• The Canadian Chiropractic Association, Canadian Federation of Chiropractic Regulatory Boards, Clinical Practice Guidelines Development Initiative, Guidelines Development Committee (GDC). Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash. J Can Chiropr Assoc 2005;49(3):158-209. [218 references]

This is the current release of the guideline.

All recommendations should be considered to be expert extrapolations from the evidence, "equivalent" to an Oxford Centre for Evidence-based Medicine (OCEBM) Grade D rating.

Treatment

Most of the following treatment recommendations are based on the evidence discussed in greater detail in the technical version of the original guideline document:

1. The Guideline Development Committee (GDC) recommends the 3 sequential steps in the decision algorithm (see Figure 1 of the original guideline document)--diagnosis (or assessment leading to diagnosis), treatment, reassessment--to treat patients with acute pain, an acute exacerbation of a recurrent pain, or chronic pain. Similarly, the GDC recommends the 3 sequential steps to treat patients with idiopathic pain or pain with an identified cause. The selection and dosages of treatment modalities will differentiate best practices for each unique combination of pain condition and patient. The selection and dosage of treatment modalities should respect recommendation 2 below.
2. The GDC also recommends manipulation, mobilization, ischemic pressure, clinic- and home-based exercise, traction, education, low-power laser, massage, transcutaneous electrical nerve stimulation (TENS), pillows, pulsed electromagnetic therapy, or ultrasound--for patients with acute or chronic pain, where the origin of pain is known or unknown, to improve pain and some range of motion (ROM)--in dosages and methods based on the practitioner's experience and the patient's specific situation, as there is insufficient published evidence to support or refute narrow generalizations about the use of these treatment modalities.
3. In the absence of objective findings with neck pain not due to whiplash (e.g., ROM, muscle hypertonicity), the GDC does not recommend that treatment be initiated. If, after a complete examination, all findings except for pain are normal, the GDC recommends discharge of the patient from chiropractic care and, possibly, referral based on the practitioner's experience.
4. In addition to the details of the 3-step sequence in recommendation #1, if home exercise is prescribed, the GDC recommends frequent monitoring of its quality and a reassessment of the quality and effect of the home exercise after 2 to 4 weeks.
5. Based on the short- and medium-term benefit from manipulation, the GDC does not recommend crossed bilateral transverse pisiform or anterior thoracic manipulations to be added to a course of cervical manipulations to improve pain and some ROM, unless where required for non-cervical benefits.
6. Based on the summary exercise benefit statement and the short-, medium-, and long-term benefit from home exercise with or without education or ultrasound, the GDC does not recommend generic home exercise designed to improve pain or ROM that is not tailored to the individual patient. The GDC recommends tailored home exercise treatment, as rigorous as the patient can tolerate, if a loss of ROM, strength, or endurance is found. It can be as frequent as once daily, with its rigor adjusted progressively.
7. Based on the medium term benefit from pillows, in addition to the details of the 3-step sequence in the first recommendation (above), the GDC recommends a cervical pillow as a secondary treatment that should be initiated only after at least one cycle of diagnosis (or assessment leading to diagnosis), treatment, and reassessment--and if prescribed, the pillow should be used nightly.
8. Based on the short- and medium-term benefit from pulsed electromagnetic field therapy, in addition to the details of the 3-step sequence in the first recommendation (above), the GDC recommends pulsed electromagnetic field treatment as an adjunctive, secondary treatment that should be initiated only after at least one cycle of diagnosis (or assessment leading to diagnosis), treatment, and reassessment.
9. Based on no additional benefit from magnets in necklaces, the GDC does not recommend permanent magnet necklaces to improve pain, specifically because the monetary and lifestyle costs of a magnetic necklace do not appear to be counter-balanced by a clinical benefit.
10. Based on no benefit from education or relaxation alone, the GDC does not recommend education or relaxation alone to improve pain or ROM.
11. Based on no immediate benefit from head retraction-extension exercise combinations alone, the GDC does not recommend head retraction-extension exercise combinations to improve pain.
12. Based on no immediate benefit from occipital release treatments alone, the GDC does not recommend occipital release treatments to improve pain.

Natural History of Neck Pain

13. The GDC does not recommend treatments that are expected to show less or slower improvement than the expected natural history of the treated pain in a particular patient, unless: a) the treatment also addresses non-pain problems that, left untreated, may have permanent sequelae, or b) it is deemed that treatment will halt the evolution of acute pain to a chronic condition.
14. If maximum clinical progress has been reached without all clinical goals being met, the GDC recommends continuing care only if the patient chooses support or maintenance care. If all clinical goals have been met, the GDC recommends continuing care only if the patient chooses "wellness" care.

The Role of Focusing on Immediate Clinical Outcomes

15. The GDC recommends the planned one-time use of a treatment specifically and only to determine the utility of further treatments or to permit the immediate use of an otherwise painful intervention, both purposes therefore requiring an immediately-subsequent patient assessment. Thus, the GDC does not recommend the planned one-time use of a treatment to merely achieve an immediate clinical effect.

Multi-Sectoral Care

16. The GDC recommends a concerted effort to mesh chiropractic care into that of other health disciplines to maximize patients' gains from their chiropractic treatments (recovery from pain, impairment, and disability, reduced costs, increased patient safety, increased satisfaction among patients and health care payers).

Managing the Risk of Adverse Events

17. To manage the risk of adverse events associated with a treatment modality, if a chiropractor is uncertain about the caliber of any aspect of his or her technique with a particular patient, the GDC very strongly recommends discontinuance of care and referral to colleagues until this is addressed.

Managing the Risk of Adverse Events Not Associated With a Treatment Modality, but That Occur in the Clinical Setting (Non-Tx-AE)

18. Before, during, or after treatment, the GDC recommends immediate, in-depth consideration of possible explanations and reconsideration of treatment options or referral to the appropriate health services when an adverse event (not known to be associated with a treatment) is noted (i.e., when a patient demonstrates signs or symptoms of an undiagnosed condition or signs or symptoms not known to be associated with a treatment).

Managing the Risk of Adverse Events Associated with a Treatment Modality, but not a Known or Observable Risk Factor (Unforeseen-Tx-AE)

19. During or after treatment, the GDC recommends heightened vigilance for adverse events associated with a treatment modality, but not a known or observable risk factor (unforeseen-Tx-AE) when a relevant treatment is planned or administered--and immediate, in-depth consideration of possible explanations and reconsideration of treatment options or referral to the appropriate health services when an event is noted.

Managing the Risk of Adverse Events Associated with a Treatment Modality and Predicted by an Observable Risk Factor (Foreseen-Tx-AE)

20. The GDC recommends respecting the absolute contraindications listed in Tables 3a to 3h of the original guideline document (and in the "Contraindications" field of this summary), and the best-practice patterns of absolute contraindications, treatment modality modification, and caution described in Sections 5.3.1, 5.3.2, and 5.3.3 of the original guideline document.

Please see the original guideline document for Research Recommendations 21 through 27.

Spotlight on Dissection

Informed Consent

28. The GDC very strongly recommends obtaining informed consent based on current evidence, and respecting the 3 sequential steps in the decision algorithm (see Figure 1 of the original guideline document)--diagnosis (or assessment leading to diagnosis), treatment, reassessment--when caring for any patient.

Predispositions to Dissection in a Patient's History

29. The GDC recommends caution in treating a patient with trauma, a smoking habit, or known arterial tissue abnormalities to manage the risk for dissection, but the evidence does not warrant that these be contraindications to manipulation.

Noting Predispositions During Physical Examination; Impaired Vertebral Artery Flow Doppler Identification of Impaired Vertebral Artery Flow

30. The GDC recommends an assessment for signs and symptoms of unprovoked vertebrobasilar insufficiency (VBI) (differentiated from benign paroxysmal positional vertigo [BPPV]) to identify the possibility of impaired vertebral artery flow (signs and symptoms are nystagmus, nausea, numbness, diplopia, drop attacks, dysphagia, dysarthria, and ataxia), because the GDC recommends caution in treating a patient with suspected impairment of flow. However, the evidence does not warrant this being a contraindication to manipulation.
31. The GDC does not recommend an assessment for signs or symptoms of unprovoked VBI (differentiated from BPPV) to identify the presence of dissection or to identify patients with greater or lesser risk of symptomatic (ischemia-provoking) dissection subsequent to manipulation; the assessment lacks predictive value.
32. The GDC does not recommend Doppler or provocative pre-manipulative vertebral artery function tests (e.g., deKleyn's test) to identify impaired vertebral artery flow, the presence of dissection, or patients with greater or lesser risk of symptomatic (ischemia-provoking) dissection subsequent to manipulation; the assessment lacks predictive value.

Dissection in the Chiropractic Clinic

Identifying the Occurrence of Dissection Before or During a Visit

33. The GDC does not recommend manipulation for patients who present with active or existing vertebral artery dissection (VAD) or carotid artery dissection (CAD).
34. The GDC recommends caution in treating a patient who reports a recent (but not ongoing) neck or occipital pain with a sharp quality and severe intensity, or a severe and persistent headache, which was sudden and unlike any previously experienced pain or headache (even when it is suspected the pain was of a musculoskeletal or neuralgic origin).
35. The GDC recommends immediate discontinuance of treatment and referral to emergency health services when a patient complains in the course of care (diagnosis [or assessment leading to diagnosis], treatment, reassessment) of neck or occipital pain with a sharp quality and severe intensity, or a severe and persistent headache, which is sudden and unlike any previously experienced pain or headache (even when it is suspected the pain is of a musculoskeletal or neuralgic origin).

Mitigating the Harm of VAD: A Stroke

36. The GDC recommends immediate discontinuance of treatment and referral to emergency health services when, in the course of care (diagnosis [or assessment leading to diagnosis], treatment, reassessment), a patient demonstrates at least 1 of 4 signs or symptoms of neurovascular impairment (unilateral facial paresthesia, objective cerebellar signs, lateral medullary signs, visual field defects) or other signs or symptoms of neurovascular impairment with unknown cause, irrespective of complaints of neck or head pain. In addition, the GDC recommends immediate investigation for these 4 signs or symptoms of neurovascular impairment whenever a patient demonstrates vertigo--if none are present, the GDC recommends caution in treating the patient because of the continued risk for neurovascular impairment.

Stroke; An Adverse Event of the Rotation Component of Manipulation?

37. Although the role (alleviating, neutral, exacerbating, causative) of manipulation in cerebrovascular (CV) accidents is unclear, the GDC recommends using a minimal rotation in administering an upper-cervical spine manipulation until better information is available, to maximize the benefit to harm balance.
38. Extrapolating from their recommendation to use a minimal rotation in administering an upper-cervical spine manipulation, the GDC also recommends the use of a minimal rotation in administering any modality of upper-cervical spine treatment.

Algorithms are provided in the original guideline document for:

• Clinical decision algorithm
• Cervical spine manipulative therapy; decision algorithms coping with the theoretic risk of dissection

The type of supporting evidence for specific treatment recommendations is tabulated in Appendix 3 of the original guideline document.

Most of the recommendations concerning management of risk of adverse effects were based on level 5 evidence (subjective extrapolation or observation, frequently based on a case study), and only a very few being level 3 or better.

• The Canadian Chiropractic Association, Canadian Federation of Chiropractic Regulatory Boards, Clinical Practice Guidelines Development Initiative, Guidelines Development Committee (GDC). Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash. J Can Chiropr Assoc 2005;49(3):158-209. [218 references]

Not applicable: The guideline was not adapted from another source.

2005

Canadian Chiropractic Association - Professional Association
Canadian Federation of Chiropractic Regulatory Boards - National Government Agency [Non-U.S.]

Unrestricted grant from the Ontario Ministry of Health and Long-term Care to the Ontario Chiropractic Association

Guidelines Development Committee (GDC)

Committee Members: Elizabeth Anderson-Peacock, BSc, DC, DICCP (Barrie, ON); Jean-Sébastien Blouin, PhD, DC (School of Human Kinetics, University of British Columbia, Vancouver, BC); Roland Bryans, BA, DC, Co-chair (Clarenville, NL); Normand Danis, DC, Co-chair (Montreal, PQ); Andrea Furlan, MD (Evidence-Based Practice Co-ordinator, Institute for Work & Health, Toronto, ON); Henri Marcoux, DC, FCCS(C), DABCO (Winnipeg, MB); Brock Potter, BSc, DC (North Vancouver, BC); Rick Ruegg, BSc, PhD, DC (Associate Dean, Clinics, Canadian Memorial Chiropractic College [CMCC], Toronto, ON); Janice Gross Stein, BA, MA, PhD (Belzberg Professor of Conflict Management and Negotiation, Department of Political Science, Director of the Munk Centre for International Studies, University of Toronto, Toronto, ON); Eleanor White, MSc, DC (Markham, ON)

Contributing Advisors:

Literature Search Team (treatment and dissection, all at CMCC, Toronto, ON): Carol Hagino, BSc, MBA; Janet Hayes RN, CCRP; Kim Humphreys, PhD, DC; Anne Taylor-Vaisey, MLS; Howard Vernon DC, PhD, FCCS(C)

Literature Search Team (adverse events): Andrea Furlan, MD; Anne Taylor-Vaisey, MLS

Literature Search Team (treatment update): Anne Taylor-Vaisey, MLS

Evidence Extraction Team: Thor Eglington, BSc, BA, MSc, RN (Ottawa, ON); Bruce P Squires, PhD, MD (Ottawa, ON)

Critical commentary: Donald R Murphy, DC, DACAN (Rhode Island Spine Center, Department of Community Health, Brown University School of Medicine, Providence, RI, USA)

Review Panel: Robert R Burton, BSc, DC, FCCRS(C), DACRB (St John's, NL); Andrea Furlan, MD; Richard Roy, DC (Université du Québec à Trois-Rivières, Trois Rivières, QC ); Steven Silk, BSc, DC (Wiarton, ON); Roy Till, DC, FCCRS(C) (Stoney Creek, ON)

Task Force: Grayden Bridge, DC (President, The Canadian Chiropractic Association [The CCA]); H James Duncan, BFA, ex-officio (The CCA); Wanda Lee MacPhee, BSc, DC (President, Canadian Federation of Chiropractic Regulatory Boards [CFCRB]); Bruce Squires, BA, MBA (ex-officio, Ontario Chiropractic Association [OCA]); Greg Stewart, BPE, DC (The CCA); Keith Thomson, DC (CFCRB); Dean Wright, DC (ex-officio, President, OCA)

The contributing individuals declared no conflict of interest. Guideline Development Committee member Andrea Fulran and Janice Gross Stein received a per diem for their participation. The literature search and evidence extraction team were contracted.

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on January 19, 2006. The information was verified by the guideline developer on February 1, 2006.