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chiropractic neck pain whiplashA clinical practice guideline on the management of neck pain–associated disorders (NADs) and whiplash-associated disorders (WADs) was recently developed and replaces existing chiropractic guidelines on these topics (Bussières, Stewart et al, 2016). The Guideline Development Group of the Canadian Chiropractic Guideline Initiative (CCGI) conducted the updated guidelines. They considered recently published systematic reviews on NAD and WAD from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Below is a brief summary of the guidelines.  Please refer to the numerous links in this blog post to gain access to the original paper and the full guidelines which are freely available.

Neck pain and its associated disorders (NAD), including headache and radiating pain into the arm and upper back, are common. These disorders often result in significant social, psychological, and economic burden.  Neck pain is a common reason for people to seek chiropractic care.

Motor vehicle collisions most commonly are associated with neck pain related to whiplash-associated disorders (WADs). Whiplash-associated disorders also affect the daily functioning of our patients in terms of considerable pain, suffering, disability, and costs.  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 body parts.  Symptoms of WADs commonly include headache, stiffness, shoulder and back pain, numbness, dizziness, sleeping difficulties, fatigue, and cognitive deficits.

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, be included under the classification of NAD.  The 4 grades of NAD are:

  • 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 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
  • IV – Signs or symptoms of major structural pathology (e.g., fracture, tumor, infection)

After searching and synthesizing the latest scientific literature on these topics, the guideline committee provided their recommendations.  Below is the summary of the recommendations.  The full guideline and accompanying documents are available from the CCGI website at www.chiroguidelines.org. There are excellent resources for practitioners and patients available from this website including exercise videos and forms.

Global summary of recommendations: A multimodal approach including manual therapy, self-management advice and exercise is an effective treatment strategy for both recent onset and persistent neck pain and whiplash associated disorders.

A) Summary of Recommendations for Grades I-III Neck Pain and Associated Disorders (NAD)

  • For recent-onset (0-3 months) neck pain grades I-II, based on patient preference and practitioner experience we suggest offering advice with:
    • multimodal care;
    • manipulation or mobilization;
    • Range of motion home exercises or multimodal manual therapy.
  • For recent-onset (0-3 months) neck pain grade III, based on patient preference and practitioner experience we suggest offering advice with:
    • supervised graded strengthening exercises.
  • For persistent (>3 months) neck pain grades I-II, based on patient preference and practitioner experience we suggest offering advice with:
    • multimodal care or stress self-management;
    • multimodal care or advice alone;
    • manipulation in conjunction with soft tissue therapy;
    • supervised yoga; supervised group exercise; supervised strengthening exercises or home exercises;
    • mixed supervised and unsupervised high-intensity strength training or advice alone for workers with persistent neck and shoulder pain;
    • high dose massage.
  • For persistent (>3 months) neck pain grade III, based on patient preference and practitioner experience we suggest offering advice with:
    • multimodal care or advice alone;
    • mixed supervised and unsupervised high-intensity strength training or advice alone for workers with persistent neck and shoulder pain.

B) Summary of Recommendations for Grade I-III Whiplash and Associated Disorders (WAD)

  • For recent onset (0-3 months) whiplash grades I-III, based on patient preference and practitioner experience we suggest offering advice with:
    • multimodal care.
  • For persistent (>3 months) whiplash grades I-II, based on patient preference and practitioner experience we suggest offering advice with:
    • supervised exercise or advice alone.

Source: Bussières AE, Stewart G, Al-Zoubi F et al. The Treatment of Neck Pain-Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline. J Manipulative Physiol Ther. 2016 Oct;39(8):523-564.

Podcast

Dr. Michael Freeman

In this discussion, Dr. Michael Freeman talks about his research involving motor vehicle collisions, whiplash and forensic applications. Dr. Michael Freeman is a consultant in forensic medicine, and as such is a member of the Faculty of Forensic and Legal Medicine (FFLM) of the Royal College of Physicians in the United Kingdom. He has provided expert testimony more than 1,200 times in a wide variety of civil and criminal cases, including injury and death litigation, automotive and other product liability, toxic tort litigation, life expectancy, and medical negligence cases, as well as in homicide, assault, and other criminal matters.

Dr. Freeman has published around 220 scientific papers, books, and book chapters, primarily focusing on issues relating to forensic applications of epidemiology and general and specific causation. Research and publication topics include traffic crash-related injury and death, injury biomechanics and injury causation, genocide, cancer epidemiology, chronic pain mechanisms, and adult autologous stem cell therapy, among others. Dr. Freeman is the co-editor and co-author of the authoritative text on forensic applications of epidemiology; Forensic Epidemiology: Principles and Practice, published in 2016.

His published 3-step approach has been adopted by U.S. courts as a generally accepted injury causation methodology, as described in the 2016 10th circuit US DCA Etherton decision.

Dr. Freeman is a tenured associate professor of forensic medicine and epidemiology at Maastricht University Medical Center and a joint clinical professor of psychiatry and public health and preventative medicine at Oregon Health & Science University School of Medicine. He is a fellow of the American College of Epidemiology and the American Academy of Forensic Sciences. Dr. Freeman is a past Fulbright Fellow with the U.S. Department of State in the area of forensic medicine, and holds a diploma of legal medicine with the FFLM in the United Kingdom.

Dr. Freeman holds a doctor of medicine degree from Umeå University in Sweden, a Ph.D. and master’s in public health in epidemiology from Oregon State University, a master’s of forensic medical sciences with the Academy for Forensic Medical Sciences in the UK, a doctor of chiropractic from what is now the University of Western States, and a bachelor’s of science from University of Oregon. He has completed a 2-year fellowship in forensic pathology through Umeå University and the Allegheny County Office of the Medical Examiner.

Please see Dr. Michael Freeman’s research profile at researchgate profile.

Below are the articles Dr. Michael Freeman discusses in this episode:

1.Estimating the number of traffic crash-related cervical spine injuries in the United States; An analysis and comparison of national crash and hospital data.Freeman MD, Leith WM.Accid Anal Prev. 2020 Jul;142:105571. doi: 10.1016/j.aap.2020.105571. Epub 2020 May 12.PMID: 32413544
2.Diagnostic Accuracy of Videofluoroscopy for Symptomatic Cervical Spine Injury Following Whiplash Trauma.Freeman MD, Katz EA, Rosa SL, Gatterman BG, Strömmer EMF, Leith WM.Int J Environ Res Public Health. 2020 Mar 5;17(5):1693. doi: 10.3390/ijerph17051693.PMID: 32150926 Free PMC article.
3.Is Acceleration a Valid Proxy for Injury Risk in Minimal Damage Traffic Crashes? A Comparative Review of Volunteer, ADL and Real-World Studies. Nolet PS, Nordhoff L, Kristman VL, Croft AC, Zeegers MP, Freeman MD.Int J Environ Res Public Health. 2021 Mar 12;18(6):2901. doi: 10.3390/ijerph18062901. PMCID: PMC8001694.
4.A systematic approach to clinical determinations of causation in symptomatic spinal disk injury following motor vehicle crash trauma. Freeman MD, Centeno CJ, Kohles SS. PM R. 2009 Oct;1(10):951-6. doi: 10.1016/j.pmrj.2009.07.009. PMID: 19854423.

Listen as Dr. Cassidy and I discuss his career in chiropractic, research, and hear his thoughts on a variety of important issues including the powerful role of psychosocial factors on health.  Dr. Cassidy is a Professor of Epidemiology and Health Policy at the Dalla Lana School of Public Health at the University of Toronto. He is also an Adjunct Globalization Professor at the Faculty of Health at the University of Southern Denmark. He began his career as a chiropractor (CMCC 1975) and later obtained graduate degrees in Surgery (MSc University of Saskatchewan), Pathology (PhD University of Saskatchewan) and Injury Epidemiology (DrMedSc Karolinska Institute, Sweden). His past appointments include Assistant Professor of Surgery and Rehabilitation Medicine at the University of Saskatchewan (1994-1999), Associate Professor of Public Health and Medicine at the University of Alberta (2000-2003), Senior Scientist at the Toronto Western Hospital Research Institute (2003-2017) and Professor of Sport Science and Clinical Biomechanics at the University of Southern Denmark (2011-2016).

His research focus is injury epidemiology, neurotrauma, musculoskeletal disorders and evidence-based health care and policy. He has published over 300 research papers and chapters in textbooks over his career, including papers in the New England Journal of Medicine, the British Medical Journal, Annals of Internal Medicine, JAMA Psychiatry and the Archives of Physical and Rehabilitation Medicine to name a few. He is particularly interested in the psychosocial determinants of injury recovery and long-term consequences of injury.

View Dr. Cassidy’s research at researchgate.net.

We talked about a lot of research articles, too many to list in the show notes.  You can see a listing of Dr. Cassidy’s research at pubmed.com.