Chiropractic & Manual Therapies 2014 (Mar 24); 22 (1): 11 ~ FULL TEXT
Lisa C Carlesso, Joy C MacDermid, Anita R Gross, David M Walton, P Lina Santaguida
Toronto Western Research Institute,
University Health Network,
399 Bathurst Street - MP11-328,
Toronto, Ontario M5T 2S8, Canada
BACKGROUND: Clinical practice guidelines on the management of neck pain make recommendations to help practitioners optimize patient care. By examining the practice patterns of practitioners, adherence to CPGs or lack thereof, is demonstrated. Understanding utilization of various treatments by practitioners and comparing these patterns to that of recommended guidelines is important to identify gaps for knowledge translation and improve treatment regimens.Aim: To describe the utilization of interventions in patients with neck pain by clinicians.
METHODS: A cross-sectional international survey was conducted from February 2012 to March 2013 to determine physical medicine, complementary and alternative medicine utilization amongst 360 clinicians treating patients with neck pain.
RESULTS: The survey was international (19 countries) with Canada having the largest response (38%). Results were analyzed by usage amongst physical therapists (38%) and chiropractors (31%) as they were the predominant respondents. Within these professions, respondents were male (41–66%) working in private practice (69–95%). Exercise and manual therapies were consistently (98–99%) used by both professions but tests of subgroup differences determined that physical therapists used exercise, orthoses and 'other' interventions more, while chiropractors used phototherapeutics more. However, phototherapeutics (65%), Orthoses/supportive devices (57%), mechanical traction (55%) and sonic therapies (54%) were not used by the majority of respondents. Thermal applications (73%) and acupuncture (46%) were the modalities used most commonly. Analysis of differences across the subtypes of neck pain indicated that respondents utilize treatments more often for chronic neck pain and whiplash conditions, followed by radiculopathy, acute neck pain and whiplash conditions, and facet joint dysfunction by diagnostic block. The higher rates of usage of some interventions were consistent with supporting evidence (e.g. manual therapy). However, there was moderate usage of a number of interventions that have limited support or conflicting evidence (e.g. ergonomics).
CONCLUSIONS: 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.
From the Full-Text Article:
Clinical practice guidelines are developed to provide statements and recommendations with
the intention of helping practitioners optimize patient care . By examining the practice
patterns of practitioners, adherence to CPGs or lack thereof, is
demonstrated. Recommendations for practice can then be formed. Understanding existing practice patterns
provides insight into how current evidence impacts on practice and can identify where greater
efforts in knowledge translation are needed. Clinical practice will vary dependent on a
number of factors such as location, resources available, patient population, and professional
background. Several CPGs from varying professionals who treat patients with neck pain exist [2–5]. To our knowledge no examination of practice patterns across hea
lth care professionals who treat patients with neck pain has been published.
Neck pain is a common problem with an episodic course that affects a large proportion of the
population. Estimates for the prevalence of neck pain vary from 0.4% to 86.8% (mean
23.1%) in the general population, whereas the range for the one year incidence is reported to
be smaller (10.4% to 21.3%) . Risk factors for new onset neck pain include being female,
between the ages of 35 to 49 years and having a previous episode of neck pain [6–8].
Estimated expenditures on spine related care in the United States have almost doubled in the
last decade [7, 9]. The number of emergency room visits related to motor vehicle accidents
(MVA) has been steadily increasing in the last three decades . Direct healthcare costs
may only be a small piece of this burden, while the indirect costs of work absenteeism and
disability are much greater [6, 11].
Over the past decade the evidence base guiding the choice of effective treatments for
reducing symptoms and increasing function has evolved. The association between severity
and disability of neck pain has been established by numerous studies [12–15]. There are
numerous health care practitioners that treat patients with neck pain with a variety of
interventions such as physical medicine, manual therapies, exercise, electrotherapeutic
agents, and ergonomics . Manual therapies in combination with exercise may provide
optimal treatment effects . Outcomes such as better pain reduction, better patient
satisfaction, improved function, increased range of motion and increased strength in people
with neck pain have been reported in patients who received manual therapy alone or in
combination with other modalities [16, 18–22]. While evidence exists for other interventions,
the number of studies is few with conflicting results leading to less confidence in their
effectiveness [16, 23–25].
Our recent reviews of reviews [26, 27] provide some guidance for practitioners. There is
moderate evidence for specific modalities such as laser and acupuncture for pain reduction
while there is evidence of no benefit for the use of collars, ergonomic or physical
environment changes in the workplace. Ideally, providers make treatment choices based on
their experience, the available evidence, and the clinical presentation of their
In reality however, provider choices of care may be influenced by factors such as scope of
practice, patient preferences, types of providers the patient chooses to see or insurance
coverage, thereby influencing the types of treatments received and by their interaction with
providers. Even within the same profession, providers’ choices of care may vary depending
upon the degree to which they are aware of current evidence on treatment effectiveness and
the degree to which they choose to incorporate the evidence into their practice. For example,
care provided by a physical therapist will differ, in some ways, from care provided by a
physician or from another physical therapist. Patient centered care and the shared decision
making model have incorporated patient preferences into treatment planning. This denotes
the importance of flexibility in the way that health professional s structure the decision-making process so that individual patient differences can be respected
. The incorporation of patient preferences has the potential to shift ‘ideal’ choice
s to more practical ones based on preferences of each individual. For example, a patient treated previously
for a different problem and presenting with a new problem may have had a successful
outcome using an evidence based intervention. However applying the same intervention to a
different area may not be supported. Given the favourable outcome, the patient may request that
the same intervention be used. The practitioner is therefore faced with making treatment decisions that
incorporate patient expectation and it has been suggested that doing so may improve
adherence and satisfaction with care . The end result is more varied care and a modification of the ‘ideal’ treatment
allowing incorporation of patient preferences and expectations but straying slightly from recommended guidelines.
There is little evidence in the literature about guideline adherence in patients with neck pain.
A study by Oostendorp et al. (2013) used quality indicators of treat ment based on guideline
recommendations for patients with non specific neck pain . The study by Oostendorp et al.
used a sample of 38 physiotherapists and 96 patients in the Netherlands. Adherence to the
identified treatment quality indicators ranged from weak (34%) to adequate (59%). These
findings provide some initial insight into the potential variability in care that may exist for
this patient population and practitioner group but does not provide details about the types of
interventions or the frequency with which they were used.
The International Collaboration on Neck Pain (ICON) project is a collaborative project
amongst internationally recognized experts in the field of neck pain. The goal of ICON is to
establish clear, actionable messages in the areas of diagnosis, prognosis, interventions and
outcomes measurement. To establish such data, ICON has implemented an international
multidisciplinary survey of clinical practice patterns that will help shape evidence based
The purposes of this study were:
1. To describe the utilization of interventions in patients with neck pain by clinicians and
2. Where appropriate, to examine whether utilization varies by profession or subgroup of disorder.
A cross sectional survey to determine practice patterns of clinicians who provide care to
patients with neck pain was conducted from February 2012 to March 2013. The survey was
approved by the McMaster University Research Ethics Board (REB#11-025).
Survey development and validation
The survey was designed to acquire information in four principle content areas. These four
areas included examination/diagnostic procedures, prognostic indicators, interventions
(including adverse events), and outcome measures. Two additional content areas determined
the demographic and caseload information of respondents.
The survey was developed using Streiner and Norman (2008)  methods in three distinct
and iterative steps – item generation using literature review, consultation with clinicians
which included clinical observation, and ICON content experts – before fielding the
questionnaire. 1) The initial core set of items was generated from systematic reviews on
conservative treatments for neck pain. 2) This set was then sentto expert clinicians identified
within and external to ICON for review of usability, technical functionality of the electronic
questionnaire and identification of issues/gaps. 3) The next set was tested using the ICON
expert panel of interdisciplinary professionals; this included physicians, psychologists,
physiotherapists, massage therapists, chiropractors, and other rehabilitative professions.
Additional items created by these experts aimed to address areas missing from the initial item
generation to ensure they were designed to be appropriate for administration across different
health care professionals commonly treating people with neck pain.
This content area being sufficiently large was divided into the following two separate
1. Physical medicine or CAM interventions; and
2. Pharmacological and psychological interventions.
Items in the physical medicine and CAM survey covered
exercise, manual therapies, modalities, mechanical traction, orthoses/supportive devices,
ergonomic and work related interventions. An ‘other’ response option was included where
appropriate within each category and allowed respondents to add any interventions that may
have been missed. Broadly, items asked about utilization of each treatment category (yes, no,
outside scope of practice). The questions progressed in the following sequence. If a
respondent indicated ‘yes’ to the initial utilization question, then inquiry of frequency of use
(commonly, occasionally, never) followed. If respondents indicated ‘common’ or
‘occasional’ use of an intervention, then use of that intervention (commonly, occasionally,
never, not applicable) among the following common subgroups of neck pain disorders was
also inquired about:
1. acute nonspecific neck pain,
2. chronic nonspecific neck pain,
3. facet joint dysfunction (as diagnosed by diagnostic block),
4. acute whiplash associated disorder (WAD),
5. chronic WAD and
For the modalities category, respondents were also asked about indications for use. Routing
questions were sequentially designed to reduce respondent burden allowing avoidance of
categories not relevant to respondents.
Face and content validity of the survey were addressed in an iterative process involving
multiple revisions and content experts. In the first round, there was a focus on accuracy of
item content and clarity in the wording of each item and response. In the second round, there
was a focus on the organizational structure of the survey so as to have logical grouping,
sequencing of items and routing questions. In the third round, responses were piloted within
the electronic survey format to evaluate presentation and routing. Finally, the ICON working
group (n = 38) that had representation from all the disciplinesincluded in our target audience
was used for field-testing. These experts reviewed the survey for accuracy, clarity,
completeness and burden. After each round of revisions, editing occurred for clarity. This
resulted in minor changes to items and a few additions. The finalized version was mounted
using LimeSurveya, a software program for web-based survey administration.
Our sampling frame was all health care professional groups identified as having a major role
in the management of neck pain, relying on both our reviews and clinical experience to
identify these groups. This included physicians (general practitioners, physiatrists,
psychiatrists) physiotherapists, chiropractors, massage therapists, occupational therapists,
psychologists and complementary medicine specialists. We wanted to include an international perspective.
Given the number of national associations and a general lack of willingness for professional associations
to burden their members with survey requests we relied on Snowball sampling strategies.
This method allowed clinician experts identified by ICON within each of the professions.
Invitations were sent to the contact person identified for each association and requested they assist
with sending out links to our survey to their professional links and colleagues. If the
association responded and agreed to send out the link on our behalf, it was done so at their
discretion. In total 37 groups were contacted, 19 of which did not respond. Survey invitations
were distributed via e-mail blast to members, and electronic postings (e.g., e-newsletter,
website, Facebook or Twitter pages) by national and international professional groups for:
Danish Chiropractors’ Association;
European Academy of Chiropractic;
Netherlands Chiropractic Association;
New Zealand Chiropractors’ Association;
Ontario Chiropractic Association)
Canadian Academy of Manipulative Physical Therapy;
Dutch Association for Manual Therapy;
Finnish Association for Orthopedic Manual Therapy;
German Manual Therapy Journal;
International Federation of Orthopaedic Manipulative Physical Therapists
Massage Therapists’ Association of British Columbia
North American Spine Society;
University of British Columbia Department of Family Medicine
American Physical Therapy Association – Orthopedic Section;
and other health care professionals
Canadian Physiotherapy Association – Pain Sciences Division;
Hong Kong Physiotherapy Association;
Musculoskeletal Physiotherapy Australia;
Osteopathic Society of New Zealand
The method of recruitment meant we were unable to determine how many people received our
requests for participation. We were unaware if the associations sent the survey link to all
members or only those who agreed to receive it.
The survey was administered through the International Collaboration on Neck (ICON) group
and was estimated to take 15–20 minutes to answer. An e-mail including information about
the survey, and a registration link were provided. No incentives were offered. Public
registration was required to participate in the survey and individuals who volunteered to
receive the survey link were considered “registrants”. Once respondents registered, an email
containing the link to participate in this survey was sent out immediately. Respondents
remained anonymous by storing the identification tokens (name and e-mail address) that
provided access to the survey on a secure separate database. Registrants were notified that
clicking the survey link indicated that they were electronically consenting to participate.
Weekly reminders were sent to registrants until they completed the survey, opted out, or
received a maximum of four reminders. Response rates amongst registrants were calculated
based on the number of registrants who completed at least part of the survey.
Data quality was assessed by randomly sampling 10% of the dataset to check for errors.
Discrepant entries (< 1%) were resolved through this process. Descriptive statistics were used
to summarize participants and their responses to each question. Chi-squared analyses were
used to test for differences in the frequency of use of various treatment interventions based on
profession. Rank order was used to assess frequency of use of interventions amongst subtypes
of neck pain.
There were 360 respondents (332 full and 28 partial) spanning 17 countries. Respondents
were mainly physical therapists (38%) or chiropractors (31%) and largely male (41–66%).
Due to lack of adequate representation from professions other than physical therapists
and chiropractors, we focused the analyses on these two groups. Based on the relevant
physiotherapy and chiropractic professional associations’ membership information that we
were able to ascertain, as many as 17773 individuals were invited to respond to our survey.
This is likely a high estimate as more detailed information from a few organizations indicates
that variation existed due to inactive emails, unsent links (one international body represents
22 countries) and membership number fluctuations throughout the year. Using this very
conservative total, results in a response rate of approximately two percent. Table 1 provides
the characteristics for the whole sample and physical therapists and chiropractors only.
Within the two professions, there was an average of 15 years of clinical experience, and 34%
had obtained a Master’s degree. The majority (80%) worked in private practice, with
reimbursement through private insurance (79%) in a fee for service private payment model
(64%). Over half of the respondents indicated that patients with neck pain made up at least
one quarter of their caseload. The largest subset of respondents was from Canada (38%). The
gender distribution of this subset of respondents is representative of both professions (males
49% physical therapists; 66% chiropractors) [32, 33].
Table 2 demonstrates the frequency of use (‘Yes’) of the various physical medicine and CAM
treatment interventions along with their subtypes. Exercise prescription was used at least by
98% of respondents, as were manual therapies. Ergonomic advice (83%), work related interventions
(73%) and thermal agents (73%) rounded out the top 5 most frequently endorsed treatment approaches.
Respondents indicated that they largely did not provide (‘No’) ‘other’ interventions (70%),
phototherapeutics (65%), orthoses/supportive devices (57%), mechanical traction (55%), sonic therapies
(54%) or electrotherapeutics (47%).
Different types of exercise were more commonly used such as those for postural control
(84%), stretching of the neck/upper thorax (79%) and strengthening of the neck/upper thorax
(77%). The exceptions were motor control (41%) and cardiovascular training (51%), which
were used more occasionally. The most commonly used modalities included hot and cold
applications (55%) and acupuncture (traditional 17%, dry needling 18%). A substantial
number of respondents rarely or never used short wave diathermy (31%), biofeedback (26%),
shock wave sonic therapy (21%) and muscle stimulation (19%). The major ity of respondents
commonly used manual therapies and this was most frequently mobilization (90%) compared
to manipulation (56%). Work related interventions such as work hardening, site modification,
communication with the employer and site restrictions were used occasionally (35–47%).
Table 3 highlights the use of modalities and their indications for use. The only two modalities
that the majority of respondents indicated that they used were Thermal applications and
TENS. Both were indicated for pain relief, 90% and 71% respectively. For the remaining
modalities, for all but ultrasound and muscle stimulation (45% each), the majority of
respondents indicated that they ‘Do not use/outside scope of practice’.
Looking across physical therapists and chiropractors, differences in their use of the various
interventions were found. Table 4 shows that the two differ in their prescription of exercise,
phototherapeutics, acupuncture, orthoses/supportive devices and the category of ‘other’
interventions. Both collars and taping are used more often by physical therapists than
chiropractors (p = 0.01 and p = 0.03 respectively). Examples of ‘other’ interventions used
more frequently by physical therapists include pain education, referral to other healthcare
professionals, use of McKenzie methods , self-management strategies, breathing/relaxation
strategies and prolotherapy.
Figure 1 depicts the differences in exercise prescription between the two. Significant differences
were found in the prescription of some types of exercise (greater by physical therapists p=0.01)
except stretching of other body parts, strengthening of neck/upper back and other body parts and
cardiovascular training where there was no difference.
Figure 2 shows the differences in use of modalities.
Significant differences between professions in exercise prescription.
Significant differences between professions in modality use.
Chiropractors use of laser (p = 0.00), and electrical muscular stimulation (p = 0.01) was significantly greater than physical therapists.
Although there is no significant difference between the two in the overall use of manual therapies, there is a
significant difference in the use of thrust manipulation (p = 0.00) with chiropractors performing it more often.
Table 5 outlines the use of treatment interventions according to disorder subgroup.
Respondents reported using exercises, manual therapy, and ergonomic interventions most
frequently in patients with chronic nonspecific neck pain compared to the five other
conditions. Differences between chronic nonspecific neck pain and chronic WAD were
minimal. The use of orthoses/supportive devices was variable across the 6 subgroup
disorders. Respondents indicated that collars were used most frequently for patients with
acute WAD (24%), pillows for patients with chronic nonspecific neck (27%), while the use of
taping (16%) was split across three subgroups and adaptive equipment (5%) in chronic non-
specific neck pain. Utilization of three of the four work related interventions was equal in
patients with chronic non specific neck pain or chronic WAD (43 to 68%). Respondents
indicated that they used mechanical traction most frequently for patients with radiculopathy
or WAD III (27%). Rank ordering of interventions within the subgroups from most utilized to
least utilized resulted in the following:
1. chronic nonspecific neck pain;
2. chronic WAD;
4. acute nonspecific neck pain;
5. acute WAD; and
6. facet joint dysfunction by diagnostic block.
This would indicate that chronic conditions are being treated with the interventions we inquired
about more frequently and that respondents are also utilizing a wider range of interventions.
Summary of main findings
Our results from this survey demonstrate that the interventions most commonly used by
physical therapists and chiropractors for the treatment of people with neck pain (exercise and
manual therapy) are those that also have strong evidence for their effectiveness, [17, 35–38]
particularly when combined. It is these two interventions that are also recommended by
clinical practice guidelines [2, 4]. Other treatments do not reflect the best evidence for
effective treatment. The results also indicate variable use of interventions with low or very
low evidence. Some are being used to a larger degree (ergonomic and work related
interventions) [39, 40] while others are not being used (mechanical traction,
orthoses/supportive devices and modalities) [23, 24]. Other treatments may be used more as
they address immediate or short term symptom relief but they lack sufficient focus on long-term functioning [17, 27].
A Cochrane review of exercise interventions for patients with neck pain highlighted that a
combination of cervical and scapulothoracic stretching and strengthening improves pain and
function and leads to greater patient satisfaction in people with chronic neck pain. Endurance
exercises of the cervical and scapulothoracic regions are effective at reducing pain,
improving function and global perceived effect for subacute/chronic cervicogenic headache,
while neck strengthening is effective at reducing pain in acute cervical radiculopathy. Neither
upper extremity stretching, strengthening or a general exercise program is recommended for
chronic neck pain . In this study, respondents’ reported the greatest utilization of exercise
in chronic nonspecific neck pain and WAD conditions demonstrating that current practice
patterns are in sync with evidence based recommendations. We did not have a specific category to
capture cervicogenic headache so we cannot be certain of how this subgroup was considered. Our
response options regarding exercise covered many general concepts ranging from stretching,
strengthening, endurance, postural control, motor control and stabilization, but did not allow
for details within these categories to be explored. Overall exercise prescription was reported
most often in the two chronic neck pain conditions and radiculopathy, which is consistent with
the findings of the systematic review.
Manual therapies are a core skill for the majority of respondents so it is not surprising that
they are used as frequently as exercise. Mobilization and massage therapy/soft tissue work were
the two most commonly reported of the four techniques. Possible explanations for this
lie in our sample representing physical therapists and chiropractors as well as in the evidence
base. A Cochrane review has reported the benefit of using mobilization techniques and that
no differential benefit for spinal manipulation as opposed to mobilization has been shown for
the outcomes of pain, function and patient satisfaction . Using the techniques alone
compared to combining them with exercise is mainly of short term benefit on pain only .
Regarding the effectiveness of massage therapy/soft tissue techniques, findings of systematic
reviews are concordant [41–43]. Evidence indicates some pain reduction and improvement in
function for subacute and chronic neck pain immediately post massage therapy/soft tissue
treatment but there is inconclusive evidence of any long-term benefit. Despite the lack of
clear direction in the literature, the proportion of utilization of massage therapy/soft tissue
techniques was similar between the physical therapists and chiropractors in this survey.
Massage/soft tissue techniques may be selected for a variety of reasons including
complementary or preparatory effects prior to vertebral mobilization/manipulations  and
the fact that patients report it being very helpful for neck pain [44, 45]. It is possible that there
are differences in the type of soft tissue techniques performed by the two different
professions, but the nature of survey work does not allow for these distinctions.
Ergonomics, work related interventions and Orthotics/ Supportive devices
The association between poor workstation design and awkward work postures with neck pain
has been documented . Recent systematic reviews reported limited evidence for
decreased neck pain when physical ergonomic interventions were used compared to none at
all [39, 47]. The following interventions are reported to have no evidence of benefit:
ergonomic education (for intervention), workplace physical environment changes (for
intervention and primary prevention), and individual worker upper extremity stretching and
endurance training program (for intervention, primary and secondary prevention) . In the
absence of strong evidence for ergonomic or work related intervent ions, and considering the
difficulties and potential high costs of these interventions it may be that practitioners are less
likely to select this treatment approach. Our survey does not allow us to determine why
people select different interventions and thus whether it is perceived effectiveness, skills or
resources that drive the lower utilization of ergonomic and workplace interventions. The
lower rate of utilization of these interventions by respondents, particularly for complex
patients like those with chronic WAD may reflect the challenge that practitioners face in
addressing interventions for complex patients with limited evidence [48, 49].
Overall, respondents provided little endorsement for the use of mechanical traction, and
orthoses/supportive devices. However, responses suggest that there may be subgroups where
clinicians feel these interventions could be beneficial. For example, mechanical traction was
used most frequently in the radiculopathy/WAD III population compared to the other
subgroups, despite inconclusive evidence for its use either intermittently or continuously
. This may suggest that practitioners expect that a force to unload pressure on the nerve is
indicated in nerve root compression. Some evidence does exist for intermittent traction for
generalized mechanical neck pain which may be influencing practitioner usage  and we
have recently found evidence of moderate benefit for intermittent traction for chronic neck
pain . We did not ask about intermittent versus continuous application and therefore
cannot be certain how this was interpreted.
Cervical pillows were used most commonly in chronic neck pain and WAD conditions while
collar use was reported most often in acute non specific neck pain despite evidence of no
benefit [51, 52] or that collar use is detrimental to recovery . In our concurrent review we
found no evidence to support the effectiveness of soft collars in acute neck pain or WAD .
We did not inquire about modality usage by disorder subgroup but by indications for use.
When implemented, the rationale selected by respondents for specific modalities was
consistent with their accepted indications. TENS, Heat/cold and acupuncture were used for
pain relief and laser therapy for tissue healing. The existing literature base shows moderate
evidence supporting the use of these modalities for neck pain [16, 23, 54] with the exception of
heat/cold where little evidence is present. A survey of patients in one state in the USA
seeking care for neck pain reported that heat and cold therapy were received by 57% and 48%
respectively compared to prescribed exercise (53%), spinal manipulation (37%) or TENS
(22%) . A survey of chiropractors in two states in the USA also reported use of thermal
and electrical modalities more than exercise . There may be several reasons for these
discrepancies between the practice patterns reported in these two American studies versus the
current findings. This could include factors such as: patient preferences, time management in
busy clinics, clinicians balancing observations of treatment efficacy with the published
evidence or perhaps being unaware of the current recommendations for care.
Our concurrent review of reviews indicates that acupuncture (short term pain relief) and low-level
laser (short and intermediate term pain relief and function improvement) both have
moderate evidence of benefit for chronic neck pain. Evidence of no benefit was found for
pulsed ultrasound, or continuous traction . Our data shows that respondents are practicing
in line with the evidence in their minimal use of ultrasound and traction and greater use of
acupuncture, but deviates from the evidence in their minimal use of low level laser.
Our data indicated some difference in treatment selection across different types of neck pain.
Chronic neck pain conditions presented in our survey as non specific and WAD were more
likely to be treated with physical medicine and CAM treatment interventions in comparison
to radiculopathy/WAD III, (presented in our survey as acute neck conditions and facet joint
dysfunction). Although it is tenuous to make assumptions about why respondents selected
different interventions from this type of survey, it does appear that the pattern of utilization is
consistent with variations in the complexity of the condition. Chronic neck pain conditions,
particularly those arising following WAD [13, 57] are often more complex, and associated
with greater degrees of disability and impairment . Our respondents indicated use of more
varied interventions for chronic neck conditions compared to acute conditions, possibly in
line with the complexity of the condition. Cervical nerve root pathology leading to upper
extremity symptoms is often caused by space occupying lesions such as disc herniation,
spondylosis, or osteophytosis that can be resistant to conservative treatment . There is
conflicting evidence around the efficacy of manual therapy, exercise, and other modalities for
radiculopathy [3, 58]. Acute neck pain and WAD if uncomplicated by high levels of pain
severity, functional limitation or psychological distress will likely resolve within a reasonable
timeframe. Our survey results seem to reflect this as these acute conditions had the lowest
frequency of intervention utilization.
There is little published evidence on the effectiveness of conservative treatments for facet
joint dysfunction confirmed by diagnostic block. The relative lack of evidence for treatment
specific to this syndrome may be why respondents ranked it last of our listed disorders
regarding overall frequency of utilization of interventions. Practitioners may suspect facet
joint dysfunction after screening but it is likely that few are confirmed by diagnostic block
thus making certainty of the diagnosis difficult.
Differences and similarities between professions
Our findings indicate that some differences exist in the utilization of interventions between
physical therapists and chiropractors. Although the scope of practice of these two professions
is similar, these findings are not unexpected, as differences based on education and clinical
paradigms could be expected that may influence their approach to treatment. Practitioner’s
use of interventions can be shaped by factors other than their entry-level education such as
courses taken post professionally, clinical environments, characteristics of the population
treated, or use of evidence base medicine. The nature of the survey does not allow us to
determine why differences existed between the professional groups. The higher utilization of
exercise by physical therapists could reflect the fact that physical therapists have a strong
focus on use of therapeutics exercise in their entry-level training or that there is a substantial
body of therapeutic exercise evidence developed by physical therapists. We could anticipate
that clinicians attend to research that is published within their own professional journals to a
greater extent than literature from other disciplines [59–61]. Similarly, innovations in pain
education have arisen in physical therapy literature and were cited in the ‘other’ category by
physical therapists [62, 63]. The higher use of manipulation by chiropractors (100%) is consistent
with this intervention being at the core of chiropractic education. Explanations for the differences
in the remaining categories were less dramatic and the reasons for them were less intuitive.
Similarities between the physical therapists and chiropractors were demonstrated in their
utilization of electrotherapeutics, thermal agents, sonic agents, acupuncture, manual
therapies, mechanical traction, ergonomic and work related interventions. Our review of the
evidence has indicated that most of these categories have poor supporting evidence with the
exception of manual therapies. The similarity in the use of manual therapies in general is not
surprising since they are at the core of entry-level education for both professions. Reasons for
their similarity in practice patterns with respect to the remaining interventions can only be
speculated. It may be that a combination of factors is contributingto this practice pattern
including caseload, patient expectations, infrastructure within the clinics, post-professional
training, mentorship and others. For example, patients with neck pain may have a preference
for heat applications and in busy private clinics supplementing the treatment sessions with
heat may improve patient satisfaction and facilitate other aspects of the treatment program.
Although workers compensation accounted for approximately one third of reimbursement in
our respondents, it may be that practitioners are seeing patients who are having issues
managing their neck pain at work even though the problem may not have directly resulted
from a work injury. This along with practitioners implementing primary or secondary
prevention strategies could explain the high use of ergonomic and work related interventions.
Overall the practice patterns demonstrated by this data suggest that chiropractors and physical
therapists demonstrate strong utilization of interventions widely supported by the literature to
manage neck pain. Interventions with limited or conflicting evidence have low to moderate
use that is consistent with the uncertainty in the literature. The variability in use of
interventions reflects the multimodal practice of practitioners that are commonly used to treat
this population. Clinicians faced with applying the evidence-base must customize
interventions to the presentation of the individual patient and we know that even within
clinical trials response patterns vary across different patients. Therefore, some of the
variability in practice patterns reflects this customization. There are multiple patient and
practitioner preferences that affect the treatment choices made in clinician and patient
interactions around managing neck pain. These can include previous experience, stage of
healing, or practitioner type. However understanding the gaps between the evidence base and
practice patterns is important for identifying areas needing targeted knowledge translation.
Comparing current evidence with our survey results indicates that there are areas for
education of chiropractors and physical therapists to increase utilization of interventions with
supportive evidence. This includes low level laser and acupuncture therapy that were reported
by only 13% and 45% respectively of our respondents. Our results also indicate an even
greater need to educate practitioners about their use of interventions with weak supporting
evidence such as work related and ergonomic interventions which were utilized by the
majority of respondents. A greater understanding of explanatory factors of utilization may
require further mixed methods research. As the evidence-based becomes clearer, it might be
expected that practice patterns should become less variable.
To our knowledge our practice survey is the first to compare practice patterns of
chiropractors and physical therapists for people with neck pain. Previous surveys pertaining
to specific professions, reporting more broadly or on specific aspects of treatment have been
published making comparison difficult. Within the physical therapy profession, surveys have
focused on the utilization of manual therapies with greater attention to spinal (thrust)
manipulation for neck pain. Internationally and in Canada, a decrease in manipulative
procedures to the neck have been reported [64, 65] and there is evidence of them generally
being used less often in the neck compared to mobilization techniques [65–68]. Chiropractic
surveys report much higher utilization of spinal (thrust) manipulative procedures [56, 69, 70],
and this is not surprising since spinal manipulation is a core intervention within the paradigm
of chiropractic practice. Chiropractors see a client base that consists mainly of people with
back or neck pain  and are sought by the public for the treatment these problems [44, 55].
In one population based survey, chiropractors and physical therapists were the second and
third most utilized practitioners respectively for the treatment of chronic neck pain .
The effort to provide clear consistent messaging to relevant health professionals and the
public regarding treatments with demonstrated effect as well as those without or even
impeding recovery must continue and occur in multiple formats and mediums. This will help
with the expenditure and appropriate allocation of healthcare dollars to minimize over-treatment
with ineffective therapies or under-treatment of patients presenting with more complex conditions.
This survey has limitations that should be considered when interpreting the results. Our
survey was cross-sectional and therefore provides a one-time perspective of general treatment
trends. The benefit of this is that it can be revisited over time and results compared to detect
change. We are also aware that our sample was not proportional and over-represented
Canadian clinicians compared to other countries. It also was largely representative of the
chiropractic and physical therapy professions. Our snowball sampling technique was limited
by the associations known within our network and likely resulted in the exclusion of several
relevant associations, that had we been able to sample, their input could have altered our
results. Also we cannot be certain of our response rate due to the limitations of the information
that we were able to receive from the organizations that distributed the survey link. We are
aware of the potential for significant variation in the numbers of people that actually
received the link and therefore the response rate provided is likely a very
conservative one, yet still quite low. Those who choose to participate in survey research may
represent a systematically different type of practitioner than those who don’t choose to
participate. This survey was descriptive and to our knowledge the first of its kind. We did not
conduct a Bonferroni correction to our results therefore allowing for the possibility that some
reported differences in professions are due to chance. The results should not be considered
generalizable but rather hypothesis generating to be further explored in future studies.
Therefore, transferring the conclusions of this study to disciplines may not be appropriate.
Our survey respondents indicated that they widely use interventions with a strong evidence
base for effectiveness and that they also use a variety of other interventions with limited
support or conflicting evidence. This suggests there is a need for research to fill gaps in
evidence that are associated with variable practice patterns and knowledge translation to
reduce the usage of some interventions that have been shown to be ineffective. Examining the
consistency or lack of it between available evidence and current treatment patterns can
influence guideline dissemination as well as other interventions, such as payment reform, to
improve the effectiveness of current care for neck pain.
a LimeSurvey software, Survey Service & Consulting, Hamburg, Germany.
The authors declare that they have no competing interests.
LC provided input at all stages of survey development, conducted the analysis, drafted the
manuscript and incorporated feedback from all co-authors. JCM, ARG, DM and PLS provided
input at all stages of survey development and provided feedback on the analysis and
on the draft of the manuscript. All have given final approval for publication.
ICON is a multi-disciplinary collaborative group that includes scientist-authors (listed below)
and support staff (Margaret Lomotan) that conduct knowledge synthesis and translation
aimed at reducing the burden of neck pain. The ICON authors provided direction of the project;
input into the survey questions and review of the findings/manuscript and includes (in alphabetical order)
: Gert Bronfort, Norm Buckley, Lisa Carlesso, Linda Carroll, Pierre Côté, Jeanette Ezzo, Paulo Ferreira, Tim Flynn,
Charlie Goldsmith, Anita Gross, Ted Haines, Jan Hartvigsen, Wayne Hing, Gwendolen Jull, Faith Kaplan, Ron Kaplan,
Helge Kasch, Justin Kenardy, Per Kjær, Janet Lowcock, Joy MacDermid, Jordan Miller, Margareta Nordin,
Paul Peloso, Jan Pool, Duncan Reid, Sidney Rubinstein, P. Lina Santaguida, Anne Söderlund,
Natalie Spearing, Michele Sterling, Grace Szeto, Robert Teasell, Arianne Verhagen,
David M. Walton, Marc White. Lisa Carlesso is supported by a Canadian Health Research Institute Fellowship.
ICON (International Collaboration on Neck)
This work was supported by Canadian Institutes of Health Research (CIHR) grant(s)
FRN: KRS-102084 and FRN: 114380.
About Systematic Evidence Reviews and Clinical Practice Guidelines.
Anderson-Peacock, E, Blouin, JS, Bryans, R et al.
Chiropractic Clinical Practice Guideline: Evidence-based
Treatment of Adult Neck Pain Not Due to Whiplash
J Canadian Chiro Assoc 2005 (Sep); 49 (3): 158–209
Bono CM, Ghiselli G, Gilbert TJ, Kreiner DS, Reitman C, Summers JT, Baisden JL, Easa
J, Fernand R, Lamer T, Matz PG, Mazanec DJ, Resnick DK, Shaffer WO, Sharma AK,
Timmons RB, Toton JF, North American Spine S:
An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders.
Spine J 2011, 11:64–72.
Childs JD, Cleland JA, Elliott JM, Teyhen DS, Wainner RS, Whitman JM, Sopky BJ,
Godges JJ, Flynn TW, American Physical Therapy A:
Neck pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and
Health from the Orthopedic Section of the American Physical Therapy Association.
J Orthop Sports Phys Ther 2008, 38:A1–A34.
Chou R, Huffman LH; American Pain Society.
Nonpharmacologic Therapies for Acute and Chronic Low Back Pain:
A Review of the Evidence for an American Pain Society/
American College of Physicians Clinical Practice Guideline
Annals of Internal Medicine 2007 (Oct 2); 147 (7): 492–504
Hoy DG, Protani M, De R, Buchbinder R:
The epidemiology of neck pain.
Best Pract Res Clin Rheumatol 2010, 24:783–792.
Martin, BI, Deyo, RA, Mirza, SK et al.
Expenditures and Health Status Among Adults With Back and Neck Problems
JAMA 2008 (Feb 13); 299 (6): 656–664
Croft PR, Lewis M, Papageorgiou AC, Thomas E, Jayson MI, Macfarlane GJ, Silman AJ:
Risk factors for neck pain: a longitudinal study in the general population.
Pain 2001, 93:317–325.
Harkness EF, Macfarlane GJ, Silman AJ, McBeth J:
Is musculoskeletal pain more
common now than 40 years ago?: two population-based cross-sectional studies.
Rheumatology (Oxford) 2005, 44:890–895.
Haldeman S, Carroll L, Cassidy JD.
Findings From the Bone and Joint Decade 2000 to 2010 Task Force
on Neck Pain and its Associated Disorders
Journal of Occupational and Environmental Medicine 2010 (Apr); 52 (4): 424–427
Borghouts JA, Koes BW, Vondeling H, Bouter LM:
Cost-of-illness of neck pain in The
Netherlands in 1996.
Pain 1999, 80:629–636.
Sterling M, Kenardy J:
Physical and Psychological Aspects of Whiplash: Important Considerations for
Primary Care Assessment
Manual Therapy 2008 (May); 13 (2): 93–102
Thompson DP, Urmston M, Oldham JA, Woby SR:
The association between cognitive
factors, pain and disability in patients with idiopathic chronic neck pain.
Webb R, Brammah T, Lunt M, Urwin M, Allison T, Symmons D:
predictors of intense, chronic, and disabling neck and back pain in the UK general
Spine (Phila Pa 1976) 2003, 28:1195–1202.
Lee KC, Chiu TT, Lam TH:
The role of fear-avoidance beliefs in patients with neck
pain: relationships with current and future disability and work capacity.
Gross A, Goldsmith C, Hoving J, Haines T, Peloso P, Aker P, Santaguida P, Myers C:
Conservative Management of Mechanical Neck Disorders: A Systematic Review
J Rheumatol 2007 (May); 34 (5): 1083–1102
Miller J, Gross A, D'Sylva J, et al.
Manual Therapy and Exercise for Neck Pain: A Systematic Review
Man Ther. 2010 (Aug); 15 (4): 334–354
Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G:
Manipulation and mobilisation for mechanical neck disorders.
Cochrane Database Syst
Rev 2004, 1:CD004249.
Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G:
Cochrane review of manipulation and mobilization for mechanical neck disorders.
Vernon HT, Humphreys BK, Hagino CA:
A systematic review of conservative
treatments for acute neck pain not due to whiplash.
J Manipulative Physiol Ther 2005,
Vernon H, Humphreys BK:
Manual therapy for neck pain: an overview of
randomized clinical trials and systematic reviews.
Eura Medicophys 2007, 43:91–118.
Bronfort G Haas M Evans RL et al.
Efficacy of Spinal Manipulation and Mobilization for Low Back Pain and Neck Pain:
A Systematic Review and Best Evidence Synthesis
Spine J (N American Spine Soc) 2004 (May); 4 (3): 335–356
Kroeling P, Gross A, Goldsmith CH, Burnie SJ, Haines T, Graham N, Brant A:
Electrotherapy for neck pain.
Cochrane Database Syst Rev 2009, 4:CD004251.
Graham N, Gross A, Goldsmith CH, Klaber Moffett J, Haines T, Burnie SJ, Peloso PM:
Mechanical traction for neck pain with or without radiculopathy.
Syst Rev 2008, 3:CD006408.
Gross AR, Haines T, Goldsmith CH, Santaguida L, McLaughlin LM, Peloso P, Burnie S,
Hoving J, Cervical Overview G:
Knowledge to action: a challenge for neck pain
J Orthop Sports Phys Ther 2009, 39:351–363.
Gross AR, Kaplan F, Huang S, Khan M, Santaguida PL, Carlesso LC, Macdermid JC,
Walton DM, Kenardy J, Soderlund A, Verhagen A, Hartvigsen J:
patient education, orthotics, ergonomics and prevention strategies for neck pain: an
systematic overview update as part of the ICON project.
Open Orthop J 2013, 7:530–561.
Graham N, Gross AR, Carlesso LC, Santaguida PL, Macdermid JC, Walton D, Ho E:
ICON overview on physical modalities for neck pain and associated disorders.
Orthop J 2013, 7:440–460.
Charles C, Gafni A, Whelan T:
Shared decision-making in the medical encounter:
what does it mean? (or it takes at least two to tango).
Soc Sci Med 1997, 44:681–692.
Patient satisfaction with management of back pain. Part 2 an explorative,
qualitative study into patients’ satisfaction with physiotherapy.
Oostendorp RA, Rutten GM, Dommerholt J, der Sanden MW N-v, Harting J:
development and practice test of quality indicators for physiotherapy care in
patients with neck pain.
J Eval Clin Pract 2013, 19(6):1044–1053.
Streiner DL, Norman GR:
Health measurement scales: a practical guide to their
development and use. 4th edition.
New York: Oxford University Press; 2008.
CCA membership demographics survey.
Canadian Physiotherapy Association:
Member Services. ; 2013.
The MacKenzie Institute International: The MacKenzie Method.
Kay TM, Gross A, Goldsmith CH, Rutherford S, Voth S, Hoving JL, Bronfort G,
Exercises for mechanical neck disorders.
Cochrane Database Syst Rev
2012, 8, CD004250.
Gross A, Miller J, D’Sylva J, Burnie S, Goldsmith G, Graham N et al..
Manipulation or Mobilisation For Neck Pain: A Cochrane Review
Manual Therapy 2010 (Aug); 15 (4): 315–333
D’Sylva J, Miller J, Gross A, Burnie SJ, Goldsmith CH, Graham N, Haines T, Bronfort
G, Hoving JL, for the Cervical Overview G:
Manual therapy with or without physical
medicine modalities for neck pain: a systematic review.
Man Ther 2010, 15:415–433.
Furlan AD, Yazdi F, Tsertsvadze A, Gross A, Van Tulder M, Santaguida L, et. al.
A Systematic Review and Meta-analysis of Efficacy, Cost-effectiveness, and Safety
of Selected Complementary and Alternative Medicine for Neck and Low-back Pain
Evidence-Based Complementary and Alternative Medicine. 2012 (Nov 24); 2012: 953139
Driessen MT, Proper KI, van Tulder MW, Anema JR, Bongers PM, van der Beek AJ:
The effectiveness of physical and organisational ergonomic interventions on low back
pain and neck pain: a systematic review.
Occup Environ Med 2010, 67:277–285.
Verhagen AP, Karels C, Bierma-Zeinstra SM, Feleus A, Dahaghin S, Burdorf A, De Vet
HC, Koes BW:
Ergonomic and physiotherapeutic interventions for treating workrelated
complaints of the arm, neck or shoulder in adults. A Cochrane systematic
Eura Medicophys 2007, 43:391–405.
Brosseau L, Wells GA, Tugwell P, Casimiro L, Novikov M, Loew L, Sredic D, Clement
S, Gravelle A, Hua K, Kresic D, Lakic A, Menard G, Cote P, Leblanc G, Sonier M, Cloutier
A, McEwan J, Poitras S, Furlan A, Gross A, Dryden T, Muckenheim R, Cote R, Pare V,
Rouhani A, Leonard G, Finestone HM, Laferriere L, Dagenais S, et al:
evidence-based clinical practice guidelines on therapeutic massage for neck pain.
Bodyw Mov Ther 2012, 16:300–325.
Patel KC, Gross A, Graham N, Goldsmith CH, Ezzo J, Morien A, Peloso PM:
for mechanical neck disorders.
Cochrane Database Syst Rev 2012, 9, CD004871.
Bronfort G, Haas M, Evans R, Leiniger B, Triano J.
Effectiveness of Manual Therapies: The UK Evidence Report
Chiropractic & Osteopathy 2010 (Feb 25); 18 (1): 3
Wolsko PM, Eisenberg DM, Davis RB, Kessler R, Phillips RS:
Patterns and Perceptions of Care for Treatment of Back and Neck Pain: Results of a National Survey
Spine (Phila Pa 1976) 2003 (Feb 1); 28 (3): 292–297
Sherman, KJ, Cherkin, DC, Connelly, MT, Erro, J, Savetsky, JB, Davis, RB et al.
Complementary and Alternative Medical Therapies for Chronic Low Back Pain:
What Treatments Are Patients Willing To Try?
BMC Complement Altern Med. 2004 (Jul 19); 4: 9
Hogg-Johnson, S, van der Velde, G, Carroll, LJ et al.
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
Spine (Phila Pa 1976). 2008 (Feb 15); 33 (4 Suppl): S39–51
Hoe VC, Urquhart DM, Kelsall HL, Sim MR:
Ergonomic design and training for
preventing work-related musculoskeletal disorders of the upper limb and neck in adults.
Cochrane Database Syst Rev 2012, 8, CD008570.
Walton DM, Macdermid JC, Giorgianni AA, Mascarenhas JC, West SC, Zammit CA:
Risk Factors for Persistent Problems Following Acute Whiplash Injury: Update of a Systematic Review and Meta-analysis.
J Orthop Sports Phys Ther 2013, 43:31–43.
Sterling M, Pedler A:
A neuropathic pain component is common in acute whiplash and associated with a more complex clinical presentation.
Man Ther 2009, 14:173–179.
Graham N, Gross AR, Goldsmith C, Cervical Overview G:
Mechanical traction for mechanical neck disorders: a systematic review.
J Rehabil Med 2006, 38:145–152.
Hurwitz, EL, Carragee, EJ, van der Velde, G et al.
Treatment of Neck Pain: Noninvasive Interventions: Results of the Bone and Joint Decade
2000–2010 Task Force on Neck Pain and Its Associated Disorders
Spine (Phila Pa 1976). 2008 (Feb 15); 33 (4 Suppl): S123–152
Shields N, Capper J, Polak T, Taylor N:
Are cervical pillows effective in reducing neck pain?
N Z J Physiother 2006, 34:3–9.
Teasell RW, McClure JA, Walton D, Pretty J, Salter K, Meyer M, Sequeira K, Death B:
A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): part 2 - interventions for acute WAD.
Pain Res Manag 2010, 15:295–304.
Gross AR, Dziengo S, Boers O, Goldsmith CH, Graham N, Lilge L, Burnie S, White R:
Low Level Laser Therapy (LLLT) for Neck Pain: a systematic review and metaregression.
Open Orthop J 2013, 7:396–419.
Goode AP, Freburger J, Carey T:
Prevalence, practice patterns, and evidence for chronic neck pain.
Arthritis Care Res (Hoboken) 2010, 62:1594–1601.
Mootz RD, Cherkin DC, Odegard CE, Eisenberg DM, Barassi JP, Deyo RA.
Characteristics of Chiropractic Practitioners, Patients, and Encounters
in Massachusetts and Arizona
J Manipulative Physiol Ther. 2005 (Nov); 28 (9): 645–653
Elliott JM, Noteboom JT, Flynn TW, Sterling M:
Characterization of acute and chronic whiplash-associated disorders.
J Orthop Sports Phys Ther 2009, 39:312–323.
Boyles R, Toy P, Mellon J Jr, Hayes M, Hammer B:
Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review.
J Manipulative Physiol Ther 2011, 19:135–142.
Falla D, Jull G, Russell T, Vicenzino B, Hodges P:
Effect of neck exercise on sitting posture in patients with chronic neck pain.
Phys Ther 2007, 87:408–417.
Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B:
Retraining cervical joint position sense: the effect of two exercise regimes.
J Orthop Res 2007, 25:404–412.
Jull GA, Falla D, Vicenzino B, Hodges PW:
The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain.
Man Ther 2009, 14:696–701.
Louw A, Diener I, Butler DS, Puentedura EJ:
The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain.
Arch Phys Med Rehabil 2011, 92:2041–2056.
Widespread brain activity during an abdominal task markedly reduced
after pain physiology education: fMRI evaluation of a single patient with chronic low back pain.
Aust J Physiother 2005, 51:49–52.
Carlesso L, Bartlett D, Padfield B, Chesworth B:
Cervical manipulation and informed consent: Canadian manipulative physiotherapists opinions on communicating risk.
Physiother Can 2007, 59:86–96.
Carlesso L, Rivett D:
Manipulative practice in the cervical spine: a survey of IFOMPT member countries.
J Manipulative Physiol Ther 2011, 19:66–70.
Adams G, Sim J:
A survey of UK manual therapists’ practice of and attitudes towards manipulation and its complications.
Physiother Res Int 1998, 3:206–227.
Sweeney A, Doody C:
Manual therapy for the cervical spine and reported adverse effects: a survey of Irish manipulative physiotherapists.
Man Ther 2010, 15:32–36.
Use of high and low velocity cervical manipulative therapy procedures by Australian manipulative physiotherapists.
Aust J Physiother 2002, 48:189–193.
Gleberzon B, Stuber K.
Frequency of Use of Diagnostic and Manual Therapeutic Procedures of the Spine Taught at
the Canadian Memorial Chiropractic College: A Preliminary Survey of Ontario Chiropractors.
Part 1 - Practice Characteristics and Demographic Profiles
J Can Chiropr Assoc. 2013 (Jun); 57 (2): 165–175
A Survey of Practice Patterns and the Health Promotion and Prevention
Attitudes of US Chiropractors Maintenance Care: Part I
J Manipulative Physiol Ther 2000 (Jan); 23 (1): 1–9
Cherkin DC, Deyo RA, Sherman K, Erro JH, Hrbek A, Davis RB, Eisenberg DM.
Characteristics of Visits to Licensed Acupuncturists, Chiropractors,
Massage Therapists, and Naturopathic Physicians
J Am Board Fam Pract 2002; 15 (6): 463-480