A Clinical Practice Guideline Update from The CCA•CFCREAB-CPG

Authors

The Canadian Chiropractic Association (The CCA) and the Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards (CFCREAB), Clinical Practice Guidelines Development Initiative (The CCA•CFCREAB-CPG), Guidelines Development Committee (GDC) comprising (alphabetic listing): Elizabeth Anderson-Peacock, BSc, DC (Barrie, ON); Roland Bryans, BA, DC, Chair (Clarenville, NL); Martin Descarreaux, PhD, DC (Université du Québec à Trois-Rivières, Trois-Rivières, QC); Henri Marcoux, DC, DABCO, FCCS(C), FCCO(C) (Winnipeg, MB); Brock Potter, BSc, DC (North Vancouver, BC); Rick Ruegg, BSc, PhD, DC (Associate Dean, Clinical Education, Canadian Memorial Chiropractic College [CMCC], Toronto, ON); Lynn Shaw, BSc, MSc, PhD (Assistant Professor, School of Occupational Therapy, The University of Western Ontario, London, ON); Robert Watkin, BA, LLB (Chair, HIV and Aids Legal Clinic Ontario [HALCO], Toronto, ON); Eleanor White, MSc, DC (Markham, ON).

1. Introduction

In 2003, The CCA•CFCREAB-CPG committed to an ongoing process of development, dissemination, implementation, evaluation, and revision of the guidelines it is producing on behalf of the Canadian chiropractic profession. This commitment was described in the DevDIER plan.¹ In keeping with this commitment, an Evidence Monitoring Committee (EMC) tracks emerging evidence and the implications of evidence-related feedback about each guideline after its publication, and recommends to The CCA•CFCREAB-CPG appropriate action (work method details can be found on-line²). This update is the result of this work. This update applied the evidence rating method used in the original guideline,³ as adapted from the Oxford Centre for Evidence-based Medicine (OCEBM) levels of evidence.⁴ Accordingly, results and recommendations reported here are of Level 5 caliber unless otherwise noted.

Changes are described for the cervical pain guideline published in the Journal of the Canadian Chiropractic Association (JCCA),³ and for the on-line technical version of the guideline (http://www.ccachiro.org/cpg).⁵

2. Noted change

The following text should be inserted into page 26 of the on-line technical version⁵ of the cervical pain guideline, immediately following the paragraph entitled “Treatment, synthesis 20.”

Specifically regarding female patients, Ylinen et al⁵⁰⁰ compared instructions to perform 10 min of unsupervised stretching home-exercise (Table 4) 5 times a week, with twice-weekly treatments of:

• – 10 min of mobilization of cervical vertebrae based on “8 osteopathic … techniques” and including a degree of gross cROM,

• – 15 min of deep massage using longitudinal and transverse techniques over the cervical and upper thoracic regions,

• – 5 min of passive stretching of the cervical and upper thoracic regions.

After 4 weeks, the mobilization-massage-passive-stretching treatment was better than the unsupervised stretching treatment for “neck and shoulder” pain, disability indexes and stiffness {L-2b}. However, both treatments had the same effect on neck pain and several related outcomes (e.g., neck numbness, headache, impairment in work) {L-2b}. Results suggested that both groups were improved for all outcomes at 4 weeks {L-4}.

The results of a crossover mechanism incorporated into the study suggested that 4 weeks of the mobilization-massage-passive-stretching followed by 8 weeks of the unsupervised stretching, totaling 12 weeks of treatment, was the same as the reverse combination for all outcomes at 12 weeks {L-2b}. Both groups improved until week 4 {L-4}, and these improvements were likely maintained at week 12 {L-5}. These results suggest that for those first exposed to the mobilization-massage-passive-stretching treatment, unsupervised stretching is all that is required to maintain benefits {L-5}.^GDC

The following text should be inserted into page 171 of the JCCA-published cervical pain guideline³ before the title of “No additional benefit from magnets in necklaces.” The text should also be inserted into the on-line technical version⁵ of the guideline immediately following the above paragraphs.

Immediate and medium-term benefit from a mobilization-based multi-modal treatment

A medium course of unsupervised stretching 5 times a week improves pain immediately after the end of treatment {L-4}.⁵⁰⁰ The same course of twice-weekly mobilization, massage and passive-stretching improves pain better than the unsupervised stretching in the immediate term {L-2b}. A medium course of unsupervised stretching appears to maintain the benefits of a prior medium course of mobilization, massage and passive-stretching {L-5}.^GDC

Treatment recommendation

Based on the benefits from a medium-course of unsupervised stretching or mobilization, massage and passive-stretching, we recommend a medium-course of mobilization, massage and passive-stretching to improve pain immediately after the end of treatment. Further, we recommend a subsequent medium course of daily unsupervised stretching to maintain benefits.

If the mobilization, massage and passive-stretching is not an option, we recommend a medium course of daily unsupervised stretching to improve pain immediately after the end of treatment. Further, if a patient is ending a medium course of daily unsupervised stretching, we recommend a subsequent medium-course of mobilization, massage and passive-stretching to additionally improve pain through the treatment period.

The following text should be inserted into Table 4 of the on-line technical version⁵ of the cervical pain guideline:

Study reference No. 500: Unsupervised stretching home-exercise

Stretching towards lateral flexion (for the upper part of the trapezius), ipsilateral flexion and rotation (for the scalene), and flexion (for the extensor muscles), holding each movement for 30 s – each exercise repeated 3 times. Additionally, a neck straightening exercise performed by retruding (thrusting back) the head 5 times for 3 s to 5 s.

The following text should be inserted into the reference list of the JCCA-published cervical pain guideline³ and the on-line technical version⁵ of the guideline.

500 Ylinen J, Kautiainen H, Wirén K, Häkkinen A. Stretching exercises vs manual therapy in treatment of chronic neck pain: a randomized, controlled cross-over trial. J Rehabil Med 2007;39(2):126–32.

3. Rationale

The evidence disclosed herein addresses mobilization, massage and stretching modalities differently than the guideline presently does in its relevant text sections (Immediate benefit from mobilization; Medium- and long-term benefit from exercise with multi-modal treatments; Short-, medium- and long-term benefit from home exercise with or without education or ultrasound; Immediate, medium- and long-term benefit from multi-modal treatments). Further, the GDC deemed that the evidence disclosed herein clearly supported a new recommendation about a specific multi-modal treatment.