Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. There were no declared conflicts of interest
Task Force Scoping Review Citation
Woodin JA, Orkin AM, Djarv T, Singletary EM, Zideman DA. On behalf of the International Liaison Committee on Resuscitation First Aid Task Force. Cervical Spinal Motion Restriction Scoping Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force, 2019 December 29. Available from: http://ilcor.org
Methodological Preamble and Link to Published Scoping Review
The continuous evidence evaluation process started with a scoping review of spinal motion restriction conducted by the ILCOR First Aid Task Force Scoping Review team. Evidence from published and grey literature was sought and considered by the First Aid Task Force. This topic was last reviewed in 2015 and a Consensus on Science with Treatment Recommendations was published (Singletary 2015 S269, Zideman 2015 278). Critical outcomes for the 2015 review included neurologic injury and complications. For the current scoping review, all clinical outcomes were considered.
Webmaster to insert the Scoping Review citation and link to PubMed using this format when/if it is available.
Not available at this time.
Adults and children with possible traumatic cervical spinal injury
spinal motion restriction
no spinal motion restriction or another type of spinal motion restriction
All clinical outcomes were considered
Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies), case series or reports, unpublished studies (e.g., conference abstracts, trial protocols) are eligible for inclusion.
Scoping search strategy: 1999-2019 and all languages are included as long as there is an English abstract
A search strategy was developed with assistance from an ILCOR Information Specialist for use with Medline and Embase (Appendix 1).
Final searches were run with a date limit of 1999-2019. Records from database searches were exported into EndNote (Clarivate Analytics X9.2) reference management software to facilitate removal of duplicates and screened by two reviewers (JW and AO). Final database searches were conducted November 6 and 10, 2019.
A detailed search of the gray literature was not performed for this review.
Appendix 1 Search Strategy
Items Identified by Database
Number of items Identified*
Number of items (Duplicates Removed)
Total – All Sources
Inclusion and Exclusion criteria
Human studies, including adults and children >1
All studies that address the question
All languages as long as an English abstract was available.
Studies not reporting outcomes
Studies that reviewed intubation, airway devices, laryngoscopy, vertebroplasty, laminectomy, or other surgical interventions.
Appendix 2 PRISMA Chart
Cowley 2017 158
5 studies included;
Authors research question: in terms of the potential for
worsening a cervical spine injury, if the vehicle occupant
is alert and able, is it safe to allow them to self-extricate
with minimal or no cervical spine immobilization?
Hauswald article is an expert opinion stressing self-protection.
Shafer & Naunheim is a quasi-pilot study showing that self-extricating with a cervical collar had lower range of motion than other techniques.
Engsberg builds on Shafer & Naunheims study above but uses EMS personnel and lay persons, shows same result.
Dixon 2015 is a quasi-experimental study with same methods as studies above, it showed same results.
Dixon 2016 is a simulated study on 16 patients, showing that controlled self-extrication without a collar comes with least cervical motion.
The author concludes that evidence is building to support self-extrication in alert patients with minimal or no cervical spine.
Kim 2018 1,
30 healthy students 21-25 years of age were randomly assigned to three groups. Each group tested all three collars but in different order.
30 trials with cervical collar (Xcollar)
30 trials with Philadelphia Collar,
30 trials with Stifneck Select Collar
No cervical collar
Cervical range of motion was evaluated via a digital camera regarding flexion, extension, bilateral bending, bilateral axial rotation.
XCollar had least motion in all assessed directions.
Range of mean degree in all directions of cervical motion: No collar 27.6-65.1 degrees, Philadelphia 15.4-22.5 degrees, Stifneck 10.5-14.4, XCollar 6.2-9.5 degrees
Authors conclude that range of movement is decreased with the use of a cervical collar.
Lemzye 2011 532
32-year-old man, suicide attempt by hanging. Amongst other interventions the prehospital team applied a lightweight foam collar around his neck. After radiology, the neck collar was removed, significant neck swelling was observed bilaterally just below straps of the cervical collar.
The authors discuss that devices for neck stabilization might increase intracranial pressure by venous congestion. Authors suggest that cervical collars should be avoided in suicide attempts by hanging. Deaths due to hanging is mainly due to blockage of blood stream to the brain, not asphyxia due to spinal fracture.
March 2002 421,
Single-blinded prospective cohort study
20 healthy volunteers were immobilized for one hour with cervical collar and strapped to a long wooden backboard. Midline palpation of vertebra was performed every 10 minutes. Participants self-rated pain (1 (lowest-10 highest) every 5 minutes
3/10 had pain within 40 minutes
5/10 developed point tenderness of vertebrae by 60 minutes, (mainly at vertebrae C7)
18/20 complained over increasing discomfort over time.
Median pain score increased from 1 (range 1-1) at 0 minutes to 4 (range 1-9) at 60 minutes
Authors conclude that immobilization causes false-positive exam for vertebral tenderness over time.
McGrath 2009 166,
13 healthy volunteers, both the intervention and comparison were applied on each volunteer
SAM splint molded to a cervical collar
Philadelphia cervical collar
No statistically significant difference in 5 different movements was found.
Mean degree of movement was 14.5-20.6 for SAM splint compared with 15.9-20.8 for Philadelphia collar (all p=>0.068)
Sample size and power calculation was done to detect an 11-degree difference. The largest detected mean difference was 2.54 more degrees for SAM on extension.
Schneider 2007 E1,
45 healthy adult volunteers wearing 7 cervical orthoses
Philadelphia cervical collar, Aspen cervical collar, PMT cervical collar, Miami J cervical collar
Minerva cervicothoracic orthosis, Lerman noninvasive halo, Sternal-Occipital-Manidbular-Immobilizer.
All devices reduced intervertebral motion. Cervico-throracic devices limited motions more than cervical devices.
Percentage of participants with intervertebral rotation >3 degrees on C1-C7, lowest rotation was mostly on C1-C2, greatest rotation was mostly on C3-C4-C5;
Pinless halo: 17.8-64.4%
Participants were asked to maximally flex/extend, laterally tilt bilateral and axial rotate bilat without deforming the device.
Task Force Insights
1. Why this topic was reviewed.
The 2015 ILCOR Consensus on Science for this topic identified very low certainty evidence from 8 observational studies evaluating the critical outcomes of neurologic injury and complications [Singletary 2015 S269, Zideman 2015 278]. That review was limited to mechanical cervical immobilization devices accessible to first aid providers, including cervical collars and sandbags with tape, but did not include spine boards. No evidence was identified to address the critical outcomes of neurologic injury and complications, the important outcomes of overall mortality, pain, and patient comfort, and the less important outcome of hospital length of stay. Since that review, the ILCOR continuous evidence evaluation process has included automated regular database searches for new studies, and no studies that would trigger a systematic review have been identified. Thus, the First Aid Task Force sought to conduct a scoping review to search for additional publications that would support past recommendations or lead to a systematic review.
2. Narrative summary of evidence identified
Six studies (Kim 2018 1, March 2002 421, Schneider 2007 E1, McGrath 2009 166, Cowley 2017 158, Lemzye 2011 532) were identified for inclusion for this scoping review; 1 single blinded prospective study, 2 comparative studies, 1 biomechanical evaluation of orthoses (experimental), 1 literature review, and 1 case report. Reported results and outcomes of these studies were insufficient to support a more specific systematic review for this PICOST.
Kim, J. G. et al. (Kim 2018 1) measured cervical range of motion (CROM) in three planes involving flexion/ extension, bilateral bending, and bilateral axial rotation in three cervical collars: Philadelphia® Collar (Philadelphia Collar Company, Philadelphia, PA), Stifneck® Select™ Collars (Laerdal, Wappingers Falls, NY) and XCollarÒ (Emegear). A total of 30 healthy university students including 15 men and 15 women aged 21-25 years, were allocated into three randomized groups. Cervical range of flexion and extension were measured in the seated position, and cervical range of bilateral axial rotation was measured in the supine position. The results showed that CROM was reduced with all collars, but that one collar was superior in its performance.
March et al. (March 2002 421) performed a single-blinded, prospective study enrolling twenty healthy volunteers (13 male and 7 females) without previous back pain or injuries, to determine whether spinal immobilization causes changes in physical exam findings over time. This study was undertaken to determine whether immobilization with a cervical collar and long board causes midline vertebral pain that is reproducible on palpation. Participants were fully immobilized for one hour with a cervical collar and strapped to a long wooden backboard. Midline palpation of vertebrae to illicit pain was performed at 10-minute intervals. In addition, the participants were asked to rate neck and back pain on a scale from 1 to 10 (1 for no pain, and 10 for unbearable pain), to see whether subjective pain from immobilization correlated with tenderness to palpation. Three participants had point tenderness of cervical vertebrae within 40 minutes. Five developed point tenderness of vertebrae by 60 minutes. Eighteen of 20 participants complained of increasing discomfort over time. The median initial pain scale was 1 (range 1–1), in contrast to 4 (range 1–9) at 60 minutes, p < 0.05.
Schneider et al. (Schneider 2007 E1) evaluated the biomechanical effectiveness of 7 different contemporary cervical orthoses for restricting head motion in 45 healthy adult volunteers as well as intervertebral motion in the cervical spine. Reported comfort of each brace was also recorded. Overall range of motion of the head in 3 planes as well as intervertebral motion in the sagittal plane were measured while wearing 7 cervical orthoses. This study showed all cervical braces signiﬁcantly reduced overall sagittal plane ﬂexion/extension motion of the head, as well as axial rotation and coronal plane side-to-side bending (p<0.0001) and all braces signiﬁcantly (p <0.001) reduced intervertebral rotation at all levels. Comfort varied between braces.
McGrath et al. (McGrath 2009 166) performed a prospective study using 13 healthy volunteers evaluating the effectiveness in limitation of cervical spine motion in 5 different movements with use of a single piece SAMÒ splint molded into a cervical collar compared with use of a 2-piece PhiladelphiaÒ cervical collar. The results of this small study showed no statistically signiﬁcant difference between the PhiladelphiaÒ collar and the SAMÒ splint at limiting movement of the cervical spine in any of the measured movements or in total allowed degrees of movement and suggest that the SAMÒ splint, when molded into a cervical collar, is as effective as the PhiladelphiaÒ collar at limiting movement of the cervical spine.
Cowley et al. (Cowley 2017 158) performed a review of the literature evaluating cervical spine motion during vehicle extrication. Five motion capture studies suggest that a patient who is allowed to self-extricate from a vehicle may move their neck up to four times less than a patient who is extricated by traditional methods, and an alert patient with a neck injury will demonstrate a self-protection mechanism, ensuring injuries are not worsened.
Lemzye et al. (Lemzye, 2011, 532) reported the case of a young man who attempted suicide by hanging and whose neurological status deteriorated until the cervical collar, which had been correctly placed by the prehospital team, was removed.
3. Narrative Reporting of the task force discussions
Similar to the 2015 CoSTR on cervical spinal motion restriction (Singletary 2015 S269, Zideman 2015 e225), this scoping review identified biomechanical and cohort studies (Schneider 2007 E1, Kim 2018 1, McGrath 2009 166) that report the ability to restrict cervical motion in varying amounts with the use of cervical collars. We also identified one case report (Lemzye 2011 532) and one small cohort study (March 2002 421) that identified a complication of worsening neurologic status, and a small prospective cohort study in healthy volunteers demonstrating a false positive tenderness with midline vertebral palpation following use of a cervical collar in combination with spinal motion restriction using a long backboard.
No studies were identified that directly addressed other outcomes such as neurological injury, survival, hospital length of stay, or additional outcomes such as the ability to correctly apply a cervical collar.
In Task Force discussions it was noted that the ability to properly apply a cervical collar is not a skill typically taught in first aid courses, although some large groups of first aid providers or first responders may receive specialized training and regular practice to allow them to use cervical collars, such as for sports-associated injuries. Task Force members representing multiple different countries and continents noted that cervical collars are no longer used routinely for trauma, other than for accidents where there is concern for high risk of cervical spinal injury. Additional concerns were expressed over the ability of a first aid provider to discriminate between high- or low-risk for spine injury. It was noted that criteria for determining high risk for cervical spine injury were reviewed in 2010 for ILCOR, but that other criteria have been developed by various organizations since then, and this topic of first aid recognition of high risk for c-spine injury may be in need of a future scoping or systematic review.
Given these discussion points, combined with the limited additional evidence on spinal motion restriction identified in this review, the task force did not feel there was sufficient information to prompt new systematic reviews or the reconsideration of current resuscitation guidelines/treatment recommendations.
Although this scoping review has not identified sufficient new evidence to prompt a systematic review it highlights significant gaps in the research evidence related to spinal motion restriction.
- There were no randomized controlled trials identified that evaluated spinal motion restriction compared with no spinal motion restriction adults and children considered to be at high-risk for cervical spine injury
- No comparative studies in children with potential spine injuries were identified that evaluate outcomes with cervical spinal motion restriction
- Research is needed to evaluate training requirements for the proper application of a cervical collar
Cowley A, Hague A, Durge N; Cervical spine immobilization during extrication of the awake patient: a narrative review. Eur J Emergency Med. 2017 Jun;24(3):158-161.
Kim, JG, Bang SH , Kang GH, Jang YS, Kim W, Choi HY, Kim GM; Comparison of the Efficacy of Three Cervical Collars in Restricting Cervical Range of Motion: A randomized study. Hong Kong Journal of Emergency Medicine 2018 11/12 1–6
Lemzye M, Palud A, Favory R, Mathieu D; Unintentional Strangulation by a Cervical Collar After Attempted Suicide by Hanging Emergency Medicine Journal 2011:28:532.
March JA, Ausband SC, Brown LH; Changes in Physical Examination Caused by Use of Spinal Immobilization Prehospital Emergency Care 2002;6:421–424
McGrath T, Murphy C; Comparison of a SAM Splint-Molded Cervical Collar with a Philadelphia Cervical Collar. Wilderness and Environmental Medicine, 20, 166 168 (2009)
Schneider AM, Hipp JA, Nguyen L, Reitman CA; Reduction in Head and Intervertebral Motion Provided by 7 Contemporary Cervical Orthoses in 45 individuals 2007 SPINE Volume 32, Number 1, pp E1–E6
Singletary EM, Zideman DA, De Buck ED, Chang WT, Jensen JL, Swain JM, Woodin JA, Blanchard IE, Herrington RA, Pellegrino JL, Hood NA, Lojero-Wheatley LF, Markenson DS, Yang HJ; Part 9: First Aid: 2015 International Consensus on First Aid Science with Treatment Recommendations. Circulation. Oct 20 2015;132 (16 Suppl 1):S269-311.
Zideman DA, Singletary EM, , De Buck EDJ, Chang WT, Jensen JL, Swain JM, Woodin JA, Blanchard IE, Herrington RA, Pellegrino JL, Hood NA, Lojero-Wheatley LF, Markenson DS, Yang HJ; on behalf of the First Aid Chapter Collaborators. Part 9: First aid: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.
Resuscitation. 2015; 95: e225 - e261
Ovid Multi-Database Search – run November 6, 2019
Cochrane Database of Systematic Reviews 2005 to October 30, 2019, EBM Reviews - ACP Journal Club 1991 to October 2019, EBM Reviews - Database of Abstracts of Reviews of Effects 1st Quarter 2016, EBM Reviews - Cochrane Clinical Answers September 2019, EBM Reviews - Cochrane Central Register of Controlled Trials September 2019, EBM Reviews - Cochrane Methodology Register 3rd Quarter 2012, EBM Reviews - Health Technology Assessment 4th Quarter 2016, EBM Reviews - NHS Economic Evaluation Database 1st Quarter 2016, Embase 1974 to 2019 November 05, Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily 1946 to November 05, 2019
exp "Neck Injuries"/ or exp "Cervical Vertebrae"/in
(exp "Neck"/ or exp "Cervical Vertebrae"/) and (injury or injuries or trauma* or compression).ti,ab,kf,kw.
(((neck or cervical) adj2 (injury or injuries or trauma* or compression or cadaver* or volunteer*)) or whiplash*).ti,ab,kf,kw.
("Spinal Cord Injuries"/ or "spinal cord injury"/ or (((spinal or spine) adj2 (injury or injuries or trauma* or compression)) or cadaver* or volunteer*).ti,ab,kf,kw.) and ("Neck"/ or (neck or cervical).ti,ab,kf,kw.)
or/1-4 [NECK INJURY]
exp "Spinal Cord Injuries"/ or exp "Spine"/in
((spine or spinal or vertebra* or coccyx or intervertebral or lumbar or sacrum or sacral) adj2 (injury or injuries or trauma* or compression or cadaver* or volunteer*)).ti,ab,kf,kw.
6 or 7 [SPINE INJURY]
5 or 8 [NECK/SPINE INJURY]
(immobiliz* or immobilis* or immobile or stabiliz* or stabilis* or restrain* or "trap squeeze" or "trapezius squeeze" or "head squeeze" or "trap grip" or "trapezius grip" or "head grip").ti,ab,kf,kw.
((reduction or reducing or reduce* or restrain* or decreas* or limit or limiting or restrict*) adj2 (movement or movements or motion or mobility or mobile)).ti,ab,kf,kw.
(neutral adj2 position*).ti,ab,kf,kw.
"Movement"/ph or "Head Movements"/ or "head movement"/ or (movement or motion or application).ti,ab,kf,kw.
"Emergency Medical Services"/mt or "First Aid"/mt
(out-of-hospital or "out of hospital" or prehospital or pre-hospital or pre-hospitalization or prehospitalization or pre-hospitalisation or prehospitalisation or (before adj2 hospital) or (before adj2 hospitalization) or (before adj2 hospitalisation)).ti,ab,kf,kw.
(EMS or "emergency medical service" or paramedic* or EMT or "emergency medical technician*" or "first responder*" or ambulance*).ti,ab,kf,kw.
(bystander* or by-stander* or stranger or strangers or layperson* or lay or public or "first aid" or "in position found").ti,ab,kf,kw.
"Orthotic Devices"/ or "orthoses"/ or "Braces"/ or "brace"/ or "Restraint, Physical"/mt or (orthotic* or orthosis or orthoses or orthesis or "orthopedic support device*" or "orthopaedic support device*" or collar* or brace* or bracing or restraint*).ti,ab,kf,kw.
(or/13-17) and 18
9 and 20 [(NECK/SPINE INJURY) + (IMMOBILIZATION/STABILIZATION]
(Animals/ or "Animal Experimentation"/ or "Models, Animal"/ or "Disease Models, Animal"/) not (Humans/ or "Human Experimentation"/)
(exp "animal model"/ or exp "animal experiment"/ or "nonhuman"/ or exp "vertebrate"/) not (exp "human"/ or exp "human experiment"/)
21 not (22 or 23) [(NECK/SPINE INJURY) + (IMMOBILIZATION/STABILIZATION), HUMAN]
(comment or letter or "newspaper article" or news or note).pt.
24 not 25 [(NECK/SPINE INJURY) + (IMMOBILIZATION/STABILIZATION), HUMAN, SUBSTANTIVE]
(Randomized Controlled Trial or Controlled Clinical Trial or Pragmatic Clinical Trial or Equivalence Trial or Clinical Trial, Phase III).pt.
Randomized Controlled Trial/
exp Randomized Controlled Trials as Topic/
Controlled Clinical Trial/
exp Controlled Clinical Trials as Topic/
(random* or sham or placebo*).ti,ab,kf,kw.
((singl* or doubl*) adj (blind* or dumm* or mask*)).ti,ab,kf,kw.
((tripl* or trebl*) adj (blind* or dumm* or mask*)).ti,ab,kf,kw.
(control* adj3 (study or studies or trial* or group*)).ti,ab,kf,kw.
(nonrandom* or non random* or non-random* or quasi-random* or quasirandom*).ti,ab,kf,kw.
((open label or open-label) adj5 (study or studies or trial*)).ti,ab,kf,kw.
((equivalence or superiority or non-inferiority or noninferiority) adj3 (study or studies or trial*)).ti,ab,kf,kw.
(pragmatic study or pragmatic studies).ti,ab,kf,kw.
((pragmatic or practical) adj3 trial*).ti,ab,kf,kw.
((quasiexperimental or quasi-experimental) adj3 (study or studies or trial*)).ti,ab,kf,kw.
(phase adj3 (III or "3") adj3 (study or studies or trial*)).ti,ab,kf,kw.
"Observational Studies as Topic"/ or observational study.pt.
Cohort Studies/ or Follow-Up Studies/ or Longitudinal Studies/ or Prospective Studies/ or Retrospective Studies/
"Evaluation Studies as Topic"/ or evaluation studies.pt.
(((evaluation or cohort or cohorts or longitudinal or followup or follow-up or prospective or observational or retrospective or population-based or multidimensional or multi-dimensional or case-control or comparative or cross-sectional or evaluation) adj1 (study or studies)) or "cohort analys*").ti,ab,kf,kw.
"Epidemiologic Studies"/ or "Cross-Over Studies"/ or "crossover procedure"/
(((epidemiologic* or intervention or experimental) adj1 (study or studies)) or cross-over or crossover or questionnaire* or survey*).ti,ab,kf,kw.
("before and after" or "interrupted time series").ti,ab,kf,kw.
or/62-65 [ADDITIONAL STUDIES]
26 and (53 or 61 or 66) [(NECK/SPINE INJURY) + (IMMOBILIZATION/STABILIZATION), HUMAN, SUBSTANTIVE, WITH STUDY FILTERS]
limit 67 to yr="1999 -Current" [Limit not valid in DARE; records were retained]
EBM Reviews - Cochrane Clinical Answers <October 2019>
EBM Reviews - Cochrane Methodology Register <3rd Quarter 2012>
EBM Reviews - Health Technology Assessment <4th Quarter 2016>
remove duplicates from 68
EBM Reviews - Cochrane Clinical Answers <October 2019>
EBM Reviews - Cochrane Methodology Register <3rd Quarter 2012>
EBM Reviews - Health Technology Assessment <4th Quarter 2016>
CINAHL Plus with Full Text (EBSCOhost) – run November 10, 2019