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Evidence-Based Guidelines for the Chiropractic Treatment of Adults With Neck Pain

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Objective: The purpose of this study was to develop evidence-based treatment recommendations for the treatment of nonspecific (mechanical) neck pain in adults. Methods: Systematic literature searches of controlled clinical trials published through December 2011 relevant to chiropractic practice were conducted using the databases MEDLINE, EMBASE, EMCARE, Index to Chiropractic Literature, and the Cochrane Library. The number, quality, and consistency of findings were considered to assign an overall strength of evidence (strong, moderate, weak, or conflicting) and to formulate treatment recommendations. Results: Forty-one randomized controlled trials meeting the inclusion criteria and scoring a low risk of bias were used to develop 11 treatment recommendations. Strong recommendations were made for the treatment of chronic neck pain with manipulation, manual therapy, and exercise in combination with other modalities. Strong recommendations were also made for the treatment of chronic neck pain with stretching, strengthening, and endurance exercises alone. Moderate recommendations were made for the treatment of acute neck pain with manipulation and mobilization in combination with other modalities. Moderate recommendations were made for the treatment of chronic neck pain with mobilization as well as massage in combination with other therapies. A weak recommendation was made for the treatment of acute neck pain with exercise alone and the treatment of chronic neck pain with manipulation alone. Thoracic manipulation and trigger point therapy could not be recommended for the treatment of acute neck pain. Transcutaneous nerve stimulation, thoracic manipulation, laser, and traction could not be recommended for the treatment of chronic neck pain. Conclusions: Interventions commonly used in chiropractic care improve outcomes for the treatment of acute and chronic neck pain. Increased benefit has been shown in several instances where a multimodal approach to neck pain has been used.
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WFC 2013 AWARD WINNING PAPER
EVIDENCE-BASED GUIDELINES FOR THE CHIROPRACTIC
TREATMENT OF ADULTS WITH NECK PAIN
Roland Bryans, DC,
a
Philip Decina, DC,
b
Martin Descarreaux, DC, PhD,
c
Mireille Duranleau, DC,
d
Henri Marcoux, DC,
e
Brock Potter, DC,
f
Richard P. Ruegg, PhD, DC,
g
Lynn Shaw, PhD, OT,
h
Robert Watkin, BA, LLB,
i
and Eleanor White, MSc, DC
j
ABSTRACT
Objective: The purpose of this study was to develop evidence-based treatment recommendations for the treatment of
nonspecific (mechanical) neck pain in adults.
Methods: Systematic literature searches of controlled clinical trials published through December 2011 relevant to
chiropractic practice were conducted using the databases MEDLINE, EMBASE, EMCARE, Index to Chiropractic
Literature, and the Cochrane Library. The number, quality, and consistency of findings were considered to assign an
overall strength of evidence (strong, moderate, weak, or conflicting) and to formulate treatment recommendations.
Results: Forty-one randomized controlled trials meeting the inclusion criteria and scoring a low risk of bias were used to
develop 11 treatment recommendations. Strong recommendations were made for the treatment of chronic neck pain with
manipulation, manual therapy, and exercise in combination with other modalities. Strong recommendations were also
made for the treatment of chronic neck pain with stretching, strengthening, and endurance exercises alone. Moderate
recommendations were made for the treatment of acute neck pain with manipulation and mobilization in combination
with other modalities. Moderate recommendations were made for the treatment of chronic neck pain with mobilization as
well as massage in combination with other therapies. A weak recommendation was made for the treatment of acute neck
pain with exercise alone and the treatment of chronic neck pain with manipulation alone. Thoracic manipulation and
trigger point therapy could not be recommended for the treatment of acute neck pain. Transcutaneous nerve stimulation,
thoracic manipulation, laser, and traction could not be recommended for the treatment of chronic neck pain.
Conclusions: Interventions commonly used in chiropractic care improve outcomes for the treatment of acute and
chronic neck pain. Increased benefit has been shown in several instances where a multimodal approach to neck pain
has been used. (J Manipulative Physiol Ther 2014;37:42-63)
Key Indexing Terms: Chiropractic; Practice Guideline; Therapy; Therapeutics; Review; Evidence-Based Practice
The annual prevalence of nonspecific neck pain is
estimated to range between 30% and 50%.
1
Persistent or recurrent neck pain continues to be
reported by 50% to 85% of patients 1 to 5 years after initial
onset.
2
Its course is usually episodic, and complete recovery
is uncommon for most patients.
3
Twenty-seven percent of
patients seeking chiropractic treatment report neck or
cervical problems.
4
Thus, treatment of neck pain is an
integral part of chiropractic practice.
Treatment modalities typically used by doctors of
chiropractic (DCs) to care for patients with neck pain include
spinal manipulation, mobilization, device-assisted spinal
a
Guidelines Development Committee (GDC) Chairman;
Chiropractor, Clarenville, Newfoundland, Canada.
b
Assistant Professor, Canadian Memorial Chiropractic College,
Clinical Education, Toronto, Canada.
c
Professor, Département de Chiropratique, Université du
Québec à Trois-Rivières, Trois-Rivières, Canada.
d
Chiropractor, Montréal, Quebec, Canada.
e
Chiropractor, Winnipeg, Manitoba, Canada.
f
Chiropractor, North Vancouver, British Columbia, Canada.
g
Editor, Clinical Practice Guidelines Initiative, Toronto,
Ontario, Canada.
h
Associate Professor, Faculty of Health Sciences, School of
Occupational Therapy, Western University, London, Ontario,
Canada.
i
Public Member, Toronto, Ontario, Canada.
j
Chiropractor, Markham, Ontario, Canada.
Submit requests for reprints to: Richard P. Ruegg, PhD, DC,
4325, Longmoor Drive, Burlington, ON, Canada L7L 5A7
(e-mail: rruegg@cogeco.ca).
Paper submitted May 4, 2013; in revised form July 25, 2013;
accepted August 1, 2013.
0161-4754/$36.00
Copyright © 2014 by National University of Health Sciences.
http://dx.doi.org/10.1016/j.jmpt.2013.08.010
42
manipulation, education about modifiable lifestyle factors,
physical therapy modalities, heat/ice, massage, soft tissue
therapies such as trigger point therapy, and strengthening and
stretching exercises. There is a growing expectation for DCs
and other health professionals to adopt and use research-
based knowledge, taking sufficient account of the quality of
available research evidence to inform clinical practice. As a
result, the purpose of the Canadian Chiropractic Association
and the Federation Clinical Practice Guidelines Project is to
develop evidence-based treatment guidelines. The clinical
practice guideline (CPG) experience began in Canada with a
consensus conference in April of 1993 that culminated with
the publication of Clinical Guidelines for Chiropractic
Practice in Canada
5
in 1994. Since then, the chiropractic
profession in Canada has published 3 additional guidelines
6-
8
that are intended to provide practitioners with the most
current evidence for the treatment for patients in light of the
clinician's experience and the patient's preferences.
The original Neck Pain Guideline
6
published in 2005
relied on studies that were drawn from the literature in a
search conducted up to October 2004. The treatment
recommendations developed at that time were supported
largely by the expert opinion of the Guidelines Develop-
ment Committee (GDC) in the absence of a solid, high-
quality research base. Therefore, an update to the earlier
neck pain guidelines that reflects evidence extracted from
the published scientific literature about effective chiroprac-
tic treatment(s) for adult patients with nonspecific neck pain
was needed. The purposes of this study were to develop
evidence-based treatment recommendations for the treat-
ment of nonspecific (mechanical) neck pain in adults and to
present recommendations synthesized from this evidence
and strength rating of each recommendation.
METHODS
This study addresses chiropractic treatments for which
there is evidence. There may be other treatments for which
there is no evidence and for which this study cannot make
recommendations. Therefore, this CPG does not provide a
comprehensive overview of all chiropractic treatment that may
be rendered to patients, only those for which there is evidence.
The procedures identified the high-quality (low risk of
bias) studies that investigated the benefits of commonly used
chiropractic modalities for the treatment for adults with
nonspecific neck pain as determined by validated clinical
outcome measures compared with placebo or other in-
terventions. Neck pain resulting from whiplash or serious
pathology was not included. For the purposes of this
guideline, chiropractic treatment of neck pain includes any
of the techniques or procedures commonly used by DCs, but
excludes acupuncture, surgical procedures, invasive analge-
sic procedures, injections, psychological interventions, or
medications (either prescription or over-the-counter).
The methods used in the development of recommenda-
tions for this guideline have been described in detail
elsewhere.
9
The GDC has adopted systematic processes for
literature searching, screening, review, analysis, and
interpretation, which are consistent with the criteria
proposed by the Appraisal of Guidelines Research and
Evaluationcollaboration (http://www.agreecollaboration.
org). This guideline is a supportive tool for practitioners and
for their patients and is not intended as a standard of care.
The intent of this guideline is to link clinical practice to the
best available published evidence and is only one
component of an evidence-based approach to patient care,
which should include clinical judgment and patient values.
Data Sources and Searches
A systematic search of the literature was conducted. The
search strategy was developed by the GDC in conjunction
with an experienced medical research librarian in MED-
LINE by exploring MeSH terms related to chiropractic and
specific interventions (see Appendix A). The databases
searched included the following: MEDLINE, EMBASE,
EMCARE, Index to Chiropractic Literature, and the
Cochrane Library. Searches included articles published in
English or with English abstracts. The search strategy was
limited to adults (18 years). A study population was
considered to be adult when drawn from a workplace.
The search spanned the period January 2004 to December
2011. Reference lists provided in systematic reviews (SRs)
were also reviewed to avoid missing relevant articles. Some
of the treatment modalities included in this guideline are not
exclusive to DCs but include those that may also be
delivered by other health care professionals.
Evidence Selection Criteria
Search results were screened electronically, and a multistage
screening was conducted (see Appendix B: level 1 (title and
abstract), duplicate citations were removed, and remaining
articles were retrieved as electronic and/or hard copies for
detailed analysis; level 2 (full-text methodology and relevance);
Table 1. Strength of evidence and recommendations
Evidence
Strength of
recommendation
Consistent findings among 2 low-risk-of-bias
controlled trials with no limiting factors
Strong
Consistent findings among 2 low-risk-of-bias
controlled trials with minor limiting factors
Moderate
or
1 low-risk-of-bias controlled trial with no
limiting factors
1 low-risk-of-bias controlled trial with
limiting factors
Weak
Unresolvable differences between the findings
of 2 or more low-risk-of-bias controlled trials
Inconsistent
43Bryans et alJournal of Manipulative and Physiological Therapeutics
Neck Pain Clinical Practice GuidelineVolume 37, Number 1
level 3 (screening randomized controlled trials [RCTs] and
systematically conducted reviews); and level 4 (full-text final
screening for relevant clinical content and risk of bias assessment
and identification of potential methodological flaws).
The primary outcome measures for this guideline were
validated measures of neck painor neck disability.
Secondary outcomes included the following: cervical range
of motion(cROM), activities of daily living, quality of life
(QoL), and time to recovery.
Only RCTs were selected as the evidence base for this
guideline consistent with current standards for interpreting
clinical findings. The selected literature was next categorized
accordingtointerventiontypeand the articles in each category
assessed by the Evidence Rating Team (ERTR.B., M.D.,
R.R., and L.S.) for quality, relevance to common chiropractic
practice, and the suitability for further analysis and inclusion in
this guideline. The inclusion or exclusion of a treatment
category was predetermined by consensus among stakeholders
in the profession.
The evidence base did not permit the assignment of any
RCTs to a separate subacute category. As a result, RCTs were
assigned to an acute or chronic category for each of the
interventions. In instances where the experimental partici-
pants were of a variable duration of symptom(s) (both acute
and chronic), the assignment to a category was determined by
the predominance (average or mean) of symptom duration.
Studies that included participants with subacute symptom
duration were assigned to the acute category. In instances
where the mix of participants could not be determined or was
relatively equal, the study was excluded.
Developing Recommendations
Two processes were used to assess the RCTs. The first
was to assess the risk of bias of the methods, and the second
was to assess any factors that may influence the
interpretation and subsequent grading of the results.
Risk of Bias Assessment
The rating of the treatment literature was conducted using
methods recommended by the Cochrane Back Review Group
(CBRG) (http://back.cochrane.org). Only RCTs were rated
for risk of bias using a template adapted from the CBRG. In
this instance, a low risk of biasequates to a high quality
study and high risk of biasequates to low quality.The
CBRG rating instrument for randomized trials identifies 5
inclusion criteria scored yesor no.Twelve criteria were
identified for risks of bias that can be scored as low risk
(score 1)or high risk (score 0)/unclear (score 0)as follows:
1. Was the method of randomization adequate?
2. Was the treatment allocation concealed?
3. Was the patient blinded to the intervention?
4. Was the care provider blinded to the intervention?
5. Was the outcome assessor blinded to the intervention?
Fig 1. Screening flowchart. RCT, randomized controlled trial. (Color version of figure is available online.)
44 Journal of Manipulative and Physiological TherapeuticsBryans et al
January 2014Neck Pain Clinical Practice Guideline
6. Were incomplete outcome data adequately addressed?
7. Are reports of the study free of suggestion of selective
outcome reporting?
8. Were the groups similar at baseline regarding the
most important prognostic indicators?
9. Were cointerventions avoided or similar in all groups?
10. Was compliance acceptable in all groups?
11. Are all patients reported and analyzed in the group to
which they were allocated (intention-to-treat)?
12. Was the timing of outcome assessment similar in all
groups?
No weighting factor was applied to individual criteria, and
possible bias ratings ranged from 0 (greatest number of risk of
bias criteria) to 12 (no risk of bias criteria). Observational
studies, case series, or case reports were excluded because of
their uncontrolled nature and inappropriate design to assess
treatment effect.
In many instances (particularly when the intervention is a
form of manual therapy), it is difficult (if not impossible) to
blind either the participant or care provider. Therefore criteria 3
and 4 were scored low risk only when blinding was reported
and deemed to be possible by the raters. Whenever an outcome
was determined by a participant-directed questionnaire (eg,
Neck Disability Index), the outcome assessor was considered to
be free of bias (criterion 5). Where the baseline characteristics
of study groups have not undergone statistical analysis, the
source of bias (criterion 8) was scored high risk, unless all
significant prognostic indicators were similar upon inspection
by the raters. In studies that tested the immediate effectof an
intervention, the domains of cointervention (criterion 9) and
compliance (criterion 10) for the rating instrument were
deemed to be not applicable(N/A). In these cases, rather than
artificially inflating the scores by rating these domains as low
risk, the domain was not scored and the score totalled out of 10
rather than 12. When the identified sources of bias (method of
randomization, allocation concealment, blinding, reporting of
missing data, cointerventions, compliance, or intention-to-
treat) were not reported, a high risk was scored.
Two assessors (R.R. and J.G.) independently rated the
literature for risk of bias and were not blinded as to study
authors, institutions, and source journals. Two members of the
ERT (M.D. and L.S.) corroborated quality rating methods by
completing quality assessments on a subset of 8 citations.
Consensus of all individual ratings was established by
discussion among the ERT.
Studies are rated as having a low risk of bias when at least
50% of CBRG criteria were met (ie, 6/12 or 5/10 for scores
of 10). Studies with fewer than 50% of the criteria met were
rated as having a high risk of bias. There is empirical
evidence from a methodological study conducted with data
from the CBRG that a scoring threshold of less than 50% of
the criteria is associated with bias.
10
A high level of
agreement was confirmed across quality ratings. Complete
agreement on all items was achieved for most studies. All
discrepancies were easily resolved through discussion.
Grading the Strength of Treatment Recommendations
Recent advances in the development of treatment recom-
mendations have led to a systematic approach to developing
and grading the recommendations that aid in interpretation and
minimizes bias.
11
A comparable approach has been used by
the Cochrane Collaboration (http://back.cochrane.org/) and has
been adapted here. The results of the RCTs in each treatment
category were evaluated by the GDC for factors concerning the
final interpretation of the results for grading as reported in the
Literature Summary. These factors included limitations in
study design and/or execution, inconsistency of results,
indirectness of evidence, imprecision of results, and clinical
Table 2. Categories of treatment modality
Category No. Rationale for inclusion
1 Acupuncture 10 Previously established GDC
exclusion criterion
2 Cervical Pillow 3 Insufficient evidence
for recommendations
3 Collar 1 Insufficient evidence
for recommendations
4 Diathermy 1 Insufficient evidence
for recommendations
5 Patient Education 11 Category combined with Exercise.
6 Exercise 67 Included
7 Flexion-Distraction 1 Included in the traction group
8 Laser 14 Included
9 Magnetic
stimulation
1 Not deemed to be a commonly
used intervention
10 Manipulation 46 Included
11 Manual therapy 28 Included. Some articles included more
appropriately assigned to the
manipulation or mobilization groups
12 Massage 5 Included
13 Mobilization 24 Included
14 Neuroemotional
technique
1 Not deemed to be a commonly
used intervention
15 Physical activity 5 Articles included in exercise
16 Physiotherapy 4 Articles included in exercise,
manipulation, or mobilization
17 Postural
reeducation
1 Article included in exercise
18 Pulsed
electromagnetic
energy
6 Evidence excessively heterogeneous
19 Rehabilitation 7 Articles included in exercise
20 Relaxation 1 Article included in exercise
21 Resistance training 3 Articles included in exercise
22 Rolfing 1 Article included in massage
23 Sustained natural
apophyseal glide
1 Article included in exercise
24 TENS 4 Included
25 Thoracic
manipulation
15 Included
26 Traction 8 Included
27 Trigger point
therapy
2 Included
GDC, Guidelines Development Committee; TENS, transcutaneous nerve
stimulation.
45Bryans et alJournal of Manipulative and Physiological Therapeutics
Neck Pain Clinical Practice GuidelineVolume 37, Number 1
relevance. To assign an overall strength of recommendation
(strong, moderate, weak, or inconsistent), the GDC considered
the number, quality, and consistency of research results.
A strong recommendation was considered only when 2 or
more low-risk-of-bias RCTs had consistent findings and
were free of limiting factors. Recommendations were graded
moderatewith the support of 2 or more low-risk-of-bias
RCTs with limiting factors, or 1 high-quality RCT free of
limiting factors. A weakrecommendation is supported by
only 1 low-risk-of-bias RCT with methodological flaws. In
instances where conflicting evidence (inconsistency of
results) was found, the GDC reviewed all study findings
to determine if these differences could be resolved, for
example, a clear prevalence of positive studies over negative
studies. Whenever the differences were resolved, the
recommendation was graded (strong, moderate or weak)
according to the number and ratio of positive to negative
studies. Recommendations for practice were developed in
collaborative working group meetings. No recommenda-
tions were made when consistent findings could not be
established or if there was no evidence (Table 1).
Use of SRs
Systematic reviews were identified as a source of
comparison for the recommendations developed for this
guideline. The SRs were assessed by the ERT for quality using
procedures described by Oxman and Guyatt.
12
Quality rating
of SRs included 9 criteria answered by yes (score 1) or no
(score 0)/do not know (score 0) and a determination of overall
scientific quality (no flaws, minor flaws or major flaws), based
on the literature raters' answers to the 9 items. Possible ratings
ranged from 0 to 9. Systematic reviews scoring more than half
of the total possible rating (ie, 5) with no or minor flaws
were rated as high quality. Systematic reviews scoring 4 or
less and/or having major flaws identified were excluded.
RESULTS
Literature Screening and Ratings
The search identified 555 citations that were subsequently
augmented by a hand search of the SRs, for a total of 560
publications. Level 1 (title and abstract) reduced this number
to 237 (Fig 1). These citations were categorized by treatment
modality and the categories, number of selected articles, and
reason(s) for inclusion are presented in Table 2.Intotal,10
interventions (treatment categories) were identified by the
ERT for the evidence to be assessed for risk of bias. Level 2
(full-text methodology and relevance) reduced this number to
195. Level 3 (screening controlled clinical trials, RCTs, and
systematically conducted reviews) further reduced the number
of citations to 65 controlled trials and 27 SRs. Duplicate
citations were removed, and the remaining articles were
retrieved as electronic and/or hard copies for detailed analysis.
Level 4 (full-text final screening for relevant clinical content
and elimination of high risk of bias studies) produced 41
citations (Tables 3 and 4) that were used to develop the
recommendations. In the discussion, findings of 24 SRs are
compared with the recommendations of this CPG. Excluded
citations (RCTs and SRs) are shown in Table 5.
Treatment Recommendations
Manipulation
Manipulation/MultimodalAcute Neck Pain. Spinal ma-
nipulative therapy is recommended for the treatment of acute
neck pain for both short- and long-term benefit (pain and the
number of days to recover) when used in combination with
other treatment modalities (advice, exercise, and mobilization;
grade of recommendationmoderate). This recommendation
is based on 3 low-risk-of-bias studies, 2 with limiting
factors.
20,49,56
These 3 studies used several treatment sessions
(4 and 5, or an average of 15) for 2 or 12 weeks, respectively.
ManipulationChronic Neck Pain. Spinal manipulative
therapy is recommended in the treatment of chronic neck
pain for short- and long-term benefit (pain, disability; grade
of recommendationweak). This recommendation is
based on 1 low-risk-of-bias study with a limiting factor
54
that used 2 treatments per week for 9 weeks.
Manipulation/MultimodalChronic Neck Pain. Spinal
manipulative therapy is recommended in the treatment of
chronic neck pain as part of a multimodal approach (including
advice, upper thoracic high velocity low amplitude thrust, low-
level laser therapy, soft tissue therapy, mobilizations, pulsed
short wave diathermy, exercise, massage, and stretching) for
both short- and long-term benefit (pain, disability, cROMs;
grade of recommendationstrong). This recommendation
was graded strong owing to 2 low-risk-of-bias studies.
30,69
This recommendation is also supported by 5 low-risk-of-
bias studies with limiting factors that used a number of
treatments over several weeks, in addition to assessing the
impact of a single treatment over the short term.
19,32,52,58,64
Mobilization
Mobilization/MultimodalAcute Neck Pain. Mobiliza-
tion is recommended for the treatment of acute neck pain
for short-term (up to 12 weeks) and long-term benefit (days
to recovery, pain) in combination with advice and exercise
(grade of recommendationmoderate). This recommendation
is supported by 2 low-risk-of-bias studies with limiting
factors.
20,49
Leaver et al
49
used 4 treatment sessions over a
2-week period.
MobilizationChronic Neck Pain. Mobilization is recom-
mended for the treatment of chronic neck pain for short-term
(immediate) benefit (pain, cROM; grade of recommendation
46 Journal of Manipulative and Physiological TherapeuticsBryans et al
January 2014Neck Pain Clinical Practice Guideline
Table 3. Risk of bias ratings
a
Citation Criteria
Risk of bias
Score123456789 10 1112
Andersen et al
13
√√4/12
Andersen et al
14
√ √ √√√ 5/12
Andersen et al
15
√√√√√√ √ √ 11/12
Aquino et al
16
√ √ √√√√√N/A N/A √√ 9/10
Blikstad and Gemmell
17
√ √√√ N/A N/A √√ 7/10
Borman et al
18
√√3/12
Boyles et al
19
√√ √ √ 6/12
Bronfort et al
20
√√√ √ √ 8/12
Chiu et al
21
√√ √ √ 7/12
Chiu et al
22
√√√√ √ √ 9/12
Chiu et al
23
√√ √ √ 7/12
Chow et al
24
√√√√√√ √ √ √ 11/12
Cleland et al
25
√√√ √ N/A N/A 6/10
Cleland et al
26
√√√√ √ √ 8/12
Cunha et al
27
√√ √ √3/12
Dellve et al
28
√√ √ √4/12
Dundar et al
29
√√√√ √ √ 9/12
Dunning et al
30
√√√√ √ √ 9/12
Dusunceli et al
31
√√ √ √ 6/12
Dziedzic et al
32
√√√8/12
Escortell-Mayor et al
33
√√√√ √ √ 8/12
Gemmell et al
34
√√√ √ N/A N/A √√ 7/10
González-Iglesias et al
35
√√ √√√√ √ √ 10/12
González-Iglesias et al
36
√√√√√√√ √ √ 11/12
Griffiths et al
37
√ √ √ √√√ 9/12
Häkkinen et al
38
√√√√√ 7/12
Häkkinen et al
39
√√6/12
Helewa et al
40
√√√9/12
Hoving et al
41
√√√√ √ √ 9/12
Jay et al
42
√√√√√√√√ √ √ 11/12
Jellad et al
43
√√√√ 6/12
Kanlayanaphotporn et al
44
√ √ √√√√ 8/12
Klaber Moffett et al
45
√√ √ √ 6/12
Krauss et al
46
√√√√ √ √ 8/12
Lansinger et al
47
√√√ √ √ 7/12
Lau et al
48
√√√√ √ √ 8/12
Leaver et al
49
√√√ √ √ √ 9/12
Ma et al
50
√√ √ √ 5/12
Martel et al
51
√√√√√√√ √ √ 11/12
Martinez-Segura et al
52
√√ √ √N/A N/A 6/10
McReynolds and Sheridan
53
√√ √N/A N/A 3/10
Muller and Giles
54
√√ √ √ 7/12
Pool et al
55
√√√ √6/12
Puentedura et al
56
√√√ √ √ 8/12
Reid et al
57
√√ √√√√√ √ √ 10/12
Saayman et el
58
√√√√ √ √ 9/12
Salo et al
59
√ √ √√√√ 8/12
Schomacher
60
√√√ N/A N/A √√ 6/10
Sherman et al
61
√√ √ √7/12
Sillevis et al
62
√ √ √√√N/A N/A 6/10
Sjögren et al
63
√√ √ √ 6/10
Skillgate et al
64
√√√√ √ √ 9/12
Sutbeyaz et al
65
√√√ √√ √ 8/12
Tuttle et al
66
√√2/12
Vitiello et al
67
√√√ √ √ 7/12
Vonk et al
68
√√√ √ √ 8/12
Walker et al
69
√√√√ √ √ 8/12
Ylinen et al
70
√√4/12
Ylinen et al
71
√√√√ √ √ 6/12
Ylinen et al
72
√√√ 4/12
(continued on next page)
47Bryans et alJournal of Manipulative and Physiological Therapeutics
Neck Pain Clinical Practice GuidelineVolume 37, Number 1
moderate). This recommendation is based on 3 low-risk-
of-bias studies with limiting factors.
16,44,60
Manual Therapy
Manual Therapy/MultimodalChronic Neck Pain. Man-
ual therapy is recommended in the treatment of chronic neck
pain for the short- and long-term benefit (pain, disability,
cROM, strength) in combination with advice, stretching,
and exercise (grade of recommendationstrong). This
recommendation is based on 2 low-risk-of-bias studies.
38,73
This recommendation is also supported by 2 low-risk-of-
bias studies with limiting factors.
32,55
Exercise
ExerciseAcute Neck Pain. Home exercise with advice or
training is recommended in the treatment of acute neck pain
for both long- and short-term benefits (neck pain; grade of
recommendationweak). This recommendation is based on 1
low-risk-of-bias study with a limiting factor.
20
This study used
a regime of daily home exercise (6-8 repetitions per day) for
12 weeks with two 1-hour advice/training sessions 1 to 2
weeks apart.
ExerciseChronic Neck Pain. Regular home stretching
(3-5 times per week) with advice/training is recom-
mended in the treatment of chronic neck pain for long-
and short-term benefits in reducing pain and analgesic
intake (grade of recommendationstrong). This recom-
mendation is based on 3 low-risk-of-bias studies.
38,39,73
Home strengthening and endurance exercises with advice/
training/supervision are recommended for both short- and long-
term benefits (neck pain, cROM) in the treatment of chronic
neck pain (grade of recommendationstrong). This recom-
mendation is based on 4 low-risk-of-bias studies.
39,47,69,75
One
additional study with a limiting factor
63
supported this
recommendation. In all 5 studies, regular home exercises
were performed daily to 3 times per week. Two additional low-
risk citations with limiting factors
32,40
found exercises of no
benefit. Despite the conflicting results, this recommendation
was graded strong owing to the 4 low-risk-of-bias studies.
Exercise/MultimodalChronic Neck Pain. Exercise (in-
cluding stretching, isometric, stabilization, and strengthening)
is recommended for short- and long-term benefits (pain,
disability, muscle strength, QoL, cROM) as part of a
multimodal approach to the treatment of chronic neck pain
when combined with infrared radiation, massage, or other
physical therapies (grade of recommendationstrong). This
recommendation is based on 4 low-risk-of-bias
studies.
21,22,31,71
Exercises were typically done 2 to 5 times
per week for several weeks.
Laser
LaserChronic Neck Pain. Based on inconsistent findings
from 3 low-risk-of-bias studies,
24,29,58
there is insufficient
evidence that supports a recommendation for the use of
infrared laser (830 nm) in the treatment of chronic neck pain.
Massage
Massage/MultimodalChronic Neck Pain. Massage is
recommended for the treatment of chronic neck pains for
short-term (up to 1 month) benefit (pain, disability, and
cROM) when provided in combination with self-care,
stretching, and/or exercise (grade of recommendation
moderate). This recommendation is based on 1 low-risk-of-
bias study
76
and 1 low-risk-of-bias study with a limiting
factor.
61
In both studies, 5 to 10 upper body/neck massage
sessions lasting 1 hour to 75 minutes were provided.
Transcutaneous Nerve Stimulation
Transcutaneous Nerve Stimulation/MultimodalChronic
Neck Pain. There is insufficient evidence that supports a
recommendation for transcutaneous nerve stimulation
(TENS) for the treatment of chronic neck pain. This
conclusion is based on 1 low-risk-of-bias study with more
than 1 limiting factors.
22
Thoracic Manipulation
Thoracic ManipulationAcuteNeckPain. Based on
inconsistent findings from 2 low-risk-of-bias studies,
35,56
there is insufficient evidence that supports a recommenda-
tion for the use of thoracic manipulation in combination with
Table 3. (continued)
Citation Criteria
Risk of bias
Score123456789 10 1112
Ylinen et al
73
√√5/12
Ylinen et al
74
√√√√ √ √ 6/12
Ylinen et al
75
√√ √ √ 6/12
Zaproudina et al
76
√√√ 8/12
a
In previous guidelines, we have assessed the literature using a quality-measuring tool
6
that would rate studies as being either high or low quality.
48 Journal of Manipulative and Physiological TherapeuticsBryans et al
January 2014Neck Pain Clinical Practice Guideline
Table 4. Literature summary
Study Treatment Comparators Outcomes Score Comments
Adverse
events
Acute neck pain
Blikstad and
Gemmell
17
Trigger point therapy
(N = 15; N = 15)
Sham US cROM 7/10
a
- Higher percentage of
participants improved
(immediate)
Not
recorded
- Subacute (4 12 wk)
Bronfort et al
b20
Manipulation (N = 91)
with mobs
Medication, HEA Pain 8/12 - Small to moderate effect
size; participants include
subacute participants
None
reported
Patient education
(N = 91) - Short- and long-term
benefit
- Home exercise with
advice is superior to
medication and
comparable with spinal
manipulative therapy
Gemmell et al
34
Trigger point therapy
(N = 15; N = 15)
Sham US Pain, cROM 7/10
a
- Clinical significance with
ischemic compression
(immediate)
Not
recorded
- Acute and subacute pain
b3mo
González-Iglesias
et al
b35
Thoracic manipulation
(N = 23)
Electrotherapy Pain, disability,
mobility
11/12 - Relatively small
experimental group size
(N = 23)
Not
recorded
- Improvement as part of a
multimodal approach in
combo with
electrotherapy
- Pain duration b1mo
Leaver et al
b49
Manipulation (N = 91) Mobilization Days to recovery 9/12 - Large confidence interval;
small clinical changes
Minor
events
reported
ManipulationMobilization (N = 91)
- As good as mobilization
- May include advice
+ exercise
- Participants with
b3-mo duration
Pool et al
b55
Manual therapy
(N = 75)
Behavioral graded
activity
Pain, disability 6/12 - All participants were of
subacute symptom duration
Not
recorded
- No differences found
- Exercise + advice
b
Puentedura
et al 2011
56
Manipulation (N = 14) Thoracic
manipulation
Pain, disability 8/12 - Small group size (N = 14) None
reportedThoracic manipulation
(N = 10)
- Netter than thoracic
manipulation + exercise
Chronic neck pain
Aquino et al
16
Mobilization (N = 24) Mobilization at
random level
Pain 9/10
a
- Small experimental group
size (N = 24)
None
reported
- Comparable benefit in
both groups (immediate)
Boyles et al
b19
Manipulation (N = 23) Nonthrust
techniques
Pain, disability 6/12 - Participants pre-dominantly
chronic but include acute
as well
None
reported
- No better than nonthrust
- MPT + exercise
Chiu et al
b21
Patient education Control
(nonexercise)
Pain, disability,
muscle strength
7/12 - Benefit for exercise + IRR None
reportedExercise or stretching
(N = 67)
Chiu et al
b22
Patient education TENS, IRR Pain, muscle
strength
9/12 - Effects are small and not
clinically relevant
None
reportedExercise or stretching
(N = 67)
TENS (N = 73)
- Best results with TENS
+ exercise
(continued on next page)
49Bryans et alJournal of Manipulative and Physiological Therapeutics
Neck Pain Clinical Practice GuidelineVolume 37, Number 1
Table 4. (continued)
Study Treatment Comparators Outcomes Score Comments
Adverse
events
Chronic neck pain (continued)All groups including IRR
Chiu et al
23
Traction (N = 39) Placebo IRR Pain, disability,
cROM
7/12 - Not superior to placebo None
reported
Chow et al
24
Laser (N = 45) Placebo Pain, disability,
QoL
11/12 - Improvement with
laser treatment
Minor
events
reported- More frequently
in control group
Dundar et al
b29
Laser (N = 32) Placebo Pain, disability,
QoL
9/12 - No improvement
over placebo
None
reported
- Including exercise
and stretching
Dunning et al
30
Manipulation Nonthrust
techniques
Pain, disability 9/12 - More effective than
nonthrust in the short term
None
reportedThoracic
manipulation
(N = 56)
- Combination of cervical
and thoracic thrusting
+ advice was effective
- mean duration N300 d
Dusunceli et al
b31
Patient education
(N = 60)
PT, stretching Medication,
disability, cROM
6/12 - Superiority of the neck
stabilization exercises +PT
Not
recorded
Exercise
(N = 19; N = 19)
- Predominantly chronic
(average 40 mo.)
Dziedzic et al
b32
Patient education
(N = 60)
MT, pulsed short-
wave diathermy
Disability 8/12 - Some participants are of
acute symptom duration and
small clinical effects
None
reported
Exercise (N = 115;
N = 115; N = 121) - No significant differences
- MT + advice + exercise
- Most with neck pain N3mo
Häkkinen et al
38
Manual therapy
(N = 62)
Exercise crossover Pain, neck strength,
and mobility
7/12 - Clinically relevant changes
not due specifically to
manual therapy alone
None
reported
Exercise or
stretching (N = 125) - Short-term benefit
for both
Häkkinen et al
39
Patient education Strength training and
stretching
Pain, disability,
cROM, strength
6/12 - Small but clinically
relevant changes
Not
recordedExercise or stretching
(N = 49; N = 52) - No differences
- 1-y follow-up from 2007
Helewa et al
b40
Exercise
(N = 49; N = 33)
Massage, pillow,
active exercise
Pain 9/12 - No difference None
reported- Including heat or
cold pack
Kanlayanphotporn
et al
44
Mobilization
(N = 30)
Varied mobilization
approaches
Pain, cROM 8/12 - Small experimental
group size (N = 30)
None
reported
- Comparable benefit
for pain
- Mean duration N1500 d
Lansinger et al
47
Patient education Qigong Pain, disability,
cROM
7/12 - Large confidence interval Not
recordedExercise or stretching
(N = 62)
- No difference
- Ergonomic advice
- 1-5 y in duration
Lau et al
b48
Thoracic manipulation
(N = 60)
IRR and education Pain, disability,
QoL
8/12 - Greater improvement None
reported- Both groups received IRR
Martinez-Segura
et al
52
Manipulation (N = 34) Manual mobilization Pain, cROM 6/10
a
- Some participants of acute
symptom duration
Not
recorded
- More immediate benefit
than control mobilization
- At least 1 mo.; mean
~4 mo
Muller and Giles
54
Manipulation (N = 25) Medication,
acupuncture
Pain, disability 7/12 - Relatively small effect size
and experimental group size
(N = 25)
Not
recorded
- Best long-term benefit
50 Journal of Manipulative and Physiological TherapeuticsBryans et al
January 2014Neck Pain Clinical Practice Guideline
Table 4. (continued)
Study Treatment Comparators Outcomes Score Comments
Adverse
events
Chronic neck pain (continued)
Saayman et al
b58
Laser (N = 20; N = 20) CMT Pain, disability,
cROM
9/12 - Some participants may be of
acute symptom duration; small
to moderate effect size; small
experimental group size
(N = 20)
None
reported
- All treatment groups
improved; no difference
- CMT + LLLT
most effective
- 1-12 mo in duration
Schomacher
60
Mobilization (N = 59;
N = 67)
Mobilization at
adjacent segment
Pain 6/10
a
- Used several different
mobilization techniques;
no significant difference
None
reported
-As good as
- NP duration N70 mo
Sherman et al
b61
Massage (N = 32) Self-care Disability 7/12 - Small effects size; relatively
small experimental group size
(N = 32)
None
reported
- Clinical benefit
- May include self-care and
exercise
Sillevis et al
62
Thoracic manipulation
(N = 50)
Sham manipulation Pain 6/10
a
- No difference shown None
reported- Immediate effect
Sjögren et al
b63
Patient education Crossover Intensity of
symptoms
6/12 - Pain experienced sometime
in the previous 12 mo; small
clinical effects and large
confidence interval
None
reportedExercise or stretching
(N = 53)
- Significant
improvement
- Advice on posture
and movement
Skillgate et al
b64
Manual therapy
(N = 206)
Naprapathic care,
advice
Pain, disability 8/12 - Participants predominantly
chronic but include acute
as well
None
reported
- MT effective in short
term
- Multimodal
- Mixedminimum 2 wk;
majority N12 mo
Sutbeyaz et al
65
Electrotherapy
(N = 18)
Placebo Pain, disability 8/12 - Significant improvement
immediately after treatment
Not
recorded
- Unconventional
electrotherapy
Vitiello et al
67
Electrotherapy
(N=9;N=7)
TENS, sham Pain, disability,
function, QoL
7/12 - Significant improvement in
all outcomes with ENAR
None
reported
- Unconventional
electrotherapy
Walker et al
b69
Patient education
(N = 47)
GP care Pain, disability 8/12 - MT with stretching
more effective
None
reported
Manual therapy
exercise (N = 47)
- Average duration N500 d
Ylinen et al
b71
Patient education Control Pain, disability 6/12 - Effective strength
and endurance training
Not
recordedExercise or stretching
(N = 60; N = 60) - Multimodal
(PT, massage, mobs)
Ylinen et al
b73
Manual therapy (N = 62) Stretching exercises
crossover
Pain, disability 6/12 - Both were effective Not
recorded- MT + exercisePatient education
(continued on next page)
51Bryans et alJournal of Manipulative and Physiological Therapeutics
Neck Pain Clinical Practice GuidelineVolume 37, Number 1
electrotherapy or exercise for the treatment of acute
neck pain.
Thoracic ManipulationChronic Neck Pain. Based on
inconsistent findings from 3 low-risk-of-bias studies,
30,48,62
there is insufficient evidence that supports a recommenda-
tion for the use of thoracic manipulation for the treatment of
chronic neck pain.
Traction
TractionChronic Neck Pain. There is insufficient
evidence to support a recommendation for intermittent
mechanical traction for the treatment of chronic neck pain.
This conclusion is based on 1 low-risk-of-bias study
23
that
found no additional improvement in pain or disability after
10 to 12 treatment sessions when combined with nonther-
apeutic infrared irradiation.
Trigger Point Therapy
Trigger Point TherapyAcute Neck Pain. There is
insufficient evidence that supports a recommendation for
activator, ischemic compression, and trigger point pressure
release for the treatment of acute neck pain based on 2 low-
risk-of-bias studies.
17,34
Both studies report a clinical
improvement, but there was no indication of a significant
statistical change.
DISCUSSION
In this guideline, recommendations have been developed
that updates the body of evidence supporting chiropractic
treatment of neck pain. These recommendations offer a broad
range of evidence-based treatment options for practitioners to
use in patient-centered care. The development of these
Table 4. (continued)
Study Treatment Comparators Outcomes Score Comments
Adverse
events
Chronic neck pain (continued)
Ylinen et al
75
Patient education Strength, endurance
and stretching
Pain, disability 6/12 - Large but variable
clinical effects
Not
recordedExercise or stretching
(N = 57; N = 59; N = 63) - Strength and endurance
exercise more effective than
stretching
Zaproudina
et al
b76
Massage (N = 33) PT, TBS Pain, disability,
mobility
8/12 - No difference Not
recorded- PT including massage +
exercise + stretching
Variable duration neck pain
Cleland et al
25
Thoracic manipulation
(N = 19)
Placebo Pain, disability 6/10
a
- Immediate pain relief None
reported- Mixed (12 wk
average duration)
Cleland et al
26
Thoracic manipulation
(N = 17)
Nonthrust Pain, disability 8/12 - Thrust results in significantly
better improvement
(immediate)
Not
recorded
- Mixed average duration
~55 d
Escortell-Mayor
et al
b33
Manual therapy
(N = 47)
TENS, MT Pain, disability,
QoL
8/12 - No differences found + advice
+ home exercise
None
reported
TENS (N = 43) - Mixed; mean ~ 140 d
Hoving et al
b41
Manual therapy
(N = 60)
PT, GP care Pain, disability 9/12 - MT showed early
improvement
None
reported
- Including exercise + home
exercise
- Mixedminimum 2 wk
Jellad et al
b43
Traction
(N = 13; N = 13)
Standard rehab Pain, disability 6/12 - Improvement as part of a
multimodal approach
(standard rehab)
Not
recorded
- Mixedonset previous
3 mo at enrollment
CMT, cervical manipulative therapy; cROM, cervical range of motion; ENAR, Electro neuro adaptive regulator; GP, general practitioner; HEA, home
exercise with advice; IRR, infrared radiation; LLLT, low-level laser therapy; MPT, manipulative physical therapy; MT, manual therapies; PSWD, pulsed
short wave diathermy; PT, physical therapies; QoL, quality of life; TBS, traditional bone setting; TENS, transcutaneous nerve stimulation; US, ultrasound.
N = number of participants in experimental group. Adverse events: Not recordedindicates that there were no notes of participants being asked about any
adverse events; None reportedindicates that participants were asked about adverse events but there were none to report.
a
Studies with immediate outcomes after the intervention were scored out of 10 for risk of bias.
b
Multimodal intervention(s).
52 Journal of Manipulative and Physiological TherapeuticsBryans et al
January 2014Neck Pain Clinical Practice Guideline
recommendations reflects the most recent evidence (2004 or
later), which is limited to low-risk-of-bias studies. Wherever
possible, recommendations were made for each of the
treatment modalities identified as relevant to common
chiropractic practice and for which current evidence was
available. Limitations in the current evidence are described
and used in making suggestions for advancing the quality of
future research.
During review of the materials, a generalizable weakness
of the studies was noted including the heterogeneity of
treatment protocols (ie, the use of a primary intervention in
combination with other therapeutic treatments). For
Table 5. Citations excluded after rating and data extraction
Citation Score Rationale
RCTs
Andersen et al
13
4/12 - High risk of bias
- Study compared different forms of exercise
Andersen et al
14
5/12 - Participants with neck pain also experiencing pain at other locations
- Not the objective of this guideline to address neck pain in participants with co-morbidities
- High risk of bias
Andersen et al
15
11/12 - Healthy participants. Study focused on reducing the frequency and intensity of painful episodes
in participants prone to neck/shoulder pain.
Borman et al
18
3/12 - High risk of bias
Cuhna et al
27
3/12 - High risk of bias
- Study compared effectiveness of different forms of exercise
Dellve et al
28
4/12 - High risk of bias
- Study was focused on work ability rather than pain reduction
González-Iglesias et al
36
11/12 - Results included in González-Iglesias et al
36
Griffiths et al
37
9/12 - The study was not designed to provide evidence for the effectiveness of general exercise,
for nonspecific neck pain.
Jay et al
42
11/12 - Participants are drawn from a population with a high prevalence of musculoskeletal symptoms.
There is no assessment of the duration of neck pain only baseline and subsequent intensity.
Klaber Moffett et al
45
6/12 - Not all participants are identified as having chronic pain (51 78%).
- Approximately 2/3 of the randomized participants were low backrather than neck.
Not possible to separate
Konstantinovic et al
77
10/12 - Participants with radiating arm pain
- Relatively small experimental group (N = 30)
Krauss et al
46
8/12 - Insidious onset of neck pain. No chronicity was identified.
Ma et al
50
5/12 - High risk of bias
- Study focused on the comparative effect of biofeedback
Martel et al
51
11/12 - This study focused more on the preventive benefits of manipulation rather than the effect on
active cases of acute or chronic neck pain.
McReynolds and Sheridan
53
3/10 - High risk of bias
- Group size was exceedingly small (N = 7, 11)
Reid et al
57
10/12 - Sustained natural apophyseal glide was not considered a commonly used/known intervention
Salo et al
59
8/12 - No measures of pain or cROM although neck pain was assessed at baseline.
- Primary outcome was QoL
Sutbeyaz et al
65
8/12 - Unconventional form of pulsed electromagnetic frequency
Tuttle et al
66
2/12 - High risk of bias
- Failed to meet all inclusion criteria
Vitiello et al
67
7/12 - Unconventional therapy
Vonk et al
68
8/12 - The focus of this study was a comparison of Behavior Graded Activity and conventional exercise,
both of which are combined with massage and/or mobilizations. Unfortunately, there's no description
of the actual exercises or how frequently they were done.
Ylinen et al
70
4/12 - High risk of bias
- Study used pressure pain thresholds in levator and traps rather than traditional
measures of neck pain or cROM
Ylinen et al
72
4/12 - High risk of bias
Ylinen et al
74
5/12 - High risk of bias
Cochrane/SRs
Ezzo et al
78
7/9 - Duplication of Haraldsson et al
91
Jensen and Harms-Ringdahl
79
4/9 - Low rating score
- Major flaws
Ylinen
80
2/9 - Low rating score
- Major flaws
cROM, cervical range of motion; QoL, quality of life; RCT, randomized controlled trial.
53Bryans et alJournal of Manipulative and Physiological Therapeutics
Neck Pain Clinical Practice GuidelineVolume 37, Number 1
example, many of the studies on manipulation were
pragmatic and therefore included exercises, advice, and
soft tissue work, thus making it difficult or impossible to
isolate the therapeutic effect as a stand-aloneinterven-
tion. When therapies are combined, for example, the use
of manipulation with electrotherapy or exercise, it was
sometimes possible to address making recommendations
for the particular intervention when provided in combi-
nation with.In other instances, interventions are provided
in combination with so many other treatment modalities,
for example, manipulation with exercise, advice, stretch-
ing, and pulsed shortwave diathermy, that a recommen-
dation can only be structured for a multimodalform of
intervention. In developing treatment recommendations
for multimodal interventions, the GDC considered the
manner in which practitioners would apply them. We
believe that, in many instances, the practitioner uses more
than 1 treatment modality in the management of patients
with nonspecific neck pain. All studies in which
participants received more than 1 intervention or in-
terventions in addition to the primary intervention being
investigated are noted, and the recommendation was
referenced as multimodal.
Several of the treatment recommendations in this
document are diminished by some of the studies that
based findings on too few study participants. Specific
studies of low subject numbersare identified and
recorded in The Literature Summary (Table 4). Although
this limitation was considered a contributing factor to the
imprecision of results and, ultimately, clinical relevance,
our recommendations would be fortified by greater
participant numbers and clinical relevance.
The inclusion of participants with variable duration of
symptoms in a study made it difficult to formulate
recommendations. In some cases, it was impossible to
determine whether the observed effects (or lack of effect)
of an intervention was caused by its impact on
participants with acute, subacute, or chronic neck pain.
Valuable data may have been missed in excluding studies
in which the chronicity of the pain among the participants
could not be determined (see above). Despite the positive
outcomes reported, no recommendations could be formu-
lated for neck pain of variable duration for the manual
therapy,
33,41
TENS,
33
thoracic manipulation,
25,26
or
traction
43
interventions.
Developing treatment recommendations related to the
diversity of interventions reported as exercise (stability,
mobility, relaxation, rehabilitation, range of motion, strength
and endurance exercises, as well as stretching) was
challenging. Although few studies are directly comparable
in terms of the form of exercise used as the intervention, all
demonstrated a degree of benefit for the participant.
Similarly, the breadth, diversity, and understanding of
the intervention described as patient education (advice,
training, supervision, and instruction of any kind provided
to the patient) were a challenge. Many of the studies
reported the inclusion of patient education (either generally
or very specifically). In this article, the 11 RCTs identified
as patient education were allocated to the exercise category
because they specifically dealt with patient education and
exercise. All encounters between the patient and practi-
tioner incorporate at least some form of education to the
patient. This component of care is essential when directing
a patient for the elements of active care (eg, exercise). In
addition, patients receiving the described interventions of
passive care (eg, manipulation, mobilization, massage, etc)
are also educated with regard to diagnostic, investigative,
and treatment procedures; anticipated outcomes; potential
adverse events; informed consent, and so on. Whenever the
author(s) of a study has included an element of patient
education as part of the treatment protocol, it has been
included as part of the recommendation.
Comparison with SRs
As a result of the search and screening process, 24 current
(2005 or later) SRs were identified that assessed the literature
with regard to therapeutic benefit for the 10 treatment
modalities reviewed in this guideline (Table 6). Although the
SRs are considered current, the literature that they assess
included studies that are sometimes much older. By contrast,
the studies assessed in this guideline were limited to much
more recent publications (2005 or later) and generally reflect
a higher quality (low risk of bias). A number of SRs (N = 13)
assessed the literature for more than 1 treatment modality and,
of these, 7 identified interventions that were delivered in
combination with other therapies (multimodal).
In general, the individual SR findings within an interven-
tion category remained fairly consistent. For example, within
the category of manipulation, 11 of 12 SRs identified by the
search suggested some degree of therapeutic benefit from the
intervention. Similarly, of the 13 SRs for exercise, all but 1
concluded that therapeutic benefit had been evidenced. Eleven
SRs assessed the evidence for only 1 intervention.
In comparing the treatment recommendations of this
guideline with the findings of the relevant SRs, there
would appear to be a general agreement. However,
inconsistency within the SR findings or a paucity of
high-quality evidence precludes complete agreement in the
cases of massage, traction, and trigger point therapy. In
these 3 instances, the SRs predate the studies used in
developing the recommendations.
Adverse Events
There were no serious adverse events reported in any of
the citations used in developing these treatment recom-
mendations. A summary of the adverse event reporting
from the literature summary (Table 4) is shown in Table 7.
Of the 43 studies included in this summary, 14 made no
54 Journal of Manipulative and Physiological TherapeuticsBryans et al
January 2014Neck Pain Clinical Practice Guideline
mention of adverse events. Of the remaining 33, all studies
reported either none or only minor adverse events from a
total of 1682 study participants and several treatment
sessions (on average) per participant.
Considerations for Future Research
Since our original neck pain guideline published in 2005,
6
the number and quality of clinical trials in chiropractic care
have increased significantly. Nonetheless, as a result of our
experience in developing these practice guidelines, we
would suggest the following be considered to help guide
future studies.
We suggest the investigation of treatment interventions
on a stand-alone basis that will allow the treatment
outcomes to be evaluated without the influence of other
forms of care. For example, when manipulative therapy is
provided in combination with exercise, heat, cold, and so
on, the benefit of the intervention becomes difficult to
interpret, especially when the auxiliary therapies have also
been shown to be of benefit.
The use of placebo, control, or sham comparators (whenever
ethical) to determine the efficacy of a stand-alone treatment
intervention is suggested. When comparing the outcomes of 2
or more interventions, it becomes increasingly difficult to
establish if any of the treatment modalities provides anything
more than placebo effect or the natural history of recovery,
especially in instances of acute neck pain. In several instances,
improvements that were identified in patient outcomes were
frequently seen as no better thanor as good as2ormore
interventions. Typically, no references are made to the natural
history or progression of the condition.
A more thorough reporting of adverse events in the course
of conducting a study for the balancing of benefit against risk
Table 6. Review findingsCochrane and SRs
Citation
Intervention
Score
1.
Manipulation
2.
Mobilization
3.
Manual
therapy
4. Exercise
(incl Pat
Educ)
5.
Laser
6.
Massage
7.
TENS
8. Thoracic
manipulation
9.
Traction
10. Trigger
point therapy
Binder
81
5√√ √ ??
Bronfort et al
a82
6
a
a
a
a
Chow and
Barnsley
83
5
Chow et al
84
9
Cross et al
85
7
D'Sylva et al
a86
9√√ √
a
Gemmell and
Miller
87
7? ? ?
Graham et al
88
7 ?
Gross et al
89
9
a
a
a
√√
Gross et al
90
9√√ √
a
Haraldsson
et al
91
7?
Hurwitz et al
a92
7√√
Kay et al
a93
9
a
a
a
Kay et al
94
9
Kroeling et al
95
7?
Leaver et al
a96
9√√
Macaulay et al
a97
7
a
a
Miller et al
a98
9
a
a
a
a
Sargiovannis and
Hollins
99
7?
Sihawong
et al
100
7
Smidt et al
101
7?
Vernon and
Humphreys
102
9√√ ––?
Vernon et al
103
7√√
Walser et al
104
9
Neck pain guideline
Acute
a
a
??
Chronic
a
√√
a
/
a
??? ?
Key: , demonstration of benefit; ?, inconclusive; , no demonstration of benefit.
a
Interventions were delivered in combination with other interventions (multimodal).
55Bryans et alJournal of Manipulative and Physiological Therapeutics
Neck Pain Clinical Practice GuidelineVolume 37, Number 1
when considering treatment options is needed. Although
some studies do report that adverse events were queried and
tracked by the researchers/clinicians, they were frequently
reported as noneor minor,with no additional information
being provided. In other instances, there was simply no
mention of adverse events whatsoever.
We suggest that authors clearly define and identify the
composition of the participant pool in terms of the
duration of symptoms (acute, subacute, and chronic) and
that the reporting of results (outcomes) be separated for
each duration of symptomsgroup. The results of some
studies were reported for groups that included a mix of
participants with acute, subacute, and chronic symptoms.
Consequently, it was not possible to determine if one
group fared better than another or if the response was truly
shared. It appears that the focus of neck pain research
remains on the chronic condition.
In summary, researchers are encouraged to use suitable
controls as experimental comparators. We also suggest a clear
separation of participants with acute and chronic symptoms
within studies as well as a more thorough reporting of the
occurrence or absence of adverse events. The investigation of
treatment modalities on a stand-alone basis is needed.
Limitations
The limitations of this study are consistent with those of
SRs and clinical guidelines development. Although we
made every attempt to include all relevant studies, it is
possible that other relevant literature was missed. This
study is limited in that literature was searched through
December 2011; therefore, more recent literature studies in
the publication process were not included in the recom-
mendations. Thus, best judgement should be used to
incorporate new high-quality evidence.
Although the focus of the guideline development was
on chiropractic treatments, other stakeholders or contri-
butions to what DCs do in practice could have been
missed. The literature searched may have included
procedures that DCs perform, but the research did not
include practicing DCs and thus was omitted from our
study. As with any use of the literature, we are limited by
what has been published. Thus, publication bias may have
an influence in the types of studies or topics included in
our searches.
There are inherent limitations in guideline development.
Expert opinion and interpretation are necessary procedures
for guideline development. Thus, some subjectivity in
judgments is present when assessing the strength of the
evidence. Also, when evidence is lacking, expert opinion
is required.
CONCLUSIONS
The studies included in this guideline indicate that
cervical manipulation, mobilization, manual therapy,
exercise, and massage can be recommended for the
chiropractic treatment of nonspecific, mechanical neck
pain. The strongest recommendations are typically made
for the primary intervention in combination with another
intervention, usually exercise and/or patient education.
Owing to conflicting findings in the literature, no
recommendation could be made for laser, TENS, or
thoracic manipulation in the treatment of chronic neck pain
or for the use of thoracic manipulation in the treatment of
acute neck pain. There is a lack of evidence to support the
use of laser, trigger point therapy, or traction for
nonspecific, mechanical neck pain in adults.
ACKNOWLEDGMENTS
The authors thank the following for assistance during the
preparation of this guideline: members of the Clinical
Practical Applications
Forty-one RCTs were used to develop 11
treatment recommendations.
Recommendations were made for acute neck
pain using exercise and a multimodal approach
to manipulation, mobilization.
Recommendations were also made for chronic
neck pain using manipulation, mobilization,
and exercise and multimodal approaches to
manipulation, manual therapy, exercise and
massage.
Table 7. Adverse events
Intervention No. of studies Total no. of participants
Studies not recording adverse events
Manipulation 2 59
Manual therapy 1 62
Exercise 5 670
Electrotherapy 3 64
Thoracic manipulation 1 17
Trigger point therapy 2 30
Studies having no adverse or serious events reported
Manipulation 4 147
Mobilization 4 180
Manual therapy 5 465
Exercise 6 408
Laser 3 65
Massage 2 55
TENS 3 95
Thoracic manipulation 4 185
Traction 2 52
TENS, transcutaneous nerve stimulation.
56 Journal of Manipulative and Physiological TherapeuticsBryans et al
January 2014Neck Pain Clinical Practice Guideline
Practice Guidelines Task Force (Ron Brady, DC; H. James
Duncan, BFA, CAE; Wanda Lee MacPhee, DC; Keith
Thomson, BSc, DC, ND; Dean Wright, DC) and Jaroslaw
Grod, DC, for literature screening and evidence rating.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST
Sponsorship and funding were provided by the Canadian
Chiropractic Association, Canadian Chiropractic Protective
Association, and the Canadian Federation of Chiropractic
Regulatory and Educational Accrediting Boards (The
Federation). No conflicts of interest were reported for
this study.
CONTRIBUTORSHIP INFORMATION
Concept development (provided idea for the research):
RB, MD, RR, LS.
Design (planned the methods to generate the results):
RB, MD, RR, LS.
Supervision (provided oversight, responsible for orga-
nization and implementation, writing of the manuscript):
RB, MD, RR, LS.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data): RR
Analysis/Interpretation (responsible for statistical anal-
ysis, evaluation, and presentation of the results): RB,
MD, RR, LS.
Literature search (performed the literature search): RR.
Writing (responsible for writing a substantive part of the
manuscript): RB, MD, RR, LS, RW.
Critical review (revised manuscript for intellectual
content, this does not relate to spelling and grammar
checking): RB, PD, MD, Mireille D, HM, BP, LS,
EW, RW.
Editing of manuscript: RR.
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