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Research Review By Dr. Keshena Malik©


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Date Posted:

April 2015

Study Title:

Clinical practice guidelines for the management of conditions related to traffic collisions: A systematic review by the OPTIMa Collaboration


Wong JJ, Cote P, Shearer HM et al.

Author's Affiliations:

UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Canada; Canada Research Chair in Disability Prevention and Rehabilitation, Toronto, Canada; School of Public Health, University of Alberta, Edmonton, Canada; Toronto Health Economics and Technology Assessment Collaborative, Toronto, Canada; Faculty of Pharmacy, University of Toronto, Toronto, Canada; Institute for Work and Health, Toronto, Canada.

Publication Information:

Disability & Rehabilitation 2014; 25: 1-19.

Background Information:

Musculoskeletal (MSK) injuries, head injuries and psychological disorders related to traffic collisions are associated with clinically important pain and disability (1-4). Epidemiological studies have shown that individuals injured in traffic collisions most commonly suffer from whiplash-associated disorders (WAD), shoulder pain, headaches and/or back pain (5). These MSK injuries are frequently associated with mild traumatic brain injuries (MTBI), depressive symptomatology and/or post-traumatic stress disorders (4, 6, 7).

The majority of individuals injured in traffic collisions recover within weeks to a few months after their injuries (1, 6, 8). However, a significant proportion of patients develop persistent pain and disability (3, 8, 9). Preventing the development of persistent pain and disability in these patients has been challenging for clinicians, as few effective treatments are available (10, 11). The prognosis for these patients is complex and influenced by initial severity of injury, psychological factors (such as passive coping), compensation factors and intensity of health care use (8). Clinical guidelines providing support for initial and ongoing clinical decisions on care would be helpful.

Clinical practice guidelines are systematically developed statements designed to assist clinicians in providing quality care to patients. Guidelines are intended to reduce the gap between research and practice for clinicians, and assist decisions at the system and population levels for policymakers (12-15). Despite recent growth in their popularity, there are concerns about the methodological quality of commonly used guidelines (16). For example, concerns have been raised about the negative impact of potentially biased guidelines on patient care and health outcomes (14, 17-19).

There are several clinical practice guidelines available for the management of common traffic injuries, however, the quality of these guidelines has not been critically appraised. Poor methods in developing guidelines may impact the validity of their recommendations and the quality of patient care that reults (20, 21). Identified barriers to adopting guidelines include lack of understanding on how recommendations were developed, unclear recommendations and inconsistency in recommendations across guidelines (22). A systematic review of these guidelines is needed to assess their methodological quality and help guide appropriate management of individuals with traffic injuries. This systematic review study critically appraised and synthesized the recommendations of evidence-based clinical practice guidelines for the management of common conditions related to traffic collisions.

Pertinent Results:

Literature Search Results
The search yielded 9863 citations, of which 848 (8.6%) were duplicates and excluded. Of the 9015 screened titles and abstracts, 8916 (90.4%) did not meet the eligibility criteria. 118 full-text citations were screened, of which 102 were deemed ineligible, leaving 16 guidelines to critically appraise. Authors of 8 guidelines were contacted for further information and 4 responded. A total of 8 guidelines were deemed scientifically admissible – 4 on WAD, 1 on anxiety and 3 on mild traumatic brain injuries relating to traffic collisions.

Methodological Quality
The methodological quality of the relevant guidelines varied considerably. Overall, most guidelines did not adequately address guideline applicability (i.e. facilitators and barriers, resource implication, monitoring or auditing criteria upon implication). Half of the guidelines did not address potential competing interests of the group that developed the guideline.

The 8 scientifically inadmissible guidelines had one or more major limitations with:
  • no systematic methods to search evidence
  • no clear description of the strengths or weaknesses of the literature
  • no explicit link between recommendations and supporting evidence
  • lack of specific and unambiguous recommendations (e.g. patient population, intervention or intended outcome)
  • did not report editorial independence from the funding body
The 8 scientifically admissible guidelines had one or more minor limitations with:
  • did not adequately address applicability domain
  • did not report any competing interests of the guideline development group
  • all guidelines required modifications (i.e. for use in specific jurisdictions, updating the literature, improve guideline applicability and modifying the scope of the guideline to include/exclude certain interventions)
Four of the eight admissible guidelines addressed management of WAD (25-28), one addressed the management of anxiety after traffic collisions (29), and three discussed the management of brain injuries including MTBI (30-32).

Guidelines for WAD I-III

Recommended Interventions for WAD Management:
  • All guidelines recommended education (i.e. staying active, acting as usual, promoting mobility, advice on self-management and coping strategies, reassurance about prognosis and goals of improving function) and neck exercises in acute WAD (25-28) and most guidelines recommended these interventions in subacute and chronic WAD (25-27).
  • All guidelines recommended that passive joint mobilization or manipulation can be considered in the management of WAD (25-28).
  • Three guidelines recommended pharmacotherapy (e.g. simple analgesics/non-steroidal anti-inflammatory drugs) for early management of WAD (25-27).
  • Multi-modal therapy (i.e. therapeutic package consisting of joint mobilization, relaxation techniques, electrotherapies, exercise) was recommended as a consideration in all grades of WAD in one guideline (26), while another only recommended it for subacute WAD (28).
Interventions Recommended Against for WAD Management:
  • All guidelines recommended against the use of cervical collars in the early management of WAD (25-28).
  • The use of surgery in early management (25-27) – however, two guidelines suggested that surgery be considered in WAD III cases with progressive neurological deficits and/or chronic debilitating pain (25, 26).
  • The use of pharmacological injections (25, 26).
Interventions Neither Supported nor Refuted for WAD Management:
  • Massage: Three guidelines found no evidence for massage, however, two guidelines recommended its consideration for acute and subacute WAD; one guideline recommended against its use.
  • Acupuncture: Two guidelines found no evidence to support nor refute acupuncture, while one guideline recommended consideration for all grades of WAD.
  • Magnetic Necklace: Two guidelines found no evidence for magnetic necklace use; one guideline recommended against its use.
  • Electrical Nerve Stimulation (ENS): One guideline found no evidence for use of ENS in the management of any grade of WAD; another guideline found no evidence for chronic WAD only; while one guideline recommended ENS in acute WAD.
Guidelines for Anxiety Following Traffic Collisions

Recommended Interventions for Anxiety Management:
One guideline for management of anxiety following traffic collisions focused on acute and post-traumatic stress disorders (29). This guideline recommended that first-line management include psychological first aid (i.e. comfort, information and support to help patients cope with injuries), pharmacotherapy (selective serotonin re-uptake inhibitors first then other anti-depressants) and cognitive behavioural therapy (cognitive therapy, exposure therapy and anxiety management) (29).

Interventions Recommended Against for Anxiety Management:
  • Supportive counselling
  • Eye movement desensitization and reprocessing
  • Hypnotherapy
  • Psychodynamic therapy
  • One-on-one psychological debriefing
  • Relaxation and biofeedback (when not in combination with another interventions)
Guidelines for Mild Traumatic Brain Injury (MTBI) Management

Recommended Interventions for MTBI Early Management:
  • One guideline recommended hourly observations until at least 4 hours post-injury for patients with MTBI first presenting to emergency department (30).
  • All three guidelines advised not to consider discharge until the patient scores 15 on the Glasgow Coma Scale (30-32).
  • All guidelines recommended providing case-specific discharge advice (i.e. strategies to manage symptoms and information on common symptoms) and information to patients and caregivers (30-32).
  • All guidelines advised clinicians to encourage patients to follow-up with their physicians about worrisome symptoms or complications upon discharge (30-32).
  • Two guidelines recommended reassuring patients that they are likely to recover within days to a few weeks (30, 32). One guideline suggested that clinicians advise patients that they could experience reduced cognitive function, which may take a few days to three months to resolve (30).
  • One guideline recommended that patients should be advised to stop driving for at least 24-hours upon discharge. A period longer than 24-hours is advised if there is loss of good judgement or motor skills, decreased intellectual capacity, post-traumatic seizures or visual impairment (30).
Interventions Recommended for MTBI After Hospital Discharge
One guideline described the management of persistent MTBI symptoms (e.g. post-traumatic headache, sleep disturbance, mental health disorders, cognitive difficulties, fatigue, balance or visual disorders) (30). Recommendations included the following:
  • Patients should be followed every two to four weeks until symptom resolution or the next re-assessment.
  • Patients with pre-injury psychiatric difficulties should be provided with an early referral to a multi-disciplinary treatment clinic capable of managing post-MTBI symptoms.

Clinical Application & Conclusions:

The core components of programs of care designed to manage common traffic injuries such as WAD, anxiety and MTBI should include advice, education and reassurance. Depending on the condition, the following specific interventions should be considered:
  1. WAD: exercise, early return to activity, mobilization/manipulation, analgesics and avoidance of cervical collar.
  2. Anxiety: psychological first aid, pharmacotherapy and cognitive behaviour therapy.
  3. MTBI: use of specific discharge criteria, education upon discharge from emergency room and post-discharge care.
The methodological quality of guidelines varies greatly. The need for trustworthiness of guidelines in general is very important, since they are used to guide decisions about patients, practice measures, insurance coverage and reimbursement (16). The AGREE II instrument has provided the most widely accepted standards for appraising quality of guidelines (23). Effort from medical societies and government agencies are needed to improve adherence to guideline standards (33) using instruments such as this.

Study Methods:

Literature Search
The search strategy combined terms relevant to traffic injuries, traffic collisions, and guidelines, and included free text words and subject heading specific to each database. The following databases/websites were searched from January 1, 1995 to October 25, 2012:
  • PsycINFO
  • Cochrane database of systematic reviews
  • Database of Abstracts of Reviews of Effects
  • Cochrane Central Register of Controlled Trials
  • National Health Services Economic Evaluation Database
  • Health Technology Assessment Database
  • Index to Chiropractic Literature
  • National Guideline Clearinghouse
  • Canadian Medical Association Infobase
  • Guidelines International Network
  • PEDro
  • Trip database
  • American College of Physicians Clinical Recommendations
  • Australian Government
  • National Health and Medical Research Council
  • Health Services/Technology Assessment Texts (HSTAT)
  • Institute of Clinical Systems Improvement (ISCI)
  • National Institute for Health and Clinical Excellence (NICE) Guidance
  • NICE Pathways
  • New Zealand Guidelines Group
  • Scottish Intercollegiate Guidelines Network (SIGN)
  • World Health Organization (WHO) Guidelines
  • Google search
Study Selection

Inclusion Criteria:
  • Published in English
  • Subjects were adults and/or children with common physical, mental or psychological injuries (e.g. WAD grades I-III)
  • Related to traffic collisions
  • Guidelines, programs of care or treatment protocols were discussed
  • Included recommendations for therapeutic management
Exclusion Criteria:
  • Did not include treatment recommendations
  • Summary or copy of previous guidelines
  • Developed solely on the basis of consensus
  • Did not conduct a systematic literature search or critical appraisal of the studies that were used to derive recommendations
  • Guidelines not specific to post-collision psychological conditions
Title and Abstract Screening:
A two-stage screening process by random pairs of independent reviewers was used. First, reviewers independently screened titles and abstracts for eligibility. If eligibility was not able to be determined based on title and abstract, a second screening stage was conducted and reviewers independently reviewed the full text. Disagreements between reviewers were resolved by discussion to reach consensus. If a consensus could not be reached, a third reviewer settled the disagreement. Authors were contacted if additional information was necessary to determine eligibility.

Critical Appraisal of Eligible Studies:
Relevant guidelines were appraised, using the Appraisal of Guidelines for Research and Evaluation version II (AGREE II) (23, 24), by random pairs of independent reviewers. Discussions were held between pairs of reviewers to reach consensus on:
  • individual AGREE II items
  • overall quality of the guideline
  • whether the guideline was scientifically admissible
  • whether modifications to the guideline would be needed for use in specific jurisdictions
Authors were contacted if additional information was necessary to determine eligibility.

For data synthesis, guidelines with poorly conducted systematic searches of the literature or with inadequate methods to critically appraise evidence were deemed to have fatal flaws and hence were deemed scientifically inadmissible. Also, lack of editorial independence from the funding body was considered a limitation to the quality of the guideline, since it suggests poor reporting and lack of transparency in guideline development (14).

Study Strengths / Weaknesses:

  • This review is the first systematic review and critical appraisal of guidelines for common traffic injuries.
  • The AGREE II critical appraisal instrument for evaluating guidelines maintains high methodological rigor (23).
  • All reviewers received standardized training in the AGREE II critical appraisal guidelines.
  • Effort was made to contact authors for additional information and the response rate was 81%.
  • Study designs other than randomized controlled trials were included in the guidelines reviewed, which may contribute to the overall poor quality of the evidence and methodological flaws. The study design must be valid and adhere to rigorous methodological standards.
  • The authors acknowledged that the guidelines reviewed were out of date.
  • Only English language guidelines were screened for eligibility, therefore it is possible that some well-conducted and admissible studies may have been excluded.

Additional References:

  1. Cassidy JD, Carroll LJ, Cote P, et al. Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury. N Engl J Med 2000; 342(2): 1179–86.
  2. Cassidy JD, Carroll L, Cote P, et al. Mild traumatic brain injury after traffic collisions: a population-based inception cohort study. J Rehabil Med 2004; 43S: 15–21.
  3. Cassidy JD, Carroll LJ, Cote P, et al. Does multidisciplinary rehabilitation benefit whiplash recovery?: Results of a population based incidence cohort study. Spine 2007; 32(1): 126–31.
  4. Cassidy JD, Carroll LJ, Peloso PM, et al. Incidence, risk factors and prevention of mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med 2004; 43S: 28–60.
  5. Hincapie CA, Cassidy JD, Cote P, et al. Whiplash injury is more than neck pain: a population-based study of pain localization after traffic injury. J Occup Environ Med 2010; 52(4): 434–40.
  6. Carroll LJ, Cassidy JD, Cote P. Frequency, timing, and course of depressive symptomatology after whiplash. Spine 2006; 31(16): E551–6.
  7. Kenardy J, Dunne R. Traumatic injury and traumatic stress. Spine 2011; 36(25S): S233–7.
  8. Carroll LJ, Holm LW, Hogg-Johnson S, et al. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33(4S): S83–92.
  9. Carroll LJ, Cassidy JD, Cote P. The role of pain coping strategies in prognosis after whiplash injury: passive coping predicts slowed recovery. Pain 2006; 124(1-2): 18–26.
  10. Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of neck pain: Non-invasive interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33(4S): S123–52.
  11. Holm L, Cassidy JD, Carroll LJ, et al. Summary of the WHO Collaborating Centre for Neurotrauma Task Force on Mild Traumatic Brain Injury. J Rehabil Med 2005; 37(3): 137–41.
  12. Shekelle PG, Woolf SH, Eccles M, et al. Clinical guidelines: Developing guidelines. BMJ 1999; 318 (7183): 593–6.
  13. Shekelle P, Woolf S, Grimshaw JM, et al. Developing clinical practice guidelines: reviewing, reporting, and publishing guidelines. Implement Sci 2012; 7: 62 (1–7).
  14. Alonso-Coello P, Irfan A, Sola I, et al. The quality of clinical practice guidelines over the last two decades: a systematic review of guideline appraisal studies. Qual Saf Health Care 2010; 19(6): e58.
  15. Whitworth JA. Best practices in use of research evidence to inform health decisions. Health Res Policy Syst 2006; 4: 11.
  16. Ransohoff DF, Pignone M, Sox HC. How to decide whether a clinical practice guideline is trustworthy. JAMA 2013; 309(2): 139–40.
  17. Shaneyfelt TM, Centor RM. Reassessment of clinical practice guidelines: go gently into that good night. JAMA 2009; 301(8): 868–9.
  18. Tricoci P, Allen JM, Kramer JM, et al. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA 2009; 301(8): 831–41.
  19. Chou R. Evidence-based medicine and the challenge of low back pain: where are we now? Pain Pract 2005; 5(3): 153–78.
  20. Manchikanti L. Evidence-based medicine, systematic reviews, and guidelines in interventional pain management, part I: introduction and general considerations. Pain Physician 2008; 11: 161–86.
  21. Cote AM, Durand MJ, Tousignant M, et al. Physiotherapists and use of low back pain guidelines: a qualitative study of the barriers and facilitators. J Occup Rehabil 2009; 19: 94–105.
  22. Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ 2010; 182(18): E839–42.
  23. Brouwers MC, Kho ME, Browman GP, et al. Development of the AGREE II, part 2: assessment of validity of items and tools to support application. CMAJ 2010; 182(10): E472–8.
  24. South Australian Centre for Trauma and Injury Recovery (TRACsa). Clinical guidelines for best practice management of acute and chronic whiplash-associated disorders. Adelaide: TRACsa; 2008.
  25. Motor Accidents Authority. Guidelines for the management of acute whiplash associated disorders for health professionals. Sydney: Motor Accidents Authority; 2007
  26. Spitzer WO, Skovron ML, Salmi LR, et al. Scientific Monograph of the Quebec Task Force on Whiplash-Associated Disorders. Spine 995; 20(8S): 1S–73S.
  27. Chartered Society of Physiotherapists. Clinical guidelines for the physiotherapy management of whiplash associated disorder. London, UK: Chartered Society of Physiotherapists; 2004.
  28. Marshall S, Bayley M, McCullagh S, et al. Clinical practice guidelines for mild traumatic brain injury and persistent symptoms. Canadian Family Physician 2012; 58(3): 257–67, e128–40.
  29. Scottish Intercollegiate Guidelines Network (SIGN). Early management of patients with a head injury: a national clinical guideline. Edinburgh: SIGN; 2009.
  30. Agency for Healthcare Research and Quality (AHRQ). Triage, assessment, investigation and early management of head injury in infants, children and adults. Available from: http://guideline.gov/content.aspx?id=11468&search=(collision*+or+crash+or+crashes+or+mvc*+or+accident*)%27+and+%27(motor+or+vehicle*+or+automobile*+or+car+or+truck*+or+bus*+or+traffic+or+motorcycle*)[last accessed 2 Sep 2013].
  31. Kung J, Miller RR, Mackowiak PA. Failure of clinical practice guidelines to meet Institute of Medicine standards: two more decades of little, if any, progress. Arch Intern Med 2012; 172(21): 1–6.

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