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REVIEW ARTICLE
Management of neck pain and associated disorders: A clinical
practice guideline from the Ontario Protocol for Traffic Injury
Management (OPTIMa) Collaboration
Pierre Co
ˆ
te
´
1,2
•
Jessica J. Wong
2,3
•
Deborah Sutton
2,3
•
Heather M. Shearer
2,3
•
Silvano Mior
3,4
•
Kristi Randhawa
2,3,5
•
Arthur Ameis
6
•
Linda J. Carroll
7
•
Margareta Nordin
8,9
•
Hainan Yu
2,3
•
Gail M. Lindsay
4
•
Danielle Southerst
10
•
Sharanya Varatharajan
2,3,5
•
Craig Jacobs
2,11
•
Maja Stupar
2
•
Anne Taylor-Vaisey
2
•
Gabrielle van der Velde
12,13,14
•
Douglas P. Gross
15,16
•
Robert J. Brison
17,18
•
Mike Paulden
19
•
Carlo Ammendolia
14,20
•
J. David Cassidy
21,22
•
Patrick Loisel
3,23
•
Shawn Marshall
24
•
Richard N. Bohay
25
•
John Stapleton
26
•
Michel Lacerte
27,28
•
Murray Krahn
20
•
Roger Salhany
29
Received: 4 September 2015 / Revised: 15 February 2016 / Accepted: 15 February 2016
Springer-Verlag Berlin Heidelberg 2016
Abstract
Purpose To develop an evidence-based guideline for the
management of grades I–III neck pain and associated dis-
orders (NAD).
Methods This guideline is based on recent systematic
reviews of high-quality studies. A multidisciplinary expert
panel considered the evidence of effectiveness, safety,
cost-effectiveness, societal and ethical values, and patient
experiences (obtained from qualitative research) when
formulating recommendations. Target audience includes
clinicians; target population is adults with grades I–III
NAD \6 months duration.
Recommendation 1 Clinicians should rule out major
structural or other pathologies as the cause of NAD. Once
Roger Salhany—Retired Judge from the Ontario Superior Court of
Justice, Toronto, Canada
Electronic supplementary material The online version of this
article (doi:10.1007/s00586-016-4467-7) contains supplementary
material, which is available to authorized users.
& Pierre Co
ˆ
te
´
pierre.cote@uoit.ca
1
Canada Research Chair in Disability Prevention and
Rehabilitation, University of Ontario Institute of Technology
(UOIT), 2000 Simcoe Street North, Oshawa, ON L1H 7L7,
Canada
2
UOIT-CMCC Centre for the Study of Disability Prevention
and Rehabilitation, University of Ontario Institute of
Technology (UOIT) and Canadian Memorial Chiropractic
College (CMCC), 6100 Leslie Street, Toronto, ON M2H 3J1,
Canada
3
Graduate Education and Research Programs, Canadian
Memorial Chiropractic College (CMCC), 6100 Leslie Street,
Toronto, ON M2H 3J1, Canada
4
Faculty of Health Sciences, University of Ontario Institute of
Technology (UOIT), 2000 Simcoe Street North, Oshawa,
ON L1H 7L7, Canada
5
Undergraduate Education, Canadian Memorial Chiropractic
College (CMCC), 6100 Leslie Street, Toronto, ON M2H 3J1,
Canada
6
Certification Program in Insurance Medicine and Medico-
legal Expertise, Faculty of Medicine, University of Montreal,
N-414, Roger-Gaudry Building, 2900, Boulevard Edouard-
Montpetit, Montreal, QC H3T 1J4, Canada
7
Injury Prevention Centre and School of Public Health,
University of Alberta, 3-300 Edmonton Clinic Health
Academy, 11405 – 87 Ave, Edmonton, AB T6G 1C9, Canada
8
Department of Orthopedic Surgery, Occupational and
Industrial Orthopedic Center, NYU School of Medicine, New
York University, 550 1st Avenue, New York, NY 10016,
USA
9
Department of Environmental Medicine, Occupational and
Industrial Orthopedic Center, NYU School of Medicine, New
York University, 550 1st Avenue, New York, NY 10016,
USA
10
Rebecca MacDonald Centre for Arthritis and Autoimmune
Disease, Mount Sinai Hospital, Joseph and Wolf Lebovic
Health Complex, 60 Murray Street, 2nd Floor (Main),
Toronto, ON M5T 3L9, Canada
123
Eur Spine J
DOI 10.1007/s00586-016-4467-7
major pathology has been ruled out, clinicians should
classify NAD as grade I, II, or III.
Recommendation 2 Clinicians should assess prognostic
factors for delayed recovery from NAD.
Recommendation 3 Clinicians should educate and reas-
sure patients about the benign and self-limited nature of the
typical course of NAD grades I–III and the importance of
maintaining activity and movement. Patients with wors-
ening symptoms and those who develop new physical or
psychological symptoms should be referred to a physician
for further evaluation at any time during their care.
Recommendation 4 For NAD grades I–II B3 months
duration, clinicians may consider structured patient edu-
cation in combination with: range of motion exercise,
multimodal care (range of motion exercise with manipu-
lation or mobilization), or muscle relaxants. In view of
evidence of no effectiveness, clinicians should not offer
structured patient education alone, strain-counterstrain
therapy, relaxation massage, cervical collar, elec-
troacupuncture, electrotherapy, or clinic-based heat.
Recommendation 5 For NAD grades I–II [3 months
duration, clinicians may consider structured patient edu-
cation in combination with: range of motion and
strengthening exercises, qigong, yoga, multimodal care
(exercise with manipulation or mobilization), clinical
massage, low-level laser therapy, or non-steroidal anti-in-
flammatory drugs. In view of evidence of no effectiveness,
clinicians should not offer strengthening exercises alone,
strain-counterstrain therapy, relaxation massage, relaxation
therapy for pain or disability, electrotherapy, shortwave
diathermy, clinic-based heat, electroacupuncture, or botu-
linum toxin injections.
Recommendation 6 For NAD grade III B3 months
duration, clinicians may consider supervised strengthening
exercises in addition to structured patient education. In
view of evidence of no effectiveness, clinicians should not
offer structured patient education alone, cervical collar,
low-level laser therapy, or traction.
Recommendation 7 For NAD grade III [3 months dura-
tion, clinicians should not offer a cervical collar. Patients
who continue to experience neurological signs and dis-
ability more than 3 months after injury should be referred
to a physician for investigation and management.
Recommendation 8 Clinicians should reassess the patient
at every visit to determine if additional care is necessary,
the condition is worsening, or the patient has recovered.
Patients reporting significant recovery should be
discharged.
Keywords Clinical practice guideline Neck pain
Treatment Management Practice guideline Therapies
Therapy Disease management Whiplash
11
Division of Clinical Education, Canadian Memorial
Chiropractic College (CMCC), 6100 Leslie Street, Toronto,
ON M2H 3J1, Canada
12
Toronto Health Economics and Technology Assessment
(THETA) Collaborative, 144 College Street, Toronto,
ON M5S 3M2, Canada
13
Leslie Dan Faculty of Pharmacy, University of Toronto, 144
College St, Toronto, ON M5S 3M2, Canada
14
Institute for Work and Health, 481 University Ave, Toronto,
ON M5G 2E9, Canada
15
Department of Physical Therapy, University of Alberta, 2-50
Corbett Hall, Edmonton, AB T6G 2G4, Canada
16
Rehabilitation Research Centre, University of Alberta, 3-62
Corbett Hall, Edmonton, AB T6G 2G4, Canada
17
Clinical Research, Kingston General Hospital, 76 Stuart
Street, Kingston, ON K7L 2V7, Canada
18
Department of Emergency Medicine, School of Medicine,
Queen’s University, 15 Arch Street, Kingston, ON K7L 3N6,
Canada
19
Faculty of Medicine and Dentistry, University of Alberta, 116
St & 85 Ave, Edmonton, AB T6G 2R3, Canada
20
Institute for Health Policy, Management and Evaluation,
University of Toronto, 155 College Street, Toronto,
ON M5T 3M7, Canada
21
University of Southern Denmark, Campusvej 55,
5230 Odense M, Denmark
22
Dalla Lana School of Public Health, University of Toronto,
155 College Street, Toronto, ON M5T 3M7, Canada
23
Division of Occupational and Environmental Health, Dalla
Lana School of Public Health, University of Toronto, 155
College Street, Toronto, ON M5T 3M7, Canada
24
University of Ottawa, 505 Smyth Road, Ottawa,
ON K1H 8M2, Canada
25
Schulich School of Medicine and Dentistry, Western
University, Dental Sciences Building, London, ON N6A 5C1,
Canada
26
Open Policy Ontario, Toronto, Canada
27
Universite
´
de Montre
´
al, 2375 Cote Ste-Catherine, Montreal,
QC H3T 1A8, Canada
28
Department of Physical Medicine and Rehabilitation,
Schulich School of Medicine and Dentistry, Western
University, London, ON N6A 5C1, Canada
29
Toronto, Canada
Eur Spine J
123
Introduction
Background
More than 80 % of individuals experience neck pain and
associated disorders (NAD) during their lifetime, with
30–50 % of the general adult population reporting neck
pain annually [1, 2]. The course of neck pain is favorable
for most people; however, 23 % of individuals who recover
from an episode of neck pain will experience a subsequent
episode [3]. For many patients, neck pain is a complex
biopsychosocial disorder with problematic physical and
psychological symptoms. Neck pain is associated with
decreased health-related quality of life, decreased work
productivity, daily activity limitations, and increased
healthcare utilization [2, 4–6]. In the United States,
approximately 10.2 million visits are made annually to
physician offices and hospital outpatient departments for
neck pain [7]. In 2010, neck pain ranked fourth among all
conditions contributing to years lived with disability [8].
NAD that results from motor vehicle collisions is com-
monly known as whiplash-associated disorders (WAD) [9].
In Canada, 86.2 % of people injured in motor vehicle
collisions develop NAD [6]. Recovery from NAD can be
prolonged and associated with high health resource use [10,
11]. Costs related to managing this condition are substan-
tial due to medical costs and costs associated with pro-
ductivity changes [5, 12].
The clinical management of NAD is often challenging.
Recommendations from clinical practice guidelines aim to
inform clinical practice. However, the quality of current
clinical practice guidelines varies [13], and recommenda-
tions that are not evidence-based cannot be relied upon to
reduce symptoms or facilitate patient recovery. An up-to-
date, high quality evidence-based clinical practice guideline
is needed to inform the management of NAD grades I–III.
Scope and purpose of the guideline
We used the best available evidence to develop a clinical
practice guideline for the management of NAD grades I–III
(including WAD) of less than 6 months duration (Table 1).
NAD includes non-traumatic, traumatic, or work-related neck
pain. The target population is adults (18 years of age or older)
with recent-onset (0–3 months duration) and persistent
(4–6 months duration) NAD grades I–III; it does not cover
NAD that persists for more than 6 months. The management
of NAD grade IV is beyond the scope of this guideline
because it refers to significant pathology that may require
invasive/surgical interventions. The target audience for the
current guideline includes clinicians (medical doctors, phys-
iotherapists, nurse practitioners, chiropractors, kinesiologists,
psychologists, and massage therapists) caring for patients
with neck pain in primary, secondary, and tertiary health care
settings. This guideline aims to: (1) accelerate recovery; (2)
reduce the intensity of symptoms; (3) promote early restora-
tion of function; (4) prevent chronic pain and disability; (5)
improve health related quality of life; (6) reduce recurrences;
and (7) promote active participation of patients in their care.
Moreover, this guideline aims to promote uniform high
quality care for individuals with NAD.
The guideline was developed by the Ontario Protocol for
Traffic Injury Management (OPTIMa) Collaboration, which is
a multidisciplinary team of expert clinicians (from medicine,
dentistry, physiotherapy, chiropractic, psychology, occupa-
tional therapy, and nursing disciplines), academics and sci-
entists (epidemiologists, clinical epidemiologists, library
sciences, and health economists), a patient liaison, a consumer
representative, a retired judge, and automobile insurance
industry experts. The OPTIMa Collaboration was mandated
by the Ontario Ministry of Finance and the Financial Services
Commission of Ontario to develop an evidence-based clinical
practice guideline for neck pain and its associated disorders.
Table 1 Classification of Neck Pain and Associated Disorders (NAD) [24] and Whiplash Associated Disorders (WAD) [9]
Grade Definition
The 2000–2010 Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders Classification of NAD [24]
I No signs or symptoms suggestive of major structural pathology and no or minor interference with activities of daily living
II No signs or symptoms of major structural pathology, but major interference with activities of daily living
III No signs or symptoms of major structural pathology, but presence of neurologic signs such as decreased deep tendon reflexes, weakness
or sensory deficits
IV Signs or symptoms of major structural pathology
The Quebec Task Force Classification of WAD [9]
I Neck pain and associated symptoms in the absence of objective physical signs
II Neck pain and associated symptoms in the presence of objective physical signs and without evidence of neurological involvement
III Neck pain and associated symptoms with evidence of neurological involvement including decreased or absent reflexes, decreased or
limited sensation, or muscular weakness
IV Neck pain and associated symptoms with evidence of fracture or dislocation
Eur Spine J
123
Methods
Systematic reviews
We updated the systematic reviews from the Bone and
Joint Decade 2000–2010 Task Force on Neck Pain and Its
Associated Disorders (Neck Pain Task Force) [14]. This
update included eight systematic reviews examining the
effectiveness, cost-effectiveness, and safety of non-inva-
sive interventions for the management of NAD grades I–III
[15–22]. All systematic reviews were registered with the
International Prospective Register of Systematic Reviews
(PROSPERO) [23].
The systematic reviews included studies examining the
effectiveness of non-invasive interventions for the manage-
ment of NAD grades I–III (Table 1; Appendix) [15–22]. We
excluded studies on the management of grade IV NAD (e.g.,
fractures, dislocations, neoplasms, inflammatory diseases).
Non-invasive interventions included acupuncture, exercise,
manual therapy, passive physical modalities, psychological
interventions, soft tissue therapy, structured patient education,
multimodal care, analgesics, non-steroidal anti-inflammatory
drugs (NSAIDs), and muscle relaxants (Appendix I). Eligible
comparators included other interventions, placebo/sham
interventions, non-intervention effects associated with wait
listing, or no intervention. Eligible outcomes included self-
rated recovery, functional recovery, disability, pain intensity,
health-related quality of life, psychological outcomes, or
adverse events. We considered randomized controlled trials
(RCTs), cohort studies, and case–control studies published in
English. Only full economic evaluations that jointly analyzed
costs and health outcomes were eligible for inclusion in the
cost-effectiveness review.
We searched MEDLINE, EMBASE, PsycINFO, and
Cochrane Central Register of Controlled Trials through
Ovid Technologies, Inc., and CINAHL Plus with Full Text
through EBSCOhost (Appendix IIA and IIB). We also
searched EconLit through ProQuest, Health Technology
Assessment (Cochrane), and National Health Service
Economic Evaluation Database (Cochrane) for economic
evaluations. Our initial searches included publication dates
from January 1990 to January 2015 (search dates varied
between reviews). In May 2015, we updated all searches in
MEDLINE to retrieve recent RCTs, full economic evalu-
ations, or systematic reviews.
Random pairs of independent, trained reviewers
screened and critically appraised eligible studies using the
Scottish Intercollegiate Guidelines Network (SIGN) crite-
ria [25]. Low risk of bias studies were included in the
evidence synthesis [26]. Low risk of bias studies were
defined as studies where selection bias, information bias,
and confounding were deemed unlikely by two
independent reviewers to have threatened the internal
validity of the study. Minimal clinically important differ-
ence thresholds from the literature were used to determine
the clinical importance of the results between groups from
low risk of bias studies [27–30].
Development of recommendations
The principle of patient-centered care was fundamental to
the development of this guideline. We developed the evi-
dence-based recommendations according to:
• Key decision determinants [overall clinical benefit
(effectiveness and safety), value for money (i.e., cost-
effectiveness data when available), and consistency
with expected societal and ethical values] based on the
Ontario Health Technology Advisory Committee
framework [31];
• Best evidence obtained from critical review of scientific
literature; and
• Findings from qualitative research exploring the expe-
riences of persons treated for traffic injuries in Ontario
[32]. These findings on patient experiences were
considered under the key decision determinant ‘ex-
pected societal and ethical values.’
All systematic reviews were reviewed and approved by
a multidisciplinary Guideline Expert Panel that included 21
individuals representing emergency medicine, internal
medicine, rehabilitation medicine, orthopedic surgery,
dentistry, chiropractic, physical therapy, psychology,
nursing, health economics, epidemiology, clinical epi-
demiology, law, patient liaison, consumer representative,
and insurers (non-voting members). The translation of
scientific evidence into guideline recommendations fol-
lowed five steps (Table 2). Recommended interventions
were supported by evidence of effectiveness from studies
with low risk of bias, and where available, by evidence of
benefits outweighing harm to patients. When evidence was
sparse (e.g., red flags or pharmacological treatments for
neck pain), the Guideline Expert Panel used evidence from
the low back pain literature to inform its recommendations.
This guideline adapted the National Institute for Health
and Care Excellence methodology to develop the wording
of guideline recommendations (Table 3)[33]. Based on
this methodology, recommendations start with the word
‘‘offer’’ (for interventions that are of superior effectiveness
compared to other interventions, placebo/sham interven-
tions, or no intervention), ‘‘consider’’ (for interventions
providing similar effectiveness to other interventions), or
‘‘do not offer’’ (for interventions providing no benefit
beyond placebo/sham or are harmful). An intervention was
deemed to have superior effectiveness if evidence of
Eur Spine J
123
statistically significant and clinically important benefits
was identified in at least one RCT with a low risk of bias.
The frequency and duration of interventions was inclu-
ded in the recommendations. This was determined by
averaging or by reporting treatment frequencies and dura-
tions of care for interventions that were effective [15, 16].
Specifically, for recommended interventions that were
supported by one low risk of bias RCT, we used the fre-
quency and duration of treatment that were tested in that
RCT. For recommended interventions that were based on
more than one low risk of bias study, we computed the
mean frequency and duration of care across studies with
superior outcomes for a specific intervention.
Each recommendation was integrated into care path-
ways, which were approved by the Guideline Expert Panel
(Figs. 1, 2, 3, 4). Interventions for which there is
inconclusive evidence of effectiveness were not included in
the care pathways (Appendix III).
The applicability (e.g., facilitators, barriers, resource
implications, dissemination, implementation) of this
guideline is beyond the scope of this project because it was
developed for the Government of Ontario. The Government
will determine its applicability to the Ontario automobile
insurance and healthcare system. It is recommended that
this guideline be updated in 5 years so that the guideline is
based on current evidence [34]. The update should use
methodology similar to the development of this guideline.
External review
This evidence-based clinical practice guideline was
developed for the Government of Ontario. The
Table 2 Guideline recommendations: translation of scientific evidence into guideline recommendations by the Ontario Protocol for Traffic
Injury Management (OPTIMa) Collaboration
Step Description of process
1 Draft recommendations based on the best-evidence synthesis of the literature were developed by the authors of each systematic review
2 The recommendation sub-committee
a
used the key decision determinants of the Ontario Health Technology Advisory Committee
framework [31] to modify the draft recommendation, evaluating its consistency with patients’ experiences and preferences, expected
societal and ethical values and incorporating economic evidence
3 The recommendation subcommittee reviewed the draft recommendation, debated its validity and, if necessary, made modifications based
upon the scientific evidence
4 The recommendation subcommittee reached consensus on the draft recommendation
5 Draft recommendations (with supporting decision determinants) were presented to the Guideline Expert Panel at quarterly meetings. The
Guideline Expert Panel provided feedback and voted to accept, reject, or modify each recommendation. Recommendations requiring
modification were reformulated and a new, separate vote for the revised recommendation occurred. Voting was done through secret
ballot. Consensus was reached when 75 % of the Guideline Expert Panel accepted a recommendation
a
The recommendation subcommittee included individuals representing rehabilitation medicine, nursing, chiropractic, epidemiology, health
economics, and patient liaison
Table 3 Guideline recommendations: wording of guideline recommendations as adapted from the National Institute for Health and Care
Excellence Methodology [33]
Effectiveness of interventions Wording of recommendations
Interventions that should be used are interventions demonstrated to be
clearly superior to other interventions, placebo/sham interventions, or
no intervention (i.e., statistically significant and clinical important
between group differences favouring the intervention)
Recommendations start with the word ‘‘offer’’
Interventions that should not be offered because they provide no benefit
beyond placebo/sham (i.e., statistically significant and clinical
important between group differences favouring placebo/sham) or
because they are harmful (i.e., serious adverse events or high frequency
of minor adverse events)
Recommendations start with the words ‘‘do not offer’’
Recommendations for interventions providing similar effectiveness to
other interventions (between group differences of the interventions
were not statistically significant and/or clinically important)
Recommendations start with the word ‘‘consider’’; the choice of
interventions should be influenced by patients’ values and
preferences
Evidence was deemed inconclusive when the results of multiple low risk
of bias studies conflicted
Intervention was categorized under ‘inconclusive evidence’;
conflicting results prevented the development of a coherent
statement of effectiveness
The Guideline Expert Panel was confident that the treatment will do more good than harm for the ‘offer’ or ‘consider’ interventions, and that the
treatment will not benefit patients for ‘do not offer’ interventions
Eur Spine J
123
Fig. 1 Quick reference guide for the management of Neck Pain and Associated Disorders (NAD) grades I and II
Eur Spine J
123
Person with neck pain
Are symptoms ≤ 3 months? Symptoms are ˃ 3 months.
Based upon shared decision making by the paent and provider, the
following therapeuc intervenons are rec ommended:
b,d,e
A. Home and clinic based intervenons:
1. Structured educaon (advice to stay acve), reassurance & one of
the following:
i) Unsupervised neck range of moon exercises
ii) Mul-modal care that includes the combina on of:
a) Manipulaon or mobilizaon
b) Unsupervised neck range of moon exercises
iii) Muscle relaxants
f
Refer to specific recommendaon for treatment details (Secon 4.1.3)
Do Not Offer:
g
1) Struct ure d pae nt educaon al one, in ve rbal or wrien formats
2) Strain-counterstrain or relaxaon massage
3) Cervica l colla r
4) EMS, heat (clinic-based)
5) Electroacupuncture (electrical smulaon of acupuncture points with
acupuncture needle s or electrotherapy appli ed to the skin)
Offer informaon on nature, management, course of NAD as a
framework for iniaon of a program of care
Yes
No
Yes
Go to Care Pathway for the
Management of NAD III
Is treatment required?
Yes
DischargeNo
Care Pathway for the Management of NAD Grade I and II
Poor prognosc
factors?
c
No
Address
modifiable
prognostic
factors
Yes
NAD III
4
2
11
12
13
14
16
9
10
7
8
1
Conduct an appropriate clinical evaluaon
Risk factors for serious
pathologies or NAD IV
a
?
Yes Refer to physician
No
NAD I or
NAD II
b
?
No
Yes
3
5
6
15
Based upon shared decision making between the paent and provider,
the following therapeuc intervenons are recommended:
b,d,e
A. Home and clinic based intervenons:
1. Structured educaon (advice to stay acve), reassurance & one of the
following:
i) Supervised combined exercis es
Ii) Su per vis ed qi gong exerci ses
iii) Iyenga r yoga
iv) Mulmodal care that i ncludes the combinaon of (if not previously
given in 1
st
3 months of care):
a) Neck range of moon exercises
b) Manipulaon or mobilizaon
v) Clinical massage
vi) Low-level laser therapy
vii) Non-steroidal an-inflammatory drugs
f
Refer to specific recommendaon for treatment details (Secon 4.1.4)
Do Not Offer:
g
1) Programs solely of clinic-based supervised high dose strengthening
exercises
2) Strai n-cou nterst ra in or relaxao n mas sage
3) Relaxaon therapy for pain or disability outcomes
4) TENS, EMS, pulsed shortwave diathermy, heat (clinic-based)
5) Electroacupuncture (electrical smulaon of acupuncture points with
acupuncture needle s or electrotherapy applied to the skin)
6) Botulinum toxin injecons
Fig. 2 Care pathway for the management of Neck Pain and Associated Disorders (NAD) grades I and II
Eur Spine J
123
Government invited stakeholders to review and comment
on the guideline. Moreover, the government held a series of
public consultations on the clinical practice guideline from
August 17–21, 2015.
Recommendations
All recommended interventions are supported by evidence
of effectiveness, safety, cost-effectiveness (when cost-ef-
fectiveness data were available), and are consistent with
societal and ethical values. Interventions that are not rec-
ommended did not satisfy the criteria of one or more key
decision determinants (i.e., evidence of effectiveness,
safety, cost-effectiveness, and/or consistency with societal
and ethical values).
Recommendation 1: evaluation of NAD
Clinicians should rule out major structural or other
pathologies as the cause of NAD. Clinicians should classify
NAD as grade I, II, or III.
Clinicians should conduct a clinical evaluation to rule
out major structural or other pathologies (NAD grade IV)
as the cause of signs and symptoms. The Canadian C-spine
Rule should be used to rule out cervical spine fractures and
dislocations associated with acute trauma (Appendix IV)
[35]. The Canadian C-spine Rule was designed and vali-
dated for use in emergency departments, and can be used in
acute care settings. The presence of risk factors for serious
pathologies (also termed ‘red flags’) identified during the
history/examination warrants further investigation and
referral to the appropriate healthcare professional (Table 4)
[36–38]. As there is a paucity of literature on red flags for
neck pain, the list of red flags was informed by the low
back pain literature [36–38].
Clinicians should assess for neurological signs (de-
creased deep tendon reflexes, muscle weakness, sensory
deficits). NAD III refers to neck pain associated with
clear clinical evidence of neurologic signs (decreased
deep tendon reflexes, weakness, or sensory deficits) on
physical examination. Once major pathology has been
ruled out, clinicians should classify the grade of NAD as
grade I, II, or III; as recent or persistent; and the patient
should receive the appropriate evidence-based interven-
tions (Figs. 1, 2).
Recommendation 2: prognostic factors for delayed
recovery
Clinicians should assess prognostic factors for delayed
recovery from NAD (Appendix V). Most patients will
Reassess a nd Monitor for the presence of acute stress disorder, post-
traumac stress disorder, kinesiophobia, passive coping, depression,
anxiety, anger, frustraon and fear
Reassess and Monitor for the presence of acute stres s disorder, post-
traumac stress disorder, kinesiophobia, passive coping, depression,
anxiety, anger, frustraon and fear
Is i nj ure d person
recovered?
Is injured person
recovered?
Yes YesDischarge
1) Incomplete recovery: iniate persistent protocol (Box 16)
2) Signs progress to Grade III: proceed to NAD III care pathway
3) Development of serious pathology (new or worsening physical,
mental or psychological symptoms): refer to physician
No
No
1) Incomplete recover y: refer to physician
2) Signs progress to Grade III: proceed to NAD III care pathway
3) Development of serious pathology (new or worsening physical,
menta l or ps ychologi cal s ympt oms ): refer to physician
a
Risk factors for serious pathologies (also known as red flags): Cancer (history of cancer, unexplained weight loss, nocturnal pain, age >50), vertebral infecon (fever, intravenous drug
use, recent infecon ), osteoporo c fractures (hi story of osteoporosis, use of c orc osteroid, older age), traumac fracture (posive Canadian C-Spine rule), myelopathy – severe/
progressive neurological deficits (painful sff neck , arm pain and weakness, sensory changes in lower extremity, motor weakness and atrophy, hype r-reflexia, spasc gai t), carod/
vertebral artery dissec on (sudden and intense onset o f head ache o r neck p ain), brain haemorrhage/mass lesio n (sud den and intense onset of headache), inflammatory arthris
(morning sffn ess, swelli ng in mulple j oi nt s)
b
If symp tom s progre ss pr oceed to NAD III protoco l o r refer.
c
Facto rs delayin g recovery: older age, prior history of neck pain, high levels o f inial pain, high level s o f inial di sabilit y , post-crash psychological factors [poor recovery expectaon,
symptoms of acute stress disorder (symptoms ≤ 4 weeks of the injury), symptoms of post-traumac stress disorder (symptoms > 4 weeks), depressed mood or feelings of depression
about pai n, anxiety or fear about pain, high level s o f frustraon or anger about pain, passi ve coping, kinesiopho bia, avoiding acvies due to fear of pain]
d
This gui deline does not include interveno ns f or wh ich th ere is a lack of evid ence of eff ecve ness
e
The ordering of intervenons does not reflect superiority of effecveness
f
The evidence indicates that analgesia is the primary therapeuc benefit of the muscle relaxant and NSAID classes of medica on. Pain redu con should be apparent during the inial
per iod o f usage; in t he absence of therapeuc benefit , prolongaon of usage i s no t warranted. There is no evide nce of d iffer enal efficacy for the various drugs within each class.
There is also no evidence that any combinaon of these medicaons provides added benefit. There are potenally significant adverse effects associated with use of these classes of
med icaon s. F inal ly, th e no n-op io id first ‘step ’ in t he An algesic Ladd er i nclud es NSAI Ds, muscle relaxant and acet amino ph en (Vargas-Schaff er G. Is th e WHO an algesic lad der sll valid?
Twenty-fo ur years of experienc e. Vol 56: June 2010 Canadian F amily P hysician). However, the evidence does not i ndi cate that acetaminophen is an effecve analgesic for either NAD or
low back pain; th eref ore, the use of acetaminophen is not recommended.
g
Based on evidence of no benefit to paents
17
18
20
21
19
22
23
Fig. 2 continued
Eur Spine J
123
Fig. 3 Quick reference guide for the management of Neck Pain and Associated Disorders (NAD) grade III
Eur Spine J
123
recover. Patients with NAD grade I can be expected to
recover more quickly, while those with NAD grade III are
expected to recover more slowly [11, 24, 39–42]. Patients
with the following prognostic factors may have a higher
risk for delayed recovery [11, 24, 39–42]:
• Demographic factors: older age.
• Physical health: prior history of neck pain; high levels
of initial pain; and high levels of initial disability.
• Psychological factors following a traffic collision: poor
expectation of recovery, symptoms of acute stress
Persons with neck pain
Poor prognosc
factors?
c
Address modifiable
prognosc factors
Yes
Are symptoms
≤ 3 months?
No
Based upon shared decision making between the paent and
provider, the following therapeuc intervenons are
recommended:
b,d,e
1) Structured educaon, reassurance
2) Supervised graded neck strengthening exercise
Refer to specific recommendaon for treatment details (Secon
4.2.3)
Do not offer :
f
1) Str ucture d pae nt edu caon al one , in e ithe r ver bal o r wri en
formats
2) Low level laser therapy
3) Intermient tracon
4) Cervical colla r
Yes
Go to care pathway for the
management of NAD I/II
1) Refe r to medical physician f or consi de ra on of furthe r
invesgaon of the neurological deficits
b,d
Do not offer :
f
1) Cervical collar
Offer informaon on nature, management, course of NAD III
as a framework for iniaon of a program of care.
No
Yes
7
1
8
9
11
13
14
Care Pathway for the Management of NAD Grade III
Conduct an appropriate clinical evaluaon
Risk factors for serious
pathologies or NAD IV
a
?
Yes Refer to physician
No
No
Yes
NAD III
b
NAD I or II
Symptoms are
˃ 3 months.
Yes
2
3
4
10
56
12
Fig. 4 Care pathway for the management of Neck Pain and Associated Disorders (NAD) grade III
Eur Spine J
123
disorders (symptoms exhibited within 4 weeks of
injury), symptoms of post-traumatic stress disorder
(symptoms lasting at least 4 weeks); depressed mood or
feelings of depression about pain, anxiety or fear about
pain, high levels of frustration or anger about the pain,
passive coping, kinesiophobia, avoiding activities due
to fear of pain.
Recommendation 3: management of NAD
Clinicians should educate and reassure patients about the
benign and self-limited nature of the typical course of NAD
grades I–III and the importance of maintaining activity and
movement. Patients with worsening symptoms and those
who develop new physical or psychological symptoms
should be referred to a physician for further evaluation at
any time during their care.
For NAD grades I–III, clinicians should provide care in
partnership with the patient and involve the patient in care
planning and decision-making. Clinicians should reassure
patients that, in the majority of cases, NAD is benign and
has a self-limited course. Patients should be educated about
the benefits of being actively engaged and participating in
their care plan by remaining active and maintaining
movement of their neck. Clinicians should emphasize
active rather than passive treatments and deliver time-
limited care that includes effective interventions [15–17,
43, 44].
Recommendation 4: management of recent NAD
grades I–II (Tables 5, 6; Figs. 1, 2)
For patients with NAD grades I–II B3 months duration,
clinicians may consi der structured patient education in
combination with: range of motion exercise, multimodal
care (range of motion exercise with manipulation or
mobilization), or a short course of muscle relaxants (as
indicated). In view of evidence of no effectiveness, clini-
cians should not offer structured patient education alone,
strain-counterstrain therapy, relaxation massage, cervical
Reassess and Monitor for the presence of acute stress disorder,
post-traumac stress disorder, kinesiophobia, passive coping,
depression, anxiety, anger, frustraon and fear
Reassess and Monitor for the presence of acute stres s disorder,
post-traumac stress disorder, kinesiophobia, passive coping,
depression, anxiety, anger, frustraon and fear
Is i nj ure d per son
recovered?
DischargeYes
a
Risk factors for serious pathologies (also known as red flags): Cancer (history of cancer, unexplained weight loss, nocturnal pain, age >50), vertebral
infecon (fever, intravenous drug use, recent infecon), osteoporoc fractures (history of osteoporosis, use of corcosteroid, older age), traumac
fracture (posive Canadian C-Spine rule), myelopathy – severe/progressive neurological deficits (painful s ff neck, arm pain and weakness, sensory
changes in lower extremity, motor weakness and atrophy, hyper-reflexia, spasc gait), carod/vertebral artery dissecon (sudden and intense onset of
headache or neck pain), brain haemorrhage/mass lesion (sudden and intense onset of headache), inflammatory arthris (morning sffness, swelling in
mulple joints)
b
Conduct ongoing assessment for Improvement or worsening/progress of symptoms during intervenon and refer accordingly.
c
Assess for factors delaying recovery: older age, prior history of neck pain, high levels of inial pain, high levels of inial disability, post-crash
psychological factors [poor recovery expectaon, symptoms of acute stress disorder (symptoms ≤ 4 weeks of the injury), symptoms of post-traumac
stress disorder (symptoms ≤ 4 weeks), depressed mood or feelings of depression about pain, anxiety or fear about pain, high levels of frustraon or
anger about pain, passive coping, kinesiophobia, avoiding acvies due to fear of pain]
d
This guideline does not include intervenons for which there is a lack of evidence of effecveness.
e
The ordering of intervenons does not re flect s upe riority of effecveness
f
Based on evidence of no benefit to paents
Refer to physician
Refer to NAD I/II care
pathway
Are
there neurological signs,
major symptom change or
development of serious
pathology?
Yes
No
15
16
17
18
21
20
19
Fig. 4 continued
Eur Spine J
123
collar, electroacupuncture, electrotherapy, or clinic-based
heat.
Structured patient education Clinicians should provide
information about the nature, management, and course of
NAD as a framework for initiating the program of care.
This recommendation is based on universal principles of
health professions’ standards of practice wherein patients
are informed and educated about their condition, and par-
ticipate in the decision-making process [45].
Clinicians should not offer structured patient education
alone [17, 46]. This recommendation is based on one low
risk of bias RCT suggesting that although structured edu-
cation was less costly than multimodal care, it was also less
effective than multimodal care [17, 46].
However, clinicians can consider a structured patient
education program as an adjunct to an effective program
based on individual patient presentation [17, 46–48]. The
structured education should focus on providing advice to
stay active and reassuring the patient by addressing
expectations of recovery. This recommendation is based on
three low risk of bias RCTs suggesting that: (1) a course of
physiotherapy including self-care advice is more effective
than one session of oral advice in improving the recovery
of patients [17, 46]; and (2) an educational video combined
with usual emergency care may be more effective than
usual emergency care alone in reducing neck pain for
recent WAD [17, 47, 48].
Exercise Clinicians may consider range of motion
exercises (5–10 repetitions with no resistance, up to 6–8
times per day) [15, 49]. This involves unsupervised and
gentle daily home-based controlled range of motion exer-
cises of neck and shoulder, including neck retraction,
extension, flexion, rotation, lateral bending, and scapular
retraction. The exercise program should be taught to the
patient by a healthcare professional. This recommendation
is based on one low risk of bias RCT that found similar
outcomes between home exercise and advice, medication,
and manual therapy for recent NAD I–II [49].
Multimodal care Clinicians may consider a maximum of
six sessions over 8 weeks of multimodal care that includes
range of motion exercise and manual therapy (manipulation
or mobilization to the cervical and/or thoracic spine as
clinically indicated) [16]. This recommendation is based on
our systematic review [16] that identified 14 low risk of bias
RCTs examining the effectiveness of multimodal care for
NAD [46, 49–64]. This body of evidence suggests that the
effective multimodal programs of care included exercise,
manual therapy, and education [16]. On average, effective
multimodal care was achieved within six visits over
8 weeks [16]. Cost-effectiveness data suggest that exercise
and manual therapy is more cost-effective than two other
programs of multimodal care (i.e., a program with exercise,
traction, soft tissue therapy, and passive physical modalities
or a program with advice and analgesics) [65].
Soft tissue therapy Clinicians should not offer strain-
counterstrain therapy (Glossary—Appendix VI) [21]. This
recommendation is based on two low risk of bias RCTs
suggesting that: (1) ischemic compression and strain-
counterstrain therapy provided no added benefit to muscle
energy technique for improving neck pain, motion and
disability in the short-term for recent NAD [21, 66] and (2)
strain-counterstrain therapy is not more effective than sham
strain-counterstrain therapy in the short-term [21, 67].
Clinicians should not offer relaxation massage to treat
recent onset NAD (Glossary—Appendix VI) [21]. This
recommendation is based on one low risk of bias RCT
suggesting that relaxation massage was less effective than
sham laser acupuncture or acupuncture for NAD of vari-
able duration [21, 68].
Passive physical modalities Clinicians should not offer a
cervical collar [21]. This recommendation is based on three
low risk of bias RCTs suggesting that collars provide less
Table 4 Risk factors for serious pathology (red flags) for neck pain
Possible cause Risk factors for serious pathology
identified during history or physical
examination
a
Fracture/dislocation Positive Canadian C-spine rule (with
possible red flags)
Cancer History of cancer
Unexplained weight loss
Nocturnal pain
Age [50
Vertebral infection Fever
Intravenous drug use
Recent infection
Osteoporotic fractures History of osteoporosis
Use of corticosteroid
Older age
Myelopathy—severe/
progressive neurological
deficits
Painful stiff neck
Arm pain and weakness
Sensory changes in lower extremity
Motor weakness and atrophy
Hyper-reflexia
Spastic gait
Carotid/vertebral artery
dissection
Sudden and intense onset of headache
or neck pain
Brain haemorrhage/mass
lesion
Sudden and intense onset of headache
Inflammatory arthritis Morning stiffness
Swelling in multiple joints
a
This list of risk factors for serious pathology was informed from
the following peer reviewed articles rather than being developed from
a systematic review of the literature on ‘‘red flags’’ [36–38]
Eur Spine J
123
benefit than advice or active mobilization alone and similar
benefit to receiving no care [21, 69–72].
Similarly, clinicians should not offer electrical muscle
stimulation or moist heat as an intervention in the clinic
[21]. This recommendation is based on one low risk of bias
RCT suggesting that electrical muscle stimulation or moist
heat provided no additional benefit to a course of spinal
manipulation or mobilization [21, 73].
Acupuncture Clinicians should not offer elec-
troacupuncture [21]. This recommendation is based on one
low risk of bias RCT that found similar outcomes between
electroacupuncture and simulated acupuncture for WAD of
variable duration [21, 74]. The evidence for needle
acupuncture was inconclusive (Appendix III).
Medication The non-opioid first ‘step’ in the World
Health Organization analgesic ladder includes non-ster-
oidal anti-inflammatory drugs (NSAIDs), muscle relaxants
and acetaminophen [75]. Notwithstanding the prevalence
and readily available nature of these over-the-counter
(OTC) drugs, there is remarkably little evidence to support
a clinical prescription decision for any of these drugs for
NAD. This is particularly true for acetaminophen, for
which the best available evidence does not indicate that
acetaminophen is an effective analgesic for NAD and
spinal pain [20, 76, 77]; therefore, acetaminophen should
not be recommended or prescribed as a routine
intervention.
There was insufficient evidence for any clinical pre-
scription decision concerning NSAIDs for NAD and spinal
pain [18].
Evidence suggests that clinicians may consider a short
course of muscle relaxants (cyclobenzaprine) [20]. This
recommendation is based on one low risk of bias RCT
suggesting that use of an oral muscle relaxant may be more
Table 5 Treatment recommendations for Neck Pain and Associated Disorders (NAD) I–III
Consider Recommendation
NAD grades I–II NAD grade III
0–3 months 4–6 months 0–3 months 4–6 months
Provide information about the nature, management, and course of
NAD as a framework for the initiation of the program of care
dddd
A structured patient education program as an adjunct to an effective
program of care based on individual patient presentation
ddds
Unsupervised stretching/range of motion exercises (5–10 repetitions
of each exercise with no resistance, up to 6–8 times per day)
dsss
A maximum of six sessions over 8 weeks of multimodal care that
includes exercise and manual therapy. Multimodal care for
persistent grades I–II NAD should only be considered if not
previously given in the first 3 months of care. However, a second
course could be indicated if the patient demonstrates ongoing and
significant improvement
ddss
Muscle relaxants dsss
A program of supervised combined exercise (strengthening,
stretching/range of motion, and flexibility exercises). The program
should be limited to a maximum of two sessions/week for 12 weeks
sdss
A program of qigong exercises supervised by a certified qigong
instructor. The program should be limited to a maximum of two
sessions/week for 12 weeks
sdss
A long-term program of Iyengar yoga supervised by a certified
Iyengar yoga teacher. The program should be limited to a maximum
of nine sessions over 9 weeks
sdss
Up to ten sessions over 10 weeks of clinical massage sdss
Up to 12 sessions over 4 weeks of clinic-based low level laser therapy
(LLLT) (continuous or pulsed application; wavelength = 830 or
904 nm)
sdss
Non-steroidal anti-inflammatory drugs (NSAIDs) sdss
Two sessions/week for 6 weeks of supervised graded neck
strengthening exercises
ssds
NAD neck pain and associated disorders
d recommended interventions to be considered for the specified duration/grade of NAD
s there is no ‘consider’ recommendation for this intervention with respect to the specified duration/grade of NAD
Eur Spine J
123
effective than placebo [78]. Paradoxically, the evidence
suggests that analgesia, rather than muscle relaxation, is the
primary therapeutic benefit. Prolonged use is not war-
ranted. There is evidence that significant adverse effects
are associated with use of muscle relaxants; therefore,
patient education about the side effects and close moni-
toring are warranted [20]. There is no evidence of differ-
ential effectiveness for the various muscle relaxant drugs
[20]. There is no evidence that combining muscle relaxants
with other medications provides added benefit [20].
Recommendation 5: management of persistent NAD
grades I–II (Tables 5, 6; Figs. 1, 2)
For patients with NAD grades I–II NAD [3 months
duration, clinicians may consider structured patient edu-
cation in combination with: range of motion and
strengthening exercises, qigong, yoga, multimodal care
(exercise with manipulation or mobilization), clinical
massage, low-level laser therapy, or non-steroidal anti-
inflammatory drugs. In view of evidence of no effectiveness,
clinicians should not offer strengthening exercises alone,
strain-counterstrain therapy, relaxation massage, relax-
ation therapy for pain or disability, electrotherapy, short-
wave diathermy, clinic-based heat , electroacupuncture, or
botulinum toxin injections.
Structured patient education As described above, clini-
cians should provide information about the nature, man-
agement, and course of NAD as a framework for initiating
the program of care. This recommendation is based on two
low risk of bias studies suggesting that: (1) structured
advice alone offers similar outcomes to physiotherapy-
based graded exercises with structured advice [17, 79]; and
(2) a self-management program based on an educational
booklet may be as effective as multimodal physical therapy
[17, 56].
Exercise Clinicians may offer a program of supervised
combined exercise (range of motion and strengthening
exercises) limited to a maximum of two sessions per week
for 12 weeks [15]. This recommendation is based on two
low risk of bias RCTs in which supervised combined
strengthening and range of motion exercises offered greater
benefit than being randomized to wait list [15, 80, 81].
Clinicians may offer a program of qiqong exercises
(Glossary—Appendix VI) supervised by a certified qigong
instructor, limited to a maximum of two sessions per week
for 12 weeks [15]. This recommendation is based on two
low risk of bias RCTs in which qigong offered greater
benefit than waitlist [15, 80, 81].
Clinicians may offer a program of Iyengar yoga (Glos-
sary—Appendix VI) supervised by a certified Iyengar yoga
teacher, limited to a maximum of nine sessions over
Table 6 Treatment interventions that should NOT be offered for Neck Pain and Associated Disorders (NAD) I–III
Do not offer Recommendation
NAD grades I–II NAD grade III
0–3 months 4–6 months 0–3 months 4–6 months
Structured patient education alone, in either verbal or written formats dsds
Strain-counterstrain therapy ddss
Relaxation massage ddss
A cervical collar dsdd
Moist heat as an intervention in the clinic ddss
Electrical muscular stimulation ddss
Electroacupuncture ddss
Programs consisting solely of clinic-based supervised high dose
strengthening exercises
sdss
Transcutaneous electrical nerve stimulation (TENS) sdss
Pulsed short-wave diathermy sdss
A standalone course of relaxation training for pain intensity or
disability outcomes
sdss
Botulinum toxin injections sdss
Low level laser therapy (LLLT) ssds
Traction ssds
NAD neck pain and associated disorders
d interventions that should not be offered for the specified duration/grade of NAD
s there is no ‘do not offer’ recommendation for this intervention with respect to the specified duration/grade of NAD
Eur Spine J
123
9 weeks [15]. This recommendation is based on one low
risk of bias RCT that found Iyengar yoga offered greater
benefit than education and a home exercise program [15,
82].
Clinicians should not offer an exercise program con-
sisting solely of clinic-based supervised high-dose
strengthening exercises (Glossary—Appendix VI) [15]. The
body of evidence suggests that supervised high-dose
strengthening exercises do not offer benefit compared to
unsupervised strengthening exercises or advice [15, 83, 84].
Multimodal care Clinicians may consider a maximum of
six sessions over 8 weeks of multimodal care that includes
range of motion exercises and manual therapy (manipula-
tion or mobilization to the cervical and/or thoracic spine as
clinically indicated) [16]. Multimodal care may only be
considered if not previously provided in the first 3 months
of care. However, a second course may be indicated if the
patient has demonstrated ongoing and significant
improvement. As described above, this recommendation is
informed by two systematic reviews [16, 22].
Soft tissue therapy Clinicians may consider up to ten
sessions over 10 weeks of clinical massage (Glossary—
Appendix VI) [21]. Clinical massage is expected to provide
short-term benefits only. The body of evidence suggests
that clinical massage with self-care offers benefit compared
to self-care advice alone [21, 68, 85].
However, clinicians should not offer relaxation massage
(Glossary—Appendix VI) [21]. This recommendation is
based on one low risk of bias RCT suggesting that relax-
ation massage (e.g., Swedish massage) was less effective
than sham laser acupuncture or acupuncture for NAD of
variable duration [21, 68].
Clinicians should not offer strain-counterstrain therapy
(Glossary—Appendix VI) [21]. This recommendation is
based on two low risk of bias RCTs suggesting that: (1)
ischemic compression and strain-counterstrain therapy
provided no added benefit to muscle energy technique for
improving neck pain intensity, disability and motion in the
short-term for recent NAD [21, 66]; (2) strain-counterstrain
therapy is not more effective than sham strain-counterstrain
therapy in the short-term [21, 67].
Passive physical modalities Clinicians may consider up
to 12 sessions over 4 weeks of clinic-based low level laser
therapy (LLLT) [21]. LLLT may be offered in a continuous
or pulsed application (wavelength = 830 or 904 nm). This
recommendation is based on six RCTs in which the pre-
ponderance of evidence suggests that clinic-based LLLT
offers greater benefit than placebo [21, 86–91].
Clinicians should not offer transcutaneous electrical
nerve stimulation (TENS) [
21]. This recommendation is
based on two low risk of bias RCTs suggesting that: (1)
TENS is no more effective than placebo [21, 92]; (2) TENS
provides similar outcomes to multimodal programs of care
that include ineffective interventions (i.e., Jones technique)
[21, 51].
Clinicians should not offer pulsed short-wave diathermy
[21]. This recommendation is based on one RCT suggest-
ing that adding short-wave diathermy to advice and exer-
cise provides no benefit [21, 93]. Cost-effectiveness data
suggest that short-wave diathermy appears less cost-ef-
fective than advice and exercise [94].
Clinicians should not offer electrical muscle stimulation
or moist heat as an intervention in the clinic [21]. This
recommendation is based on one low risk of bias RCT
suggesting that electrical muscle stimulation or moist heat
provided no additional benefit to a course of spinal
manipulation or mobilization [21, 73].
Psychological intervention Clinicians should not offer a
stand-alone course of relaxation training for pain intensity or
disability outcomes [19]. This recommendation is based on
two low risk of bias RCTs [52, 53, 95]. The first RCT found
that group-based pain and stress self-management (focused
on relaxation training) by physiotherapists leads to similar
pain and disability outcomes to multimodal physiotherapy
[52, 53]. However, the second RCT found that relaxation
training is no more effective than the advice to act as usual for
pain and disability [95]. Therefore, evidence suggests that
muscle relaxation training is not effective for improving pain
or disability outcomes in patients with persistent NAD
grades I–II. This should not, however, be taken as ruling out
the use of psychological interventions where these are indi-
cated for treatment of psychological distress, as opposed to
pain or disability management alone.
Acupuncture Clinicians should not offer elec-
troacupuncture [21]. This recommendation is based on one
low risk of bias RCT that found similar outcomes between
electroacupuncture and simulated acupuncture for WAD of
variable duration [21, 74].
Medication The non-opioid first ‘step’ in the World
Health Organization analgesic ladder includes NSAIDs,
muscle relaxants and acetaminophen [75]. However, the
best available evidence does not indicate that acet-
aminophen is an effective analgesic for persistent NAD and
spinal pain [20, 76]; therefore, acetaminophen should not
be recommended or prescribed as a routine intervention.
Moreover, there was insufficient evidence to support
prescriptions of muscle relaxants for persistent NAD and
spinal pain [20].
However, the evidence suggests that clinicians may
consider NSAIDs for this population [18]. This recom-
mendation is based on two low risk of bias RCTs from one
low risk of bias systematic review suggesting that NSAIDs
may be more effective than placebo [14]. Prolonged use is
not warranted and the potential adverse effects associated
Eur Spine J
123
with NSAIDs should be discussed with the patient [18].
Finally, there is no evidence of differential effectiveness
across various drugs within the NSAID class [18] and there
is also no evidence that combining NSAIDs with other
medications provides added benefit [18].
With respect to off-label usage of botulinum toxin
injections for NAD and spinal pain, on the basis of a
purported analgesic or muscle relaxant effect, clinicians
should not offer botulinum toxin injections [20]. This
recommendation is based on six low risk of bias RCTs in
two low risk of bias systematic reviews [96] suggesting
that there were no differences between botulinum toxin
injections and placebo [96, 97].
Recommendation 6: management of recent NAD
grade III (Tables 5, 6; Figs. 3, 4)
For patients with NAD grade III B3 months duration,
clinicians may consider supervised strengthening exercise
in addition to structured patient education. In view of
evidence of no effectiveness, clinicians should not offer
structured patient education alone , cervical collar, low-
level laser therapy, or traction.
Structured patient education As described above, clini-
cians should provide information about the nature, man-
agement, and course of NAD III as a framework for
initiating the program of care. The structured education
program should focus on providing advice to stay active
and reassuring the patient by addressing expectations of
recovery [17, 46].
Clinicians should not offer structured patient education
alone [17]. This recommendation is based on six low risk
of bias RCTs suggesting that: (1) structured patient edu-
cation alone provides no benefits compared to other con-
servative treatments (i.e., physiotherapy, supervised
exercises, massage) or unstructured advice in improving
the recovery of patients with NAD [17, 46, 56, 79, 85, 98];
(2) one method of delivering an education intervention is
not superior to another [17, 99].
Exercise Clinicians may consider two sessions per week
for 6 weeks of supervised graduated neck strengthening
exercises [15] (Appendix VII). This can be supplemented
with a home exercise program that includes daily stretch-
ing, strengthening, and relaxation exercises and may be
supplemented by acetaminophen or NSAIDs. This recom-
mendation is based on one low risk of bias RCT suggesting
that strengthening exercises are more beneficial than advice
but provide similar benefits as a semi-hard cervical collar
and rest for recent-onset cervical radiculopathy [15, 100].
However, a cervical collar is not recommended due to its
potential risk of harm (e.g., iatrogenic disability, inactivity,
deconditioning, lack of self-efficacy) that exceeds the
potential for benefit [101].
Traction Clinicians should not offer traction [21]. This
recommendation is based on one low risk of bias RCT
suggesting that traction provides no added benefit to mul-
timodal care for cervical radiculopathy [21, 102].
Passive physical modalities Clinicians should not offer a
cervical collar [21]. Despite similar outcomes for the use of a
semi-rigid cervical collar and graded neck strengthening
exercises [21, 100], we do not recommend using cervical
collars for NAD III based on: (1) the need to monitor the use
and prescription of a cervical collar as outlined in the trial
protocol would be impractical; (2) the widely recognized
ethical concerns that the potential risk of harm (e.g., iatro-
genic disability, inactivity, deconditioning, lack of self-ef-
ficacy) exceed the potential for benefit [101].
Clinicians should not offer LLLT [21]. This recom-
mendation is based on one low risk of bias RCT suggesting
that LLLT was equal to placebo LLLT for recent-onset
cervical radiculopathy [21, 103].
Recommendation 7: management of persistent NAD
grade III (Tables 5, 6; Figs. 3, 4)
Clinicians should not offer a cervical collar. Patients who
continue to experience neurological signs and disability
more than 3 months after injury should be referred to a
physician or for investigation and management.
This recommendation is based on one low risk of bias
RCT suggesting that use of a cervical collar provides
outcome similar to an individualized multimodal program
of care in the medium and long term [21, 69]. However, we
do not recommend the use of cervical collars given the
ethical concerns that the potential risk of harm exceeds the
potential for benefit [101].
Recommendation 8: reevaluation and discharge
Clinicians should reassess the patient at every visit to
determine if: (1) additional care is necessary; (2) the
condition is worsening; or (3) the patient has recovered.
Patients should be discharged as soon as they report
significant recovery. Health care professionals should use
the self-rated recovery question to measure recovery:
‘‘How well do you feel you are recovering from your
injuries?’’ [104–108]. The response options include: (1)
completely better, (2) much improved, (3) slightly
improved, (4) no change, (5) slightly worse, (6) much
worse, (7) worse than ever. Patients reporting to be
‘completely better’ or ‘much improved’ should be con-
sidered recovered. The self-rated recovery question is a
valid and reliable global measure of recovery in patients
with neck pain [104–108]. Patients who have not
recovered should follow the care pathway outlined in the
guideline (Figs. 1, 2, 3, 4).
Eur Spine J
123
Discussion
We developed an evidence-based clinical practice guide-
line to help clinicians deliver effective interventions for the
management of NAD (which includes WAD) and promote
uniform high quality care for patients with neck pain. The
recommendations are based on recent systematic reviews
of the literature and synthesis of best available evidence.
Implementing evidence-based recommendations for a
common condition, such as neck pain, will likely improve
patient outcomes, reduce regional variations, and improve
the efficiency of the healthcare system [109, 110].
The guideline identifies clinical interventions that should
not be prescribed because they are ineffective or because
their effectiveness is not clearly established. For example,
we found inconclusive evidence for the effectiveness of
needle acupuncture, cognitive behavioral therapy, and
biofeedback for the management of persistent NAD grades
I–II [19, 21]. The evidence on the effectiveness of these
interventions is inconclusive because the results of multiple
high-quality RCTs conflicted with each other. Finally, the
guideline does not recommend interventions that have not
been evaluated in high-quality studies.
Summary of recommendations
Clinicians should rule out major structural or other
pathologies as the cause of NAD. In the absence of major
structural or other pathologies, clinicians should classify
NAD as grades I, II, or III and determine the presence of
prognostic factors for delayed recovery. The management of
all patients should include education, advice, encouragement
to stay active (including return to work where appropriate),
and reassurance that NAD is typically of a time-limited
nature. In the context of shared decision-making, clinicians
should discuss with the patient the range of effective inter-
ventions available for the management of NAD. Supple-
menting self-management strategies with clinical care may
be indicated provided the intervention is likely to enable
recovery through symptom relief and improvement in
function. For such interventions, there is no evidence that
effectiveness can be increased through more frequent
attendance or prolonged course of treatment [43, 44].
The following clinical interventions can be considered
for recent onset NAD grades I and II (B3 months): range of
motion exercises with or without manipulation or mobi-
lization, or muscle relaxants. For persistent NAD grades I–
II ([3 months), clinicians can consider supervised range of
motion and strengthening exercises, qigong, yoga, multi-
modal care (exercise with manipulation or mobilization),
clinical massage, LLLT, or NSAIDs. It is important to note
that all recommended interventions provide small benefits
at best.
Patients with recent NAD grade III (B3 months) should
be treated with supervised strengthening exercise. Patients
with NAD grade III who still experience neurological signs
and disability 3 months after injury should be referred to a
physician for further investigation of neurological deficits.
Comparison to previous guidelines
Overall, our recommendations agree with those of previous
clinical practice guidelines [9, 13, 111–116]. Our recent
systematic review of guidelines for the management of
WAD suggests that treatment options include: advice,
education, reassurance, exercise, return-to-activity, mobi-
lization/manipulation, and analgesics [13]. All guidelines
agree that collars are contraindicated for WAD [13].
Moreover, the 2008 clinical practice guideline from the
American Physical Therapy Association recommends that
the management of neck pain include: education, cervical
and thoracic mobilization/manipulation, exercises, and
traction; and that neck-related arm pain should be managed
with thoracic mobilization/manipulation and exercises
[115].
There are a few important differences between previ-
ous guidelines and ours. Specifically, we do not recom-
mend analgesics or traction for the management of neck
pain. This difference is likely because most of the pre-
vious guidelines are dated [34]. The Neck Pain Task
Force identified one study that found no differences
between an analgesic (benorylate) and placebo for
reducing pain [14, 117]. Our recent systematic review did
not find any eligible studies that evaluated the effective-
ness of analgesics for neck pain. For traction, the Neck
Pain Task Force did not find enough evidence to deter-
mine the effectiveness of traction [14, 118
]. Our recent
systematic review identified one study that found traction
does not provide added benefit to a multimodal program
for NAD grade III [21, 102]. Moreover, our guideline
specifies the interventions that should not be used because
the evidence suggests that they are ineffective [14, 102,
117, 118].
The evidence published since the release of previous
clinical practice guidelines has improved our ability to
effectively manage patients with neck pain. Prior to the
OPTIMa guideline, the most recent guidelines were pub-
lished in 2008 [111, 115]. Since then, high quality RCTs
suggest that multimodal care (i.e., exercises and manipu-
lation/mobilization) is effective for the management of
recent-onset neck pain and that Iyengar yoga, qigong, and
clinical massage may benefit patients with persistent neck
pain [16, 80–82, 85]. Moreover, the evidence indicates that
strain-counterstrain, relaxation massage, and elec-
troacupuncture should not be used to manage patients with
recent-onset and persistent neck pain [67, 68, 74, 85]. For
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recent NAD grade III, recent evidence suggests that graded
neck strengthening exercises should be used, while LLLT
and traction should not be used [100, 102, 103]. Finally, the
OPTIMa guideline provides parameters on the dosage of
interventions that are informed by high quality RCTs.
Therefore, recent literature provides clinicians with current
best evidence that informs the management of their
patients.
We conducted eight systematic reviews to update the
work of the Bone and Joint Decade Task Force on Neck
Pain and Its Associated Disorders and inform these rec-
ommendations [15–22]. Despite recent improvement in
the quality of the literature on the management of neck
pain, there are still important gaps. Specifically, the evi-
dence is still inconclusive on the effectiveness of
acupuncture, cognitive behavioral therapy and biofeed-
back [19, 21]. Therefore, efforts should be dedicated to
determine the effectiveness of these interventions. In
addition, research should also consider identifying the
most effective dosage to optimize treatment response for
all interventions.
Dissemination and implementation of this guideline
It is important to consider factors related to dissemination
and implementation of this guideline. Few of the previous
high quality guidelines in this area assessed the resource
implications and implementation issues related to their
adoption by clinicians and policy makers [13]. In Canada,
the Government of Ontario is considering the applicability
of this guideline to the Ontario health care system and
automobile insurance system.
The guideline could be adapted for local use in other
jurisdictions. We recommend that clinicians, insurers and
policy-makers use the ADAPTE framework to adapt this
guideline to their needs and environment [119].
Strengths and limitations
This clinical practice guideline was informed by compre-
hensive literature searches and its recommendations were
based on high-quality evidence. When developing clinical
recommendations, the Guideline Expert Panel considered
effectiveness, safety, cost-effectiveness, consistency with
societal and ethical values, and patient preferences and
experiences. Moreover, the recommendations include
consideration of effect sizes and minimal clinically
important differences to assess the magnitude of benefit of
an intervention on patient outcomes. Finally, the Guideline
Expert Panel disclosed any conflicts of interest and main-
tained editorial independence [120].
We conducted a supplementary search of MEDLINE
extending to May 2015 to identify any recently published
RCTs and systematic reviews relevant to the guideline.
This search (extending from January 1, 2013 and May 29,
2015) yielded 592 articles, of which 20 were relevant and
15 RCTs were of high quality [121–135] (five studies were
low quality [134, 136–139]). The low risk of bias studies
from the updated search investigated the following inter-
ventions: (1) acupuncture [121, 122, 133]; (2) exercise
[123–126, 134]; (3) manual therapy [127, 128]; (4) passive
physical modalities [129]; (5) soft tissue therapy [122,
130]; (6) multimodal care [
125, 126, 131, 132, 135]; and
psychological interventions [123]. None of these trials
presented information that conflicted with the recommen-
dations of this guideline.
Our recommendations were limited by the amount,
nature, and quality of evidence published in the literature
[15–22]. For example, very few studies have investigated
the effectiveness of medication for the management of
patients with NAD [18, 20]. Moreover, most RCTs studied
the relative effectiveness of commonly-used interventions,
but little evidence is available to determine whether pop-
ular interventions are more effective than placebo/sham
treatments. Inconclusive evidence on the effectiveness of
commonly-used interventions (e.g., needle acupuncture)
prevents the development of clinical recommendations.
There is a need for research to address these limitations in
the literature. Finally, our supplemental search extending to
May 2015 was conducted in MEDLINE only; however,
MEDLINE is one of the main biomedical databases to
search healthcare literature [140].
Acknowledgments The authors would like to acknowledge the
invaluable contributions to this guideline from: Lynn Anderson,
Poonam Cardoso, Brenda Gamble, Willie Handler, Vivii Riis, Paula
Stern, Thepikaa Varatharajan, Angela Verven, and Leslie Verville.
Compliance with ethical standards
Funding The development of this clinical practice guideline was
funded by the Ministry of Finance and the Financial Services Com-
mission of Ontario (OSS_00267175). The Ministry of Finance and
Financial Services Commission of Ontario were not involved in the
design, conduct, or interpretation of the research that informed the
development of the care pathways included in this report. The
development of the guideline by the Guideline Expert Panel was not
influenced by the Ministry of Finance or Financial Services Com-
mission of Ontario; the views and interests of the funding body did
not influence the final recommendations. All individuals involved in
the project declared any competing interests. This research was
undertaken, in part, thanks to funding from the Canada Research
Chairs program to Dr. Pierre Co
ˆ
te
´
, Canada Research Chair in Dis-
ability Prevention and Rehabilitation at the University of Ontario
Institute of Technology, and funding from Alberta Innovates—Health
Solutions to Dr. Linda Carroll, Health Senior Scholar.
Conflict of interest Dr. Brison reports no commercial interest; a
university role that incorporates research activities related to guide-
line development. Dr. Lacerte reports an active clinical practice and
conducting medicolegal assessments or reports for plaintiff lawyers
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