EVIDENCE-BASED GUIDELINES FOR THE CHIROPRACTIC

WFC 2013 A WARD W INNING PAPER

E VIDENCE -B ASED G UIDELINES FOR THE C HIROPRACTIC
T REATMENT OF A DULTS W ITH N ECK P AIN

Roland Bryans, DCa, Philip Decina, DCb, Martin Descarreaux, DC, PhDc, Mireille Duranleau, DCd,
Henri Marcoux, DC,e Brock Potter, DC,f Richard P. Ruegg, PhD, DCg, Lynn Shaw, PhD, OTh,
Robert Watkin, BA, LLBi, and Eleanor White, MSc, DCj

A BSTRACT

Objective: The purpose of this study was to develop evidence-based treatment recommendations for the treatment of
nonspeci c (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 o ndings were considered to assign an
overall strength of evidence (strong, moderate, weak, or con icting) 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 bene t 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

T he annual prevalence of nonspeci c neck pain ispatients seeking chiropractic treatment report neck or
estimated to range between 30% and 501%. cervical problems4. Thus, treatment of neck pain is an
Persistent or recurrent neck pain continues to beintegral part of chiropractic practice.
reported by 50% to 85% of patients 1 to 5 years after initial Treatment modalities typically used by doctors of
onset.2 Its course is usually episodic, and complete recovery chiropractic (DCs) to care for patients with neck pain include
is uncommon for most patient3s.Twenty-seven percent of spinal manipulation, mobilization, device-assisted spinal

a Guidelines Development Committee (GDC) Chairman; Occupational Therapy, Western University, London, Ontario,
Chiropractor, Clarenville, Newfoundland, Canada. Canada.
b Assistant Professor, Canadian Memorial Chiropractic College, i Public Member, Toronto, Ontario, Canada.
Clinical Education, Toronto, Canada. j Chiropractor, Markham, Ontario, Canada.
c Professor, Département de Chiropratique, Université du Submit requests for reprints to: Richard P. Ruegg, PhD, DC,
Québec à Trois-Rivières, Trois-Rivières, Canada. 4325, Longmoor Drive, Burlington, ON, Canada L7L 5A7
d Chiropractor, Montréal, Quebec, Canada. (e-mail: [email protected]).
e Chiropractor, Winnipeg, Manitoba, Canada. Paper submitted May 4, 2013; in revised form July 25, 2013;
f Chiropractor, North Vancouver, British Columbia, Canada. accepted August 1, 2013.
g Editor, Clinical Practice Guidelines Initiative, Toronto, 0161-4754/$36.00
Ontario, Canada. Copyright © 2014 by National University of Health Sciences.
h Associate Professor, Faculty of Health Sciences, School of http://dx.doi.org/10.1016/j.jmpt.2013.08.010

42

Journal of Manipulative and Physiological Therapeutics Bryans et al 43
Volume 37, Number 1 Neck Pain Clinical Practice Guideline

Table 1. Strength of evidence and recommendations comprehensive overview of all chiropractic treatment that may

Strength of be rendered to patients, only those for which there is evidence.
The procedures identi ed the high-quality (low risk of
Evidence recommendation

Consistent ndings among≥ 2 low-risk-of-bias Strong bias) studies that investigated the bene ts of commonly used
chiropractic modalities for the treatment for adults with
controlled trials with no limiting factors

Consistent ndings among≥ 2 low-risk-of-bias Moderate nonspeci c neck pain as determined by validated clinical
controlled trials with minor limiting factors outcome measures compared with placebo or other in-
terventions. Neck pain resulting from whiplash or serious
or pathology was not included. For the purposes of this
1 low-risk-of-bias controlled trial with no guideline, chiropractic treatment of neck pain includes any

limiting factors

1 low-risk-of-bias controlled trial with Weak

limiting factors Inconsistent of the techniques or procedures commonly used by DCs, but
Unresolvable di erences between the ndings excludes acupuncture, surgical procedures, invasive analge-
sic procedures, injections, psychological interventions, or
of 2 or more low-risk-of-bias controlled trials

medications (either prescription or over-the-counter).
manipulation, education about modi able lifestyle factors, The methods used in the development of recommenda-
physical therapy modalities, heat/ice, massage, soft tissuetions for this guideline have been described in detail
therapies such as trigger point therapy, and strengthening anedlsewhere.9 The GDC has adopted systematic processes for
stretching exercises. There is a growing expectation for DCs literature searching, screening, review, analysis, and
and other health professionals to adopt and use researchin- terpretation, which are consistent with the criteria
based knowledge, taking su cient account of the quality ofproposed by the“Appraisal of Guidelines Research and
available research evidence to inform clinical practice. As a Evaluation” collaboration h( ttp://www.agreecollaboration.
result, the purpose of the Canadian Chiropractic Associationorg). This guideline is a supportive tool for practitioners and
and the Federation Clinical Practice Guidelines Project is to for their patients and is not intended as a standard of care.
develop evidence-based treatment guidelines. The clinicaTl he intent of this guideline is to link clinical practice to the
practice guideline (CPG) experience began in Canada with abest available published evidence and is only one
consensus conference in April of 1993 that culminated withcomponent of an evidence-based approach to patient care,
the publication of“Clinical Guidelines for Chiropractic which should include clinical judgment and patient values.
Practice in Canada” 5 in 1994. Since then, the chiropractic
profession in Canada has published 3 additional guidelin6-es
8 that are intended to provide practitioners with the mosDtata Sources and Searches
current evidence for the treatment for patients in light of the A systematic search of the literature was conducted. The
clinician's experience and the patient's preferences. search strategy was developed by the GDC in conjunction
The original Neck Pain Guideline6 published in 2005 with an experienced medical research librarian in MED-
relied on studies that were drawn from the literature in aLINE by exploring MeSH terms related to chiropractic and
search conducted up to October 2004. The treatmenstpeci c interventions (seeAppendix A). The databases
recommendations developed at that time were supportesdearched included the following: MEDLINE, EMBASE,
largely by the expert opinion of the Guidelines Develop-EMCARE, Index to Chiropractic Literature, and the
ment Committee (GDC) in the absence of a solid, high- Cochrane Library. Searches included articles published in
quality research base. Therefore, an update to the earlierEnglish or with English abstracts. The search strategy was
neck pain guidelines that re ects evidence extracted fromlimited to adults ≥( 18 years). A study population was
the published scienti c literature about e ective chiroprac-considered to be adult when drawn from“aworkplace.”
tic treatment(s) for adult patients with nonspeci c neck painThe search spanned the period January 2004 to December
was needed. The purposes of this study were to develop2011. Reference lists provided in systematic reviews (SRs)
evidence-based treatment recommendations for the treawt-ere also reviewed to avoid missing relevant articles. Some
ment of nonspeci c (mechanical) neck pain in adults and toof the treatment modalities included in this guideline are not
present recommendations synthesized from this evidencexclusive to DCs but include those that may also be
and strength rating of each recommendation. delivered by other health care professionals.

METHODS Evidence Selection Criteria
Search results were screened electronically, and a multistage
This study addresses chiropractic treatments for whichscreening was conducted (seAeppendix B: level 1 (title and
there is evidence. There may be other treatments for whichabstract), duplicate citations were removed, and remaining
there is no evidence and for which this study cannot makearticles were retrieved as ecletronic and/or hard copies for
recommendations. Therefore, this CPG does not provide adetailed analysis; level 2 (full-text methodology and relevance);

44 Bryans et al Journal of Manipulative and Physiological Therapeutics
January 2014
Neck Pain Clinical Practice Guideline

Fig 1. Screening owchart. RCT, randomized controlled trial. (Color version o gure is available online.)

level 3 (screening randomized controlled trials [RCTs] and duration were assigned to the acute category. In instances
systematically conducted reviews); and level 4 (full-text nal where the mix of participants could not be determined or was
screening for relevant clinical content and risk of bias assessmentrelatively equal, the study was excluded.
and identi cation of potential methodological aws).
(oSvQaef olcmiTOdoLhna)no,eltdtyaeioapndrRndry”iCmmt(oTicmasueRrtaOyewcsoMuetoomrr)uee,retsaecssccoeoitomnlifevv“cceienltturieeeymddcs.ekeodaafspstudhatraeihnei”elsfyoeofllolivorvriiwdn“teginhnn,ei“gscqcc:ekuegraubvdliaiidtcissyeaeallobinrfioaleiinrtfeygwt.”eheirseDwwineaateTssvrwetpoltorooeapptsasirantoeissgocssenesRtshsaeseencsdoraiwsmnskueymrobefsfeeabunqcisadtuesodaeorntstiftootgnhtahressaasmdteisnesmtghtaoohydfestRh,inCaenTrdsue.estTuhnhlecteses.ecrtsohtned
guideline consistent with current standards for interpreting
clinical ndings. The selectedliterature was next categorized Risk of Bias Assessment
according to intervention typenad the articles in each category The rating of the treatment literature was conducted using
assessed by the Evidence Rating Team (ERT—R.B., M.D., methods recommended by the Cochrane Back Review Group
R.R., and L.S.) for quality, relevance to common chiropractic (CBRG) ( http://back.cochrane.or)g. Only RCTs were rated
practice, and the suaitbility for further analysis and inclusion in for risk of bias using a template adapted from the CBRG. In
this guideline. The inclusion or exclusion of a treatmentthis instance, a“low risk of bias” equates to a“high quality”
category was predetermined by consensus among stakeholdesrstudy and“high risk of bias” equates to“low quality.” The
in the profession. CBRG rating instrument for randomized trials identi es 5
The evidence base did not permit the assignment of anyinclusion criteria scored“yes” or “no.” Twelve criteria were
RCTs to a separate subacute category. As a result, RCTs were identi ed for risks of bias that can be scored a“slow risk
assigned to an acute or chronic category for each of the(score 1)” or “high risk (score 0)/unclear (score 0”)as follows:
interventions. In instances where the experimental partici- 1. Was the method of randomization adequate?
pants were of a variable duration of symptom(s) (both acute 2. Was the treatment allocation concealed?
and chronic), the assignment to a category was determined by 3. Was the patient blinded to the intervention?
the predominance (average or mean) of symptom duration. 4. Was the care provider blinded to the intervention?
Studies that included participants with subacute symptom 5. Was the outcome assessor blinded to the intervention?

Journal of Manipulative and Physiological Therapeutics Bryans et al 45
Volume 37, Number 1 Neck Pain Clinical Practice Guideline

Table 2. Categories of treatment modality studies, case series, or case reports were excluded because of

Category No. Rationale for inclusion their uncontrolled nature and inappropriate design to assess
treatment e ect.
1 Acupuncture 10 Previously established GDC In many instances (particularly when the intervention is a
exclusion criterion
form of manual therapy), it is id cult (if not impossible) to
2 Cervical Pillow 3 Insu cient evidence

3 Collar for recommendations blind either the participant or care provider. Therefore criteria 3
4 Diathermy 1 Insu cient evidence and 4 were scored low risk only when blinding was reported
and deemed to be possible by the raters. Whenever an outcome
for recommendations was determined by a participant-directed questionnaire (eg,
1 Insu cient evidence Neck Disability Index), the outcome assessor was considered to

for recommendations

5 Patient Education 11 Category combined with Exercise.

6 Exercise 67 Included be free of bias (criterion 5). Where the baseline characteristics
of study groups have not undergone statistical analysis, the
7 Flexion-Distraction 1 Included in the traction group source of bias (criterion 8) was scored high risk, unless all
signi cant prognostic indicators were similar upon inspection
8 Laser 14 Included

9 Magnetic 1 Not deemed to be a commonly

stimulation used intervention by the raters. In studies that tested t“hiemmediate e ec”tof an

10 Manipulation 46 Included

11 Manual therapy 28 Included. Some articles included more intervention, the domains of cnotiervention (criterion 9) and
appropriately assigned to the compliance (criterion 10) for the rating instrument were
12 Massage manipulation or mobilization groups deemed to be“not applicable” (N/A). In these cases, rather than
13 Mobilization 5 Included arti cially in ating the scoers by rating these domains as low

24 Included risk, the domain was not scored and the score totalled out of 10

14 Neuroemotional 1 Not deemed to be a commonly

technique used intervention rather than 12. When the identi ed sources of bias (method of
15 Physical activity 5 Articles included in exercise randomization, allocation concealment, blinding, reporting of
16 Physiotherapy 4 Articles included in exercise, missing data, cointerventions, ocmpliance, or intention-to-
treat) were not reported, a high risk was scored.
17 Postural manipulation, or mobilization Two assessors (R.R. and J.G.) independently rated the
1 Article included in exercise

reeducation

18 Pulsed 6 Evidence excessively heterogeneous literature for risk of bias and were not blinded as to study
electromagnetic authors, institutions, and soucer journals. Two members of the
energy 7 Articles included in exercise ERT (M.D. and L.S.) corroborat ed quality rating methods by
1 Article included in exercise completing quality assessments on a subset of 8 citations.
19 Rehabilitation Consensus of all individual ratings was established by
20 Relaxation

21 Resistance training 3 Articles included in exercise

22 Rol ng 1 Article included in massage discussion among the ERT.
Studies are rated as having a low risk of bias when at least
23 Sustained natural 1 Article included in exercise
50% of CBRG criteria were met (ie, 6/12 or 5/10 for scores
apophyseal glide of 10). Studies with fewer than 50% of the criteria met were

24 TENS 4 Included

25 Thoracic 15 Included rated as having a high risk of bias. There is empirical

manipulation

26 Traction 8 Included evidence from a methodological study conducted with data
27 Trigger point 2 Included from the CBRG that a scoring threshold o ess than 50% of
the criteria is associated with bia1s0. A high level of
therapy

GDC , Guidelines Development CommitteeT; ENS , transcutaneous nerve agreement was con rmed across quality ratings. Complete
stimulation. agreement on all items was achieved for most studies. All

6. Were incomplete outcome data adequately addressedd?iscrepancies were easily resolved through discussion.
7. Are reports of the study free of suggestion of selective
outcome reporting?
8. Were the groups similar at baseline regarding theGrading the Strength of Treatment Recommendations
most important prognostic indicators?
Recent advances in the development of treatment recom-
9. Were cointerventions avoided or similar in all groups? mendations have led to a systematic approach to developing
10. Was compliance acceptable in all groups? and grading the recommendations that aid in interpretation and
11. Are all patients reported and analyzed in the group tominimizes bias.11 A comparable approach has been used by
which they were allocated (intention-to-treat)? the Cochrane Collaborationh(ttp://back.cochrane.org) a/nd has
12. Was the timing of outcome assessment similar in all been adapted here. The results of the RCTs in each treatment
groups? category were evaluated by the GDC for factors concerning the

nal interpretation of the results for grading as reported in the
No weighting factor was applide to individual criteria, and Literature Summary. These factors included limitations in
possible bias ratings ranged from 0 (greatest number of risk osftudy design and/or execution, inconsistency of results,
bias criteria) to 12 (no risk of bias criteria). Observational indirectness of evidence, imprecision of results, and clinical

46 Bryans et al Journal of Manipulative and Physiological Therapeutics
January 2014
Neck Pain Clinical Practice Guideline

relevance. To assign an overall strength of recommendationand elimination of high risk of bias studies) produced 41
(strong, moderate, weak, or incnosistent), the GDC considered citations (Tables 3 and 4) that were used to develop the
the number, quality, and constiesncy of research results. recommendations. In the discussion, ndings of 24 SRs are
A strong recommendation was considered only when 2 orcompared with the recommendations of this CPG. Excluded
more low-risk-of-bias RCTs had consistent ndings and citations (RCTs and SRs) are shown in Table 5.
were free o imiting factors. Recommendations were graded
“moderate” with the support of 2 or more low-risk-of-bias
RCTs with limiting factors, or 1 high-quality RCT free of Treatment Recommendations
limiting factors. A “weak” recommendation is supported by Manipulation

csriotesraneeottocxnuussccalltuldodydomaalmiirebnt1eedpstocssm)eill.e.nroerawesR,mgwtWaneai-ivwtdcscnrhoeiolaesheefmtkotneawi-hoiurremofoeenpnvfrte-edrknbhwencr,iueinovdaatsmagnstahsehlteebRieggiondeCcrrGnctriToaideDsnduaewioCgenpfroifdedetrrphnmreeero(cpvvsmaenesirtitdeiaecsreitootecewitivntcnhnseeioogccogdfuseew,dstl.poumadew(oNlldrilooenesbiogeirsdcteetsioierucrveornedaerdascevsleytooiestvesoolrmtaevelnwolenvnmonerdedsepcged.,igwyenanI,andgttedthifosavioaivefkner-fgnnoiMn(e)s4atueircpahaacmtbnudeknoalierbrdappsstetoeu.ra5i2revdfli0,naaeo,r4otte9fifrmto,coo5hdano6nreeanmn/TrbyaM3hatsompvemtutyehesloloeortniaisswddmr3hgeara-oeeorcsltiirtocitsdootuio—kv-eafnd-—meslao1irmen(5f)mAa-sd)obwdceufdiuvloneahosetirs,edecnered2neagxsNtd-oseetuteuerre)fs.cvocdr1eiTemkrsid2ehretaPsiwh,bisl,naaeeetrinr2nenectedrcko.eaeosmwmta,mmtStribotmpe(mehpibsinnnepaiealtnaiielnztnilstimcadoemtaotansiiinvtfostaieidinnawo-olcg;ynnitut.hshtee
tions were made when consistent ndings could not be
established or if there was no evidenceTa(ble 1). Manipulation—Chronic Neck Pain. Spinal manipulative
therapy is recommended in the treatment of chronic neck
pain for short- and long-term bene t (pain, disability; grade
Use of SRs of recommendatio—n weak). This recommendation is

Systematic reviews were identi ed as a source of based on 1 low-risk-of-bias study with a limiting facto54r
comparison for the recommendations developed for thitshat used 2 treatments per week for 9 weeks.
guideline. The SRs were assessed by the ERT for quality using
procedures described by Oxman and Guya1t2t.Quality rating Manipulation/Multimoda—l Chronic Neck Pain. Spinal
of SRs included 9 criteria answered by yes (score 1) or no manipulative therapy is recommended in the treatment of
(score 0)/do not know (score 0) and a determination of overalcl hronic neck pain as part of a mltuimodal approach (including
scienti c quality (no aws, minor aws or major aws), based advice, upper thoracic high velcoity low amplitude thrust, low-
on the literature raters' answertso the 9 items. Possible ratings level laser therapy, soft tissuehterapy, mobilizations, pulsed
ranged from 0 to 9. Systematic reviews scoring more than halfshort wave diathermy, exercise, massage, and stretching) for
of the total possible rating (ie≥, 5) with no or minor aws both short- and long-term bente(pain, disability, cROMs;
were rated as high quality. Sytsematic reviews scoring 4 or grade of recommendatio—n strong). This recommendation
less and/or having major aws identi ed were excluded. was graded strong owing to 2 low-risk-of-bias studie30s,.69
This recommendation is also supported by 5 low-risk-of-
bias studies with limiting factors that used a number of
RESULTS treatments over several weeks, in addition to assessing the
Literature Screening and Ratings impact of a single treatment over the short te1rm9,3.2,52,58,64

The search identi ed 555 cittaions that were subsequently
augmented by a hand search of the SRs, for a total of 560 Mobilization
publications. Level 1 (title and bastract) reduced this number
to 237 (Fig 1). These citations were categorized by treatment Mobilization/Multimoda—l Acute Neck Pain. Mobiliza-
modality and the categories, nubmer of selected articles, and tion is recommended for the treatment of acute neck pain
reason(s) for inclusion are presented iTnable 2. In total, 10 for short-term (up to 12 weeks) and long-term bene t (days
interventions (treatment ceagtories) were identi ed by the to recovery, pain) in combination with advice and exercise
ERT for the evidence to be assessed for risk of bias. Level 2 (grade of recommendatio—n moderate). This recommendation
(full-text methodology and relevance) reduced this number tois supported by 2 low-risk-of-bias studies with limiting
195. Level 3 (screening controlled clinical trials, RCTs, and factors.20,49 Leaver et al49 used 4 treatment sessions over a
systematically conducted revwies) further reduced the number 2-week period.
of citations to 65 controlledritals and 27 SRs. Duplicate
citations were removed, and the remaining articles wereMobilization—Chronic Neck Pain. Mobilization is recom-
retrieved as electronic and/or hdarcopies for detailed analysis. mended for the treatment of chronic neck pain for short-term
Level 4 (full-text nal screening for relevant clinical content (immediate) bene t (pain, cROM; grade of recommendation

Journal of Manipulative and Physiological Therapeutics Bryans et al 47
Volume 37, Number 1 Neck Pain Clinical Practice Guideline

Table 3. Risk of bias ratings a

Risk of bias

C itation C riteria 12 3 4 5 6 7 8 9 10 11 12 Score

Andersen et a1l3 √ √√ √ √ 4/12
Andersen et a1l4 √ 5/12
Andersen et a1l5 √ √ √√√ √ 11/12
Aquino et al 16 √ 9/10
Blikstad and Gemmell17 √ √√ √√√√√√ √ √ √ 7/10
Borman et al18 √ 3/12
Boyles et al19 √ √√ √ √ √ √ √ N/A N/A √ √ 6/12
Bronfort et al20 √ 8/12
Chiu et al21 √ √ √√√ √ N/A N/A √ √ 7/12
Chiu et al22 √ 9/12
Chiu et al23 √ √√ √ 7/12
Chow et al24 √ 11/12
Cleland et al25 √ √ √ √√ √√ 6/10
Cleland et al26 √ 8/12
Cunha et a2l 7 √ √√ √√√ √ √√ 3/12
Dellve et al28 √ 4/12
Dundar et a2l 9 √ √√ √ √√ √√ 9/12
Dunning et a3l0 √ 9/12
Dusunceli et a3l 1 √ √√ √√√√ √ √√ 6/12
Dziedzic et al32 √ 8/12
Escortell-Mayor et al33 √ √√ √ √√ √√ 8/12
Gemmell et al34 √ 7/10
González-Iglesias et al35 √ √ √√√√√√ √ √ √√ 10/12
González-Iglesias et al36 √ 11/12
Gri ths et al37 √ √√ √ √ √ N/A N/A √ 9/12
Häkkinen et al38 √ 7/12
Häkkinen et al39 √ √√ √√√√ √ √ 6/12
Helewa et al40 √ 9/12
Hoving et al41 √ √ √√ 9/12
Jay et al42 √ 11/12
Jellad et al43 √ √√ √√ 6/12
Kanlayanaphotporn et a4l4 √ 8/12
Klaber Mo ett et al45 √ √ √ √√√√ √ √√ 6/12
Krauss et al46 √ 8/12
Lansinger et a4l 7 √ √√ √√√√ √ √√ 7/12
Lau et al48 √ 8/12
Leaver et al49 √ √ √ √√ √ √ 9/12
Ma et al50 √ 5/12
Martel et al51 √ √√ √√√ √ √ √ 11/12
Martinez-Segura et a5l2 √ 6/10
McReynolds and Sheridan53 √ √√ √√√√ √√ 3/10
Muller and Giles54 √ 7/12
Pool et al55 √ √√ √ √ √ N/A N/A √ √ 6/12
Puentedura et a5l6 √ 8/12
Reid et al57 √ √ √√ √√√√ √ √√ 10/12
Saayman et e5l8 √ 9/12
Salo et al59 √ √ √√√√√√√ √ √√ 8/12
Schomacher60 √ 6/10
Sherman et a6l1 √ √ √√ √ √ √ √ √ √ 7/12
Sillevis et al62 √ 6/10
Sjögren et a6l 3 √ √√√√√ √ √ 6/10
Skillgate et al64 √ 9/12
Sutbeyaz et a6l5 √ √√ √√ √√ 8/12
Tuttle et al66 √ 2/12
Vitiello et al67 √ √√ √ √√√ √ √ √ 7/12
Vonk et al68 √ 8/12
Walker et al69 √ √√ √√√√ √ √√ 8/12
Ylinen et al70 √ 4/12
Ylinen et al71 √ √ √√√√√√√√ √ √ √ 6/12
Ylinen et al72 √ 4/12
√ √√√√ √

√√ √√√√ √ √

√√ √√ √√

√ √√√√ √ √√

√ √√√ √ √√

√√ √√√√ √√

√√ √√√ √ √ √√

√ √√ √ √

√ √√√√√√√ √ √√

√ √√ √ √ N/A N/A √

√ √ N/A N/A √

√√ √ √√ √√

√ √√ √ √√

√√ √√√ √√

√ √√ √√√√√ √√

√√ √√√√ √ √√

√√ √√√√ √ √

√ √√√ N/A N/A √ √

√√ √√ √ √√

√√ √ √ √ N/A N/A √

√√ √√ √√

√√ √√√√ √ √√

√ √√√ √√ √

√√

√ √√ √ √ √

√ √√ √ √√ √√

√ √ √√√√ √√

√√ √√

√√√√ √√

√√√ √

(continued on next pag)e

48 Bryans et al Journal of Manipulative and Physiological Therapeutics
January 2014
Neck Pain Clinical Practice Guideline

Table 3. (continued)

Risk of bias

C itation C riteria 12 3 4 5 6 7 8 9 10 11 12 Score

Ylinen et al73 √ √√ √ √√ 5/12
Ylinen et al74 √ √√√√ √√ 6/12
Ylinen et al75 √√ √ √√ √√ 6/12
Zaproudina et a7l6 √√ √ √√√√ 8/12
√√

a In previous guidelines, we have assessed the literature using a quality-measuring6ttohoalt would rate studies as being either high or low quality.

—moderate). This recommendation is based on 3 low-risk-Exercise/Multimodal—Chronic Neck Pain. Exercise (in-
of-bias studies with limiting factors1.6,44,60 cluding stretching, isometric, astbilization, and strengthening)
is recommended for short- and long-term bene ts (pain,
disability, muscle strength, QoL, cROM) as part of a
Manual Therapy multimodal approach to theetartment of chronic neck pain

acpuMRnaaaOldinntMhuefea,oxrlrseaTtprtrhcheyeiesniresgasrptheh(yogc)/rorMtaimn-duamelctnioemdomnfodlboderinaned—glcai-otnCtimeohtrhnmrmoewentbnriicetedhanNatetmeai—ocdetknvns(iPcpttareaooi,infnnsc.g,thr)dre.oMitscTnaahhibnciiins-lnigtey,c,srppwkteehuhcrydeoswniiemcesace.2mlok1t,m2ehf2oenb,3rr1idans,7paee1ivtdeEiesoxrwaen(glirtcwrhiaisesdeieneskfbsrwoa.aferserreeeddcatodrymipaoitmcnioaelnlny4,dmdalotoai—noswesnsa-t2grroiestn,okgo-5)or. other
This
f-bias
times

recommendation is based on 2 low-risk-of-bias studie38s,.73 Laser
This recommendation is also supported by 2 low-risk-of-
bias studies with limiting factors3.2,55
Laser—Chronic Neck Pain. Based on inconsistent ndings
from 3 low-risk-of-bias studies2,4,29,58 there is insu cient
evidence that supports a roecmmendation for the use of
Exercise infrared laser (830 nm) in therteatment of chronic neck pain.

Exercise—Acute Neck Pain. Home exercise with advice or Massage
training is recommended in the treatment of acute neck pain
for both long- and short-term bene ts (neck pain; grade oMf assage/Multimoda—l Chronic Neck Pain. Massage is
recommendatio—n weak). This recommendation is based on 1 recommended for the treatment of chronic neck pains for
low-risk-of-bias study with a limiting factor2.0 This study used short-term (up to 1 month) bene t (pain, disability, and
a regime of daily home exercsei (6-8 repetitions per day) for cROM) when provided in combination with self-care,
12 weeks with two 1-hour adviec/training sessions 1 to 2 stretching, and/or exercise (grade of recommendat—ion
weeks apart. moderate). This recommendation is based on 1 low-risk-of-

bias study76 and 1 low-risk-of-bias study with a limiting
factor.61 In both studies, 5 to 10 upper body/neck massage
Exercise—Chronic Neck Pain. Regular home stretching sessions lasting 1 hour to 75 minutes were provided.
(3-5 times per week) with advice/training is recom-
mended in the treatment of chronic neck pain for long- Transcutaneous Nerve Stimulation
and short-term bene ts in reducing pain and analgesic
intake (grade of recommendatio—nstrong). This recom- Transcutaneous Nerve Stimulation/Multimod—alChronic
mendation is based on 3 low-risk-of-bias studie3s8.,39,73 Neck Pain. There is insu cient evidence that supports a
Home strengthening and endurance exercises with advicer/ecommendation for transcutaneous nerve stimulation
training/supervision are recmomended for both short- and long-(TENS) for the treatment of chronic neck pain. This
term bene ts (neck pain, cROM) in the treatment of chronicconclusion is based on 1 low-risk-of-bias study with more
neck pain (grade of recommendati—onstrong). This recom- than 1 limiting factors2.2
mendation is based on 4 low-risk-of-bias studie3s9.,47,69,75 One
additional study with a limiting facto63r supported this Thoracic Manipulation
recommendation. In all 5 studies, regular home exercises
were performed daily to 3 times per week. Two additional low-Thoracic Manipulation—Acute Neck Pain. Based on
risk citations with limiting factor3s2,40 found exercises of no inconsistent ndings from 2 low-risk-of-bias studie3s5,,56
bene t. Despite the con ictign results, this recommendation there is insu cient evidence that supports a recommenda-
was graded strong owing to the 4 low-risk-of-bias studies. tion for the use of thoracic manipulation in combination with

Journal of Manipulative and Physiological Therapeutics Bryans et al 49
Volume 37, Number 1 Neck Pain Clinical Practice Guideline

Table 4. Literature summary

Study Treatment Comparators Outcomes Score Comments Adverse
Sham US events
Acute neck pain Trigger point therapy
Blikstad and (N = 15; N = 15) Medication, HEA cROM 7/10 a - Higher percentage of Not
Pain
Gemmell17 Sham US participants improved recorded
Pain, cROM
Electrotherapy Pain, disability, (immediate)
mobility
Bronfort et alb 20 Mobilization - Subacute (4– 12 wk)
Manipulation Days to recovery
Manipulation (N = 91) 8/12 - Small to moderate e ect None
with mobs Behavioral graded Pain, disability
activity Pain, disability size; participants include reported
Patient education Thoracic
(N = 91) manipulation subacute participants
Mobilization at
random level - Short- and long-term
Nonthrust
techniques bene t

Control - Home exercise with
(nonexercise)
advice is superior to
TENS, IRR
medication and

comparable with spinal

manipulative therapy
Gemmell et al34 7/10 a - Clinical signi cance with
Trigger point therapy Not
(N = 15; N = 15)
ischemic compression recorded

(immediate)

- Acute and subacute pain

b3 mo

González-Iglesias Thoracic manipulation 11/12 - Relatively small Not
et alb 35
(N = 23) experimental group size recorded

(N = 23)

- Improvement as part of a

multimodal approach in

combo with

electrotherapy

Leaver et alb 49 - Pain durationb1 mo

Manipulation (N = 91) 9/12 - Large con dence interval; Minor
Mobilization (N = 91)
small clinical changes events

- As good as mobilization reported

- May include advice

+ exercise

- Participants with

Pool et alb 55 b3-mo duration

Manual therapy 6/12 - All participants were of Not
(N = 75)
subacute symptom duration recorded

- No di erences found

bPuentedura - Exercise + advice
et al 201156
Chronic neck pain Manipulation (N = 14) 8/12 - Small group size (N = 14) None
Aquino et al16 Thoracic manipulation
(N = 10) - Netter than thoracic reported

Mobilization (N = 24) manipulation + exercise

Boyles et al b 19 Manipulation (N = 23) Pain 9/10a - Small experimental group None
size (N = 24) reported
Chiu et alb 21 Patient education Pain, disability - Comparable bene t in
Chiu et alb 22 Exercise or stretching both groups (immediate) None
(N = 67) Pain, disability, reported
muscle strength 6/12 - Participants pre-dominantly
Patient education chronic but include acute None
Exercise or stretching as well reported
(N = 67) - No better than nonthrust
TENS (N = 73) - MPT + exercise

7/12 - Bene t for exercise + IRR

Pain, muscle 9/12 - E ects are small and not None
strength clinically relevant reported

- Best results with TENS
+ exercise

(continued on next pag)e

50 Bryans et al Journal of Manipulative and Physiological Therapeutics
January 2014
Neck Pain Clinical Practice Guideline

Table 4. (continued)

Study Treatment Comparators Outcomes Score Comments Adverse
events
Chronic neck pain ( continued) All groups including IRR
Chiu et al23 None
Traction (N = 39) Placebo IRR Pain, disability, 7/12 - Not superior to placebo reported
Minor
Chow et al24 cROM events
reported
Laser (N = 45) Placebo Pain, disability, 11/12 - Improvement with None
reported
QoL laser treatment
None
- More frequently reported

Dundar et alb 29 Laser (N = 32) in control group Not
recorded
Placebo Pain, disability, 9/12 - No improvement
None
QoL over placebo reported

- Including exercise None
reported
Dunning et a3l0 and stretching
Not
Manipulation Nonthrust Pain, disability 9/12 - More e ective than recorded
Thoracic
manipulation techniques nonthrust in the short term None
(N = 56) reported
- Combination of cervical None
reported
and thoracic thrusting
Not
+ advice was e ective recorded

Dusunceli et alb 31 - mean durationN300 d None
Dziedzic et alb 32 reported
Patient education PT, stretching Medication, 6/12 - Superiority of the neck Not
(N = 60) recorded
disability, cROM stabilization exercises +PT
Exercise Not
(N = 19; N = 19) - Predominantly chronic recorded
Patient education
(N = 60) (average 40 mo.)
Exercise (N = 115;
N = 115; N = 121) MT, pulsed short- Disability 8/12 - Some participants are of

wave diathermy acute symptom duration and

small clinical e ects

- No significant differences

- MT + advice + exercise

Häkkinen et al38 - Most with neck painN3 mo

Manual therapy Exercise crossover Pain, neck strength, 7/12 - Clinically relevant changes
(N = 62)
and mobility not due speci cally to
Exercise or
stretching (N = 125) manual therapy alone

- Short-term benefit

Häkkinen et al39 for both

Patient education Strength training andPain, disability, 6/12 - Small but clinically
Exercise or stretching
(N = 49; N = 52) stretching cROM, strength relevant changes

- No differences

Helewa et alb 40 - 1-y follow-up from 2007

Exercise Massage, pillow, Pain 9/12 - No di erence
(N = 49; N = 33)
active exercise - Including heat or

cold pack

Kanlayanphotporn Mobilization Varied mobilization Pain, cROM 8/12 - Small experimental
et al44
(N = 30) approaches group size (N = 30)

- Comparable bene t

for pain

Lansinger et a4l 7 - Mean durationN 1500 d

Lau et alb 48 Patient education Qigong Pain, disability, 7/12 - Large con dence interval
Martinez-Segura Exercise or stretching
et al52 (N = 62) cROM - No di erence

Thoracic manipulation - Ergonomic advice
(N = 60)
Manipulation (N = 34) - 1-5 y in duration

IRR and education Pain, disability, 8/12 - Greater improvement

QoL - Both groups received IRR
6/10a - Some participants of acute
Manual mobilization Pain, cROM

symptom duration

- More immediate bene t

than control mobilization

- At least 1 mo.; mean

Muller and Giles54 Manipulation (N = 25) ~ 4 mo

Medication, Pain, disability 7/12 - Relatively small e ect size

acupuncture and experimental group size

(N = 25)

- Best long-term bene t

Journal of Manipulative and Physiological Therapeutics Bryans et al 51
Volume 37, Number 1 Neck Pain Clinical Practice Guideline

Table 4. (continued)

Study Treatment Comparators Outcomes Score Comments Adverse
CMT events
Pain, disability,
Chronic neck pain ( continued) cROM 9/12 - Some participants may be of None
Saayman et alb 58 Laser (N = 20; N = 20)

acute symptom duration; small reported

to moderate e ect size; small

experimental group size

(N = 20)

- All treatment groups

improved; no di erence

- CMT + LLLT

most e ective

Schomacher60 - 1-12 mo in duration
6/10a - Used several di erent
Mobilization (N = 59; Mobilization at Pain None
N = 67)
adjacent segment mobilization techniques; reported

no signi cant di erence

- “As good as”

Sherman et alb 61 Massage (N = 32) - NP durationN70 mo

Self-care Disability 7/12 - Small e ects size; relatively None

small experimental group size reported

(N = 32)

- Clinical bene t

- May include self-care and

exercise
Sillevis et al62 6/10a - No di erence shown
Sjögren et alb 63 Thoracic manipulation Sham manipulation Pain None
(N = 50)
Patient education - Immediate e ect reported

Exercise or stretching Crossover Intensity of 6/12 - Pain experienced sometime None
(N = 53) symptoms
in the previous 12 mo; small reported

clinical e ects and large

con dence interval

- Signi cant

improvement

- Advice on posture

Skillgate et alb 64 Manual therapy and movement
(N = 206)
Naprapathic care, Pain, disability 8/12 - Participants predominantly None
advice
chronic but include acute reported

as well

- MT e ective in short

term

- Multimodal

- Mixed—minimum 2 wk;

Sutbeyaz et a6l5 majority N12 mo

Electrotherapy Placebo Pain, disability 8/12 - Signi cant improvement Not
(N = 18)
immediately after treatment recorded

- Unconventional

Vitiello et al67 electrotherapy

Electrotherapy TENS, sham Pain, disability, 7/12 - Signi cant improvement in None
(N = 9; N = 7) function, QoL
all outcomes with ENAR reported

- Unconventional

Walker et al b 69 electrotherapy
Ylinen et al b 71
Ylinen et al b 73 Patient education GP care Pain, disability 8/12 - MT with stretching None
(N = 47) Control Pain, disability
more e ective reported
Manual therapy
exercise (N = 47) - Average durationN500 d
Patient education
Exercise or stretching 6/12 - E ective strength Not
(N = 60; N = 60) and endurance training recorded
- Multimodal
Manual therapy (N = 62) Stretching exercises Pain, disability (PT, massage, mobs) Not
recorded
Patient education crossover 6/12 - Both were e ective
- MT + exercise

(continued on next pag)e

52 Bryans et al Journal of Manipulative and Physiological Therapeutics
January 2014
Neck Pain Clinical Practice Guideline

Table 4. (continued)

Study Treatment Comparators Outcomes Score Comments Adverse
events

Chronic neck pain ( continued)
Ylinen et al75
Patient education Strength, endurancePain, disability 6/12 - Large but variable Not
and stretching 8/12
Exercise or stretching clinical e ects recorded

(N = 57; N = 59; N = 63) - Strength and endurance

exercise more e ective than

stretching

Zaproudina Massage (N = 33) PT, TBS Pain, disability, - No di erence Not
et alb 76 Placebo mobility
Nonthrust - PT including massage + recorded
Pain, disability
exercise + stretching
Pain, disability
Variable duration neck pain
Cleland et al25 6/10a - Immediate pain relief
Thoracic manipulation None

(N = 19) - Mixed (12 wk reported

Cleland et al26 average duration)

Thoracic manipulation 8/12 - Thrust results in signi cantly Not
(N = 17)
better improvement recorded

(immediate)

- Mixed average duration

~ 55 d

Escortell-Mayor Manual therapy TENS, MT Pain, disability, 8/12 - No di erences found + adviceNone
et alb 33 (N = 47) PT, GP care QoL
Hoving et alb 41 + home exercise reported
T E NS (N = 43) Pain, disability
Manual therapy - Mixed; mean ~140 d
(N = 60)
9/12 - MT showed early None

improvement reported

- Including exercise + home

exercise

Jellad et alb 43 - Mixed—minimum 2 wk

Traction Standard rehab Pain, disability 6/12 - Improvement as part of a Not
(N = 13; N = 13)
multimodal approach recorded

(standard rehab)

- Mixed—onset previous

3 mo at enrollment

CMT , cervical manipulative therapyc; ROM , cervical range of motion;ENAR , Electro neuro adaptive regulatorG; P , general practitioner;HEA , home
exercise with advice;IRR , infrared radiation;LLLT , low-level laser therapy;MPT , manipulative physical therapyM; T, manual therapies;PSWD , pulsed
short wave diathermyP; T , physical therapies;QoL, quality o ife; TBS , traditional bone settingT;ENS , transcutaneous nerve stimulationU;S, ultrasound.
N = number of participants in experimental group. Adverse even“tNs:ot recorded” indicates that there were no notes of participants being asked about any
adverse events;“None reported” indicates 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).

electrotherapy or exercise for the treatment of acute Trigger Point Therapy
neck pain.

Trigger Point Therapy—Acute Neck Pain. There is
Thoracic Manipulation—Chronic Neck Pain. Based on insu cient evidence that supports a recommendation for
inconsistent ndings from 3 low-risk-of-bias studie3s0,,48,62 activator, ischemic compression, and trigger point pressure
there is insu cient evidence that supports a recommendar-elease for the treatment of acute neck pain based on 2 low-
tion for the use of thoracic manipulation for the treatment orfisk-of-bias studies.17,34 Both studies report a clinical
chronic neck pain. improvement, but there was no indication of a signi cant

Traction statistical change.

Traction—Chronic Neck Pain. There is foinrsuintecrimenitttenDt ISCUSSION
evidence to support a recommendation
mechanical traction for the treatment of chronic neck pain. In this guideline, recommendations have been developed
This conclusion is based on 1 low-risk-of-bias stud2y3 that that updates the body of evidence supporting chiropractic
found no additional improvement in pain or disability aftertreatment of neck pain. These recommendations o er a broad
10 to 12 treatment sessions when combined with nonther-ange of evidence-based treatment options for practitioners to
apeutic infrared irradiation. use in patient-centered care. The development of these

Journal of Manipulative and Physiological Therapeutics Bryans et al 53
Volume 37, Number 1 Neck Pain Clinical Practice Guideline

Table 5. Citations excluded after rating and data extraction

C itation Score R ationale

RCTs 4/12 - High risk of bias
Andersen et a1l3 5/12 - Study compared di erent forms of exercise
Andersen et a1l4 - Participants with neck pain also experiencing pain at other locations
11/12 - Not the objective of this guideline to address neck pain in participants with co-morbidities
Andersen et a1l5 3/12 - High risk of bias
Borman et al18 3/12 - Healthy participants. Study focused on reducing the frequency and intensity of painful episodes
Cuhna et al27 4/12 in participants prone to neck/shoulder pain.
Dellve et al28 11/12 - High risk of bias
González-Iglesias et al36 9/12 - High risk of bias
Gri ths et al37 11/12 - Study compared e ectiveness of di erent forms of exercise
Jay et al42 6/12 - High risk of bias
Klaber Mo ett et al45 - Study was focused on work ability rather than pain reduction
10/12 - Results included in González-Iglesias et a36l
Konstantinovic et a7l7 8/12 - The study was not designed to provide evidence for the e ectiveness of general exercise,
Krauss et al46 5/12 for nonspeci c neck pain.
Ma et al50 11/12 - Participants are drawn from a population with a high prevalence of musculoskeletal symptoms.
Martel et al51 3/10 There is no assessment of the duration of neck pain only baseline and subsequent intensity.
McReynolds and Sheridan53 10/12 - Not all participants are identi ed as having chronic pain (5–178%).
Reid et al57 8/12 - Approximately 2/3 of the randomized participants we“rleow back” rather than“neck.”
Salo et al59 8/12
Sutbeyaz et a6l5 2/12 Not possible to separate
Tuttle et al66 7/12 - Participants with radiating arm pain
Vitiello et al67 8/12 - Relatively small experimental group (N = 30)
Vonk et al68 - Insidious onset of neck pain. No chronicity was identi ed.
4/12 - High risk of bias
Ylinen et al70 - Study focused on the comparative e ect of biofeedback
4/12 - This study focused more on the preventive bene ts of manipulation rather than the e ect on
Ylinen et al72 5/12 active cases of acute or chronic neck pain.
Ylinen et al74 - High risk of bias
- Group size was exceedingly small (N = 7, 11)
- Sustained natural apophyseal glide was not considered a commonly used/known intervention
- No measures of pain or cROM although neck pain was assessed at baseline.
- Primary outcome was QoL
- Unconventional form of pulsed electromagnetic frequency
- High risk of bias
- Failed to meet all inclusion criteria
- Unconventional therapy
- 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.
- High risk of bias
- Study used pressure pain thresholds in levator and traps rather than traditional

measures of neck pain or cROM
- High risk of bias
- High risk of bias

Cochrane/SRs 7/9 - Duplication of Haraldsson et a9l1
Ezzo et al78
Jensen and Harms-Ringdah7l9 4/9 - Low rating score

Ylinen 80 - Major aws

2/9 - Low rating score

- Major aws

cROM, cervical range of motion;QoL, quality o ife; RCT , randomized controlled trial.

recommendations re ects the most recent evidence (2004 oarnd used in making suggestions for advancing the quality of
later), which is limited to low-risk-of-bias studies. Wherever future research.
possible, recommendations were made for each of the During review of the materials, a generalizable weakness
treatment modalities identi ed as relevant to commonof the studies was noted including the heterogeneity of
chiropractic practice and for which current evidence wastreatment protocols (ie, the use of a primary intervention in
available. Limitations in the current evidence are describedcombination with other thepraeutic treatments). For

54 Bryans et al Journal of Manipulative and Physiological Therapeutics
January 2014
Neck Pain Clinical Practice Guideline

example, many of the studies on manipulation wereto the patient) were a challenge. Many of the studies
pragmatic and therefore included exercises, advice, andreported the inclusion of patient education (either generally
soft tissue work, thus making it di cult or impossible to or very speci cally). In this article, the 11 RCTs identi ed
isolate the therapeutic e ect as “astand-alone” interven- as patient education were allocated to the exercise category
tion. When therapies are combined, for example, the usebecause they speci cally dealt with patient education and
of manipulation with electrotherapy or exercise, it wasexercise. All encounters between the patient and practi-
sometimes possible to address making recommendationtsioner incorporate at least some form of education to the
for the particular intervention“when provided in combi- patient. This component of care is essential when directing
nation with”. In other instances, interventions are provideda patient for the elements of active care (eg, exercise). In
in combination with so many other treatment modalitiesa,ddition, patients receiving the described interventions of
for example, manipulation with exercise, advice, stretch-passive care (eg, manipulation, mobilization, massage, etc)
ing, and pulsed shortwave diathermy, that a recommena-re also educated with regard to diagnostic, investigative,
dation can only be structured for “amultimoda”l form of and treatment procedures; anticipated outcomes; potential
intervention. In developing treatment recommendationasdverse events; informed consent, and so on. Whenever the
for multimodal interventions, the GDC considered theauthor(s) of a study has included an element of patient
manner in which practitioners would apply them. Weeducation as part of the treatment protocol, it has been
believe that, in many instances, the practitioner uses moreincluded as part of the recommendation.
than 1 treatment modality in the management of patients
with nonspeci c neck pain. All studies in which
participants received more than 1 intervention or in-Comparison with SRs
terventions in addition to the primary intervention being As a result of the search and screening process, 24 current
investigated are noted, and the recommendation wa(s2005 or later) SRs were identi ed that assessed the literature
referenced as multimodal. with regard to therapeutic bene t for the 10 treatment
Several of the treatment recommendations in thismodalities reviewed in this guidelineTa( ble 6). Although the
document are diminished by some of the studies thaStRs are considered current, the literature that they assess
based ndings on too few study participants. Speci cincluded studies that are sometimes much older. By contrast,
studies of “low subject number”s are identi ed and the studies assessed in this guideline were limited to much
recorded in The Literature SummaryT(able 4). Although more recent publications (2005 or later) and generally re ect
this limitation was considered a contributing factor to thea higher quality (low risk of bias). A number of SRs (N = 13)
imprecision of results and, ultimately, clinical relevance, assessed the literature for more than 1 treatment modality and,
our recommendations would be forti ed by greaterof these, 7 identi ed interventions that were delivered in
participant numbers and clinical relevance. combination with other therapies (multimodal).
The inclusion of participants with variable duration of In general, the individual SR ndings within an interven-
symptoms in a study made it di cult to formulatetion category remained fairly consistent. For example, within
recommendations. In some cases, it was impossible tothe category of manipulation, 11 of 12 SRs identi ed by the
determine whether the observed e ects (or lack of e ects)earch suggested some degree of therapeutic bene t from the
of an intervention was caused by its impact onintervention. Similarly, of the 13 SRs for exercise, all but 1
participants with acute, subacute, or chronic neck pain.concluded that therapeutic bene t had been evidenced. Eleven
Valuable data may have been missed in excluding studiesSRs assessed the evidence for only 1 intervention.
in which the chronicity of the pain among the participants In comparing the treatment recommendations of this
could not be determined (see above). Despite the positiveguideline with the ndings of the relevant SRs, there
outcomes reported, no recommendations could be formuw- ould appear to be a general agreement. However,
lated for neck pain of variable duration for the manualinconsistency within the SR ndings or a paucity of
therapy,33,41 TENS, 33 thoracic manipulation2,5,26 or high-quality evidence precludes complete agreement in the
traction43 interventions. cases of massage, traction, and trigger point therapy. In
Developing treatment recommendations related to thtehese 3 instances, the SRs predate the studies used in
diversity o nterventions reported as exercise (stability, developing the recommendations.
mobility, relaxation, rehabilitation, range of motion, strength
and endurance exercises, as well as stretching) was
challenging. Although few studies are directly comparableAdverse Events
in terms of the form of exercise used as the intervention, all There were no serious adverse events reported in any of
demonstrated a degree of bene t for the participant. the citations used in developing these treatment recom-
Similarly, the breadth, diversity, and understanding ofmendations. A summary of the adverse event reporting
the intervention described as patient education (advicef,rom the literature summaryT(able 4) is shown in Table 7.
training, supervision, and instruction of any kind providedOf the 43 studies included in this summary, 14 made no

Journal of Manipulative and Physiological Therapeutics Bryans et al 55
Volume 37, Number 1 Neck Pain Clinical Practice Guideline

Table 6. Review ndings—Cochrane and SRs

Intervention

3. 4. Exercise

1. 2. Manual (incl Pat 5. 6. 7. 8. Thoracic 9. 10. Trigger
Massage TENS
Citation Score Manipulation Mobilization therapy Educ) Laser manipulation Traction point therapy
?
Binder81 5 √ √√ √a ?
Bronfort et ala82 6 √a √a √a √
?
Chow and 5 √ √ ?
Barnsley83 ?
Chow et al84 √a √ –
Cross et al85 9 √ √
√ √ √a
7 √a ?? √
D'Sylva et al a86 9 √
√a
Gemmell and 7
Miller 87 √
Graham et a8l 8 7 √
Gross et al89 √a √a √ ?
Gross et al90 9 √ √
√a
9

Haraldsson 7
et al91
Hurwitz et ala92 7
Kay et al a93 √ √√ √
√a √a
Kay et al94 9

9 √
Kroeling et al95 7
Leaver et ala96 9
√√ √
Macaulay et ala97 7 √a √a
Miller et al a98 9 √a √a √a

Sargiovannis and 7 ?
Hollins 99

Sihawong 7 √
et al100
Smidt et al101 7
?
Vernon and 9 √ –?
Humphreys102 √
Vernon et al103 7
Walser et al104 9

Neck pain guideline √a √a √ ? ?
Acute √a √ a √/√ a ? ?
Chronic √ ?√ ?

Key: √, demonstration of bene t; ?, inconclusive–; , no demonstration of bene t.
a Interventions were delivered in combination with other interventions (multimodal).

mention of adverse events. Of the remaining 33, all studiesprovided in combination with exercise, heat, cold, and so
reported either none or only minor adverse events from aon, the bene t of the intervention becomes di cult to
total of 1682 study participants and several treatmenitnterpret, especially when the auxiliary therapies have also
sessions (on average) per participant. been shown to be of bene t.
The use of placebo, control, or sham comparators (whenever
ethical) to determine the e cya of a stand-alone treatment
Considerations for Future Research intervention is suggested. When comparing the outcomes of 2
Since our original neck pain guideline published in 20065, or more interventions, it becmoes increasingly di cult to
the number and quality of clinical trials in chiropractic careestablish if any of the treatmnet modalities provides anything
have increased signi cantly. Nonetheless, as a result of ourmore than placebo e ect or the natural history of recovery,
experience in developing these practice guidelines, weespecially in instances of acute neck pain. In several instances,
would suggest the following be considered to help guideimprovements that were ideniteidf in patient outcomes were
future studies. frequently seen as“no better tha”nor “as good as” 2 or more
We suggest the investigation of treatment interventionisnterventions. Typically, no reef rences are made to the natural
on a stand-alone basis that will allow the treatmenthistory or progression of the condition.
outcomes to be evaluated without the in uence of other A more thorough reporting of adverse events in the course
forms of care. For example, when manipulative therapy isof conducting a study for the balancing of bene t against risk

56 Bryans et al Journal of Manipulative and Physiological Therapeutics
January 2014
Neck Pain Clinical Practice Guideline

Table 7. Adverse events Although the focus of the guideline development was
on chiropractic treatments, other stakeholders or contri-
Intervention No. of studies Total no. of participants butions to what DCs do in practice could have been
missed. The literature searched may have included
Studies not recording adverse events procedures that DCs perform, but the research did not
include practicing DCs and thus was omitted from our
Manipulation 2 59 study. As with any use of the literature, we are limited by
what has been published. Thus, publication bias may have
Manual therapy 1 62 an in uence in the types of studies or topics included in
our searches.
Exercise 5 670
There are inherent limitations in guideline development.
Electrotherapy 3 64 Expert opinion and interpretation are necessary procedures
for guideline development. Thus, some subjectivity in
Thoracic manipulation 1 17 judgments is present when assessing the strength of the
evidence. Also, when evidence is lacking, expert opinion
Trigger point therapy 2 30 is required.

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. C ONCLUSIONS

brwmtsdtecserhotoaueauhpeamcmircWednntohakengpitrteeeti“tioohodsesdcpstsnenduuouiwrbtroodangiroyaoesevfis“gfterniipnaitededsoshdooseeyndetvnrrordmtoeieeftni.or”pnhrpergfsoIogeasttnehosrprtetty“eaomeoreaommevrfrudtcsetahippthrntnthee(fmteahaotooorsrrsacrurestmr,ut”iiw/snlcn”gtctaswtishscelprdigtloina,eaaotv(rtuhiosnnaoepcsupuroicrtuntalsbisteeypoonecasvp.nosta,dceeh,osTmduevrtaoth.dhteheitleeseinnset,riite)yniorensanecnbeanwwslwaeenduuteelddadleirtrsecnsreeeseihmdfddpoqsor.fesoirarufmeamnArneqastlpoiratomitcuifhlfete)myyeioiddoxnatteunnhhntafgolooeednyhrecaOfitpcofnrodehhecxrawtcroueriieTfronvrirtootrhnaecim.hvrcpceigeeTsanmritecnhalhesp,tceetemctiortmnoukiiauasmcdndnatpnsa,icrandeeaiottoprirsiiunypononeusmgn.aufliuianetTnlitaamatchschtisclttteloloesueoiiyronnarrrnduveaegngetleieccdne,indxioscotetmmiahfcbronmicnaemeonldinaansbticeneonrtigimknnehinlbpisadizsaoaseuctpaandfmolitteadegnemiircetoo/vueiionnnobiicfdtdrtosn,icohnee,romeapanilmfnitrmnacmlcieaaeotletheiisnehnettretcenueynooihrnrdpwa,tnaatsdleiriintcuctTeieduachipEtacdnarlhplNtaeuetyamfeleo,oSccnrrmk,aeraontnttnptpehaiotohottyhcadahren,koieteenr.f
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 Practical Applications
remains on the chronic condition.
• Forty-one RCTs were used to develop 11
In summary, researchers are encouraged to use suitable treatment recommendations.
controls as experimental comparators. We also suggest a clear
separation of participants with acute and chronic symptoms • Recommendations were made for acute neck
within studies as well as a more thorough reporting of the pain using exercise and a multimodal approach
occurrence or absence of adverse events. The investigation of to manipulation, mobilization.
treatment modalities on a stand-alone basis is needed.
• Recommendations were also made for chronic
neck pain using manipulation, mobilization,
and exercise and multimodal approaches to
manipulation, manual therapy, exercise and
massage.
Limitations

The limitations of this study are consistent with those of
SRs and clinical guidelines development. Although we use o aser, trigger point therapy, or traction for
made every attempt to include all relevant studies, it isnonspeci c, mechanical neck pain in adults.
possible that other relevant literature was missed. This
study is limited in that literature was searched through
December 2011; pthroecreefsosrew, emreorneortecinencltulditeedratinurethseturdeiceosminA-
the publication CKNOWLEDGMENTS

mendations. Thus, best judgement should be used to The authors thank the following for assistance during the
incorporate new high-quality evidence. preparation of this guideline: members of the Clinical

Journal of Manipulative and Physiological Therapeutics Bryans et al 57
Volume 37, Number 1 Neck Pain Clinical Practice Guideline

Practice Guidelines Task Force (Ron Brady, DC; H. James Canadian Chiropractic Association; 1993. Available from:
Duncan, BFA, CAE; Wanda Lee MacPhee, DC; Keith http://www.chiro.org/LINKS/FULL/CANADA/index.html .
Thomson, BSc, DC, ND; Dean Wright, DC) and Jaroslaw 6. Anderson-Peacock E, Blouin JS, Bryans R, et al. Chiropractic
Grod, DC, for literature screening and evidence rating. clinical practice guideline: evidence-based treatment of adult
neck pain not due to whiplash. J Can Chiropr Assoc 2005;49:
158-209.
7. Shaw L, Descarreaux M, Bryans R, et al. A systematic
FUNDING SOURCES AND POTENTIAL C ONFLICTS OF INTEREST review of chiropractic management of adults with

Sponsorship and funding were provided by the Canadian whiplash-associated disorders: recommendations for ad-
Chiropractic Association, Canadian Chiropractic Protective vancing evidence-based practice and research. Work 2010;
Association, and the Canadian Federation of Chiropractic 35:369-94.
Regulatory and Educational Accrediting Boards (The 8. Bryans R, Descarreaux M, Duranleau M, et al. Evidence-
“Federation”). No con icts o nterest were reported for based guidelines for the chiropractic treatment of adults
with headache. J Manipulative Physiol Ther 2011;34:
274-89.
this study. 9. CCA/CFCRB-CPG. The Canadian Chiropractic Association

and the Canadian Federation of Chiropractic Regulatory
Boards Clinical Practice Guidelines Development Initiative
C ONTRIBUTORSHIP INFORMATION (The CCA/CFCRB-CPG) development, dissemination, im-
plementation, evaluation, and revision (DevDIER) plan.
J Can Chiropr Assoc 2004;48:56-72.
Concept development (provided idea for the research): 10. van Tulder MW, Suttorp M, Morton S, Bouter LM, Shekelle
RB, MD, RR, LS. P. Empirical evidence of an association between internal
Design (planned the methods to generate the results): validity and e ect size in randomized controlled trials of
RB, MD, RR, LS. low-back pain. Spine (Phila Pa 1976) 2009;34:1685-92.
11. Brozek JL, Akl EA, Alonso-Coello P, et al. Grading quality
Supervision (provided oversight, responsible for orga- of evidence and strength of recommendations in clinical
nization and implementation, writing of the manuscript): practice guidelines. Part 1 of 3. An overview of the GRADE
RB, MD, RR, LS. approach and grading quality of evidence about interven-
Data collection/processing (responsible for experiments, tions. Allergy 2009;64:669-77.
patient management, organization, or reporting data): RR 12. Oxman AD, Guyatt GH. Validation of an index of the quality
Analysis/Interpretation (responsible for statistical anal- of review articles. J Clin Epidemiol 1991;44:1271-8.
ysis, evaluation, and presentation of the results): RB, 13. Andersen LL, Kjaer M, Sogaard K, Hansen L, Kryger AI,
MD, RR, LS.
Sjogaard G. E ect of two contrasting types of physical exercise
on chronic neck muscle pain. Arthritis Rheum 2008;59:84-91.
Literature search (performed the literature search): RR. 14. Andersen LL, Christensen KB, Holtermann A, et al. E ect of
Writing (responsible for writing a substantive part of the physical exercise interventions on musculoskeletal pain in all
manuscript): RB, MD, RR, LS, RW. body regions among o ce workers: a one-year randomized
Critical review (revised manuscript for ainndtelgleractmumal ar15. controlled trial. Man Ther 2010;15:100-4.
content, this does not relate to spelling Andersen LL, Saervoll CA, Mortensen OS, Poulsen OM,
checking): RB, PD, MD, Mireille D, HM, BP, LS, Hannerz H, Zebis MK. E ectiveness of small daily
amounts of progressive resistance training for frequent
EW, RW. neck/shoulder pain: randomised controlled trial. Pain 2011;
152:440-6.
Editing of manuscript: RR. 16. Aquino RL, Caires PM, Furtado FC, Loureiro AV, Ferreira

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speci c neck pain: a systematic review. J Geophys Res 2010; meta-analysis of randomzied clinical trials. J Man
56:73-85. Manip Ther 2009;17:237-46.

Journal of Manipulative and Physiological Therapeutics Bryans et al 61
Volume 37, Number 1 Neck Pain Clinical Practice Guideline

APPENDIX A. N ECK PAIN : 2004-2011 LITERATURE DATABASE SEARCH TERM LOGIC

Search DIALOG Databases: Index to Chiropractic
Step No. PubMed MEDLINE, AMED, Literature
1 Chiropractic[mesh] EMCare, EMBASE

2 Electromagnetic Phenomena[mesh] (Chiropractic or E lectromagnetic Fields or Subject: Chiropractic

3 Exercise Therapy[mesh] Exercise Therapy! or “Manipulation,

4 “Manipulation, Chiropractic”[mesh] Chiropractic” or “Manipulation, Spina”l
5 “Manipulation, Spina”l [mesh]
6 Massage[mesh] or Massage or Traction or Transcutaneous
7 T raction[mesh]
8 Transcutaneous Electric Nerve Electric Nerve Stimulation or Ultrasonic

Stimulation[mesh Therapy)/Maj
9 Ultrasonic Therapy[mesh]
(Manipulative Medicine! or Electromagnetic Subject:“Electromagnetic Phenomen”a
10 1 or 2 or 3 or 4 or 5 or 6 or
7 or 8 or 9 Field! or Kinesiotherapy or Traction Therapy

11 chiropractic*[tiab] or Transcutaneous Nerve Stimulation or
12 adjustment*[tiab]
13 ischemic pressure[tiab] Ultrasound Therapy)/Maj
14 ischaemic pressure[tiab]
15 spinal mobilization*[tiab] OR (Chiropractic? or Adjustment or Subject:“Exercise Therapy”

spinal mobilisation*[tiab] Ischemic(W)Pressure or
16 ultrasound[tiab]
17 ultrasonic[tiab] Spinal(W)Mobilization? Or

18 low power laser[tiab] OR low Spinal(W)Mobilisation or Ultrasound or
level laser[tiab]
Ultrasonic or Low(W)Power(W)Laser or

Low(W)Level(W)Laser or Pulsed(W)

Electromagnetic(W)Therapy)/TI

1 OR 2 OR 3 Subject:“Manipulation, Spina”l

(Neck Pain or Neck Injuries! or Neck Injury!)/ Subject: Massage

MAJ

(Neck(W)Pain or Neck(W)Injury OR Subject: Traction

Neck(W)Injuries)/TI

5 OR 6 Subject:“Transcutaneous Electric

Nerve Stimulation”

4 AND 7 Subject:“Ultrasonic Therapy”

(Clinical Trial or Meta Analysis or Article Title: chiropractic*

Practice Guideline or Randomized

Controlled Trial or Review or Case Report

or Classical Article)/DT

(Clinical(W)Trial? ? or Controlled(W)Trial? Abstract/Notes: chiropractic*

? or Controlled(W)Trial? ? or Metaanalys?

or Meta(W)Analys? ? or Practice(W)Guideline?

? or Randomized(W)Controlled or

Randomized(W)Controlled or

Randomized(W)Controlled or

Randomised(W)Controlled or

Randomized(W)Trial? ? or

Randomised(W)Trial? ? or

Case(W)Report or Clinical(W)Conference or

Evaluation(W)Study or Evaluation(W)studies or

Multicenter(W)study or

Multicenter(W)studies)/TI,AB

(R eview or Guideline)/T I A rticle T itle:

adjustment*

8 AND 9 A bstract/Notes: adjustment*

9 OR 10 OR 11 A rticle T itle: "ischemic pressure"

8 A ND 13 A bstract/Notes: “ischemic pressure”

(Letter? ? or Comment? ? OR Editorial??)/TI,DT Article Title: “ischaemic pressure”

1 4 NOT 15 A bstract/Notes: “ischaemic pressure”
14/2004:2012,Human A rticle T itle: “spinal mobilization*”
or Article Title:
R D (unique items) “spinal mobilisation*”
A bstract/Notes:
“spinal mobilization*” or
Abstract/Notes:“spinal mobilisation*”

62 Bryans et al Journal of Manipulative and Physiological Therapeutics
January 2014
Neck Pain Clinical Practice Guideline
Index to Chiropractic
APPENDIX A. (continued) DIALOG Databases: Literature
. (continued) MEDLINE, AMED, A rticle T itle:
EMCare, EMBASE “low power lase”r or Article Title:
Search “low level laser”
Step No. PubMed Abstract/Notes:“low power lase”r or
19 spinal manipulation*[tiab] Abstract/Notes:
“low level laser”
20 11 or 12 or 13 or 14 or 16 or Article Title: “spinal manipulation”*
17 or 18 or 19 Abstract/Notes:“spinal manipulation*”
A rticle T itle: ultrasound or A rticle T itle:
21 10 or 20 ultrasonic
22 Neck Pain[mesh] Abstract/Notes: ultrasound or
23 Neck Injuries[mesh] Abstract/Notes: ultrasonic
9 or 10 or 11 or 12 or 13 or 14 or
24 22 or 23 15 or 16 or 17 or
18 or 19 or 20 or 21 or 22 or 23 or 24
25 neck pain[tiab] OR neck injury[tiab] OR Subject: “Neck Pain”
neck injuries[tiab] Subject: “Neck Injuries”
Article Title: neck
26 24 or 25
27 21 and 26 A bstract/Notes: neck
28 #27 Limits: Clinical Trial, Meta-Analysis, 26 or 27 or 28 or 29

Practice Guideline, 25 and 30
Randomized Controlled Trial, Review, Article Title:
Case Reports, Classical Article, Clinical “neck pain” or Article Title:
Conference, Clinical Trial, Phase I, “neck injury” or Article Title:
Clinical Trial, Phase II, Clinical Trial, “neck injuries”
Phase III, Clinical Trial, Phase IV, Abstract/Notes:“neck pain” or
Controlled Clinical Trial, Evaluation Abstract/Notes:
Studies, Guideline, Multicenter Study “neck injury” or Abstract/Notes:
29 #27 Sort by: PublicationDate “neck injuries”
30 clinical trial*[tiab] or controlled trial* 26 or 27 or 32 or 33
[tiab] or controled trial*[tiab] or metaanalys* 25 and 34
[tiab] or meta analys*[tiab] All Fields: pubmed or All Fields:
or practice guideline*[tiab] or medline
guideline[ti] or randomized controlled[tiab] 35 and not 36
or randomized controled[tiab] or Limiting 35 to study types
randomised controlled[tiab] or
randomised controled[tiab] or
randomized trial*[tiab] or randomised
trial*[tiab] or review[ti] or case report
[tiab] or clinical conference[tiab] or
evaluation study[tiab] or evaluation
studies[tiab] or multicenter study[tiab] or
multicenter studies[tiab]
31 27 and 30
32 28 or 31

33 32 not 28

34 Whiplash Injuries[mesh] or whiplash[tiab]
35 32 not 34
36 32 not 35

37
38

Journal of Manipulative and Physiological Therapeutics Bryans et al 63
Volume 37, Number 1 Neck Pain Clinical Practice Guideline

APPENDIX B

Literature screening steps Internet-based interventions
Level 1 screening criteria (N = 555 + hand searches = Laboratory tests
560) Titles and abstracts Laser acupuncture
Inclusion criteria
Related to neck pain Letters to the editor
Nasal or aural or oral interventions
Related to chiropractic treatment (manual therapies such Newspaper articles
as manipulation and mobilization; rehabilitation exercises No original data presented
including home exercise; physical therapies such as Non-SRs
traction, ischemic pressure, massage, cold packs, pillows, Not related to adult humanNs18 years
and laser; and electrical modalities (pulsed electromagnetic Nutritional supplements
eld therapy, ultrasound, transcutaneous electrical nerve Percutaneous interventions
stimulation) Press releases
English
Exclusion criteria Prevalence and epidemiologic studies
Psychological interventions
Studies with principal aims to assess acupuncture, Re exology
psychological interventions, and drugs Relaxation training
Not related to adult humanNs18 years
No original data presented Self-care not guided by a practitioner
Single-case reports
Case reports Use o ntervention surveys
Level 2 screening criteria (N = 237) Selection of clinical Level 3 screening criteria (N = 195) Screening of clinical
and controlled trials and controlled trials
Inclusion criteria
Related to neck pain Inclusion criteria
English
Related to chiropractic treatment (manual therapy, RCTs and systematically conducted reviews
physical therapy, exercise therapy, and lifestyle interventions) Related to chiropractic treatment
English Does it meet any exclusion criteria (speci ed below)
Exclusion criteria
Abstracts not published as full studies Exclusion criteria
Previously identi ed exclusion criteria
Acupressure Level 4 screening criteria (RCTs N = 65); (SRs N = 27)
Adverse events
Behavioral interventions Full-text screening and risk of bias rating
Inclusion criteria
Biofeedback Met eligibility criteria at all previous levels of screening
Cadaver studies
Cognitive interventions Low risk of bias rating
Exclusion criteria
Conference proceedings Methodological quality or relevance to chiropractic so
Drug interventions or tests
Hypnosis low that it precluded extracting any useful credible
information
Imaging/electromyogram (EMG)/electroencephalogram High risk of bias rating
(EEG)/advanced testing (RCTs N = 42; SRs N = 24)

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