THE BACK PAGE RESEARCH REVIEW Evidence-based treatment of neck pain (part 1 of 2) REVIEWED BY SHAWN THISTLE Study title: Evidence-based guidelines for the chiropractic treatment of adults with neck pain Authors: Bryans R, Decina P, Descarreaux M, et al. Publication information: Journal of Manipulative & Physiological Therapeutics 2014; 37: 42-63 D octors of chiropractic use a variety of treatment modal-ities to care for patients with neck pain. Neck Pain Guidelines were previously developed by the Canadian Chiroprac-tic Association and the Federation Clinical Practice Guidelines Project and published in 2005. It relied on studies derived from a literature search conducted up to October 2004. How-ever, because of the lack of high-quality research, the resulting treatment rec-ommendations were mainly supported by the expert opinion of the Guidelines Development Committee (GDC). With the help of an experienced medical research librarian, a search strategy was developed and used to search the following databases pub-lished between January 2004 and De-cember 2011: Medline, Embase, Em-care, Index to Chiropractic Literature and the Cochrane Library. The guideline developers considered chiropractic treatment of neck pain to include any of the techniques or proce-dures that are commonly used by DCs. However, only chiropractic treatment modalities for which there is sufficient evidence were addressed. Treatment had to include adults with non-specific neck pain that was evaluated by vali-dated clinical outcome measures. For each of the interventions, rand-omized controlled trials (RCTs) were assigned to acute or chronic categories based on the length of time the patients had symptoms. Some of the RCTs in-cluded both acute and chronic partic-ipants. In those cases, category assign-ment was determined by the average symptom duration of the group. Stud-ies that included sub-acute participants were assigned to the acute category. The strength of treatment recom-mendations was rated as strong, mod-erate, weak or inconsistent, based on the number, quality and consistency of research results, as follows: Strong – when two or more low-risk-of-bias RCTs had consistent findings and were free of limiting factors. Moderate – when there were two or more low-risk-of-bias RCTs, but with limiting factors, or one high-quality RCT that was free of limiting factors. Weak – when only one low-risk-of-bias RCT that had methodological flaws was found. Where there is conflicting evidence, support for the treatment was rated as inconsistent. Strengths, weaknesses Very good procedures were used to develop these guidelines, so the results should be trustworthy and the findings will be helpful to practitioners in the management of neck pain in adults. When the guidelines were compared with the conclusions of the included systematic reviews (SRs), findings within intervention categories re-mained reasonably consistent. For in-stance, 11 of the 12 included SRs that considered manipulation pointed to a therapeutic benefit, as did 12 of the 13 SRs for exercise. Blinding of both participants and providers is difficult to carry out when manual therapies are being studied. As a result, two items in the study-rating questionnaire that had to do with blinding were frequently not met. Nonetheless, studies were scored as low risk only when blinding was re-ported and deemed to be possible. When potential sources of bias ex-isted in studies – such as method of randomization, allocation conceal-ment, blinding, reporting of missing data – yet were not reported, a high risk of bias score was given. In studies where the intervention’s “immediate effect” was tested, the rating criteria co-intervention and compliance were deemed “not applicable” and simply not counted in the scoring. Many of the studies used to develop the guidelines were “pragmatic stud-ies” in which the intervention of inter-est was used in combination with other treatments. However, pragmatic stud-ies make it difficult to discriminate the therapeutic effect of the primary inter-vention from the co-treatment(s). This is a common problem in chiropractic research, since most practitioners pro-vide various forms of multimodal treatments to neck pain. Furthermore, the results of “explanatory studies,” wherein an individual intervention is compared with a placebo or alternate treatment, are often not comparable to what actually occurs in practice. (Next: Conclusions, practical applications and Guideline Development Committee’s recommendations for neck pain treatment ) For more Research Review articles, visit canadianchiropractor.ca. www.canadianchiropractor.ca DR. SHAWN THISTLE owns and operates Research Review Service Inc., helping clinicians integrate scientific evidence into practice through subscription-based service (researchreviewservice.com), online courses (onlinecourses.researchreviewservice.com) and seminars (epicureanscholar.com). 42 Canadian Chiropractor September 2014
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