The CCA/CFCREAB Clinical Practice Guidelines Project Status Report April 2008

1. The CCA/CFCREABClinical Practice Guidelines ProjectStatus ReportApril 2008

2. Guiding Principles • Credit to the Profession outside the Profession • Benefit to Chiropractors as they treat patients • Identification of the Current Evidence

3. Guidelines and Research • A Symbiotic Relationship

4. Task Force • Dr. Ron Brady, The CCA, Saskatchewan • Dr. Grayden Bridge, The CCA, Alberta • Dr. Dean Wright, The CCA, Ontario • Dr. Wanda Lee MacPhee, CFCREAB, Nova Scotia • Dr. Keith Thomson, CFCREAB, Ontario • Jim Duncan, CAE, The CCA • Peter Waite, CAE, CFCREAB • Wayne Glover, CAE, General Manager

5. Guidelines Development Committee • Dr. Roly Bryans – Chair, Newfoundland • Dr. Liz Anderson-Peacock, Ontario • Dr. Martin Descarreaux, UQTR • Dr. Mireille Durlanleau, Quebec • Dr. Henri Marcoux, Manitoba • Dr. Brock Potter, British Columbia • Dr. Rick Ruegg, CMCC • Lynn Shaw, PhD (interprofessional member) • Robert Watkin (public member) • Dr. Eleanor White, Ontario • Thor Eglington MSc RN, Editor • Wayne Glover, CAE, General Manager

6. Review Panel • Dr. Steven Silk, Ontario • Dr. Roy Till, Ontario • Dr. Andrea Furlan, Inter-professional • Dr. Richard Roy, Quebec • Dr. Robert Burton, Newfoundland

7. Newfoundland & Labrador Chiropractic Association Newfoundland & Labrador Chiropractic Board Board of the Nova Scotia College of Chiropractors Council of the Nova Scotia College of Chiropractors Prince Edward Island Chiropractic Association New Brunswick Chiropractors' Association Association des Chiropraticiens du Québec Ordre des Chiropraticiens du Québec Ontario Chiropractic Association College of Chiropractors of Ontario Manitoba Chiropractors' Association The Chiropractors' Association of Saskatchewan Alberta College and Association of Chiropractors British Columbia Chiropractic Association British Columbia College of Chiropractors Chiropractic Registrar, Department of Justice, Yukon Territory The Canadian Chiropractic Association Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards Canadian Memorial Chiropractic College Université du Québec à Trois Rivières Canadian Chiropractic Historical Association Canadian Chiropractic Protective Association Canadian Chiropractic Research Foundation Chiropractic Awareness Council College of Chiropractic Orthopedists College of Chiropractic Rehabilitation Sciences Chiropractic College of Radiologists College of Chiropractic Sciences College of Chiropractic Sports Sciences Stakeholder Organizations

8. Evidence Monitoring Committee • Dr. Roly Bryans • Dr. Rick Ruegg • Thor Eglington

9. Evidence Based vs. Best Practice • Evidence Based Guidelines • Best Practice Guidelines • Opportunities for both • Commitment to Evidence Based • Compromise Needed

11. How We Are Funded

12. Our Expenses

13. Agenda • Neck Pain Guideline Update: Dr. Wanda Lee MacPhee • Whiplash Guideline Update: Dr. Roly Bryans • Headache and Lumbar Guidelines Update: Wayne Glover and Dr. Rick Ruegg • Structure and Function Guideline Update: Dr. Wanda Lee MacPhee • Future Actions: Dr. Ron Brady

14. The CCA/CFCREABClinical Practice Guidelines Project

15. Neck Pain Guideline • Two updates to the guideline • Publication in JCCA • Evidence Monitoring Committee’s work • Future Updates of the guideline

16. Neck Pain Guideline • Bone and Joint Neck Pain Task Force Report • TF and GDC members in attendance, November 2007 • Corroborated many CPG findings and recommendations

17. Comparison of CPG and BJD Work • Updates to Body of Work • Databases Used to Support Work • Methodology • Multidisciplinary approach • Consistency of Finding • Expansion into Care Modalities or Methods • Time and Cost • World Standard

18. Neck Pain Guideline: Next Steps • Continue EMC activities • Inclusion of BJD data and dissection information • Disseminate information • Use guideline for excellent public care

19. The CCA/CFCREABClinical Practice Guidelines Project

20. Bone and Joint Decade & The CCA/CFCREAB Guidelines Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Spine Feb, 2008) are congruent with our developed guidelines

21. Bone and Joint Decade & The CCA/CFCREAB Guidelines Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Spine Feb, 2008) blend WAD and non-WAD in Dx no evidence rating

22. Bone and Joint Decade & The CCA/CFCREAB Guidelines Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Spine Feb, 2008) blend WAD and non-WAD in Dx no evidence rating search breadth: 6-10 literature databases WAD current to July 2006, cervical to 2004 # studies underlying our clinical conclusions: 90 = cervical pain Tx vs ~57 24 = WAD Tx vs ~19

23. Bone and Joint Decade & The CCA/CFCREAB Guidelines Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Spine Feb, 2008) impact on our guidelines’ evidence-base = none impact on the expert opinion included in our guidelines = supportive

24. WAD Guideline Evidenced Based Care of Whiplash Associated Disorders in Adults

25. WAD Guideline Feedback Technical and Advice draft posted Expected academic, research and practitioner feedback Very little formal feedback Informal feedback insightful Concerns voiced Editor-in-Chief should be a science-PhD chiropractor Academic, research and practicing chiropractors who saw them were frustrated by complexity of both pieces

26. Response Editor-in-Chief RFP to be released Thor Eglington to remain as “Consulting Editor” Complexity Process change Content changes

27. Work-process changes Literature Search Evidence Extraction Evidence Rating Technical Version Review Panel Journal Version GDC Authorship Process Practitioner Version GDC Authorship Process task force GDC Authorship Process task force Stakeholder feedback task force GDC Authorship Process The CCA and CFCREAB Ratification JCCA Peer Review On-line posting Technical Publication of Journal in JCCA Practitioner version distribution

28. Content changes • Simplification of text • Simplification of Figures • WAD grade image becomes linear decision tree • HVLA guidance Figures and adjunctive Tx Tables consolidated

29. OLD: Refined WAD Grades First, it is determined that whiplash has occurred. Then, WAD diagnosis is: or WAD- 2 musculoskeletal signs e.g., point tenderness, decreased cROM no WAD no neck symptoms, no physical sign WAD-1 non-tender physical signs e.g., non-tender palpable - joint dysfunction - muscle hypertonicity WAD-3 neurological signs WAD-4 fracture or dislocation neck symptoms e.g., pain, stiffness e.g., decreased or absent deep tendon reflexes, weakness, sensory deficits whiplash has occurred but the patient is fine at the time of assessment

30. NEW: Refined WAD Grades It is determined that whiplash has occurred. Neck symptoms e.g., pain, stiffness no WAD no neck symptoms, no physical signs (whiplash has occurred, but the patient is fine at the time of assessment) WAD-1 non-tender physical signs e.g., non-tender palpable joint dysfunction muscle hypertonicity WAD-2 musculoskeletal signs e.g., point tenderness, decreased cROM WAD-3 neurological signs e.g., decreased or absent deep tendon reflexes, weakness, sensory deficits WAD-4 fracture or dislocation

31. OLD: Figure 1: HVLA manipulation for WAD-1 patients 4th dimension: indicators prognostic of chronicity • at all times: history of gross body pain and pain meds • acute: initial cervical disability, high pain immediately after injury • subacute: increasing age in years, low education level, high pain and poor ROM , somatization, sleep difficulties, work inabilities, being female, being single, high NDI scores, low cold pain thresholds, poor sympathetic reactivity, and high emotional distress • after late-subacute: low self-efficacy 1 patient occupies an area this size 0 3d 2d 6 wks 3 wks 12 m acute subacute chronic 2nd dimension: time-since-injury (phase of healing) 1st dimension: grade of WAD • Dimension of time since injury • (= tissue reconstruction in a healthy individual*): • inflammatory 0 -to- 3 days = acute • repair 2 days -to- 6 weeks = subacute • remodeling 3 weeks -to- >12 months = chronic *N.B., In an ill patient, tissue healing may be retarded, and the clinical approach should be adjusted accordingly: an ill patient may be 'acute' for months, and an 'acute' clinical approach is appropriate. no HVLA manipulation A B C almost mostly no non-sensory non-sensory 3rd dimension: pain experience 4 3 2 1

32. NEW: Figure 1: HVLA manipulation for WAD-1 patients No HVLA manipulation Force=low-med, frequency=high, amplitude=low, velocity=all, location of treatment=all Force=low-med, frequency=low-med, amplitude=low, velocity=all, location of treatment=all Force=all, frequency=med, amplitude=all, velocity=all, location of treatment=all All patients: cROM-exercise (supervised/unsupervised), Instruction, Information tools no HVLA manipulation CBT PAIN EXPERIENCE sensory psychosocial Electrotherapies Exercise (not cROM, supervised/unsupervised) Collar 0d 3d 3wks 6wks 12wks > 6 m acute chronic - TIME SINCE INJURY -

33. The CCA/CFCREABClinical Practice Guidelines Project

34. Headache Guideline • Evidenced Based Care of Headache in Adults • Timeline: • April 2006 • September 2006 • February 2007 • August 2007 • December 2007

35. Headache Guideline • Next Steps: • Contract Writers immediately following stakeholder meeting • Review Panel • Authorship work by Guidelines Development Committee • Review by Profession • Publication: Target date, early 2009

36. Lumbar Guideline • Treatment of the Lumbar Spine • Extraction Work: • Identification of Evidence Extractors • Contract

37. Headache Guideline • Evidenced Based Care of Headache in Adults • What we have discovered so far in the review of the extracted material

38. Take Home Message You can significantly reduce the risk-to-benefit ratio by limiting the use of cervical spinal manipulation to those conditions research has shown to respond positively.

39. Categorization of Headaches Primary headaches Secondary headaches Cranial neuralgias

40. Primary Headaches Migraine headaches Tension-type headaches Cluster headaches

41. Tension-type Headaches • May/may not involve pericranial muscles • Etiology unknown • Tight band around head • Typically responds well to OTC’s • More prevalent in women • Commonly a family history of headache • Often begin before the age of 10

42. Secondary Headaches Headache attributed to head and neck trauma Headache attributed to cranial or cervical vascular disorders Headache attributed to non-vascular cranial disorder Headache attributed to withdrawal Headache attributed to a disorder of the neck, cranium, eyes, ears, nose, sinuses, teeth, mouth etc. Cranial neuralgias

43. Headache Attributed to a Disorder of the Head or Neck Headaches commonly seen by chiropractors Cervicogenic headaches Reproduced with provocative testing TMJ headache precipitated by jaw movements or chewing

44. SMT Treatable Headaches The current literature supports the use of SMT in the treatment of: • Migraine headaches • Cervicogenic Headaches When neck related symptoms or findings indicate these structures to be the cause of the headache, the diagnosis should be ‘cervicogenic’ rather than ‘tension-type’

45. Risk Management An accurate diagnosis of headache requires a complete and thorough history and physical examination. The chiropractic treatment of headaches must be limited to those that have been shown to respond to SMT. All others must be referred for the appropriate assessment. When indicated, referral for emergency medical assessment should be made without delay.

46. Role of a Clinical Guideline • Evidence-Based – the literature will support what we do. • Risk management – reduction of risk by treating only those headaches amenable to chiropractic manipulation. • Improves clinical efficacy

47. The CCA/CFCREABClinical Practice Guidelines Project

48. Structure and Function Guideline • Insufficient literature • Have Monitored literature/research • Currently doing another search • Results expected within the next month • Still commitment to create a guideline once there is sufficient literature to create an evidence-based guideline

49. The CCA/CFCREABClinical Practice Guidelines Project

50. Future Directions • Whiplash Guideline • Practitioner-friendly version • Published in JCCA by year end