Neck Pain

Management of Neck Pain and Associated Disorders

By Frank M. Painter|March 23, 2016|Guidelines, Neck Pain, Whiplash|

Management of Neck Pain and Associated Disorders: A Clinical Practice Guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

SOURCE: Eur Spine J. 2016 (Mar 16) [Epub]

Côté P, Wong JJ, Sutton D, Shearer HM, Mior S et. al.

Canada Research Chair in
Disability Prevention and Rehabilitation,
University of Ontario Institute of Technology (UOIT),
2000 Simcoe Street North,
Oshawa, ON, L1H 7L7, Canada.

PURPOSE: To develop an evidence-based guideline for the management of grades I-III neck pain and associated disorders (NAD).

METHODS: This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I-III NAD <6 months duration.

RECOMMENDATION 1: Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III.

RECOMMENDATION 2: Clinicians should assess prognostic factors for delayed recovery from NAD.

RECOMMENDATION 3: Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I-III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care.

RECOMMENDATION 4: For NAD grades I-II ≤3 months duration, clinicians may consider structured patient education in combination with: range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat.

RECOMMENDATION 5: For NAD grades I-II >3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections.

RECOMMENDATION 6: For NAD grade III ≤3 months duration, clinicians may consider supervised strengthening exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction.

RECOMMENDATION 7: For NAD grade III >3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management.

RECOMMENDATION 8: Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.

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Where the United States Spends its Spine Dollars

By Frank M. Painter|November 5, 2015|Low Back Pain, Neck Pain|

Where the United States Spends its Spine Dollars: Expenditures on Different Ambulatory Services for the Management of Back and Neck Conditions

The Chiro.Org Blog

SOURCE: Spine 2012 (Sep 1); 37 (19): 1693–1701 ~ FULL TEXT

Matthew A. Davis, DC, MPH

The Dartmouth Institute for Health Policy and Clinical Practice,
Lebanon, NH 03766, USA.
matthew.a.davis@dartmouth.edu

STUDY DESIGN: Serial, cross-sectional, nationally representative surveys of noninstitutionalized US adults.

OBJECTIVE: To examine expenditures on common ambulatory health services for the management of back and neck conditions.

SUMMARY OF BACKGROUND DATA: Although it is well recognized that national costs associated with back and neck conditions have grown considerably in recent years, little is known about the costs of care for specific ambulatory health services that are used to manage this population.

METHODS: We used the Medical Expenditure Panel Survey to examine adult (aged 18 yr or older) respondents from 1999 to 2008 who sought ambulatory health services for the management of back and neck conditions. We used complex survey design methods to make national estimates of mean inflation-adjusted annual expenditures on medical care, chiropractic care, and physical therapy per user for back and neck conditions.

RESULTS: Approximately 6% of US adults reported an ambulatory visit for a primary diagnosis of a back or neck condition (13.6 million in 2008). Between 1999 and 2008, the mean inflation-adjusted annual expenditures on medical care for these patients increased by 95% (from $487 to $950); most of the increase was accounted for by increased costs for medical specialists, as opposed to primary care physicians. During the study period, the mean inflation-adjusted annual expenditures on chiropractic care were relatively stable; although physical therapy was the most costly service overall, in recent years those costs have contracted.

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Prognostic Factors for Recurrences in Neck Pain Patients Up to 1 Year After Chiropractic Care

By Frank M. Painter|September 28, 2015|Chronic Pain, Neck Pain|

Prognostic Factors for Recurrences in Neck Pain Patients Up to 1 Year After Chiropractic Care

The Chiro.Org Blog

SOURCE: J Manipulative Physiol Ther. 2015 (Sep 15 ~ FULL TEXT

Anke Langenfeld, MS, B. Kim Humphreys, DC, PhD,
Jaap Swanenburg, PhD, Cynthia K. Peterson, RN, DC, MMedEd, PhD

PhD Student,
CAPHRI School of Public Health and Primary Care,
Department of Epidemiology,
Maastricht University,
Maastricht, The Netherlands

OBJECTIVE: Information about recurrence and prognostic factors is important for patients and practitioners to set realistic expectations about the chances of full recovery and to reduce patient anxiety and uncertainty. Therefore, the purpose of this study was to assess recurrence and prognostic factors for neck pain in a chiropractic patient population at 1 year from the start of the current episode.

METHODS: Within a prospective cohort study, 642 neck pain patients were recruited by chiropractors in Switzerland. After a course of chiropractic therapy, patients were followed up for 1 year regarding recurrence of neck pain. A logistic regression analysis was used to assess prognostic factors for recurrent neck pain. The independent variables age, pain medication usage, sex, work status, duration of complaint, previous episodes of neck pain and trauma onset, numerical rating scale, and Bournemouth questionnaire for neck pain were analyzed. Prognostic factors that have been identified in previous studies to influence recovery of neck pain are psychologic distress, poor general health at baseline, and a previous history of pain elsewhere.

RESULTS: Five hundred forty five patients (341 females), with a mean age of 42.1 years (SD, 13.1) completed the 1-year follow-up period. Fifty-four participants (11%) were identified as “recurrent.” Prognostic factors associated with recurrent neck pain were previous episodes of neck pain and increasing age.

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Spinal Manipulative Therapy and Exercise For Seniors with Chronic Neck Pain

By Frank M. Painter|March 6, 2015|Chiropractic Care, Chronic Pain, Neck Pain|

Spinal Manipulative Therapy and Exercise For Seniors with Chronic Neck Pain

The Chiro.Org Blog

SOURCE: Spine J. 2014 (Sep 1); 14 (9): 1879–1889

Michele Maiers, DC, MPH, Gert Bronfort, DC, PhD,
Roni Evans, DC, MS, Jan Hartvigsen, DC, PhD,
Kenneth Svendsen, MS, Yiscah Bracha, MS,
Craig Schulz, DC, MS, Karen Schulz, DC,
Richard Grimm, MD, PhD

Northwestern Health Sciences University,
Wolfe-Harris Center for Clinical Studies,
2501 W. 84th St, Bloomington, MN 55431, USA
mmaiers@nwhealth.edu

BACKGROUND CONTEXT: Neck pain, common among the elderly population, has considerable implications on health and quality of life. Evidence supports the use of spinal manipulative therapy (SMT) and exercise to treat neck pain; however, no studies to date have evaluated the effectiveness of these therapies specifically in seniors.

PURPOSE: To assess the relative effectiveness of SMT and supervised rehabilitative exercise, both in combination with and compared to home exercise (HE) alone for neck pain in individuals ages 65 years or older.

STUDY DESIGN/SETTING: Randomized clinical trial.

PATIENT SAMPLE: Individuals 65 years of age or older with a primary complaint of mechanical neck pain, rated =3 (0-10) for 12 weeks or longer in duration.

OUTCOME MEASURES: Patient self-report outcomes were collected at baseline and 4, 12, 26, and 52 weeks after randomization. The primary outcome was pain, measured by an 11-box numerical rating scale. Secondary outcomes included disability (Neck Disability Index), general health status (Medical Outcomes Study Short Form-36), satisfaction (7-point scale), improvement (9-point scale), and medication use (days per week).

METHODS: This study was funded by the US Department of Health and Human Services, Health Resources and Services Administration. Linear mixed model analyses were used for comparisons at individual time points and for short- and long-term analyses. Blinded evaluations of objective outcomes were performed at baseline and 12 weeks. Adverse event data were collected at each treatment visit.

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Treatment Preferences Amongst Physical Therapists and Chiropractors for the Management of Neck Pain: Results of an International Survey

By Frank M. Painter|March 30, 2014|Neck Pain|

Treatment Preferences Amongst Physical Therapists and Chiropractors for the Management of Neck Pain: Results of an International Survey

The Chiro.Org Blog

SOURCE: Chiropractic & Manual Therapies 2014 (Mar 24); 22 (1): 11

Lisa C Carlesso, Joy C MacDermid, Anita R Gross,
David M Walton, P Lina Santaguida

Toronto Western Research Institute,
University Health Network,
399 Bathurst Street – MP11-328,
Toronto, Ontario M5T 2S8, Canada

BACKGROUND: Clinical practice guidelines on the management of neck pain make recommendations to help practitioners optimize patient care. By examining the practice patterns of practitioners, adherence to CPGs or lack thereof, is demonstrated. Understanding utilization of various treatments by practitioners and comparing these patterns to that of recommended guidelines is important to identify gaps for knowledge translation and improve treatment regimens.Aim: To describe the utilization of interventions in patients with neck pain by clinicians.

METHODS: A cross-sectional international survey was conducted from February 2012 to March 2013 to determine physical medicine, complementary and alternative medicine utilization amongst 360 clinicians treating patients with neck pain.

RESULTS: The survey was international (19 countries) with Canada having the largest response (38%). Results were analyzed by usage amongst physical therapists (38%) and chiropractors (31%) as they were the predominant respondents. Within these professions, respondents were male (41-66%) working in private practice (69-95%). Exercise and manual therapies were consistently (98-99%) used by both professions but tests of subgroup differences determined that physical therapists used exercise, orthoses and ‘other’ interventions more, while chiropractors used phototherapeutics more. However, phototherapeutics (65%), Orthoses/supportive devices (57%), mechanical traction (55%) and sonic therapies (54%) were not used by the majority of respondents. Thermal applications (73%) and acupuncture (46%) were the modalities used most commonly. Analysis of differences across the subtypes of neck pain indicated that respondents utilize treatments more often for chronic neck pain and whiplash conditions, followed by radiculopathy, acute neck pain and whiplash conditions, and facet joint dysfunction by diagnostic block. The higher rates of usage of some interventions were consistent with supporting evidence (e.g. manual therapy). However, there was moderate usage of a number of interventions that have limited support or conflicting evidence (e.g. ergonomics).

CONCLUSIONS: This survey indicates that exercise and manual therapy are core treatments provided by chiropractors and physical therapists. Future research should address gaps in evidence associated with variable practice patterns and knowledge translation to reduce usage of some interventions that have been shown to be ineffective.

From the Full-Text Article:

Background

Clinical practice guidelines are developed to provide statements and recommendations with the intention of helping practitioners optimize patient care [1]. By examining the practice patterns of practitioners, adherence to CPGs or lack thereof, is demonstrated. Recommendations for practice can then be formed. Understanding existing practice patterns provides insight into how current evidence impacts on practice and can identify where greater efforts in knowledge translation are needed. Clinical practice will vary dependent on a number of factors such as location, resources available, patient population, and professional background. Several CPGs from varying professionals who treat patients with neck pain exist [2-5]. To our knowledge no examination of practice patterns across health care professionals who treat patients with neck pain has been published.

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

By Frank M. Painter|November 28, 2013|Chiropractic Care, Chiropractic Research, Evidence-based Medicine, Neck Pain|

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

The Chiro.Org Blog

SOURCE: J Manipulative Physiol Ther 2014 (Jan); 37 (1): 42–63

Roland Bryans, DC, Philip Decina, DC, Martin Descarreaux, DC, PhD, Mireille Duranleau, DC, Henri Marcoux, DC, Brock Potter, BSc, DC, Richard P. Ruegg, PhD, DCs, Lynn Shaw, PhD, OT, Robert Watkin, BA, LLB, Eleanor White, MSc, DC

Guidelines Development Committee (GDC) Chairman; Chiropractor, Clarenville, Newfoundland, Canada.

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.

Thanks to Dynamic Chiropractic for these comments from their article:
The Science of Treating Neck Pain

Following a literature search of controlled clinical trials through December 2011, 560 studies were narrowed to 41 that met the authors’ inclusion criteria and served as the basis for their treatment recommendations, graded as strong, moderate or weak based on the number, quality and consistency of research results.

Treatment strategies given strong recommendations for chronic neck pain included manipulation, manual therapy and exercise in combination with other modalities; as well as stretching, strengthening and endurance exercises alone.

Mobilization, as well as massage in combination with other therapies, received moderate recommendations for chronic neck pain.

Manipulation and mobilization in combination with other modalities received moderate recommendations for treating acute neck pain.

Here are the recommendations:

Acute Neck Pain

Manipulation / Multimodal: “Spinal manipulative therapy is recommended for the treatment of acute neck pain for both short- and long-term benefit (pain and the number of days to recover) when used in combination with other treatment modalities (advice, exercise, and mobilization;
(grade of recommendation – moderate).”

Mobilization/ Multimodal: “Mobilization is recommended for the treatment of acute neck pain for short-term (up to 12 weeks) and long-term benefit (days to recovery, pain) in combination with advice and exercise
(grade of recommendation – moderate).”

Exercise: “Home exercise with advice or training is recommended in the treatment of acute neck pain for both long- and short-term benefits
(neck pain; grade of recommendation – weak).”

Chronic Neck Pain

Manipulation / Multimodal: “Spinal manipulative therapy is recommended in the treatment of chronic neck pain as part of a multimodal approach (including advice, upper thoracic high-velocity low-amplitude thrust, low-level laser therapy, soft-tissue therapy, mobilizations, pulsed short-wave diathermy, exercise, massage, and stretching) for both short- and long-term benefit
(pain, disability, cROMs; grade of recommendation – strong).”

Manual Therapy / Multimodal: “Manual therapy is recommended in the treatment of chronic neck pain for the short- and long-term benefit (pain, disability, cROM, strength) in combination with advice, stretching, and exercise
(grade of recommendation – strong).”

Exercise: “Regular home stretching (3-5 times per week) with advice / training is recommended in the treatment of chronic neck pain for long- and short-term benefits in reducing pain and analgesic intake
(grade of recommendation – strong).”

Exercise / Multimodal: “Exercise (including stretching, isometric, stabilization, and strengthening) is recommended for short- and long-term benefits (pain, disability, muscle strength, QoL, cROM) as part of a multimodal approach to the treatment of chronic neck pain when combined with infrared radiation, massage, or other physical therapies
(grade of recommendation – strong).”

Mobilization: “Mobilization is recommended for the treatment of chronic neck pain for short-term (immediate) benefit
(pain, cROM; grade of recommendation – moderate)”

Massage / Multimodal: “Massage is recommended for the treatment of chronic neck pain for short-term (up to 1 month) benefit (pain, disability, and cROM) when provided in combination with self-care, stretching, and/or exercise (grade of recommendation – moderate).”

Manipulation: “Spinal manipulative therapy is recommended in the treatment of chronic neck pain for short- and long-term benefit
(pain, disability; grade of recommendation – weak).”

In their conclusion, the authors note that their findings suggest “interventions commonly used in chiropractic care improve outcomes for the treatment of acute and chronic neck pain” and that “increased benefit has been shown in several instances where a multimodal approach to neck pain has been used.”

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