What is a Clinical Practice Guideline?
The Institute of Medicine defines a clinical practice guideline as systematically developed statements used to assist practitioners and patients in making decisions about the appropriate health care for specific clinical circumstances (1).
Let’s digest what that means before we dive into this blog.
The “statements” in clinical practice guidelines contain evidence-based medical recommendations. Recommendations are developed after third-party organizations collect high-quality systematic reviews and other published medical literature. Both doctors and patients can use these compiled recommendations when developing a care plan for any condition or situation.
Clinical practice guidelines (or CPG’s) exist to manage allergies, men’s health, and psychiatry, to name a few. This blog post will break down a few of the current clinical practice guidelines regarding the chiropractor’s role in pain management of neck and low back pain.
Why are Chiropractic Clinical Practice Guidelines Important?
Disorders of the spine can cause significant pain and a high strain on patients’ lives.
Let’s start at the beginning with the neck.
Neck pain can be connected to an injury, work, or other activities and is a common reason patients consult health care providers, including chiropractors, physical therapists, and primary care medical doctors. Neck pain is also a leading source of chronic disability globally, contributing a considerable amount to social, psychological, and economic burdens. With the highest incidence noted in office and computer workers, it’s no surprise that over half of individuals with neck pain also report pain one to five years later (2, 3).
A significant cause of neck pain is a whiplash-associated disorder (or WAD), with the most common cause occurring from motor vehicle accidents.
The Mayo Clinic reports that whiplash is most commonly caused by rear-end collisions (4).
Whiplash associated disorders are defined as an injury to the neck that occurs with the sudden acceleration or deceleration of the head or neck relative to other parts of the body (2). Imagine the snappy back-and-forth movement of a whip occurring in your upper spine – ouch! This action can lead to sprains and strains of the muscles, ligaments, and tendons in the neck. More than 85% of patients experience neck pain after a motor vehicle accident (2,5).
Whiplash associated disorders can cause more than neck pain, including headaches, sleeping difficulties, and even dizziness.
The Bone and Joint Task Force on Neck Pain recommended that whiplash-associated disorders be included in the neck pain classification system, making it easier for clinicians, and chiropractors, to effectively diagnose and treat it (3). The proposed classification system is widely accepted by clinicians and consists of four grades of neck pain.
These grades are based on the severity of the patient’s symptoms and the clinician’s physical examination findings.
Clinical Practice Guidelines and The Low Back
Moving right along down the spine makes sense to focus on why low back pain is essential for a clinical practice guideline. Low back pain is the leading cause of years lived with disability in the United States. Similar to neck pain, low back pain also contributes to disability and economic burdens (6).
Low back pain impacts more than 31 million Americans, with numbers growing every day (7). The American College of Physicians reports that one of the most common reasons for physician visits in the United States is low back pain.
Additionally, the American College of Physicians supports low back pain classification based on the possible cause and duration of the low back pain (8). Conventionally, low back pain is classified into primary categories based on symptom duration, including acute, subacute, or chronic.
Other categories do exist to encompass more specific conditions like radicular low back pain.
In this respect, chronic pain can be incredibly disruptive to the daily lives of individuals worldwide due not just to pain severity and disability but because of the overall cost to patients and healthcare systems.
Chiropractic Clinical Practice Guidelines
While the Council on Chiropractic Practice provided a valuable resource regarding chiropractic practices in 2013 (9), for this article, we will focus on those that are more current and pertain specifically to the neck and low back pain management. The National Institute of Health provides information regarding the most recent clinical practice guideline for low back pain; however, there is no recommended clinical practice guideline for treating neck pain.
Two recently published high-quality clinical practice guidelines exist regarding the conservative care of neck pain.
The first was released in 2016 by the Ontario Protocol for Traffic Injury Management Collaboration, and the second was released in the Journal of Manipulative and Physiological Therapeutics. Additional information regarding the management for clinicians can be found in the Bone and Joint Decade Task Force report on Neck Pain and Its Associated Disorders.
The guidelines used in conjunction with one another can provide a reasonably substantial evidence-informed information base for chiropractic clinicians.
The neck is a complex and intricate anatomical area, so the foremost recommendations include thorough history taking wherein major structural or other pathologies are ruled out, assessing factors causing potentially delayed recovery, and clinician education of patients about the typical self-limiting nature of the neck pain (2,3,5). These guidelines collectively support the use of multimodal treatment for grades one and two neck pain.
All of these guidelines define multimodal care to include a range of motion exercise in addition to manipulation or mobilization.
For pain management, the National Center for Complementary and Integrative Health offers ample resources for clinical practice guidelines and specific recommendations for diagnosing and treating low back pain published in the Annals of Internal Medicine. This publication is accepted by the American College of Physicians and used in their 2017 clinical practice guideline regarding low back pain, which is the one we’re breaking down today.
The American College of Physicians recommends shifting away from pharmaceutical treatments as a primary treatment for low back pain.
It directly states that “for patients with low back pain, clinicians and patients should initially select nonpharmacologic treatments” with further specific mention of spinal manipulation (8).
The implications of this recommendation should not be lost on chiropractic practitioners who have known the benefits of conservative care for years. This public support for nonpharmacologic treatments encapsulates the unanimous broadening recognition from medical professionals that prescription medications for low back pain management may be less beneficial than previously thought.
How the Guidelines Impact Other Treatments
Of course, spinal manipulation (chiropractic adjustments) is not the only answer to the call for increased nonpharmacologic treatments.
For neck pain, both clinical practice guidelines summarized above do not recommend only multimodal care.
In addition to multimodal care for acute neck pain, the Ontario Protocol for Traffic Injury Management Collaboration recommends a range of motion exercises or muscle relaxants. For chronic neck pain, other recommendations include a range of motion or strengthening exercises, qigong, yoga, massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs (5).
Additional recommendations for acute neck pain by the authors of the clinical practice guideline published in the Journal of Manipulative and Physiologic Therapeutics include strengthening exercises for grade two neck pain and chronic neck pain.
Further recommendations include stress self-management, manipulation with soft tissue therapy, massage, supervised or home strengthening exercises, and yoga (2). Aside from spinal manipulation for low back pain, the American College of Physicians makes different but interrelated recommendations for acute and chronic low back pain and further recommendations for chronic low back pain that does not respond to nonpharmacologic therapies.
Other recommended treatment approaches include superficial heat, massage, or acupuncture for acute or subacute low back pain.
For chronic low back pain, many recommendations are given, including exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, and cognitive behavioral therapy. It should be noted that pharmacologic recommendations are made for all types of low back pain.
However, they are not recommended as the first line of therapy unless a patient has shown no response to nonpharmacologic care (8).
Many organizations have recognized the growing presence of neck and low back pain and have expressed interest in new treatment strategies for pain management.
One example is creating the Interagency Pain Research Coordinating Committee by the Department of Health and Human Services.
The committee was formed to enhance pain research efforts and has aimed attention at prevention and patient care. These guidelines show that evidence is leading future research directions down the conservative care pathway. Evidence for chiropractic care as a primary option in this pathway for treating neck and low back pain is strengthened seemingly every day by new publications.
What does that mean for you as a smart chiropractor? The future is bright! Research can inform policies that have potential impacts not only on your scope of practice but your practicing authority within insurances or even hospital settings.