REVIEW ARTICLE

Management of neck pain and associated disorders: A clinicalpractice guideline from the Ontario Protocol for Traffic InjuryManagement (OPTIMa) Collaboration

Pierre Cote1,2 • Jessica J. Wong2,3 • Deborah Sutton2,3 • Heather M. Shearer2,3 •

Silvano Mior3,4 • Kristi Randhawa2,3,5 • Arthur Ameis6 • Linda J. Carroll7 •

Margareta Nordin8,9 • Hainan Yu2,3 • Gail M. Lindsay4 • Danielle Southerst10 •

Sharanya Varatharajan2,3,5 • Craig Jacobs2,11 • Maja Stupar2 • Anne Taylor-Vaisey2 •

Gabrielle van der Velde12,13,14 • Douglas P. Gross15,16 • Robert J. Brison17,18 •

Mike Paulden19 • Carlo Ammendolia14,20 • J. David Cassidy21,22 • Patrick Loisel3,23 •

Shawn Marshall24 • Richard N. Bohay25 • John Stapleton26 • Michel Lacerte27,28 •

Murray Krahn20 • Roger Salhany29

Received: 4 September 2015 / Revised: 15 February 2016 / Accepted: 15 February 2016

� Springer-Verlag Berlin Heidelberg 2016

Abstract

Purpose To develop an evidence-based guideline for the

management of grades I–III neck pain and associated dis-

orders (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

Roger Salhany—Retired Judge from the Ontario Superior Court of

Justice, Toronto, Canada

Electronic supplementary material The online version of thisarticle (doi:10.1007/s00586-016-4467-7) contains supplementarymaterial, which is available to authorized users.

& Pierre Cote

pierre.cote@uoit.ca

1 Canada Research Chair in Disability Prevention and

Rehabilitation, University of Ontario Institute of Technology

(UOIT), 2000 Simcoe Street North, Oshawa, ON L1H 7L7,

Canada

2 UOIT-CMCC Centre for the Study of Disability Prevention

and Rehabilitation, University of Ontario Institute of

Technology (UOIT) and Canadian Memorial Chiropractic

College (CMCC), 6100 Leslie Street, Toronto, ON M2H 3J1,

Canada

3 Graduate Education and Research Programs, Canadian

Memorial Chiropractic College (CMCC), 6100 Leslie Street,

Toronto, ON M2H 3J1, Canada

4 Faculty of Health Sciences, University of Ontario Institute of

Technology (UOIT), 2000 Simcoe Street North, Oshawa,

ON L1H 7L7, Canada

5 Undergraduate Education, Canadian Memorial Chiropractic

College (CMCC), 6100 Leslie Street, Toronto, ON M2H 3J1,

Canada

6 Certification Program in Insurance Medicine and Medico-

legal Expertise, Faculty of Medicine, University of Montreal,

N-414, Roger-Gaudry Building, 2900, Boulevard Edouard-

Montpetit, Montreal, QC H3T 1J4, Canada

7 Injury Prevention Centre and School of Public Health,

University of Alberta, 3-300 Edmonton Clinic Health

Academy, 11405 – 87 Ave, Edmonton, AB T6G 1C9, Canada

8 Department of Orthopedic Surgery, Occupational and

Industrial Orthopedic Center, NYU School of Medicine, New

York University, 550 1st Avenue, New York, NY 10016,

USA

9 Department of Environmental Medicine, Occupational and

Industrial Orthopedic Center, NYU School of Medicine, New

York University, 550 1st Avenue, New York, NY 10016,

USA

10 Rebecca MacDonald Centre for Arthritis and Autoimmune

Disease, Mount Sinai Hospital, Joseph and Wolf Lebovic

Health Complex, 60 Murray Street, 2nd Floor (Main),

Toronto, ON M5T 3L9, Canada

123

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DOI 10.1007/s00586-016-4467-7

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 reas-

sure 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 wors-

ening 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 B3 months

duration, clinicians may consider structured patient edu-

cation in combination with: range of motion exercise,

multimodal care (range of motion exercise with manipu-

lation 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, elec-

troacupuncture, electrotherapy, or clinic-based heat.

Recommendation 5 For NAD grades I–II [3 months

duration, clinicians may consider structured patient edu-

cation 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-in-

flammatory 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 botu-

linum toxin injections.

Recommendation 6 For NAD grade III B3 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 dura-

tion, clinicians should not offer a cervical collar. Patients

who continue to experience neurological signs and dis-

ability 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.

Keywords Clinical practice guideline � Neck pain �Treatment � Management � Practice guideline � Therapies �Therapy � Disease management � Whiplash

11 Division of Clinical Education, Canadian Memorial

Chiropractic College (CMCC), 6100 Leslie Street, Toronto,

ON M2H 3J1, Canada

12 Toronto Health Economics and Technology Assessment

(THETA) Collaborative, 144 College Street, Toronto,

ON M5S 3M2, Canada

13 Leslie Dan Faculty of Pharmacy, University of Toronto, 144

College St, Toronto, ON M5S 3M2, Canada

14 Institute for Work and Health, 481 University Ave, Toronto,

ON M5G 2E9, Canada

15 Department of Physical Therapy, University of Alberta, 2-50

Corbett Hall, Edmonton, AB T6G 2G4, Canada

16 Rehabilitation Research Centre, University of Alberta, 3-62

Corbett Hall, Edmonton, AB T6G 2G4, Canada

17 Clinical Research, Kingston General Hospital, 76 Stuart

Street, Kingston, ON K7L 2V7, Canada

18 Department of Emergency Medicine, School of Medicine,

Queen’s University, 15 Arch Street, Kingston, ON K7L 3N6,

Canada

19 Faculty of Medicine and Dentistry, University of Alberta, 116

St & 85 Ave, Edmonton, AB T6G 2R3, Canada

20 Institute for Health Policy, Management and Evaluation,

University of Toronto, 155 College Street, Toronto,

ON M5T 3M7, Canada

21 University of Southern Denmark, Campusvej 55,

5230 Odense M, Denmark

22 Dalla Lana School of Public Health, University of Toronto,

155 College Street, Toronto, ON M5T 3M7, Canada

23 Division of Occupational and Environmental Health, Dalla

Lana School of Public Health, University of Toronto, 155

College Street, Toronto, ON M5T 3M7, Canada

24 University of Ottawa, 505 Smyth Road, Ottawa,

ON K1H 8M2, Canada

25 Schulich School of Medicine and Dentistry, Western

University, Dental Sciences Building, London, ON N6A 5C1,

Canada

26 Open Policy Ontario, Toronto, Canada

27 Universite de Montreal, 2375 Cote Ste-Catherine, Montreal,

QC H3T 1A8, Canada

28 Department of Physical Medicine and Rehabilitation,

Schulich School of Medicine and Dentistry, Western

University, London, ON N6A 5C1, Canada

29 Toronto, Canada

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Introduction

Background

More than 80 % of individuals experience neck pain and

associated disorders (NAD) during their lifetime, with

30–50 % of the general adult population reporting neck

pain annually [1, 2]. The course of neck pain is favorable

for most people; however, 23 % of individuals who recover

from an episode of neck pain will experience a subsequent

episode [3]. For many patients, neck pain is a complex

biopsychosocial disorder with problematic physical and

psychological symptoms. Neck pain is associated with

decreased health-related quality of life, decreased work

productivity, daily activity limitations, and increased

healthcare utilization [2, 4–6]. In the United States,

approximately 10.2 million visits are made annually to

physician offices and hospital outpatient departments for

neck pain [7]. In 2010, neck pain ranked fourth among all

conditions contributing to years lived with disability [8].

NAD that results from motor vehicle collisions is com-

monly known as whiplash-associated disorders (WAD) [9].

In Canada, 86.2 % of people injured in motor vehicle

collisions develop NAD [6]. Recovery from NAD can be

prolonged and associated with high health resource use [10,

11]. Costs related to managing this condition are substan-

tial due to medical costs and costs associated with pro-

ductivity changes [5, 12].

The clinical management of NAD is often challenging.

Recommendations from clinical practice guidelines aim to

inform clinical practice. However, the quality of current

clinical practice guidelines varies [13], and recommenda-

tions that are not evidence-based cannot be relied upon to

reduce symptoms or facilitate patient recovery. An up-to-

date, high quality evidence-based clinical practice guideline

is needed to inform the management of NAD grades I–III.

Scope and purpose of the guideline

We used the best available evidence to develop a clinical

practice guideline for the management of NAD grades I–III

(including WAD) of less than 6 months duration (Table 1).

NAD includes non-traumatic, traumatic, or work-related neck

pain. The target population is adults (18 years of age or older)

with recent-onset (0–3 months duration) and persistent

(4–6 months duration) NAD grades I–III; it does not cover

NAD that persists for more than 6 months. The management

of NAD grade IV is beyond the scope of this guideline

because it refers to significant pathology that may require

invasive/surgical interventions. The target audience for the

current guideline includes clinicians (medical doctors, phys-

iotherapists, nurse practitioners, chiropractors, kinesiologists,

psychologists, and massage therapists) caring for patients

with neck pain in primary, secondary, and tertiary health care

settings. This guideline aims to: (1) accelerate recovery; (2)

reduce the intensity of symptoms; (3) promote early restora-

tion of function; (4) prevent chronic pain and disability; (5)

improve health related quality of life; (6) reduce recurrences;

and (7) promote active participation of patients in their care.

Moreover, this guideline aims to promote uniform high

quality care for individuals with NAD.

The guideline was developed by the Ontario Protocol for

Traffic Injury Management (OPTIMa) Collaboration, which is

a multidisciplinary team of expert clinicians (from medicine,

dentistry, physiotherapy, chiropractic, psychology, occupa-

tional therapy, and nursing disciplines), academics and sci-

entists (epidemiologists, clinical epidemiologists, library

sciences, and health economists), a patient liaison, a consumer

representative, a retired judge, and automobile insurance

industry experts. The OPTIMa Collaboration was mandated

by the Ontario Ministry of Finance and the Financial Services

Commission of Ontario to develop an evidence-based clinical

practice guideline for neck pain and its associated disorders.

Table 1 Classification of Neck Pain and Associated Disorders (NAD) [24] and Whiplash Associated Disorders (WAD) [9]

Grade Definition

The 2000–2010 Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders Classification of NAD [24]

I No signs or symptoms suggestive of major structural pathology and no or minor interference with activities of daily living

II No signs or symptoms of major structural pathology, but major interference with activities of daily living

III No signs or symptoms of major structural pathology, but presence of neurologic signs such as decreased deep tendon reflexes, weakness

or sensory deficits

IV Signs or symptoms of major structural pathology

The Quebec Task Force Classification of WAD [9]

I Neck pain and associated symptoms in the absence of objective physical signs

II Neck pain and associated symptoms in the presence of objective physical signs and without evidence of neurological involvement

III Neck pain and associated symptoms with evidence of neurological involvement including decreased or absent reflexes, decreased or

limited sensation, or muscular weakness

IV Neck pain and associated symptoms with evidence of fracture or dislocation

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Methods

Systematic reviews

We updated the systematic reviews from the Bone and

Joint Decade 2000–2010 Task Force on Neck Pain and Its

Associated Disorders (Neck Pain Task Force) [14]. This

update included eight systematic reviews examining the

effectiveness, cost-effectiveness, and safety of non-inva-

sive interventions for the management of NAD grades I–III

[15–22]. All systematic reviews were registered with the

International Prospective Register of Systematic Reviews

(PROSPERO) [23].

The systematic reviews included studies examining the

effectiveness of non-invasive interventions for the manage-

ment of NAD grades I–III (Table 1; Appendix) [15–22]. We

excluded studies on the management of grade IV NAD (e.g.,

fractures, dislocations, neoplasms, inflammatory diseases).

Non-invasive interventions included acupuncture, exercise,

manual therapy, passive physical modalities, psychological

interventions, soft tissue therapy, structured patient education,

multimodal care, analgesics, non-steroidal anti-inflammatory

drugs (NSAIDs), and muscle relaxants (Appendix I). Eligible

comparators included other interventions, placebo/sham

interventions, non-intervention effects associated with wait

listing, or no intervention. Eligible outcomes included self-

rated recovery, functional recovery, disability, pain intensity,

health-related quality of life, psychological outcomes, or

adverse events. We considered randomized controlled trials

(RCTs), cohort studies, and case–control studies published in

English. Only full economic evaluations that jointly analyzed

costs and health outcomes were eligible for inclusion in the

cost-effectiveness review.

We searched MEDLINE, EMBASE, PsycINFO, and

Cochrane Central Register of Controlled Trials through

Ovid Technologies, Inc., and CINAHL Plus with Full Text

through EBSCOhost (Appendix IIA and IIB). We also

searched EconLit through ProQuest, Health Technology

Assessment (Cochrane), and National Health Service

Economic Evaluation Database (Cochrane) for economic

evaluations. Our initial searches included publication dates

from January 1990 to January 2015 (search dates varied

between reviews). In May 2015, we updated all searches in

MEDLINE to retrieve recent RCTs, full economic evalu-

ations, or systematic reviews.

Random pairs of independent, trained reviewers

screened and critically appraised eligible studies using the

Scottish Intercollegiate Guidelines Network (SIGN) crite-

ria [25]. Low risk of bias studies were included in the

evidence synthesis [26]. Low risk of bias studies were

defined as studies where selection bias, information bias,

and confounding were deemed unlikely by two

independent reviewers to have threatened the internal

validity of the study. Minimal clinically important differ-

ence thresholds from the literature were used to determine

the clinical importance of the results between groups from

low risk of bias studies [27–30].

Development of recommendations

The principle of patient-centered care was fundamental to

the development of this guideline. We developed the evi-

dence-based recommendations according to:

• Key decision determinants [overall clinical benefit

(effectiveness and safety), value for money (i.e., cost-

effectiveness data when available), and consistency

with expected societal and ethical values] based on the

Ontario Health Technology Advisory Committee

framework [31];

• Best evidence obtained from critical review of scientific

literature; and

• Findings from qualitative research exploring the expe-

riences of persons treated for traffic injuries in Ontario

[32]. These findings on patient experiences were

considered under the key decision determinant ‘ex-

pected societal and ethical values.’

All systematic reviews were reviewed and approved by

a multidisciplinary Guideline Expert Panel that included 21

individuals representing emergency medicine, internal

medicine, rehabilitation medicine, orthopedic surgery,

dentistry, chiropractic, physical therapy, psychology,

nursing, health economics, epidemiology, clinical epi-

demiology, law, patient liaison, consumer representative,

and insurers (non-voting members). The translation of

scientific evidence into guideline recommendations fol-

lowed five steps (Table 2). Recommended interventions

were supported by evidence of effectiveness from studies

with low risk of bias, and where available, by evidence of

benefits outweighing harm to patients. When evidence was

sparse (e.g., red flags or pharmacological treatments for

neck pain), the Guideline Expert Panel used evidence from

the low back pain literature to inform its recommendations.

This guideline adapted the National Institute for Health

and Care Excellence methodology to develop the wording

of guideline recommendations (Table 3) [33]. Based on

this methodology, recommendations start with the word

‘‘offer’’ (for interventions that are of superior effectiveness

compared to other interventions, placebo/sham interven-

tions, or no intervention), ‘‘consider’’ (for interventions

providing similar effectiveness to other interventions), or

‘‘do not offer’’ (for interventions providing no benefit

beyond placebo/sham or are harmful). An intervention was

deemed to have superior effectiveness if evidence of

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statistically significant and clinically important benefits

was identified in at least one RCT with a low risk of bias.

The frequency and duration of interventions was inclu-

ded in the recommendations. This was determined by

averaging or by reporting treatment frequencies and dura-

tions of care for interventions that were effective [15, 16].

Specifically, for recommended interventions that were

supported by one low risk of bias RCT, we used the fre-

quency and duration of treatment that were tested in that

RCT. For recommended interventions that were based on

more than one low risk of bias study, we computed the

mean frequency and duration of care across studies with

superior outcomes for a specific intervention.

Each recommendation was integrated into care path-

ways, which were approved by the Guideline Expert Panel

(Figs. 1, 2, 3, 4). Interventions for which there is

inconclusive evidence of effectiveness were not included in

the care pathways (Appendix III).

The applicability (e.g., facilitators, barriers, resource

implications, dissemination, implementation) of this

guideline is beyond the scope of this project because it was

developed for the Government of Ontario. The Government

will determine its applicability to the Ontario automobile

insurance and healthcare system. It is recommended that

this guideline be updated in 5 years so that the guideline is

based on current evidence [34]. The update should use

methodology similar to the development of this guideline.

External review

This evidence-based clinical practice guideline was

developed for the Government of Ontario. The

Table 2 Guideline recommendations: translation of scientific evidence into guideline recommendations by the Ontario Protocol for Traffic

Injury Management (OPTIMa) Collaboration

Step Description of process

1 Draft recommendations based on the best-evidence synthesis of the literature were developed by the authors of each systematic review

2 The recommendation sub-committeea used the key decision determinants of the Ontario Health Technology Advisory Committee

framework [31] to modify the draft recommendation, evaluating its consistency with patients’ experiences and preferences, expected

societal and ethical values and incorporating economic evidence

3 The recommendation subcommittee reviewed the draft recommendation, debated its validity and, if necessary, made modifications based

upon the scientific evidence

4 The recommendation subcommittee reached consensus on the draft recommendation

5 Draft recommendations (with supporting decision determinants) were presented to the Guideline Expert Panel at quarterly meetings. The

Guideline Expert Panel provided feedback and voted to accept, reject, or modify each recommendation. Recommendations requiring

modification were reformulated and a new, separate vote for the revised recommendation occurred. Voting was done through secret

ballot. Consensus was reached when 75 % of the Guideline Expert Panel accepted a recommendation

a The recommendation subcommittee included individuals representing rehabilitation medicine, nursing, chiropractic, epidemiology, health

economics, and patient liaison

Table 3 Guideline recommendations: wording of guideline recommendations as adapted from the National Institute for Health and Care

Excellence Methodology [33]

Effectiveness of interventions Wording of recommendations

Interventions that should be used are interventions demonstrated to be

clearly superior to other interventions, placebo/sham interventions, or

no intervention (i.e., statistically significant and clinical important

between group differences favouring the intervention)

Recommendations start with the word ‘‘offer’’

Interventions that should not be offered because they provide no benefit

beyond placebo/sham (i.e., statistically significant and clinical

important between group differences favouring placebo/sham) or

because they are harmful (i.e., serious adverse events or high frequency

of minor adverse events)

Recommendations start with the words ‘‘do not offer’’

Recommendations for interventions providing similar effectiveness to

other interventions (between group differences of the interventions

were not statistically significant and/or clinically important)

Recommendations start with the word ‘‘consider’’; the choice of

interventions should be influenced by patients’ values and

preferences

Evidence was deemed inconclusive when the results of multiple low risk

of bias studies conflicted

Intervention was categorized under ‘inconclusive evidence’;

conflicting results prevented the development of a coherent

statement of effectiveness

The Guideline Expert Panel was confident that the treatment will do more good than harm for the ‘offer’ or ‘consider’ interventions, and that the

treatment will not benefit patients for ‘do not offer’ interventions

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Person with neck pain

Are symptoms ≤ 3 months? Symptoms are ˃3 months.

Based upon shared decision making by the pa�ent and provider, the following therapeu�c interven�ons are recommended:b,d,e

A. Home and clinic based interven�ons:1. Structured educa�on (advice to stay ac�ve), reassurance & one of

the following:i) Unsupervised neck range of mo�on exercisesii) Mul�-modal care that includes the combina�on of:

a) Manipula�on or mobiliza�onb) Unsupervised neck range of mo�on exercises

iii) Muscle relaxantsf

Refer to specific recommenda�on for treatment details (Sec�on 4.1.3)

Do Not Offer:g

1) Structured pa�ent educa�on alone, in verbal or wri�en formats2) Strain-counterstrain or relaxa�on massage3) Cervical collar4) EMS, heat (clinic-based)5) Electroacupuncture (electrical s�mula�on of acupuncture points with

acupuncture needles or electrotherapy applied to the skin)

Offer informa�on on nature, management, course of NAD as a framework for ini�a�on of a program of care

Yes

No

Yes

Go to Care Pathway for the Management of NAD III

Is treatment required?

Yes

DischargeNo

Care Pathway for the Management of NAD Grade I and II

Poor prognos�c factors?c

No

Address modifiable prognostic

factors

Yes

NAD III

4

2

1112

13

14

16

9

10

7

8

1

Conduct an appropriate clinical evalua�on

Risk factors for serious pathologies or NAD IVa? Yes Refer to physician

No

NAD I or NAD IIb? No

Yes

3

56

15

Based upon shared decision making between the pa�ent and provider, the following therapeu�c interven�ons are recommended:b,d,e

A. Home and clinic based interven�ons: 1. Structured educa�on (advice to stay ac�ve), reassurance & one of the following:

i) Supervised combined exercisesIi) Supervised qigong exercisesiii) Iyengar yogaiv) Mul�modal care that includes the combina�on of (if not previously

given in 1st 3 months of care):a) Neck range of mo�on exercisesb) Manipula�on or mobiliza�on

v) Clinical massagevi) Low-level laser therapyvii) Non-steroidal an�-inflammatory drugsf

Refer to specific recommenda�on for treatment details (Sec�on 4.1.4)

Do Not Offer:g

1) Programs solely of clinic-based supervised high dose strengthening exercises2) Strain-counterstrain or relaxa�on massage3) Relaxa�on therapy for pain or disability outcomes4) TENS, EMS, pulsed shortwave diathermy, heat (clinic-based)5) Electroacupuncture (electrical s�mula�on of acupuncture points with acupuncture needles or electrotherapy applied to the skin)6) Botulinum toxin injec�ons

Fig. 2 Care pathway for the management of Neck Pain and Associated Disorders (NAD) grades I and II

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Government invited stakeholders to review and comment

on the guideline. Moreover, the government held a series of

public consultations on the clinical practice guideline from

August 17–21, 2015.

Recommendations

All recommended interventions are supported by evidence

of effectiveness, safety, cost-effectiveness (when cost-ef-

fectiveness data were available), and are consistent with

societal and ethical values. Interventions that are not rec-

ommended did not satisfy the criteria of one or more key

decision determinants (i.e., evidence of effectiveness,

safety, cost-effectiveness, and/or consistency with societal

and ethical values).

Recommendation 1: evaluation of NAD

Clinicians should rule out major structural or other

pathologies as the cause of NAD. Clinicians should classify

NAD as grade I, II, or III.

Clinicians should conduct a clinical evaluation to rule

out major structural or other pathologies (NAD grade IV)

as the cause of signs and symptoms. The Canadian C-spine

Rule should be used to rule out cervical spine fractures and

dislocations associated with acute trauma (Appendix IV)

[35]. The Canadian C-spine Rule was designed and vali-

dated for use in emergency departments, and can be used in

acute care settings. The presence of risk factors for serious

pathologies (also termed ‘red flags’) identified during the

history/examination warrants further investigation and

referral to the appropriate healthcare professional (Table 4)

[36–38]. As there is a paucity of literature on red flags for

neck pain, the list of red flags was informed by the low

back pain literature [36–38].

Clinicians should assess for neurological signs (de-

creased deep tendon reflexes, muscle weakness, sensory

deficits). NAD III refers to neck pain associated with

clear clinical evidence of neurologic signs (decreased

deep tendon reflexes, weakness, or sensory deficits) on

physical examination. Once major pathology has been

ruled out, clinicians should classify the grade of NAD as

grade I, II, or III; as recent or persistent; and the patient

should receive the appropriate evidence-based interven-

tions (Figs. 1, 2).

Recommendation 2: prognostic factors for delayed

recovery

Clinicians should assess prognostic factors for delayed

recovery from NAD (Appendix V). Most patients will

Reassess and Monitor for the presence of acute stress disorder, post-trauma�c stress disorder, kinesiophobia, passive coping, depression, anxiety, anger, frustra�on and fear

Reassess and Monitor for the presence of acute stress disorder, post-trauma�c stress disorder, kinesiophobia, passive coping, depression, anxiety, anger, frustra�on and fear

Is injured person recovered?

Is injured person recovered? Yes YesDischarge

1) Incomplete recovery: ini�ate persistent protocol (Box 16) 2) Signs progress to Grade III: proceed to NAD III care pathway3) Development of serious pathology (new or worsening physical,

mental or psychological symptoms): refer to physician

No No

1) Incomplete recovery: refer to physician2) Signs progress to Grade III: proceed to NAD III care pathway3) Development of serious pathology (new or worsening physical,

mental or psychological symptoms): refer to physician

a Risk factors for serious pathologies (also known as red flags): Cancer (history of cancer, unexplained weight loss, nocturnal pain, age >50), vertebral infec�on (fever, intravenous drug use, recent infec�on), osteoporo�c fractures (history of osteoporosis, use of cor�costeroid, older age), trauma�c fracture (posi�ve Canadian C-Spine rule), myelopathy – severe/progressive neurological deficits (painful s�ff neck , arm pain and weakness, sensory changes in lower extremity, motor weakness and atrophy, hyper-reflexia, spas�c gait), caro�d/vertebral artery dissec�on (sudden and intense onset of headache or neck pain), brain haemorrhage/mass lesion (sudden and intense onset of headache), inflammatory arthri�s (morning s�ffness, swelling in mul�ple joints)b If symptoms progress proceed to NAD III protocol or refer.c Factors delaying recovery: older age, prior history of neck pain, high levels of ini�al pain, high levels of ini�al disability, post-crash psychological factors [poor recovery expecta�on, symptoms of acute stress disorder (symptoms ≤ 4 weeks of the injury), symptoms of post-trauma�c stress disorder (symptoms > 4 weeks), depressed mood or feelings of depression about pain, anxiety or fear about pain, high levels of frustra�on or anger about pain, passive coping, kinesiophobia, avoiding ac�vi�es due to fear of pain]d This guideline does not include interven�ons for which there is a lack of evidence of effec�venesse The ordering of interven�ons does not reflect superiority of effec�venessf The evidence indicates that analgesia is the primary therapeu�c benefit of the muscle relaxant and NSAID classes of medica� on. Pain reduc�on should be apparent during the ini�al period of usage; in the absence of therapeu�c benefit , prolonga�on of usage is not warranted. There is no evidence of differen�al efficacy for the various drugs within each class . There is also no evidence that any combina�on of these medica�ons provides added benefit. There are poten�ally significant adverse effects associated with use of these classes of medica�ons. Finally, the non-opioid first ‘step’ in the Analgesic Ladder includes NSAIDs, muscle relaxant and acetaminophen (Vargas-Schaffer G. Is the WHO analgesic ladder s�ll valid? Twenty-four years of experience. Vol 56: June 2010 Canadian Family Physician). However, the evidence does not indicate that acetaminophen is an effec�ve analgesic for either NAD or low back pain; therefore, the use of acetaminophen is not recommended. gBased on evidence of no benefit to pa�ents

17 18

20 2119

22 23

Fig. 2 continued

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Fig.3

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recover. Patients with NAD grade I can be expected to

recover more quickly, while those with NAD grade III are

expected to recover more slowly [11, 24, 39–42]. Patients

with the following prognostic factors may have a higher

risk for delayed recovery [11, 24, 39–42]:

• Demographic factors: older age.

• Physical health: prior history of neck pain; high levels

of initial pain; and high levels of initial disability.

• Psychological factors following a traffic collision: poor

expectation of recovery, symptoms of acute stress

Persons with neck pain

Poor prognos�c factors?c

Address modifiable prognos�c factorsYes

Are symptoms ≤ 3 months? No

Based upon shared decision making between the pa�ent and provider, the following therapeu�c interven�ons are recommended:b,d,e

1) Structured educa�on, reassurance 2) Supervised graded neck strengthening exercise

Refer to specific recommenda�on for treatment details (Sec�on 4.2.3)

Do not offer :f

1) Structured pa�ent educa�on alone, in either verbal or wri�en formats

2) Low level laser therapy3) Intermi�ent trac�on4) Cervical collar

Yes

Go to care pathway for the management of NAD I/II

1) Refer to medical physician for considera�on of further inves�ga�on of the neurological deficitsb,d

Do not offer :f

1) Cervical collar

Offer informa�on on nature, management, course of NAD III as a framework for ini�a�on of a program of care.

No

Yes

7

1

8 9

11

13 14

Care Pathway for the Management of NAD Grade III

Conduct an appropriate clinical evalua�on

Risk factors for serious pathologies or NAD IVa? Yes Refer to physician

No

No

Yes

NAD IIIb NAD I or II

Symptoms are ˃3 months.

Yes

2

34

10

5 6

12

Fig. 4 Care pathway for the management of Neck Pain and Associated Disorders (NAD) grade III

Eur Spine J

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disorders (symptoms exhibited within 4 weeks of

injury), symptoms of post-traumatic stress disorder

(symptoms lasting at least 4 weeks); depressed mood or

feelings of depression about pain, anxiety or fear about

pain, high levels of frustration or anger about the pain,

passive coping, kinesiophobia, avoiding activities due

to fear of pain.

Recommendation 3: management of NAD

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.

For NAD grades I–III, clinicians should provide care in

partnership with the patient and involve the patient in care

planning and decision-making. Clinicians should reassure

patients that, in the majority of cases, NAD is benign and

has a self-limited course. Patients should be educated about

the benefits of being actively engaged and participating in

their care plan by remaining active and maintaining

movement of their neck. Clinicians should emphasize

active rather than passive treatments and deliver time-

limited care that includes effective interventions [15–17,

43, 44].

Recommendation 4: management of recent NAD

grades I–II (Tables 5, 6; Figs. 1, 2)

For patients with NAD grades I–II B3 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 a short course of muscle relaxants (as

indicated). In view of evidence of no effectiveness, clini-

cians should not offer structured patient education alone,

strain-counterstrain therapy, relaxation massage, cervical

Reassess and Monitor for the presence of acute stress disorder, post-trauma�c stress disorder, kinesiophobia, passive coping, depression, anxiety, anger, frustra�on and fear

Reassess and Monitor for the presence of acute stress disorder, post-trauma�c stress disorder, kinesiophobia, passive coping, depression, anxiety, anger, frustra�on and fear

Is injured person recovered? DischargeYes

a Risk factors for serious pathologies (also known as red flags): Cancer (history of cancer, unexplained weight loss, nocturnal pain, age >50), vertebral infec�on (fever, intravenous drug use, recent infec�on), osteoporo�c fractures (history of osteoporosis, use of cor�costeroid, older age), trauma�c fracture (posi�ve Canadian C-Spine rule), myelopathy – severe/progressive neurological deficits (painful s�ff neck, arm pain and weakness, sensory changes in lower extremity, motor weakness and atrophy, hyper-reflexia, spas�c gait), caro�d/vertebral artery dissec�on (sudden and intense onset of headache or neck pain), brain haemorrhage/mass lesion (sudden and intense onset of headache), inflammatory arthri�s (morning s�ffness, swelling in mul�ple joints)b Conduct ongoing assessment for Improvement or worsening/progress of symptoms during interven�on and refer accordingly.c Assess for factors delaying recovery: older age, prior history of neck pain, high levels of ini�al pain, high levels of ini�al disability, post-crash psychological factors [poor recovery expecta�on, symptoms of acute stress disorder (symptoms ≤ 4 weeks of the injury), symptoms of post-trauma�c stress disorder (symptoms ≤ 4 weeks), depressed mood or feelings of depression about pain, anxiety or fear about pain, high levels of frustra�on or anger about pain, passive coping, kinesiophobia, avoiding ac�vi�es due to fear of pain] d This guideline does not include interven�ons for which there is a lack of evidence of effec�veness .e The ordering of interven�ons does not reflect superiority of effec�venessf Based on evidence of no benefit to pa�ents

Refer to physician

Refer to NAD I/II care pathway

Are there neurological signs,

major symptom change or development of serious

pathology?

Yes

No

15 16

17 18

21

2019

Fig. 4 continued

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collar, electroacupuncture, electrotherapy, or clinic-based

heat.

Structured patient education Clinicians should provide

information about the nature, management, and course of

NAD as a framework for initiating the program of care.

This recommendation is based on universal principles of

health professions’ standards of practice wherein patients

are informed and educated about their condition, and par-

ticipate in the decision-making process [45].

Clinicians should not offer structured patient education

alone [17, 46]. This recommendation is based on one low

risk of bias RCT suggesting that although structured edu-

cation was less costly than multimodal care, it was also less

effective than multimodal care [17, 46].

However, clinicians can consider a structured patient

education program as an adjunct to an effective program

based on individual patient presentation [17, 46–48]. The

structured education should focus on providing advice to

stay active and reassuring the patient by addressing

expectations of recovery. This recommendation is based on

three low risk of bias RCTs suggesting that: (1) a course of

physiotherapy including self-care advice is more effective

than one session of oral advice in improving the recovery

of patients [17, 46]; and (2) an educational video combined

with usual emergency care may be more effective than

usual emergency care alone in reducing neck pain for

recent WAD [17, 47, 48].

Exercise Clinicians may consider range of motion

exercises (5–10 repetitions with no resistance, up to 6–8

times per day) [15, 49]. This involves unsupervised and

gentle daily home-based controlled range of motion exer-

cises of neck and shoulder, including neck retraction,

extension, flexion, rotation, lateral bending, and scapular

retraction. The exercise program should be taught to the

patient by a healthcare professional. This recommendation

is based on one low risk of bias RCT that found similar

outcomes between home exercise and advice, medication,

and manual therapy for recent NAD I–II [49].

Multimodal care Clinicians may consider a maximum of

six sessions over 8 weeks of multimodal care that includes

range of motion exercise and manual therapy (manipulation

or mobilization to the cervical and/or thoracic spine as

clinically indicated) [16]. This recommendation is based on

our systematic review [16] that identified 14 low risk of bias

RCTs examining the effectiveness of multimodal care for

NAD [46, 49–64]. This body of evidence suggests that the

effective multimodal programs of care included exercise,

manual therapy, and education [16]. On average, effective

multimodal care was achieved within six visits over

8 weeks [16]. Cost-effectiveness data suggest that exercise

and manual therapy is more cost-effective than two other

programs of multimodal care (i.e., a program with exercise,

traction, soft tissue therapy, and passive physical modalities

or a program with advice and analgesics) [65].

Soft tissue therapy Clinicians should not offer strain-

counterstrain therapy (Glossary—Appendix VI) [21]. This

recommendation is based on two low risk of bias RCTs

suggesting that: (1) ischemic compression and strain-

counterstrain therapy provided no added benefit to muscle

energy technique for improving neck pain, motion and

disability in the short-term for recent NAD [21, 66] and (2)

strain-counterstrain therapy is not more effective than sham

strain-counterstrain therapy in the short-term [21, 67].

Clinicians should not offer relaxation massage to treat

recent onset NAD (Glossary—Appendix VI) [21]. This

recommendation is based on one low risk of bias RCT

suggesting that relaxation massage was less effective than

sham laser acupuncture or acupuncture for NAD of vari-

able duration [21, 68].

Passive physical modalities Clinicians should not offer a

cervical collar [21]. This recommendation is based on three

low risk of bias RCTs suggesting that collars provide less

Table 4 Risk factors for serious pathology (red flags) for neck pain

Possible cause Risk factors for serious pathology

identified during history or physical

examinationa

Fracture/dislocation Positive Canadian C-spine rule (with

possible red flags)

Cancer History of cancer

Unexplained weight loss

Nocturnal pain

Age[50

Vertebral infection Fever

Intravenous drug use

Recent infection

Osteoporotic fractures History of osteoporosis

Use of corticosteroid

Older age

Myelopathy—severe/

progressive neurological

deficits

Painful stiff neck

Arm pain and weakness

Sensory changes in lower extremity

Motor weakness and atrophy

Hyper-reflexia

Spastic gait

Carotid/vertebral artery

dissection

Sudden and intense onset of headache

or neck pain

Brain haemorrhage/mass

lesion

Sudden and intense onset of headache

Inflammatory arthritis Morning stiffness

Swelling in multiple joints

a This list of risk factors for serious pathology was informed from

the following peer reviewed articles rather than being developed from

a systematic review of the literature on ‘‘red flags’’ [36–38]

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benefit than advice or active mobilization alone and similar

benefit to receiving no care [21, 69–72].

Similarly, clinicians should not offer electrical muscle

stimulation or moist heat as an intervention in the clinic

[21]. This recommendation is based on one low risk of bias

RCT suggesting that electrical muscle stimulation or moist

heat provided no additional benefit to a course of spinal

manipulation or mobilization [21, 73].

Acupuncture Clinicians should not offer elec-

troacupuncture [21]. This recommendation is based on one

low risk of bias RCT that found similar outcomes between

electroacupuncture and simulated acupuncture for WAD of

variable duration [21, 74]. The evidence for needle

acupuncture was inconclusive (Appendix III).

Medication The non-opioid first ‘step’ in the World

Health Organization analgesic ladder includes non-ster-

oidal anti-inflammatory drugs (NSAIDs), muscle relaxants

and acetaminophen [75]. Notwithstanding the prevalence

and readily available nature of these over-the-counter

(OTC) drugs, there is remarkably little evidence to support

a clinical prescription decision for any of these drugs for

NAD. This is particularly true for acetaminophen, for

which the best available evidence does not indicate that

acetaminophen is an effective analgesic for NAD and

spinal pain [20, 76, 77]; therefore, acetaminophen should

not be recommended or prescribed as a routine

intervention.

There was insufficient evidence for any clinical pre-

scription decision concerning NSAIDs for NAD and spinal

pain [18].

Evidence suggests that clinicians may consider a short

course of muscle relaxants (cyclobenzaprine) [20]. This

recommendation is based on one low risk of bias RCT

suggesting that use of an oral muscle relaxant may be more

Table 5 Treatment recommendations for Neck Pain and Associated Disorders (NAD) I–III

Consider Recommendation

NAD grades I–II NAD grade III

0–3 months 4–6 months 0–3 months 4–6 months

Provide information about the nature, management, and course of

NAD as a framework for the initiation of the program of care

d d d d

A structured patient education program as an adjunct to an effective

program of care based on individual patient presentation

d d d s

Unsupervised stretching/range of motion exercises (5–10 repetitions

of each exercise with no resistance, up to 6–8 times per day)

d s s s

A maximum of six sessions over 8 weeks of multimodal care that

includes exercise and manual therapy. Multimodal care for

persistent grades I–II NAD should only be considered if not

previously given in the first 3 months of care. However, a second

course could be indicated if the patient demonstrates ongoing and

significant improvement

d d s s

Muscle relaxants d s s s

A program of supervised combined exercise (strengthening,

stretching/range of motion, and flexibility exercises). The program

should be limited to a maximum of two sessions/week for 12 weeks

s d s s

A program of qigong exercises supervised by a certified qigong

instructor. The program should be limited to a maximum of two

sessions/week for 12 weeks

s d s s

A long-term program of Iyengar yoga supervised by a certified

Iyengar yoga teacher. The program should be limited to a maximum

of nine sessions over 9 weeks

s d s s

Up to ten sessions over 10 weeks of clinical massage s d s s

Up to 12 sessions over 4 weeks of clinic-based low level laser therapy

(LLLT) (continuous or pulsed application; wavelength = 830 or

904 nm)

s d s s

Non-steroidal anti-inflammatory drugs (NSAIDs) s d s s

Two sessions/week for 6 weeks of supervised graded neck

strengthening exercises

s s d s

NAD neck pain and associated disorders

d recommended interventions to be considered for the specified duration/grade of NAD

s there is no ‘consider’ recommendation for this intervention with respect to the specified duration/grade of NAD

Eur Spine J

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effective than placebo [78]. Paradoxically, the evidence

suggests that analgesia, rather than muscle relaxation, is the

primary therapeutic benefit. Prolonged use is not war-

ranted. There is evidence that significant adverse effects

are associated with use of muscle relaxants; therefore,

patient education about the side effects and close moni-

toring are warranted [20]. There is no evidence of differ-

ential effectiveness for the various muscle relaxant drugs

[20]. There is no evidence that combining muscle relaxants

with other medications provides added benefit [20].

Recommendation 5: management of persistent NAD

grades I–II (Tables 5, 6; Figs. 1, 2)

For patients with NAD grades I–II NAD [3 months

duration, clinicians may consider structured patient edu-

cation 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, relax-

ation therapy for pain or disability, electrotherapy, short-

wave diathermy, clinic-based heat, electroacupuncture, or

botulinum toxin injections.

Structured patient education As described above, clini-

cians should provide information about the nature, man-

agement, and course of NAD as a framework for initiating

the program of care. This recommendation is based on two

low risk of bias studies suggesting that: (1) structured

advice alone offers similar outcomes to physiotherapy-

based graded exercises with structured advice [17, 79]; and

(2) a self-management program based on an educational

booklet may be as effective as multimodal physical therapy

[17, 56].

Exercise Clinicians may offer a program of supervised

combined exercise (range of motion and strengthening

exercises) limited to a maximum of two sessions per week

for 12 weeks [15]. This recommendation is based on two

low risk of bias RCTs in which supervised combined

strengthening and range of motion exercises offered greater

benefit than being randomized to wait list [15, 80, 81].

Clinicians may offer a program of qiqong exercises

(Glossary—Appendix VI) supervised by a certified qigong

instructor, limited to a maximum of two sessions per week

for 12 weeks [15]. This recommendation is based on two

low risk of bias RCTs in which qigong offered greater

benefit than waitlist [15, 80, 81].

Clinicians may offer a program of Iyengar yoga (Glos-

sary—Appendix VI) supervised by a certified Iyengar yoga

teacher, limited to a maximum of nine sessions over

Table 6 Treatment interventions that should NOT be offered for Neck Pain and Associated Disorders (NAD) I–III

Do not offer Recommendation

NAD grades I–II NAD grade III

0–3 months 4–6 months 0–3 months 4–6 months

Structured patient education alone, in either verbal or written formats d s d s

Strain-counterstrain therapy d d s s

Relaxation massage d d s s

A cervical collar d s d d

Moist heat as an intervention in the clinic d d s s

Electrical muscular stimulation d d s s

Electroacupuncture d d s s

Programs consisting solely of clinic-based supervised high dose

strengthening exercises

s d s s

Transcutaneous electrical nerve stimulation (TENS) s d s s

Pulsed short-wave diathermy s d s s

A standalone course of relaxation training for pain intensity or

disability outcomes

s d s s

Botulinum toxin injections s d s s

Low level laser therapy (LLLT) s s d s

Traction s s d s

NAD neck pain and associated disorders

d interventions that should not be offered for the specified duration/grade of NAD

s there is no ‘do not offer’ recommendation for this intervention with respect to the specified duration/grade of NAD

Eur Spine J

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9 weeks [15]. This recommendation is based on one low

risk of bias RCT that found Iyengar yoga offered greater

benefit than education and a home exercise program [15,

82].

Clinicians should not offer an exercise program con-

sisting solely of clinic-based supervised high-dose

strengthening exercises (Glossary—Appendix VI) [15]. The

body of evidence suggests that supervised high-dose

strengthening exercises do not offer benefit compared to

unsupervised strengthening exercises or advice [15, 83, 84].

Multimodal care Clinicians may consider a maximum of

six sessions over 8 weeks of multimodal care that includes

range of motion exercises and manual therapy (manipula-

tion or mobilization to the cervical and/or thoracic spine as

clinically indicated) [16]. Multimodal care may only be

considered if not previously provided in the first 3 months

of care. However, a second course may be indicated if the

patient has demonstrated ongoing and significant

improvement. As described above, this recommendation is

informed by two systematic reviews [16, 22].

Soft tissue therapy Clinicians may consider up to ten

sessions over 10 weeks of clinical massage (Glossary—

Appendix VI) [21]. Clinical massage is expected to provide

short-term benefits only. The body of evidence suggests

that clinical massage with self-care offers benefit compared

to self-care advice alone [21, 68, 85].

However, clinicians should not offer relaxation massage

(Glossary—Appendix VI) [21]. This recommendation is

based on one low risk of bias RCT suggesting that relax-

ation massage (e.g., Swedish massage) was less effective

than sham laser acupuncture or acupuncture for NAD of

variable duration [21, 68].

Clinicians should not offer strain-counterstrain therapy

(Glossary—Appendix VI) [21]. This recommendation is

based on two low risk of bias RCTs suggesting that: (1)

ischemic compression and strain-counterstrain therapy

provided no added benefit to muscle energy technique for

improving neck pain intensity, disability and motion in the

short-term for recent NAD [21, 66]; (2) strain-counterstrain

therapy is not more effective than sham strain-counterstrain

therapy in the short-term [21, 67].

Passive physical modalities Clinicians may consider up

to 12 sessions over 4 weeks of clinic-based low level laser

therapy (LLLT) [21]. LLLT may be offered in a continuous

or pulsed application (wavelength = 830 or 904 nm). This

recommendation is based on six RCTs in which the pre-

ponderance of evidence suggests that clinic-based LLLT

offers greater benefit than placebo [21, 86–91].

Clinicians should not offer transcutaneous electrical

nerve stimulation (TENS) [21]. This recommendation is

based on two low risk of bias RCTs suggesting that: (1)

TENS is no more effective than placebo [21, 92]; (2) TENS

provides similar outcomes to multimodal programs of care

that include ineffective interventions (i.e., Jones technique)

[21, 51].

Clinicians should not offer pulsed short-wave diathermy

[21]. This recommendation is based on one RCT suggest-

ing that adding short-wave diathermy to advice and exer-

cise provides no benefit [21, 93]. Cost-effectiveness data

suggest that short-wave diathermy appears less cost-ef-

fective than advice and exercise [94].

Clinicians should not offer electrical muscle stimulation

or moist heat as an intervention in the clinic [21]. This

recommendation is based on one low risk of bias RCT

suggesting that electrical muscle stimulation or moist heat

provided no additional benefit to a course of spinal

manipulation or mobilization [21, 73].

Psychological intervention Clinicians should not offer a

stand-alone course of relaxation training for pain intensity or

disability outcomes [19]. This recommendation is based on

two low risk of bias RCTs [52, 53, 95]. The first RCT found

that group-based pain and stress self-management (focused

on relaxation training) by physiotherapists leads to similar

pain and disability outcomes to multimodal physiotherapy

[52, 53]. However, the second RCT found that relaxation

training is no more effective than the advice to act as usual for

pain and disability [95]. Therefore, evidence suggests that

muscle relaxation training is not effective for improving pain

or disability outcomes in patients with persistent NAD

grades I–II. This should not, however, be taken as ruling out

the use of psychological interventions where these are indi-

cated for treatment of psychological distress, as opposed to

pain or disability management alone.

Acupuncture Clinicians should not offer elec-

troacupuncture [21]. This recommendation is based on one

low risk of bias RCT that found similar outcomes between

electroacupuncture and simulated acupuncture for WAD of

variable duration [21, 74].

Medication The non-opioid first ‘step’ in the World

Health Organization analgesic ladder includes NSAIDs,

muscle relaxants and acetaminophen [75]. However, the

best available evidence does not indicate that acet-

aminophen is an effective analgesic for persistent NAD and

spinal pain [20, 76]; therefore, acetaminophen should not

be recommended or prescribed as a routine intervention.

Moreover, there was insufficient evidence to support

prescriptions of muscle relaxants for persistent NAD and

spinal pain [20].

However, the evidence suggests that clinicians may

consider NSAIDs for this population [18]. This recom-

mendation is based on two low risk of bias RCTs from one

low risk of bias systematic review suggesting that NSAIDs

may be more effective than placebo [14]. Prolonged use is

not warranted and the potential adverse effects associated

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with NSAIDs should be discussed with the patient [18].

Finally, there is no evidence of differential effectiveness

across various drugs within the NSAID class [18] and there

is also no evidence that combining NSAIDs with other

medications provides added benefit [18].

With respect to off-label usage of botulinum toxin

injections for NAD and spinal pain, on the basis of a

purported analgesic or muscle relaxant effect, clinicians

should not offer botulinum toxin injections [20]. This

recommendation is based on six low risk of bias RCTs in

two low risk of bias systematic reviews [96] suggesting

that there were no differences between botulinum toxin

injections and placebo [96, 97].

Recommendation 6: management of recent NAD

grade III (Tables 5, 6; Figs. 3, 4)

For patients with NAD grade III B3 months duration,

clinicians may consider supervised strengthening exercise

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.

Structured patient education As described above, clini-

cians should provide information about the nature, man-

agement, and course of NAD III as a framework for

initiating the program of care. The structured education

program should focus on providing advice to stay active

and reassuring the patient by addressing expectations of

recovery [17, 46].

Clinicians should not offer structured patient education

alone [17]. This recommendation is based on six low risk

of bias RCTs suggesting that: (1) structured patient edu-

cation alone provides no benefits compared to other con-

servative treatments (i.e., physiotherapy, supervised

exercises, massage) or unstructured advice in improving

the recovery of patients with NAD [17, 46, 56, 79, 85, 98];

(2) one method of delivering an education intervention is

not superior to another [17, 99].

Exercise Clinicians may consider two sessions per week

for 6 weeks of supervised graduated neck strengthening

exercises [15] (Appendix VII). This can be supplemented

with a home exercise program that includes daily stretch-

ing, strengthening, and relaxation exercises and may be

supplemented by acetaminophen or NSAIDs. This recom-

mendation is based on one low risk of bias RCT suggesting

that strengthening exercises are more beneficial than advice

but provide similar benefits as a semi-hard cervical collar

and rest for recent-onset cervical radiculopathy [15, 100].

However, a cervical collar is not recommended due to its

potential risk of harm (e.g., iatrogenic disability, inactivity,

deconditioning, lack of self-efficacy) that exceeds the

potential for benefit [101].

Traction Clinicians should not offer traction [21]. This

recommendation is based on one low risk of bias RCT

suggesting that traction provides no added benefit to mul-

timodal care for cervical radiculopathy [21, 102].

Passive physical modalities Clinicians should not offer a

cervical collar [21]. Despite similar outcomes for the use of a

semi-rigid cervical collar and graded neck strengthening

exercises [21, 100], we do not recommend using cervical

collars for NAD III based on: (1) the need to monitor the use

and prescription of a cervical collar as outlined in the trial

protocol would be impractical; (2) the widely recognized

ethical concerns that the potential risk of harm (e.g., iatro-

genic disability, inactivity, deconditioning, lack of self-ef-

ficacy) exceed the potential for benefit [101].

Clinicians should not offer LLLT [21]. This recom-

mendation is based on one low risk of bias RCT suggesting

that LLLT was equal to placebo LLLT for recent-onset

cervical radiculopathy [21, 103].

Recommendation 7: management of persistent NAD

grade III (Tables 5, 6; Figs. 3, 4)

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 or for investigation and management.

This recommendation is based on one low risk of bias

RCT suggesting that use of a cervical collar provides

outcome similar to an individualized multimodal program

of care in the medium and long term [21, 69]. However, we

do not recommend the use of cervical collars given the

ethical concerns that the potential risk of harm exceeds the

potential for benefit [101].

Recommendation 8: reevaluation and discharge

Clinicians should reassess the patient at every visit to

determine if: (1) additional care is necessary; (2) the

condition is worsening; or (3) the patient has recovered.

Patients should be discharged as soon as they report

significant recovery. Health care professionals should use

the self-rated recovery question to measure recovery:

‘‘How well do you feel you are recovering from your

injuries?’’ [104–108]. The response options include: (1)

completely better, (2) much improved, (3) slightly

improved, (4) no change, (5) slightly worse, (6) much

worse, (7) worse than ever. Patients reporting to be

‘completely better’ or ‘much improved’ should be con-

sidered recovered. The self-rated recovery question is a

valid and reliable global measure of recovery in patients

with neck pain [104–108]. Patients who have not

recovered should follow the care pathway outlined in the

guideline (Figs. 1, 2, 3, 4).

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Discussion

We developed an evidence-based clinical practice guide-

line to help clinicians deliver effective interventions for the

management of NAD (which includes WAD) and promote

uniform high quality care for patients with neck pain. The

recommendations are based on recent systematic reviews

of the literature and synthesis of best available evidence.

Implementing evidence-based recommendations for a

common condition, such as neck pain, will likely improve

patient outcomes, reduce regional variations, and improve

the efficiency of the healthcare system [109, 110].

The guideline identifies clinical interventions that should

not be prescribed because they are ineffective or because

their effectiveness is not clearly established. For example,

we found inconclusive evidence for the effectiveness of

needle acupuncture, cognitive behavioral therapy, and

biofeedback for the management of persistent NAD grades

I–II [19, 21]. The evidence on the effectiveness of these

interventions is inconclusive because the results of multiple

high-quality RCTs conflicted with each other. Finally, the

guideline does not recommend interventions that have not

been evaluated in high-quality studies.

Summary of recommendations

Clinicians should rule out major structural or other

pathologies as the cause of NAD. In the absence of major

structural or other pathologies, clinicians should classify

NAD as grades I, II, or III and determine the presence of

prognostic factors for delayed recovery. The management of

all patients should include education, advice, encouragement

to stay active (including return to work where appropriate),

and reassurance that NAD is typically of a time-limited

nature. In the context of shared decision-making, clinicians

should discuss with the patient the range of effective inter-

ventions available for the management of NAD. Supple-

menting self-management strategies with clinical care may

be indicated provided the intervention is likely to enable

recovery through symptom relief and improvement in

function. For such interventions, there is no evidence that

effectiveness can be increased through more frequent

attendance or prolonged course of treatment [43, 44].

The following clinical interventions can be considered

for recent onset NAD grades I and II (B3 months): range of

motion exercises with or without manipulation or mobi-

lization, or muscle relaxants. For persistent NAD grades I–

II ([3 months), clinicians can consider supervised range of

motion and strengthening exercises, qigong, yoga, multi-

modal care (exercise with manipulation or mobilization),

clinical massage, LLLT, or NSAIDs. It is important to note

that all recommended interventions provide small benefits

at best.

Patients with recent NAD grade III (B3 months) should

be treated with supervised strengthening exercise. Patients

with NAD grade III who still experience neurological signs

and disability 3 months after injury should be referred to a

physician for further investigation of neurological deficits.

Comparison to previous guidelines

Overall, our recommendations agree with those of previous

clinical practice guidelines [9, 13, 111–116]. Our recent

systematic review of guidelines for the management of

WAD suggests that treatment options include: advice,

education, reassurance, exercise, return-to-activity, mobi-

lization/manipulation, and analgesics [13]. All guidelines

agree that collars are contraindicated for WAD [13].

Moreover, the 2008 clinical practice guideline from the

American Physical Therapy Association recommends that

the management of neck pain include: education, cervical

and thoracic mobilization/manipulation, exercises, and

traction; and that neck-related arm pain should be managed

with thoracic mobilization/manipulation and exercises

[115].

There are a few important differences between previ-

ous guidelines and ours. Specifically, we do not recom-

mend analgesics or traction for the management of neck

pain. This difference is likely because most of the pre-

vious guidelines are dated [34]. The Neck Pain Task

Force identified one study that found no differences

between an analgesic (benorylate) and placebo for

reducing pain [14, 117]. Our recent systematic review did

not find any eligible studies that evaluated the effective-

ness of analgesics for neck pain. For traction, the Neck

Pain Task Force did not find enough evidence to deter-

mine the effectiveness of traction [14, 118]. Our recent

systematic review identified one study that found traction

does not provide added benefit to a multimodal program

for NAD grade III [21, 102]. Moreover, our guideline

specifies the interventions that should not be used because

the evidence suggests that they are ineffective [14, 102,

117, 118].

The evidence published since the release of previous

clinical practice guidelines has improved our ability to

effectively manage patients with neck pain. Prior to the

OPTIMa guideline, the most recent guidelines were pub-

lished in 2008 [111, 115]. Since then, high quality RCTs

suggest that multimodal care (i.e., exercises and manipu-

lation/mobilization) is effective for the management of

recent-onset neck pain and that Iyengar yoga, qigong, and

clinical massage may benefit patients with persistent neck

pain [16, 80–82, 85]. Moreover, the evidence indicates that

strain-counterstrain, relaxation massage, and elec-

troacupuncture should not be used to manage patients with

recent-onset and persistent neck pain [67, 68, 74, 85]. For

Eur Spine J

123

recent NAD grade III, recent evidence suggests that graded

neck strengthening exercises should be used, while LLLT

and traction should not be used [100, 102, 103]. Finally, the

OPTIMa guideline provides parameters on the dosage of

interventions that are informed by high quality RCTs.

Therefore, recent literature provides clinicians with current

best evidence that informs the management of their

patients.

We conducted eight systematic reviews to update the

work of the Bone and Joint Decade Task Force on Neck

Pain and Its Associated Disorders and inform these rec-

ommendations [15–22]. Despite recent improvement in

the quality of the literature on the management of neck

pain, there are still important gaps. Specifically, the evi-

dence is still inconclusive on the effectiveness of

acupuncture, cognitive behavioral therapy and biofeed-

back [19, 21]. Therefore, efforts should be dedicated to

determine the effectiveness of these interventions. In

addition, research should also consider identifying the

most effective dosage to optimize treatment response for

all interventions.

Dissemination and implementation of this guideline

It is important to consider factors related to dissemination

and implementation of this guideline. Few of the previous

high quality guidelines in this area assessed the resource

implications and implementation issues related to their

adoption by clinicians and policy makers [13]. In Canada,

the Government of Ontario is considering the applicability

of this guideline to the Ontario health care system and

automobile insurance system.

The guideline could be adapted for local use in other

jurisdictions. We recommend that clinicians, insurers and

policy-makers use the ADAPTE framework to adapt this

guideline to their needs and environment [119].

Strengths and limitations

This clinical practice guideline was informed by compre-

hensive literature searches and its recommendations were

based on high-quality evidence. When developing clinical

recommendations, the Guideline Expert Panel considered

effectiveness, safety, cost-effectiveness, consistency with

societal and ethical values, and patient preferences and

experiences. Moreover, the recommendations include

consideration of effect sizes and minimal clinically

important differences to assess the magnitude of benefit of

an intervention on patient outcomes. Finally, the Guideline

Expert Panel disclosed any conflicts of interest and main-

tained editorial independence [120].

We conducted a supplementary search of MEDLINE

extending to May 2015 to identify any recently published

RCTs and systematic reviews relevant to the guideline.

This search (extending from January 1, 2013 and May 29,

2015) yielded 592 articles, of which 20 were relevant and

15 RCTs were of high quality [121–135] (five studies were

low quality [134, 136–139]). The low risk of bias studies

from the updated search investigated the following inter-

ventions: (1) acupuncture [121, 122, 133]; (2) exercise

[123–126, 134]; (3) manual therapy [127, 128]; (4) passive

physical modalities [129]; (5) soft tissue therapy [122,

130]; (6) multimodal care [125, 126, 131, 132, 135]; and

psychological interventions [123]. None of these trials

presented information that conflicted with the recommen-

dations of this guideline.

Our recommendations were limited by the amount,

nature, and quality of evidence published in the literature

[15–22]. For example, very few studies have investigated

the effectiveness of medication for the management of

patients with NAD [18, 20]. Moreover, most RCTs studied

the relative effectiveness of commonly-used interventions,

but little evidence is available to determine whether pop-

ular interventions are more effective than placebo/sham

treatments. Inconclusive evidence on the effectiveness of

commonly-used interventions (e.g., needle acupuncture)

prevents the development of clinical recommendations.

There is a need for research to address these limitations in

the literature. Finally, our supplemental search extending to

May 2015 was conducted in MEDLINE only; however,

MEDLINE is one of the main biomedical databases to

search healthcare literature [140].

Acknowledgments The authors would like to acknowledge the

invaluable contributions to this guideline from: Lynn Anderson,

Poonam Cardoso, Brenda Gamble, Willie Handler, Vivii Riis, Paula

Stern, Thepikaa Varatharajan, Angela Verven, and Leslie Verville.

Compliance with ethical standards

Funding The development of this clinical practice guideline was

funded by the Ministry of Finance and the Financial Services Com-

mission of Ontario (OSS_00267175). The Ministry of Finance and

Financial Services Commission of Ontario were not involved in the

design, conduct, or interpretation of the research that informed the

development of the care pathways included in this report. The

development of the guideline by the Guideline Expert Panel was not

influenced by the Ministry of Finance or Financial Services Com-

mission of Ontario; the views and interests of the funding body did

not influence the final recommendations. All individuals involved in

the project declared any competing interests. This research was

undertaken, in part, thanks to funding from the Canada Research

Chairs program to Dr. Pierre Cote, Canada Research Chair in Dis-

ability Prevention and Rehabilitation at the University of Ontario

Institute of Technology, and funding from Alberta Innovates—Health

Solutions to Dr. Linda Carroll, Health Senior Scholar.

Conflict of interest Dr. Brison reports no commercial interest; a

university role that incorporates research activities related to guide-

line development. Dr. Lacerte reports an active clinical practice and

conducting medicolegal assessments or reports for plaintiff lawyers

Eur Spine J

123

and occasionally independent medical examinations for lawyers and

insurers; Consultancies: Drs. Ameis and Lacerte reports non-paid

consultancy for the Catastrophic Impairment Expert Panel; Honoraria:

Drs. Gross and Bohay report honoraria during the conduct of this

study; Grants: Dr. Cote reports grants from Ontario Ministry of

Finance and Financial Services Commission of Ontario during the

conduct of this study; grants from Aviva Canada outside the sub-

mitted work. Dr. Gross reports grants from Workers’ Compensation

Board of Alberta, grants from Workers’ Compensation Board of

Manitoba, outside the submitted work; Other: Drs. Brison and Mar-

shall report participation in guideline development. Dr. Cote reports

funding from Canada Research Chair Program - Canadian Institutes

of Health Research during the conduct of this study; personal fees

from National Judicial Institute, Societe des experts en evaluation

medico-legale du Quebec, and European Spine Society, outside the

submitted work. Dr. Ameis reports his past role as medical director

and current consultant to Granite Health Service. For the remaining

authors, no conflicts were declared.

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