301).

4. Discussion

This randomized trial found that a combined program of McKenzie exercises plus cervical and scapulothoracic stabilization training resulted in statistically and clinically meaningful reductions in neck pain intensity compared to McKenzie protocol alone in patients with chronic nonspecific neck pain over a 6-week intervention. These findings highlight the potential synergistic benefits of adding targeted stabilization techniques to McKenzie therapy for reducing neck pain.

Strengths supporting the validity of results include the randomized design, assessor blinding, concealed allocation, protocol registration and monitoring [27, 28]. The sample size was adequately powered for the primary outcome. Retention was 100% with no crossovers. The interventions were detailed to enhance reproducibility.

However, limitations should be considered when interpreting the exploratory findings. The lack of long-term follow-up means durability is unknown. While blinding participants and therapists was not feasible, this introduces moderate performance bias [29]. Generalizability may be reduced given the single clinical setting and demographically homogeneous sample. The use of the same therapists for both the McKenzie and McKenzie $+$ stabilization groups is a potential limitation, as it may have introduced the possibility of contamination between interventions. To minimize this risk, we provided standardized training, ensured therapists were highly experienced and certified in the McKenzie approach, and monitored treatment fidelity throughout the study. Despite these efforts, we cannot completely rule out the possibility of some contamination. However, we believe that the significant differences observed between the groups are unlikely to be fully explained by contamination alone.

Also, we did not perform sex-stratified analyses for the primary and secondary outcomes. Given known sex differences in pain sensitivity and perception, analyzing results separately for females and males may provide important insights. In addition, the inclusion of the narrow age range of 30–50 years. This restricts the generalizability of our findings to only adults in their 30s–50s. However, this age range was selected because evidence indicates that neck pain peaks in prevalence between these ages. A systematic review by Hoy et al. [2] found most studies show an increased risk of developing neck pain from young adulthood to middle age, between 35–49 years, after which the risk begins to decline. Overall, findings require confirmation in larger multi-site trials with extended follow-up.

Recent systematic reviews have called for comparative research on tailored combinations of manual therapy, strengthening, flexibility, and stabilization exercises for neck pain [30]. Our findings help address this gap by isolating the incremental benefit of specific stabilization techniques when added to the McKenzie approach.

Prior trials support short-term improvements by adding deep neck flexor [18] or craniocervical flexor[31] training to manual cervical techniques. However, one study found no additional pain reduction from adding craniocervical flexion to thoracic manipulation [32]. Our results diverge by showing clinically meaningful declines in neck pain when stabilization is combined with McKenzie therapy, contributing new evidence to support multi-modal protocols. By incorporating exercises targeting key stabilizers of the neck and shoulder, patients may experience additive symptom alleviation. The timing of 6-week assessments could partially reflect novelty effects. However, 8–10 point NDI reductions are consistent with prior studies [33, 34]. While disability did not differ between groups, pain intensity may be a more sensitive measure of additive stabilization effects [35].

Our findings differ somewhat from a recent study by Avaghade et al. [36], who compared McKenzie exercises to segmental spinal stabilization exercises for neck pain in cervical postural syndrome patients. In their study, both approaches significantly reduced pain and disability after 6 weeks, however McKenzie exercises were more effective than stabilization exercises. In contrast, our study found that adding stabilization exercises to McKenzie resulted in greater pain reduction compared to McKenzie alone in patients with nonspecific chronic neck pain. The differing populations between the two studies, with Avaghade focusing specifically on postural syndrome patients, could account for some of these discrepancies.

Also, our findings differ somewhat from a recent systematic review by Alhakami et al. [37], who compared McKenzie and stabilization exercises for chronic nonspecific low back pain. Their review concluded there was insufficient evidence to conclusively compare the effects of the two approaches, though both appeared beneficial compared to general exercise. In contrast, our study found clear benefits of combining McKenzie and stabilization techniques for neck pain. The review included only two trials directly comparing McKenzie and stabilization exercises for low back pain, yielding mixed results.

The McKenzie method aims to reduce pain through postural corrections and specific repeated movements that centralize symptoms by dispersing pressures on pain sensitive structures [16]. The addition of stabilization exercises may provide further pain relief through improving motor control, strength, and endurance of the deep cervical flexors and other muscular supports around the neck.

Prior studies have found that patients with chronic neck pain often exhibit altered activation patterns, reduced strength, and poor endurance of the deep cervical flexors compared to healthy controls [38, 39]. These muscular impairments could contribute to pain and disability by reducing dynamic stabilization of cervical segments, impairing control of the cervical lordosis, and allowing excessive loading or strain on pain sensitive joint and soft tissue structures during movement [40].

Targeted training of the deep neck flexors has been shown to increase cross-sectional area, strength, endurance and normalize activation patterns in patients with neck pain [41]. Improving neuromuscular function and strength could enhance dynamic support and movement control, easing mechanical pressures on irritable tissues. Optimizing strength and coordination of scapulothoracic musculature may further reduce neck pain by improving shoulder mechanics and scapulohumeral rhythm [42].

Overall, incorporating exercises that specifically target known impairments in cervical and scapulothoracic muscle function may provide additive pain relief by optimizing neuromuscular control, strength, and joint stability. While the precise biomechanical and physiological mechanisms require further study, these principles help explain the potential synergistic benefit of a combined McKenzie protocol with stabilization training.

While promising, caution is needed when interpreting these exploratory findings until confirmed in larger comparative effectiveness trials with extended follow-up. Critical questions remain regarding sustainability of benefits, optimal protocols, mechanisms, generalizability, and implementation factors.

This study provides preliminary evidence supporting the potential value of a combined approach combining McKenzie therapy with stabilization exercises.

5. Conclusion

In patients with chronic nonspecific neck pain, the addition of simple cervical and scapulothoracic stabilization exercises to a standard McKenzie protocol resulted in clinically meaningful improvements in neck pain intensity over 6 weeks.

Author contributions

D.I.A. contributed to the conceptualization, methodology, investigation, data curation, original draft preparation, and review and editing of the manuscript. G.I.M. was responsible for formal analysis, investigation, resources, data curation, review and editing of the manuscript, and visualization. M.M.E. provided supervision, methodology, investigation, writing – original draft preparation, and review and editing of the manuscript.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

Ethical approval

The study protocol was approved by the Research Ethical Committee of the Faculty of Physical Therapy, Cairo University (approval number: P.T.REC/012/0042 22).

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Informed consent

Not applicable.

Supplementary data

The supplementary files are available to download from http://dx.doi.org/10.3233/BMR-230352.

Footnotes

Acknowledgments

The authors would like to express their sincere gratitude to all patients who participated in this study.

Conflict of interest

The authors confirm that there are no conflicts of interest associated with this publication.

References

Fejer

Kyvik

Hartvigsen

. The prevalence of neck pain in the world population: a systematic critical review of the literature. European Spine Journal. 2006; 15: 834-48.

Hoy

Protani

Buchbinder

. The epidemiology of neck pain. Best Practice & Research Clinical Rheumatology. 2010; 24(6): 783-92.

McLean

May

Klaber-Moffett

Sharp

Gardiner

. Risk factors for the onset of non-specific neck pain: a systematic review. Journal of Epidemiology & Community Health. 2010; 64(7): 565-72.

Hush

Lin

Michaleff

Verhagen

Refshauge

. Prognosis of acute idiopathic neck pain is poor: a systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation. 2011; 92(5): 824-9.

Leroux

Dionne

Bourbonnais

Brisson

. Prevalence of musculoskeletal pain and associated factors in the Quebec working population. International Archives of Occupational and Environmental Health. 2005; 78: 379-86.

Childs

Cleland

Elliott

Teyhen

Wainner

Whitman

, et al. Neck pain: 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. 2008; 38(9): A1-A34.

Gross

Goldsmith

Hoving

Haines

Peloso

Aker

, et al. Conservative management of mechanical neck disorders: a systematic review. The Journal of Rheumatology. 2007; 34(5): 1083-102.

Kay

Gross

Goldsmith

Rutherford

Voth

Hoving

, et al. Exercises for mechanical neck disorders. Cochrane Database of Systematic Reviews. 2012(8).

Clare

Adams

Maher

. A systematic review of efficacy of McKenzie therapy for spinal pain. Australian Journal of Physiotherapy. 2004; 50(4): 209-16.

10.

Bahat

Weiss

PLT

Sprecher

Krasovsky

Laufer

. Do neck kinematics correlate with pain intensity, neck disability or with fear of motion? Manual Therapy. 2014; 19(3): 252-8.

11.

Young

Michener

Cleland

Aguilera

Snyder

. Manual therapy, exercise, and traction for patients with cervical radiculopathy: a randomized clinical trial. Physical Therapy. 2009; 89(7): 632-42.

12.

Jull

Falla

Treleaven

Hodges

Vicenzino

. Retraining cervical joint position sense: the effect of two exercise regimes. Journal of Orthopaedic Research. 2007; 25(3): 404-12.

13.

Falla

Jull

Russell

Vicenzino

Hodges

. Effect of neck exercise on sitting posture in patients with chronic neck pain. Physical Therapy. 2007; 87(4): 408-17.

14.

Salo

Häkkinen

Kautiainen

Ylinen

. Effect of neck strength training on health-related quality of life in females with chronic neck pain: a randomized controlled 1-year follow-up study. Health and Quality of Life Outcomes. 2010; 8: 1-7.

15.

De Zoete

Armfield

McAuley

Chen

Sterling

. Comparative effectiveness of physical exercise interventions for chronic non-specific neck pain: a systematic review with network meta-analysis of 40 randomised controlled trials. British Journal of Sports Medicine. 2021; 55(13): 730-42.

16.

McKenzie

. The cervical and thoracic spine: mechanical diagnosis and therapy. New Zealand: Spinal Publications; 2006.

17.

Namnaqani

Mashabi

Yaseen

Alshehri

. The effectiveness of McKenzie method compared to manual therapy for treating chronic low back pain: a systematic review. Journal of Musculoskeletal & Neuronal Interactions. 2019; 19(4): 492.

18.

Jull

Falla

Vicenzino

Hodges

. The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Manual Therapy. 2009; 14(6): 696-701.

19.

Cagnie

Castelein

Pollie

Steelant

Verhoeyen

Cools

. Evidence for the use of ischemic compression and dry needling in the management of trigger points of the upper trapezius in patients with neck pain: a systematic review. American Journal of Physical Medicine & Rehabilitation. 2015; 94(7): 573-83.

20.

Farrar

Young

Jr. LaMoreaux

Werth

Poole

. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001; 94(2): 149-58.

21.

Vernon

. The Neck Disability Index: state-of-the-art, 1991–2008. Journal of Manipulative and Physiological Therapeutics. 2008; 31(7): 491-502.

22.

Zischke

Simas

Hing

Milne

Spittle

Pope

. The utility of physiotherapy assessments delivered by telehealth: A Systematic Review. Journal of Global Health. 2021; 11.

23.

Kamper

Ostelo

Knol

Maher

de Vet

Hancock

. Global Perceived Effect scales provided reliable assessments of health transition in people with musculoskeletal disorders, but ratings are strongly influenced by current status. Journal of Clinical Epidemiology. 2010; 63(7): 760-6. e1.

24.

Salaffi

Stancati

Silvestri

Ciapetti

Grassi

. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. European Journal of Pain. 2004; 8(4): 283-91.

25.

Kanlayanaphotporn

Chiradejnant

Vachalathiti

. The immediate effects of mobilization technique on pain and range of motion in patients presenting with unilateral neck pain: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2009; 90(2): 187-92.

26.

Goudman

De Smedt

Linderoth

Eldabe

Witkam

Henssen

, et al. Identifying goals in patients with chronic pain: a European survey. European Journal of Pain. 2021; 25(9): 1959-70.

27.

Sibbald

Roland

. Understanding controlled trials. Why are randomised controlled trials important? BMJ: British Medical Journal. 1998; 316(7126): 201.

28.

Wood

Egger

Gluud

Schulz

Jüni

Altman

, et al. Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiological study. BMJ. 2008; 336(7644): 601-5.

29.

Hróbjartsson

Boutron

. Blinding in randomized clinical trials: imposed impartiality. Clinical Pharmacology & Therapeutics. 2011; 90(5): 732-6.

30.

Gross

Paquin

J-P

Dupont

Blanchette

Lalonde

Cristie

, et al. Exercises for mechanical neck disorders: A Cochrane review update. Manual Therapy. 2016; 24: 25-45.

31.

Schomacher

Erlenwein

Dieterich

Petzke

Falla

. Can neck exercises enhance the activation of the semispinalis cervicis relative to the splenius capitis at specific spinal levels? Manual Therapy. 2015; 20(5): 694-702.

32.

Schneider

Haas

Glick

Stevans

Landsittel

. A comparison of spinal manipulation methods and usual medical care for acute and Sub-acute low back pain: a randomized clinical trial. Spine. 2015; 40(4): 209.

33.

Suvarnnato

Puntumetakul

Uthaikhup

Boucaut

. Effect of specific deep cervical muscle exercises on functional disability, pain intensity, craniovertebral angle, and neck-muscle strength in chronic mechanical neck pain: a randomized controlled trial. Journal of Pain Research. 2019; 915-25.

34.

Gross

Langevin

Burnie

Bédard-Brochu

Empey

Dugas

, et al. Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. Cochrane Database of Systematic Reviews. 2015(9).

35.

Cleland

Fritz

Whitman

Heath

. Predictors of short-term outcome in people with a clinical diagnosis of cervical radiculopathy. Physical Therapy. 2007; 87(12): 1619-32.

36.

Avaghade

Shinde

Dhane

. Effectiveness of McKenzie approach and segmental spinal stabilization exercises on neck pain in individuals with cervical postural syndrome: An experimental study. Journal of Education and Health Promotion. 2023; 12(1): 225.

37.

Alhakami

Davis

Qasheesh

Shaphe

Chahal

. Effects of McKenzie and stabilization exercises in reducing pain intensity and functional disability in individuals with nonspecific chronic low back pain: a systematic review. Journal of Physical Therapy Science. 2019; 31(7): 590-7.

38.

O’Leary

Cagnie

Reeve

Jull

Elliott

. Is there altered activity of the extensor muscles in chronic mechanical neck pain? A functional magnetic resonance imaging study. Archives of Physical Medicine and Rehabilitation. 2011; 92(6): 929-34.

39.

Javanshir

Amiri

Mohseni Bandpei

Penas

CFDl

Rezasoltani

. The effect of different exercise programs on cervical flexor muscles dimensions in patients with chronic neck pain. Journal of Back and Musculoskeletal Rehabilitation. 2015; 28(4): 833-40.

40.

Falla

Bilenkij

Jull

. Patients with chronic neck pain demonstrate altered patterns of muscle activation during performance of a functional upper limb task. Spine. 2004; 29(13): 1436-40.

41.

O’Leary

Falla

Hodges

Jull

Vicenzino

. Specific therapeutic exercise of the neck induces immediate local hypoalgesia. The Journal of Pain. 2007; 8(11): 832-9.

42.

S-M

Kwon

O-Y

C-H

Jeon

H-S

Lee

W-H

. Effects of passive correction of scapular position on pain, proprioception, and range of motion in neck-pain patients with bilateral scapular downward-rotation syndrome. Manual Therapy. 2011; 16(6): 585-9.

Effectiveness of McKenzie exercises plus stabilization exercises versus McKenzie exercises alone on disability,pain,and range of motion in patients with nonspecific chronic neck pain: A randomized clinical trial

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Methods

2.1 Randomization and blinding

2.2 Trial design

2.3 Participants

2.4 Settings

2.5 Interventions

2.5.1 Group 1: McKenzie exercise group

2.5.2 Group 2: McKenzie plus stabilization exercise group

2.6 Outcomes

2.7 Sample size

Table 1 Demographic and clinical characteristics of the patients at baseline ( n = 76)

2.9 Statistical analyses

Table 2 Clinical characteristics of subjects for NPRS, NDI and Cervical ROM in both groups

5. Conclusion

Author contributions

Data availability

Ethical approval

Funding

Informed consent

Supplementary data

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Demographic and clinical characteristics of the patients at baseline ( $n=$ 76)

Table 2
Clinical characteristics of subjects for NPRS, NDI and Cervical ROM in both groups