The effect of craniocervical flexor exercise on chronic neck pain: a systematic review and meta-analysis

OBJECTIVE: This systematic review and meta-analysis evaluated the effectiveness of craniocervical flexor (CCF) exercises on pain intensity, functional disability, muscle endurance, muscle strength, cervical flexion range of motion, and craniovertebral angle (CVA) in patients with chronic neck pain (CNP). METHODS: Twenty-five randomized controlled trials (1,166 participants) were included. Methodological quality was assessed using the PEDro scale, and risk of bias via the RoB 2 tool. Meta-analysis was performed using standardized mean differences (SMD) from random effects models. RESULTS: Compared to other interventions, CCF exercises produced a moderate-to-large reduction in pain (SMD: -0.97) and moderate improvement in disability (SMD: -0.50). Combining CCF with other interventions yielded a very large pain reduction (SMD: -1.70). Muscle endurance showed a very large increase (SMD: 1.55), muscle strength a moderate increase (SMD: 0.60), cervical flexion range of motion substantial improvement (SMD: 0.83), and CVA moderate improvement (SMD: 0.51). CONCLUSION: CCF exercises, alone or combined, appear to improve pain, function, and forward head posture in CNP. However, due to substantial heterogeneity, variable risk of bias, and diverse protocols, findings are suggestive rather than definitive. Higher-quality RCTs with standardized protocols are needed to confirm these clinically promising results. PROTOCOL REGISTRATION: www.crd.york.ac.uk/prospero identifier CRD420251176050.