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Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 561–573 DOI 10.3233/BMR-140556 IOS Press

Pharmacological, psychological, and patient education interventions for patients with neck pain: Results of an international survey Lisa C. Carlessoa,b,∗, Anita R. Grossb , Joy C. MacDermidb,c, David M. Waltond and P. Lina Santaguidae a

University Health Network, Toronto, ON, Canada School of Rehabilitation Sciences, McMaster University, Hamilton, ON, Canada c Clinical Research Lab, Hand and Upper Limb Centre, St. Joseph’s Health Centre, London, ON, Canada d School of Physical Therapy, Western University, London, ON, Canada e Department of Clinical Epidemiology and Biostatistics, McMaster University Evidence-based Practice Centre, Hamilton, ON, Canada b

Abstract. BACKGROUND: Examination of practice patterns compared to existing evidence identifies knowledge to practice gaps. OBJECTIVES: To describe the utilization of pharmacological, patient education, primary psychological interventions and relaxation therapies in patients with neck pain by clinicians. METHODS: An international cross-sectional survey was conducted to determine the use of these interventions amongst 326 clinicians treating patients with neck pain. RESULTS: Nineteen countries participated. Results were analyzed by usage amongst physical therapists (39%) and chiropractors (35%), as they were the predominant respondents. Patient education (95%) and relaxation therapies (59%) were the most utilized interventions. Tests of subgroup differences determined that physical therapists used patient education significantly more than chiropractors. Use of medications and primary psychological interventions were reported by most to be outside of scope of practice. The high rate of patient education is consistent with supporting evidence. However, usage of relaxation therapies is contrary to evidence suggesting no benefit for improved pain or function for chronic neck pain. CONCLUSION: This survey indicates that patient education and relaxation therapies are common treatments provided by chiropractors and physical therapists for patients with neck pain. Future research should address gaps associated with variable practice patterns and knowledge translation to reduce usage of interventions shown to be ineffective. Keywords: Survey, neck pain, treatment, practice patterns, patient education, psychology

1. Introduction Neck pain is a common musculoskeletal problem with a global burden second only to low back pain in the number of people it affects and the years lived ∗ Corresponding author: Lisa Carlesso, Toronto Western Research Institute, University Health Network, 399 Bathurst Street – MP11328, Toronto, ON M5T 2S8, Canada. Tel.: +1 416 603 5800 x5665; Fax: +1 416 603 6288; E-mail: [email protected].

with disability [1]. According to the Global Burden of Disease 2010 study, the overall impact of neck pain on death and disability accounts for one fifth of all musculoskeletal diseases [2]. For those suffering from back and neck conditions, the mean inflation-adjusted annual expenditures on medical care has increased to $950 in the United States [3]. Direct costs can be ascribed to healthcare related contacts, medication use and other socioeconomic costs (i.e. sick leave, lost productivity capacity) [4].

c 2015 – IOS Press and the authors. All rights reserved ISSN 1053-8127/15/$35.00 

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L.C. Carlesso et al. / Pharmacological, psychological, and patient education interventions for patients with neck pain

Most clinical guidelines for the management of neck pain include some form of pharmacotherapy. These are most commonly prescribed by physicians, although in some regions other healthcare providers can also prescribe Tier 1 (non-opioid) analgesics. Common drug classes offered for neck pain include opioid or nonopioid analgesics, anti-inflammatories, muscle relaxants, anti-anxiolytics or anti-depressants. Interventionists may also try injection therapies into the muscles or joints of the neck, although reports of their effectiveness have been varied. Other interventions like psychological care and education may help people understand, self-manage, or limit the influence of injury on the pain and related disability experienced. People with chronic neck pain may manifest symptoms of psychological distress that may be treated appropriately with psychological counseling [5]. Due to the complexity of chronic pain, multidisciplinary and multimodal approaches are often used to address pain and disability related to physical and psychological factors [6,7]. The scope of psychological care is broad and may be divided into psychological treatments (i.e. cognitivebehavioral approach, interpersonal behavioral activation, etc.), psychosocial interventions (i.e. multidisciplinary care, psychologist as advisor to other health professionals), and mind-body wellness approaches (i.e. yoga, Tai Chi etc.) [8]. Patient education and selfmanagement strategies are taught to help patients cope on a day to day basis with their pain and dysfunction [9]. The goal of patient education strategies is to transmit knowledge, have patients acquire skills and maintain gained abilities [10]. Evidence for their effectiveness is mixed [8]. The evidence base guiding the choice of effective conservative treatments for reducing symptoms and increasing function has evolved. The association between severity of neck pain and magnitude of painrelated disability has been established by numerous studies [11–14]. Our recent reviews of reviews provide some guidance for practitioners based on the current evidence base [8,15,16]. Treatment choices are commonly made from a patient centered care model [17] and can vary within professions depending upon the degree to which practitioners are aware of current evidence on treatment effectiveness and the degree to which they choose to incorporate the evidence into their practice. The International Collaboration on Neck Pain (ICON) project is a collaborative project amongst internationally recognized experts in the field of neck pain. The goal of ICON is to establish clear, actionable

messages in the areas of diagnosis, prognosis, interventions and outcomes measurement. Examining utilization patterns allows for comparison of the evidence base to current practice trends. To this end, ICON has implemented an international multidisciplinary survey of clinical practice patterns that will help shape evidence based recommendations. Having current insight into the patterns of existing practice will help inform how current practice is similar or different than the evidence and can thus identify where efforts in knowledge translation are needed. Our objectives were 1. To describe the utilization of pharmacological, patient education, primary psychological interventions and relaxation therapies in patients with neck pain by clinicians and 2. Where appropriate, to examine whether utilization varies by profession or subgroup of disorder.

2. Methodology An international cross sectional survey was conducted to determine practice patterns of clinicians who provide care to patients with neck pain from October 2011 to February 2013. The survey was approved by the McMaster University Research Ethics Board. The methods addressing survey development and validation along with the sampling frame have been previously reported and will be summarized here [18,19]. 2.1. Survey development and validation This survey design was focused on acquiring information about interventions. Two additional content areas determined the demographic and caseload information of respondents. This intervention content area was sufficiently large to warrant division into the following two separate surveys: 1. Pharmacological, psychological interventions and patient education including self-management strategies. 2. Physical medicine or complementary and alternative medicine interventions. Items in the pharmacological interventions section of the survey covered the use of oral, injectable and intravenous medications, the types of medications, the frequency with which they are generally prescribed, and for which subgroups of neck disorders they were commonly used. In the psychological interventions section of the survey, items addressed the types of psychological interventions and relaxation techniques used. In the patient education and self-management strategies

L.C. Carlesso et al. / Pharmacological, psychological, and patient education interventions for patients with neck pain

items asked about the content of education and selfmanagement strategies taught, the format, mediums and techniques used for their delivery. An ‘other’ response option was included where appropriate within each category and allowed respondents to add any interventions that may have been missed. Broadly, items asked about utilization of each treatment category (yes, no, outside scope of practice). The questions progressed in the following sequence. If a respondent indicated ‘yes’ to the initial utilization question, then inquiry of frequency of use (commonly, occasionally, never) followed. If respondents indicated ‘common’ or ‘occasional’ use of an intervention, then use of that intervention (commonly, occasionally, never, not applicable) among the following common subgroups of neck pain disorders was collected: 1. Acute nonspecific neck pain, 2. Chronic nonspecific neck pain, 3. Facet joint dysfunction (as diagnosed by diagnostic block), 4. Acute WAD, 5. Chronic WAD and 6. Radiculopathy/WAD III. Finally we inquired about the impact of various factors (e.g. patient, professional, healthcare system) on decision making regarding the treatment interventions. The items for the treatment surveys were developed based on evidence from systematic reviews of conservative treatments for neck pain and were supplemented by input from expert clinicians that included physicians, psychologists, physiotherapists, massage therapists, chiropractors, and other rehabilitative professions. For items in this survey deemed to be more specific to certain professions e.g. medications/injections and primary psychological interventions, physicians and psychologists were consulted. Items were designed to be appropriate for administration across different health care professionals commonly treating people with neck pain. The development of the survey was iterative and involved multiple revisions. This included item content and clarity in the wording of each item/response, the organizational structure of the survey, addressing grouping, and sequencing and piloting the electronic survey format to evaluate presentation and routing. Finally, an expert group (n = 38) with representation from all disciplines included in our target audience was used for field-testing. These experts reviewed the survey for accuracy, clarity, completeness and burden. The revisions resulted in minor changes to items and a few additions. The finalized version was mounted us-

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ing LimeSurvey,1 an open-source online platform for web-based survey administration.

2.2. Sampling frame Our sampling frame was all healthcare professional groups that were identified as having a major role in the management of neck pain. We relied on both our reviews and clinical experience to identify these groups. This included physicians (general practitioners, physiatrists, psychiatrists) physiotherapists, chiropractors, massage therapists, occupational therapists, psychologists and complementary medicine specialists. For reasons of feasibility, a snowball recruitment strategy was adopted. This method required identification of experts within each of the professions and requested they assist with sending out links to the survey to their professional connections and colleagues. Survey invitations were distributed via e-mail blast to members, and electronic postings (e.g., e-newsletter, website, Facebook or Twitter pages) by national and international professional groups for chiropractors (Danish Chiropractors’ Association; European Academy of Chiropractic; Netherlands Chiropractic Association; New Zealand Chiropractors’ Association; Ontario Chiropractic Association); manual therapists (Canadian Academy of Manipulative Physical Therapy; Dutch Association for Manual Therapy; Finnish Association for Orthopedic Manual Therapy; German Manual Therapy Journal; International Federation of Orthopaedic Manipulative Physical Therapists); massage therapists (Massage Therapists’ Association of British Columbia); physicians (North American Spine Society; University of British Columbia Department of Family Medicine); physiotherapists (American Physical Therapy Association – Orthopedic Section; Canadian Physiotherapy Association – Pain Sciences Division; Hong Kong Physiotherapy Association; Musculoskeletal Physiotherapy Australia; Physiopedia); and other health care professionals (Osteopathic Society of New Zealand). The method of recruitment meant that it was impossible to determine how many people received requests for participation; thus, response rates to the invitations could not be calculated. 1 LimeSurvey software, Survey Service and Consulting, Hamburg, Germany.

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L.C. Carlesso et al. / Pharmacological, psychological, and patient education interventions for patients with neck pain Table 1 Demographics

Demographics

Respondents (n = 326)

Years in practice since graduation (mean(sd)) Gender

17 (12) 46% female, 50% male

Profession Physical Therapist (Manual Therapist) Chiropractor Massage Therapist Physician Psychologist Country Canada United Kingdom Denmark New Zealand United States of America Netherlands Other (Australia, Belgium, Brazil, Finland, Germany, Hong Kong, Italy, Norway, Portugal, South Africa, Spain, Sweden, Switzerland) Practice setting Private clinic Outpatient Rehab facility Teaching hospital General hospital Private consultant Other % of Caseload with Neck Pain 50 Health care reimbursement system Private Insurance Public Health Insurance Workers Compensation Salary reimbursement scheme Salary – Fixed Fee for Service – Public Fee for service – Private Education – Highest level Obtained Diploma Bachelor’s Degree Masters Degree Doctor of Medicine Doctorate/PhD Other

2.3. Survey administration The survey was administered through ICON group and was estimated to take 15 to 20 minutes to answer. An e-mail including information about the survey, and a registration link were provided. No incentives were offered. Public registration was required to participate in the survey and individuals who volunteered to receive the survey link were considered “registrants”. Once respondents registered, an email containing the link to participate in this survey was sent out imme-

39% (13%) 35% 9% 6% 4%

Respondents (n = 239) Chiro or PT only 17 (12) PT = 60% female, 40% male CH = 31% female, 69% male 55% 45%

39% 9% 9% 8% 7% 6% 22%

38% 12% 12% 6% 7% 6% 14%

74% 10% 8% 7% 7% 15%

80% 8% 7% 8% 5% 12%

2% 21% 54% 19%

2% 25% 54% 20%

76% 47% 39%

79% 47% 38%

27% 23% 66%

33% 19% 64%

8% 19% 32% 4% 19% 14%

5% 21% 34% 2% 20% 18%

diately. Respondents remained anonymous by storing the identification tokens (name and e-mail address) that provided access to the survey on a secure separate database. Registrants were notified that clicking the survey link indicated that they were electronically consenting to participate. Weekly reminders were sent to registrants until they completed the survey, opted out, or received a maximum of four reminders. Response rates amongst registrants were calculated based on the number of registrants who completed at least part of the survey.

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Table 2 Provision of Treatment Interventions (n = 239) Interventions Oral medications Anti-inflammatory Simple analgesic Muscle relaxant Psychotropic Opioids/neuropathic meds Other Injections Subcutaneious Intramuscular Nerve block Intra-articular Intravenous medication Glucocorticoids Opioids Patient education (Format) Independent learning One on one learning Group learning Support learning (Medium) Oral Written Audiovisual E-based (Lecture techniques) Discussion Demonstration Role playing scenario Primary psychological interventions Cognitive Behavioural therapy Interpersonal therapy Behaviour therapy Supportive counselling Family counselling Problem solving therapy Psychodynamic therapy Bibliotherapy Distraction therapy Relaxation therapies Relaxation techniques Biofeedback Hypnosis Imagery therapy Other psychological interventions Spiritual counselling Meditation Other

Yes % 28

Yes Commonly %

Yes Occasionally %

Yes Never %

11 13 1 0 0 1

16 15 9 3 7 1

2 1 18 26 21 26

0 1 1 0

1 3 5 6

8 4 2 1

0 0

0 0

0 0

23 80 5 11

52 13 23 33

20 2 67 52

92 59 14 10

4 33 32 39

0 3 50 47

64 67 5

18 20 21

14 9 69

9 1 3 4 1 3 1 0 2

13 8 10 12 8 8 3 1 7

2 16 11 8 16 14 21 23 16

27 4 0 5

31 18 5 19

1 37 54 35

1 1 1

4 8 8

9 5 5

8

0

95

24

59

14

2.4. Analysis Data quality was assessed by randomly sampling 10% of the dataset to check for errors. Discrepant entries (< 1%) were resolved through this process. Descriptive statistics were used to summarize participants and their responses to each question. Chi-squared analyses were used to test for differences in the frequency

No % 11

Outside scope of practice % 61

19

74

20

80

4

1

32

44

28

13

55

31

of use of various treatment interventions based on profession. A Bonferroni correction was applied where multiple comparisons were made. 3. Results There were 326 respondents spanning 19 countries. Respondents were mainly physical therapists

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L.C. Carlesso et al. / Pharmacological, psychological, and patient education interventions for patients with neck pain Table 3 Different types of patient education/self management content used (n = 239) Advice to rest Advice to be active Advice on cognitive behavioural approach Coping strategies Ergonomic advice Pain education Self management philosophy Self management of pain Technical information on pathology and anatomy Injury prevention Navigating the health care system Community and social resources

(PT, 39%) or chiropractors (CH, 35%) and 26% other (6% physicians, 4% psychologists). Due to lack of adequate representation from professions other than physical therapists and chiropractors, the analyses focused on these two groups. However we also report results from physicians where appropriate e.g. medication use as it is valuable information and pertinent to their scope of practice. Table 1 provides the characteristics for the whole sample and physical therapists and chiropractors only. There was a significant difference in gender between professions PT 60% female, CH 69% male (p < 0.01). Average clinical experience across the two professions was 17 years, and 54% had obtained either a Master’s degree or PhD. The majority (80%) worked in private practice, with reimbursement through private insurance (79%) in a fee for service private payment model (64%). Over half of the respondents indicated that patients with neck pain made up at least one fifth of their caseload. The largest subset of respondents was from Canada (38%). Table 2 demonstrates the frequency of use (‘Yes’) of the various pharmacological, patient education and self-management strategies along with psychological interventions and their subtypes. Patient education was most frequently endorsed (95%), with the next most common being relaxation therapies (59%). All three categories of pharmaceutical delivery were indicated by the majority of respondents to be ‘Outside scope of practice’ (Oral medication (61%), injections (74%) and intravenous medication (80%) limiting interpretability of those categories. Respondents also indicated that primary psychological interventions were ‘Outside the scope of practice’ (44%), while “other” psychological interventions were not used (‘No’) by the majority (55%). In comparison, the top three interventions used by physicians were oral medications (92%), patient education (85%) and injectable medicines (62%).

Commonly % 29 86 40 57 82 74 61 71 65 72 18 10

Occasionally % 61 9 39 37 13 19 26 19 28 21 61 63

Never % 9 4 17 3 0 2 8 5 2 3 17 23

Physiotherapists and chiropractors recommended the use of pharmaceuticals and amongst these they ‘occasionally’ recommended the following oral medications – anti-inflammatory (16%), simple analgesics (15%) and injections – nerve block (5%), intra articular (6%), while the remaining medication items were all reported as never being used. In the category of patient education and self-management strategies, the most frequent commonly used interventions were one-on-one learning (80%), oral medium (92%), written medium (59%) and demonstration (67%) or discussion (64%). The format of independent learning (52%) was ‘occasionally’ used. In contrast, 67% of respondents indicated they ‘never’ used group educational formats, and 52% ‘never’ used support learning. Educational formats most frequently endorsed as ‘never’ being used were audiovisual (50% never used), e-based (47% never used), and roleplaying (69% never used). There were no commonly used interventions in the psychological category. The most frequently endorsed therapy in this category was relaxation therapy, used ‘occasionally’ by 31% of respondents. Conversely, imagery therapy, biofeedback, and hypnosis were ‘never’ used by 35, 37 and 54%, respectively. Table 3 shows the different types of patient education/self-management strategies used by respondents. The top three areas of focus within patient education and self-management were advice to be active (86%), ergonomic advice (82%) and pain education (74%). Community and social resources were occasionally recommended by 63% of respondents. Advice to rest and assistance with navigating the healthcare system were ‘occasionally’ used by 61% of respondents each. Table 4 reports respondents’ ratings (modal response) of the amount of impact of various factors on the delivery of care are provided. No factor was indicated by most respondents as having a large influence.

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Table 4 Factors impacting on delivery of care (n = 239) Factors

Large influence (often conclusive finding) % 10 6 16 15 31 6 3 1 11 3

Cost of treatment Burden of care Professional regulations/scope of practice Invasiveness of treatment Patient factors Health care system Culture/religion Family support Access to care Other

Moderate influence (usually important finding) % 43 35 27 21 44 29 17 30 37 8

Small influence (sometimes important; minimal effect) % 33 45 36 32 19 35 38 48 34 20

Rarely influence (rarely important) % 13 14 21 33 5 30 43 21 18 70

140 PT

Chiro

120

percentage

100 80 126

60

102 40

85 56

20 0 Relaxation Therapies

Patient Education

Fig. 1. Differences between physiotherapists and chiropractors in use of interventions (n = 239) p < 0.01.

Three factors were rated as having a moderate influence, patient factors (44%), cost of treatment (43%) and access to care (37%). Factors reported as having a small influence were family support (48%), burden of care (45%), professional scope of practice (36%) and health care system (35%). Two factors reported as having a rare influence were culture/religion (43%) and invasiveness of treatment (33%). Table 5 outlines the use of treatment interventions according to disorder subgroup. For patients with acute nonspecific neck pain, acute whiplash or radiculopathy, oral anti-inflammatories and simple analgesics were recommended most often (21 to 24% of respondents). Pharmacological usage dropped in patients with chronic conditions of non-specific neck pain (17%; 20%) and chronic whiplash disorder (17%; 19%). Recommendation of all other types of medications was very low across all subgroups (0 to 8%). In the remaining categories of primary psychological in-

terventions, relaxation therapies and other psychological interventions, respondents reported highest usage in patients with chronic conditions. Frequencies were almost identical in the use of primary psychological interventions between patients with chronic non-specific neck pain and those with chronic whiplash disorder. There was slightly greater use of relaxation therapies in patients with chronic non-specific neck pain (4 to 58%) than in patients with chronic whiplash (3 to 54%). Usage of all interventions in patients with facet joint dysfunction was generally much lower (< 10%) with the exception of relaxation techniques (26%). 3.1. Subgroup analysis Comparison between physical therapists and chiropractors across the main intervention categories demonstrated differences in the use of two interventions. Figure 1 depicts the differences in relaxation

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L.C. Carlesso et al. / Pharmacological, psychological, and patient education interventions for patients with neck pain Table 5 Provision of Treatment Interventions by Subgroups (n = 239)

Interventions Oral medications Anti-inflammatory Simple analgesic Muscle relaxant Psychotropic Opioids/Neuropathic meds Other Injections Subcutaneous Intramuscular Nerve block Intra-articular Intravenous medication Glucocorticoids Opioids Primary psychological interventions Cognitive behavioural therapy Interpersonal therapy Behaviour therapy Supportive counseling Family counseling Problem solving therapy Psychodynamic therapy Bibliotherapy Distraction therapy Relaxation therapies Relaxation techniques Biofeedback Hypnosis Imagery therapy Other psychological interventions Spiritual counselling Meditation Other

Acute non Chronic non Facet joint dysfunction by Acute WAD Chronic WAD Radiculopathy specific NP+ % specific NP % diagnostic block % % % (WAD III) % 26 27 8 0 3 1

17 20 5 2 4 1

8 9 3 1 1 1

24 24 7 1 3 1

17 19 5 3 4 1

22 21 6 2 7 1

1 1 0 0

1 3 3 4

1 1 2 4

1 1 0 0

1 3 2 5

1 2 5 3

0 0

0 0

0 0

0 0

0 0

0 0

10 3 6 6 3 7 1 1 4

21 7 12 15 7 9 2 1 8

7 3 5 5 7 5 1 1 3

13 4 8 10 3 8 1 1 5

22 7 12 15 7 9 2 1 8

15 3 8 9 4 8 2 1 6

44 12 1 11

58 21 3 23

26 8 1 8

43 11 1 12

54 18 4 20

43 13 1 14

2 3 4

5 10 1

1 2 2

2 3 4

3 8 7

3 5 5

+NP = Neck Pain.

therapies between the two (PT = 85, CH = 56, p < 0.01) and in use of patient education (PT = 126, CH = 102, p < 0.01). There was no significant difference between the two in any of the remaining interventions after applying a Bonferroni correction for multiple comparisons.

4. Discussion 4.1. Summary of main findings Results from our survey demonstrate that patient education (one-on-one oral and written format using techniques of demonstration and discussion) and psychological based interventions (relaxation techniques) were most commonly recommended by physical therapists and chiropractors for the treatment of people with neck pain. Use of medication and primary psycholog-

ical interventions were noted to be mostly outside of their scope of practice. We simultaneously conducted multiple reviews of reviews of these treatment interventions and found ranging treatment effects [8,16]. The current focus on patient education is consistent with evidence; although it does not reflect evidence about the educational strategies that are most effective [8]. Similarly, there is discordance between practice and evidence with respect to the use of relaxation therapy, as it was endorsed as commonly used by our respondents however, evidence is lacking to support its effectiveness [8]. Additionally, cognitive behavioral approaches to rehabilitation [8] that have more supporting evidence, were not commonly endorsed. Although the evidence remains low to very low GRADE2 2 Grading of Recommendations, Assessment, Development and Evaluation working group. www.gradeworkinggroup.org.

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(in other words uncertain to greatly uncertain for neck pain) the evidence is in support of using certain antiinflammatories and simple analgesics and is in concordance with reported practice patterns in this survey [16]. The trade-off with harms is perhaps unclear with less substantive evidence from our review of review data but most of these treatment approaches appear to have transient short term adverse side effects [8,16] with rare serious consequences (e.g. antiinflammatory) [16]. 4.2. Medications Although physical therapists and chiropractors are typically non-medication prescribing health professionals, the questions in our survey were worded to include ‘prescription’ or ‘recommendation’ of an intervention. This wording allowed for capture of practice patterns around the usage of pharmaceuticals by these professional groups. Prescribing of pharmaceuticals is an emerging area of practice within physical therapy and chiropractic [20–23] and this data may be instrumental in documenting the changing scope of practice as it unfolds. Currently our results reflect a limitation in their scope of practice as the majority indicated that all categories of pharmacological interventions were outside of their scope. The two medications most frequently reported as being recommended occasionally were oral anti-inflammatories and simple analgesics. The recommendation of these medications by these practitioners is in line with commonly seen neck pain conditions whose history and presentation are traditionally associated with pain and inflammation [24]. There is however, little evidentiary support for these medications specific to neck pain. In our recent review of reviews of pharmacologic interventions for neck pain, low to very low GRADE of evidence of benefit as well as evidence of no benefit were found for medications in these categories [16]. Thus, the evidence is uncertain or greatly uncertain. Moderate GRADE evidence and a recommendation of benefit was found in only one trial examining the effect of a muscle relaxant (eperison hydrochloride) [25]. This finding is in contrast to our survey results where respondents mainly reported that they never recommend this type of medication. Given that the evidence is based on only one trial, a discrepancy from practice patterns is not surprising. As non-prescribing health professionals, it may be assumed that the educational content regarding medications in entry level physical therapy and chiropractic programs is very limited compared to physicians or

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pharmacists. As patients with neck pain can be taking various medications for their neck pain, it is important that physical therapists and chiropractors have a general knowledge about classes of pharmaceuticals and their indications, however it is not in their scope of practice to have detailed knowledge on the full scope of medications and the ability to advise patients on medication use. Recognizing the limitations of the results of this survey due to our respondent group, further trials specific to patients with neck pain, particularly those with complex presentations would be a valuable addition to the evidence base. 4.3. Patient education Not surprisingly, the broad intervention category of patient education was the most commonly used by our respondents. A survey of chiropractic practice patterns has previously reported patient education as being highly important in patient care [26]. Its inclusion in entry-level curricula has also been acknowledged by both professions [27,28]. In our review of reviews, we found moderate evidence for use of patient education in the form of video on advice to activate for patients with acute whiplash presenting to an emergency department [8]. However, low GRADE evidence of no benefit was shown for the numerous educational interventions on ‘advice focused on activation’, ‘pain and stress-coping skills education’, ‘work place ergonomic education and pain plus stress-coping skills education’ and ‘self-management education strategies’ (ergonomics, exercise, self-care, relaxation) for varied outcomes (mostly pain, function) and comparators [8]. This finding is in line with the usage reported by our respondents, as advice to activate was the most commonly reported type of patient education. Our review also found evidence of no benefit for patient education in the form of self-management strategies in patients with chronic non-specific or acute neck pain. Our respondents reported common usage of self-management philosophy and self-management of pain at 61% and 71% respectively. The evidence base pertaining to patient education for patients with neck pain is small and uncertain (low quality). With few trials addressing the topic and many options available to practitioners, it is likely that they may respond based on clinical experience, or scope of practice. This could explain for example the high endorsement of injury prevention, ergonomic advice and pain education. Until the evidence base sufficiently increases to provide practitioners with information that they can apply in practice, they will have to continue along this course.

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4.4. Primary psychological interventions The category of relaxation therapy was the second most frequently utilized intervention by our respondents however closer examination of the specific usage of these techniques revealed that only relaxation techniques were used occasionally while the remaining types were never used. It is beyond the scope of this survey to understand the exact techniques that respondents are employing to enhance patient relaxation and how they might differ from the other items in this category. The support for relaxation techniques contrasts the findings from our review of reviews in which we found moderate GRADE evidence of no benefit for intensive relaxation training for patients with chronic nonspecific neck pain [8]. Interestingly, respondents to this survey reported the highest usage of relaxation techniques in patients with chronic conditions. It could be that respondents were thinking about the efficacy of relaxation therapies more broadly for chronic pain [29,30] or the implementation of these therapies in chronic pain management programs [31]. This explanation would not account for respondents’ lack of use of other relaxation therapies in our survey with demonstrated efficacy such as hypnosis or guided imagery [30,32]. A more plausible explanation may be that the other techniques listed in the relaxation therapy category were more specialized than the more general item of relaxation techniques and a lack of experience in the use of hypnosis or imagery would explain its low endorsement. Further, these techniques may have been interpreted as being outside of the scope of practice of physical therapists and chiropractors. In this study, respondents’ reported occasional recommendation of cognitive behavioral therapy (CBT), behavioral therapy and supportive counseling and these interventions were most frequently used in patients with chronic non-specific neck pain or chronic WAD. It is likely that perceived scope of practice issues for physical therapists and chiropractors, may explain their focus on physical interventions rather than psychological ones, and that this has not provided a representative picture of usage of psychological interventions for this population of patients. Unfortunately the lack of response from other health care practitioners, particularly psychologists restricted our ability to determine if this evidence has infiltrated practice of psychologists. However, it is noteworthy that there is no scope of practice restrictions that would keep physical therapists or chiropractors from using cognitive/behavioral rehabilitation approaches and in fact there are multiple

studies to support this approach [33–35]. The evidence based recommendations from our review of reviews in this area, demonstrated a moderate GRADE evidence (1 trial, 268 participants) of no difference from standard physiotherapy when physical therapists delivered a cognitive behavioral program in the form of solution finding [8]. In a broader context of evaluating evidence on psychological care, a 2012 update of a Cochrane review on psychological interventions for chronic pain found that CBT but not behavioral therapy had weak or small effects on improving pain and associated disability [36]. In another review of behaviour therapy for chronic low back pain, moderate grade evidence of benefit was found [37]. Given this additional psychological evidence taken from a broader context, these findings may suggest that there is underutilization of cognitive and psychological approaches for managing neck pain amongst physiotherapists and chiropractors. Since these approaches may not naturally align with the perceived scope of practice, then knowledge translation activities that include specific training on techniques may be needed to increase uptake.

4.5. Factors impacting on delivery of care Patient factors were most endorsed as a mediating factor on delivery of care, followed closely by cost and access to care. It is beyond the ability of our survey to understand the details of what respondents meant by patient factors but some examples exist in the literature. A 2011 population based study by Chevan et al., compared factors of care seeking in patients with spinal pain between physical therapists, chiropractors and physicians [38]. There was no difference in the behavior of patients with neck or back pain, however, patients seeking care with physical therapists were more likely to be female, have lower self health ratings and a greater number of disability days compared to patients seeking chiropractic care [38]. Chevan et al., also found that people seeking care from a physical therapist had a higher income. The authors postulated that this may be related to the time required to complete the plan of care, the costs of coverage for physical therapy, and the ability of those with higher incomes to take time off work [38]. Higher income may also be interpreted as having a direct impact on access to care affecting the ability of those who cannot afford care or limiting care due to limited coverage for care.

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4.6. Disorder subgroups Looking across disorder subgroups, some variation can be seen. Medications were used most frequently in patients with acute non specific neck pain suggesting that short term relief was the primary treatment goal. For all other categories of intervention there was greater utilization for chronic neck pain conditions including non-specific neck pain and WAD. It would appear that the pattern of utilization is consistent with variation in the complexity of the condition. Chronic neck pain conditions, particularly those arising following WAD [12] are often associated with greater degrees of disability and impairment. [24] as well as psychological distress [11,39]. Acute neck pain and WAD if uncomplicated by high levels of pain severity, functional limitation or psychological distress will likely resolve within a reasonable timeframe and are likely more manageable with medication. Chronic pain conditions are known to be best managed by multidisciplinary rehabilitation due to the complexity of issues [33,40,41]. Our survey results seem to reflect this as these acute conditions generally had the lowest frequency of intervention utilization. Overall, these findings do suggest that the acuity of the condition and the subtype of neck pain present affect treatment patterns. 4.7. Differences between professions Our findings indicate that physiotherapists’ utilization of patient education and relaxation therapy interventions is significantly greater than chiropractors. While there is considerable overlap in the scope of practice of these two professions, these findings are not unexpected, as differences based on education and clinical paradigms may influence their approach to treatment. Practitioner’s use of interventions can be shaped by factors other than their entry-level education such as courses taken post professionally, clinical environments, characteristics of the population treated, or use of evidence base medicine. The nature of the survey does not allow us to determine why differences existed between the professional groups. It is likely that clinicians are more aware of evidence communicated within their own professional journals and conferences than that communicated through other professions. There are multiple patient and practitioner preferences that affect the treatment choices made in clinician and patient interactions around managing neck pain. These can include previous experience, stage of healing, or practitioner type. However, understand-

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ing the gaps between the evidence base and practice patterns is important for identifying areas needing targeted knowledge translation. The practice patterns demonstrated by this data suggest that chiropractors and physical therapists consistently use patient education in patients with neck pain, although with poor outcomes [42]. These results may be due to an unsystematic approach. Evidence supports the use of well designed patient education programs to improve health outcomes in various diseases [43]. Otherwise these practitioners have variable practice patterns that are inconsistently supported by evidence regarding neck pain management. To our knowledge this practice survey is the first to compare practice patterns of chiropractors and physical therapists for people with neck pain in the areas of pharmacological, psychological, patient education and relaxation therapies. Previous surveys pertaining to specific professions, reporting more broadly or on specific aspects of treatment have been published making comparison difficult. The effort towards knowledge translation with clear and consistent messaging for relevant health professionals and the public regarding recommended treatments, as well as for those without, must continue and occur in multiple formats and mediums. This will help practitioners to minimize overtreatment with ineffective therapies or under-treatment of patients presenting with more complex conditions and make consumers more knowledgeable of their options. There are several limitations to this survey that should be considered when interpreting the results. First, our survey was cross-sectional and can only provide a snapshot of practitioner utilization. By revisiting practice patterns as they evolve over time, results can be compared to detect change. Second our sample over-represented Canadian clinicians compared to other countries and was largely representative of the chiropractic and physiotherapy professions, limiting the generalizability of the results. Thirdly, this survey was descriptive and to our knowledge the first to look at practice patterns regarding this group of interventions. Those who chose to participate in this survey may represent a systematically different type of practitioner than those who didn’t. Lastly, in presenting the results specific to chiropractic and physical therapy professionals, particularly for interventions that are typically outside of their scope of practice, it is likely that results from practitioners whose practice includes prescribing medication or primary psychological interventions may change how practice patterns

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match up with the existing evidence. The results should be considered as hypothesis generating to be further explored in future studies. Therefore, transferring the conclusions of this study to different disciplines may not be appropriate.

Per Kjær, Janet Lowcock, Joy MacDermid, Jordan Miller, Margareta Nordin, Paul Peloso, Jan Pool, Duncan Reid, Sidney Rubinstein, P. Lina Santaguida, Anne Söderlund, Natalie Spearing, Michele Sterling, Grace Szeto, Robert Teasell, Arianne Verhagen, David M. Walton, Marc White.

5. Conclusions References The practice patterns of our survey respondents indicated variable of use interventions with weak to moderate supporting evidence (muscle relaxants, CBT) as well as those with conflicting or no evidence (antiinflammatories, relaxation techniques, patient education). Due to the small number of trials that exist on these interventions in neck pain populations, future trials have the potential to make important contributions to the evidence base, thus influencing practice patterns. It may also suggest there is a need for research to fill gaps in evidence that is associated with variable practice patterns and knowledge translation to reduce the usage of some interventions that have been shown to be ineffective. Once the evidence base has expanded, it will be important to re-examine practice patterns to determine if the knowledge to practice gap is being filled. Examining the consistency or lack of it between available evidence and current treatment patterns can influence guideline dissemination as well as other interventions, such as payment reform, to improve the effectiveness of current care for neck pain.

Acknowledgements Lisa Carlesso is supported by a Canadian Health Research Institute Fellowship. This work was supported by Canadian Institutes of Health Research (CIHR) grant(s) FRN: KRS-102084. ICON is a multi-disciplinary collaborative group that includes scientist-authors (listed below) and support staff (Margaret Lomotan) that conduct knowledge synthesis and translation aimed at reducing the burden of neck pain. The ICON authors provided direction of the project; input into the survey questions and review of the findings/manuscript and includes (in alphabetical order): Gert Bronfort, Norm Buckley, Lisa Carlesso, Linda Carroll, Pierre Côté, Jeanette Ezzo, Paulo Ferreira, Tim Flynn, Charlie Goldsmith, Anita Gross, Ted Haines, Jan Hartvigsen, Wayne Hing, Gwendolen Jull, Faith Kaplan, Ron Kaplan, Helge Kasch, Justin Kenardy,

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