The treatment of neck pain-associated and whiplash-associated disorders A Clinical Practice Guideline Thank you for attending this presentation. Today we will be looking at a recent clinical practice guideline from the Canadian Chiropractic Guideline Initiative (CCGI) for the treatment of neck pain-associated and whiplash-associated disorders.

What patients want Patients want to know that the care they receive from their clinician is based on the latest scientific evidence and clinical practice guidelines. They want to be sure that their clinician is familiar with the latest recommendations, and is providing them with the best care available. So it is important for clinicians to stay up-to-date with the latest clinical practice guidelines and recommendations for care.

Clinical Practice Guidelines are: ‘statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options’. Institute of Medicine, 2011 What are clinical practice guidelines? The Institute of Medicine describes them as statements that include recommendations intended to optimize patient care, informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options. In other words, they summarize the latest and best scientific evidence available, and recommend treatments that are in the best interests of the patient.

Guidelines are not !!!! Don’t forget, guidelines are tools not rules. They are not standards of care and they are not meant to be restrictive. They are there to provide direction to clinicians and reassurance to patients.

Clinicians don’t only use clinical practice guidelines and research evidence when making decisions about treatment. They also use their clinical expertise along with patient values and preferences when making decisions about the best treatment to offer. This is called evidence-informed practice. The balance between all these aspects is important in the decision-making process and all three aspects should be taken into account. Clinicians who work in this way are called evidence-informed practitioners.

Developing new guidelines Whether it is within the scope of practice Prevalence & burden of disease Priorities for patients and clinicians Available/new scientific evidence Resources needed to implement recommendations Time required to update a guideline When developing a new guideline, researchers need to consider the following questions. Is the treatment within the scope of practice of the healthcare professional concerned? How serious is the prevalence and burden of the disease? What aspects of care are a priority for patients and clinicians? How much new scientific evidence is available since the last guideline was published? What resources are needed to implement new recommendations? For example, is it more costly? Is it difficult to find trained professionals, or does it require extra equipment? How long will it take to update the guideline and when will it be published?

The 2010/2013 guidelines on Neck Pain-Associated and Whiplash-Associated Disorders were due for an update 2010 2013 The 2010 guidelines on the management of whiplash, and the 2013 guidelines on the treatment of neck pain were due for an update. A lot of new research had been published since then and the Canadian Chiropractic Guideline Initiative (CCGI) wanted to review the most recent evidence on these two topics. In 2015, the CCGI guideline panel decided to update both guidelines at the same time.

The CCGI Guideline panel Included researchers, clinicians and a patient representative Met twice in person to consider the most recent literature on neck pain associated and whiplash associated disorders Looked at best research up to December 2015 Agreed on 13 recommendations Published a paper and created tools for clinicians In 2015-2016, the CCGI guideline panel met twice in Toronto to review all the recent research. They agreed on 13 new recommendations and published a paper with a new clinical practice guideline for neck pain and whiplash associated disorders. It took around 18 months for the whole process to be completed. The team included researchers, clinicians and a patient representative. If you are interested, you can read more about exactly how the recommendations were developed in the full manuscript of the guideline, published in the JMPT.

New Guideline 2016 Treatment of Neck Pain-Associated Disorders (NAD) and Whiplash-Associated Disorders (WAD) The new guideline was published by the Canadian Chiropractic Guideline Initiative (CCGI) in October 2016 in the Journal of Manipulative and Physiological Therapeutics. This is the Educational Executive Summary of Recommendations for Practitioners. The full manuscript is also available, along with a QuickView summary (one page). It contains the most recent recommendations for the management of neck pain and whiplash associated disorders.

Summary of 13 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. In summary, the recommendations suggest practitioners offer patients a multimodal approach, including manual therapy, self-management, advice and exercise for recent onset and persistent neck pain and whiplash disorders.

Recommendations for Neck Pain Associated Disorders Here are more details about the recommendations for neck pain associated disorders. The recommendations for neck pain grades I-II are shown in the two left columns (under the green diamond). The recommendations for neck pain grade III are shown in the two right columns (under the yellow diamond). Most recommendations include a combination of manipulation, mobilization and exercises. You can download this algorithm on the CCGI website. To find more details on the recommendations in the CCGI QuickView summary or Educational Executive Summary.

Recommendations for Whiplash Associated Disorders Here are more details about the recommendations for whiplash associated disorders. The recommendations for whiplash grades I-II are shown in the two left columns (under the green diamond). The recommendations for whiplash grade III are shown in the two right columns (under the yellow diamond). Most recommendations include multimodal care and/or exercise. There was insufficient evidence for a recommendation for persistent WAD grade III. You can download this algorithm on the CCGI website. To find more details on the recommendations in the CCGI QuickView summary or Educational Executive Summary.

Key message Clinicians should consider offering a combination of manual therapy, self-management, advice and exercise for neck pain and whiplash associated disorders. Remember that clinicians should consider offering patients with neck pain associated or whiplash associated disorders a combination of manual therapy, self-management, advice and exercise. Sometimes clinicians are not sure about what advice to offer, self-management strategies or which exercises to offer. CCGI has created resources to help. We will talk about those in a moment.

Is there evidence that guidelines work? Guideline dissemination and implementation strategies can encourage practitioners to conform to best practices and lead to improvements in care (Lugtenberg 2009, Grimshaw 2006, Solomon 1998) Do we know if using guidelines can make a difference to patient care? Yes we do. Research shows that when clinicians are encouraged to use best practices, this can lead to improvements in patient health outcomes. This is very important. When patients see improvements in their health, they are likely to be satisfied with the care they are receiving. When patients are happy with their care, their clinician is likely to see an increase in referrals and patient satisfaction.

Barriers for clinicians to use CPGs Lack of motivation Lack of time So why is it difficult for some clinicians to use clinical practice guidelines? Many clinicians tell us that they simply lack the time in their day, that they are not always very motivated to stay up-to-date, or they feel overwhelmed by the amount of reading that is required to learn about best practices. Sometimes they simply don’t know where to start, and it’s easier just to carry on with their regular practice style. They may feel they lack the skills or confidence to find, interpret, assess and apply research findings with their patients. Too much data

Don’t forget to follow CCGI on LinkedIn and Twitter CCGI is here to help you implement best practices by providing tools and resources Visit: Don’t forget to follow CCGI on LinkedIn and Twitter www.chiroguidelines.org CCGI understands that busy clinicians have very little time in their day. We have created easy-to-use tools and resources to make best practices as user-friendly as possible for clinicians and patients. You can find all the most recent research and guidelines on the CCGI website, and download many helpful resources for clinicians and patients.

Resources on the new NAD WAD guideline for clinicians and patients CCGI webinars & online learning modules (CE hours may be available) For example, you can find the handouts on the new neck pain and whiplash guidelines, the algorithms and patient handouts. You can also find out how to take the CCGI educational learning modules and webinars which are free of charge.

New! CCGI patient exercise videos & downloadable forms are available We also created a new video series of patient exercises, based on the most recent recommendations for neck pain. You can find these on the CCGI website, along with patient forms that can be downloaded or forwarded to your patients, with your notes for them to do at home. This will help your patients to continue their self-management between visits and help them to feel better. You can also post a link to these exercises on your clinic website.

and Best Practice Collaborator program CCGI Opinion Leader and Best Practice Collaborator program 18 CCGI Opinion Leaders and 112 best practice collaborators are promoting EIP across Canada. They are available to help you apply recommendations in your practice and find resources for you and your patients. Find your local opinion leaders and best practice collaborators at www.chiroguidelines.org Sometimes it can be helpful to have a colleague to talk to about guidelines and best practice. CCGI has a network of opinion leaders and best practice collaborators across Canada who are available to help. Find your local collaborators by visiting the CCGI website. You can ask them about resources and tools, and they may also be able to visit your clinic and make a presentation.

What’s next? Review of Low Back Pain guidelines (due Fall 2017) Shoulder, ankle, headache and thoracic spine to be considered in 2018 Stay tuned! What’s next? In 2017, the CCGI guideline panel is completing a new review of guidelines on low back pain and this should be available in the Fall of 2017. Thereafter, they hope to look at shoulder, ankle, headache and thoracic spine in 2017-18. Updating guidelines is a constant process.

Acknowledgements www.chiroguidelines.org CCGI would like to thank their stakeholders for their support of this project. Thank you for listening. If you have any questions or comments please let us know! Helping practitioners and patients make the right choice for optimal care www.chiroguidelines.org