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Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

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Abstract

Purpose

To develop an evidence-based guideline for the management of grades I–III neck pain and associated disorders (NAD).

Methods

This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I–III NAD <6 months duration.

Recommendation 1

Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III.

Recommendation 2

Clinicians should assess prognostic factors for delayed recovery from NAD.

Recommendation 3

Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I–III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care.

Recommendation 4

For NAD grades I–II ≤3 months duration, clinicians may consider structured patient education in combination with: range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat.

Recommendation 5

For NAD grades I–II >3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections.

Recommendation 6

For NAD grade III ≤3 months duration, clinicians may consider supervised strengthening exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction.

Recommendation 7

For NAD grade III >3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management.

Recommendation 8

Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.

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Acknowledgments

The authors would like to acknowledge the invaluable contributions to this guideline from: Lynn Anderson, Poonam Cardoso, Brenda Gamble, Willie Handler, Vivii Riis, Paula Stern, Thepikaa Varatharajan, Angela Verven, and Leslie Verville.

Author information

Authors and Affiliations

  1. Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, ON, L1H 7L7, Canada

    Pierre Côté

  2. UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada

    Pierre Côté, Jessica J. Wong, Deborah Sutton, Heather M. Shearer, Kristi Randhawa, Hainan Yu, Sharanya Varatharajan, Craig Jacobs, Maja Stupar & Anne Taylor-Vaisey

  3. Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada

    Jessica J. Wong, Deborah Sutton, Heather M. Shearer, Silvano Mior, Kristi Randhawa, Hainan Yu, Sharanya Varatharajan & Patrick Loisel

  4. Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, ON, L1H 7L7, Canada

    Silvano Mior & Gail M. Lindsay

  5. Undergraduate Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada

    Kristi Randhawa & Sharanya Varatharajan

  6. Certification Program in Insurance Medicine and Medico-legal Expertise, Faculty of Medicine, University of Montreal, N-414, Roger-Gaudry Building, 2900, Boulevard Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada

    Arthur Ameis

  7. Injury Prevention Centre and School of Public Health, University of Alberta, 3-300 Edmonton Clinic Health Academy, 11405 – 87 Ave, Edmonton, AB, T6G 1C9, Canada

    Linda J. Carroll

  8. Department of Orthopedic Surgery, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 550 1st Avenue, New York, NY, 10016, USA

    Margareta Nordin

  9. Department of Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 550 1st Avenue, New York, NY, 10016, USA

    Margareta Nordin

  10. Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, Joseph and Wolf Lebovic Health Complex, 60 Murray Street, 2nd Floor (Main), Toronto, ON, M5T 3L9, Canada

    Danielle Southerst

  11. Division of Clinical Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada

    Craig Jacobs

  12. Toronto Health Economics and Technology Assessment (THETA) Collaborative, 144 College Street, Toronto, ON, M5S 3M2, Canada

    Gabrielle van der Velde

  13. Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON, M5S 3M2, Canada

    Gabrielle van der Velde

  14. Institute for Work and Health, 481 University Ave, Toronto, ON, M5G 2E9, Canada

    Gabrielle van der Velde & Carlo Ammendolia

  15. Department of Physical Therapy, University of Alberta, 2-50 Corbett Hall, Edmonton, AB, T6G 2G4, Canada

    Douglas P. Gross

  16. Rehabilitation Research Centre, University of Alberta, 3-62 Corbett Hall, Edmonton, AB, T6G 2G4, Canada

    Douglas P. Gross

  17. Clinical Research, Kingston General Hospital, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada

    Robert J. Brison

  18. Department of Emergency Medicine, School of Medicine, Queen’s University, 15 Arch Street, Kingston, ON, K7L 3N6, Canada

    Robert J. Brison

  19. Faculty of Medicine and Dentistry, University of Alberta, 116 St & 85 Ave, Edmonton, AB, T6G 2R3, Canada

    Mike Paulden

  20. Institute for Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada

    Carlo Ammendolia & Murray Krahn

  21. University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark

    J. David Cassidy

  22. Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada

    J. David Cassidy

  23. Division of Occupational and Environmental Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada

    Patrick Loisel

  24. University of Ottawa, 505 Smyth Road, Ottawa, ON, K1H 8M2, Canada

    Shawn Marshall

  25. Schulich School of Medicine and Dentistry, Western University, Dental Sciences Building, London, ON, N6A 5C1, Canada

    Richard N. Bohay

  26. Open Policy Ontario, Toronto, Canada

    John Stapleton

  27. Université de Montréal, 2375 Cote Ste-Catherine, Montreal, QC, H3T 1A8, Canada

    Michel Lacerte

  28. Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, ON, N6A 5C1, Canada

    Michel Lacerte

  29. Toronto, Canada

    Roger Salhany

Authors
  1. Pierre Côté
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  2. Jessica J. Wong
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  3. Deborah Sutton
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  4. Heather M. Shearer
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  5. Silvano Mior
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  6. Kristi Randhawa
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  7. Arthur Ameis
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  8. Linda J. Carroll
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  9. Margareta Nordin
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  10. Hainan Yu
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  11. Gail M. Lindsay
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  13. Sharanya Varatharajan
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  14. Craig Jacobs
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  15. Maja Stupar
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  16. Anne Taylor-Vaisey
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  17. Gabrielle van der Velde
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  18. Douglas P. Gross
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  19. Robert J. Brison
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  20. Mike Paulden
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  21. Carlo Ammendolia
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  22. J. David Cassidy
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  23. Patrick Loisel
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  24. Shawn Marshall
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  25. Richard N. Bohay
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  26. John Stapleton
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  28. Murray Krahn
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  29. Roger Salhany
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Corresponding author

Correspondence to Pierre Côté.

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Funding

The development of this clinical practice guideline was funded by the Ministry of Finance and the Financial Services Commission of Ontario (OSS_00267175). The Ministry of Finance and Financial Services Commission of Ontario were not involved in the design, conduct, or interpretation of the research that informed the development of the care pathways included in this report. The development of the guideline by the Guideline Expert Panel was not influenced by the Ministry of Finance or Financial Services Commission of Ontario; the views and interests of the funding body did not influence the final recommendations. All individuals involved in the project declared any competing interests. This research was undertaken, in part, thanks to funding from the Canada Research Chairs program to Dr. Pierre Côté, Canada Research Chair in Disability Prevention and Rehabilitation at the University of Ontario Institute of Technology, and funding from Alberta Innovates—Health Solutions to Dr. Linda Carroll, Health Senior Scholar.

Conflict of interest

Dr. Brison reports no commercial interest; a university role that incorporates research activities related to guideline development. Dr. Lacerte reports an active clinical practice and conducting medicolegal assessments or reports for plaintiff lawyers and occasionally independent medical examinations for lawyers and insurers; Consultancies: Drs. Ameis and Lacerte reports non-paid consultancy for the Catastrophic Impairment Expert Panel; Honoraria: Drs. Gross and Bohay report honoraria during the conduct of this study; Grants: Dr. Côté reports grants from Ontario Ministry of Finance and Financial Services Commission of Ontario during the conduct of this study; grants from Aviva Canada outside the submitted work. Dr. Gross reports grants from Workers' Compensation Board of Alberta, grants from Workers' Compensation Board of Manitoba, outside the submitted work; Other: Drs. Brison and Marshall report participation in guideline development. Dr. Côté reports funding from Canada Research Chair Program - Canadian Institutes of Health Research during the conduct of this study; personal fees from National Judicial Institute, Société des experts en évaluation médico-légale du Québec, and European Spine Society, outside the submitted work. Dr. Ameis reports his past role as medical director and current consultant to Granite Health Service. For the remaining authors, no conflicts were declared.

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Roger Salhany—Retired Judge from the Ontario Superior Court of Justice, Toronto, Canada

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Côté, P., Wong, J.J., Sutton, D. et al. Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J 25, 2000–2022 (2016). https://doi.org/10.1007/s00586-016-4467-7

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