Course Content Tag: Traffic Collisions

Danielle Southerst DC, FCCS(C)

Dr. Southerst is a Doctor of Chiropractic with clinical and research experience in the areas of disability and rehabilitation of musculoskeletal disorders, in which she has contributed to dozens of systematic reviews and two clinical practice guidelines on diagnosis and management. Dr. Southerst holds a Fellowship in Chiropractic Clinical Sciences from the College of Chiropractic Sciences (Canada). She practices evidence-based chiropractic care with a focus on combining manual therapy with therapeutic exercise, education, self-management strategies and lifestyle modification in a biopsychosocial approach to rehabilitation at the Occupational and Industrial Orthopaedic Center at the NYU Langone Orthopaedic Hospital in New York, NY.

ABSTRACT

The objective of this narrative review is to provide clinicians with a guide to the evidence-based assessment and treatment of neck pain caused or exacerbated by traffic collisions. Findings and recommendations from recent evidence-based clinical practice guidelines and associated systematic reviews are summarized.

INTRODUCTION

Each year in North America, roughly 300 per 100,000 people experience neck pain and associated disorders (NAD) as a result of a traffic collision.1 Generally, the prognosis of these injuries is favorable, however some experience prolonged pain and disability.^2-3 Persistent symptoms can have an adverse effect on health and well-being, as well as the ability to work and perform normal activities of daily living.⁴

Clinical practice guidelines assist healthcare providers in the delivery of quality care to patients. High-quality clinical practice guidelines systematically review the best available evidence and close the gap between evidence and practice through expert consensus and consideration of the patient’s values and preferences. The following is a narrative synthesis of findings and recommendations from two recent guideline initiatives concerning NAD related to traffic collisions. The Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration was formed by an interdisciplinary group of researchers, clinicians, policy advisors and patient representatives to develop care pathways to “enable and optimize recovery of individuals injured in traffic collisions.”^4-5

The Cervical Assessment and Diagnosis Research Evaluation (CADRE) Collaboration is currently completing a clinical practice guideline with recommendations on the assessment of patients with neck pain. Recommendations will be based on five systematic reviews. As of the date of this publication, two of their systematic reviews have been published: one on clinical tests for assessing anatomical integrity of the cervical spine and related structures,⁶ and one on clinical prediction rules used to assess alert, low-risk patients following blunt trauma to the neck.⁷ Healthcare providers are urged to view the following as an overview and to consult the full guidelines for a more complete representation of the content.

COURSE AND PROGNOSIS OF TRAFFIC-RELATED NAD

One of the tasks undertaken by the OPTIMa Collaboration was to update findings of the 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force; NPTF) regarding the course and determinants of recovery from traffic- related NAD. With respect to recovery, about half of those with neck pain related to traffic collisions recover within three to six months, depending on the definition of “recovery” used in the study. More conservative definitions of “recovery” (for example, complete recovery of pain and/or disability) are associated with longer recovery time, whereas less conservative definitions are associated with shorter recovery time. Recovery time is longer (roughly six to 12 months) in studies of patients making personal injury claims to insurers.^2,4

A number of factors have been shown to be associated with poorer recovery from neck pain following traffic collisions. There is strong evidence that a history of traffic-related NAD increases the risk of future neck pain. Other factors include poor expectations for recovery, passive coping style, high levels of initial healthcare utilization, and post-collision pain-related psychological symptoms including fear, anxiety, anger, frustration and depression.^2,4 These factors should be assessed by healthcare providers regularly throughout the course of treatment.

There is preliminary evidence that a number of other factors may be associated with poorer recovery including greater post-collision neck pain and/or disability, post-collision anxiety, worry, or kinesiophobia, and older age. These factors require further study, but nonetheless should be assessed for their potential influence on recovery. Table 1 outlines some of the key risk factors for delayed recovery and tools that can be used to assess them.

Table 1. Assessing prognosis in patients with traffic-related NAD

Assessing Prognosis in Patients with Traffic-Related Neck Pain and Associated Disorders (NAD)4
Prognostic factor	Tool	Cut-offs indicating increased risk for prolonged recovery
	Do you think that your injury will:
Poor expectations of recovery	Get better soon Get better slowly Never get better Don’t know	Responses of “never get better” or “don’t know”
Depressed mood or feelings of anxiety about pain	Patient Health Questionnaire-9 (PHQ-9) Center for Epidemiologic Studies Depression Scale Revised (CESD-R) Hospital Anxiety and Depression Scale (HADS) Beck Depression Inventory-II (BDI-II)	CESD-R ≥ 1615 HADS score of 11 or higher16
Kinesiophobia	Tampa Scale of Kinesiophobia (TSK)	Score of 37 or higher17
Fear avoidance	Fear Avoidance Beliefs Questionnaire (FABQ)	Physical activity subscale over 1418, Work subscale over 2919
High levels of frustration or anger about pain	How frustrated/angry do you feel about your pain? (Rating Scale 0-10; 0 means no frustration/anger and 10 means as frustrated/ angry as you can imagine)	6 or above
Passive Coping	Vanderbilt Pain Management Inventory (VPMI) Pain Catastrophizing Scale (PCS)	PCS over 3820

CLASSIFICATION OF TRAFFIC-RELATED NAD

In 2008, The NPTF proposed a new classification system for all neck pain, including that related to traffic collisions.⁸ Using this classification system, neck pain is graded according to symptom severity and impact on activities of daily living (Table 2). The OPTIMa Collaboration recommended following the NPTF proposed terminology. The care pathways discussed herein refer to the management of NAD grades I-III caused or exacerbated by a traffic collision, including musculoskeletal thoracic spine and chest wall pain as well as pain radiating from the neck to the head, arms or trunk.

Table 2. The Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders Classification

The 2000-2010 Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders Classification of Neck Pain and Associated Disorders (NAD)8
Grade	Description
I	No signs or symptoms suggestive of major structural pathology and no or minor interference with activities of daily living
II	No signs or symptoms of major structural pathology, but major interference with activities of daily living
III	No signs or symptoms of major structural pathology, but presence of neurologic signs such as decreased deep tendon reflexes, weakness or sensory deficits
IV	Signs or symptoms of major structural pathology

ASSESSMENT AND DIAGNOSIS OF TRAFFIC-RELATED NAD

A thorough evaluation is necessary to diagnose and categorize patients with traffic-related NAD. Appropriate diagnosis is necessary to guide patient management and inform prognosis. Clinicians rely on clinical tools and tests that can be performed in-office for the diagnosis and classification of NAD, and for ruling out potentially serious pathology. Valid and reliable tests are important to ensuring diagnostic accuracy and maximizing efficiency. Clinical tests that do not have evidence for reliability and validity should not be used in clinical practice.

Although most cases of traffic-related NAD are benign, it is important to be able to rule out or identify specific and sometimes serious causes of neck pain that occur in a minority of patients, including cervical radiculopathy, fracture and dislocation. Failure to diagnose some of these injuries may result in serious consequences. Red flags are risk factors for serious underlying pathology and should be thoroughly assessed during history-taking. Table 3 contains a full list of red flags that should be assessed in patients with traffic-related NAD.

Table 3. Risk factors for pathological causes of neck pain (red flags).5 Adapted with permission from Springer, Eur Spine J, Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration, Côté P, Wong JJ, Sutton D, et al., 2016.

Suspected pathological cause	Risk factors identified during history or physical examination
Cancer	History of cancer Unexplained weight loss Night pain Age over 50
Infection	Fever Intravenous drug use Recent infection
Osteoporotic fracture	History of osteoporosis Corticosteroid use Older age History of fragility fracture (wrist, hip)
Myelopathy (severe/progressive neurological deficit)	Arm pain and weakness Sensory changes in lower extremity Motor weakness and atrophy Hyper-reflexia in the lower limbs Spastic gait
Carotid/vertebral artery dissection	Sudden and intense onset headache and/or neck pain
Brain hemorrhage/mass lesion	Sudden and intense onset headache
Inflammatory arthritis	Morning stiffness Swelling in multiple joints

For patients with acute injury following blunt trauma, the first priority is to rule out fractures and dislocations. Reliance on diagnostic imaging for all patients is an inefficient practice, with low diagnostic yield at a relatively high cost and healthcare resource use.⁷ Clinical prediction rules such as the Canadian C-Spine Rule and the NEXUS Low-Risk Criteria are used to screen alert, low-risk patients following blunt trauma to the neck without the use of imaging or special tests. The evidence consistently indicates the Canadian C-Spine Rule has perfect sensitivity, but very low specificity for the detection of cervical spine injury.⁷ Therefore, a negative result using the Canadian C-Spine Rule is highly useful for ruling out clinically significant cervical spine injuries. However, due to the high rate of false positives, a positive finding is not necessarily confirmatory and is an indication for further investigation.

The inter-examiner reliability of the Canadian C-Spine Rule varies depending on the training and experience level of the examiners, highlighting the need for proper training in the use and interpretation of findings.⁷ Given the limited research related to the validity and reliability of the NEXUS Low-Risk Criteria and in light of consistent findings of validity and reliability, clinicians should choose the Canadian C-Spine Rule to rule out clinically significant cervical spine injuries.^4-5,7

The next priority for assessing patients with traffic-related NAD is to assess neurological function.^4-5 A thorough neurological evaluation includes manual muscle testing, dermatomal sensory testing and eliciting deep tendon reflexes. If decreased deep tendon reflexes, muscle weakness or sensory deficits are present, the diagnosis should be determined as NAD III. All other cases of neck pain should be classified as NAD I or NAD II, depending on interference with activities of daily living.

Evidence suggests that neurological examination has high sensitivity but low specificity for the diagnosis of radiculopathy. However, some aspects of the neurological examination have inadequate inter-rater reliability, leading to the possibility for misclassification or misdiagnosis.⁶ Therefore, in cases where diagnosis is likely to change the course of treatment or significantly affect the patient’s prognosis, diagnosis should rest on more valid and reliable measures such as imaging or nerve conduction testing.

The diagnosis of patients with traffic-related NAD should indicate chronicity. Patients who present in the first three months following a traffic collision are diagnosed with recent NAD, whereas patients who present more than three months after their injury are diagnosed with persistent NAD. Whether patients are diagnosed with NAD I, NAD II or NAD III, and whether neck pain is classified as recent or persistent will inform the prognosis for recovery and the selection of appropriate evidence-based interventions (Figures 1 and 2).

Other tests can be helpful for determining potential pain generators despite the fact that they may not be helpful in generating a specific diagnosis. These clinical tests include range of motion, palpation and orthopaedic testing. For the assessment of active cervical range of motion, a cervical range of motion (CROM) unit or a single inclinometer are recommended for their ease of use and their validity and reliability.⁹ There is no evidence to suggest that the use of more complex or technologically advanced equipment enhances the reliability of measuring active cervical range of motion.¹⁰ Visual estimation should not be used to measure active cervical range of motion as it is not reliable.⁹

The passive assessment of segmental intervertebral motion is used by manual practitioners to guide treatment for patients with neck pain. The reliability of assessing passive intervertebral motion is low. However, there is substantial reliability when pain provocation is used to identify dysfunctional intervertebral motion.^11-12 Overall, very little evidence is available to support the use of most orthopaedic tests for the assessment of neck pain. Clinicians should consider using the cervical extension-rotation (Kemp’s) test for the identification of pain arising from the facet joints, as preliminary evidence supports its validity and reliability. However, for enhanced sensitivity, results should be interpreted in the context of findings from spinal examination and palpation for spinal tenderness.⁶

For the diagnosis of traffic-related NAD III, nerve root provocation tests such as Spurling’s test (combined lateral flexion and axial compression) and upper limb tension tests for the median, ulnar, and radial nerves are valid, but may be associated with a risk for misclassification or misdiagnosis due to inadequate reliability.⁶ As such, in cases where diagnosis is likely to change the course of treatment or significantly affect the patient’s prognosis, diagnosis should rest on more valid and reliable measures, such as imaging or nerve conduction testing.

CARE PATHWAYS FOR MANAGEMENT OF TRAFFIC-RELATED NAD I-III

OPTIMa care pathways for traffic-related NAD I-II (Figure 1) and NAD III (Figure 2) were created through consideration of evidence on the effectiveness of conservative interventions alongside what is known about the natural history of NAD, factors that influence recovery, and the perspectives and experiences of people injured in traffic collisions.

One of the first priorities for managing patients with traffic-related NAD is to educate the patient on their positive prognosis. NAD I and NAD II are relatively benign and self-limiting, and patients should be encouraged to stay active during their recovery. Similarly, NAD III patients should be reassured that their neck and arm pain will resolve within a few months from injury. Patients should also be reassured that there is no reason to suspect major structural pathologies. Furthermore, clinicians may need to reassure patients that no further diagnostic testing or imaging is indicated. Patients should be made aware that it is common to experience anxiety, distress or anger following a traffic collision. Concerns about these feelings should be discussed and the care plan may be adjusted accordingly to involve other healthcare providers.

It is important to recognize that not all patients with traffic-related NAD (especially those with NAD I) require ongoing clinical care beyond education and reassurance. High levels of initial healthcare utilization are prognostic of prolonged recovery in patients with NAD I/II. Therefore, the concept of “less is more” may apply. If ongoing care is required, emphasis should be placed on the patient’s active participation in treatment. Active care should be a component of all treatment plans for patients with NAD regardless of whether the patient has a recent injury or persistent symptoms.

Treatment plans should be goal-oriented, with a main focus on reducing symptoms and returning the patient to their usual activities of daily living. Plans of management should evolve based on reassessment and the patient’s response to treatment. Ongoing reassessment is required to determine whether additional or alternative care is necessary, or if the condition is worsening. In the event that a patient displays worsening symptoms or develops new symptoms, referral to a physician for further evaluation may be required. Conversely, patients who report significant improvement or recovery of symptoms should be discharged from care with appropriate instructions for self-care and follow-up, if necessary.

Patient-reported outcome measures are an important part of ongoing assessment. Evidence supports the use of a number of valid and reliable tools that are easily administered in clinical practice and can be used to assess pain and disability (Table 4).¹³ For the assessment of recovery, the OPTIMa Collaboration recommends a single recovery question. Patients who are either “completely better” or “much improved” should be considered recovered. Patients with NAD I/II who have not recovered remain within the care pathway.

Table 4. Assessing outcome and recovery in patients with traffic-related NAD

Neck Pain and Associated Disorders (NAD)4
Outcome	Tool	Interpretation
Pain	Numeric Rating Scale (0- no pain; 10- worst pain imaginable)	Clinically meaningful change = 2 points21 Treatment goal: 30% change from baseline
Disability	Neck Disability Index22	Total Score /50 0-4: No disability 5-14: Mild disability 15-24: Moderate disability 25-34: Severe disability Above 34: Complete disability Clinically meaningful change = 5 points23 Treatment goal: 30% change from baseline
Recovery	How well do you feel you are recovering from your injuries? Completely better Much improved Slightly improved No change Slightly worse Much worse Worse than ever	Recovery: “Completely better” or “much improved”

Should recovery not be attained within the first three months following injury, the patient’s care should be progressed to follow the care pathway outlined for persistent NAD I-II. For patients with NAD III whose arm symptoms improve but whose neck pain persists, care should continue under the appropriate care pathway for the management of NAD I-II. For patients with NAD III whose arm symptoms persist beyond the first three months of injury, a referral for further evaluation is indicated.

The delivery of evidence-based and patient-centered care should revolve around understanding patients’ experiences. The OPTIMa Collaboration performed a study on the experiences of people injured in traffic collisions.¹⁴ Injured patients consistently highlighted the importance of developing partnerships with their healthcare providers. These partnerships are formed when healthcare providers take the time to explain the diagnosis and treatment options and to understand the patient’s experiences, and they are central to shared decision-making and patient-centered care.

Another important experience identified by patients following injury in a traffic collision is emotional distress. It was common for patients to relate feelings of anxiety and depression, and express a need for more emotional and psychological support. This highlights the importance of a biopsychosocial approach to care for these patients.

SUMMARY

Recent clinical practice guidelines and systematic reviews from the OPTIMa and CADRE Collaborations provide healthcare providers with evidence-based recommendations on the assessment and management of patients with traffic-related NAD. The clinical assessment should serve as a means to rule out serious pathology and to categorize patients (NAD I, II or III). Treatment plans should be created following principles of shared decision-making and patient-centered care. Reassurance and education regarding the history and nature of NAD should be provided. If ongoing care is required, it should be time-limited, and patients should remain active participants. Active treatments should be emphasized over passive treatments for all patients with traffic-related NAD. Ongoing reassessment is necessary to establish response to care or need for further intervention, or to determine a plan for discharge.

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