CCGI Best Practice Collaborators
CCGI Best Practice Collaborators
CCGI Best Practice Collaborators
In April 2016, CCGI Opinion Leaders were joined by a new team of CCGI Best Practice Collaborators. These are influential evidence-informed clinicians recently nominated by their colleagues in a nationwide survey. They are assisting Opinion Leaders in their area with reaching out to other chiropractors and teaching them about critical thinking, proper interpretation of evidence-informed clinical practice guidelines, and evidence-informed practice in general.
CCGI is delighted to have them on board and looks forward to collaborating with them to take the best practices forward in Canada.
Roles and Activities of CCGI Best Practice Collaborators
-
understanding how clinical practice guidelines are developed;
-
discussing best practices and guidelines with colleagues;
-
having a presence on social media to raise awareness of resources on evidence-informed practice;
-
encouraging clinicians and patients to use the CCGI website and resources;
-
making presentations on evidence-informed practice at continuing education events and conferences in collaboration with their local opinion leaders team.
In April 2016, CCGI Opinion Leaders were joined by a new team of CCGI Best Practice Collaborators. These are influential evidence-informed clinicians recently nominated by their colleagues in a nationwide survey. They are assisting Opinion Leaders in their area with reaching out to other chiropractors and teaching them about critical thinking, proper interpretation of evidence-informed clinical practice guidelines, and evidence-informed practice in general.
CCGI is delighted to have them on board and looks forward to collaborating with them to take the best practices forward in Canada.
Roles and Activities of CCGI Best Practice Collaborators
-
understanding how clinical practice guidelines are developed;
-
discussing best practices and guidelines with colleagues;
-
having a presence on social media to raise awareness of resources on evidence-informed practice;
-
encouraging clinicians and patients to use the CCGI website and resources;
-
making presentations on evidence-informed practice at continuing education events and conferences in collaboration with their local opinion leaders team.
In April 2016, CCGI Opinion Leaders were joined by a new team of CCGI Best Practice Collaborators. These are influential evidence-informed clinicians recently nominated by their colleagues in a nationwide survey. They are assisting Opinion Leaders in their area with reaching out to other chiropractors and teaching them about critical thinking, proper interpretation of evidence-informed clinical practice guidelines, and evidence-informed practice in general.
CCGI is delighted to have them on board and looks forward to collaborating with them to take the best practices forward in Canada.
Roles and Activities of CCGI Best Practice Collaborators
-
understanding how clinical practice guidelines are developed;
-
discussing best practices and guidelines with colleagues;
-
having a presence on social media to raise awareness of resources on evidence-informed practice;
-
encouraging clinicians and patients to use the CCGI website and resources;
-
making presentations on evidence-informed practice at continuing education events and conferences in collaboration with their local opinion leaders team.
Are you interested in getting involved with CCGI?
We are always looking to get people involved in our projects. No experience necessary - we provide training!
Contact us today!
Are you interested in getting involved with CCGI?
We are always looking to get people involved in our projects. No experience necessary - we provide training!
Contact us today!
Cervicogenic and Tension-Type Headaches Care Pathway
Date of last update: August, 2024
1. Record Keeping
Record keeping serves as a recall aid for the clinician of their interaction with the patient. It should concisely “tell the story” of the patient, and accurately reflect those interactions. Record-keeping requirements may be established by your jurisdiction’s standards of practice. These standards should be adhered to when maintaining your clinical records.
Subjective: Document the patient's reported symptoms, feelings, and feedback at each visit.
Objective: Record observable and measurable data such as physical examination findings and outcome measures.
Assessment: Provide a clinical assessment based on the subjective and objective data. Affirm or revise the diagnosis. Information about the patient's progress towards their goals could be recorded here.
Plan: Outline the treatment plan, any adjustments made, advice or other additional interventions or referrals. Any care or plan of care should reasonably be supported by the documented patient “story”. Timeline for follow-up and re-evaluation could be recorded here.
1. Record Keeping
-
Document all findings and recommendations on an ongoing basis, including SOAP notes at each visit (subjective, objective, assessment, plan).
-
Adhere to jurisdictional standards.
2. Informed Consent
-
Document verbal consent for health history taking, physical examination, contact in sensitive areas.
-
Obtain written consent for treatment.
-
Adhere to jurisdictional standards.
3. Health History
-
Apply cultural awareness and trauma-informed care principles.
-
Sociodemographic: Age, gender, sex.
-
Main complaint: Location, temporal factors (onset, mechanism, duration, time of day, pattern, triggering events), radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.
-
Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, muscles and joints, bone density, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
-
Health, lifestyle, family, social, and occupational history: Past medical conditions, medications (including opioids, oral contraception, etc.), supplements, trauma/injuries, hospitalizations, surgeries, volume and intensity of exercise, diet, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.
-
Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.
-
Previous treatments and responses: Effectiveness and any adverse events.
-
Beliefs and expectations: Understanding of their condition, treatment expectations.
-
Red, yellow, and orange flags (sections 4 – 6).
Meaningful Outcomes:
-
Pain: Pain scales (e.g., NRS), pain diagram.
-
Function and Participation: : Impact of headache on daily activities (PSFS, WHODAS, HIT6, HDI, NDI, MYMOP, MYMOP Follow-up).
-
Recovery: Self-rated recovery scales.
-
Quality of Life: SF-12.
-
Work Status: Return to work/school/activities.
-
Individual Goals: SMART goal setting: Specific, Measurable, Achievable, Relevant, Timely.
-
Patient Feedback: Experience and satisfaction with care.
4. Differential Diagnosis Requiring Medical Attention
ACTION: Refer to emergency care immediately for red flags:
-
Meningitis: Neck stiffness, severe headache worsening with neck flexion, fever, vomiting, rash, altered mental status, photophobia, drowsiness, flexed hip/knee posturing.
-
Spinal Infection: Immunosuppression, recent infection or surgery, TB (tuberculosis) history, unexplained constitutional symptoms (e.g., fever/chills), IV drug use, poor living conditions.
-
Intracranial/Brain Lesion: Sudden intense headache (thunderclap); unexplained headache, dizziness, or visual changes.
-
Vertebral/Carotid Artery Dissection: Severe neck pain or headache (“worst pain ever”), double vision, difficulty swallowing, facial numbness, difficulty walking, drop attacks, nausea, nystagmus.
-
Traumatic Spinal Fracture: Age ≥65 years, dangerous mechanism (e.g., pedestrian struck, high-speed motor vehicle collision, rollover, ejection from motor vehicle, fall from elevation ≥3 feet or 5 stairs, axial load to head), extremity weakness/tingling/burning, inability to actively rotate neck 45° left and right, midline cervical spine tenderness (Canadian C-Spine Rule).
-
Acute Narrow-angle Glaucoma: Severe unilateral eye pain, blurred vision, light halos, nausea or vomiting.
-
Cervical Myelopathy: Gait disturbances, hand clumsiness, non-dermatomal numbness, lower extremity numbness or weakness, bowel or bladder dysfunction.
-
Giant Cell Arteritis: Temporal headache, scalp tenderness, jaw claudication, intermittent or permanent vision loss. Commonly associated with polymyalgia rheumatica.
ACTION: Refer to appropriate medical provider:
-
Non-traumatic Spinal Fracture: Sudden severe pain, osteoporosis, corticosteroid use, female sex, age >60, spinal fracture/cancer history.
-
Spinal Malignancy: Progressive pain, cancer history, constitutional symptoms (e.g., fatigue, weight loss), progressive headache worse with exertion.
-
Inflammatory Arthritides (e.g., spondyloarthropathies, rheumatoid arthritis, systemic lupus erythematosus): Morning stiffness > 1hour, systemic symptoms (e.g., fatigue, weight loss, fever), symmetrical joint pain, joint swelling/deformity, skin lesions.
-
Migraine: Moderate to severe unilateral or bilateral throbbing pain, aggravated by physical activity, associated with nausea, vomiting, photophobia, phonophobia, possible aura.
6. Psychosocial Factors (Yellow Flags)
-
Factors that may delay recovery: Fear of movement, poor recovery expectations, depression, anxiety, reduced activity, over-reliance on passive treatments, lack of social support, work-related issues, family issues, litigation or compensation claims, maladaptive coping mechanisms.
-
Action: Address these as part of conservative care, co-manage, or refer to an appropriate provider.
7. Physical Examination
-
Observation: Abnormalities, asymmetries, posture, balance, gait, movements, facial expression.
-
Vitals: Blood pressure, heart rate, respiratory rate, temperature. May include eye exam (e.g.., visual acuity, pupil response, fundoscopic examination).
-
Range of Motion: Cervical spine’s active, passive, resisted ROM (flexion, extension, lateral flexion, rotation).
-
Palpation: Bone, joint, and muscle for tenderness, swelling, muscle tightness, or temperature changes.
-
Neurological Examination: Motor strength, sensory and reflex testing (C5, C6, C7, C8, T1); upper and lower motor neuron signs, cranial nerves screening (including facial numbness; facial movements such as smile, tongue deviation, eye movements).
-
Special/Orthopedic Tests: Select as appropriate based on clinical judgment.
-
Advanced Diagnostics: Radiography is not routinely recommended in the absence of red flags or other specific individual factors (e.g., potential contraindications to treatment).
8. Diagnostic Criteria for Cervicogenic and Tension-Type Headaches
A. Cervicogenic Headache (secondary to cervical spine disorders)
-
Pain: Unilateral, starting from the nuchal area and extending to oculofrontal area.
-
Signs/Symptoms: Moderate-intensity, non-throbbing, episodic pain. Headache and cervical disorder develop in a similar time frame.
-
Exam: Headache reproduced during cervical spine range of motion and tests (e.g., cervical flexion-rotation, myofascial trigger points). Normal upper extremity and cranial nerve neurological tests.
B. Tension-Type Headache (TTH)
-
Pain: Bilateral, pressing/tightening, non-pulsating, “tight band around head” or at base of skull. Can be episodic or chronic.
-
Signs/Symptoms: Varies from mild to moderate intensity. May include one of: photophobia, phonophobia, or mild nausea, but not associated with moderate or severe nausea/vomiting. May involve scalp or neck muscle tenderness. Does not worsen with routine activity.
-
Exam: Normal upper extremity and cranial nerve neurological tests.
9. Treatment Considerations for Cervicogenic and Tension-Type Headaches
After providing a report of findings and obtaining written informed consent.
-
Essential Interventions:
-
Education and reassurance
-
Self-care (exercise, nutrition, sleep, stress management, healthy body weight, no smoking/substance abuse)
-
Encouragement to maintain activities of daily living
-
Address yellow flags (psychosocial factors) (e.g., education, mindfulness, meditation, CBT, referral)
-
Engage in social and work activities
-
-
Optional Interventions (with Rationale and Shared Decision Making):
-
Manual therapy (e.g., spinal manipulation/mobilization particularly for cervicogenic headache, soft tissue techniques, clinical or relaxation massage)
-
Electrotherapies (e.g., low-level laser, TENS, IFC)
-
Needling therapies
-
Psychological or social support
-
Medications: Over-the-counter pain relievers (e.g., acetaminophen, ibuprofen)/prescription, with caution due to the risk of medication-overuse headache (MOH). Discuss options and risks with your medical provider.
-
Multicomponent biopsychosocial care (e.g., exercise therapy, cognitive behavioural therapy, structured education and social support)
10. Prognosis
-
Recovery: Can be episodic, chronic, or recurrent.
-
Negative Prognostic Factors: Passive coping strategies, higher initial pain levels, poor recovery expectations, mental health issues, younger age, persistent symptoms, arm pain, work-related factors, previous neck pain, functional limitations.
11. Ongoing Follow-up
-
Continuously realign treatment plan with patient’s evolving goals, feedback, outcomes, and clinical judgment.
-
Consider referral or co-management if no improvement within established timeline for treatment (e.g., 6-8 weeks).
12. Criteria for Discharge
-
Establish clear criteria for discharge (e.g., achieving initial goals, reaching a plateau, progressing signs and symptoms).
-
Discuss post-discharge plans, including self-management strategies and potential follow-ups.
References
Contact information for further inquiries or feedback
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.
All content and media on the Canadian Chiropractic Guideline Initiative (CCGI) website is created and published online for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. Always seek the guidance of a qualified health professional with questions, concerns or management regarding your health.
