| GRADE Symbol |
GRADE* and Recommendation |
Clinical Importance
Magnitude of Effect
Duration of Effect |
Reported
Adverse Effect or Side Effects |
|
Strong
Evidence of Benefit:
(Strongly recommend use) |
|
|
|
No recommendation |
NA |
NA |
|
Moderate
Evidence of Benefit:
(Suggested use) |
|
|
| ●●●●
|
Patient Education:
Advice on Activation
Educational video on advice on activation (1 trial [29], 405 participants)
vs no treatment
for acute WAD at ST, IT and LT follow-up |
Magnitude of effect:
ST MEDIUM
LT SMALL
ST Pain (0-5 scale)
SMD: -0.67 (95%CI: -0.87 to -0.46)
WMD: -1.00 (95%CI: -1.30 to -0.70)
IT Pain
SMD: -0.38 (95%CI -0.59 to -0.17)
WMD: -1.00 (95%CI: -1.56 to -0.44)
LT Pain:
SMD: -0.44 (95%CI -0.66 to -0.23)
WMD: -1.00 (95%CI: -1.48 to -0.52)
NNT 23 |
NR |
| ●●
|
Mind-Body
by certified instructor
Cognitive (mindfulness & emotional balance) during Dantian Qigong exercises + advice delivered by approved Qigong therapists, all being members of the German Qigong Society (M-A: 2 trials [27; 28], 191 participants)
vs no treatment
for chronic neck pain at IP and ST follow-up |
Magnitude of effect:
ST SMALL
ST Pain (VAS 0-100)
SMDp: -0.34 (95%CI -0.67 to -0.01)
WMDp: -14.90 95%CI: -22.40 to -7.39)
ST Function (NDI or NPDI 0-100)
SMDp: -0.36 (95%CI -0.68 to -0.03)
WMDp: -10.38 (-17.11 to -3.64)
Pain NNT 4 to 6
Function NNT 5 to 8 |
NR |
| ● |
Workplace Intervention &
2° Prevention:
Individual Worker Changes
1 trial, 2 arms, 198 participants
1) 2-minute scapulothoracic endurance training program x 10 weeks
(1 trial [31], 127 participants)
vs control
2) 12-minute scapulothoracic endurance training program x 10 weeks
(1 trial [31], 129 participants)
vs control
for (sub)acute/chronic myofascial neck pain immediately post treatment for workers from white collar organizations at IP follow-up |
Magnitude of Effect:
2-minute IP SMALL
12-minute IP SMALL
IP Pain (VAS 0 to 10) 2-minute
SMD: -0.66 (95%CI: -1.02 to -0.30)
WMD: -1.30 (95%CI: -1.98 to -0.62)
IP Pain (VAS 0 to 10) 12-minute
SMD: -0.59 (95%CI: -0.94 to -0.23)
WMD: -1.30 (95%CI: -2.06 to -0.54)
Pain NNT 4 |
No long lasting or major complications. Minor transient side effects: worsening of neck muscle tension, shoulder, upper arm or forearm/wrist joint pain during training ; worsening of headache after training |
|
Strong
Evidence of NO Benefit:
(Strongly recommend use) |
|
|
|
No recommendation |
NA |
NA |
|
Moderate
Evidence of NO Benefit
(Suggested not to use) |
|
|
| ○○○○ |
Psychosocial Intervention
by PT:
1) Cognitive behavioral principles - Solution Finding
(1 trial [56], 268 participants):
Guidance to identify the problems correlated to their pain; Identification of solutions; goal setting based on CBT principles; booklet or pamphlet
delivered by PT
vs usual PT at LT follow-up
|
1) LT QALY (Patient-specific quality-adjusted life years): brief intervention provided only slightly less health benefit on average
|
NR |
| ○○○○ |
2) Intensive relaxation training(1 trial [57], 258 participants) -progressive relaxations, functional relaxation, autogenic training, systematic desensitization- delivered by PT
vs no control
for chronic non-specific neck pain at LT follow-up |
2) LT Pain NSD
LT Function NSD |
NR |
| ○○○○ |
Workplace Intervention:
Mental Health Education
Intensive relaxation training
(1 trial [57], 258 participants) -progressive relaxations, functional relaxation, autogenic training, systematic desensitization- delivered by PT
vs no control
for chronic non-specific neck pain in office workers at LT follow-up |
LT Pain NSD
LT Function NSD |
NR |
| ○○○○
|
Workplace Intervention:
Ergonomic Education & Mental Health Education
1) mental health education and physical health education, relaxation, breaks (1 trial [59], 2 arms, 466 participants)
a) work style (1 trial, 210 participants analysed at LT)
b) work style + physical activity (1 trial, 209 participants analysed at LT)
vs no intervention |
1) IT Pain NSD
LT Pain NSD |
NR |
| ○ |
2) Weekly Email
(1 trial [31], 3 arms, 198 participants): physical exercise, advice to stay active in spite of pain, diet, smoking, alcohol use, stress-management, workplace ergonomics (n=64)
vs 2-minute of exercise (n=63)
vs 12-minutes of exercise (n=65)
for acute to chronic myofascial neck pain in 2 large white collar organizations at IP follow-up |
2) IP Pain favoured the comparison treatments: 2-minute or 12-minute training groups |
NR |
| ○○ |
Workplace Intervention &
1° or 2° Prevention:
Physical Environment Changes
Physical Ergonomic Interventions (M-A 4 trials [61-64], 1546 participants):
a) ergonomic training on workplace adjustment
for university workers;
b) ergonomic training
in kitchen workers;
c) postural training & work station changes
for computer workers;
d) adjustment to desk/ keyboard/mouse position/ forearm support
for call centre workers
vs no intervention
for non-sick listed neck pain free workers at ST follow-up |
ST Neck Pain incidence/ prevalence: (M-A) NSD
RRp: 0.93 (95%CI: 0.84 to 1.03)
|
NR |
| ○○○○ |
Workplace Intervention &
2° Prevention:
Individual Worker Change
Upper extremity stretching & strengthening endurance training (1 trial [57], 265 participants)
vs no intervention
for chronic neck pain at LT follow-up |
IP Pain
ST Pain
LT Pain
IP Disability
ST Disability
LT Disability
LT Sick Leave |
NR |
| ○○○○ |
Orthotics: Collar
1) Soft Collar use in combination with Advice to self-mobilize: collar worn during waking hours for two weeks, after two weeks add active range of motion exercises (no M-A 5 trials [72-76], 637 participants]
vs general PT
for acute WAD neck pain at LT follow-up |
1) LT Pain NSD
LT Function NSD
LT QoL NSD
LT Ability toWork NSD |
No side effects reported |
| ○○○ |
2) Soft collar use (no M-A
3 trials [77-79], 641 participants)
vs general PT
for acute neck pain with cervicogenic headache at ST and IT follow-up |
2) ST Pain favoured PT
IT Pain favoured PT
ST Disability favoured PT
|
NR |
| ○○○○ |
Patient Education:
Self-management strategy
1) Education on aerobic exercise + stretching (1 trial [33], 180 participants)
vs specific endurance and strengthening exercises
for chronic non-specific neck pain at LT follow-up |
1) All outcomes favoured neck strengthening exercise
LT Pain
LT Disability
|
NR |
| ○○○○ |
2) Advice on neck care (1 trial [80], 218 participants)
vs intensive neck exercises
for acute neck pain for pain and disability at ST and LT follow-up |
2) All of the following outcomes favoured intensive exercise
ST Pain
LT Pain
ST Disability
LT Disability |
NR |
GRADE*: study design, within study risk of bias, consistency of results, directness (generalizability), precision (sufficient data), reporting bias (publication, language, funding, other); open symbol= no benefit; closed symbol = beneficial; duration of effect noted by number of symbols: one = IP, two = ST, three = IT, 4 = LT; diamond (♦ or ◊) = high GRADE; dot (● or ○) = moderate GRADE with solid symbol indicating benefit and open symbol indication no benefit
Clinically Important is determined by considering the following factors: minimal detectable change, minimal clinically important difference (> 15%), large magnitude of effect measured by weighted mean difference, number needed to treat, absolute benefit &, treatment advantage, high dose response gradient, duration of the effect (IP – immediate post treatment, ST - short term for about 3 months, IT – intermediate term for about 6 months, LT – long term for about 1 year)
Key: WAD – whiplash associated disorder; IP – immediate post-treatment follow-up; ST – short-term follow-up; IT – intermediate-term follow-up; LT – long-term follow-up; SMDp – pooled standard mean difference; WMDp – weighted mean difference; RRp – pooled relative risk; M-A –meta-analysis; NNT – number-needed-to-treat; 95%CI – 95% confidence interval, † no significant difference between groups for this outcome, GPE – global perceived effect; VAS – visual analogue scale; QALY – quality of life years; PT – physiotherapy; CBT – cognitive behavioral training; NR – not reported; NA – not applicable, vs – verses.