Journal of Manipulative and Physiological Therapeutics
Original ResearchThe Treatment of Neck Pain–Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline
Introduction
Neck pain and its associated disorders (NAD), including headache and radiating pain into the arm and upper back, are common and result in significant social, psychological, and economic burden.1, 2, 3, 4 Neck pain, whether attributed to work, injury, or other activities,5 is a prevalent source of disability and a common reason for consulting primary health care providers, including chiropractors, physical therapists, and primary care physicians.6 The estimated annual incidence of neck pain measured in 4 studies ranged between 10.4% and 21.3%, with a higher incidence noted in office and computer workers.7 Although some studies report that between 33% and 65% of people have recovered from an episode of neck pain at 1 year, most cases follow an episodic course over a person’s lifetime, and thus, relapses are common.7 Neck pain is a leading cause of morbidity and chronic disability worldwide.5, 8 In 2008 the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders reported that 50% to 75% of individuals with neck pain also report pain 1 to 5 years later.4 Several modifiable and nonmodifiable environmental and personal factors influence the course of neck pain, including age, previous neck injury, high pain intensity, self-perceived poor general health, and fear avoidance.7
Neck pain related to whiplash-associated disorders (WADs) most commonly results from motor vehicle accidents.9, 10 Whiplash-associated disorders disrupt the daily lives of adults around the world and are associated with considerable pain, suffering, disability, and costs.3, 11 Whiplash-associated disorders are defined as an injury to the neck that occurs with sudden acceleration or deceleration of the head and neck relative to other parts of the body, typically occurring during motor vehicle collisions.10, 12 The majority of adults with traffic injuries report pain in the neck and upper limb pain. Other common symptoms of WADs include headache, stiffness, shoulder and back pain, numbness, dizziness, sleeping difficulties, fatigue, and cognitive deficits.9, 10 The global yearly incidence rate of emergency department visits as a result of acute whiplash injuries after road traffic crashes is between 235 and 300 per 100,000.3, 13, 14 In 2010, there were 3.9 million nonfatal traffic injuries in the United States.11 The economic costs of motor vehicle crashes that year totaled USD$242 billion, including $23.4 billion in medical costs and $77.4 billion in lost productivity (both market and household).11 In Ontario, traffic collisions are a leading cause of disability and health care use and expenditures, resulting in the automobile insurance system paying nearly CND$4.5 billion in accident benefits in 2010.15
More than 85% of patients experience neck pain after a motor vehicle accident, often associated with sprains and strains to the back and extremities, headache, psychological symptomatology, and mild traumatic brain injury.10 Whiplash injuries have an effect on general health, with recovery in the short term reported by 29% to 40% of individuals with WAD in Western countries that have compensation schemes for whiplash injuries.16, 17 The median time to first reported recovery is estimated at 101 days (95% confidence interval: 99-104) and about 23% are still not recovered after 1 year.13
The 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders recommended that all types of neck pain, including WADs,18 be included under the classification of NAD.19 NAD can be classified into 4 grades, distinguished by the severity of symptoms, signs, and impact on activities of daily life (Table 1).
The clinical management of musculoskeletal disorders, and neck pain in particular, can be complex and often involves combining multiple interventions (multimodal care) to address its symptoms and consequences.19 In this guideline, multimodal care refers to treatment involving at least 2 distinct therapeutic methods, provided by 1 or more health care disciplines.20 Manual therapy (including spinal manipulation), medication, and home exercise with advice are commonly used multimodal treatments for recent-onset and persistent neck pain.21, 22 Thus, there is a need to determine which treatments or combinations of treatments are more effective for managing NAD and WAD.
The Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration20 recently updated the systematic reviews from the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force).23 Consequently, it was deemed timely to update the recommendations of 2 chiropractic guidelines on NAD (2014)24 and WAD (2010)25 produced by the Canadian Chiropractic Association and the Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards (the “Federation”) into a single guideline.
The aim of this clinical practice guideline (CPG) was to synthesize and disseminate the best available evidence on the management of adults and elderly patients with recent onset (0-3 months) and persistent (>3 months) neck pain and its associated disorders, with the goal of improving clinical decision making and the delivery of care for patients with NAD and WAD grades I to III. Guidelines are “Statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.”26
The target users of this guideline are chiropractors and other primary care health care providers delivering conservative care to patients with NADs and WADs, as well as policymakers. We define conservative care as treatment designed to avoid invasive medical therapeutic measures or operative procedures.
OPTIMa published a closely related guideline in the European Spine Journal.27 Although we reached similar results, OPTIMa developed recommendations using the modified Ontario Health Technology Advisory Committee (OHTAC) framework.28 In contrast, our guideline used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. GRADE provides a common, sensible, and transparent approach to grading quality (or certainty) of evidence and strength of recommendations (http://www.gradeworkinggroup.org). GRADE was the highest scoring instrument among 60 evidence grading systems29 and has been determined to be reproducible among trained raters.30 GRADE is now considered a standard in guideline development and has been adopted by many international guideline organizations and journals.31 The Canadian Chiropractic Guideline Initiative (CCGI) guideline panel considered available high-quality systematic reviews, updated the search of the peer-reviewed published reports up to December 2015, and then used the GRADE approach to formulate recommendations for the management of neck pain and associated disorders.
To inform its work, the CCGI considered recent advances in methods to conduct knowledge synthesis,32 derive evidence-based recommendations,31, 33 adapt high-quality guidelines,34 and develop35 and increase the uptake of CPGs.36, 37 An overview of CCGI structure and methods is provided in Appendix 1.
Section snippets
Ethics
Because no novel human participant intervention was required and secondary analyses were considered, the research presented in this guideline is exempt from institutional ethics review board approval.
Selection of Guideline Development Panelists
The CCGI project lead (A.B.) appointed 2 co-chairs (J.O. and G.S.) for the guideline development group and nominated the project executive committee and the remaining guideline panelists. J.O. served as the lead methodologist on the guideline panel. G.S. helped ensure geographic representation of
Key Question Development
Thirty-two standardized key questions were developed in line with the PICO (population, intervention, comparator, outcome) format. The panel recognized overlap in content and relevance among some key questions. After combining 3 questions, we ultimately addressed a total of 29 key questions (Table 2).
Study Selection and Quality Assessment: OPTIMa Reviews
OPTIMa searches yield 26 335 articles screened.38, 39, 40, 41, 42 After removal of duplicates and screening, 26 273 articles did not meet selection criteria, leaving 109 articles eligible for
Recommendations
We present recommendations as follows:
- 1
Recent-onset (0-3 months) grades I to III NAD
- 2
Recent-onset (0-3 months) grades I to III WAD
- 3
Persistent (>3 months) grades I to III NAD
- 4
Persistent (>3 months) grades I to III WAD
Discussion
This evidence-based guideline establishes the best practice for the management of NAD and WAD resulting from or aggravated by a motor vehicle collision and updates 2 previous guidelines on similar topics.24, 25 This guideline covers recent-onset (0-3 months) and persistent (>3 months) NADs and WADs grades I to III. It does not cover the management of musculoskeletal thoracic spine or chest wall pain.
The primary outcomes reported in the selected studies were neck pain intensity and disability.
Conclusion
This CPG supersedes the original (2005) and revised (2014) neck pain guideline as well as the 2010 whiplash-associated guidelines produced by the Canadian Chiropractic Association (CCA); Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards (CFCREAB).
People should receive care based on evidence-based therapeutic options. Based on patient preference and resources available, a mixed multimodal approach including manual therapy and advice about self-management and
Funding Sources and Conflicts of Interest
Funds provided by the Canadian Chiropractic Research Foundation. The views of the funding body have not influenced the content of the guideline. No conflicts of interest were reported for this study.
Guideline Disclaimer
The evidence-based practice guidelines published by the CCGI include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.21 Guidelines are intended to inform clinical decision making, are not prescriptive in nature, and do not replace professional chiropractic care or advice, which always should be sought for any specific condition. Furthermore, guidelines may not be
Contributorship Information
Concept development (provided idea for the research): A.B., J.O., G.S.
Design (planned the methods to generate the results): A.B., J.O., G.S.
Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): A.B., J.O., G.S.
Data collection/processing (responsible for experiments, patient management, organization, or reporting data): A.B., J.O., G.S., F.A.Z.
Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the
Acknowledgments
We thank the following people for their contributions to this paper: Dr. John Riva, DC, observer; Heather Owens, Research Coordinator, proofreading; Cameron McAlpine (Director of Communication & Marketing, Ontario Chiropractic Association), for assistance in producing the companion document intended for patients with NAD; members of the guideline panel who served on the Delphi consensus panel, who made this project possible by generously donating their expertise and clinical judgment.
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Paper submitted June 6, 2016; in revised form July 14, 2016; accepted August 10, 2016.