Care Pathways for Enabling Recovery from Common Traffic Injuries: A Focus on the Injured Person

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1 Care Pathways for Enabling Recovery from Common Traffic Injuries: A Focus on the Injured Person Jessica J. Wong, DC, MPH, FCCSC Research Associate, UOIT-CMCC Centre for Disability Prevention and Rehabilitation University of Ontario Institute of Technology (UOIT) Canadian Memorial Chiropractic College (CMCC)

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3 Outline Overview and Methodology Management of Acute Neck Pain and Whiplash-associated Disorders Management of Chronic Neck Pain and Whiplashassociated Disorders Key Messages

4 Overview and Methodology

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6 Develop a minor injury protocol suitable for incorporation by FSCO into a new Minor Injury Guideline for the treatment of minor injuries regularly resulting from motor vehicle accidents based on best evidence as identified through appropriate research.

7 Evidence-based Medicine (EBM) Sackett DL et al. BMJ 1996;312:71 EBM is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of patients EBM integrates clinical expertise + best available clinical evidence from systematic research Clinically relevant research Emphasizes patient-centred clinical research Efficacy and safety New evidence may invalidate previously accepted treatments Replace them with more efficacious and safer ones

8 Patient-centered Care Requires the practitioner to empower the patient, share in the power relationship and consider the whole person the interaction between mind and body (Belle Brown et al., 2003) It is health care that is delivered humanely and respectful of patient needs and preferences (Institute of Medicine, 2001)

9 Multidisciplinary Guideline Expert Panel Clinical Specialty Scientific Specialty Other Perspectives Rehabilitation medicine Epidemiology Consumers Emergency medicine Clinical epidemiology Patients Internal medicine Health economics Insurers Orthopedic surgery Qualitative research Legal - Retired judge Dentistry Health policy Chiropractic Library sciences Physiotherapy Psychology Nursing

10 Methodology 1 Scope What health conditions are included? What health conditions are excluded? What clinical interventions are eligible? 2 43 Systematic reviews by Internal Research Team Qualitative Study 3 Approved by Core Scientific Team Explore experiences 4 Approved by Guideline Expert Panel

11 Systematic Review A scientific investigation that focuses on a specific question and uses explicit, pre-specified scientific methods to identify, select, assess, and summarize the findings of similar but separate studies. It may include a quantitative synthesis (meta-analysis), depending on the available data - Institute of Medicine, 2011

12 The Systematic Review Process Systematic Search Screening Critical Appraisal Data Synthesis 43 Systematic Reviews: OVERALL TOTAL TOTAL CITATIONS SCREENED APPRAISED ADMISSIBLE

13 - 30 published/accepted papers - The Spine Journal - J Occupational Rehabilitation - European Spine Journal - Journal of Manipulative and Physical Therapeutics - Journal of the Canadian Chiropractic Association - Manual Therapy - Physical Therapy - Disability and Rehabilitation - Clinical J Pain - 1 in progress

14 5 Draft Recommendation by Recommendation Development Subgroup OHTAC Determinants Overall clinical benefits Review and Approval by Guideline Expert Panel 2. Consistency with societal and ethical values 3. Value for money Report to Superintendent 4. Feasibility of adoption in the automobile insurance system

15 Outcomes 1. Accelerate recovery 2. Reduce the intensity of symptoms 3. Promote early restoration of function 4. Prevent chronic pain and disability 5. Improve health-related quality of life 6. Reduce recurrences 7. Promote active participation of patients in their care

16 Conditions Covered by the Guideline Physical, mental and psychological impairments No significant loss of anatomical alignment or no loss of structural integrity Evidence of favourable recovery (50% recover within 6 months) Grades I to III NAD Headaches associated with neck pain Mid and lower back pain Thoracic and lumbar radiculopathy Grades I and II sprains and strains Skin and muscle contusions, abrasions and skin lacerations Mild traumatic brain injuries Psychological signs and symptoms

17 Care Pathway Structure of Guidelines

18 Structure of Guidelines Quick Reference Guide

19 Recommendations Structure of Guidelines

20 Management of Acute Neck Pain and Whiplash-associated Disorders

21 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders Neck pain and its associated disorders (NAD) refers to neck pain, stiffness or tenderness not attributed to pathology such as fractures, dislocations, infections or tumours

22 Citations identified through database searching: 38,135 Duplicates removed: 7,007 Citations screened using titles and abstracts: 31,128 Citations excluded due to ineligibility: 30,858 Articles eligible for critical appraisal: 270 Articles with a high risk of bias: 98 Articles with a low risk of bias included in qualitative synthesis: 172 (reporting 168 studies)

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24 R 1 R 2 R 3

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26 Poor Prognostic Factors

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34 Management of Chronic Neck Pain and Whiplash-associated Disorders

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45 Measuring Recovery How well do you feel you are recovering from your injuries? 1. Completely better 2. Much improved 3. Slightly improved 4. No change 5. Slightly worse 6. Much worse 7. Worse than ever Recovered

46 Key Messages 1. Establish the plan of management on partnership with the patient, with a patient-centered care approach 2. The management of acute neck pain should include structured education in combination with: Unsupervised range of motion exercises Manipulation or mobilization Muscle relaxants

47 Key Messages 1. The management of persistent neck pain should include structured education in combination with: Supervised combined exercises for the neck (range of motion, strengthening, and flexibility) Qigong Iyengar yoga A short course of multimodal care A short course of clinical massage Low level laser therapy Non-steroidal anti-inflammatory drugs 2. Effective interventions provide small benefits 3. Reassess patients at every visit and discharge patient when recovered 4. Avoid using ineffective interventions

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