Best Practice Guidelines for Chiropractic Care of Neck Pain and Whiplash Disorders

Peer commentary by Donald Corenman, MD, DC, with reply from guideline authors.

Peer Reviewed

The most effective chiropractic care for neck pain and whiplash disorders includes multimodal treatment with spinal manipulation, mobilization, and exercise, according to best practices recommendations recently published in the Journal of Manipulative and Physiologic Therapeutics.

chiropractic care of a mature manChiropractic physical examination procedures are condition specific and include findings on palpation, sensation, reflexes and motor strength. Photo Source: iStock.com.Other treatments for neck pain and whiplash that have demonstrated efficacy include low-level laser therapy, massage, acupuncture, electrical stimulation such as TENS, traction, and other modalities. The paper also recommends short trials of care (6 to 12 visits) to determine if chiropractic treatments are effective, as well as collaborative care with other providers as necessary, according to the guidelines.

SpineUniverse spoke with lead author of the guidelines Wayne M. Whalen, DC, to understand how to apply these guidelines in practice as well as how these guidelines help fill knowledge gaps on modalities that lack definitive scientific evidence. In addition, SpineUniverse Editorial Board Member Donald S. Corenman, MD, DC, commented on topics that he believes should be addressed in future guideline updates, including chiropractic management of myelopathy from cervical stenosis and radiculopathy.

What are the key practice pearls from this guideline?

Dr. Whalen: Chiropractors should obtain a thorough history and evaluate for potential “red” or “yellow” flags that might suggest the possibility of more serious or potentially complicating factors in patients with neck pain or whiplash disorders. Physical examination procedures should be condition specific, and typically involve findings on palpation, sensation, reflexes and motor strength, and relevant orthopaedic testing. Imaging studies are appropriate but should be condition specific and consistent with national guidelines.

Patients should be informed of their condition and treatment options, including no care, and physicians should obtain informed consent, and provide evidence-based recommendations for treatment.

Treatment generally should be evaluated in brief trials of care, typically 6 to 12 visits, with further care predicated largely based upon improvement in functional capacity. Treatments we recommend include spinal manipulation, spinal mobilization, exercise, home advice, acupuncture, massage therapy, TENS, traction, and low-level laser therapy, based on the evidence currently available. Some patients will require periodic care to maintain therapeutic gains, and a small number of patients with chronic pain may require scheduled ongoing care.

How do these guidelines differ from previous guidelines in terms of incorporating procedures and practices with lower levels of evidence?

Dr. Whalen: Some excellent prior guidelines based their recommendations almost exclusively on the highest possible level of evidence, and where there is no such evidence, choose to make no recommendations. As we point out, however, that leaves a number of treatment options with good evidence, though not the highest-level evidence, without clear recommendations. Examples include low-level laser therapy, TENS, and traction, among others.

While it is laudable to try to base recommendations on the highest level of evidence, that does not always mean it must the highest possible level of evidence. Sometimes the literature has simply not reached that point, and we do not have a definitive answer. To bridge the gap between the best possible evidence and the best available evidence, these best practices recommendations relied on a modified Delphi process involving over 50 experienced providers weighing in with expert consensus. What results is a more pragmatic guideline for clinicians and payors covering the most commonly used approaches for neck pain.

This does not mean that the recommendations are based on poor evidence or no evidence. Rather, there may be conflicting conclusions in the literature, or a dearth of evidence one way or the other, but extensive clinical experience as well as at least some reliable evidence. Conclusions may change with additional evidence, but for the present, these recommendations represent the best available description of “best practices” for this condition.

The guidelines note that “These recommendations may reduce friction between payers and providers regarding appropriate care.” Can you elaborate on this?

Dr. Whalen: There is a perception, at least among some providers, that payors often use guidelines as a means of denying care, rather than as a vehicle for finding the best approach for a particular patient. Dr. David L. Sackett famously pointed out that “The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”1

Again, there is a perception that some payors rely exclusively on the guidelines in making coverage decisions and ignore clinical expertise and patient preferences in making those determinations. This may be exacerbated when guidelines rely only on the highest possible evidence and make no recommendations about treatments that fall into a “grey zone.” By clarifying recommended “Best Practices” regarding those grey-zone treatments, we hope to reduce areas of potential disagreement between providers and payors. Certainly, it is to everyone’s benefit, not least to the patient, when all parties can agree on what care is most efficacious.

Is there anything else you would like to tell SpineUniverse readers?

Dr. Whalen: It has certainly been my experience, shared by my co-authors, that many of our colleagues in medicine and other health care professionals have at most a superficial understanding of the clinical approach doctors of chiropractic take with their patients. We hope that this guideline will be of use to them in considering collaborative care and help frame their reasonable expectations. Some have suggested that chiropractic is like a box of chocolates, and you never know what you are going to get. We hope this paper helps everyone to understand what you should get.

Disclosures
Dr. Whalen has no relevant disclosures.

Source
Whalen W, Farabaugh RJ, Hawk C, Minkalis AL, et al. Best-practice recommendations for chiropractic management of patients with neck pain. J Manipulative Physiol Ther. 2019 Dec 20. doi: 10.1016/j.jmpt.2019.08.001. [Epub ahead of print]

Reference
1. Sackett DL. Evidence-based medicine. Semin Perinatol. 1997;21(1):3-5.

Commentary

Donald S. Corenman, MD, DC
Orthopaedic Spine Surgeon and Chiropractor
The Steadman Clinic
Vail, CO

This paper tries to solve the problem of neck pain treatment with some algorithmic guidelines and is commendable. However, a few items are missing from the guidelines that warrant coverage.

For example, the guidelines focus on vertebral artery dissection and stroke, although these conditions are very uncommon. Instead, the paper should focus on the most common red flag disorder, myelopathy from cervical stenosis.

The following statement in the guidelines is nonspecific:

“Other red flags do not necessarily require referral or present a contraindication to spinal manipulation or other chiropractic procedures. These depend on the findings of the additional evaluation. Although some red flags represent contraindications to use of high-velocity low-amplitude manipulation, other approaches using less biomechanical force may be used to address the musculoskeletal disorders while the red-flag issues are being addressed via further diagnostic testing, referral, or interdisciplinary care coordination.”

Gentile extension maneuvers can aggravate myelopathy from stenosis, so the above statement has some peril.

This paper does not scrutinize the physical examination findings of myelopathy (long tract signs) or what to do in case these exam findings are discovered (at the very least imaging studies). Symptoms of myelopathy (imbalance, loss of fine motor control, non-dermatomal paresthesias and bowel/bladder dysfunction should be part of a thorough history. An absolute “do not manipulate” rule should be noted in patients with central stenosis and myelopathy.

In addition, radiculopathy should be in this discussion as lateralized neck pain can be generated by radiculopathy due to foraminal stenosis and arm pain is commonly caused by nerve root compression. The physical examination is key to diagnosis and exam findings for this condition are not mentioned. Changes in treatment technique would be necessary to accommodate the root compression.

X-rays with discal collapse juxtaposed with degenerative spondylolisthesis and instability have very different treatment routines (no manipulation with instability), but there are no guidelines noted for these disorders.

Furthermore, the constant repudiation that vertebral artery injury is not related to cervical manipulation is a common “head in the sand” denial that needs to be addressed by the chiropractic field. There are obvious incidences of vascular wall intimal injury after vigorous upper cervical manipulation and that needs to be considered.

In spite of the missing information, the paper is well written and a welcome addition to treatment algorithms for chiropractors.

Disclosures
Dr. Corenman has no relevant disclosures.

Reply From the Guideline Authors

We are grateful to Dr. Corenman for his comments and unique perspective as both a doctor of chiropractic (DC) and orthopaedic surgeon.

We agree that vertebral artery dissection-associated stroke is very uncommon but felt discussion regarding the topic was warranted given the extensive though inaccurate characterizations in the popular press as well as among some medical providers. Additional discussion regarding other potentially serious issues, such as spinal stenosis with associated myelopathy would be useful but given the already lengthy paper and the caveats listed under “red flags,” we did not provide additional elaboration. Future iterations of this work may include deeper review regarding both stenosis and myelopathy. However, similar to the artery dissection/stroke issue, reported adverse effects related to these conditions have not been identified as serious consequences of care rendered by DCs on a frequent basis. DCs are fully trained to screen for contraindications for spinal manipulation, and professional liability data experience supports this viewpoint.

We agree the “red flags” are somewhat nonspecific, but they are intended to address a wide variety of potential problems, from connective tissue disorders and osteopenia, to loss of sensation and frank neuropathic signs. The intent was to encourage DCs to consider potentially serious complications when evaluating patients, but by no means does it represent an exhaustive list.

Similarly, we did not provide a more comprehensive discussion regarding physical examination findings associated with stenosis-related myelopathy. We specifically highlighted “abnormal upper extremity sensory, motor, or deep tendon reflexes” as significant red flags that warrant further evaluation and also indicated in the graphic that potential red flags warrant additional diagnostics or referral. We agree however that greater clarity regarding the potential risks of stenosis and myelopathy are warranted, though some authors do not feel it is an absolute contraindication given the range of spinal manipulative techniques and technology at the disposal of DCs today.1,2

Further, we appreciate the comments regarding radiculopathy, disc injuries, and spondylosis with associated spondylolisthesis and potential instability. All are topics worthy of additional discussion as part of a framework of evaluation and treatment recommendations for the chiropractic profession, but we felt a reasonably thorough review of these, and related topics was beyond the scope of this paper, although we agree they would be worthy topics for future papers.

Finally, while Dr. Corenman initially appropriately characterized vertebral artery dissection/stroke as “very uncommon,” he raises the issue of manipulation and vertebral artery intimal injury again later in his critique. This is an admittedly controversial but important topic that has been the subject of numerous previous investigations. As a result, we did not feel compelled to address it again beyond the brief discussion found in our paper.

Again, we are grateful for Dr. Corenman’s comments and will bear them in mind during future updates.

References
1. Murphy DR, Hurwitz EL, Gregory AA. Manipulation in the presence of cervical spinal cord compression: A case series. J Manipulative Physiol Ther. 2006;29(3):236-44.

2. Puentedura EJ, March J, Anders J, Perez A, et al. Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports. J Man Manip Ther. 2012;20(2):66–74. doi:10.1179/2042618611Y.0000000022

Updated on: 02/06/20
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Spine Surgery Improves Physical Functioning and QOL in Mild Degenerative Cervical Myelopathy
Wayne M. Whalen, DC, FIACN, FICC
Chiropractor
Whalen Chiropractic
Santee, CA
Donald S. Corenman, MD, DC
Orthopaedic Spine Surgeon and Chiropractor
The Steadman Clinic
Vail, CO
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