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Research - Guidelines for the Chiropractic Treatment of Neck Pain Mar/Apr 2014
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March/April 2014

Guidelines for the Chiropractic Treatment of Neck Pain

Summary provided by Dean L. Smith, D.C., Ph.D.


The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders undertook a best-evidence synthesis to estimate the burden and identify determinants of neck pain.  The annual prevalence estimates in adults ranged from 30% to 50%.  Incidence estimates ranged from 0.055 per 1000 person-years for disc herniation with radiculopathy to 213 per 1000 person-years for self-reported neck pain, which peaks in middle age. Observed frequencies of neck pain among children and adolescents are similar to those of adults.
Risk factors and prognostic factors for neck pain/disability are mostly the same as those for back pain. With the exception of neck pain with radiculopathy, degenerative disc changes do not appear to be associated with neck pain incidence. The time course of neck pain is usually episodic, and complete recovery is uncommon for most patients. Psychological distress and poor coping have been found to impede recovery, on the other hand, physical activity may improve prognosis.
Neck pain is not as prevalent as back pain but is very common in workers particularly in developed countries and leads to considerable disability and reduced productivity. The one-year prevalence of activity-limiting neck pain in workers ranges between 11% and 14% although the annual estimate of neck pain is between 25-50% in this population. It appears that workers in jobs requiring prolonged sitting, repetitive or precision work or awkward postures are at greater risk of neck pain.
Twenty-seven percent of patients seeking chiropractic treatment report neck or cervical problems. Thus, treatment of neck pain is an integral part of chiropractic practice. Treatment modalities typically used by doctors of chiropractic (DCs) to care for patients with neck pain include spinal manipulation, mobilization, device-assisted spinal manipulation, education about modifiable lifestyle factors, physical therapy modalities, heat/ice, massage, soft tissue therapies such as trigger point therapy, and strengthening and stretching exercises.
In accordance with utilizing the best evidence based knowledge, the Canadian Chiropractic Association and the Federation Clinical Practice Guidelines Project sought to develop evidence-based treatment guidelines for adults with neck pain. The purpose of the current treatment guideline was to update the original neck pain guideline (2005) with the most current evidence and to provide a strength rating of each recommendation.  
This clinical practice guideline does not provide a comprehensive overview of all chiropractic treatment that may be rendered to patients, only those for which there is evidence.  High-quality (low risk of bias) studies were sought that investigated the benefits of commonly used chiropractic modalities for the treatment for adults with nonspecific neck pain not resulting from whiplash or serious pathology. This guideline is a supportive tool for practitioners and for their patients and is not intended as a standard of care. The methods used in the development of recommendations for this guideline are widely adopted.
Results of the guidelines found 41 randomized controlled trials that were used to develop 11 treatment recommendations.  Below is a very brief summary of the 11 recommendations.  Please see Bryans et al (2014) for a more detailed analysis of each recommendation.
Weak Treatment Recommendations:
▪ Spinal manipulative therapy (SMT) for chronic neck pain for short- and long-term benefit
▪ Home exercise with advice or training for acute neck pain for both long- and short-term benefits
Moderate Recommendations:
▪ SMT for acute neck pain for both short- and long-term benefit when used in combination with other treatment modalities
▪ Mobilization for acute neck pain for short-term and long-term benefit in combination with advice and exercise
▪ Mobilization for chronic neck pain for short-term (immediate) benefit
▪ Massage for chronic neck pain for short-term benefit when provided in combination with self-care, stretching, and/or exercise
Strong Recommendations:
▪ SMT for chronic neck pain as part of a multimodal approach for both short- and long-term benefit
▪ Manual therapy for chronic neck pain for short- and long-term benefit in combination with advice, stretching, and exercise
▪ Regular home stretching with advice/training for chronic neck pain for long- and short-term benefits in reducing pain and analgesic intake
▪ Home strengthening and endurance exercises for chronic neck pain with advice/training/supervision for both short- and long-term benefits
▪ Exercise (including stretching, isometric, stabilization, and strengthening) for short- and long-term benefits as part of a multimodal approach for chronic neck pain when combined with infrared radiation, massage, or other physical therapies
No recommendation could be made for laser, TENS, or thoracic manipulation in the treatment of chronic neck pain or for the use of thoracic manipulation in the treatment of acute neck pain. In addition, there is a lack of evidence to support the use of laser, trigger point therapy, or traction for nonspecific, mechanical neck pain in adults.  
In conclusion, the studies included in the guidelines 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 usually made for the principal intervention in combination with another intervention (usually exercise and/or patient education).

Reference: Bryans R, Decina P, Descarreaux M, Duranleau M, Marcoux H, Potter B, Ruegg RP, Shaw L, Watkin R, White E. Evidence-based guidelines for the chiropractic treatment of adults with neck pain. J Manipulative Physiol Ther. 2014 Jan;37(1):42-63.


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