Research Review By Dr. Brynne Stainsby©

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Date Posted:

April 2017

Study Title:

The Treatment of Neck Pain-Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline

Authors:

Bussières AE, Stewart G, Al-Zoubi F et al.

Author's Affiliations:

Departments of: Physical and Occupational Therapy, McGill University, Montreal, QC; Chiropractic, Université du Quebec a Trois-Rivières; Science, University of Winnipeg, Winnipeg, MB; Clinical Education, Canadian Memorial Chiropractic College, Toronto, ON; Sciences de l’Activité Physique, Université du Quebec a Trois-Rivières, QC; Community Health and Epidemiology, Dalhousie University, Halifax, NS; Health and Community Studies, Mount Royal University, Calgary, AB; University Health Network, Toronto Western Research Institute, University of Toronto, Dalla Lana School of Public Health, Toronto, ON; d’Anatomie, Université du Quebec a Trois-Rivières; Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB; Human Health and Nutritional Science, University of Guelph, Guelph, ON, ALL in Canada; Health Systems Management, Rush University, Chicago, IL, USA.

Publication Information:

Journal of Manipulative and Physiological Therapeutics 2016; 39: 523-544.

Background Information:

Neck pain (NP) and neck associated disorders (NAD), such as headache, upper back pain and radiating pain into the arms, are considered common and important social, psychological and economic burdens, and represent leading causes of morbidity and disability globally (1-4, 6). They are common reasons patients present to healthcare providers for musculoskeletal complaints (6). Most studies report a cyclical or episodic-recurrent course of NP and NAD, with 50-75% of individuals reporting NP also having pain 1 to 5 years later (4, 6).

The 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders recommended that all types of neck pain (including whiplash associated disorders [WAD]) be classified into four grades of NAD (7, 8). This categorical classification distinguishes NAD based on the severity of signs and symptoms, along with the impact on an individual’s function, as follows (7, 8):
  • Grade I: No signs or symptoms suggestive of major structural pathology and no or minor interference with activities of daily living
  • Grade II: No signs or symptoms of major structural pathology, but major interference with activities of daily living
  • Grade III: No signs or symptoms of major structural pathology, but presence of neurologic signs such as decreased deep tendon reflexes, weakness or sensory deficits
  • Grade IV: Signs or symptoms of major structural pathology
In addition to providing information about prognosis, it is hoped that categorical diagnoses may guide clinicians to effective, evidence-informed management strategies. In order to synthesize the large body of evidence related to the clinical management of NAD, clinical practice guidelines are systemically developed to optimize care and improve patient outcomes. As such, the purpose of this guideline was to determine which treatments or combinations of treatments are most effective for the management of NAD and WAD.

Summary:

Literature Search:
  • This CPG updated the search performed by the OPTIMa collaboration, and yielded 7784 articles.
  • 52 articles underwent full review and critical appraisal.
  • The panel developed 32 key questions and made recommendations based on the strength of the evidence related to these questions.
Recommendations for Neck Associated Disorders (NAD):

For grades I to II NAD of 0-3 months’ duration, the following recommendations were made:
  1. Manipulation or mobilization is recommended based on patient preference (weak recommendation, low quality evidence)
  2. Either range-of-motion home exercises, medication or multimodal manual therapy is recommended to reduce pain and disability (weak recommendation, moderate quality evidence)
For grade III NAD of 0-3 months’ duration, the following recommendations were made:
  1. Supervised graded strengthening exercise is recommended over advice alone (weak recommendation, moderate quality evidence)
  2. No recommendation was made for or against the use of cervical collars, low level laser therapy, or work disability prevention interventions
For grades I and II NAD of greater than 3 months’ duration, the following recommendations were made:
  1. Supervised group exercises (including qigong, ROM, flexibility and strengthening exercises) are recommended to reduce neck pain and disability (weak recommendation, moderate quality evidence)
  2. Supervised Iyengar yoga with a maximum of nine sessions over nine weeks is recommended over education and home exercise (weak recommendation, low quality evidence)
  3. Multi-modal care (including manipulation, mobilization, massage, traction, acupuncture, heat, transcutaneous electrical stimulation and/or exercise) or stress management (including relaxation, balance and body awareness exercises, pain and stress self-management lectures, and discussion) are suggested based on patient preference, response to care and resources available (weak recommendation, low quality evidence)
  4. Manipulation is recommended in conjunction with soft tissue therapy (weak recommendation, low quality evidence)
  5. High-dose massage (60 minute massage, three times a week for four weeks) is recommended over no treatment (weak recommendation, low quality evidence)
  6. Supervised strengthening and home exercises are recommended to reduce neck pain and disability (weak recommendation, low quality evidence)
  7. No recommendations were made regarding patient education compared to massage therapy, low level laser therapy, or transcutaneous electrical stimulation could be made
For grades I to III NAD of greater than 3 months’ duration, the following recommendations were made:
  1. Multimodal care (thrust/nonthrust manipulation, muscle energy, stretching and home exercises) or practitioner advice are recommended (weak recommendation, low quality evidence)
  2. For workers with neck and shoulder pain, mixed supervised and unsupervised high-intensity strength training or advice alone are recommended (weak recommendation, moderate quality evidence)
  3. No recommendations were made regarding work disability prevention interventions in those with work-related rotator cuff tendonitis, neck and shoulder pain or upper extremity symptoms
Recommendations for Whiplash Associated Disorders (WAD):

For grades I to III WAD of 0-3 months’ duration, the following recommendation was made:
  1. Multimodal care is recommended over education alone (weak recommendation, moderate quality evidence)
For grades I and II WAD greater than 3 months’ duration, the following recommendations were made:
  1. Supervised exercises with advice or advice alone are recommended based on patient preference and resources available (weak recommendation, low quality evidence)
  2. No recommendations were made comparing multimodal care to self-management strategies, or comparing patient education to advice

Clinical Application & Conclusions:

This review identifies some recommended interventions based on the questions posed by the CPG panel. Although it is difficult to ascertain the most effective interventions for the management of NAD in all clinical cases, this guideline does recommend patients be provided with education and be encouraged to remain active, either through home or supervised exercise programs. Depending on patient preferences and resources available, multimodal care including manipulation and/or mobilization may also be reasonable.

Overall, the recommendations are based on low to moderate quality evidence, and typically little information was available regarding the optimal frequency and duration of interventions. This CPG highlights the need for high quality research regarding of effectiveness of individual and combined therapies, and the optimal dose for prescribing them.

COMMENTARY FROM CCGI PROJECT LEAD - Dr. André Bussières:

The Canadian Chiropractic Guideline Initiative (CCGI) develops evidence-based clinical practice guidelines and best practice recommendations, along with knowledge translation strategies designed to facilitate the application of best-practice guidelines by both clinicians and patients, and ultimately to improve patient health. 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.

The new CPG on neck pain associated and whiplash associated disorders, along with best practice tools, research and self-management resources can be found at www.chiroguidelines.org. CCGI has developed specific tools and resources to accompany this new CPG. A free online learning module, webinar, a practitioner guide and algorithms, are available to help clinicians apply the recommendations. We are especially pleased to present a new CCGI video series with recommended exercises for patients. Clinicians will now have an easy-to-use tool for implementing multimodal care in the clinic, and helping their patients with self-management.

Study Methods:

  • The CPG panel created key questions related to the management of NAD and WAD.
  • Databases were searched to update the OPTIMa collaboration reviews. Literature searches were updated on 24 December 2015 in the Medline and Cochrane Collaboration databases.
  • Two authors independently screened titles and abstracts for inclusion.
  • Two independent reviewers appraised the internal validity of eligible studies using the SIGN criteria (9).
  • One reviewer extracted data and built evidence tables. A second reviewer confirmed the data.
  • Recommendations were developed using the GRADE approach (10) and the quality of the evidence was assessed in the context of primary care. The panel considered the balance of desirable and undesirable consequences to determine whether a recommendation was “strong” or “weak”. They based recommendations on evidence of clinically meaningful changes, the values and preferences of the population, along with associated costs.

Study Strengths / Weaknesses:

Strengths:

This Clinical Practice Guideline had many strengths:
  • Independent screening of titles and abstracts, and full texts.
  • Only those trials assessed as being of high quality were included.
  • Assessment of risk of bias was performed with a validated set of criteria.
  • In addition to methodological quality, clinical relevance was also assessed.
  • Two authors independently extracted the data from the included articles.
Weaknesses:
  • All recommendations are weak, and based on (an often limited quantity of) low to moderate quality evidence.
  • Given the high risk of bias combined with the lack of high quality findings, it is not possible to determine the most effective interventions or dosages for neck pain treatment. We need more high quality work in these areas in order to make more conclusive recommendations.

Additional References:

  1. Ferrari R, Russell A. Regional musculoskeletal conditions: neck pain. Best Pract Res Clin Rheumatol 2003; 17(1): 57-70.
  2. Hogg-Johnson S, van der Velde G, Carroll LJ, et al. The burden and determinants of neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33(4 Suppl): S39-S51.
  3. Holm L, Carroll L, Cassidy JD, et al. The burden and determinants of neck pain in whiplash-associated disorders after traffic collisions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33(4 Suppl): S52-S59.
  4. Cote P, van der Velde G, Cassidy JD, et al. The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33(4 Suppl): S60-S74.
  5. Cote P, Cassidy JD, Carroll L. The treatment of neck and low back pain: Who seeks care? Who goes where? Med Care 2001; 39: 956–967.
  6. Hoy DG, Protani M, De R, Buchbinder R. The epidemiology of neck pain. Best Pract Res Clin Rheumatol. 2010; 24(6): 783-792.
  7. Guzman J, Hurwitz EL, Carroll LJ, et al. A new conceptual model of neck pain: linking onset, course, and care: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008; 33(4 Suppl): S14-S23.
  8. Leaver A, Maher C, McAuley J et al. Characteristics of a new episode of neck pain. Man Ther 2013; 18(3): 254-257.
  9. van der Velde G, van Tulder M et al. The sensitivity of review results to methods used to appraise and incorporate trial quality into data synthesis. Spine 2007; 32(7): 796-806.
  10. Network GI, GRADE Working Group. Resources. Available at: http://www.g-i-n.net/working-groups/updating-guidelines/resources. Accessed May 5, 2016.