Guidelines - Neck Pain

CCGI Guideline Summary

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Scope and Purpose of Guideline

 

Objective: This guideline aims to provide management for grades I-III neck pain and associated disorders (NAD) including whiplash-associated disorders (WAD)

Target population: 

  • Adults (18 years of age and older) with recent-onset (0-3 months duration) and persistent (4-6 months duration) NAD grades I-III. This guideline does not cover NAD that persists for more than 6 months.

Definitions

Title of Guideline: Management of neck pain and associated disorders: A clinical practice guideline

Author(s): ​Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

Year of Publication: ​2016

Link for Full Guideline: link

2000-2010 Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders Classification of NAD

I: No signs or symptoms suggestive of major structural pathology and no or minor interference with activities of daily living

II: No signs or symptoms suggestive of major structural pathology, but major interference with activities of daily living

III: No signs or symptoms of major structural pathology, but presence of neurologic signs such as decreased deep tendon reflexes, weakness or sensory deficits

Quebec Task Force Classification of WAD

I: Neck pain and associated symptoms in the absence of objective physical signs

II: Neck pain and associated symptoms in the presence of objective physical signs and without evidence of neurological involvement

III: Neck pain and associated symptoms with evidence of neurological involvement including decreased or absent reflexes, decreased or limited sensation, or muscular weakness

Wording of Recommendations

 

'Offer': Interventions demonstrated to be clearly superior to other interventions, placebo/sham interventions, or no intervention

'Consider': Interventions providing similar effectiveness to other interventions

'Do not offer': Interventions providing no benefit beyond placebo/sham or because they are harmful

'Inconclusive evidence': Results of multiple low risk of bias studies conflicted

Key Recommendations

 

Assessment:

  • Conduct a clinical evaluation to rule out major structural or other pathologies as the cause of NAD, and classify NAD as grade I, II or III

    • Use the Canadian C-spine Rule to rule out cervical spine fractures and dislocations associated with acute trauma​

    • Refer the patient to the appropriate healthcare professional if they identify risk factors for serious pathologies during the history/examination

  • Assess for neurological signs (decreased deep tendon reflexes, muscle weakness, sensory deficits)​

  • Once major pathology has been ruled out, classify the grade of NAD as grade I, II or III; as recent or persistent; and the patient should receive the appropriate intervention

Education and self-management:

  • 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 including return-to-work, where appropriate

  • Share decision making with patients such that they discuss with the patient the range of effective interventions available for the management of NAD

Management of recent NAD (grades I-II):

  • Consider structured patient education in combination with:

    • range of motion exercise ​

    • multimodal care (range of motion exercise with manipulation or mobilization)

    • a short course of muscle relaxants (as indicated)

  • Consider a structured patient education program as an adjunct to an effective program based on individual patient presentation​

  • Do not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat

  • Do not offer or recommend acetaminophen as a routine intervention

 

Recommendation Details:

Structured Patient Education

  • Provide information about the nature, management, and course of NAD

Range of Motion Exercises

Multimodal Care

  • Maximum of six sessions over 8 weeks of multimodal care that includes range of motion exercise and manual therapy (manipulation or mobilization to the cervical and/or thoracic spine as clinically indicated)

Management of persistent NAD (grades I-II):

  • 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

    • non-steroidal anti-inflammatory drugs

  • Do 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 Details:

Structured Patient Education

  • Provide information about the nature, management, and course of NAD

Range of Motion Exercises

  • Supervised combined exercise (range of motion and strengthening exercises) limited to a maximum of two sessions per week for 12 weeks

  • Qiqong exercises supervised by a certified qigong instructor, limited to a maximum of two sessions per week for 12 weeks

  • Iyengar yoga supervised by a certified iyengar yoga teacher, limited to a maximum of nine sessions over 9 weeks

Multimodal Care

  • Including range of motion exercises and manual therapy (manipulation or mobilization to the cervical and/or thoracic spine as clinically indicated) for a maximum of six sessions over 8 weeks

    • Multimodal care may only be considered if not previously provided in the first 3 months of care. However, a second course may be indicated if the patient has demonstrated ongoing and significant improvement​

Soft-tissue Therapy 

  • Ten sessions over 10 weeks of clinical massage. Clinical massage is expected to provide short-term benefits only

Passive Physical Modalilties

  • 12 sessions over 4 weeks of clinic-based low-level laser therapy (LLLT). LLLT may be offered in a continuous or pulsed application (wavelength = 830 or 904 nm)

Management of recent NAD grade III

  • Consider supervised strengthening exercise in addition to structured patient education for patients with NAD grade III </= 3 months duration

  • Do not offer structured patient education alone, cervical collar, low-level laser therapy, or traction

 

Recommendation Details:

Structured Patient Education

  • Provide information about the nature, management, and course of NAD III

    • the ​structured education program should focus on providing advice to stay active and reassuring the patient by addressing expectations of recovery

Exercise

  • Two sessions per week for 6 weeks of supervised graduated neck strengthening exercises

    • This can be supplemented with a home exercise program that includes daily stretching, strengthening, and relaxation exercises and may be supplemented by acetaminophen or NSAIDs​

Management of persistent NAD grade III

  • Do 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

 

Re-evaluation and Discharge

  • Reassess the patient at every visit to determine if: (1) additional care is necessary; (2) the condition is worsening; or (3) the patient has recovered

  • Patients should be discharged as soon as they report significant recovery

  • Use the self-rated recovery question to measure recovery:

    • ‘‘How well do you feel you are recovering from your injuries?’’ The response options include: (1) completely better, (2) much improved, (3) slightly improved, (4) no change, (5) slightly worse, (6) much worse, (7) worse than ever​

    • Patients reporting to be ‘completely better’ or ‘much improved’ should be considered recovered

  • Patients who have not recovered should continue to follow the appropriate care pathway outlined in this guideline and summarized above

Referrals and Collaboration

  • Refer the patient to a physician for further evaluation at any time during their care if they develop worsening symptoms and new physical and psychological symptoms

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CCGI is funded by provincial associations and regulatory boards, and national associations including the Canadian Chiropractic Association

and Canadian Chiropractic Protective Association. CCGI maintains editorial independence from funders.

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