Background Clinical guidelines make vague recommendations as to exercise training (ET) type and dosage to manage chronic non-specific neck pain (CNSNP). Objective To synthesise evidence on the effectiveness of different ET programmes to reduce CNSNP and associated disability, and whether dosage affects outcomes. Methods A systematic review and data synthesis was conducted according to a published registered protocol (PROSPERO CRD42018096187). A sensitive topic-based search was conducted of CINAHL, MEDLINE, EMBASE, PEDro, grey literature sources and key journals from inception to 6 th January 2020 for randomised controlled trials, investigating ET for CNSNP or disability. Two reviewers independently completed eligibility screening, data extraction, risk of bias assessment (Cochrane Risk of Bias Tool) and rated the overall strength of evidence using Grading of Recommendations Assessment, Development and Evaluation. Data was tabulated for narrative synthesis and grouped by intervention, outcome and time point to compare across studies. Results Twenty-six trials from 3990 citations (n = 2288 participants) investigated fifteen ET programmes. High RoB and low sample sizes reduced evidence quality. Clinical heterogeneity prevented meta-analyses. A range of ET programmes reduce pain/disability in the short term (low to moderate evidence). Pillar exercises reduce pain/disability in the intermediate term (low level evidence). Moderate to very large pain reduction is found with ET packages

Background Chronic non-specific neck pain is highly prevalent, resulting in significant disability. Despite exercise being a mainstay treatment, guidance on optimal exercise and dosage variables is lacking. Combining submaximal effort deep cervical muscles exercise (motor control) and superficial cervical muscles exercise (segmental) reduces chronic non-specific neck pain, but evaluation of optimal exercise and dosage variables is prevented by clinical heterogeneity. Objective To gain consensus on important motor control and segmental exercise and dosage variables for chronic non-specific neck pain. Methods An international 3-round e-Delphi study, was conducted with experts in neck pain management (academic and clinical). In round 1, exercise and dosage variables were obtained from expert opinion and clinical trial data, then analysed thematically (two independent researchers) to develop themes and statements. In rounds 2 and 3, participants rated their agreement with statements (1–5 Likert scale). Statement consensus was evaluated using progressively increased a priori criteria using descriptive statistics. Results Thirty-seven experts participated (10 countries). Twenty-nine responded to round 1 (79%), 26 round 2 (70%) and 24 round 3 (65%). Round 1 generated 79 statements outlining the interacting components of exercise prescription. Following rounds 2 and 3, consensus was achieved for 46 important components of exercise and dosage prescription across 5 themes (clinical reasoning, dosage variables, exercise variables, evaluation criteria and progression) and 2 subthemes (progression criteria and progression variables). Excellent agreement and qualitative data supports exercise prescription complexity and the need for individualised, acceptable, and feasible exercise. Only 37% of important exercise components were generated from clinical trial data. Agreement was highest (88%-96%) for 3 dosage variables: intensity of effort, frequency, and repetitions. Conclusion Multiple exercise and dosage variables are important, resulting in complex and individualised exercise prescription not found in clinical trials. Future research should use these important variables to prescribe an evidence-informed approach to exercise.

IntroductionClinical guidelines and systematic reviews recommend exercise in the management of chronic non-specific neck pain. Although exercise training programmes that consist of both motor control exercise and exercises for the superficial cervical muscles (segmental exercises) are effective, the exercise variables including dosage vary considerably across trials or are poorly reported. This study aims to gain expert consensus on these exercise variables so that they can be described clearly using intervention reporting checklists to inform clinical practice and future clinical trials.Methods and analysisThis protocol for an international Delphi study is informed by the Guidance on Conducting and REporting DElphi Studies recommendations and published to ensure quality, rigour and transparency. The study will consist of three rounds using anonymous online questionnaires. Expert exercise professionals (physiotherapists, strength and conditioning coaches and so on) and academics in neck pain management will be identified through literature searches, peer referral and social media calls for expression of interest. In round 1, participants will answer open-ended questions informed by intervention and exercise reporting checklists. Responses will be analysed thematically by two independent reviewers. In round 2, participants will rate their level of agreement with statements generated from round 1 and previous clinical trials using a 5-point Likert scale where 1=strongly disagree and 5=strongly agree. In round 3, participants will re-rate their agreement with statements that achieved consensus in round 2. Statements reaching consensus among participants must meet progressively increased a priori criteria at rounds 2 and 3, measured using descriptive statistics: median, IQR and percentage agreement. Inferential statistics will be used to evaluate measures of agreement between participants (Kendall’s coefficient of concordance) and stability between rounds (Wilcoxon rank-sum test). Statements achieving consensus in round 3 will provide expert recommendations of the key exercise and dosage variables in the management of chronic non-specific neck pain.Ethics and disseminationEthical approval was provided by the University of Birmingham Ethics Committee (Ref:ERN_19–1857). Results will be disseminated through peer-reviewed publications and conference presentations.

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