Chronic Neck Pain and Chiropractic

	Integrating Chiropractic Care and Tai Chi Training for the Treatment of Chronic Nonspecific Neck Pain in Nurses: A Single-Arm Mixed-Methods Pilot Trial J Integr Complement Med 2024 (Aug 22) [EPUB] ~ FULL TEXT Observed reductions in neck pain and disability suggest the potential utility of combined multimodal chiropractic care (MCC) and Tai Chi (TC) interventions for managing chronic nonspecific neck pain (CNNP). Along with qualitative feedback regarding facilitators and barriers to participation, the findings support and inform a future randomized trial evaluating the combined benefits of MCC and TC for CNNP in nurses.
	How Well Do Participants in Clinical Trials Represent the U.S. Population with Chronic Neck or Back Pain? BMC Musculoskelet Disord 2024 (May 27); 25 (1): 414 ~ FULL TEXT Randomized clinical trials (RCTs) are the gold standard for assessing treatment effectiveness; however, they have been criticized for generalizability issues such as how well trial participants represent those who receive the treatments in clinical practice. We assessed the representativeness of participants from eight RCTs for chronic spine pain in the U.S., which were used for an individual participant data meta-analysis on the cost-effectiveness of spinal manipulation for spine pain. In these clinical trials, spinal manipulation was performed by chiropractors.
	The Association Between Cervical Degenerative MRI Findings and Self-reported Neck Pain, Disability and Headache: A Cross-sectional Exploratory Study Chiropractic & Manual Therapies 2023 (Oct 11); 31: 45 ~ FULL TEXT Overall, very few studies have investigated the association between cervical degenerative MRI findings and clinical symptoms. A systematic review from 2019 [13] investigated the presence of cervical MRI findings in patients with NP compared to pain-free controls and found, based on two studies, no differences in terms of disc degeneration between people with chronic non-specific NP and pain-free controls. [10, 27] One of the studies [10] also examined disc contour changes and found that disc herniation (but not disc protrusion) was associated with NP, although this was based on only four subjects. In comparison, our results identified an OR for NP of 1.6 (95% CI 1.1–2.4) for participants with disc degeneration or disc contour changes compared to those without these findings. The discrepancy between our results and those of other studies is probably due to differences in the study population, sample size, imaging system and classification of MRI findings. One of the two studies in the review included only 31 people [10], so the results are therefore somewhat uncertain. In addition, the data in that study were collected in 1996 and MRI has undergone enormous technological development since, which also affects the direct comparability. The other study in the review, a study from Japan [27] included 975 participants from the general population with a mean age of 66 years and found that NP did not differ between people with or without disc degeneration. The study reported that the prevalence of cervical MRI findings increased with age, and in the age group < 50 years, the prevalence of disc degeneration was comparable to our findings. However, the study did not analyse the association between MRI findings and NP stratified by age group and it is therefore unclear if an association exists for the younger group.
	Clinical Indicators for Recommending Continued Care to Patients with Neck Pain in Chiropractic Practice: A Cohort Study Chiropractic & Manual Therapies 2023 (Aug 31); 31: 33 ~ FULL TEXT Receiving maintenance care (MC) (i.e. continued care as decided by the chiropractor) compared to receiving symptom-guided therapy (i.e. further care decided by the patient when they perceive a need) have been examined in patients with recurrent and persistent low back pain. [18] It was concluded that MC was more effective in reducing the total number of days with bothersome pain over a year’s time. [18] However, MC is currently being investigated and not included in clinical practice guidelines as a recommended evidence-based treatment strategy for prevention. Focus groups and surveys have systematically explored chiropractors’ indications for using MC in patients with low back pain. [13] According to these studies, MC is offered to patients who have experienced previous pain episodes, long pain duration, and have shown improvement after initial treatment. [19–21] These indicators for MC were confirmed in an observational study of patients with low back pain and previous pain episodes was found to be a strong predictor for recommending MC. [22] In addition, the recommendation of MC may also depend on the chiropractor and the clinical setting. Chiropractors who were trained in the US compared to Europe, as well as chiropractors with more experience and clinic ownership, tend to recommend MC more frequently and to a greater extent to their patients. [19]
	Multivariable Prediction Models for the Recovery of and Claim Closure Related to Post-collision Neck Pain and Associated Disorders Chiropractic & Manual Therapies 2023 (Aug 25); 31: 32 ~ FULL TEXT We developed clinical prediction models that predict recovery and claim closure in individuals with NAD following traffic collisions. Prognostic factors included expectation of recovery, age, having a prior neck injury claim, percentage of body in pain, baseline neck pain and headache intensity, and disability. In addition, depressive symptoms remained predictive in the model predicting claim closure. Our models have limited predictive ability and require an impact analysis before being used in clinical settings.
	Longitudinal Care Patterns and Utilization Among Patients with New-Onset Neck Pain by Initial Provider Specialty Spine (Phila Pa 1976) 2023 (Aug 1) [EPUB] ~ FULL TEXT The cohort included 770,326 patients with new-onset neck pain visits. The most common initial provider specialty was chiropractor (45.2%), followed by primary care (33.4%). Initial provider specialty was strongly associated with the receipt of subsequent neck pain visits with the same provider specialty. Rates and types of diagnostic imaging and therapeutic interventions during follow-up also varied widely by initial provider specialty. While uncommon after initial visits with chiropractors (≤2%), CT or MRI scans occurred in over 30% of patients with initial visits with emergency physicians, orthopedists, or neurologists. Similarly, 6.8% and 3.4% of patients initially seen by orthopedists received therapeutic injection and major surgery, respectively, as compared to 0.4% and 0.1% of patients initially seen by a chiropractor.   Within a large, national cohort, chiropractors were the initial provider for a plurality of patients with new-onset neck pain. Compared to patients initially seen by physician providers, patients with chiropractor initial providers received fewer and less costly imaging services and were less likely to receive invasive therapeutic interventions during follow-up.
	Spinal Pain, Chronic Health Conditions and Health Behaviors: Data from the 2016-2018 National Health Interview Survey Int J Environ Res Public Health 2023 (Apr 3); 20 (7): 5369 ~ FULL TEXT Spinal pain and chronic health conditions are highly prevalent, burdensome, and costly conditions, both in the United States and globally. All four chronic health conditions significantly increased the prevalence odds of spinal pain; cardiovascular conditions by 58%, hypertension by 40%, diabetes by 25% and obesity by 34%, controlling for all the confounders. For all chronic health conditions, tobacco use (45–50%), being insufficiently active (17–20%), sleep problems (180–184%), cognitive impairment (90–100%), and mental health conditions (68–80%) significantly increased the prevalence odds of spinal pain compared to cases without spinal pain. These findings provide evidence to support research on the prevention and treatment of non-musculoskeletal conditions with approaches of spinal pain management.
	Non-serious Adverse Events Do Not Influence Recovery in Patients with Neck Pain Treated with Manual Therapy; An Observational Study Musculoskelet Sci Pract 2022 (Oct); 61: 102607 ~ FULL TEXT We found that the occurrence of non-serious adverse events (NSAEs e.g. aggravation of complaints, stiffness, irradiating pain) did not influence recovery in patients with neck pain treated by physiotherapists with postgraduate qualifications in manual therapy (MT). Currently, there is no need for physiotherapists to consider NSAEs when making prognosis in these patients. But, keeping in mind the criticism on the one-in-ten rule, we cannot exclude the possibility that our study was underpowered.
	The Association Between Different Outcome Measures and Prognostic Factors in Patients with Neck Pain: A Cohort Study BMC Musculoskelet Disord 2022 (Jul 14); 23 (1): 673 ~ FULL TEXT The highest correlation between outcome change scores was found between NDI and EQ-5D and lower association with pain. The prognostic model also showed best performance for NDI as outcome and the poorest for pain intensity. The predictive impact of the predictors was consistent across all outcomes. These results suggest that we need more knowledge on the reasons for the differences in predictive performance variation across outcomes.
	Acute Inflammatory Response via Neutrophil Activation Protects Against the Development of Chronic Pain Science Translational Medicine 2022 (May 11); 14 (644): eabj9954 “This paper paints a very clear picture that early neutrophil activation is very important for preventing the sensitization of pain pathways. [The authors] lay out a beautiful roadmap to explore this. I would want to know how S100A8 and S100A9 are eventually acting on neurons to resolve pain, and how we could exploit neutrophils in other ways to decrease the excitability of neurons in pain pathways,” said Price.
	Limited Prognostic Value of Pain Duration in Non-specific Neck Pain Patients Seeking Chiropractic Care European Journal of Pain 2022 (Apr 21) [EPUB]~ FULL TEXT Significance statement:   The relatively large dataset of neck pain patients challenges the widely accepted wisdom that pain duration is an important predictor of pain outcomes and that very chronic patients might only have a small likelihood of getting better. It is postulated that these results are important for the attitude of the first encounter between healthcare professionals and chronic patients.
	Chiropractic Care of a Female Veteran After Cervical Total Disk Replacement: A Case Report J Chiropractic Medicine 2022 (Mar); 21 (1): 60–65 ~ FULL TEXT This is the first instance, to our knowledge, of a published case of chiropractic manipulation after CTDR. Before this case report, there was no available literature to guide chiropractic care after CTDR. This will hopefully serve as a call for future research to guide clinicians in the management of patients after CTDR. Evidence-based guidelines for chiropractic care after CTDR would be of value for chiropractors and other health care practitioners in guiding optimal patient care. This case report will hopefully stimulate discussion and future efforts to create a guideline for postsurgical chiropractic care in CTDR. The optimal treatment dosage for chiropractic treatment depends on the severity, chronicity, and demographic characteristics of the patient. [13] Whalen et al published a chiropractic best practice recommending treatment of acute neck pain 3 times per week for 4 weeks, and chronic neck pain 2 times per month for several months; additionally, chronic neck pain with radiculopathy may take several months to treat, with an initial trial of care consisting of treatments 3 times per week for 4 weeks and then tapering in frequency as the patient improves. [13] In attempting to be consistent with guidelines recommended by the VA Chiropractic Field Advisory Committee, the initial trial of care consisted of 6 visits, which was stretched over 3 weeks. [18] After the initial 6–visit trial, care was continued twice a week for several weeks before treatment frequency was tapered as the patient improved.
	Neck Pain: Global Epidemiology, Trends and Risk Factors BMC Musculoskelet Disord 2022 (Jan 3); 23 (1): 26 ~ FULL TEXT Neck pain has a high prevalence around the world, although its burden has not changed substantially over the period 1990–2019. Recent literature has shown that psychological factors (e.g., stress, some cognitive factors, and sleep problems) and individual/biological factors (e.g., preexisting neuromuscular or autoimmune disorders, aging, and genetic) both contribute to the development of neck pain (Figure 6). The relationship between personality types and gender on the risk of neck pain is not yet clear, so further research is needed to investigate the association that neck pain has with gender, personality, and several other psychological factors.
	Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain Frontiers in Pain Ressearch 2021 (Oct 25); 2: 765921 ~ FULL TEXT For the management of LBP, most guidelines recommend SMT, with some discrepancies regarding the circumstances in which it should be administered. [19, 125] For example, the United Kingdom's National Institute for Health and Care Excellence (NICE) guidelines make it imperative that SMT be offered alongside exercise therapy for LBP irrespective of the stage. [113] In contrast, the American College of Physicians' guidelines endorse SMT as a frontline non-invasive intervention, partly because patients with acute LBP improve over time regardless of treatment. [17] Specifically, for acute stages with or without radiculopathy, clinical practice guidelines recommend the addition of SMT to education, advice to remain active, and self-management. [112, 114, 116] For chronic LBP, the guidelines tend to recommend the use of SMT either alone or preferably in combination with other approaches (frequently second to advice, education, and reassurance) for patients with or without leg pain. [114, 115] Recently, a decision aid developed for managing chronic back pain by Canadian colleges of family physicians endorsed exercise and SMT as the only interventions for which benefits likely exceed harms. [15] For low- and middle-income countries, the Global Spine Care Initiative produced guidelines taking into consideration practical aspects such as cost. [18] Their recommendations are to consider the use of manual therapy (SMT and mobilizations) as one of the primary treatment options in patients with both acute and chronic spine pain and SMT specifically for radicular pain. [18]
	Spinal Manipulative Therapy for Acute Neck Pain: A Systematic Review and Meta-Analysis of Randomised Controlled Trials J Clinical Medicine 2021 (Oct 28); 10 (21): 5011~ FULL TEXT To our knowledge, this is the first systematic review on the effectiveness of SMT treating acute neck pain. The main conclusion is that SMT alone or in combination with another modality is likely to be effective in the treatment of acute neck pain, and the RCTs reported few, mild and transient AEs. The methodological quality of manual therapy RCTs is frequently being criticised for being too low. [36] However, manual therapy studies cannot reach what is considered the gold standard in pharmacological RCTs, because the manual therapist cannot be blinded.
	Sensory, Motor, and Psychosocial Characteristics of Individuals with Chronic Neck Pain: A Case–Control Study Physical Therapy 2021 (Mar 26); pzab104~ FULL TEXT Local hyperalgesia, impaired conditioning pain modulation, depressive symptoms, pain catastrophizing, poor quality of life and reduced active ROM for neck rotation were observed in individuals with nonspecific chronic neck pain. Additionally, there is a significant correlation between intensity pain, neck disability and psychosocial factors. As such, pain management, neck mobility and psychosocial components should be assessed and taken into account in the therapeutic approach adopted for this population.
	Visual Trajectory Pattern as Prognostic Factors for Neck Pain European J Pain 2020 (Oct); 24 (9): 1752–1764 ~ FULL TEXT The study indicates that pain expectations are formed by pain history. The patients' expectations were similar to or more optimistic compared with their pain history. The prognostic ability of the model including a simplified combination of previous and expected patterns, together with a few other predictors, suggests that the trajectory patterns might have potential for clinical use. The dynamic nature of neck pain can be captured by visual illustrations of trajectory patterns. We report, that trajectory patterns of pain history and future expectations to some extent are related. The patterns also reflect a difference in severity assessed by higher degree of symptoms and distress. Moreover, the visual trajectory patterns predict outcome at 12-weeks. Since the patterns are easily applicable, they might have potential as a clinical tool.
	Best Practices for Chiropractic Management of Patients with Chronic Musculoskeletal Pain: A Clinical Practice Guideline J Altern Complement Med 2020 (Oct); 26 (10): 884–901 ~ FULL TEXT The Delphi process was conducted January-February 2020. The 62-member Delphi panel reached consensus on chiropractic management of five common chronic MSK pain conditions: low-back pain (LBP), neck pain, tension headache, osteoarthritis (knee and hip), and fibromyalgia. Recommendations were made for nonpharmacological treatments, including acupuncture, spinal manipulation/mobilization, and other manual therapy; modalities such as low-level laser and interferential current; exercise, including yoga; mind-body interventions, including mindfulness meditation and cognitive behavior therapy; and lifestyle modifications such as diet and tobacco cessation. Recommendations covered many aspects of the clinical encounter, from informed consent through diagnosis, assessment, treatment planning and implementation, and concurrent management and referral. Appropriate referral and comanagement were emphasized.
	Implementation of the Primary Spine Care Model in a Multi-Clinician Primary Care Setting: An Observational Cohort Study J Manipulative Physiol Ther 2020 (Sep); 43 (7): 667–674 ~ FULL TEXT Among patients with spine-related disorders (SRDs) included in this study, implementation of the primary spine care (PSC) model within a conventional primary care setting was associated with a trend toward reduced total expenditures for spine care compared with usual primary care. Implementation of PSC may lead to reduced costs and resource utilization, but may be no more effective than usual care regarding clinical outcomes.
	Association of Initial Provider Type on Opioid Fills for Individuals With Neck Pain Archives of Phys Med and Rehabilitation 2020 (Aug); 101 (8): 1407–1413 ~ FULL TEXT Compared to patients with neck pain who saw a primary health care provider, patients with neck pain who initially saw a conservative therapist were 72%–91% less likely to fill an opioid prescription in the first 30 days, and between 41%–87% less likely to continue filling prescriptions for 1 year. People with neck pain who initially saw emergency medicine physicians had the highest odds of opioid use during the first 30 days (OR, 3.58; 95% CI, 3.47–3.69; P<.001).
	Experiences With Chiropractic Care for Patients with Low Back or Neck Pain J Patient Exp 2020 (Jun); 7 (3): 357–364 ~ FULL TEXT We found similar reports of communication for the chiropractic sample and patients in the 2016 CAHPS National Database, but 85% in the database versus 79% in the chiropractic sample gave the most positive response to the time spent with provider item. More patients in the CAHPS database rated their provider at the top of the scale (8 percentage points). More chiropractic patients reported always getting answers to questions the same day (16 percentage points) and always being seen within 15 minutes of their appointment time (29 percentage points). The positive experiences of patients with chronic back and neck pain are supportive of their use of chiropractic care.
	Predictors of Visit Frequency for Patients Using Ongoing Chiropractic Care for Chronic Back and Chronic Neck Pain; Analysis of Observational Data BMC Musculoskeletal Disorders 2020 (May 13); 21 (1): 298 ~ FULL TEXT According to NIH Medline Plus, a publication of the National Institutes of Health, “chronic pain usually cannot be cured, but it can be managed.” [99] Several provider-based nonpharmacologic therapies have been recommended for chronic spinal pain, and these therapies may be used on an long-term ongoing basis by patients for pain management. Despite this need, ongoing provider-based care is not well-addressed in the evidence or supported in health and payer policies, [25–27] and this adds another barrier to the use of these recommended nonpharmacologic therapies [37]. This study examined data from a large sample of patients with CLBP and/or CNP to see how these real-world patients used chiropractic care over time to manage their pain. Our sample patients’ high pain management self-efficacy and long-term experience living with their conditions make them good source for information on how ongoing provider-based care for pain management might work. Chiropractic patients with CLBP and CNP manage their pain using a range of visit frequencies and the predictors of these frequencies could be useful for developing policies for ongoing provider-based care.
	Exposure to a Motor Vehicle Collision and the Risk of Future Neck Pain: A Systematic Review and Meta-analysis Accident; Analysis and Prevention 2020 (May 18); 142: 105546 ~ FULL TEXT Eight articles were identified of which seven were of lower risk of bias. Six studies reported a positive association between a neck injury in an MVC and future NP compared to those without a neck injury in a MVC. Pooled analysis of the six studies indicated an unadjusted relative risk of future NP in the MVC exposed population with neck injury of 2.3 (95% CI [1.8, 3.1]), which equates to a 57% attributable risk under the exposed. In two studies where exposed subjects were either not injured or injury status was unknown, there was no increased risk of future NP. There was a consistent positive association among studies that have examined the association between MVC-related neck injury and future NP. These findings are of potential interest to clinicians, insurers, patients, governmental agencies, and the courts.
	Clinical Scenarios for Which Cervical Mobilization and Manipulation Are Considered by an Expert Panel to Be Appropriate (and Inappropriate) for Patients with Chronic Neck Pain Clin J Pain 2020 (Apr); 36 (4): 273–280 ~ FULL TEXT Three hundred seventy-two clinical scenarios were defined and rated by an 11-member expert panel as to the appropriateness of cervical mobilization and manipulation. Across clinical scenarios more were rated inappropriate than appropriate for both therapies, and more scenarios were rated inappropriate for manipulation than mobilization. However, the number of patients presenting with each scenario is not yet known. Nevertheless, DTA indicates that all clinical scenarios that included red flags (eg, fever, cancer, inflammatory arthritides, or vasculitides), and some others involving major neurological findings, especially if previous manual therapy was unfavorable, were rated as inappropriate for both cervical mobilization and manipulation. DTA also identified the absence of cervical disk herniation, stenosis, or foraminal osteophytosis on additional testing as the most important patient characteristic in predicting ratings of appropriate.
	The Course and Factors Associated with Recovery of Whiplash-associated Disorders: An Updated Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration European J Physiotherapy 2020 (Mar 25); 23 (5): 1–16 ~ FULL TEXT The current best evidence synthesis updates findings published by the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders with respect to prognostic factors in WAD. This update provides a substantial body of evidence supporting the important prognostic role of post-collision psychological factors in WAD recovery.
	Best-Practice Recommendations for Chiropractic Management of Patients With Neck Pain J Manipulative Physiol Ther. 2019 (Nov); 42 (9): 635–650 ~ FULL TEXT A set of best-practice recommendations for chiropractic management of patients with neck pain based on the best available evidence reached a high level of consensus by a large group of experienced chiropractors. The recommendations indicate that manipulation and mobilization as part of a multimodal approach are front-line approaches to patients with uncomplicated neck pain.
	Prevalence and Characteristics of Chronic Spinal Pain Patients with Different Hopes (Treatment Goals) for Ongoing Chiropractic Care J Alternative and Complementary Medicine 2019 (Oct 1); 25 (10): 1015–1025 ~ FULL TEXT Although much of health policy is based on a curative model, less than a third of a large sample of patients with CLBP and CNP under ongoing chiropractic care have a stated hope or goal of cure—their pain going away permanently. Instead, most patients have goals related to the ongoing successful management of their chronic spinal pain. How can this goal of provider-based pain management be viably supported and sustained? Policy makers need more information about how patients are using ongoing providerbased care to develop policies regarding this care. This study provides some of this information.
	Electronic Measures of Movement Impairment, Repositioning, and Posture in People with and without Neck Pain - A Systematic Review Systematic Reviews 2019 (Aug 27); 8 (1): 220 ~ FULL TEXT People with varying types of neck pain have reduced active range of motion, reduced movement speed, and impaired head repositioning accuracy when compared with people without neck pain. Due to poor and inconsistent reporting regarding test methods, test subjects, blinding of examiners, and examiner background and training, these results should be interpreted with caution. Longitudinal studies are necessary to investigate the underlying factors for movement impairments and their potential to guide clinical interventions.
	Trajectories of Pain Intensity Over 1 Year in Adults With Disabling Subacute or Chronic Neck Pain Clinical J Pain 2019 (Aug); 35 (8): 678–685 ~ FULL TEXT Most individuals with disabling subacute or chronic neck pain show improvement in pain intensity over 1 year. However, a quarter present unfavorable trajectories, following either a fluctuating or a persistent pattern of pain over time despite undergoing a cycle of therapies for pain control. High pain intensity at baseline, depressive symptoms, younger age, female sex, and sudden onset of pain are factors associated with unfavorable trajectories of neck pain in this study.
	Conservative Spine Care Pathway Implementation Is Associated with Reduced Health Care Expenditures in a Controlled, Before-After Observational Study J General Internal Medicine 2019 (Aug); 34 (8): 1381-1382 ~ FULL TEXT In this retrospective, controlled, before-after study, we found that implementation of a conservative spine pain treatment pathway was associated with significant reductions in per-member-per-month (PMPM) healthcare expenditures for spine pain care; most cost savings were attributable to reduction in spine surgery costs. Our Poisson model found relatively reduced opioid utilization and relatively increased manual care costs, both anticipated by-products of guideline implementation. [4] While our findings are preliminary, in an era of increasing healthcare costs and use of complex and expensive spine surgery techniques they show promise for meaningful care cost reduction and value enhancement when providers conservatively manage spine pain. Importantly, our analysis underscores the value of using control groups, formal analytics, and academic partnerships to understand the impact of quality improvement and clinical effectiveness projects, measures that have been recommended to improve the robustness of quality improvement efforts. [5]
	Group and Individual-level Change on Health-related Quality of Life in Chiropractic Patients with Chronic Low Back or Neck Pain Spine (Phila Pa 1976) 2019 (May 1); 44 (9): 647–651 ~ FULL TEXT The results of this study contribute to the literature by providing evidence that chiropractic care is associated with improvements in functioning and well-being among individuals with chronic low back or neck pain. The study findings provide empirical verification of why some chronic pain patients utilize chiropractic care on a regular basis. It supports the use of chiropractic care as one option for improving functioning and well-being of patients with chronic low back pain or neck pain. While we are unable to infer the underlying mechanism for the observed improvements in patients, spinal manipulation is designed to relieve pain and improve physical functioning. Studies of the biomechanics indicate that spinal manipulation produces reflex responses and movements of vertebral bodies in the paraphysiologic zone. [27]
	Manipulation and Mobilization for Treating Chronic Nonspecific Neck Pain: A Systematic Review and Meta-Analysis for an Appropriateness Panel Pain Physician. 2019 (Mar); 22 (2): E55–E70 ~ FULL TEXT Studies published since January 2000 provide low-moderate quality evidence that various types of manipulation and/or mobilization will reduce pain and improve function for chronic nonspecific neck pain compared to other interventions. It appears that multimodal approaches, in which multiple treatment approaches are integrated, might have the greatest potential impact. The studies comparing to no treatment or sham were mostly testing the effect of a single dose, which may or may not be helpful to inform practice. According to the published trials reviewed, manipulation and mobilization appear safe. However, given the low rate of serious adverse events, other types of studies with much larger sample sizes would be required to fully describe the safety of manipulation and/or mobilization for nonspecific chronic neck pain.
	Cost-effectiveness of Spinal Manipulation, Exercise, and Self-management for Spinal Pain Using an Individual Participant Data Meta-analysis Approach: A Study Protocol Chiropractic & Manual Therapies 2018 (Nov 13); 26: 46 ~ FULL TEXT Combined analyses of economic data are rarely possible due to differences in resource utilization outcomes, costs and healthcare settings. [56, 57] Additionally, individual clinical trials rarely include a sufficient number of participants to detect important differences in economic outcomes. This project represents a unique opportunity to potentially combine clinical and economic data collected in eight randomized clinical trials using an IPDMA approach. This will provide more precise estimates of the cost-effectiveness of spinal manipulation, exercise therapy, and self-management compared to analysis of the individual trials. Further, an IPDMA approach has many advantages over traditional meta-analysis including the ability to conduct standardized within-study analyses, account for missing data at the individual level, and investigate potential sub-group effects at the participant level which may account for heterogeneity in estimates across studies. [52]
	Physical Risk Factors for Adolescent Neck and Mid Back Pain: A Systematic Review Chiropractic & Manual Therapies 2018 (Sep 24); 26: 36 ~ FULL TEXT This systematic review could not identify distinct risk factors for adolescent NP and MBP. It could however show a strong need for prospective studies in this field using a consistent definition of NP and MBP, preferably using an illustration. The Young Spine Questionnaire (YSQ) [42] fulfills this requirement and its use is strongly encouraged, although further validation and cross-cultural adaptation is needed. [1] Furthermore, the inconsistency in reporting comparable outcomes should be reduced. This could possibly be achieved through an interdisciplinary consensus conference between stakeholders regarding this research topic and by further investigating the interplay between thoracic and cervical spine. Based on this review, sagittal alignment in sitting and standing should be further investigated as possible risk factors for adolescent NP and MBP using a consistent terminology for the outcomes and longitudinal research designs.
	Characteristics of Chiropractic Patients Being Treated for Chronic Low Back and Neck Pain J Manipulative Physiol Ther. 2018 (Sep); 27 (Suppl 6): 901–914 ~ FULL TEXT This study provides insight into the characteristics of patients who are successfully managing their chronic low back pain (CLBP) and chronic neck pain (CNP). Findings of this descriptive study of a large sample of chiropractic patients with CLBP or CNP reveal this sample to be similar to those found in other studies of chiropractic patients: highly-educated, non-Hispanic, white women, with at least partial insurance coverage for chiropractic. These individuals have also been in pain and using chiropractic care for years. Most came to chiropractic after trying other types of care, and just under a third continued to receive other concurrent care for their pain. Prior to chiropractic, they saw the best results with massage therapy and acupuncture and reported high levels of belief in the success of chiropractic in reducing their pain.
	Changes in Female Veterans' Neck Pain Following Chiropractic Care at a Hospital for Veterans Complement Ther Clin Pract. 2018 (Feb); 30: 91–95 ~ FULL TEXT Female veterans with neck pain included in this study experienced statistically and clinically significant reductions in numeric rating scale (NRS) and Neck Bournemouth Questionnaire (NBQ) scores over a short course of chiropractic management with a mean of 8.8 treatments. Chiropractic management may be an effective treatment strategy for female veterans with neck pain complaints. Further research is warranted given the lack of published evidence.
	Long-term Trajectories of Patients with Neck Pain and Low Back Pain Presenting to Chiropractic Care: A Latent Class Growth Analysis European J Pain 2018 (Jan); 22 (1): 103–113 ~ FULL TEXT Most patients with NP or LBP presenting in chiropractic care show a trajectory of symptoms characterized by persistent or fluctuating pain of low or medium intensity. Only a minority either experience a rapid complete recovery or develop chronic severe pain. The two most common classes ‘recovering from mild baseline pain’ and ‘recovering from high baseline pain’ were consistent for both NP and LBP and accounted for 90% of the patients. The other two classes were less frequent and differed between NP and LBP patients. The four different classes showed distinct baseline patient characteristics and outcome in pain and functional status at 6 and 12 months
	The Efficacy of Manual Therapy and Exercise for Treating Non-specific Neck Pain: A Systematic Review J Back Musculoskelet Rehabil 2017 (Nov 6); 30 (6): 1149-1169 ~ FULL TEXT This systematic review updates the evidence for manual therapy (MT) combined or not with exercise and/or usual medical care for different stages of neck pain (NP) and provides recommendations for future studies. Two majors points could be highlighted, the first one is that combining different forms of MT with exercise is better than MT or exercise alone, and the second one is that mobilization need not be applied at the symptomatic level(s) for improvements of NP patients. These both points may have clinical implications for reducing the risk involved with some MT techniques applied to the cervical spine.
	Influence of Initial Provider on Health Care Utilization in Patients Seeking Care for Neck Pain Mayo Clin Proc Innov Qual Outcomes. 2017 (Oct 19); 1 (3): 226–233 ~ FULL TEXT These findings support that initiating care with a nonpharmacological provider for a new episode of neck pain may present an opportunity to decrease opioid exposure (DC and PT) and advanced imaging and injections (DC only). Although these findings need confirmation in a better controlled study, our results suggest that adopting such a strategy aligns well with recent CDC and ACP recommendations and has the potential to decrease the management burden of neck pain by PCPs. Future research is needed to examine the association of patient-centered outcomes and health care utilization and to explore whether seeking care from a nonpharmacological provider is also associated with cost savings in addition to decreased health care utilization.
	Exploring the Definition of Acute Neck Pain: A Prospective Cohort Observational Study Comparing the Outcomes of Chiropractic Patients with 0-2 Weeks, 2-4 Weeks and 4-12 Weeks of Symptoms Chiropractic & Manual Therapies 2017 (Aug 16); 25: 24 ~ FULL TEXT The time period with 0–4 weeks of symptoms as the definition of “acute” neck pain should be maintained. Patients with a shorter period (0–2 weeks) of symptoms recover faster than patients with a longer period of symptoms (2–4 weeks) but this difference is only statistically significant at the 1 week and 1 month time periods. These results for neck pain patients are different from those obtained in the similar study investigating acute low back pain patients where the 0–2 weeks time period as the definition of ‘acute’ was recommended. Medium-term and long-term outcome is favourable for acute as well as subacute neck pain patients, independent of the exact duration of symptoms.
	A NAME="Factors_in_Patient_Responsiveness"> Factors in Patient Responsiveness to Directional Preference-Matched Treatment of Neck Pain With or Without Upper Extremity Radiation J Patient Cent Res Rev. 2017 (Apr 25); 4 (2): 60–68 ~ FULL TEXT Patient compliance with directional preference exercise is associated with patient responsiveness to directional preference therapy in conservative care treatments of neck pain. Patients 55 years of age or older, those with acute/subacute chronicity and those who report symptom improvement following the first treatment session showed significant improvement. Implementation of these findings could improve care of patients with neck pain, with or without upper extremity radiation, at a local level.
	Chronic Neck Pain Patients With Traumatic or Non-traumatic Onset: Differences in Characteristics. A Cross-sectional Study Scand J Pain. 2017 (Jan); 14: 1-8 ~ FULL TEXT This study showed significant differences between chronic neck pain patients when differentiated into groups based on their onset of pain. However, no specific clinical test or self-reported characteristic could differentiate between the groups at an individual patient level.   Pressure pain threshold tests, cervical muscle performance tests and patient-reported characteristics about self-perceived function and psychological factors may assist in profiling chronic neck pain patients. The need for more intensive management of those with a traumatic onset compared with those with a non-traumatic onset should be examined further.
	Does Structured Patient Education Improve the Recovery and Clinical Outcomes of Patients with Neck Pain? A Systematic Review from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration Spine J. 2016 (Dec); 16 (12): 1524–1540 Results suggest that structured patient education alone cannot be expected to yield large benefits in clinical effectiveness compared with other conservative interventions (including spinal manipulation, massage, supervised exercise, and physiotherapy) for patients with WAD or NAD. Moreover, structured patient education may be of benefit during the recovery of patients with WAD when used as an adjunct therapy to physiotherapy or emergency room care. These benefits are small and short lived.
	Are Manual Therapies, Passive Physical Modalities, or Acupuncture Effective for the Management of Patients with Whiplash-associated Disorders or Neck Pain and Associated Disorders? An Update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the OPTIMa Collaboration Spine J. 2016 (Dec); 16 (12): 1598-1630 ~ FULL TEXT Our review adds new evidence to the Neck Pain Task Force and suggests that mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain. It also suggests that electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, and ultrasound) are not effective and should not be used to manage neck pain.
	Cost-effectiveness of Spinal Manipulative Therapy, Supervised Exercise, and Home Exercise for Older Adults with Chronic Neck Pain Spine J. 2016 (Nov); 16 (11): 1292–1304 Total costs for spinal manipulative therapy (SMT) + home exercise and advice (HEA) were 5% lower than HEA (mean difference: –$111; 95% confidence interval [CI] –$1,354 to $899) and 47% lower than supervised rehabilitative exercise (SRE) + HEA (mean difference: –$1,932; 95% CI –$2,796 to –$1,097).   SMT+HEA also resulted in a greater reduction of neck pain over the year relative to HEA (0.57; 95% CI 0.23 to 0.92) and SRE+HEA (0.41; 95% CI 0.05 to 0.76). Differences in disability and quality-adjusted life years (QALYs) favored SMT+HEA.
	Are People With Whiplash Associated Neck Pain Different to People With Non-Specific Neck Pain? J Orthop Sports Phys Ther. 2016 (Oct); 46 (10): 894–901 2,578 participants were included in the study. Of these 488 (19%) were classified as having WAD. At presentation patients with WAD were statistically different to patients without WAD for almost all characteristics investigated. While most differences were small (1.1 points on an 11-point pain rating scale and 11 percentage points on the Neck Disability Index) others including the presence of dizziness and memory difficulties were substantial. The between group differences in pain and disability increased significantly (P<.001) over 12 months. At 12–month follow-up the patients with WAD on average had approximately 2 points more pain and 16 percentage points more disability than those with non-specific neck pain.
	The Treatment of Neck Pain-Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline J Manipulative Physiol Ther. 2016 (Oct); 39 (8): 523–564 ~ FULL TEXT The objective was to develop a clinical practice guideline on the management of neck pain-associated disorders (NADs) and whiplash-associated disorders (WADs). This guideline replaces 2 prior chiropractic guidelines on NADs and WADs.
	Neck Pain In Children: A Retrospective Case Series J Can Chiropr Assoc. 2016 (Sep); 60 (3): 212–219 ~ FULL TEXT In our study, 50 pediatric patients between 6 and 18 years (average 13 years) were found to have evidence of mechanical neck pain. Treatment was provided on average of 5 visits over an average of 19 days. These patients were successfully managed primarily using SMT. There were no worsening of symptoms nor adverse events recorded. This exploratory study provides data to help inform the role, indication and dose of manual therapy in the management of pediatric mechanical neck pain. It highlights a treatment option with minimal risk and reported successful pain management for a commonly experienced MSK condition by many pediatric patients. The results can be used in designing more robust explanatory studies.
	Management of Neck Pain and Associated Disorders: A Clinical Practice Guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration European Spine Journal 2016 (Jul); 25 (7): 2000–2022 ~ FULL TEXT 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.
	Manual and Instrument Applied Cervical Manipulation for Mechanical Neck Pain: A Randomized Controlled Trial J Manipulative Physiol Ther. 2016 (Jun); 35 (5): 319–329 ~ FULL TEXT This study demonstrates that a single cervical manipulation is capable of producing immediate and short-term benefits for mechanical neck pain (MNP). The study also demonstrates that not all manipulative techniques have the same effect and that the differences may be mediated by neurological or biomechanical factors inherent to each technique. There are more articles like this at our: Instrument Adjusting Page
	Variations in Patterns of Utilization and Charges for the Care of Neck Pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis J Manipulative Physiol Ther. 2016 (May); 39 (4): 240–251 ~ FULL TEXT Increases in utilization and charges were the highest among patterns involving MDs, PTs and referral providers.   These findings are consistent with previous studies showing that medical specialty, diagnostic imaging, and invasive procedures (eg, spine injections, surgery) [17, 19, 20, 21] are significant drivers of increasing spine care costs. When costs are viewed vertically as if in “silos” (eg, DC-only costs, MD-only costs), increasing utilization of one particular provider is seen as a net cost increase. However, when costs are viewed across the silos, as this study has done, an increase in utilization of one provider group can result in a net cost decrease given its effect on the patient population.   This is an opportunity to view costs laterally versus a confined, vertical analysis. This is one of 3 of the Cost-Effectiveness Triumvirate articles.
	Symptomatic, Magnetic Resonance Imaging-Confirmed Cervical Disk Herniation Patients: A Comparative- Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either Imaging-Guided Indirect Cervical Nerve Root Injections or Spinal Manipulative Therapy J Manipulative Physiol Ther. 2016 (Mar); 39 (3): 210–217 ~ FULL TEXT "Improvement" was reported in 86.5% of SMT patients and 49.0% of CNRI patients (P = .0001). Significantly more CNRI patients were in the subacute/chronic category (77%) compared with SMT patients (46%). A significant difference between the proportion of subacute/chronic CNRI patients (37.5%) and SMT patients (78.3%) reporting "improvement" was noted (P = .002).
	Importance of Psychological Factors for the Recovery From a First Episode of Acute Non-specific Neck Pain - A Longitudinal Observational Study Chiropractic & Manual Therapies 2016 (Mar 16); 24: 9 ~ FULL TEXT Previous bio-psycho-social studies have posited that anxiety, depression and catastrophizing are associated with chronicity. However, whether they are merely “associated with” versus “contribute towards” is really still up in the air (JMHO).   To test whether these emotional elements are a natural side-effect of chronic pain as opposed to being causal, these researchers worked with 850 patients with acute non-specific neck pain with no history of previous neck or arm pain.
	Does Cervical Spine Manipulation Reduce Pain in People with Degenerative Cervical Radiculopathy? A Systematic Review of the Evidence, and a Meta-analysis Clinical Rehabilitation 2016 (Feb); 30 (2): 145–155 ~ FULL TEXT Three trials with 502 participants were included. Meta-analysis suggested that cervical spine manipulation (mean difference 1.28, 95% confidence interval 0.80 to 1.75; P < 0.00001; heterogeneity: Chi2 = 8.57, P = 0.01, I2 = 77%) improving visual analogue scale for pain showed superior immediate effects compared with cervical computer traction. The overall strength of evidence was judged to be moderate quality.
	The Anatomy and Morphometry of Cervical Zygapophyseal Joint Meniscoids Surg Radiol Anat. 2015 (Sep); 37 (7): 799–807 ~ FULL TEXT Meniscoids were identified in 86% of zygapophyseal joints examined; 50% contained both ventral and dorsal meniscoids, 7% contained a ventral meniscoid only and 29% contained a dorsal meniscoid only. Meniscoids were classified as adipose (4%), fibrous (74%), or fibroadipose (22%) based upon histological composition. There were no significant associations between meniscoid size (surface area or protrusion length) and gender, position in joint, spinal level, or articular degeneration. Increased articular degeneration was associated with fibrous meniscoid classification.
	Prognostic Factors for Recurrences in Neck Pain Patients Up to 1 Year After Chiropractic Care J Manipulative Physiol Ther. 2015 (Sep); 38 (7): 458–464 ~ FULL TEXT The results of this study suggest that recurrence of neck pain within 1 year after chiropractic intervention in Swiss chiropractic patients presenting from varied onsets is low. This study found preliminary findings that older age and a previous episode of neck may be useful predictors of neck pain recurrence within 1 year.
	Regional Supply of Chiropractic Care and Visits to Primary Care Physicians for Back and Neck Pain J American Board of Family Medicine 2015 (Jul); 28 (4): 481–490 ~ FULL TEXT Despite the inherent limitations of our study, our findings offer important insights into the indirect effects of Medicare’s chiropractic care benefit on PCP services. Our finding that chiropractic care is associated with fewer visits to PCPs for back and/or neck pain is important for health policymakers to consider. Driven by both increased spending [11, 12] and a series of reports by the Office of the Inspector General, [11–14] Medicare’s chiropractic care benefit is currently being examined. In addition to providing important information regarding the impact of coverage of chiropractic care, our study also underscores the importance of evaluating the indirect effects of ambulatory health services. When extrapolated to the nation (based on our predictions from our adjusted model), we estimate that chiropractic care is associated with a reduction of 0.37 million visits to PCPs for back and/or neck pain at a total cost of $83.5 million (Table 3).
	The Rapid and Progressive Degeneration of the Cervical Multifidus in Whiplash: An MRI Study of Fatty Infiltration Spine (Phila Pa 1976). 2015 (Jun 15); 40 (12): E694–700 ~ FULL TEXT Thirty-six subjects with whiplash injury were enrolled at less than 1 week postinjury and classified at 3 months using percentage scores on the Neck Disability Index as recovered/mild (0%–28%) or severe (≥30%). A fat/water magnetic resonance imaging measure, patient self-report of pain-related disability, and post-traumatic stress disorder were collected at less than 1 week, 2 weeks, and 3 months postinjury. The effects of time and group (per Neck Disability Index) and the interaction of time by group on MFI were determined. Receiver operating characteristic curve analysis was used to determine a cut-point for MFI at 2 weeks to predict outcome at 3 months.
	Is Neck Pain Associated with Worse Health-related Quality of Life 6 Months Later? A Population-based Cohort Spine J. 2015 (Apr 1); 15 (4): 675–684 ~ FULL TEXT Our results indicate that neck pain can affect the future physical health-related quality of life (HRQoL) of individuals. This impact was worse in individuals with worsening or persistent neck pain. These results emphasize the importance for health-care providers and policy makers to manage neck pain with early effective interventions to minimize the long-term impact on physical HRQoL. Future research needs to examine the course of neck pain on HRQoL while controlling for the confounding effects of socioeconomic, lifestyle, and comorbidities. Further research is also needed to examine the mediating and confounding effects of depression on the association between neck pain and mental HRQoL.
	Is There a Role for Neck Manipulation in Elderly Falls Prevention? An Overview J Canadian Chiro Assoc 2015 (Mar); 59 (1): 53–63 ~ FULL TEXT We conclude that chiropractors may have a role in falls prevention strategies in the subpopulation of the elderly that suffer from mechanical neck pain or dysfunction and non-specific dizziness. However, this role remains to be rigorously studied and properly defined.
	Cut-off Points for Mild, Moderate, and Severe Pain on the Visual Analogue Scale for Pain in Patients with Chronic Musculoskeletal Pain Pain 2014 (Dec); 155 (12): 2545–2550 ~ FULL TEXT The aim of this study was to find the cut-off points on the visual analogue scale (VAS) to distinguish among mild, moderate, and severe pain, in relation to the following: pain-related interference with functioning; verbal description of the VAS scores; and latent class analysis for patients with chronic musculoskeletal pain. A total of 456 patients were included. Pain was assessed using the VAS and verbal rating scale; functioning was assessed using the domains of the Short Form (36) Health Survey (SF-36). Eight cut-off point schemes were tested using multivariate analysis of variance (MANOVA), ordinal logistic regression, and latent class analysis. The study results showed that VAS scores ≤ 3.4 corresponded to mild interference with functioning, whereas 3.5 to 6.4 implied moderate interference, and ≥ 6.5 implied severe interference.
	Cut Points for Mild, Moderate, and Severe Pain on the VAS for Children and Adolescents: What Can Be Learned from 10 Million ANOVAs? Pain 2013 (Dec); 154 (12): 2626–2632 ~ FULL TEXT Cut points that classify pain intensity into mild, moderate, and severe levels are widely used in pain research and clinical practice. At present, there are no agreed-upon cut points for the visual analog scale (VAS) in pediatric samples. We applied a method based on Serlin and colleagues' procedure (Serlin RC, Mendoza TR, Nakamura Y, Edwards KR, Cleeland CS. When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. PAIN(Æ) 1995;61:277-84) that was previously only used for the 0 to 10 numerical rating scale to empirically establish optimal cut points (OCs) for the VAS and used bootstrapping to estimate the variability of these thresholds. We analyzed data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS) study and defined OCs both for parental ratings of their children's pain and adolescents' self-ratings of pain intensity. Data from 2276 children (3 to 10 years; 54% female) and 2982 adolescents (11 to 17 years; 61% female) were analyzed. OCs were determined in a by-millimeter analysis that tested all possible 4851 OC combinations, and a truncated analysis were OCs were spaced 5 mm apart, resulting in 171 OC combinations. The OC method identified 2 different OCs for parental ratings and self-report, both in the by-millimeter and truncated analyses. When we estimated the variability of the by-millimeter analysis, we found that the specific OCs were only found in 11% of the samples. The truncated analysis revealed, however, that cut points of 35:60 are identified as optimal in both samples and are a viable alternative to separate cut points. We found a set of cut points that can be used both parental ratings of their children's pain and self-reports for adolescents. Adopting these cut points greatly enhances the comparability of trials. We call for more systematic assessment of diagnostic procedures in pain research.
	Perceived Value of Spinal Manipulative Therapy and Exercise Among Seniors With Chronic Neck Pain: A Mixed Methods Study J Rehabil Med. 2014 (Nov); 46 (10): 1022–1028 ~ FULL TEXT Participants placed high value on their relationships with health care team members, supervision, individualized care, and the exercises and information provided as treatment. Change in symptoms did not figure as prominently as social and process-related themes. Percpetions of age, activities, and co-morbities influenced some seniors' expectations of treatment results, and comorbidities impacted perceptions of their ability to participate in active care. Relationship dynamics should be leveraged in clinical encounters to enhance patient satisfaction and perceived value of care.
	Adolescent Neck and Shoulder Pain--The Association with Depression, Physical Activity, Screen-based Activities, and Use of Health Care Services J Adolesc Health 2014 (Sep); 55 (3): 366–372 ~ FULL TEXT Frequent neck and shoulder pain was reported in 20% of Norwegian adolescents. Symptoms of depression and screen-based activities increased the risk of neck and shoulder pain while physical activity was protective. Individuals reporting neck and shoulder pain visited health services more frequently than others.
	Spinal Manipulative Therapy and Exercise For Seniors with Chronic Neck Pain   NCT00269308 Spine J. 2014 (Sep 1); 14 (9): 1879–1889 A total of 241 participants were randomized, with 95% reporting primary outcome data at all time points. After 12 weeks of treatment, the SMT with home exercise group demonstrated a 10% greater decrease in pain compared with the HE-alone group, and 5% change over supervised plus home exercise. A decrease in pain favoring supervised plus home exercise (HE) over HE alone did not reach statistical significance. Compared with the HE group, both combination groups reported greater improvement at week 12 and more satisfaction at all time points. Multivariate longitudinal analysis incorporating primary and secondary patient-rated outcomes showed that the SMT with HE group was superior to the HE-alone group in both the short- and long-term. No serious adverse events were observed as a result of the study treatments. Spinal manipulative therapy (SMT) with home exercise resulted in greater pain reduction after 12 weeks of treatment compared with both supervised plus HE and HE alone. Supervised exercise sessions added little benefit to the HE-alone program.
	Short Term Treatment Versus Long Term Management of Neck and Back Disability in Older Adults Utilizing Spinal Manipulative Therapy and Supervised Exercise: A Parallel-group Randomized Clinical Trial Evaluating Relative Effectiveness and Harms Chiropractic & Manual Therapies 2014 (May 23); 22: 21 ~ FULL TEXT This is one of the first full-scale randomized clinical trials to compare short term treatment and long term management using SMT and exercise to treat spine-related disability in older adults. It builds on previous research by the investigative team showing improvement with three months of SMT and exercise in similar populations, which regressed to baseline values in long term follow up without further intervention 88. As back and neck pain in older adults are often chronic and among several co-morbidities [6, 8], we theorized that long term management may result in sustained improvement compared to short term treatment. Identifying the most favorable duration of treatment is a pragmatic question common to patients, clinicians, policy makers, and third-party payers alike. [25, 89] This is especially important to address in an older population, whose long term functional ability is essential to maintaining vitality and independence.
	A Modern Neuroscience Approach to Chronic Spinal Pain: Combining Pain Neuroscience Education with Cognition-targeted Motor Control Training Phys Ther. 2014 (May); 94 (5): 730–738 ~ FULL TEXT Chronic spinal pain (CSP) is a severely disabling disorder, including nontraumatic chronic low back and neck pain, failed back surgery, and chronic whiplash-associated disorders. Much of the current therapy is focused on input mechanisms (treating peripheral elements such as muscles and joints) and output mechanisms (addressing motor control), while there is less attention to processing (central) mechanisms. In addition to the compelling evidence for impaired motor control of spinal muscles in patients with CSP, there is increasing evidence that central mechanisms (ie, hyperexcitability of the central nervous system and brain abnormalities) play a role in CSP. Hence, treatments for CSP should address not only peripheral dysfunctions but also the brain. Therefore, a modern neuroscience approach, comprising therapeutic pain neuroscience education followed by cognition-targeted motor control training, is proposed.
	Spinal Manipulation and Exercise for Low Back Pain in Adolescents: Study Protocol for a Randomized Controlled Trial   NCT01096628 Chiropractic & Manual Therapies 2014 (May 23); 22: 21 ~ FULL TEXT This is the first randomized clinical trial assessing the effectiveness of combining spinal manipulative therapy with exercise for adolescents with low back pain. The results of this study will provide important evidence on the role of these conservative treatments for the management of low back pain in adolescents.
	"I Know It's Changed": A Mixed-methods Study of the Meaning of Global Perceived Effect in Chronic Neck Pain Patients European Spine Journal 2014 (Apr); 23 (4): 888–897 ~ FULL TEXT This work provides a better understanding of the meaning of Global Perceived Effect (GPE) and influencing factors, than what was previously known. The GPE appears to capture chronic neck pain patient perceptions of change in different domains important to their individual pain experiences which may not be captured by other outcome instruments. Thus, the GPE scales are useful measurement tools for clinical practice and research.
	Treatment Preferences Amongst Physical Therapists and Chiropractors for the Management of Neck Pain: Results of an International Survey Chiropractic & Manual Therapies 2014 (Mar 24); 22 (1): 11 ~ FULL TEXT This survey indicates that exercise and manual therapy are core treatments provided by chiropractors and physical therapists. Future research should address gaps in evidence associated with variable practice patterns and knowledge translation to reduce usage of some interventions that have been shown to be ineffective.
	Mild Traumatic Brain Injury After Motor Vehicle Collisions: What Are the Symptoms and Who Treats Them? A Population-Based 1-Year Inception Cohort Study Arch Phys Med Rehabil. 2014 (Mar); 95 (3 Suppl): S286–294 ~ FULL TEXT In this first population-based inception cohort study of individuals who have experienced a mild traumatic brain injury (MTBI) during a car collision, we found a high prevalence of multiple symptoms and pain at several body sites. In addition, care-seeking from multiple providers continued throughout the first year postinjury. Studies investigating how clusters of symptoms interact and affect prognosis are needed. Most urgently however, high-quality clinical trials investigating the effectiveness and cost-effectiveness of the many kinds of treatments given to these patients are needed.
	Association Between Centralization and Directional Preference and Functional and Pain Outcomes in Patients with Neck Pain J Orthop Sports Phys Ther. 2014 (Feb); 44 (2): 68–75 ~ FULL TEXT Directional preference (DP) is a prevalent evaluation category that, when combined with treatments consisting of matched exercises and manual techniques, can be used to predict changes in function, but not pain, in patients with neck pain. There are more articles like this at our: McKenzie Method page.
	Exploring the Clinical Course of Neck Pain in Physical Therapy: A Longitudinal Study Arch Phys Med Rehabil. 2014 (Feb); 95 (2): 303–308 ~ FULL TEXT The purpose of this exploratory study was to longitudinally describe the clinical course of mechanical neck pain during 1 month of usual-care outpatient physical therapy treatment. This was intended as a hypothesis-generating rather than confirmatory exercise and to provide guidance for future clinical trials of nonmedical neck pain management. We have shown that the trajectory, on average, in our sample of 50 subjects with mechanical neck pain of varying cause and duration, suggests an improvement of roughly 1.5 NDI points and 0.5 NRS points per week that adequately approximates a linear curve. In showing a mean linear trend over the course of 1 month, clinical trialists can be confident that a 1-month follow-up period is neither too short to identify measurable change, nor too long to risk missing early, rapid change.
	Evidence-Based Guidelines for the Chiropractic Treatment of Adults With Neck Pain J Manipulative Physiol Ther 2014 (Jan); 37 (1): 42–63 ~ FULL TEXT The studies included in this guideline indicate that cervical manipulation, mobilization, manual therapy, exercise, and massage can be recommended for the chiropractic treatment of nonspecific, mechanical neck pain. The strongest recommendations are typically made for the primary intervention in combination with another intervention, usually exercise and/or patient education. Owing to conflicting findings in the literature, no recommendation could be made for laser, TENS, or thoracic manipulation in the treatment of chronic neck pain or for the use of thoracic manipulation in the treatment of acute neck pain. There is a lack of evidence to support the use of laser, trigger point therapy, or traction for nonspecific, mechanical neck pain in adults.
	The Course of Serum Inflammatory Biomarkers Following Whiplash Injury and their Relationship to Sensory and Muscle Measures: A Longitudinal Cohort Study PLoS One. 2013 (Oct 17); 8 (10): e77903 ~ FULL TEXT In summary, the results demonstrate initially higher levels of serum C-reactive protein (CRP) following whiplash injury that persist in those with persistent moderate/severe pain and disability and show moderate associations with mechanical and cold hyperalgesia. In contrast serum levels of TNF-α are elevated in those with good or fair recovery and are negatively associated with amounts of fatty infiltrate in the cervical extensor muscles. Inflammatory biomarkers appear to be associated with the presentation of acute and chronic WAD.
	Outcomes From Magnetic Resonance Imaging–Confirmed Symptomatic Cervical Disk Herniation Patients Treated With High-Velocity, Low-Amplitude Spinal Manipulative Therapy: A Prospective Cohort Study With 3-Month Follow-Up J Manipulative Physiol Ther 2013 (Oct); 36 (8): 461–467 ~ FULL TEXT 50 adult Swiss patients with neck pain and dermatomal arm pain; sensory, motor, or reflex changes corresponding to the involved nerve root; and at least 1 positive orthopaedic test for cervical radiculopathy were included. Magnetic resonance imaging-confirmed CDH linked with symptoms was required. At 2 weeks, 55.3% were "improved," 68.9% at 1 month and 85.7% at 3 months. Statistically significant decreases in neck pain, arm pain, and NDI scores were noted at 1 and 3 months compared with baseline scores (P < .0001). Of the subacute/chronic patients, 76.2% were improved at 3 months.
	Outcomes of Usual Chiropractic. The OUCH Randomized Controlled Trial of Adverse Events Spine (Phila Pa 1976). 2013 (Sep 15); 38 (20): 1723–1729 ~ FULL TEXT Completed adverse questionnaires were returned by 94.5% of the participants after appointment 1 and 91.3% after appointment 2. Thirty-three percent of the sham group and 42% of the usual care group reported at least 1 adverse event. Common adverse events were: increased pain sham 29% usual care 36% muscle stiffness sham 29% usual care 37% headache sham 17% usual care 9% The relative risk (RR) was not significant for adverse event occurrence (RR = 1.24; 95% CI: 0.85-1.81), occurrence of severe adverse events (RR = 1.9; 95% CI: 0.98-3.99), adverse event onset (RR = 0.16; 95% CI: 0.02-1.34), or adverse event duration (RR = 1.13; 95% CI: 0.59-2.18). No serious adverse events were reported. CONCLUSION: A substantial proportion of adverse events after chiropractic treatment may result from natural history variation and nonspecific effects. There are more articles like this in our Adverse Events page.
	Comparison of Outcomes in Neck Pain Patients with and without Dizziness Undergoing Chiropractic Treatment: A Prospective Cohort Study with 6 month Follow-up Chiropractic & Manual Therapies 2013 (Jan 7); 21: 3 ~ FULL TEXT Neck pain patients with dizziness reported significantly higher pain and disability scores at baseline compared to patients without dizziness. A high proportion of patients in both groups reported clinically relevant improvement on the PGIC scale. At 6 months after start of chiropractic treatment there were no differences in any outcome measures between the two groups.
	Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain Topics in Integrative Health Care 2012 (Dec 31); 3 (4) ~ FULL TEXT The complexity of clinical documentation and case management for health care providers has increased along with the rise of managed care. Keeping up with the policies of different insurers and third party administrators can be a daunting task. To address these issues for doctors of chiropractic (DCs) and policymakers, the Council for Chiropractic Guidelines and Practice Parameters (CCGPP) developed three consensus documents. Each of these documents was the outcome of a formal consensus process in which a multidisciplinary Delphi panel consisting of experts in chiropractic and low back pain treatment came to agreement on terminology and treatment parameters for the chiropractic management of spine-related musculoskeletal pain. [1–3]
	The Association of Complementary and Alternative Medicine Use and Health Care Expenditures for Back and Neck Problems Medical Care 2012 (Dec); 50 (12): 1029–1036 ~ FULL TEXT While health care conversations increasingly mention chiropractic care as a viable option for back and neck pain – and research increasingly supports its utility from a clinical standpoint – this nationwide study of complementary and alternative medicine (CAM)-related health care expenditures by 12,000-plus adults (ages 17 and older) with spinal conditions lends support to the suggestion that CAM in general, and chiropractic specifically, is also a cost-effective alternative to traditional medical care.
	Predictors of Outcome in Neck Pain Patients Undergoing Chiropractic Care: Comparison of Acute and Chronic Patients Chiropractic & Manual Therapies 2012 (Aug 24); 20 (1): 27 ~ FULL TEXT The most consistent predictor of clinically relevant improvement at both 1 and 3 months after the start of chiropractic treatment for both acute and chronic patients is if they report improvement early in the course of treatment. The co-existence of either radiculopathy or dizziness however do not imply poorer prognosis in these patients.
	Clinical Decision Rules, Spinal Pain Classification and Prediction of Treatment Outcome: A Discussion of Recent Reports in the Rehabilitation Literature Chiropractic & Manual Therapies 2012 (Jun 22); 20 (1): 19 ~ FULL TEXT Clinical decision rules are an increasingly common presence in the biomedical literature and represent one strategy of enhancing clinical-decision making with the goal of improving the efficiency and effectiveness of healthcare delivery. In the context of rehabilitation research, clinical decision rules have been predominantly aimed at classifying patients by predicting their treatment response to specific therapies. Traditionally, recommendations for developing clinical decision rules propose a multistep process (derivation, validation, impact analysis) using defined methodology. Research efforts aimed at developing a "diagnosis-based clinical decision rule" have departed from this convention. Recent publications in this line of research have used the modified terminology "diagnosis-based clinical decision guide." Modifications to terminology and methodology surrounding clinical decision rules can make it more difficult for clinicians to recognize the level of evidence associated with a decision rule and understand how this evidence should be implemented to inform patient care. We provide a brief overview of clinical decision rule development in the context of the rehabilitation literature and two specific papers recently published in Chiropractic and Manual Therapies.
	Supervised Exercise with And without Spinal Manipulation Performs Similarly and Better Than Home Exercise for Chronic Neck Pain: A Randomized Controlled Trial   NCT00269360 Spine (Phila Pa 1976). 2012 (May 15); 37 (11): 903–914 At 12 weeks, there was a significant difference in patient-rated pain between exercise therapy (ET) + spinal manipulation (SMT) and HEA (1.3 points, P < 0.001) and ET and home exercise and advice (HEA) (1.1 points, P = 0.001). Although there were smaller group differences in patient-rated pain at 52 weeks (ET + SMT vs. HEA, 0.2 points, P > 0.05; ET vs. HEA, 0.3 points, P > 0.05), linear mixed model analyses incorporating all time points yielded a significant advantage for the 2 supervised exercise groups (ET + SMT vs. HEA, P = 0.03; ET vs. HEA, P = 0.02). Similar results were observed for global perceived effect and satisfaction.
	Advancements in the Management of Spine Disorders Best Pract Res Clin Rheumatol. 2012 (Apr); 26 (2): 263–280 ~ FULL TEXT Despite, or perhaps because of its impact, spinal disorders remain one of the most controversial and difficult conditions for clinicians, patients and policymakers to manage. This paper provides a brief summary of advances in the understanding of back and neck pain over the past decade as evidenced in the current literature. This paper includes the following sections: a classification of spinal disorders; the epidemiology of spine pain in the developed and developing world; key advancements in biological and biomechanical sciences in spine pain; the current status of potential methods for the prevention of back and neck pain; rheumatological and systemic disorders that impact the spine; and evidence-based surgical and non-surgical management of spine pain. The final section of this paper looks to the future and proposes actions and strategies that may be considered by the international Bone and Joint Decade (BJD), by providers, institutions and by policymakers so that we may better address the burden of spine disorders at global and local levels.
	Pain in the Three Spinal Regions: The Same Disorder? Data From a Population-based Sample of 34,902 Danish Adults Chiropractic & Manual Therapies 2012 (Apr 5); 20: 11 ~ FULL TEXT In all, 34,902 (74%) twin individuals representative of the general Danish population, aged 20 to 71, participated in a cross-sectional nation-wide survey. Identical questions from the Standardised Nordic Questionnaire for each of the three spinal regions were used for lumbar, mid-back and neck pain respectively: Pain past year, pain ever, radiating pain, and consequences of back pain (care-seeking, reduced physical activities, sick-leave, change of work/work duties and disability pension). The relative prevalence estimates of these variables were compared for the three spinal regions.
	Clinical Decision-making to Facilitate Appropriate Patient Management in Chiropractic Practice: 'The 3-questions Model' Chiropractic & Manual Therapies 2012 (Mar 14); 20: 6 ~ FULL TEXT Clinical decision-making is considered to be a key characteristic of any modern healthcare practitioner. It is, thus, prudent for chiropractors to re-visit the concept of defensible practice with a view to facilitate capable clinical decision-making and competent patient examination skills. In turn, the perception of competence and trustworthiness of chiropractors within the wider healthcare community helps integration of chiropractic services into broader healthcare settings.
	Cervical Radiculopathy: A Systematic Review on Treatment by Spinal Manipulation and Measurement with the Neck Disability Index J Canadian Chiropractic Assoc. 2012 (Mar); 56 (1): 18–28 ~ FULL TEXT Cervical radiculopathy (CR), while less common than conditions with neck pain alone, can be a significant cause of neck pain and disability; thus the determination of adequate treatment options for patients is essential. Currently, inadequate scientific literature restricts specific conservative management recommendations for CR. Despite a paucity of evidence for high-velocity low-amplitude (HVLA) spinal manipulation in the treatment for CR, this strategy has been frequently labeled as contraindicated. Scientific support for appropriate outcome measures for CR is equally deficient. While more scientific data is needed to draw firm conclusions, the present review suggests that spinal manipulation may be cautiously considered as a therapeutic option for patients suffering from CR. With respect to outcome measures, the Neck Disability Index appears well-suited for spinal manipulative treatment of CR.
	Spinal Manipulative Therapy and Its Role in the Prevention, Treatment and Management of Chronic Pain J Canadian Chiro Assoc 2012 (Mar); 56 (1): 5-7 ~ FULL TEXT Chronic pain is a worldwide epidemic. It is characterized as “pain that persists beyond normal tissue healing time” [1] and is physiologically distinct from acute nociceptive pain. The current research estimates the prevalence of chronic pain in the general population to be anywhere from 10–55%, [2] predominantly affecting the adult population. Studies indicate that the prevalence of chronic pain in the over-60 age group is double that for younger adults. [3] Furthermore, over 80% of elderly (over 65) adults suffer from some form of painful chronic joint disease [4] and greater than 85% of the general population will experience some form of chronic myofascial pain during their lifetime. [5]
	For Neck Pain, Chiropractic and Exercise Are Better Than Drugs ~ January 3, 2012 This new study, published in the Annals of Internal Medicine, found that chiropractic care or simple exercises done at home were better at reducing pain than taking medications like aspirin, ibuprofen or narcotics.
	The Great Faceoff: Chiropractic Goes Head-to-Head wth NSAIDs and Acupuncture The following commentary involves reviewing a brilliant series of 3 consecutive studies, comparing popular forms of treatment for chronic spinal pain, including NSAID use, acupuncture, and spinal adjusting for relief. The author reports that this is the first study of long-term efficacy of 3 distinct and standardized treatment regimens for patients with chronic spinal pain syndromes.
	Spinal Manipulation, Medication, or Home Exercise wth Advice for Acute and Subacute Neck Pain: A Randomized Trial   NCT00029770 Annals of Internal Medicine 2012 (Jan 3); 156 (1 Pt 1): 1–10 ~ FULL TEXT Bronfort’s paper, published in the influential Annals of Internal Medicine, began with the hypothesis that “spinal manipulation therapy (SMT) is more effective than medication or home exercise with advice (HEA) for acute and subacute neck pain.” And indeed, when the dust settled, the neck-pain patients receiving spinal manipulation had achieved significantly more pain relief than those receiving medication. However, a third group that received a few instructional sessions of home exercise advice achieved results that were, for all practical purposes, equal to the manipulation group. Despite the fact that a New York Times article about this study was published under the headline “For Neck Pain, Chiropractic and Exercise Are Better Than Drugs” a closer analysis leads to a far more guarded set of conclusions.
	Elevated Production of Inflammatory Mediators Including Nociceptive Chemokines in Patients With Neck Pain: A Cross-Sectional Evaluation J Manipulative Physiol Ther. 2011 (Oct); 34 (8): 498–505 ~ FULL TEXT Production of inflammatory mediators was consistently elevated in NP patients in this study, both in vitro and in vivo, and activation of inflammatory pathways was accompanied by up-regulation of CC chemokine synthesis. This suggests that, in NP patients, CC chemokines may be involved in regulation of local inflammatory response through recruitment of immune cells to the inflamed tissue and exert pronociceptive effects.
	Chiropractic Management for Veterans with Neck Pain: A Retrospective Study of Clinical Outcomes J Manipulative Physiol Ther 2011 (Oct); 34 (8): 533–538 ~ FULL TEXT This study provides a retrospective review of clinical outcomes for a sample of veterans with neck pain within a VHA chiropractic clinic. Despite the levels of service-connected disability and comorbidity among this sample of veteran patients seeking care for neck pain, mean clinical outcomes were considered to be both statistically significant and clinically meaningful. Although retrospective design-based limitations are identified, this study serves as a foundation for further research and provides the most extensive account to date of chiropractic clinical outcomes for veteran patients with neck pain.
	Application of a Diagnosis-Based Clinical Decision Guide in Patients with Neck Pain Chiropractic & Manual Therapies 2011 (Aug 27); 19 (1): 19 ~ FULL TEXT The DBCDG can be applied in a busy private practice environment. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, oculomotor dysfunction, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as interexaminer reliability, validity and efficacy of treatment based on the DBCDG.
	The Trials of Evidence: Interpreting Research and the Case for Chiropractic The Chiropractic Report ~ July 2011 ~ FULL TEXT For the great majority of patients with both acute and chronic low-back pain, namely those without diagnostic red flags, spinal manipulation is recommended by evidence-informed guidelines from many authoritative sources – whether chiropractic (the UK Evidence Report from Bronfort, Haas et al. [1]), medical (the 2007 Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society [2]) or interdisciplinary (the European Back Pain Guidelines [3]).
	Neck and Back Pain in Children: Prevalence and Progression Over Time Musculoskelet Disord. 2011 (May 16); 12: 98 ~ FULL TEXT The following article appears to be the first study to track and review the progression of back pain in the same group of children, over a prolonged period, to see how (or if) it is a contributor to those same complains in adulthood. Of particular interest is Table 2, because it breaks down and tracks complaints of either neck, mid back, or low back pain in the same group of children at 3 different time periods: ages 9, 13 and 15 years old.
	Predictors for Identifying Patients with Mechanical Neck Pain Who Are Likely to Achieve Short-Term Success with Manipulative Interventions Directed at the Cervical and Thoracic Spine J Manipulative Physiol Ther 2011 (Mar); 34 (3): 144–152 ~ FULL TEXT The current study identified several prognostic clinical factors including pain intensity greater than 4.5 points, cervical extension less than 46°, hypomobility of T1 vertebra, a negative ULTT, and female sex that may potentially identify patients with mechanical neck pain who are likely to experience a rapid and positive response to the application of cervical and thoracic spine thrust manipulations. If 4 of 5 variables were present (LR+, 1.9), the likelihood of success increased from 61.7% to 86.3%.
	A Randomised Controlled Trial of Preventive Spinal Manipulation with and without a Home Exercise Program For Patients with Chronic Neck Pain   NCT00566930 BMC Musculoskelet Disord. 2011 (Feb 8); 12: 41 ~ FULL TEXT This study hypothesised that participants in the combined intervention group would have less pain and disability and better function than participants from the 2 other groups during the preventive phase of the trial. This hypothesis was not supported by the study results. Lack of a treatment specific effect is discussed in relation to the placebo and patient provider interactions in manual therapies. Further research is needed to delineate the specific and non-specific effects of treatment modalities to prevent unnecessary disability and to minimise morbidity related to NCNP. Additional investigation is also required to identify the best strategies for secondary and tertiary prevention of NCNP.
	Consequences of Spinal Pain: Do Age and Gender Matter? A Danish Cross-sectional Population-based Study of 34,902 Individuals 20-71 Years of Age BMC Musculoskelet Disord. 2011 (Feb 8); 12: 39 ~ FULL TEXT Almost two-thirds of individuals with spinal pain did not report any consequence. Generally, consequences due to LBP were more frequently reported than those due to NP or MBP. Regardless of area of complaint, care seeking and reduced physical activities were the most commonly reported consequences, followed by sick-leave, change of work, and disability pension. There was a small mid-life peak for care-seeking and a slow general increase in reduced activities with increasing age. Increasing age was not associated with a higher reporting of sick-leave but the duration of the sick-leave increased somewhat with age. Disability pension due to spinal pain was reported exceedingly rare before the age of 50. Typically, women slightly more often than men reported some kind of consequences due to spinal pain.
	Management of Neck Pain in Royal Australian Air Force Fast Jet Aircrew Military Medicine 2011 (Jan); 176 (1): 106–109 ~ FULL TEXT Eighty-two RAAF FJ aircrew responded to the survey. Ninety-five percent of the respondents experienced flight-related neck pain. The most commonly sought treatment modalities were on-base medical and physiotherapy services. Many respondents reported that currently provided on-base treatment and ancillary services such as chiropractic therapy are the most effective in alleviating symptoms.
	The Cervical Flexion-Relaxation Ratio: Reproducibility and Comparison Between Chronic Neck Pain Patients and Controls Spine (Phila Pa 1976). 2010 (Nov 15); 35 (24): 2103–2108 The cervical extensor muscles exhibit a consistent flexion-relaxation (FFR) phenomenon in healthy control subjects and the measurement is highly reproducible when measured 4 weeks apart in both controls and chronic neck pain patients. The FRR in neck pain patients is significantly higher than in control subjects suggesting that this measure may be a useful marker of altered neuromuscular function.
	Manual Therapy and Exercise for Neck Pain: A Systematic Review Manual Therapy 2010 (Aug); 15 (4): 334–354 Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias.
	Manipulation or Mobilisation For Neck Pain: A Cochrane Review Manual Therapy 2010 (Aug); 15 (4): 315–333 Moderate quality evidence showed cervical manipulation and mobilisation produced similar effects on pain, function and patient satisfaction at intermediate-term follow-up. Low quality evidence suggested cervical manipulation may provide greater short-term pain relief than a control (pSMD -0.90 (95%CI: -1.78 to -0.02)). Low quality evidence also supported thoracic manipulation for pain reduction (NNT 7; 46.6% treatment advantage) and increased function (NNT 5; 40.6% treatment advantage) in acute pain and immediate pain reduction in chronic neck pain (NNT 5; 29% treatment advantage). Optimal technique and dose need to be determined.
	Assessment of Patients With Neck Pain: A Review of Definitions, Selection Criteria, and Measurement Tools J Chiropractic Medicine 2010 (Jun); 9 (2): 49–59 ~ FULL TEXT The introduction of evidence-based practice in the last years of the 20th century stimulated the development and research of an enormous number of instruments to assess many types of patient variables. [1] Now, more rehabilitation professionals are familiarizing themselves with the use of outcome measures in clinical practice and for research purposes. [2, 3] Outcomes assessment is primarily designed to establish baselines, to evaluate the effect of an intervention, to assist in goal setting, and to motivate patients to evaluate their treatment. [4, 5] When used in a clinical setting, it can enhance clinical decision making and improve quality of care. [6] Many patients with neck pain visit health care clinics seeking treatment of their problem, and health professionals aim to use the best available evidence for making decisions about therapy. The best evidence comes from randomized clinical trials, systematic reviews, and evidence-based clinical practice guidelines. [7]
	Altered Central Integration of Dual Somatosensory Input After Cervical Spine Manipulation J Manipulative Physiol Ther. 2010 (Mar); 33 (3): 178–188 ~ FULL TEXT This study suggests that cervical spine manipulation may alter cortical integration of dual somatosensory input. These findings may help to elucidate the mechanisms responsible for the effective relief of pain and restoration of functional ability documented after spinal manipulation treatment.
	Effectiveness of Manual Therapies: The UK Evidence Report Chiropractic & Osteopathy 2010 (Feb 25); 18 (1): 3 ~ FULL TEXT Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.
	Commentary on the United Kingdom Evidence Report About the Effectiveness of Manual Therapies Chiropractic & Osteopathy 2010 (Feb 25); 18 (1): 4 ~ FULL TEXT This is an accompanying commentary on the article by Gert Bronfort and colleagues about the effectiveness of manual therapy. The two commentaries were provided independently and combined into this single article by the journal editors.
	Do Chiropractic Physician Services for Treatment of Low-Back and Neck Pain Improve the Value of Health Benefit Plans? An Evidence-Based Assessment of Incremental Impact on Population Health and Total Health Care Spending Mercer Health and Benefits LLC ~ October 12, 2009 ~ FULL TEXT This report combined a rigorous analysis of direct and indirect costs with equally relevant (though often missing from such analyses) evidence concerning clinical effectiveness. In other words, Choudhry and Milstein started with the assumption that low cost is only a virtue if a product or service effectively delivers what it promises. Including both clinical effectiveness and cost in their analysis, they concluded that chiropractic care was far more valuable than medical treatment for neck and low back pain.

The Bone and Joint Decade 2000–2010 Task Force

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The Bone and Joint Decade 2000–2010 Task Force on Neck Pain And Its Associated Disorders: Executive Summary J Manipulative Physiol Ther. 2009 (Feb); 32 (2 Suppl): S7–S9 ~ FULL TEXT The prognosis for neck pain also appears to be multifactorial. Younger age was associated with a better prognosis, whereas poor health and prior neck pain episodes were associated with a poorer prognosis. Poorer prognosis was also associated with poor psychological health, worrying, and becoming angry or frustrated in response to neck pain. Greater optimism, a coping style that involved self-assurance, and having less need to socialize, were all associated with better prognosis. A number of nonsurgical treatments appeared to be more beneficial than usual care, sham, or alternative interventions but none of the active treatments were clearly superior to any other in the short or long term. Educational videos, mobilization, manual therapy, exercises, low-level laser therapy, and perhaps acupuncture appeared to have some benefit. For both WAD and other neck pain without radicular symptoms, interventions that focused on regaining function and returning to work as soon as possible were relatively more effective than interventions that did not have such a focus.

The Empowerment of People With Neck Pain: Introduction The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders J Manipulative Physiol Ther. 2009 (Feb); 32 (2 Suppl): S10-S16 ~ FULL TEXT It is difficult to predict the impact of the work done by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders. Some of the sponsoring professional associations may endorse the findings and recommendations or incorporate specific recommendations into their own guidelines for clinical practice. Other professional groups or advocacy groups may feel that the findings of the Neck Pain Task Force are not compatible with their own perceptions regarding neck pain. One might look back at what happened in 1995 immediately after the publication of similar task force findings — specifically those from the Quebec Task Force on Whiplash Associated Disorders and from the Agency for Health Care Policy and Research on Acute Low Back Pain. These publications prompted considerable discussion and also some controversy over recommendations and conclusions. It is expected that government and insurance companies will take into account the recommendations of the Neck Pain Task Force when considering public policy decisions. However, these recommendations should not be considered prescriptive. Nor should they be interpreted in isolation by those determining such issues as reimbursement or public health policy.

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A New Conceptual Model Of Neck Pain: Linking Onset, Course, And Care: The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders J Manipulative Physiol Ther. 2009 (Feb); 32 (2 Suppl): S17–28 ~ FULL TEXT This article describes the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) conceptual model for the onset, course, and care of neck pain. We start with the scope and rationale for proposing a new conceptual model, followed by its purposes and premises. After describing the model's components and associated case definitions, we conclude with a discussion on implications of the model.

Methods for the Best Evidence Synthesis on Neck Pain and its Associated Disorders: The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders J Manipulative Physiol Ther. 2009 (Feb); 32 (2): S39–S45 ~ FULL TEXT In 1995, the Québec Task Force on Whiplash-Associated Disorders released the first systematic review of the literature on whiplash injuries. That endeavor produced a baseline of the information on the subject. [1] However, that group's mandate was focused specifically on whiplash injuries and did not permit consideration of neck pain resulting from occupational injuries/strains, or consideration of neck pain in the general population. It is also important to note that much new data on whiplash has been published in the intervening 12 years. The authors of the 1995 Québec Task Force suggested that the next review of the literature should take place within 5 years. In 2000, we assembled an international task force of scientist/clinicians and methodologists, under the auspices of the Bone and Joint Decade 2000–2010. The mandate of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) was to make recommendations that would culminate in reducing the medical, social, and economic consequences of neck pain and its associated disorders.

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The Burden and Determinants of Neck Pain in the General Population: Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders J Manipulative Physiol Ther. 2009 (Feb); 32 (2 Suppl): S46–S60 ~ FULL TEXT The annual cumulative incidence of WAD differed substantially between countries. They found that occupant seat position and collision impact direction were associated with WAD in one study. Eliminating insurance payments for pain and suffering were associated with a lower incidence of WAD injury claims in one study. Younger ages and being a female were both associated with filing claims or seeking care for WAD, although the evidence is not consistent. Preliminary evidence suggested that headrests/car seats, aimed to limiting head extension during

Course and Prognostic Factors for Neck Pain in the General Population: Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders J Manipulative Physiol Ther. 2009 (Feb); 32 (2 Suppl): S87–S96 ~ FULL TEXT The evidence suggests that approximately 50% of those with WAD will report neck pain symptoms 1 year after their injuries. Greater initial pain, more symptoms, and greater initial disability predicted slower recovery. Few factors related to the collision itself (for example, direction of the collision, headrest type) were prognostic; however, postinjury psychological factors such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery. There is also preliminary evidence that the prevailing compensation system is prognostic for recovery in WAD.

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The Burden and Determinants of Neck Pain in Workers: Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders J Manipulative Physiol Ther. 2009 (Feb); 32 (2 Suppl): S70-86 ~ FULL TEXT One hundred and nine papers on the burden and determinants of neck pain in workers were scientifically admissible. The annual prevalence of neck pain varied from 27.1% in Norway to 47.8% in Québec, Canada. Each year, between 11% and 14.1% of workers were limited in their activities because of neck pain. Risk factors associated with neck pain in workers include age, previous musculoskeletal pain, high quantitative job demands, low social support at work, job insecurity, low physical capacity, poor computer workstation design and work posture, sedentary work position, repetitive work and precision work. We found preliminary evidence that gender, occupation, headaches, emotional problems, smoking, poor job satisfaction, awkward work postures, poor physical work environment, and workers' ethnicity may be associated with neck pain. There is evidence that interventions aimed at modifying workstations and worker posture are not effective in reducing the incidence of neck pain in workers.

Course and Prognostic Factors for Neck Pain in Workers: Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders J Manipulative Physiol Ther. 2009 (Feb); 32 (2 Sup): S108–116 ~ FULL TEXT We found 226 articles related to course and prognostic factors in neck pain and its associated disorders. After a critical review, 70 (31%) were accepted on scientific merit; 14 of these studies related to course and prognostic factors in working populations. Between 60% and 80% of workers with neck pain reported neck pain 1 year later. Few workplace or physical job demands were identified as being linked to recovery from neck pain. However, workers with little influence on their own work situation had a slightly poorer prognosis, and white-collar workers had a better prognosis than blue-collar workers. General exercise was associated with better prognosis; prior neck pain and prior sick leave were associated with poorer prognosis.

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The Burden and Determinants of Neck Pain in Whiplash-associated Disorders After Traffic Collisions: Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders J Manipulative Physiol Ther. 2009 (Feb); 32 (2 Suppl): S61-69 ~ FULL TEXT The authors found 32 scientifically admissible studies related to the burden and determinants of WAD. In the Western world, visits to emergency rooms due to WAD have increased over the past 30 years. The annual cumulative incidence of WAD differed substantially between countries. They found that occupant seat position and collision impact direction were associated with WAD in one study. Eliminating insurance payments for pain and suffering were associated with a lower incidence of WAD injury claims in one study. Younger ages and being a female were both associated with filing claims or seeking care for WAD, although the evidence is not consistent. Preliminary evidence suggested that headrests/car seats, aimed to limiting head extension during rear-end collisions had a preventive effect on reporting WAD, especially in females.

Course and Prognostic Factors for Neck Pain in Whiplash-associated Disorders (WAD): Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders J Manipulative Physiol Ther. 2009 (Feb); 32 (2 Sup): S97–107 ~ FULL TEXT We found 226 articles related to course and prognostic factors in neck pain and its associated disorders. After a critical review, 70 (31%) were accepted on scientific merit; 47 of these studies related to course and prognostic factors in WAD. The evidence suggests that approximately 50% of those with WAD will report neck pain symptoms 1 year after their injuries. Greater initial pain, more symptoms, and greater initial disability predicted slower recovery. Few factors related to the collision itself (for example, direction of the collision, headrest type) were prognostic; however, postinjury psychological factors such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery. There is also preliminary evidence that the prevailing compensation system is prognostic for recovery in WAD.

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	Assessment of Neck Pain and Its Associated Disorders: Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders J Manipulative Physiol Ther. 2009 (Feb); 32 (2 Suppl): S117–S140 ~ FULL TEXT We found 359 articles on assessment of neck pain. After critical review, 95 (35%) were judged scientifically admissible. Screening protocols have high predictive values to detect cervical spine fracture in alert, low-risk patients seeking emergency care after blunt neck trauma. Computerized tomography (CT) scans had better validity (in adults and elderly) than radiographs in assessing high-risk and/or multi-injured blunt trauma neck patients. In the absence of serious pathology, clinical physical examinations are more predictive at excluding than confirming structural lesions causing neurologic compression. One exception is the manual provocation test for cervical radiculopathy, which has high positive predictive value. There was no evidence that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure. No evidence supports using cervical provocative discography, anesthetic facet, or medial branch blocks in evaluating neck pain. Reliable and valid self-report questionnaires are useful in assessing pain, function, disability, and psychosocial status in individuals with neck pain.
	Treatment of Neck Pain: Noninvasive Interventions: Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders J Manipulative Physiol Ther. 2009 (Feb); 32 (2 Suppl): S141–S175 ~ FULL TEXT For whiplash-associated disorders, there is evidence that educational videos, mobilization, and exercises appear more beneficial than usual care or physical modalities. For other neck pain, the evidence suggests that manual and supervised exercise interventions, low-level laser therapy, and perhaps acupuncture are more effective than no treatment, sham, or alternative interventions; however, none of the active treatments was clearly superior to any other in either the short- or long-term. For both whiplash-associated disorders and other neck pain without radicular symptoms, interventions that focused on regaining function as soon as possible are relatively more effective than interventions that do not have such a focus.
	Treatment of Neck Pain: Injections and Surgical Interventions: Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders J Manipulative Physiol Ther. 2009 (Feb); 32 (2 Suppl): S176–193 ~ FULL TEXT Of the 31,878 articles screened, 1203 studies were relevant to the Neck Pain Task Force mandate and of these, 31 regarding treatment by surgery or injections were accepted as scientifically admissible. Radiofrequency neurotomy, cervical facet injections, cervical fusion and cervical arthroplasty for neck pain without radiculopathy are not supported by current evidence. We found there is support for short-term symptomatic improvement of radicular symptoms with epidural corticosteroids. It is not clear from the evidence that long-term outcomes are improved with the surgical treatment of cervical radiculopathy compared to nonoperative measures. However, relatively rapid and substantial symptomatic relief after surgical treatment seems to be reliably achieved. It is not evident that one open surgical technique is clearly superior to others for radiculopathy. Cervical foramenal or epidural injections are associated with relatively frequent minor adverse events (5%-20%); however, serious adverse events are very uncommon (<1%). After open surgical procedures on the cervical spine, potentially serious acute complications are seen in approximately 4% of patients.
	Clinical Practice Implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: From Concepts and Findings to Recommendations J Manipulative Physiol Ther. 2009 (Feb); 32 (2): S227–S243 ~ FULL TEXT The Neck Pain Task Force recommends that people seeking care for neck pain should be triaged into 4 groups: Grade I neck pain with no signs of major pathology and no or little interference with daily activities; Grade II neck pain with no signs of major pathology, but interference with daily activities; Grade III neck pain with neurologic signs of nerve compression; Grade IV neck pain with signs of major pathology. In the emergency room after blunt trauma to the neck, triage should be based on the NEXUS criteria or the Canadian C-Spine Rule. Those with a high risk of fracture should be further investigated with plain radiographs and/or CT-scan. In ambulatory primary care, triage should be based on history and physical examination alone, including screening for red flags and neurologic examination for signs of radiculopathy. Exercises and mobilization have been shown to provide some degree of short-term relief of Grade I or Grade II neck pain after a motor vehicle collision. Exercises, mobilization, manipulation, analgesics, acupuncture, and low-level laser have been shown to provide some degree of short-term relief of Grade I or Grade II neck pain without trauma. Those with confirmed Grade III and severe persistent radicular symptoms might benefit from corticosteroid injections or surgery. Those with confirmed Grade IV neck pain require management specific to the diagnosed pathology.

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Research Priorities and Methodological Implications: The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders J Manipulative Physiol Ther. 2009 (Feb); 32 (2): S227–S243 ~ FULL TEXT We outline a large number of gaps in the current literature. For example, we found important gaps in our knowledge about neck pain in children (risk factors, screening criteria to rule out serious injury, management, course and prognosis); and in the prevention of neck pain-related activity limitations. Few studies addressed the impact of culture or social policies (such as governmental health policies or insurance compensation policies) on neck pain. A number of important questions remain about the effectiveness of commonly used interventions for neck pain.

End of Bone and Joint Decade 2000–2010 Task Force

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	Rehabilitation Program for Traumatic Chronic Cervical Pain Associated With Unsteadiness: A Single Case Study Chiropractic & Osteopathy 2008 (Nov 17); 16 (1): 15 ~ FULL TEXT This case report indicates that an 8-week rehabilitation program combining therapeutic exercises with spinal manipulative therapy may have had an effect on improvement of postural control in a trauma Chronic Neck Pain patient with unsteadiness. These results warrant further studies to investigate the relationships between pain amelioration, sensorimotor control of the cervical spine, muscle fitness and postural steadiness.
	Recognizing the Value of Chiropractic for Chronic Pain Dynamic Chiropractic (September 23, 2008) The guidelines actually recommend manipulation for chronic, persistent low back or neck pain and cervicogenic headache. [2] This is significant because in the past, the guidelines failed to recommend manipulation, even when other treatment strategies (medication, etc.) were rated as less effective.
	A Diagnosis-based Clinical Decision Rule For Spinal Pain Part 2: Review Of The Literature Chiropractic & Osteopathy 2008 (Aug 11); 16: 7 ~ FULL TEXT Accurate diagnosis or classification of patients with spinal pain has been identified as a research priority [1]. We presented in Part 1 the theoretical model of an approach to diagnosis in patients with spinal pain [2]. This approach incorporated the various factors that have been found, or in some cases theorized, to be of importance in the generation and perpetuation of neck or back pain into an organized scheme upon which a management strategy can be based. The authors termed this approach a diagnosis-based clinical decision rule (DBCDR). The DBCDR is not a clinical prediction rule. It is an attempt to identify aspects of the clinical picture in each patient that are relevant to the perpetuation of pain and disability so that these factors can be addressed with interventions designed to improve them. The purpose of this paper is to review the literature on the methods involved in the DBCDR regarding reliability and validity and to identify those areas in which the literature is currently lacking.
	Predictors For Immediate and Global Responses to Chiropractic Manipulation of the Cervical Spine J Manipulative Physiol Ther 2008 (Mar); 31 (3): 172–183 ~ FULL TEXT This study is the first attempt to identify variables that can predict immediate outcomes in terms of improvement and worsening of presenting symptoms, and global improvement, after cervical spine manipulation. From the findings, it was possible to identify some predictors of immediate improvement in presenting symptoms after cervical spine manipulation. Patients presenting with symptoms of “reduced neck, shoulder, arm movement, stiffness,” “neck pain,” “upper, mid back pain,” “headache,” “shoulder, arm pain,” and/or “none or one presenting symptom only” are likely to report immediate improvement in these symptoms after treatment. Patients presenting with any 4 of these symptoms were shown to have the highest probability of immediate improvement. This finding may enhance clinical decision making for selecting cervical manipulation in the treatment of patients with one or more of these complaints. Although it was possible to identify a number of predictor variables for immediate worsening in presenting symptoms and global improvement after cervical spine manipulation, these failed to provide a robust predictive model for clinical application.
	Chiropractic and Exercise for Seniors With Low Back Pain or Neck Pain: The Design of Two Randomized Clinical Trials   NCT00269308   and   NCT00269321 BMC Musculoskelet Disord. 2007 (Sep 18); 8: 94 ~ FULL TEXT To our knowledge, these are the first randomized clinical trials to comprehensively address clinical effectiveness, cost-effectiveness, and patients' perceptions of commonly used treatments for elderly LBP and NP sufferers. This article presents the rationale and design of two mixed methods clinical trials, each consisting of an RCT, with cost-effectiveness and qualitative studies conducted alongside the central trial. Both are anticipated to be completed in 2007, at which time the results will be made available.
	The Benefits Outweigh the Risks for Patients Undergoing Chiropractic Care for Neck Pain: A Prospective, Multicenter, Cohort Study J Manipulative Physiol Ther 2007 (Jul); 30 (6): 408–418 ~ FULL TEXT In contrast to clinical trials of prescription medication, researchers in the area of conservative care for musculoskeletal complaints have focused their attention on treatment effectiveness and, to a much lesser degree, on adverse events. This study, consisting of patients treated in a wide variety of chiropractic practices and settings, describes both positive and negative, and short- and long-term clinical outcomes for a relatively large study population with neck pain. Although many of the subjects (in this study) had chronic, recurrent neck pain and had undergone prior care for this complaint, many patients experienced benefit from the treatment (based upon diminished pain and disability, the percentage of patients recovered and percentage satisfied with care). Furthermore, many responded relatively quickly to treatment (48% were recovered at the fourth visit).
	Conservative Management of Mechanical Neck Disorders: A Systematic Review J Rheumatol 2007 (May); 34 (5): 1083–1102 In a review of 88 unique RCTs, the authors found that “Exercise combined with mobilization/manipulation, exercise alone, and intramuscular lidocaine for chronic MND; intravenous glucocorticoid for acute whiplash associated disorders; and low-level laser therapy demonstrated either intermediate or longterm benefits. Optimal dosage of effective techniques and prognostic indicators for responders to care should be explored in future research.”
	Neck and Shoulder Pains in Relation to Physical Activity and Sedentary Activities in Adolescence Spine 2007 (Apr 20); 32 (9): 1038–1044 Almost half of the girls and one third of the boys reported mild neck or occipital pain, or shoulder pain, and 3% of girls and 2% of boys reported severe neck or occipital pain, or shoulder pain during the past 6 months. High-level physical activity associated with an increased prevalence of both severe neck or occipital pain and severe shoulder pain in girls, but not in boys. Prolonged sitting was associated with a high prevalence of neck or occipital pain and shoulder pain in girls, and neck or occipital pain in boys. Of various sedentary activities, television watching and reading books associated with neck or occipital pain in girls, whereas playing or working with a computer associated with neck or occipital pain in boys. In girls, television watching also associated with mild shoulder pain.
	Chronic Mechanical Neck Pain in Adults Treated by Manual Therapy: A Systematic Review of Change Scores in Randomized Clinical Trials J Manipulative Physiol Ther 2007 (Mar); 30 (3): 215–227 ~ FULL TEXT There is moderate- to high-quality evidence that subjects with chronic neck pain not due to whiplash and without arm pain and headaches show clinically important improvements from a course of spinal manipulation or mobilization at 6, 12, and up to 104 weeks posttreatment. The current evidence does not support a similar level of benefit from massage.
	Cervical Spine Manipulation Alters Sensorimotor Integration: A Somatosensory Evoked Potential Study Clin Neurophysiol. 2007 (Feb); 118 (2): 391–402 Spinal manipulation of dysfunctional cervical joints can lead to transient cortical plastic changes, as demonstrated by attenuation of cortical somatosensory evoked responses. This study suggests that cervical spine manipulation may alter cortical somatosensory processing and sensorimotor integration. These findings may help to elucidate the mechanisms responsible for the effective relief of pain and restoration of functional ability documented following spinal manipulation treatment.
	Development of a Clinical Prediction Rule for Guiding Treatment of a Subgroup of Patients with Neck Pain: Use of Thoracic Spine Manipulation, Exercise, and Patient Education Phys Ther. 2007 (Jan); 87 (1): 9–23 ~ FULL TEXT The clinical prediction rule (CPR) provides the ability to a priori identify patients with neck pain who are likely to experience early success with thoracic spine thrust manipulation. However, future studies are necessary to validate the rule.
	The Impact of Psychosocial Factors on Neck Pain and Disability Outcomes Among Primary Care Patients: Results from the UCLA Neck Pain Study Disabil Rehabil 2006 (Nov 15); 28 (21): 1319–1329 Of 960 eligible patients, 336 were enrolled and 80% were followed up through 6 months. Coping strategies involving self-assurance resulted in better disability outcomes, whereas getting angry or frustrated resulted in worse pain and disability outcomes. Participants with high levels of social support from individuals were more likely to experience clinically meaningful reductions in pain and disability. No consistent relations of internal health locus of control, and physical and psychological job demands with improvements in pain and disability were detected.
	Immediate Effects on Neck Pain and Active Range of Motion After a Single Cervical High-velocity Low-amplitude Manipulation in Subjects Presenting with Mechanical Neck Pain: A Randomized Controlled Trial J Manipulative Physiol Ther 2006 (Sep); 29 (7): 511–517 ~ FULL TEXT A group of 70 patients with neck pain (25 males and 45 females, ages 20-55 years) participated in this study. The lateral gliding test was used to establish an intervertebral joint dysfunction at the C3 through C4 or C4 through C5 levels. The subjects were randomly divided into either an experimental group, which received an HVLA thrust, or a control group, which received manual mobilization. Results suggest that a single cervical HVLA manipulation is more effective in reducing neck pain at rest, and in increasing active cervical range of motion, than a control mobilization procedure in subjects suffering from mechanical neck pain.
	Back and Neck Pain in Seniors- Prevalence and Impact European Spine Journal 2006 (Jun); 15 (6): 802–806~ FULL TEXT Neck pain (NP) and back pain (BP) are common symptoms in old age and 10–20% of persons over 70 reports moderate or severe NP or BP on a monthly basis. Overall, older women report more BP and NP than older men. Altering or diminishing physical activities and seeking of treatment due to NP or BP are relatively common in the older age groups, again especially among women. 1–year prevalence estimates of NP and BP in seniors may suffer from recall bias.
	Chronic Neck Pain And Whiplash: A Case-control Study of the Relationship Between Acute Whiplash Injuries and Chronic Neck Pain Pain Res Manag. 2006 (Summer); 11 (2): 79–83 Patients were defined as individuals with chronic neck pain, and controls as those with chronic back pain. The two groups were surveyed for cause of chronic pain as well as demographic information. The two groups were compared using an exposure-odds ratio. Forty-five per cent of the patients attributed their pain to a motor vehicle accident. An OR of 4.0 and 2.1 was calculated for men and women, respectively. Based on the results of the present study, it reasonable to infer that a significant proportion of individuals with chronic neck pain in the general population were originally injured in a motor vehicle accident.
	Symptomatic Outcomes and Perceived Satisfaction Levels of Chiropractic Patients with a Primary Diagnosis Involving Acute Neck Pain J Manipulative Physiol Ther 2006 (May); 29 (4): 288–296 ~ FULL TEXT A total of 115 patients were contacted, of whom 94 became study participants, resulting in 60 women (64%) and 34 men. The mean age was 39.6 years (SD, 15.7). The mean number of visits was 24.5 (SD, 21.2). Pain levels improved significantly from a mean of 7.6 (median, 8.0) before treatment to 1.9 (median, 2.0) after treatment (P < .0001). The overall patient satisfaction rate was 94%.
	Return to Work After Two Years of Total Disability: A Case Report J Occup Rehabil 2006 (Jun 3): 16 (2): 247–254 This paper describes the conservative management of a patient who was disabled from work for 2 years, using an integrated approach including chiropractic manipulation, pain education, restricted duty and clear communications among all parties involved. After 15 weeks, the patient returned to her previous occupation as a nurse, first part time, and subsequently full time. There are more articles like this in our Case Studies Section.
	Improvement After Chiropractic Care in Cervicocephalic Kinesthetic Sensibility nd Subjective Pain Intensity in Patients with Nontraumatic Chronic Neck Pain J Manipulative Physiol Ther 2006 (Feb); 29 (2): 100–106 ~ FULL TEXT There was no difference between the treatment patients and the control subjects at the beginning with regard to age, sex, subjective pain intensity, range of motion, and HRA. At the 5-week follow-up, the treatment patients showed significant reductions in pain and improvement of all HRA aspects measured whereas the control subjects did not show any reduction in pain and improvement in only one HRA aspect. The results of this study suggest that chiropractic care can be effective in influencing the complex process of proprioceptive sensibility and pain of cervical origin. Short, specific chiropractic treatment programs with proper patient information may alter the course of chronic cervical pain.

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Chronic Spinal Pain: Spinal Manipulation vs. Acupuncture vs. Meds - A Brilliant Series of 3 Research Studies The Pilot Study (1999) Chronic Spinal Pain Syndromes: A Clinical Pilot Trial Comparing Acupuncture, A Nonsteroidal Anti-inflammatory Drug, and Spinal Manipulation J Manipulative Physiol Ther 1999 (Jul); 22 (6): 376-381 ~ FULL TEXT Randomization was successful. After a median intervention period of 30 days, spinal manipulation was the only intervention that achieved statistically significant improvements (all expressed as percentages of the original scores) with (1) a reduction of 30.7% on the Oswestry scale, (2) an improvement of 25% on the neck disability index, and (3) reductions on the visual analogue scale of 50% for low back pain, 46% for upper back pain, and 33% for neck pain (all P<.001). Neither of the other interventions showed any significant improvement on any of the outcome measures. The Trial (2003) Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation Spine (Phila Pa 1976) 2003 (Jul 15); 28 (14): 1490-1502 Randomization proved to be successful. The highest proportion of early (asymptomatic status) recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%). Manipulation achieved the best overall results, with improvements of 50% (P = 0.01) on the Oswestry scale, 38% (P = 0.08) on the NDI, 47% (P < 0.001) on the SF-36, and 50% (P < 0.01) on the VAS for back pain, 38% (P < 0.001) for lumbar standing flexion, 20% (P < 0.001) for lumbar sitting flexion, 25% (P = 0.1) for cervical sitting flexion, and 18% (P = 0.02) for cervical sitting extension. However, on the VAS for neck pain, acupuncture showed a better result than manipulation (50% vs 42%). The Long-term Follow-up (2005) Long-Term Follow-up of a Randomized Clinical Trial Assessing the Efficacy of Medication, Acupuncture, and Spinal Manipulation for Chronic Mechanical Spinal Pain Syndromes J Manipulative Physiol Ther 2005 (Jan); 28 (1): 3-11 ~ FULL TEXT The results of this “fastidious” approach were able to add some information regarding the efficacy of treatment regimens in patients with chronic spinal pain syndromes. Overall, patients who have chronic mechanical spinal pain syndromes and received spinal manipulation gained significant broad-based beneficial short-term and long-term outcomes. For patients receiving acupuncture, consistent improvements were also observed, although without reaching statistical significance (with a single exception). For patients receiving medication, the findings were less favorable. Larger studies are now clearly justified. End of the Trial Series

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	Effects of a Managed Chiropractic Benefit on the Use of Specific Diagnostic and Therapeutic Procedures in the Treatment of Low Back and Neck Pain J Manipulative Physiol Ther 2005 (Oct); 28 (8): 564–569 ~ FULL TEXT For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a significant reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.
	Exercises for Mechanical Neck Disorders Cochrane Database Syst Rev 2005 (Jul 20); 3: CD004250 The evidence summarised in this systematic review indicates that specific exercises may be effective for the treatment of acute and chronic MND, with or without headache. To be of benefit, a stretching and strengthening exercise program should concentrate on the musculature of the cervical, shoulder-thoracic area, or both. A multimodal care approach of exercise, combined with mobilisation or manipulation for subacute and chronic MND with or without headache, reduced pain, improved function, and global perceived effect in the short and long term.
	Cervicogenic Head and Neck Pain in the ENT Clinic HNO 2005 (May 11) It is discussed controversially whether cervicogenic pain in the head and/or neck is a pathogenic entity. The good results obtained with manual therapy in patients with head and neck pain contradict the refusal of the majority of the neurologists to accept the diagnosis "cervicogenic headache." Complaints about headache are frequently encountered in the general ENT clinic. The versatile picture of the cervicogenic headache is caused by the complex neural connections in the region of the upper cervical spine. The differential diagnosis of the cervicogenic headache is described.
	Determining the Relationship Between Cervical Lordosis and Neck Complaints J Manipulative Physiol Ther 2005 (Mar); 28 (3): 187-193 ~ FULL TEXT In a study of 277 lateral cervical x-rays, patients with lordosis of 20° or less were more likely to have cervicogenic symptoms (P < .001). The association between cervical pain and lordosis of 0° or less was significant (P < .0001). The odds that a patient with cervical pain had a lordosis of 0° or less was 18 times greater than for a patient with a noncervical complaint. Patients with cervical pain had less lordosis and this was consistent over all age ranges. There are more articles like this in our: Spinal Alignment or Cervical Curve Page.
	Chronic Pain in Persons With Neuromuscular Disease Clin J Pain 2005 (Jan); 21 (1): 18–26 ~ FULL TEXT In this paper, researchers in a medical school rehabilitation department were interested in finding out what treatments were most effective at reducing pain for neuromuscular diseases (like amyotrophic lateral sclerosis and myotonic muscular dystrophies). Chiropractic scored the highest pain relief rating (7.33 out of 10), scoring higher than the relief provided by either nerve blocks (6.75) or opioid analgesics (6.37). WOW!!!
	A Clinical Model for the Diagnosis and Management of Patients with Cervical Spine Syndromes Australasian Chiropractic & Osteopathy 2004 (Nov); 12 (2): 57–71 ~ FULL TEXT Neck pain and related disorders are a group of conditions that are common and often disabling. It can be argued that the importance of these disorders is under-appreciated. Because of the prevalence of low back pain and its great cost to society, much clinical attention and research dollars are focused on the low back. But epidemiological research suggests that cervical related disorders are as common and may be more costly to society than low back disorders. [1-4]
	Dose Response for Chiropractic Care of Chronic Cervicogenic Headache and Associated Neck Pain: A Randomized Pilot Study J Manipulative Physiol Ther 2004 (Nov); 27 (9): 547—553 ~ FULL TEXT Patients were randomly allocated to 1, 3, or 4 visits per week for 3 weeks. All patients received high-velocity low-amplitude spinal manipulation. Doctor of Chiropractics could apply up to 2 physical modalities at each visit from among heat and soft tissue therapy. They could also recommend modification of daily activities and rehabilitative exercises. A large clinical trial on the relationship between pain relief and the number of chiropractic treatments is feasible. Findings give preliminary support for the benefit of larger doses, 9 to 12 treatments, of chiropractic care for the treatment of cervicogenic headache.
	Patients With Neck Pain Demonstrate Reduced Electromyographic Activity of the Deep Cervical Flexor Muscles During Performance of the Craniocervical Flexion Test Spine (Phila Pa 1976). 2004 (Oct 1); 29 (19): 2108–2114 ~ FULL TEXT There was a strong linear relation between the electromyographic amplitude of the deep cervical flexor muscles and the incremental stages of the craniocervical flexion test for control and individuals with neck pain (P = 0.002). However, the amplitude of deep cervical flexor electromyographic activity was less for the group with neck pain than controls, and this difference was significant for the higher increments of the task (P < 0.05). Although not significant, there was a strong trend for greater sternocleidomastoid and anterior scalene electromyographic activity for the group with neck pain.
	Efficacy of Spinal Manipulation and Mobilization for Low Back Pain and Neck Pain: A Systematic Review and Best Evidence Synthesis Spine Journal (of the North American Spine Society) 2004 (May); 4 (3): 335–356 Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and neck pain. There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care.
	Impairment in the Cervical Flexors: A Comparison of Whiplash and Insidious Onset Neck Pain Patients Manual Therapy 2004 (May); 9 (2): 89–94 The results indicated that both the insidious onset neck pain and whiplash groups had higher measures of EMG signal amplitude (normalized root mean square) in the sternocleidomastoid during each stage of the test compared to the control subjects (all P<0.05) and had significantly greater shortfalls from the pressure targets in the test stages (P<0.05). No significant differences were evident between the neck pain groups in either parameter indicating that this physical impairment in the neck flexor synergy is common to neck pain of both whiplash and insidious origin.
	Back and Neck Pain Exhibit Many Common Features in Old Age: A Population-based Study of 4,486 Danish Twins 70-102 Years of Age Spine (Phila Pa 1976) 2004 (Mar 1); 29 (5): 576–580 ~ FULL TEXT Back pain and neck pain are common symptoms in old age. In the 70+ year age group, back pain alone affects roughly 15%, neck pain alone affects approximately 10%, and both back pain and neck pain affect about 10% on a monthly basis. The majority (>70%), however, experienced only one episode or none at all before any of the four interviews. Prevalence estimates for back pain, neck pain, and concurrent back and neck pain remain constant with increasing age both in a cross-sectional analysis and a longitudinal analysis. Back pain and neck pain are associated with many co-occurring health problems and with poorer self-rated health. Both back pain and neck pain sufferers had significantly lower scores on physical functioning tests, whereas cognitive scores were unaffected.
	Chiropractic Management of Intractable Chronic Whiplash Syndrome Clinical Chiropractic 2004 (Mar): 7 (1): 16—23 The management protocol in this case consisted of chiropractic spinal manipulative therapy, soft tissue work and post-isometric relaxation (PIR) techniques to address biomechanical somatic dysfunction. In addition, active rehabilitation exercises, self-stretches and proprioceptive exercises were utilised to address postural and muscle imbalance. On the seventh treatment, the patient reported no neck pain, no headaches and unrestricted cervical spine range of motion. At 4 months follow-up, the patient continued to be free of headaches and neck stiffness and reported only mild, intermittent neck pain.
	The Epidemiology of Neck Pain: What We Have Learned from Our Population–based Studies J Can Chiropr Assoc 2003 (Dec); 47 (4): 284–290 ~ FULL TEXT Neck pain is a public health problem. The incidence and prognosis of whiplash injuries are greatly influenced by compensation for pain and suffering, legal factors, injury severity and sociodemographic characteristics. Overall, neck pain is a multifaceted disabling problem that deserves more attention. When treating patients with neck pain, clinicians need to recognize that it is more than a physical problem and that its prognosis is influenced by broader determinants of health.
	Vertical Posture and Head Stability in Patients With Chronic Neck Pain J Rehabil Med. 2003 (Sep); 35 (5): 229–235 ~ FULL TEXT Our experiments have confirmed earlier reports on increased postural sway and decreased ability to maintain more demanding standing posture in patients with chronic neck pain, and, in addition, showed major differences in vertical postural and head stability to perturbations. The differences between the patients with whiplash associated disorders (WAD) and those suffering from work-related pain (WRP) suggest that deficits in proprioception and motor control, rather than the chronic pain itself, may be the main factors defining the clinical picture in different chronic neck pain conditions. Consequently, qualitative and quantitative measures of postural performance and head stabilization could be used to increase the precision and efficiency of diagnosis and rehabilitation of chronic neck pain of different aetiology.
	Development of Motor System Dysfunction Following Whiplash Injury Pain. 2003 (May); 103 (1-2): 65–73 Dysfunction in the motor system is a feature of persistent whiplash associated disorders. Little is known about motor dysfunction in the early stages following injury and of its progress in those persons who recover and those who develop persistent symptoms. This study measured prospectively, motor system function (cervical range of movement (ROM), joint position error (JPE) and activity of the superficial neck flexors (EMG) during a test of cranio-cervical flexion) as well as a measure of fear of re-injury (TAMPA) in 66 whiplash subjects within 1 month of injury and then 2 and 3 months post injury. Subjects were classified at 3 months post injury using scores on the neck disability index: recovered (<8), mild pain and disability (10-28) or moderate/severe pain and disability (>30).
	Cost Effectiveness of Physiotherapy, Manual Therapy, and General Practitioner Care for Neck Pain: Economic Evaluation Alongside a Randomised Controlled Trial British Medical Journal 2003 (Apr 26); 326 (7395): 911 ~ FULL TEXT A hands-on approach to treating neck pain by manual therapy may help people get better faster and at a lower cost than more traditional treatments, according to this study. After seven and 26 weeks, they found significant improvements in recovery rates in the manual therapy group compared to the other 2 groups. For example, at week seven, 68% of the manual therapy group had recovered from their neck pain vs. 51% in the physical therapy group and 36% in the medical care group. You may also enjoy this WebMD review (Thursday, April 24, 2003) titled: Manual Therapy Eases Neck Pain, Cheaply: Hands-On Approach Effective, and More Cost-Effective, than Traditional Treatments.
	Hearing Loss, Otalgia and Neck Pain: A Case Report on Long-Term Chiropractic Care That Helped to Improve Quality of Life Chiropractic Journal of Australia 2002 (Dec); 32 (4): 119-130 ~ FULL TEXT Observation over an extended period assists in understanding the progression of chronic disorders. This patient experienced substantially reduced symptoms with chiropractic care during the 7-year observation period. Of note is the repeated exacerbation of neck pain that often precedes exacerbation in ear symptoms, along with the relief of both following adjustment and an association between improved hearing and improved cervical alignment. There are more articles like this in our: Case Studies Section.
	Two-year Follow-up of a Randomized Clinical Trial of Spinal Manipulation and Two Types of Exercise for Patients with Chronic Neck Pain Spine 2002 (Nov 1); 27 (21): 2383–2389 The results of this study demonstrate an advantage of spinal manipulation combined with low-tech rehabilitative exercise and MedX rehabilitative exercise versus spinal manipulation alone over two years and are similar in magnitude to those observed after one-year follow-up. These results suggest that treatments including supervised rehabilitative exercise should be considered for chronic neck pain sufferers. Further studies are needed to examine the cost effectiveness of these therapies and how spinal manipulation compares to no treatment or minimal intervention.
	Back, Neck, and Shoulder Pain in Finnish Adolescents: National Cross Sectional Surveys British Medical Journal 2002 (Oct 5); 325 (7367): 743–745 ~ FULL TEXT To study changes in the prevalence of pain in the back or neck in adolescents between the years 1985 and 2001, the authors compared biennial nationwide postal surveys, between 1985-2001, and annual classroom surveys, from 1996-2001. They found that pain in the neck, shoulder, and lower back is becoming more common in Finnish adolescents. This pain suggests a new disease burden of degenerative musculoskeletal disorders for future adults. Prevalence of pain in the back and neck was greater in the 1990s than in the 1980s and increased steadily from 1993 to 1997. Pain of the neck and shoulder and pain of the lower back was much more common in 1999 than in 1991 and in 2001 than in 1999. Pain was more common among girls and older groups: pain of the neck and shoulder affected 24% of girls and 12% of boys in 14 year olds, 38% of girls and 16% of boys in 16 year olds, and 43% of girls and 19% of boys in 18 year olds; pain in the lower back affected 8% of girls and 7% of boys in 14 year olds, 14% of girls and 11% of boys in 16 year olds, and 17% of boys and 13% of girls in 18 year olds. There are more articles like this at our Pediatrics Section
	A Randomized Trial of Chiropractic Manipulation and Mobilization for Patients With Neck Pain: Clinical Outcomes From the UCLA Neck-Pain Study Am J Public Health 2002 (Oct); 92 (10): 1634–1641 ~ FULL TEXT Our results suggest that cervical spine mobilization is as effective as manipulation in reducing neck pain and related disability among chiropractic patients. In addition, they show that neither heat nor EMS, alone or in combination with manipulation or mobilization, appreciably improves clinical outcomes, although heat may be of short-term benefit for some patients. Given the comparable outcomes and the risk of serious complications resulting from cervical spine manipulation, chiropractors may obtain equally effective results with less risk of adverse effects by treating neck-pain patients with mobilization rather than manipulation. However, manipulation may be more effective than mobilization for specific clinical indications. Future studies should be designed and conducted to help identify such patient subgroups. The therapeutic effects, side effects, and costs of manipulation and mobilization vs other common treatments for neck pain should also be assessed in subsequent investigations.
	Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain. A Randomized, Controlled Trial Annals of Internal Medicine 2002 (May 21); 136 (10): 713–722 In this randomized, controlled trial, researchers compared the effectiveness of manual therapy, physical therapy (PT) and continued care by a general practitioner (GP) in patients with nonspecific neck pain. The success rate at seven weeks was twice as high for the manual therapy group (68.3 percent) compared to the continued care group (general practitioner). Manual therapy scored better than physical therapy on all outcome measures. Additionally, patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care. The magnitude of the differences between manual therapy and the other treatments (PT or GP) was most pronounced for perceived recovery.
	Central Hypersensitivity In Chronic Pain After Whiplash Injury Clin J Pain. 2001 (Dec); 17 (4): 306–315 The authors found a hypersensitivity to peripheral stimulation in whiplash patients. Hypersensitivity was observed after cutaneous and muscular stimulation, at both neck and lower limb. Because hypersensitivity was observed in healthy tissues, it resulted from alterations in the central processing of sensory stimuli (central hypersensitivity). Central hypersensitivity was not dependent on a nociceptive input arising from the painful and tender muscles.
	A Pilot Randomized Clinical Trial on the Relative Effect of Instrumental (MFMA) Versus Manual (HVLA) Manipulation in the Treatment of Cervical Spine Dysfunction J Manipulative Physiol Ther 2001 (May); 24 (4): 260–271 ~ FULL TEXT The results of this clinical trial indicate that both instrumental (MFMA) manipulation and manual (HVLA) manipulation have beneficial effects associated with reducing pain and disability and improving cervical range of motion in this patient population. A randomized, controlled clinical trial in a similar patient base with a larger sample size is necessary to verify the clinical relevance of these findings.
	Clinical Study on Manipulative Treatment of Derangement of the Atlantoaxial Joint J Tradit Chin Med 1999 (Dec); 19 (4): 273–278 The derangement of the atlantoaxial joint is one of main cervical sources of dizziness and headache, which were based on the observation on the anatomy of the upper cervical vertebrae, analysis of X-ray film of the atlantoaxial joint, and the manipulative treatment in 35 patients with cervical spondylosis.
	Spinal Pain Syndromes: Nociceptive, Neuropathic, and Psychologic Mechanisms J Manipulative Physiol Ther 1999 (Sep); 22 (7): 458–472 ~ FULL TEXT Although the treatment of neuropathic pain is difficult, sufficient evidence in the literature demonstrates that the treatment of nociceptive pain should be multimodal and involve spinal manipulation, muscle lengthening/stretching, trigger point therapy, rehabilitation exercises, electrical modalities, a variety of nutritional factors, and mental/emotional support.
	The Saskatchewan Health and Back Pain Survey. The Prevalence of Neck Pain and Related Disability in Saskatchewan Adults Spine (Phila Pa 1976). 1998 (Aug 1); 23 (15): 1689–1698 The age-standardized lifetime prevalence of neck pain is 66.7% (95% confidence interval, 63.8-69.5), and the point prevalence is 22.2% (95% confidence interval, 19.7-24.7). The age-standardized 6-month prevalence of low-intensity and low-disability neck pain is 39.7% (95% confidence interval, 36.7-42.7), whereas it is 10.1% (95% confidence interval, 8.2-11.9) for high-intensity and low-disability neck pain and 4.6% (95% confidence interval, 3.3-5.8) for significantly disabling neck pain. The prevalence of low-intensity and low-disability neck pain decreases with age. More women experience high-disability neck pain than men. Wave analysis suggests that the point prevalence and 6-month prevalence of high-intensity and low-disability neck pain are overestimated in this survey. This cross-sectional study shows that neck pain is highly prevalent in Saskatchewan and that it significantly disables 4.6% (95% confidence interval, 3.3-5.8) of the adult population.
	Dysafferentation: A Novel Term to Describe the Neuropathophysiological Effects of Joint Complex Dysfunction. A Look at Likely Mechanisms of Symptom Generation J Manipulative Physiol Ther 1998 (May); 21 (4): 267–280 ~ FULL TEXT Joint complex dysfunction should be included in the differential diagnosis of pain and visceral symptoms because joint complex dysfunction can often generate symptoms which are similar to those produced by true visceral disease. You may also enjoy this response from another chiropractic researcher.
	Treatment of Cervical Disc Protrusions Via Instrumental Chiropractic Adjustment J Manipulative Physiol Ther 1998 (Feb); 21 (2): 114–121 The patient was initially treated with high-velocity manual manipulation of the cervical spine and reported a subsequent aggravation of her symptoms. Thereafter, she was treated with short-lever, mechanical-force, manually-assisted chiropractic adjusting procedures to the cervical spine, utilizing an Activator Adjusting Instrument. She tolerated the treatment well and subsequently experienced a complete resolution of the presenting symptoms.
	The Chiropractic Outcome Study: Pain, Functional Ability and Satisfaction With Care J Manipulative Physiol Ther 1997 (May); 20 (4): 235–240 Based on these results, it seems that patients suffering from back and/or neck complaints experience chiropractic care as an effective means of resolving or ameliorating pain and functional impairments, thus reinforcing previous results showing the benefits of chiropractic treatment for back and neck pain.
	The Effects of Spinal Manipulation on Cervical Kinesthesia in Patients With Chronic Neck Pain: A Pilot Study J Manipulative Physiol Ther 1997 (Feb); 20 (2): 80–85 Subjects receiving manipulation demonstrated a mean reduction in visual analogue scores of 44%, along with a 41% improvement in mean scores for the head repositioning skill. In comparison, a 9% mean reduction in visual analogue scores and a 12% improvement in head repositioning scores was observed for the stretching group. The difference in the outcomes of the head repositioning skill scores was significant (p < or = .05).
	Magnetic Resonance Imaging and Clinical Follow-up: Study of 27 Patients Receiving Chiropractic Care for Cervical and Lumbar Disc Herniations J Manipulative Physiol Ther 1996 (Nov); 19 (9): 597–606 Clinically, 80% of the patients studied had a good clinical outcome with postcare visual analog scores under 2 and resolution of abnormal clinical examination findings. Anatomically, after repeat MRI scans, 63% of the patients studied revealed a reduced size or completely resorbed disc herniation. There was a statistically significant association (p < .005) between the clinical and MRI follow-up results. Seventy-eight percent of the patients were able to return to work in their predisability occupations.
	Chronic Cervical Zygapophysial Joint Pain After Whiplash: A Placebo–Controlled Prevalence Study Spine 1996 (Aug 1); 21 (15): 1737–1744 The prevalence of cervical zygapophysial joint pain after whiplash has been studied by means of comparative local anesthetic blocks. The concern is that such blocks may be compromised by placebo responses and that prevalence estimates based on such blocks may exaggerate the importance of this condition. In this study, sixty-eight consecutive patients referred for chronic neck pain after whiplash were studied. Those who did not experience pain relief together with the patients with dominant neck pain proceeded to undergo placebo-controlled local anesthetic blocks. Two different local anesthetics and a placebo injection of normal saline were administered in random order and under double-blindfolded conditions. A positive diagnosis was made if the patient's pain was completely and reproducibly relieved by each local anesthetic but not by the placebo injection. Overall, the prevalence of cervical zygapophysial joint pain (C2-C3 or below) was 60% (93% confidence interval, 46%, 73%).
	A Risk Assessment of Cervical Manipulation vs. NSAIDs for the Treatment of Neck Pain J Manipulative Physiol Ther 1995 (Oct); 18 (8): 530–536 As for comparative safety, the best available evidence indicates that NSAID use poses a significantly greater risk of serious complications and death than the use of cervical manipulation for comparable conditions. In conclusion, the best evidence indicates that cervical manipulation for neck pain is much safer than the use of NSAIDs, by as much as a factor of several hundred times. There is no evidence that indicates NSAID use is any more effective than cervical manipulation for neck pain.
	Validity of Five Common Manual Neck Pain-provoking Tests Scand J Rehabil Med 1995 (Sep); 27 (3): 131–136 This study revealed that palpation for pain was the most reproducable and accurate assessment of reported neck pain. They state: "Palpation over the facet joints in the cervical spine was found to be the most appropriate screening test to corroborate the replies in self–reported questionnaires on dysfunctions of the neck."
	The Prevalence of Chronic Cervical Zygapophysial Joint Pain After Whiplash Spine Journal 1995 (Jan 1); 20 (1): 20–26 In a significant proportion of patients with whiplash, chronic, refractory neck pain develops. Provisional data suggest many of these patients have zygapophysial joint pain, but the diagnosis has been established by single, uncontrolled diagnostic block. In this study, fifty consecutive, referred patients with chronic neck pain after whiplash injury were studied using double-blind, controlled, diagnostic blocks of the cervical zygapophysial joints. On separate occasions, the joint was blocked with either lignocaine or bupivacaine in random order. A positive diagnosis was made only if both blocks relieved the patient's pain and bupivacaine provided longer relief. In this population, cervical zygapophysial joint pain was the most common source of chronic neck pain after whiplash.
	Chiropractic Management and Manipulative Therapy for MRI Documented Cervical Disk Herniation J Manipulative Physiol Ther 1994 (Mar); 17 (3): 177–185 The patients were prescribed a treatment regimen consisting of chiropractic management including bracing, physiotherapy, cervical manipulative procedures, traction and exercises. The patients responded well to care as evidence by posttreatment MRI, electrodiagnostic studies, clinical exam findings and thermography scan findings. Patients with and without nerve root compression secondary to cervical disk herniation can and do respond well to chiropractic care. Chiropractic management of this condition can and should be employed prior to more invasive treatment.
	Contribution of Central Neuroplasticity to Pathological Pain: Review of Clinical and Experimental Evidence Pain 1993 (Mar); 52 (3): 259–285 Peripheral tissue damage or nerve injury often leads to pathological pain processes, such as spontaneous pain, hyperalgesia and allodynia, that persist for years or decades after all possible tissue healing has occurred. Although peripheral neural mechanisms, such as nociceptor sensitization and neuroma formation, contribute to these pathological pain processes, recent evidence indicates that changes in central neural function may also play a significant role.