Neck pain is one of the four common diseases worldwide and has become a significant public health issue that threatens personal health and reduces the quality of life [1,2]. The symptoms of neck pain are diverse, including restricted movement of the cervical spine and muscle spasms, which may also cause headaches, numbness in the upper limbs, and in severe cases, even affect sleep quality and work ability [3,4]. The causes of the disease are complex and are mostly related to muscle strain, soft tissue injuries, cervical joint disorders, and degeneration of cervical intervertebral discs [5,6]. At present, there is still no standardized treatment plan for this disease, and clinical practice mainly relies on drug therapy [7,8]. In this context, the course of neck pain often shows a high degree of protracted nature. Approximately half of the patients’ acute pain will turn into chronic pain, which makes it urgent for clinicians to find treatment options that can effectively control neck pain for a long term [9,10].

As a commonly used treatment method in clinical practice, drug treatment for neck pain mainly exerts its therapeutic effect in pain relief. However, it has limited effects on improving cervical spine function and restoring cervical spine curvature [11,12]. Furthermore, the drug treatment for neck pain has significant limitations. It often comes with adverse reactions such as gastrointestinal bleeding, drowsiness addiction, etc, which restricts its long-term application in clinical practice [13,14]. This has made it an urgent need in clinical practice to actively explore nonpharmacological intervention methods, further highlighting the clinical value of nonpharmacological intervention approaches such as traditional Chinese medicine (TCM) exercises [15,16]. Due to its low-risk, noninvasive and proven-effective characteristics, TCM exercises are increasingly playing a significant role in the prevention and rehabilitation management of neck pain [17-19]. TCM exercises refer to a type of active rehabilitation and preventive measure that involves the coordinated efforts of body movements, breathing and exhalation, as well as mental regulation. Through these activities, it aims to unblock meridians, regulate blood and qi, coordinate internal organs, strengthen muscles and bones, and calm the mind and soothe the spirit [17]. Common TCM exercises include Baduanjin, Yijinjing, Tai Chi and Wuqinxi. Their excellent versatility can meet the health and fitness needs of different audiences [10,15,20]. Interestingly, the benefits brought by TCM exercises extend beyond the physical level. Through regular practice, one can achieve both physical and mental improvement, alleviating anxiety while also reducing anxiety’s physical manifestations [21,22]. This characteristic enables practitioners to achieve a significant sense of participation accomplishment, which not only ensures good compliance but also constitutes its core advantage in the field of public health promotion [23,24].

Although both TCM exercises and drug therapy have been used in clinical practice, there is still a lack of systematic comparison in terms of efficacy and safety between the two. Furthermore, there are still several key issues that require in-depth exploration, such as the differences in therapeutic effects among various TCM exercise routines, and the impact of standardized intervention plans on the therapeutic outcomes. This protocol outlines a systematic review that will comprehensively compare the efficacy and safety of TCM-based exercise and medication in treating neck pain, aiming to provide evidence-based guidance for the selection of clinical treatment plans.

This is a study protocol for a systematic review and meta-analysis; therefore, no results are available at the time of publication. The systematic review is scheduled to commence in August 2025. The anticipated timeline is as follows: literature search from August to September 2025; study screening from September to December 2025; data extraction and quality assessment from January to March 2026; statistical analysis and evidence synthesis from April to May 2026; and manuscript submission by June 2026. Any deviations from this timeline will be reported in the final publication.

Neck pain is the fourth leading cause of disability worldwide, with an annual prevalence rate exceeding 30%, and represents a major contributor to labor loss and disability [25]. Its incidence is increasingly observed in younger populations, imposing substantial economic burdens on families and society [3,26]. Currently, no unified or standardized treatment protocol for neck pain exists [27]. While pharmacological therapy remains the conventional approach, nonpharmacological interventions—particularly TCM exercises—have attracted growing clinical interest due to their noninvasive nature and potential for long-term management [28,29]. However, whether TCM exercises are comparable to or more effective than oral medications in terms of both efficacy and safety remains to be systematically evaluated.

However, it should be noted that although TCM exercise has a wide variety of forms, its efficacy largely depends on individual differences [10,30]. During the clinical application process, the duration, frequency, and intensity of traditional Chinese physical therapy exercises are mostly determined by the physicians, and there are various versions of traditional Chinese physical exercises, lacking a unified standard [30,31]. This “empirical” approach to scheme formulation has led to significant differences in the application effects of the same therapy in different medical institutions and under the hands of different physicians, making it difficult to establish a replicable treatment model [32]. In addition, the differences in the effectiveness of TCM exercises between the East and the West are rooted in cultural acceptance [33,34]. In Asia, it is highly compatible with the cultural DNA of the region; however, in Europe and America, most people find it difficult to understand TCM culture, which consequently weakens the therapeutic effect [35].From a long-term management perspective, TCM exercises are generally considered to have a favorable safety profile compared to pharmacological interventions [36]. The forthcoming review will systematically assess whether the available evidence supports this assumption and whether TCM exercises can be recommended as a viable long-term strategy for chronic nonspecific neck pain. If confirmed, such findings could have implications for shifting the clinical focus from symptomatic treatment toward sustained prevention and rehabilitation. To address the cultural heterogeneity observed and enhance the global applicability of TCM exercises, future research and clinical implementation should consider strategies for cultural adaptation. This goes beyond mere translation of instructions. Potential approaches include: (1) contextualizing the practice within local wellness or mindfulness frameworks that are more familiar to non-Asian populations; (2) modifying exercise names, metaphors, and imagery to align with culturally resonant concepts (eg, emphasizing “mindful movement,” “stress reduction,” or “gentle stretching” rather than solely “meridian regulation”); (3) involving community stakeholders and target cultural groups in the design and refinement of intervention protocols to ensure relevance and acceptability; and (4) training instructors who are not only proficient in the exercises but also culturally competent in delivering them to diverse populations. By proactively integrating such cultural adaptation strategies, the external validity and effectiveness of TCM exercises in multinational trials and real-world settings outside Asia could be significantly improved.

As mentioned, this systematic review has not yet been performed. However, based on our preliminary understanding of the existing literature, we anticipate potential challenges in the forthcoming review. Methodological limitations in the primary studies are likely, such as small sample sizes, unclear reporting of randomization and allocation concealment, and challenges in blinding participants and personnel due to the nature of exercise interventions, all of which could affect the reliability of individual study results. Significant clinical and methodological heterogeneity is also expected due to variations in TCM exercise protocols (eg, type, frequency, duration), drug regimens, and outcome assessment tools, which may complicate data synthesis and interpretation. Furthermore, we are aware that the current body of evidence may be limited in volume; based on scoping searches, it is possible that most eligible trials have been conducted in Asian populations. If this geographic concentration emerges in the final included studies, coupled with potential differences in cultural acceptance of TCM practices and local health care contexts, it may limit the generalizability of our findings to non-Asian settings. Our planned subgroup analysis by geographic region (Asia vs non-Asia) will formally explore this aspect if sufficient data are available.

Given the limitations of this study, future primary studies should consider more high-quality, large-sample, multicenter head-to-head RCTs designed to clarify the differences in efficacy and safety between TCM exercise and drug treatment in different disease courses and various types of neck pain. Second, a unified intervention plan for TCM exercise (such as standard movements, practice frequency and duration in TCM) and evaluation criteria for efficacy should be formulated to reduce heterogeneity among studies. Third, long-term follow-up studies (≥1 year) should be conducted to assess the long-term efficacy, recurrence rate, and safety of TCM exercise and drug treatment. Finally, the effects of combined treatment with TCM exercise and drugs should be explored, and the applicable population and optimal treatment plan for combined treatment should be clarified to provide more comprehensive evidence-based basis for clinical treatment.