Anderson-Peacock, Elizabeth

Bryans, Roland

Descarreaux, Martin

Marcoux, Henri

Potter, Brock

Ruegg, Rick

Shaw, Lynn

Watkin, Robert

White, Eleanor

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J Can Chiropr Assoc 2008; 52(1) 7A Clinical Practice Guideline Update from The CCA•CFCREAB-CPGAuthorsThe Canadian Chiropractic Association (The CCA) andthe Canadian Federation of Chiropractic Regulatory andEducational Accrediting Boards (CFCREAB), ClinicalPractice Guidelines Development Initiative (TheCCA•CFCREAB-CPG), Guidelines Development Com-mittee (GDC) comprising (alphabetic listing): ElizabethAnderson-Peacock, BSc, DC (Barrie, ON); Roland Bry-ans, BA, DC, Chair (Clarenville, NL); Martin Descar-reaux, 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 MemorialChiropractic College [CMCC], Toronto, ON); LynnShaw, BSc, MSc, PhD (Assistant Professor, School ofOccupational Therapy, The University of Western On-tario, London, ON); Robert Watkin, BA, LLB (Chair,HIV and Aids Legal Clinic Ontario [HALCO], Toronto,ON); Eleanor White, MSc, DC (Markham, ON).1. IntroductionIn 2003, The CCA•CFCREAB-CPG committed to an on-going process of development, dissemination, implemen-tation, evaluation, and revision of the guidelines it isproducing on behalf of the Canadian chiropractic profes-sion. This commitment was described in the DevDIERplan.1 In keeping with this commitment, an EvidenceMonitoring Committee (EMC) tracks emerging evidenceand the implications of evidence-related feedback abouteach guideline after its publication, and recommends toThe CCA•CFCREAB-CPG appropriate action (workmethod details can be found on-line2). This update is theresult of this work. This update applied the evidence rat-ing method used in the original guideline,3 as adaptedfrom the Oxford Centre for Evidence-based Medicine(OCEBM) levels of evidence.4 Accordingly, results andrecommendations reported here are of Level 5 caliber un-less otherwise noted.Changes are described for the cervical pain guidelinepublished in the Journal of the Canadian Chiropractic As-sociation (JCCA),3 and for the on-line technical versionof the guideline (http://www.ccachiro.org/cpg).52. Noted changeThe following text should be inserted into page 26 of theon-line technical version5 of the cervical pain guideline,immediately following the paragraph entitled “Treat-ment, synthesis 20.”Specifically regarding female patients, Ylinen et al500compared instructions to perform 10 min of unsupervisedstretching home-exercise (Table 4) 5 times a week, withtwice-weekly treatments of:– 10 min of mobilization of cervical vertebrae based on“8 osteopathic ... techniques” and including a degree ofgross cROM,– 15 min of deep massage using longitudinal and trans-verse techniques over the cervical and upper thoracicregions,– 5 min of passive stretching of the cervical and upperthoracic regions.After 4 weeks, the mobilization-massage-passive-stretching treatment was better than the unsupervisedstretching treatment for “neck and shoulder” pain, disa-bility indexes and stiffness {L-2b}. However, both treat-ments had the same effect on neck pain and severalrelated outcomes (e.g., neck numbness, headache, im-pairment in work) {L-2b}. Results suggested that bothgroups were improved for all outcomes at 4 weeks {L-4}.The results of a crossover mechanism incorporatedinto the study suggested that 4 weeks of the mobilization-massage-passive-stretching followed by 8 weeks of theunsupervised stretching, totaling 12 weeks of treatment,was the same as the reverse combination for all outcomesat 12 weeks {L-2b}. Both groups improved until week 4{L-4}, and these improvements were likely maintained atweek 12 {L-5}. These results suggest that for those firstexposed to the mobilization-massage-passive-stretchingtreatment, unsupervised stretching is all that is requiredto maintain benefits {L-5}.GDCThe following text should be inserted into page 171 ofthe JCCA-published cervical pain guideline3 before thetitle of “No additional benefit from magnets in neck-laces.” The text should also be inserted into the on-linetechnical version5 of the guideline immediately followingthe above paragraphs.Immediate and medium-term benefit from a mobili-zation-based multi-modal treatment. A medium courseof unsupervised stretching 5 times a week improves painimmediately after the end of treatment {L-4}.500 The samecourse of twice-weekly mobilization, massage and pas-sive-stretching improves pain better than the unsupervisedCommentary8 J Can Chiropr Assoc 2008; 52(1)stretching in the immediate term {L-2b}. A mediumcourse of unsupervised stretching appears to maintain thebenefits of a prior medium course of mobilization, mas-sage and passive-stretching {L-5}.GDCTreatment recommendation: Based on the benefitsfrom a medium-course of unsupervised stretching or mo-bilization, massage and passive-stretching, we recom-mend a medium-course of mobilization, massage andpassive-stretching to improve pain immediately after theend of treatment. Further, we recommend a subsequentmedium course of daily unsupervised stretching to main-tain benefits.If the mobilization, massage and passive-stretching isnot an option, we recommend a medium course of dailyunsupervised stretching to improve pain immediately af-ter the end of treatment. Further, if a patient is ending amedium course of daily unsupervised stretching, we rec-ommend a subsequent medium-course of mobilization,massage and passive-stretching to additionally improvepain through the treatment period.The following text should be inserted into Table 4 of theon-line technical version5 of the cervical pain guideline:Study reference No. 500: Unsupervised stretchinghome-exerciseStretching towards lateral flexion (for the upper part ofthe trapezius), ipsilateral flexion and rotation (for the sca-lene), and flexion (for the extensor muscles), holdingeach movement for 30 s – each exercise repeated 3 times.Additionally, a neck straightening exercise performed byretruding (thrusting back) the head 5 times for 3 s to 5 s.The following text should be inserted into the refer-ence list of the JCCA-published cervical pain guideline3and 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. RationaleThe evidence disclosed herein addresses mobilization,massage and stretching modalities differently than theguideline presently does in its relevant text sections (Im-mediate benefit from mobilization; Medium- and long-term benefit from exercise with multi-modal treatments;Short-, medium- and long-term benefit from home exer-cise with or without education or ultrasound; Immediate,medium- and long-term benefit from multi-modal treat-ments). Further, the GDC deemed that the evidence dis-closed herein clearly supported a new recommendationabout a specific multi-modal treatment.4. References1 The Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory Boards Clinical Practice Guideline Development Initiative (The CCA•CFCRB-CPG) development, dissemination, implementation, evaluation, and revision (DevDIER) plan. J Can Chiropr Assoc 2003;48(1):56–72.2 Anderson-Peacock E, Blouin JS, Bryans R, Danis N, Furlan A, Marcoux H, Potter B, Ruegg R, White E; Guidelines Development Committee (GDC), The Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory Boards, Clinical Practice Guidelines Development Initiative (The CCA•CFCRB-CPG). Report from an Evidence Monitoring Committee of The CCA and CFCRB Clinical Practice Guideline Initiative. 2006 [cited 2007 Nov 1]. Available from: http://www.ccachiro.org/Client/cca/cca.nsf/web/Activity%20 Update?OpenDocument3 Anderson-Peacock E, Blouin JS, Bryans R, Danis N, Furlan A, Marcoux H, Potter B, Ruegg R, Gross Stein J, White E; Guidelines Development Committee (GDC), The Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory Boards, Clinical Practice Guidelines Development Initiative (The CCA•CFCRB-CPG). Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash. J Can Chiropr Assoc 2005;49(3):158–209.4 Oxford Centre for Evidence-based Medicine. Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001). Oxford (UK); 2001 [cited 2007 May 10]. Available from: http://www.cebm.net/levels_of_evidence.asp5 Anderson-Peacock E, Blouin JS, Bryans R, Danis N, Furlan A, Marcoux H, Potter B, Ruegg R, Gross Stein J, White E; Guidelines Development Committee (GDC), The Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory Boards, Clinical Practice Guidelines Development Initiative (The CCA•CFCRB-CPG). Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash (technical version). [cited 2007 Nov 1]. Available from: http://www.ccachiro.org/Client/cca/cca.nsf/object/Technical_Version/$file/cervical+pain+technical+ version.pdf

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

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

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