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Abstract Background Whiplash injuries are an important public health problem that is associated with significant disability and high health care utilization. Recent cohort studies suggest that physician care may be the most effective treatment for patients with whiplash-associated disorders. However, these findings have not been tested in a randomized controlled trial. The purpose of this study is to determine which of physician care or two rehabilitation programs of care is most effective in improving recovery of patients with recent whiplash associated disorders. Methods and Design We designed a pragmatic randomized clinical trial. A total of 444 participants (148 in each of three arms) who reside in Southern Ontario, Canada will be recruited from a large insurer. We will include individuals who are 18 years of age or older and who are diagnosed with Grade I or II Whiplash-associated Disorders. Participants will be randomized to physician-based education and activation or one of two rehabilitation programs of care currently in use in Ontario. Our primary outcome, self-rated global recovery and all secondary outcomes (neck pain intensity, whiplash disability, health-related quality of life, depressive symptomatology and satisfaction with care) will be measured at baseline by a trial coordinator and at 6 weeks, 3, 6, 9 and 12 months follow-up by an interviewer who is blind to the participants' baseline characteristics and treatment allocation. We will also collect information on general health status, other injuries, comorbidities, expectation of recovery, work status, pain coping, legal representation, and co-interventions. The primary intention-to-treat analysis will compare time to recovery between the three interventions. This trial will have 90% power at an alpha of 0.05 to detect a 20% difference in the rate of perceived recovery at one year. Secondary analyses will compare the health outcomes, rate of recurrence and the rate of adverse events between intervention groups. Conclusion The results of this study will provide the public, clinicians and policy makers much needed evidence on the effectiveness of common approaches used to manage whiplash-associated disorders. Trial registration ClinicalTrials.gov identifier NCT00546806

Objective: To evaluate the methodological quality and synthesize recommendations of evidence-based guidelines for the management of common traffic injuries. Study design: We conducted a systematic review and best evidence synthesis of guidelines on musculoskeletal injuries, psychological disorders and mild traumatic brain injuries (MTBI) from 1995 to 2012. Independent reviewers critically appraised eligible guidelines using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) criteria. Results: We retrieved 9863 citations. Of those, 16 guidelines were eligible for critical appraisal and eight were scientifically admissible (four targeting whiplash-associated disorders (WAD), one addressing anxiety and three addressing MTBI). The inadmissible guidelines had inadequate literature searches, inexplicit links between evidence and recommendations, and ambiguous recommendations. The literature used to develop most of the admissible guidelines was outdated. Major recommendations included: (1) Advice, education and reassurance for all conditions; (2) Exercise, return-to-activity, mobilization/manipulation, analgesics and avoiding collars for WAD; (3) Psychological first aid, pharmacotherapy and cognitive behavioral therapy as first-line interventions for anxiety; and (4) Monitoring for complications, discharge criteria, advice upon discharge from the emergency room and post-discharge care for MTBI. Conclusion: Fifty percent of appraised guidelines were scientifically admissible, but most need updating. Most guidelines focus on WAD and MTBI. Few guidelines make comprehensive recommendations on a wide range of consequences from traffic collisions. [ABSTRACT FROM AUTHOR]

Study Design: Best evidence synthesis. Objective: To provide evidence-based guidance to primary care clinicians about how to best assess and treat patients with neck pain. Summary of Background Data There is a need to translate the results of clinical and epidemiologic studies into meaningful and practical information for clinicians. Methods: Based on best evidence syntheses of published studies on the risk, prognosis, assessment, and management of people with neck pain and its associated disorders, plus additional research projects and focused literature reviews reported in this supplement, the 12-member multidisciplinary Scientific Secretariat of the Neck Pain Task Force followed a 4-step approach to develop practical guidance for clinicians. Results: The Neck Pain Task Force recommends that people seeking care for neck pain should be triaged into 4 groups: Grade I neck pain with no signs of major pathology and no or little interference with daily activities; Grade II neck pain with no signs of major pathology, but interference with daily activities; Grade III neck pain with neurologic signs of nerve compression; Grade IV neck pain with signs of major pathology. In the emergency room after blunt trauma to the neck, triage should be based on the NEXUS criteria or the Canadian C-spine rule. Those with a high risk of fracture should be further investigated with plain radiographs and/or CT-scan. In ambulatory primary care, triage should be based on history and physical examination alone, including screening for red flags and neurologic examination for signs of radiculopathy. Exercises and mobilization have been shown to provide some degree of short-term relief of Grade I or Grade II neck pain after a motor vehicle collision. Exercises, mobilization, manipulation, analgesics, acupuncture, and low-level laser have been shown to provide some degree of short-term relief of Grade I or Grade II neck pain without trauma. Those with confirmed Grade III and severe persistent radicular symptoms might benefit from corticosteroid injections or surgery. Those with confirmed Grade IV neck pain require management specific to the diagnosed pathology. Conclusion: The best available evidence suggests initial assessment for neck pain should focus on triage into 4 grades, and those with common neck pain (Grade I and Grade II) might be offered the listed noninvasive treatments if short-term relief is desired. [ABSTRACT FROM AUTHOR]

Study Design: Best evidence synthesis. Objective: To identify, critically appraise, and synthesize literature from 1980 through 2006 on surgical interventions for neck pain alone or with radicular pain in the absence of serious pathologic disease. Summary of Background Data: There have been no comprehensive systematic literature or evidence-based reviews published on this topic. Methods: We systematically searched Medline for literature published from 1980 to 2006 on percutaneous and open surgical interventions for neck pain. Publications on the topic were also solicited from experts in the field. Consensus decisions were made about the scientific merit of each article; those judged to have adequate internal validity were included in our Best Evidence Synthesis. Results: Of the 31,878 articles screened, 1203 studies were relevant to the Neck Pain Task Force mandate and of these, 31 regarding treatment by surgery or injections were accepted as scientifically admissible. Radiofrequency neurotomy, cervical facet injections, cervical fusion and cervical arthroplasty for neck pain without radiculopathy are not supported by current evidence. We found there is support for short-term symptomatic improvement of radicular symptoms with epidural corticosteroids. It is not clear from the evidence that long-term outcomes are improved with the surgical treatment of cervical radiculopathy compared to nonoperative measures. However, relatively rapid and substantial symptomatic relief after surgical treatment seems to be reliably achieved. It is not evident that one open surgical technique is clearly superior to others for radiculopathy. Cervical foramenal or epidural injections are associated with relatively frequent minor adverse events (5%-20%); however, serious adverse events are very uncommon (<1%). After open surgical procedures on the cervical spine, potentially serious acute complications are seen in approximately 4% of patients. Conclusion: Surgical treatment and limited injection procedures for cervical radicular symptoms may be reasonably considered in patients with severe impairments. Percutaneous and open surgical treatment for neck pain alone, without radicular symptoms or clear serious pathology, seems to lack scientific support. [ABSTRACT FROM AUTHOR]

The article analyzes clinical decisions pertaining to non-surgical treatments for neck pain. Key issues discussed include a sample case of neck pain, the difficulties of deciding between a surgical and non-surgical treatment option for the condition and the issues' implications for chiropractic medicine.