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

doi:10.1016/j.jmpt.2013.08.010

Journal of Manipulative and Physiological Therapeutics

Volume 37, Issue 1, January 2014, Pages 42-63

https://doi.org/10.1016/j.jmpt.2013.08.010 Get rights and content

Abstract

Objective

The purpose of this study was to develop evidence-based treatment recommendations for the treatment of nonspecific (mechanical) neck pain in adults.

Methods

Systematic literature searches of controlled clinical trials published through December 2011 relevant to chiropractic practice were conducted using the databases MEDLINE, EMBASE, EMCARE, Index to Chiropractic Literature, and the Cochrane Library. The number, quality, and consistency of findings were considered to assign an overall strength of evidence (strong, moderate, weak, or conflicting) and to formulate treatment recommendations.

Results

Forty-one randomized controlled trials meeting the inclusion criteria and scoring a low risk of bias were used to develop 11 treatment recommendations. Strong recommendations were made for the treatment of chronic neck pain with manipulation, manual therapy, and exercise in combination with other modalities. Strong recommendations were also made for the treatment of chronic neck pain with stretching, strengthening, and endurance exercises alone. Moderate recommendations were made for the treatment of acute neck pain with manipulation and mobilization in combination with other modalities. Moderate recommendations were made for the treatment of chronic neck pain with mobilization as well as massage in combination with other therapies. A weak recommendation was made for the treatment of acute neck pain with exercise alone and the treatment of chronic neck pain with manipulation alone. Thoracic manipulation and trigger point therapy could not be recommended for the treatment of acute neck pain. Transcutaneous nerve stimulation, thoracic manipulation, laser, and traction could not be recommended for the treatment of chronic neck pain.

Conclusions

Interventions commonly used in chiropractic care improve outcomes for the treatment of acute and chronic neck pain. Increased benefit has been shown in several instances where a multimodal approach to neck pain has been used.

Section snippets

Methods

This study addresses chiropractic treatments for which there is evidence. There may be other treatments for which there is no evidence and for which this study cannot make recommendations. Therefore, this CPG does not provide a comprehensive overview of all chiropractic treatment that may be rendered to patients, only those for which there is evidence.

The procedures identified the high-quality (low risk of bias) studies that investigated the benefits of commonly used chiropractic modalities for

Literature Screening and Ratings

The search identified 555 citations that were subsequently augmented by a hand search of the SRs, for a total of 560 publications. Level 1 (title and abstract) reduced this number to 237 (Fig 1). These citations were categorized by treatment modality and the categories, number of selected articles, and reason(s) for inclusion are presented in Table 2. In total, 10 interventions (treatment categories) were identified by the ERT for the evidence to be assessed for risk of bias. Level 2 (full-text

Discussion

In this guideline, recommendations have been developed that updates the body of evidence supporting chiropractic treatment of neck pain. These recommendations offer a broad range of evidence-based treatment options for practitioners to use in patient-centered care. The development of these recommendations reflects the most recent evidence (2004 or later), which is limited to low-risk-of-bias studies. Wherever possible, recommendations were made for each of the treatment modalities identified as

Conclusions

The studies included in this guideline indicate that cervical manipulation, mobilization, manual therapy, exercise, and massage can be recommended for the chiropractic treatment of nonspecific, mechanical neck pain. The strongest recommendations are typically made for the primary intervention in combination with another intervention, usually exercise and/or patient education. Owing to conflicting findings in the literature, no recommendation could be made for laser, TENS, or thoracic

Funding Sources and Potential Conflicts of Interest

Sponsorship and funding were provided by the Canadian Chiropractic Association, Canadian Chiropractic Protective Association, and the Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards (The “Federation”). No conflicts of interest were reported for this study.

Contributorship Information

Concept development (provided idea for the research): RB, MD, RR, LS.
Design (planned the methods to generate the results): RB, MD, RR, LS.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): RB, MD, RR, LS.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): RR
Analysis/Interpretation (responsible for statistical analysis, evaluation, and presentation of the results): RB, MD, RR, LS.

Acknowledgments

The authors thank the following for assistance during the preparation of this guideline: members of the Clinical Practice Guidelines Task Force (Ron Brady, DC; H. James Duncan, BFA, CAE; Wanda Lee MacPhee, DC; Keith Thomson, BSc, DC, ND; Dean Wright, DC) and Jaroslaw Grod, DC, for literature screening and evidence rating.

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Every second human will experience a phase of neck pain in their lifetime and a high rate of chronicity exists. Because of the complexity and multiple influencing factors, chronic pain conditions are associated with a long treatment and diagnostic process. This leads to a prolonged healing process and high costs.
To evaluate the effect of myofascial release on the variables of pain and range of motion in patients with chronic neck pain.
Selection criteria were set to create a search algorithm for a systematic search in the databases: PubMed, Google Scholar, EBM Reviews, Medline, CINAHL, PEDro, and Science Direct. The risk of bias and the methodological quality was analyzed with the PEDro scale.
Ten randomized controlled trials, with 549 participants met the eligibility criteria. The methodological quality was ranked from good to excellent. The myofascial release showed a significant difference in pain (p =  0.03), rotation to the right (p =  0.05), and lateral flexion to the right (p =  0.04), compared to other treatment methods. No significant effect was found for improvements in pressure pain threshold.
Modest effects are observed in pain reduction, suggesting potential benefits of myofascial release in managing chronic neck pain. Further research with standardized protocols and direct comparisons to established therapies is crucial for a comprehensive understanding of myofascial release efficacy.
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  Effective pain reduction: Myofascial release might significantly impact the reduction of neck pain.
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  Uncertain Impact on PPT and ROM: Outcomes for Pressure-Pain Threshold (PPT) and Range of Motion (ROM) remain inconclusive, requiring further research.
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  Treatment Diversity Complexity: Diverse treatment comparators pose challenges in isolating MFR effects, emphasizing the need for standardized protocols and caution when interpreting the results.
What does the meta-analysis add to the current literature.
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  Scientific Gap and Need for Further Research: The meta-analysis highlights a significant scientific gap in definitive evidence supporting myofascial release treatments for chronic neck pain. The identified shortage of studies underscores the need for further research to establish MFR's efficacy, emphasizing standardized protocols, long-term effects, and direct comparisons with established therapies.
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  Consideration of Treatment Modality Variations: The analysis contributes to understanding the complexity introduced by variations in treatment modalities. The meta-analysis emphasizes the importance of homogeneous study designs to enhance outcome comparability. This insight is valuable for researchers and clinicians aiming to interpret and apply findings from diverse studies in the field of MFR and chronic neck pain.
Chiropractic Day 2023: A Report and Qualitative Analysis of How Thought Leaders Celebrate the Present and Envision the Future of Chiropractic
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This study aimed to (1) collect and analyze statements about how to celebrate chiropractic in the present and roles that chiropractors may fulfill in the future, (2) identify if there was congruence among the themes between present and future statements, and (3) offer a model about the chiropractic profession that captures its complex relationships that encompass its interactions within microsystem, mesosystem, exosystem, and macrosystem levels.
For this qualitative analysis, we used pattern and grounded theory approaches. A purposive sample of thought leaders in the chiropractic profession were invited to answer the following 2 open-ended questions: (1) envision the chiropractor of the future, and (2) recommendations on how to celebrate chiropractic. Information was collected during April 2023 using Survey Monkey. The information was entered into a spreadsheet and analyzed for topic clusters, which resulted in matching concepts with social-ecological themes. The themes between the responses to the 2 questions were analyzed for congruence. We used the Standards for Reporting Qualitative Research to report our findings.
Of the 54 experts invited, 32 (59%) participated. Authors represented 7 countries and have a median of 32 years of chiropractic experience, with a range of 5 to 51 years. Nineteen major topics in the future statements and 23 major topics in statements about celebrating chiropractic were combined in a model. The topics were presented using the 4 levels of the social-ecological framework. Individual (microsystem): chiropractors are competent, well-educated experts in spine and musculoskeletal care who apply evidence-based practices, which is a combination of the best available evidence, clinical expertise, and patient values. Interpersonal relationships (mesosystem): chiropractors serve the best interests of their patients, provide person-centered care, embrace diversity, equity, and inclusion, consider specific health needs and the health of the whole person. Community (exosystem): chiropractors provide care within integrated health care environments and in private practices, serve the best interests of the public through participation in their communities, participate through multidisciplinary collaboration with and within the health care system, and work together as a profession with a strong professional identity. Societal (macrosystem): chiropractors contribute to the greater good of society and participate on a global level in policy, leadership, and research. There was concordance between both the future envisioning statements and the present celebration recommendations, which suggest logical validity based on the congruence of these concepts.
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Our aim is to provide an overview of how neck pain is classified in the literature, define and group conservative interventions into ‘nodes’, and develop draft networks of interventions in preparation for a network meta-analysis (NMA).
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Citation Excerpt :
Nonspecific neck pain (NNP) is pain in the posterior neck between the superior nuchal line and the spinous process of the first thoracic vertebra and is not associated with major disease or with neurologic signs of nerve compression.2-4 High-velocity low-amplitude cervical manipulation falls within clinical practice guidelines as an effective treatment method for NNP.5 This manipulation can be applied manually or with use of an instrument.6,7
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Thirty volunteers aged 20 to 40 years old with NNP over 3 months duration were included. Participants were randomly divided into the following 2 groups: (1) MSM group (n = 15) and (2) ISM group (n = 15). Ipsilateral (intervention side) and contralateral (opposite side of intervention) VAs and ICAs were evaluated using spectral color Doppler ultrasound before and immediately after manipulation. Measurements were recorded by visualizing the ICA carotid sinus (C4 level) and the VA at the V3 segment (C1-C2 level). The blood flow parameters of peak systolic velocity (PSV), end-diastolic velocity, resistive index, and volume flow (only for VA) were evaluated. The spinal segment, in which biomechanical aberrant movement was detected by palpation in the upper cervical spine, was manually manipulated in the MSM group. The same methodology was performed for the ISM group using an Activator V instrument (Activator Methods).
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Original ArticleWFC 2013 Award Winning PaperEvidence-Based Guidelines for the Chiropractic Treatment of Adults With Neck Pain

Abstract

Objective

Methods

Results

Conclusions

Section snippets

Methods

Literature Screening and Ratings

Discussion

Conclusions

Funding Sources and Potential Conflicts of Interest

Contributorship Information

Acknowledgments

J Manipulative Physiol Ther

J Manipulative Physiol Ther

J Clin Epidemiol

Man Ther

Pain

Clin Chiropr

Pain

Man Ther

Clinics (Sao Paulo)

Man Ther

Clin Chiropr

Man Ther

Ann Phys Rehabil Med

Man Ther

Arch Phys Med Rehabil

Arch Phys Med Rehabil

J Manipulative Physiol Ther

J Manipulative Physiol Ther

Man Ther

J Manipulative Physiol Ther

Pain

Eur J Pain

Eur J Pain

J Manipulative Physiol Ther

Best Pract Res Clin Rheumatol

Lancet

Man Ther

Man Ther

J Geophys Res

Man Ther

J Manipulative Physiol Ther

The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

Spine (Phila Pa 1976)

Course and prognostic factors for neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

Spine (Phila Pa 1976)

A new conceptual model of neck pain: linking onset, course, and care: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

Spine (Phila Pa 1976)

Clinical guidelines for chiropractic practice in Canada

Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash

J Can Chiropr Assoc

A systematic review of chiropractic management of adults with whiplash-associated disorders: recommendations for advancing evidence-based practice and research

Work

The Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory Boards Clinical Practice Guidelines Development Initiative (The CCA/CFCRB-CPG) development, dissemination, implementation, evaluation, and revision (DevDIER) plan

J Can Chiropr Assoc

Empirical evidence of an association between internal validity and effect size in randomized controlled trials of low-back pain

Spine (Phila Pa 1976)

Grading quality of evidence and strength of recommendations in clinical practice guidelines. Part 1 of 3. An overview of the GRADE approach and grading quality of evidence about interventions

Allergy

Effect of two contrasting types of physical exercise on chronic neck muscle pain

Arthritis Rheum

Applying joint mobilization at different cervical vertebral levels does not influence immediate pain reduction in patients with chronic neck pain: a randomized clinical trial

J Man Manip Ther

The efficacy of intermittent cervical traction in patents with chronic neck pain

Clin Rheumatol

The addition of cervical thrust manipulations to a manual physical therapy approach in patients treated for mechanical neck pain: a secondary analysis

J Orthop Sports Phys Ther

Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial

Ann Intern Med

A randomized controlled trial on the efficacy of exercise for patients with chronic neck pain

Spine (Phila Pa 1976)

A randomized clinical trial of TENS and exercise for patients with chronic neck pain

Clin Rehabil

A randomized controlled trial on the efficacy of intermittent cervical traction for patients with chronic neck pain

Clin Rehabil

Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial

Phys Ther

Original Article
WFC 2013 Award Winning Paper
Evidence-Based Guidelines for the Chiropractic Treatment of Adults With Neck Pain