Cervical Spinal Stabilization (FA): Scoping Review

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This Review is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final Review will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

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, Djarv T, Poole K, Singletary EM, Zideman DA. On behalf of the International Liaison Committee on Resuscitation First Aid Task Force. Cervical Spinal Injury Manual Stabilization 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 Injury Manual Stabilization 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. For this scoping review, all clinical outcomes were considered.

Scoping Review

Not available at this time

PICOST

PICOST

Description (with recommended text)

Population

Among injured adults with identified high-risk for spinal injury

Intervention

Does use of any manual stabilization technique (i.e., use of trap-squeeze or head-squeeze techniques) by first aid/ lay providers

Comparison

Compared with each other or to no manual stabilization

Outcomes

All outcomes were included

Study Design

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trials, interrupted time series, controlled before-and-after studies, cohort studies), case series or reports, unpublished studies (e.g., conference abstracts, trial protocols) were eligible for inclusion.

Timeframe

1999-2019 and all languages were included as long as there is an English abstract.

Search Strategies

A search strategy was developed with ILCOR-sponsored Information Specialist Mary-Doug Wright (Appendix 1). Final searches were run with a date limit of 1999-2019. A total of 3978 records were identified, with 3669 after removal of duplicates. 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 TD). Final database searches were conducted November 6 and 10, 2019.

Appendix 1 Search Strategy

Items Identified by Database

Database Name

Number of items Identified*

Number of items (Duplicates Removed)

Medline

2298

2296

Embase

908

868

CDSR

3

0

CCRT

166

140

ACPJC

2

2

DARE

1

1

NHSEED

1

1

CINAHL

599

361

Total – All Sources

3978

3669

Gray Literature Search

A limited Gray Literature information search was conducted on November 30, 2019, using Google Scholar to identify relevant literature not published in the database searches above. Keywords included ‘cervical spine manual stabilization’ and ‘prehospital’. The search yielded 57,500 hits and the top one hundred were reviewed for relevant articles or blogs. The gray literature search was updated to December 25, 2019.

Inclusion and Exclusion criteria

Inclusion: Human studies involving adults only that answered the PICOST question

All languages as long as an English abstract was available

Exclusion: Studies that included children under 18 years of age

Studies not reporting on outcomes

Studies that reviewed intubation, airway devices, laryngoscopy, vertebroplasty, laminectomy, or other surgical interventions.

Appendix 2 PRISMA

Data table

Reference

Methods

Participants

Interventions

Comparisons

Outcomes

Notes

Schrier 2015 116

Canada

Experimental;

The aim of the study was to assess log roll with one versus three assistants. While manually stabilizing the head and neck with either ‘head squeeze’ technique or ‘trap squeeze’ technique.

Paramedics with at least one year of experience received

standardized training 20-45 minutes.

A standardized patient was used.

10 trials of

Log roll with one assistant, 5 with head squeeze and 5 with trap squeeze

10 trials of Log roll with three assistants, 5 with head squeeze and 5 with trap squeeze

Mean cervical spine angular motion in degrees from 5 trials each (20 total). For one assistant, mean total motion with head squeeze was 24.2 degrees (95% CI, 22.0-26.4), compared with 21.4 degrees (95% CI, 19.2-23.7) when trap squeeze was used (SMD of -2.8 degrees).

For three assistant group, total mean motion with use of head squeeze was 20.2 degrees (95% CI, 18.0-22.5), compared with 18.3 degrees (95% CI, 16.1-20.5) with use of trap squeeze (SMD, -1.9 degrees).

(HS vs TS p=002,

One assistant vs three assistant p=0.0002)

Large individual difference between paramedics were found.

In summary, this study found that use of a trap squeeze during log roll generally produced less lateral flexion and rotational motion than use of head squeeze but allowed more extension in the six directions measured. However, the clinical relevance of the magnitude of the differences in movement remains unclear.

Boissy 2011 80

Canada

Experimental cross-over

12 trained rescuers, 2 male volunteer subjects,

4 test scenarios: a) 6-persons lift and slide technique to spine board b) 5-person log roll to spine board

c) agitated patient trying to sit up

d) agitated patient trying to rotate head

Manual stabilization with head squeeze

Manual stabilization with trap squeeze

No MID was found between head squeeze and trap squeeze for lift and slide.

For log roll only cervical spine extension showed a significant MID (6 degrees more for HS (p < 0.0001) and right rotation (3.9 degrees more for HS (p <0.007).

For agitated patient trying to sit up, head squeeze was inferior to trap squeeze (significant MID for flexion, lateral flexion and rotation (p=<0.00).

For agitated patient trying to rotate the head, head squeeze was inferior to trap squeeze (6.4 degrees more with head squeeze, p=<0.0001)

A priori minimal important difference (MID) was 5 degrees for flexion or extension and 3 degrees for rotation or lateral flexion.

Authors concluded that limited motion occurs during lift and slide with both head squeeze and trap squeeze, but during log roll and in confused patients, head squeeze comes with increased motion. Further, more variability was noted with head squeeze than trap squeeze.

Cowley 2017 158

Review article

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 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.

Task Force Insights

1. Why this topic was reviewed.

In 2015 an ILCOR review of Cervical Spinal Motion Restriction was completed with a Consensus on Science with Treatment Recommendations (CoSTR){Singletary 2015 S269}{Zideman 2015 e225} that suggested against the use of cervical collars by first aid providers. This led to questions regarding the role of first aid providers when caring for individuals with suspected cervical spine injury until advanced care arrives. A previous 2010 ILCOR CoSTR (FA 502){Markenson 2010 S582} described criteria for recognizing suspected traumatic cervical spinal injury.

The 2015 Red Cross-American Heart Association First Aid Guidelines{Singletary 2015 S574} for spinal motion restriction state “if a first aid provider suspects a spinal injury, he or she should have the person remain as still as possible and await the arrival of EMS providers (Class1, LOEC-EO).”

The 2015 European Resuscitation Council First Aid Guidelines{Zideman 2015 278} for cervical spinal motion restriction state “The routine application of a cervical collar by a first aid provider is not recommended. In suspected cervical spine injury, manually support the head in position limiting angular movement until experienced healthcare provision is available”.

The First Aid Task Force sought to conduct a scoping review using a newly developed PICOST question to search for scientific evidence that would provide information to support the development of a systematic review to help guide first aid for individuals with a suspected cervical spinal injury.

2. Narrative summary of evidence identified

Two studies were found in the database search that indirectly addressed this PICOST. Both of these studies evaluated the outcome of cervical spine motion while using manual stabilization techniques during patient transfer. A narrative literature review discussing cervical spine motion during vehicle extrication was also identified.

Shrier et al.{Schrier 2015 116} used a cross-over design to compare specifically trained paramedics' ability to minimize cervical spine motion during 20 subject transfers onto a vacuum mattress with two cervical manual stabilization techniques, head squeeze compared with trap squeeze, and two transfer methods, log roll using one assistant (LR2) compared with log roll using 3 assistants (LR4).

The paramedic responsible for cervical spine stabilization at the head (lead paramedic) performed each of the “interventions” (i.e., the combination of transfer method and stabilization technique) on the same subject. Each lead paramedic was randomly assigned to use either the log roll with one assistant LR2 (10 transfers) or the log roll with three assistants LR4 (10 transfers), and in each of the log roll techniques they either used the head squeeze technique (5 transfers per log roll technique) or trap squeeze technique (5 transfers per log roll technique). The lead paramedic was assisted by other paramedics attending the same data collection session, or persons specifically trained in the LR2 and LR4 transfer method. The main outcome was cervical spine motion measured using inertial measuring units with a triad of sensors (accelerometers, gyrometers and magnetometers) placed on the forehead and sternum.

  • For the one-assistant log roll (LR2) group, total motion as assessed with a mean of 5 trials in all six moving directions with use of head squeeze was 24.2 degrees (95% CI, 22.0-26.4), compared with 21.4 degrees (95% CI, 19.2-23.7) with use of trap squeeze (SMD of -2.8 degrees; p = 0.002).
  • For the three-assistant log role (LR4) group, total mean motion with use of head squeeze was 20.2 degrees (95% CI, 18.0-22.5), compared with 18.3 degrees (95% CI, 16.1-20.5) with use of trap squeeze (SMD, -1.9 degrees; p= 0.0002).
  • The effectiveness of the trap squeeze was independent of the transfer method (p = 0.42 for the interaction term).

Boissy et al.{Boissy 2011 80} performed a cross-over design study of cervical spine motion in two healthy male volunteers with a series of test scenarios using twelve experienced lead rescuers recruited from certified athletic therapists, athletic trainers and physiotherapists with specific training in cervical spine stabilization. All participants had prior training in stabilization techniques in the prior 6 months.

Four test scenarios were created to assess cervical spinal motion with use of the head squeeze (HS) compared with use of the trap squeeze (TS) cervical spine stabilization techniques on two healthy male volunteers (64kg and 77kg, respectively). The four scenarios compared both HS and TS during lift-and-slide (L&S) and log-roll (LR) placement onto a spine board. The a priori minimal important difference (MID) was 5 degrees for flexion or extension and 3 degrees for rotation or lateral flexion. Overall, the L&S technique was statistically superior to the LR technique (p <0.0001). Regarding range of motion, extension showed a MID between head squeeze and trap squeeze, (6 degrees more for HS (p < 0.0001) and right rotation (3.9 degrees more for HS (p <0.007). There was similar inter-rescuer and intertrial variability of motion for HS and TS during L&S and LR.

Cowley et al.{Cowley 2017 158} conducted a review of evidence evaluating cervical spine motion during vehicle extrication, with 5 studies identified. These motion capture studies suggest that an individual who is allowed to self-extricate from a vehicle without a cervical collar may move their neck up to four times less than one who is extricated by traditional methods.

A review of the gray literature identified in Google Scholar identified multiple webpages with blog-style articles discussing the pros and cons of cervical collar use in blunt trauma casualties, but no articles describing manual stabilization or support of the cervical spine. Database searches also provide information related to manual in-line stabilization of the injured cervical spine during airway management. These in-hospital studies were excluded from our review due to extreme indirectness.

3. Narrative Reporting of the task force discussions

The First Aid Task Force discussed many issues relating to evaluating manual stabilization of the cervical spine. Our paraphrased question was, when caring for a person who is considered at high risk for a cervical spine injury, should a first aid provider use manual stabilization techniques to support a person’s head, with the goal of preventing further movement (and potential injury) prior to arrival of emergency medical services and application of spinal motion restriction?

No studies were identified that directly review manual stabilization as might be applied in a first aid or first responder setting for persons identified at high risk for a cervical spine injury. We included two studies{Schrier 2015 116}{Boissy 2011 80} that evaluated outcomes of spine motion during use of cervical spine stabilization techniques applied to facilitate lift and transfer, which are skills requiring education and potential spaced training to perform correctly. These techniques require teamwork and are likely beyond scope of first aid. Despite this, the included studies provide evidence that may indirectly relate to this review. Although they were performed in volunteers, the included studies suggest that the use of either head squeeze or trap squeeze manual stabilization may help limit cervical spine movement in the absence of a cervical collar.

In Task Force discussions it was noted that in several countries (Japan, Australia, New Zealand, and the United Kingdom) first aid guidelines recommend that the head should be manually supported in individuals with a suspected cervical spine injury. The Royal College of Surgeons of Edinburgh RCSEd consensus statement includes “Manual-in-line stabilization is a suitable alternative to a cervical collar.”{Connor 2012 1067}

Other countries, such as Norway have national guidelines for prehospital spinal stabilization that employ a strategy of minimal handling.{Kornhall 2017 2}

A part of first aid is self-help. A narrative literature review{Cowley 2017 158} suggests that an awake and alert person who is allowed to self-extricate from a vehicle may move their neck up to four times less than someone who is extricated by traditional methods. The Task Force discussion of this study concluded that an awake and alert injured person may be capable of holding his or her own head and neck in a stable position and thus may not need to have manual stabilization applied by a first aid provider while awaiting advanced medical care. On the other hand, it was the Task Force consensus opinion in discussion that injured persons who are not alert or awake may benefit from gentle support of the head, similar to the head squeeze stabilization technique, to prevent inadvertent movement.

Given these discussion points, combined with the limited additional information identified in this review, the Task Force agreed that there is insufficient information to pursue a systematic review.

Knowledge Gaps

Although this scoping review has not identified sufficient evidence to prompt a systematic review, it highlights significant gaps in the research evidence related to cervical spinal stabilization.

  • There were no studies identified that assessed manual stabilization techniques in adults or children with possible traumatic cervical spinal injury in the first aid setting
  • It is unclear if manual cervical spine stabilization is needed in an awake and alert person who is potentially capable of ‘self-stabilization’, even if identified as at high-risk for cervical spine injury.

References

Boissy P, Shrier I, Brie`re S, Mellete J, Fecteau L, Matheson GO, Garza D, Meeuwisse WH, Segal E, Boulay J, Steele RJ: Effectiveness of Cervical Spine Stabilization Techniques. Clin J Sport Med. 2011 Mar;21(2):80-8

Connor D, Greaves I, Porter K, Bloch M. Pre-hospital spinal immobilisation: an initial consensus statement. Emerg Med J December 2013 Vol 30 No.12 1067-1069

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.

Kornhall DK, Jørgensen JJ, Brommeland T, Hyldmo PK, Asbjørnsen H, Dolven T , Hansen T, Jeppesen E. The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury. Scandinavian Journal of Trauma Resuscitation and Emergency Medicine. 2017; 25: 2.

Markenson D, Ferguson JD, Chameides L, Cassan P, Chung K-L, Epstein JL, Gonzales L, Hazinski MF, Herrington RA, Pellegrino JL, Ratcliff N, Singer AJ; on behalf of the First Aid Chapter Collaborators. Part 13: first aid: 2010 American Heart Association and American Red Cross International Consensus on First Aid Science. Circulation. 2010;122(suppl 2):S582–S605.

Shrier I, Boissy P, Lebel K, Boulay J, Segal E, Delaney JS, Vacon C, Steele RJ. Cervical Spine Motion during Transfer and Stabilization Techniques. Prehosp Emerg Care. 2015 January-March;19(1):116-125.

Singletary EM, Charlton NP, Epstein JL, Ferguson JD, Jensen JL, MacPherson AI, Pellegrino JL, Smith WR, Swain JM, Lojero-Wheatley LF, Zideman DA. Part 15: First Aid: 2015 American Heart Association and American Red Cross Guidelines Update for First Aid. Circulation. 2015;132(suppl 2):S574–S589.

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

Zideman DA, De Buck EDJ, Singletary EM, Cassan P, Chalkias AF, Evans TR, Hafner CM, Handley AJ, Meyran D, Schunder-Tatzber S, Vandekerckhove PG. European Resuscitation Council Guidelines

for Resuscitation 2015 Section 9 First Aid. Resuscitation 95 (2015): 278-287

Appendix

Appendix 1

Search strategy

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

1

exp "Neck Injuries"/ or exp "Cervical Vertebrae"/in

15189

2

(exp "Neck"/ or exp "Cervical Vertebrae"/) and (injury or injuries or trauma* or compression).ti,ab,kf,kw.

22459

3

(((neck or cervical) adj2 (injury or injuries or trauma* or compression or cadaver* or volunteer*)) or whiplash*).ti,ab,kf,kw.

28811

4

("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.)

42497

5

or/1-4 [NECK INJURY]

78407

6

exp "Spinal Cord Injuries"/ or exp "Spine"/in

60933

7

((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.

139548

8

6 or 7 [SPINE INJURY]

165185

9

5 or 8 [NECK/SPINE INJURY]

210688

10

(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.

922769

11

((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.

46661

12

(neutral adj2 position*).ti,ab,kf,kw.

7587

13

"Movement"/ph or "Head Movements"/ or "head movement"/ or (movement or motion or application).ti,ab,kf,kw.

1220630

14

"Emergency Medical Services"/mt or "First Aid"/mt

6922

15

(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.

208318

16

(EMS or "emergency medical service" or paramedic* or EMT or "emergency medical technician*" or "first responder*" or ambulance*).ti,ab,kf,kw.

124775

17

(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.

1072733

18

"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.

62391

19

(or/13-17) and 18

10134

20

or/10-12,19 [IMMOBILIZATION/STABILIZATION]

977323

21

9 and 20 [(NECK/SPINE INJURY) + (IMMOBILIZATION/STABILIZATION]

14370

22

(Animals/ or "Animal Experimentation"/ or "Models, Animal"/ or "Disease Models, Animal"/) not (Humans/ or "Human Experimentation"/)

8011146

23

(exp "animal model"/ or exp "animal experiment"/ or "nonhuman"/ or exp "vertebrate"/) not (exp "human"/ or exp "human experiment"/)

9923897

24

21 not (22 or 23) [(NECK/SPINE INJURY) + (IMMOBILIZATION/STABILIZATION), HUMAN]

13509

25

(comment or letter or "newspaper article" or news or note).pt.

3491608

26

24 not 25 [(NECK/SPINE INJURY) + (IMMOBILIZATION/STABILIZATION), HUMAN, SUBSTANTIVE]

13451

27

(Randomized Controlled Trial or Controlled Clinical Trial or Pragmatic Clinical Trial or Equivalence Trial or Clinical Trial, Phase III).pt.

1209797

28

Randomized Controlled Trial/

1071893

29

exp Randomized Controlled Trials as Topic/

309675

30

Controlled Clinical Trial/

556044

31

exp Controlled Clinical Trials as Topic/

321814

32

Randomization/

185770

33

Random Allocation/

206534

34

Double-Blind Method/

446267

35

Double-Blind Studies/

279094

36

Single-Blind Method/

84068

37

Single-Blind Studies/

85973

38

Placebos/

347423

39

Control Groups/

112184

40

Control Group/

112082

41

(random* or sham or placebo*).ti,ab,kf,kw.

3984945

42

((singl* or doubl*) adj (blind* or dumm* or mask*)).ti,ab,kf,kw.

697273

43

((tripl* or trebl*) adj (blind* or dumm* or mask*)).ti,ab,kf,kw.

3766

44

(control* adj3 (study or studies or trial* or group*)).ti,ab,kf,kw.

3039502

45

(nonrandom* or non random* or non-random* or quasi-random* or quasirandom*).ti,ab,kf,kw.

106973

46

allocated.ti,ab,kf,kw.

202888

47

((open label or open-label) adj5 (study or studies or trial*)).ti,ab,kf,kw.

132985

48

((equivalence or superiority or non-inferiority or noninferiority) adj3 (study or studies or trial*)).ti,ab,kf,kw.

30493

49

(pragmatic study or pragmatic studies).ti,ab,kf,kw.

1160

50

((pragmatic or practical) adj3 trial*).ti,ab,kf,kw.

12796

51

((quasiexperimental or quasi-experimental) adj3 (study or studies or trial*)).ti,ab,kf,kw.

18250

52

(phase adj3 (III or "3") adj3 (study or studies or trial*)).ti,ab,kf,kw.

164965

53

or/27-52 [RCT/CT]

6359525

54

"Observational Studies as Topic"/ or observational study.pt.

257141

55

Cohort Studies/ or Follow-Up Studies/ or Longitudinal Studies/ or Prospective Studies/ or Retrospective Studies/

4144413

56

Cross-Sectional Studies/

509674

57

"Evaluation Studies as Topic"/ or evaluation studies.pt.

400112

58

Case-Control Studies/

388727

59

Comparative Study.pt.

2030551

60

(((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.

2762511

61

or/54-60 [OBSERVATIONAL]

7987702

62

"Epidemiologic Studies"/ or "Cross-Over Studies"/ or "crossover procedure"/

360834

63

(((epidemiologic* or intervention or experimental) adj1 (study or studies)) or cross-over or crossover or questionnaire* or survey*).ti,ab,kf,kw.

3131261

64

("before and after" or "interrupted time series").ti,ab,kf,kw.

628823

65

"case series".ti,ab,kf,kw.

169497

66

or/62-65 [ADDITIONAL STUDIES]

4040248

67

26 and (53 or 61 or 66) [(NECK/SPINE INJURY) + (IMMOBILIZATION/STABILIZATION), HUMAN, SUBSTANTIVE, WITH STUDY FILTERS]

5646

68

limit 67 to yr="1999 -Current" [Limit not valid in DARE; records were retained]

EBM Reviews - Cochrane Database of Systematic Reviews <2005 to November 6, 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 <October 2019>

EBM Reviews - Cochrane Central Register of Controlled Trials <October 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>

4706

3

2

1

0

411

0

0

1

1989

2299

69

remove duplicates from 68

EBM Reviews - Cochrane Database of Systematic Reviews <2005 to November 6, 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 <October 2019>

EBM Reviews - Cochrane Central Register of Controlled Trials <October 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>

3379

3

2

1

0

166

0

0

1

908

2298

CINAHL Plus with Full Text (EBSCOhost) – run November 10, 2019

S1

(MH "Neck Injuries+") OR (MH "Cervical Vertebrae+/IN")

5,080

S2

((MH "Neck") OR (MH "Cervical Vertebrae+")) AND (TI (injury OR injuries OR trauma* OR compression) OR AB (injury OR injuries OR trauma* OR compression))

3,663

S3

(TI (((neck OR cervical) N2 (injury OR injuries OR trauma* OR compression OR cadaver* OR volunteer*)) OR whiplash*) OR AB (((neck OR cervical) N2 (injury OR injuries OR trauma* OR compression OR cadaver* OR volunteer*)) OR whiplash*))

5,577

S4

((MH "Spinal Cord Injuries+") OR (TI (((spinal OR spine) N2 (injury OR injuries OR trauma* OR compression)) OR cadaver* OR volunteer*) OR AB (((spinal OR spine) N2 (injury OR injuries OR trauma* OR compression)) OR cadaver* OR volunteer*)) AND ((MH "Neck") OR (TI (neck OR cervical) OR AB (neck OR cervical))

99,477

S5

S1 OR S2 OR S3 OR S4

101,704

S6

(MH "Spinal Cord Injuries+") OR (MH "Spine/IN")

19,242

S7

TI ((spine OR spinal OR vertebra* OR coccyx OR intervertebral OR lumbar OR sacrum OR sacral) N2 (injury OR injuries OR trauma* OR compression OR cadaver* OR volunteer*)) OR AB ((spine OR spinal OR vertebra* OR coccyx OR intervertebral OR lumbar OR sacrum OR sacral) N2 (injury OR injuries OR trauma* OR compression OR cadaver* OR volunteer*))

21,356

S8

S6 OR S7

27,421

S9

S5 OR S8

107,644

S10

TI (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") OR AB (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")

34,300

S11

TI ((reduction OR reducing OR reduce* OR restrain* OR decreas* OR limit OR limiting OR restrict*) N2 (movement OR movements OR motion OR mobility OR mobile)) OR AB ((reduction OR reducing OR reduce* OR restrain* OR decreas* OR limit OR limiting OR restrict*) N2 (movement OR movements OR motion OR mobility OR mobile))

5,675

S12

TI (neutral N2 position*) OR AB (neutral N2 position*)

1,083

S13

(MH "Movement/PH") OR TI (movement OR motion OR application) OR AB (movement OR motion OR application)

189,744

S14

(MH "Emergency Medical Services/MT") OR (MH "First Aid/MT")

1,949

S15

TI (out-of-hospital OR "out of hospital" OR prehospital OR pre-hospital OR pre-hospitalization OR prehospitalization OR pre-hospitalisation OR prehospitalisation OR (before N2 hospital) OR (before N2 hospitalization) OR (before Nj2 hospitalisation)) OR AB (out-of-hospital OR "out of hospital" OR prehospital OR pre-hospital OR pre-hospitalization OR prehospitalization OR pre-hospitalisation OR prehospitalisation OR (before N2 hospital) OR (before N2 hospitalization) OR (before Nj2 hospitalisation))

15,844

S16

TI (EMS OR "emergency medical service" OR paramedic* OR EMT OR "emergency medical technician*" OR "first responder*" OR ambulance*) OR TI (EMS OR "emergency medical service" OR paramedic* OR EMT OR "emergency medical technician*" OR "first responder*" OR ambulance*)

11,394

S17

TI (bystander* OR by-stander* OR stranger OR strangers OR layperson* OR lay OR public OR "first aid" OR "in position found") OR AB (bystander* OR by-stander* OR stranger OR strangers OR layperson* OR lay OR public OR "first aid" OR "in position found")

162,230

S18

(MH "Orthoses") OR (MH "Restraint, Physical/MT") OR TI (orthotic* OR orthosis OR orthoses OR orthesis OR "orthopedic support device*" OR "orthopaedic support device*" OR collar* OR brace* OR bracing OR restraint*) OR AB (orthotic* OR orthosis OR orthoses OR orthesis OR "orthopedic support device*" OR "orthopaedic support device*" OR collar* OR brace* OR bracing OR restraint*)

18,872

S19

(S13 OR S14 OR S15 OR S16 OR S16 OR S17) AND S18

2,946

S20

S10 OR S11 OR S12 OR S19

42,128

S21

S9 AND S20

3,671

S22

(MH "Vertebrates+") NOT (MH "Human")

170,306

S23

S21 NOT S22

3,608

S24

(PT "commentary" OR "editorial" OR "letter" OR "pamphlet" OR "pamphlet chapter")

325,656

S25

S23 NOT S24

3,537

S26

(MH "Randomized Controlled Trials+") OR (MH "Clinical Trials") OR (MH "Random Assignment") OR (MH "Single-Blind Studies") OR (MH "Double-Blind Studies") OR (MH "Triple-Blind Studies") OR (MH "Placebos") OR (MH "Control Group")

296,021

S27

TI (random* OR sham OR placebo*) OR AB (random* OR sham OR placebo*)

323,775

S28

TI ((singl* OR doubl* OR tripl* OR trebl*) W (blind* OR dumm* OR mask*)) OR AB ((singl* OR doubl* OR tripl* OR trebl*) W (blind* OR dumm* OR mask*))

309

S29

TI (control* N3 (study OR studies OR trial* OR group*)) OR AB (control* N3 (study OR studies OR trial* OR group*))

251,366

S30

TI (nonrandom* OR non random* OR non-random* OR quasi-random* OR quasirandom* OR ALLOCATED) OR AB (nonrandom* OR non random* OR non-random* OR quasi-random* OR quasirandom* OR ALLOCATED)

56,142

S31

TI (nonrandom* OR non random* OR non-random* OR quasi-random* OR quasirandom* OR allocated) OR AB (nonrandom* OR non random* OR non-random* OR quasi-random* OR quasirandom* OR allocated)

56,142

S32

TI (("open label" OR open-label) N5 (study OR studies OR trial*)) OR AB (("open label" OR open-label) N5 (study OR studies OR trial*))

11,032

S33

TI ((equivalence OR superiority OR non-inferiority OR noninferiority) N3 (study OR studies OR trial*)) OR AB ((equivalence OR superiority OR non-inferiority OR noninferiority) N3 (study OR studies OR trial*))

3,407

S34

TI ("pragmatic study" OR "pragmatic studies") OR AB ("pragmatic study" OR "pragmatic studies")

169

S35

TI ((pragmatic OR practical) N3 trial*) OR AB ((pragmatic OR practical) N3 trial*)

2,269

S36

TI ((quasiexperimental OR quasi-experimental) N3 (study OR studies OR trial*)) OR AB (quasiexperimental OR quasi-experimental) N3 (study OR studies OR trial*))

5,147

S37

TI (phase Nj3 (III OR "3") N3 (study OR studies OR trial*)) OR AB (phase N3 (III OR "3") N3 (study OR studies OR trial*))

9,685

S38

S26 OR S27 OR S28 OR S29 OR S30 OR S31 OR S32 OR S33 OR S34 OR S35 OR S36 OR S37

569,502

S39

(MH "Nonexperimental Studies") OR (MH "Prospective Studies+") OR (MH "Retrospective Design") OR (MH "Cross-Sectional Studies") OR (MH "Evaluation Research+") OR (MH "Case-Control Studies+") OR "MH "Comparitive Studies")

690,222

S40

TI (((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) N1 (study OR studies)) OR "cohort analys*") OR AB (((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) N1 (study OR studies)) OR "cohort analys*")

347,908

S41

S39 OR S40

854,338

S42

(MH "Epidemiologic Research") OR (MH "Crossover Design")

17,625

S43

TI (((epidemiologic* OR intervention OR experimental) N1 (study OR studies)) OR cross-over OR crossover OR questionnaire* OR survey*) OR AB (((epidemiologic* OR intervention OR experimental) N1 (study OR studies)) OR cross-over OR crossover OR questionnaire* OR survey*)

431,515

S44

TI ("before AND after" OR "interrupted time series") OR AB ("before AND after" OR "interrupted time series")

51,966

S45

TI ("case series") OR AB ("case series")

19,482

S46

S42 OR S43 OR S44 OR S45

497,744

S47

S25 AND (S38 OR S41 0R S46)

599

S48

S47 AND (DT 1999-2019)

568


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