Website Article March 2008

The following is a summary of what the Task Force on Neck Pain and its Associated
Disorders. It quotes a very significant study done on VBA stroke. Dr. Scott Haldeman is
a D.C as well as a medical neurologist. Dr. David Cassidy is also a chiropractor.
I wish to make a reminder that a lot of cervical dysfunction and pain is caused by
adaptation to dysfunction lower in the kinematic chain. Adjusting the cause of the
adaptation is the key to stopping episodal neck pain and headaches. Please note even
though the articles look similar they are slanted differently depending upon the media
and medical communities. Please read all the information presented.


FINAL – Health Trade Publications

Seven-Year Neck Pain Study Focuses Clinical Directions

TORONTO, February 15, 2008 — A seven-year, international multidisciplinary study
published in the journal Spine today could signal a shift in clinical best practices for the
treatment of neck pain.

The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated
Disorders considered almost 32,000 citations and performed critical appraisals of more
than 1,000 studies in developing its 236-page report. The years 2000-2010 have been
designated the Decade of the Bone and Joint by the United Nations and the World
Health Organization. The Task Force is an independent research group recognized by
the UN and the WHO.

“Neck pain is widespread, and is a persistent and recurrent condition for most sufferers,”
says Task Force president, Dr. Scott Haldeman, clinical professor, department of
neurology at the University of California, Irvine; and adjunct professor, department of
epidemiology University of California Los Angeles. “Our work was designed to help neck
pain sufferers and health professionals to apply the best available evidence to prevent,
diagnose and manage neck pain.”

A key recommendation of the Task Force is that neck pain, including whiplash-
associated disorders (WAD), be classified and treated in a common system of 4 grades:

Grade 1: neck pain with little or no interference with daily activities
Grade 2: neck pain that limits daily activities
Grade 3: neck pain accompanied by radiculopathy
Grade 4: neck pain with serious pathology, such as tumour, fracture, infection or
systemic disease

The published report, which synthesizes the best available scientific and clinical
evidence on the onset, course and prognosis, assessment and management of neck
pain, concludes that there is sufficient evidence to support education, exercise, neck
mobilization, neck manipulation, acupuncture, analgesics, massage and low-level laser
therapy in the treatment of Grades 1 or 2 neck pain.

The study found that many commonly prescribed treatments are unlikely to be effective
for sufferers of Grades 1 or 2 neck pain. These include: cervical collars, ultrasound,

electrical muscle stimulation, transcutaneous electrical nerve stimulation (TENS), most
injection therapies (such as corticosteroid injections in cervical facet joints) and surgery.

For the minority of neck pain sufferers who may experience Grade 3 neck pain,
corticosteroid injections may provide temporary relief, according to the Task Force study.
Surgery should only be considered if accompanied by radiculopathy or if the person is
experiencing Grade 4 neck pain due to fracture, tumor, infection or systemic disease

“There is typically no single cause and no single effective treatment for Grades 1 and 2
neck pain,” says Task Force member, Dr. Linda Carroll, Associate Professor, School of
Public Health at the University of Alberta, and Associated Scientist, Alberta Centre for
Injury Control and Research (ACICR). “But effective treatment options that have been
cited in the study are all low risk and may provide short-term relief when provided in
moderation. A variety of treatments may need to be tried and, ultimately, an informed
patient’s preferences are key to treatment decisions.”

Significantly, the Task Force study found that routine diagnostic imaging does little to
increase understanding of causation in Grades 1 and 2 neck pain. The Task Force does
recommend that patients with acute neck injuries may need radiographic examination to
rule out fracture or dislocation if they have ‘red flag’ signs and symptoms.

In addition to its comprehensive review of the existing body of research on neck pain,
the Task Force also initiated a new population-based, case-control and case-crossover
study into the association between chiropractic care and vertebrobasilar artery (VBA)
stroke. This Canadian study investigated associations between chiropractic visits and
vertebrobasilar artery stroke and compared this with visits to primary care physicians
and the occurrence of VBA stroke.

The study — which analyzed a total of 818 VBA strokes that met the inclusion/exclusion
criteria over the 9-year inception period in Ontario — concludes that VBA stroke is a very
rare event and that the risk of VBA stroke associated with a visit to a chiropractor’s office
appears to be no different from the risk of VBA stroke following a visit to a family
physician’s office.

“Our research has led us to believe that the association between VBA stroke and
chiropractic care is likely due to patients with headache and/or neck pain from a VBA
dissection seeking care in the prodrome of a stroke,” explains the study’s lead author,
Dr. David Cassidy, professor of epidemiology at the University of Toronto and senior
scientist at the University Health Network at Toronto Western Hospital.

“We found no evidence of excess risk of VBA stroke associated with chiropractic care
beyond that associated with primary physician care,” says Dr. Cassidy. He added that
these rare strokes have also been reported after ordinary neck movements such as
looking up at the sky or shoulder checking when backing up a car, and that they are
often reported as spontaneous and without known cause.

“This is an important body of research that we anticipate will help to improve the quality of
patient care by incorporating the best evidence into practice and patient education,”
concludes Dr. Carroll. “Neck pain can be a stubborn problem – we hope this
comprehensive analysis of the evidence will help both sufferers and health care providers
better manage this widespread complaint.”

FINAL – Consumer media

Seven-Year Neck Pain Study Sheds Light on Best Care


Toronto – February 15, 2008 – A seven-year, international study published today finds
that some alternative therapies such as acupuncture, neck manipulation and massage
are better choices for managing most common neck pain than many current practices.
Also included in the short-list of best options for relief are exercises, education, neck
mobilization, low level laser therapy and pain relievers.

Therapies such as neck collars and ultrasound are not recommended. The study found
that corticosteroid injections and surgery should only be considered if there is associated
pain, weakness or numbness in the arm, fracture or serious disease.

The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated
Disorders 236 page review of the current research on neck pain is published in the
journal Spine. The multi-national and inter-disciplinary study team included Canadian,
American, South American, Australasian and European researchers. The Task Force
was created to help neck pain sufferers and health professionals use the best research
evidence to prevent, diagnose and manage neck pain.

“Neck pain is not a trivial condition for many people,” says Task Force president Dr.
Scott Haldeman, clinical professor, department of neurology at the University of
California, Irvine; and adjunct professor, department of epidemiology University of
California Los Angeles. “It can be associated with headaches, arm and upper back pain
and depression. Whether it arises from sports injuries, car collisions, workplace issues
or stress, it can be incapacitating. Understanding the best way to diagnose and manage
this problem is of high importance for those who are suffering and for those who manage
and pay for its care.”

The study found that neck pain is a widespread experience that is a persistent and
recurrent condition for the majority of sufferers. It is disabling for approximately two out
of every 20 people who experience neck pain and affects their ability to carry on with
daily activities says the Task Force.

A key recommendation of the Task Force is that neck pain, including whiplash-related
pain, be classified and treated in a common system of 4 grades:

Grade 1: neck pain with little or no interference with daily activities
Grade 2: neck pain that limits daily activities
Grade 3: neck pain accompanied by radiculopathy (“pinched nerve” – pain weakness
and/or numbness in the arm)
Grade 4: neck pain with serious pathology, such as tumor, fracture, infection, or
systemic disease.

“The majority of neck pain falls into Grades 1 or 2,” says Task Force member, Dr. Linda
Carroll, Associate Professor, School of Public Health at the University of Alberta, and
Associated Scientist, Alberta Centre for Injury Control and Research (ACICR). “Many
sufferers manage to carry on with their daily activities. Others find their pain interferes
with their ability to carry out daily chores, participate in favorite activities or be effective

at work. For these people, the evidence shows there are a relatively small number of
therapies that provide some relief for a while, but there is no one best option for
everyone.”

In addition to its comprehensive review of the existing body of research on neck pain,
the Task Force also initiated a new study into the association between chiropractic care
of the neck and stroke. This innovative piece of research found that patients who visit a
chiropractor are no more likely to experience a stroke than are patients who visit their
family physician. The study concludes that this type of stroke commonly begins with
neck pain and/or headache which causes the patient to seek care from their chiropractor
or family physician before the stroke fully develops.

“This type of stroke is extremely rare and has been known to occur spontaneously or
after ordinary neck movements such as looking up at the sky or shoulder-checking when
backing up a car,” noted the study’s lead author, Dr. David Cassidy, professor of
epidemiology at the University of Toronto and senior scientist at the University Health
Network at Toronto Western Hospital.

For the minority of neck pain sufferers who experience Grade 3 neck pain – that is neck pain
accompanied by pain, weakness and/or numbness in the arm, also referred to as a “pinched
nerve”, corticosteroid injections may provide temporary relief says the study. Surgery is a
last resort according to the findings and should only be considered if accompanying arm
pain is persistent or if the person is experiencing Grade 4 pain due to serious injury or
systemic disease.

Top findings for neck pain suffers:

Stay as active as you can, exercise and reduce mental stress.
Don’t expect to find a single “cause” for your neck pain.
Be cautious of treatments that make “big” claims for relief of neck pain.
Trying a variety of therapies or combinations of therapies may be needed to find relief –
see the therapies for which the Task Force found evidence of benefits.
Once you have experienced neck pain, it may come back or remain persistent.
Lengthy treatment is not associated with greater improvements; you should see
improvement after 2-4 weeks, if the treatment is the right one for you.
There is relatively little research on what does or does not prevent neck pain;
ergonomics, cervical pillows, postural improvements etc. may or may not help.

“This is an important body of research that will help to improve the quality of patient care by
incorporating the best evidence into practice and patient education,” says Dr. Carroll. “Neck
pain can be a stubborn problem – we hope this comprehensive analysis of the evidence will
help both sufferers and health care providers better manage this widespread complaint.”


Neck pain task force collars best treatments
February 05, 2008 Andrew Skelly


LOS ANGELES An international task force with major Canadian involvement has developed a
new system of classifying neck pain;

analyzed the literature to determine which treatments may work and which ones don’t; and
conducted original research showing patients are no more likely to suffer a stroke after
visiting a chiropractor than they are after visiting a family doctor.
The findings of the Bone and Joint Decade Task Force on Neck Pain and Its Associated
Disorders were released here at the World Congress on Neck Pain last month and posted on
the website of the journal Spine. The report will appear in print as a supplement to the
journal’s February 15 issue.
Dr. Scott Haldeman, the task force president and a neurologist and clinical professor at the
University of California at Irvine, discussed the report’s key messages with the Medical Post
in advance of the congress.
“Most people develop neck pain, and 5% to 10% of the population actually find the pain
disabling. We’re talking about a huge problem, and so far we don’t treat it very well,” said Dr.
Haldeman, a Saskatchewan native who trained as a chiropractor before obtaining a PhD and
MD from the University of British Columbia.
“What is particularly interesting is once we have an episode of neck pain . . . about 50% of
people will still have neck pain one to five years later. So this is something that is a persistent
or recurrent condition in a larger number of people.”
The task force categorized neck pain into four grades:
• Grade 1: Little or no interference with daily activities;
•Grade 2: Limits daily activities;
• Grade 3: Accompanied by radiculopathy;
•Grade 4: Serious pathology such as tumour, fracture, infection, systemic disease.
The task force, whose members represented 19 clinical and scientific disciplines, screened
nearly 32,000 citations, finding 1,203 relevant articles and deeming 552 scientifically
acceptable for a synthesis of the best evidence.
They concluded that treatments worth considering for Grades 1 and 2 neck pain, which
account for most cases, include: education, exercise, mobilization, manipulation,
acupuncture, analgesics, massage and low-level laser therapy. But there was no evidence
that any one treatment was better than any other.
Treatments found unlikely to help Grades 1 and 2 neck pain were collars, ultrasound,
electrical muscle stimulation, transcutaneous electrical nerve stimulation, most injection
therapies, including corticosteroid injections in cervical facet joints, radiofrequency
neurotomies and surgery.
“Most people who know the literature will not find this a surprise,” Dr. Haldeman said. “But
those who . . . make their living with one particular technique are likely to become quite
upset.”

Patients considering chiropractic treatment may be reassured by the task force’s Ontario-
based study suggesting earlier reports of an increased risk of vertebrobasilar artery (VBA)
stroke following visits to a chiropractor were instances of “confounding by indication.”
“The increased risks of VBA stroke associated with chiropractic and (primary-care physician)
visits is likely due to patients with headache and neck pain from VBA dissection seeking care
before their stroke. We found no evidence of excess risk of VBA stroke associated with
chiropractic care compared to primary care,” concluded a team led by Dr. J. David Cassidy
(DC, PhD), a senior scientist in the Division of Health Care and Outcomes Research at the
Toronto Western Research Institute.
An earlier analysis of Ontario administrative data by the Institute for Clinical Evaluative
Sciences in Toronto, published in Stroke in October 2001, showed people under age 45
years who had suffered a VBA stroke were five times more likely than controls with no stroke
history to have visited a chiropractor within one week of the stroke. Unlike that report, the
new study also looked at stroke incidence after visits to primary-care physicians.
The researchers found 818 cases of VBA stroke admitted to Ontario hospitals from April 1,
1993 to March 31, 2002 (more than 100 million person-years of observation). Four controls
were age- and gender-matched to each case; and case and control exposures to
chiropractors and primary-care physicians were determined from health billing records.
In those younger than 45 years, cases were about three times more likely to have seen a
chiropractor or a primary-care physician in the month before their stroke than controls. There
was no increased association between chiropractic visits and VBA stroke in those older than
45, however the association remained for primary-care visits.
“It should put the controversy to rest,” said Dr. Haldeman. “Dissections appear to be an
issue, but . . . all the concerns about this being a chiropractic issue probably are not valid.”
Other key messages from the task force report:
• Conduct a thorough patient history, physical examination and patient self-assessment
questionnaire to identify or rule out Grades 3 or 4 neck pain.
• Routine imaging in Grades 1 or 2 neck pain will not increase understanding of causation.
• Patients with Grades 1 or 2 neck pain should be advised to stay as active as they can. A
variety of therapies or combinations of therapies may be needed to find pain relief, which is
often modest and short-lived.
• Be cautious of treatments that make impressive claims for relief of neck pain, and
discontinue treatments that don’t provide improvement within two to four weeks.
• Epidural corticosteroid injections may provide temporary relief of radiculopathy in Grade 3
neck pain. Consider surgery in the presence of serious pathology or persistent radiculopathy.
• In the case of emergency department visits involving neck pain, the Canadian Cervical
Spine Rule and the NEXUS Low Risk Criteria are effective at identifying patients who do not
require imaging.

• Use of MRI as a screening tool in the emergency setting is not supported by evidence; CT
scan is more sensitive than X-ray in high-risk patients (e.g. intoxicated, unconscious and/or
obtunded); and five-view X-rays are no more effective than three in identifying fractures
• In Grade 3 neck pain, there is no evidence that any one type of decompression or fusion
surgery is superior to the others.
Payment recommendations
The task force also called on public and private insurers to adopt evidence-based treatment
guidelines when paying for services.
“A physician who does multiple procedures, rightly or wrongly, is going to be paid
considerably higher than a person who sits down and talks to the patient and examines the
patient,” Dr. Haldeman said. “And the feeling is that since the evidence suggests that sitting
down and examining and talking to the patient is more likely to improve patient outcomes
than these invasive procedures, then the payers should encourage it.”
The Task Force on Neck Pain and Its Associated Disorders was established in 2000 and
was given official status by the steering committee of the United Nations/World Health
Organization Bone and Joint Decade project in 2002.


Visit us at:
http://www.chiropracticmentor.com