A 2023 review published in the Journal of Clinical Medicine makes a case that’s easy to overlook in everyday practice: exercise therapy is the go-to recommendation for chronic neck pain, but most guidelines treat “neck pain” as one thing. The author argues it isn’t — and that tailoring exercise to the type of pain a person has may matter more than picking the “best” exercise in general.
Why exercise alone doesn’t fix everyone
The review opens with a sobering fact: across systematic reviews, exercise therapy for chronic neck pain shows only modest effects — improvements in the range of 10–15% on standard pain scales. Some studies show much larger gains, others show none at all. Part of the explanation is statistical: if half of a group responds really well and half doesn’t respond at all, the average result looks unremarkable — even though exercise clearly worked for a lot of people. Non-responder rates in some trials have been as high as 50%.
That variability isn’t necessarily a flaw in the treatment. It’s a signal that we’re prescribing the same intervention to people whose pain is coming from genuinely different mechanisms.
Three types of chronic neck pain
Rather than classifying neck pain by how it started (a car accident vs. no clear trigger), the review uses a framework based on the pain mechanism itself:
- 1. Nociceptive pain Pain from actual or potential tissue damage — think osteoarthritis. It’s typically localized, and it’s provoked by movement or pressure on the area.
- 2. Neuropathic pain Caused by a lesion or disease of the nervous system itself — for example, a pinched nerve causing radiating arm pain, or nerve damage from chemotherapy or diabetes. It often feels like electric shocks, burning, or shooting pain.
- 3. Nociplastic pain Pain that persists without ongoing tissue damage — the nervous system itself has become overly sensitive. It shows up alongside things like fatigue, poor sleep, brain fog, and heightened sensitivity to light, sound, or touch.
Same complaint — “my neck hurts” — but three very different underlying stories, and (the review argues) three different reasons to prescribe exercise.
What the review recommends for each type — including any concrete dosing
This is where it’s worth being precise: this paper is a conceptual/clinical-reasoning review, not a single clinical trial. It doesn’t hand over one fixed program with a set number of reps or weeks the way an individual RCT would. But it does give directional dosing guidance for each pain type:
Nociceptive pain
- Start with high-frequency, low-intensity endurance and neuromuscular control work
- As pain/nociception improves, progress toward resistance-based exercise with reduced repetitions (i.e., heavier, less frequent)
- For pain that can’t be fully resolved (like osteoarthritis), stay with low-intensity, high-frequency routines, gradually adding resistance to maintain joint mobility and reduce stiffness
Neuropathic pain
- Start with low-to-moderate intensity — high-intensity work can flare up neuropathic symptoms
- Favor higher training volume at low intensity rather than pushing intensity up
- The review notes this matters clinically because higher overall physical activity has been linked to less neuropathic pain in people undergoing chemotherapy and those with type 2 diabetes — but the way to get there is volume, not intensity
Nociplastic pain
- Here there’s an unusually specific number: research in fibromyalgia populations found exercise at the patient’s own preferred intensity (around 45% of maximum heart rate) was more effective than higher-intensity work (>60% MHR)
- General approach: low intensity, gradually increasing volume, not intensity
- For people with high sensitivity/reactivity, start even lower: gentle range-of-motion work, motor control exercises, or pool-based (aquatic) therapy
- If even that provokes a flare-up, the recommendation is to step back to education and reassurance before reintroducing exercise
The most useful idea in the paper: dose is not one-size-fits-all
The review references two studies looking directly at “dose-response” for neck-specific exercise, and here’s the interesting part — they found somewhat contradictory things. One suggested there’s minimal difference between different resistance training parameters. The other suggested more exercise volume generally leads to better outcomes. Taken together, the honest conclusion is: we don’t have a clean, universal dose-response curve for neck pain exercise yet — which is exactly the gap this review is trying to address by shifting the question from “how much exercise” to “what kind of pain am I treating.”
What this means in practice
The takeaway isn’t “here’s your neck routine.” It’s a mindset shift for how exercise gets prescribed:
- If pain is clearly tissue-driven and movement-provoked → start gentle and frequent, build toward resistance
- If pain has a nerve-injury signature (shooting, burning, follows a nerve pattern) → keep intensity low, lean on volume instead
- If pain is out of proportion to any tissue finding and comes with fatigue, poor sleep, or whole-body sensitivity → go in low and slow, at a self-selected comfortable intensity, and don’t chase intensity as the goal
The review also makes a point worth passing on to anyone starting an exercise program for chronic neck pain: short-term flare-ups after exercise are common and don’t necessarily mean it’s not working. It can take time — sometimes weeks — before benefits become apparent, and consistency through that early period matters more than any single session.
Source: de Zoete, R.M.J. Exercise Therapy for Chronic Neck Pain: Tailoring Person-Centred Approaches within Contemporary Management. J. Clin. Med. 2023, 12(22), 7108. Full text
