Neck Pain Physiotherapy
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Clinical Guidelines JOHN D. CHILDS, PT, PhD@EI>K77$9B;B7D:"PT, PhD@7C;IC$;BB?EJJ"PT, PhD:;O:H;I$J;O>;D"PT, PhD HE8;HJI$M7?DD;H"PT, PhD@KB?;C$M>?JC7D"PT, DSc8;HD7H:@$IEFAO"MD @EI;F>@$=E:=;I"DPTJ?CEJ>OM$
Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association J Orthop Sports Phys Ther 2008;38(9):A1-A34. doi:10.2519/jospt.2008.0303
RECOMMENDATIONS$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7( INTRODUCTION$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7) METHODS$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7* CLINICAL GUIDELINES: Impairment/Function-Based Diagnosis$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7/ CLINICAL GUIDELINES: Examinations$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7'* CLINICAL GUIDELINES: Interventions$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7'/ SUMMARY OF RECOMMENDATIONS$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7(. AUTHOR/REVIEWER AFFILIATIONS & CONTACTS$ $ $ $ $ $ $ $ $ $ 7(/ REFERENCES$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7)&
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N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Recommendations* F7J>E7D7JEC?97B<;7JKH;I0 Although the cause of neck pain may be associated with degenerative processes or pathology identified during diagnostic imaging, the tissue that is causing a patient’s neck pain is most often unknown. Thus, clinicians should assess for impaired function of muscle, connective, and nerve tissues associated with the identified pathological tissues when a patient presents with neck pain. (Recommendation based on theoretical/foundational evidence.) H?IA<79JEHI0 Clinicians should consider age greater than 40, coexisting low back pain, a long history of neck pain, cycling as a regular activity, loss of strength in the hands, worrisome attitude, poor quality of life, and less vitality as predisposing factors for the development of chronic neck pain. (Recommendation based on moderate evidence.) :?7=DEI?I%9B7II?
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The following physical examination measures may be useful in classifying a patient in the ICF impairment-based category of neck pain with movement coordination impairments and the associated ICD category of sprain and strain of cervical spine. (Recommendation based on moderate evidence.) EH79?9CE8?B?P7J?ED%C7D?FKB7J?ED0 Thoracic spine thrust manipulation can be used for patients with primary complaints of neck pain. Thoracic spine thrust manipulation can also be used for reducing pain and disability in patients with neck and neck-related arm pain. (Recommendation based on weak evidence.)
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Recommendations* (continued) ?DJ;HL;DJ?EDIÅIJH;J9>?D=;N;H9?I;I0 Flexibility exercises can be used for patients with neck symptoms. Examination Zg]mZk`^m^]×^qb[bebmr^q^k\bl^l_hkma^_heehpbg`fnl\e^lZk^ suggested: anterior/medial/posterior scalenes, upper trapezius, levator scapulae, pectoralis minor, and pectoralis major. (Recommendation based on weak evidence.) ?DJ;HL;DJ?EDIÅ9EEH:?D7J?ED"IJH;D=J>;D?D="7D:;D:KH7D9;;N;H9?I;I0 Clinicians should consider the use of coordination, strengthening, and endurance exercises to reduce neck pain and headache. (Recommendation based on strong evidence.)
and nerve mobilization procedures to reduce pain and disability in patients with neck and arm pain. (Recommendation based on moderate evidence.) ?DJ;HL;DJ?EDIÅJH79J?ED0 Clinicians should consider the use of mechanical intermittent cervical traction, combined with other interventions such as manual therapy and strengthening exercises, for reducing pain and disability in patients with neck and neck-related arm pain. (Recommendation based on moderate evidence.)
?DJ;HL;DJ?EDIÅ9;DJH7B?P7J?EDFHE9;:KH;I7D:;N;H9?I;I0 Specific repeated movements or procedures to promote centralization are not more beneficial in reducing disability when compared to other forms of interventions. (Recommendation based on weak evidence.)
?DJ;HL;DJ?EDIÅF7J?;DJ;:K97J?ED7D:9EKDI;B?D=0 To improve recovery in patients with whiplash-associated disorder, clinicians should (1) educate the patient that early return to normal, non-provocative pre-accident activities is important, and (2) provide reassurance to the patient that good prognosis and full recovery commonly occurs. (Recommendation based on strong evidence.)
?DJ;HL;DJ?EDIÅKFF;HGK7HJ;H7D:D;HL;CE8?B?P7J?EDFHE9;:KH;I0 Clinicians should consider the use of upper quarter
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Introduction 7?CE<J>;=K?:;B?D; The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF).1/ The purposes of these clinical guidelines are to: =^l\kb[^^ob]^g\^&[Zl^]iarlb\Zema^kZirikZ\mb\^bg\en]ing diagnosis, prognosis, intervention, and assessment of outcome for musculoskeletal disorders commonly managed by orthopaedic physical therapists <eZllb_rZg]]^Ög^\hffhgfnl\nehld^e^mZe\hg]bmbhgl using the World Health Organization’s terminology related to impairments of body function and body structure, activity limitations, and participation restrictions B]^gmb_rbgm^ko^gmbhgllniihkm^][r\nkk^gm[^lm^ob]^g\^mh address impairments of body function and structure, activity limitations, and participation restrictions associated with common musculoskeletal conditions B]^gmb_rZiikhikbZm^hnm\hf^f^Zlnk^lmhZll^ll\aZg`^l resulting from physical therapy interventions in body function and structure as well as in activity and participation of the individual
Ikhob]^Z]^l\kbimbhgmhiheb\rfZd^kl%nlbg`bgm^kgZmbhgZeer accepted terminology, of the practice of orthopaedic physical therapists Ikhob]^bg_hkfZmbhg_hkiZr^klZg]\eZbflk^ob^p^klk^`Zk]ing the practice of orthopaedic physical therapy for common musculoskeletal conditions
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Methods Content experts were appointed by the Orthopaedic Section, APTA as developers and authors of clinical practice guidelines for musculoskeletal conditions of the cervical region that are commonly treated by physical therapists. These content experts were given the task to identify impairments of body function and structure, activity limitations, and participation restrictions, described using ICF terminology, that could (1) categorize patients into mutually exclusive impairment patterns upon which to base intervention strategies, and (2) serve as measures of changes in function over the course of an episode of care. The second task given to the content experts was to describe interventions and supporting evidence for specific subsets of patients based upon the previously chosen patient categories. It was also acknowledged by the Orthopaedic Section, APTA content experts that a systematic search and review of the evidence solely related to diagnostic categories based on International Statistical Classification of Diseases and Health Related Problems (ICD)10 terminology would not be useful for these ICF-based clinical practice guidelines as most of the evidence associated with changes in levels of impairment or function in homogeneous populations is not readily searchable using the ICD terminology. Thus, the authors of this clinical practice guideline sysm^fZmb\Zeerl^Zk\a^]F>=EBG>%ob]^g\^&;Zl^]F^]b\bg^%Hq_hk]%Ngbm^]Dbg`]hf!MZ[e^*[^ehp"'B_ma^+\hgm^gm experts did not agree on a grade of evidence for a particular article, a third content expert was used to resolve the issue.
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=H7:;IE<;L?:;D9; The overall strength of the evidence supporting recommendations made in this guideline will be graded according to guidelines described by Guyatt et al,0* as modified by FZ\=^kfb]Zg]Z]him^][rma^\hhk]bgZmhkZg]k^ob^p^klh_ this project. In this modified system, the typical A, B, C, and D grades of evidence have been modified to include the role of consensus expert opinion and basic science research to demonstrate biological or biomechanical plausibility (Table 2 below).
GRADES OF RECOMMENDATION
STRENGTH OF EVIDENCE
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Methods (continued) H;L?;MFHE9;II The Orthopaedic Section, APTA also selected consultants from the following areas to serve as reviewers of the early drafts of this clinical practice guideline: <eZbflk^ob^p ib]^fbheh`r F^]b\ZeikZ\mb\^`nb]^ebg^l HkmahiZ^]b\iarlb\Zema^kZirk^lb]^g\r^]n\Zmbhg Iarlb\Zema^kZirZ\Z]^fb\^]n\Zmbhg Lihkmliarlb\Zema^kZirk^lb]^g\r^]n\Zmbhg Comments from these reviewers were utilized by the authors to edit this clinical practice guideline prior to submitting it for in[eb\Zmbhgmhma^ChnkgZeh_HkmahiZ^]b\ LihkmlIarlb\Ze Therapy In addition, several physical therapists practicing in orthopaedic and sports physical therapy settings were sent initial drafts of this clinical practice guideline along with feedback forms to determine its usefulness, validity, and impact. All returned feedback forms from these practicing clinicians described this clinical practice guideline as: ÊFh]^kZm^ernl^_neËhkÊ^qmk^f^ernl^_neË :gÊZ\\nkZm^k^ik^l^gmZmbhgh_ma^i^^k&k^ob^p^] ebm^kZmnk^Ë :`nb]^ebg^maZmpbeeaZo^ZÊln[lmZgmbZeihlbmbo^bfiZ\mhg hkmahiZ^]b\iarlb\Zema^kZiriZmb^gm\Zk^Ë However, several reviewers noted that preliminary drafts of this clinical guideline did not clearly link data gathered during the patient’s subjective and physical examinations to diagnostic classification and intervention. To assist in clarifying these links, it was recommended that the authors add a table to
these clinical guidelines that provides a summary of symptoms, impairment findings, and matched interventions for each diagnostic category. This recommendation led the authors to add Table 4 to these clinical guidelines. 9B7II?
ICD-10 and ICF Codes Associated With Neck Pain INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS D[YaFW_dM_j^CeX_b_jo:[ÓY_ji Primary ICD-10
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INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH PRIMARY ICF CODES
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N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH (CONTINUED) Z()&( Z(*&& Z*'&& Z*'&+ Z*'+& Z*-+&
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9ecfb[j_d]j^[ZW_bohekj_d[ >WdZb_d]h[ifedi_X_b_j_[i 8[dZ_d] CW_djW_d_d]Wi_jj_d]fei_j_ed CW_djW_d_d]WijWdZ_d]fei_j_ed :h_l_d]^kcWd#fem[h[ZjhWdifehjWj_ed :h_l_d]cejeh_p[Zl[^_Yb[i :h_l_d]Wd_cWb#fem[h[ZjhWdifehjWj_ed :e_d]^eki[meha"kdif[Y_Ó[Z 9ecckd_job_\["kdif[Y_Ó[Z H[Yh[Wj_edWdZb[_ikh["kdif[Y_Ó[Z
Body functions
X(.&') X(.&'* X(.&) X-'&' X-'+' X-)&+ X-)+& X-*&& X-,&'
FW_d_dXWYa FW_d_dkff[hb_cX HWZ_Wj_d]fW_d_dWZ[hcWjec[ CeX_b_joe\i[l[hWb`e_dji IjWX_b_joe\i[l[hWb`e_dji Fem[he\ckiYb[ie\j^[jhkda Jed[e\_iebWj[ZckiYb[iWdZckiYb[]hekfi ;dZkhWdY[e\_iebWj[ZckiYb[i 9edjhebe\Yecfb[nlebkdjWhocel[c[dji
Body structure
i'(&&& i'(&&' i'(&' i')& i-'&+ i-,&&& i-,&&' i-,&' i-,&(
9[hl_YWbif_dWbYehZ J^ehWY_Yif_dWbYehZ If_dWbd[hl[i IjhkYjkh[e\c[d_d][i B_]Wc[djiWdZ\WiY_W[e\^[WZWdZd[Yah[]_ed 9[hl_YWbl[hj[XhWbYebkcd J^ehWY_Yl[hj[XhWbYebkcd CkiYb[ie\jhkda B_]Wc[djiWdZ\WiY_W[e\jhkda
Activities and participation
Z()&( Z(*&& Z*'+& Z*'+) Z*'+& Z*)&& Z*)&' Z*)&( Z*)&) Z*)&* Z*)&+ Z*-+& Z*-+& Z*-+& Z,*&/ Z/'&/ Z/(&/
9ecfb[j_d]j^[ZW_bohektine >WdZb_d]h[ifedi_X_b_j_[i CW_djW_d_d]Wbo_d]fei_j_ed CW_djW_d_d]Wi_jj_d]fei_j_ed CW_djW_d_d]WijWdZ_d]fei_j_ed B_\j_d] 9Whho_d]_dj^[^WdZi 9Whho_d]_dj^[Whci 9Whho_d]edi^ekbZ[hi"^_f"WdZXWYa 9Whho_d]edj^[^[WZ Fkjj_d]ZemdeX`[Yji :h_l_d]^kcWd#fem[h[ZjhWdifehjWj_ed :h_l_d]cejeh_p[Zl[^_Yb[i :h_l_d]Wd_cWb#fem[h[ZjhWdifehjWj_ed :e_d]^eki[meha"kdif[Y_Ó[Z 9ecckd_job_\["kdif[Y_Ó[Z H[Yh[Wj_edWdZb[_ikh["kdif[Y_Ó[Z
D[YaFW_dM_j^HWZ_Wj_d]FW_d
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
CLINICAL GUIDELINES
Impairment/Function-based Diagnosis FH;L7B;D9; Pain and impairment of the neck is common. It is estifZm^]maZm++ mh0) h_ma^ihineZmbhgpbeeaZo^g^\diZbg some time in their lives.*2%+)%-+%-,%..%**.%*+2 In addition, it has been suggested that the incidence of neck pain is increasing.*+/%*1* At any given time, 10% to 20% of the population reports neck problems,*2%--%01%*/0pbma.- h_bg]bob]nZelaZobg`^qi^kb^g\^] g^\diZbgpbmabgma^eZlm/fhgmal'42 Prevalence of neck pain increases with age and is most common in women around the fifth decade of life.-%*2%-/%**/%*/, Although the natural history of neck pain appears to be favorable,.*%2+ rates of recurrence and chronicity are high.*.%1* One study reported that 30% of patients with neck pain will develop chronic symptoms, with neck pain of greater maZg/fhgmal]nkZmbhgZü^\mbg`*- h_Zeebg]bob]nZelpah experience an episode of neck pain.19 Additionally, a recent lnko^r ]^fhglmkZm^] maZm ,0 h_ bg]bob]nZel pah ^qi^kbence neck pain will report persistent problems for at least 12 months.44 Five percent of the adult population with neck pain will be disabled by the pain, representing a serious health concern.*2%11 In a survey of workers with injuries to the neck and upper extremity, Pransky et al*,. reported that -+ fbll^]fhk^maZg*p^^dh_phkdZg]+/ ^qi^kb^g\^] recurrence within 1 year. The economic burden due to disorders of the neck is high, and includes costs of treatment, lost wages, and compensation expenditures.*/%*,1 Neck pain is second only to low back pain in annual workers’ compensambhg\hlmlbgma^Ngbm^]LmZm^l'*1* In Sweden, neck and shoul]^kikh[e^flZ\\hngm_hk*1 h_Zee]blZ[bebmriZrf^gml'*+/ C^mm^^mZe91 reported that patients with neck pain make up ZiikhqbfZm^er+. h_iZmb^gmlk^\^bobg`hnmiZmb^gmiarlbcal therapy. Additionally, patients with neck pain frequently are treated without surgery by primary care and physical therapy providers.*0%.*%2+
F7J>E7D7JEC?97B<;7JKH;I A variety of causes of neck pain have been described and include osteoarthritis, discogenic disorders, trauma, tumors, infection, myofascial pain syndrome, torticollis, and whiplash.121Ng_hkmngZm^er%\e^Zker]^Ög^]]bZ`ghlmb\\kbm^kbZ have not been established for many of these entities. Similar to low back pain, a pathoanatomical cause is not identifiable
in the majority of patients who present with complaints of neck pain and neck related symptoms of the upper quarter.*. Therefore, once serious medical pathology (such as cervical fracture or myelopathy) has been ruled out, patients with neck pain are often classified as having either a nerve root \hfikhfbl^hkZÊf^\aZgb\Zeg^\d]blhk]^k'Ë In some conditions, particularly those that are degenerative in nature or involve abnormalities of the vertebral motion segment, abnormal findings are not always associated with symimhfl' ?hnkm^^g mh *1 h_ people without neck pain demonstrate a wide range of abnormalities with imaging studies, including disc protrusion or extrusion and impingement of the thecal sac on the nerve root and spinal cord.12 However, degenerative changes are still suggested to be a possible cause of mechanical neck pain in some cases,109,130,131 despite the fact that these changes are present in asymptomatic individuals, are non-specific, and are highly prevalent in the elderly.*/1 Disorders such as cervical radiculopathy and cervical compressive myelopathy are reported to be caused by space-occupying lesions (osteophytosis or herniated cervical disc). These may be secondary to degenerative processes and can give rise to neck and/or upper quarter pain as well as neurologic signs and symptoms.*,/ While cervical disc herniation and spondylosis are most commonly linked to cervical radiculopathy and myelopathy,*)%*,/ the bony and ligamentous tissues affected by these conditions are themselves pain generators and are capable of giving rise to some of the referred symptoms observed in patients with these disorders.13,40
II
Because most patients with neck pain usually lack an identifiable pathoanatomic cause for their problem, the majority are classified as having mechanical neck disorders.1+
II
Although the cause of neck pain may be associated with degenerative processes or pathology identified during diagnostic imaging, the tissue that is causing a patient’s neck pain is most often unknown. Thus, clinicians should assess for impaired function of muscle, connective, and nerve tissues associated with the identified pathological tissues when a patient presents with neck pain.
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N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s H?IA<79JEHI Bot and colleagues18 investigated the clinical course and predictors of recovery for patients with neck and shoulder pain. Four hundred forty three patients who consulted their primary care physician with neck or shoulder symptoms were followed for 12 months. At 12 months, 32% of patients reported that they had recovered. Predictors of poor pain-related outcome at 12 months included less intense pain at baseline, a history of neck and shoulder symptoms, more worrying, worse perceived health, and a moderate or bad quality of life. The predictors for a poor disability-related response at 12 months included older age, less disability at baseline, longer duration of symptoms, loss of strength in hands, having multiple symptoms, more worrying, moderate or bad quality of life, and less vitality.
II
Hill and colleagues0/ investigated the course of neck pain in an adult population over a 12 month period. Significant baseline characteristics, which ik^]b\m^]i^klblm^gmg^\diZbgp^k^Z`^!-.&.2r^Zkl"%[^bg` off work at the time of the baseline survey (odds ratio [OR] 6*'/"%\hfhk[b]ehp[Z\diZbg!HK6*'/"%Zg][b\r\ebg`ZlZ regular activity (OR = 2.4).
II
In a prospective cohort study, Hoving et al1) examined the predictors of outcome in a patient ihineZmbhgpbmag^\diZbg':mhmZeh_*1,iZmb^gml iZkmb\biZm^]bgma^lmn]rh_pab\a/, aZ]bfikho^]ZmZ 12-month follow-up. In the short term, older age (l40), concomitant low back pain, and headache were associated with poor outcome. In the long-term, in addition to age and concomitant low back pain, previous trauma, a long duration of neck pain, stable neck pain during the 2 weeks prior to baseline measurement, and previous neck pain predicted poor prognosis.
II
Clinicians should consider age greater than 40, coexisting low back pain, a long history of neck pain, bicycling as a regular activity, loss of strength in the hands, worrisome attitude, poor quality of life, and less vitality as predisposing factors for the development of chronic neck pain.
B
9B?D?97B9EKHI; Approximately 44% of patients experiencing neck pain will go on to develop chronic symptoms,*. and many will continue to exhibit moderate disability at long-term follow-up.// A recent systematic review examined the outcomes of nontreatment control groups in clinical trials for the conservative management of chronic mechanical neck pain - not due to whiplash.*0* The outcomes of patients receiving a control or placebo intervention were analyzed and effect sizes were a10
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calculated. The changes in pain scores over the varying trial periods in these untreated subjects with chronic mechanical neck pain were consistently small and not significant.*0* Conversely, there is substantial evidence that favorable outcomes are attained following treatment of patients with cervical radiculopathy.02%*,/ For example, Radhakrishnan and colleagues*,/ reported that nearly 90% of patients with cervical radiculopathy presented with only mild symptoms at a median follow-up of 4.9 years. Honet and Puri02 found that 0) h_iZmb^gmlpbma\^kob\ZekZ]b\nehiZmar^qab[bm^]`hh]hk excellent outcomes after a 2-year follow-up. Outcomes for the patients in the aforementioned studies02%*,/ appeared favorZ[e^Zg]ln``^lmmaZm0)&2) h_mablihineZmbhg\Zg^qi^kbence improvement without surgical intervention. In contrast, the clinical prognosis of patients with whiplash-associated ]blhk]^kble^ll_ZohkZ[e^':lnko^rh_*)1iZmb^gmlpbmaZabltory of whiplash requiring care at an emergency department _hng]maZm.. aZ]k^lb]nZeiZbg(]blZ[bebmrk^_^kZ[e^mhma^ hkb`bgZeZ\\b]^gmZmZf^Zg_heehp&nih_*0r^ZkleZm^k'G^\d pain, radiating pain, and headache were the most common symptoms. Thirty-three percent of the respondents with residual symptoms suffered from work disability, compared to / bgma^`khnih_iZmb^gmlpbmahnmk^lb]nZe]blhk]^kl'+.
:?7=DEI?I%9B7II?
III
september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s conditioning, pain control, and headache, intend to capture the primary focus or goal of treatment. Fritz and Brennan,/+ nmbebsbg`Zikhli^\mbo^%h[l^koZmbhgZelmn]rh_+0-iZmb^gml% reported that patients who received interventions matched with their treatment subgroup had better outcomes than patients who received interventions that were not matched with their subgroup. The classification system described in this practice guideline linked to the ICF, parallels the Childs et al+0 and Fritz and Brennan/+ classification with 2 noteworthy differences. The first difference is that the labels in this clinical practice guideline incorporate the following ICF impairments of body functions terminology: Neck pain with mobility deficits, neck pain with headaches, neck pain with movement coordination impairments, and neck pain with radiating pain. The second difference is that Fritz and Brennan’s/+ÊiZbg\hgmkheË\Zm^`hkr%pab\apZlebgd^]mhfh[bebsZmbhgZg]kZg`^ of motion exercises following an acute cervical sprain, was ]bob]^]bgmhma^Êg^\diZbgpbmafho^f^gm\hhk]bgZmbhgbfiZbkf^gml%ËZg]Êg^\diZbgpbmafh[bebmr]^Ö\bmlË\Zm^`hkb^l% where the patient would receive interventions linked to the most relevant impairment(s) exhibited at a given period during the patient’s episode of care. The ICD diagnosis of cervicalgia, or pain in thoracic spine and the associated ICF diagnosis of neck pain with mobility deficits is made with a reasonable level of certainty when the patient presents with the following clinical findings,,%/+%1+%*//: Rhng`^kbg]bob]nZe!Z`^5.)r^Zkl" :\nm^g^\diZbg!]nkZmbhg5*+p^^dl" LrfimhflblheZm^]mhma^g^\d K^lmkb\m^]\^kob\ZekZg`^h_fhmbhg
I
The ICD diagnosis of headaches, or cervicocranial syndrome and the associated ICF diagnosis of neck pain with headaches is made with a reasonable level of certainty when the patient presents with the following clinical findings/%/+%22%*1.: NgbeZm^kZe a^Z]Z\a^ Zllh\bZm^] pbma g^\d(ln[h\\bibmZe area symptoms that are aggravated by neck movements or positions A^Z]Z\a^ikh]n\^]hkZ``kZoZm^]pbmaikhoh\Zmbhgh_ma^ ipsilateral posterior cervical myofascia and joints K^lmkb\m^]\^kob\ZekZg`^h_fhmbhg K^lmkb\m^]\^kob\Zel^`f^gmZefh[bebmr :[ghkfZe(ln[lmZg]Zk]i^k_hkfZg\^hgma^\kZgbZe\^kob\Ze×^qbhgm^lm
II
The ICD diagnosis of sprain and strain of cervical spine and the associated ICF diagnosis of neck pain with movement coordination impairments is made with a reasonable level of certainty when the patient presents with the following clinical findings++%+2%*-.%*/+%*1+%*1-:
I
Ehg`lmZg]bg`g^\diZbg!]nkZmbhg7*+p^^dl" :[ghkfZe(ln[lmZg]Zk]i^k_hkfZg\^hgma^\kZgbZe\^kob\Ze×^qbhgm^lm :[ghkfZe(ln[lmZg]Zk] i^k_hkfZg\^ hg ma^ ]^^i ×^qhk endurance test k`hghfb\ bg^ú\b^g\b^l pbma i^k_hkfbg` k^i^mbmbo^ activities The ICD diagnosis of spondylosis with radiculopathy or cervical disc disorder with radiculopathy and the associated ICF diagnosis of neck pain with radiating pain is made with a reasonable level of certainty when the patient presents with the following clinical findings*0.: Nii^k^qmk^fbmrlrfimhfl%nlnZeerkZ]b\neZkhkk^_^kk^] pain, that are produced or aggravated with Spurling’s maneuver and upper limb tension tests, and reduced with the neck distraction test =^\k^Zl^] \^kob\Ze khmZmbhg !5/)" mhpZk] ma^ bgoheo^] side Lb`glh_g^ko^khhm\hfik^llbhg Ln\\^llpbmak^]n\bg`nii^k^qmk^fbmrlrfimhflpbmabgbtial examination and intervention procedures
II
Neck pain, without symptoms or signs of serious medical or psychological conditions, associated with (1) motion limitations in the cervical and upper thoracic regions, (2) headaches, and (3) referred or radiating pain into an upper extremity are useful clinical findings for classifying a patient with neck pain into the following International Statistical Classification of Diseases and Related Health Problems (ICD) categories: cervicalgia, pain in thoracic spine, headaches, cervicocranial syndrome, sprain and strain of cervical spine, spondylosis with radiculopathy, and cervical disc disorder with radiculopathy; and the associated International Classification of Functioning, Disability, and Health (ICF) impairment-based category of neck pain with the following impairments of body function: G^\diZbgpbmafh[bebmr]^Ö\bml([0*)*Fh[bebmrh_l^o^kZe joints) G^\diZbgpbmaa^Z]Z\a^l(+1)*)IZbgbga^Z]Zg]g^\d" G^\d iZbg pbma fho^f^gm \hhk]bgZmbhg bfiZbkf^gml ([0/)*
B
The following physical examination measures may be useful in classifying a patient in the ICF impairment-based category
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a11
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s of neck pain with mobility deficits and the associated ICD categories of cervicalgia or pain in thoracic spine: <^kob\ZeZ\mbo^kZg`^h_fhmbhg <^kob\ZeZg]mahkZ\b\l^`f^gmZefh[bebmr The following physical examination measures may be useful in classifying a patient in the ICF impairment-based category of neck pain with headaches and the associated ICD categories of headaches or cervicocranial syndrome: <^kob\ZeZ\mbo^kZg`^h_fhmbhg <^kob\Zel^`f^gmZefh[bebmr
:?<<;H;DJ?7B:?7=DEI?I A primary goal of diagnosis is to match the patient’s clinical presentation with the most efficacious treatment approach. A component of this decision is determining whether the patient is, in fact, appropriate for physical therapy management. In the vast majority of patients with neck pain, symptoms can be attributed to mechanical factors. However, in a much smaller percentage of patients, the cause of neck pain may be something more serious, such as cervical myelopathy, cervical instability,49 fracture,00 neoplastic conditions,2)%*-)%*.+%*.- vascular compromise,*.* or systemic disease.1%+- Clinicians must be aware of the key signs and symptoms associated with serious pathological neck conditions, continually screen for the presence of these conditions, and initiate referral to the appropriate medical practitioner when a potentially serious medical condition is suspected.
III
When a patient with neck pain reports a history of trauma, the therapist needs to be particularly alert for the presence of cervical instability, spinal fracture, and the presence of or potential for spinal cord or brain stem injury. A clinical prediction rule has been developed to
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assist clinicians in determining when to order radiographs in individuals who have experienced trauma.*.2 In addition to medical conditions, clinicians should be aware of psychosocial factors that may be contributing to a patient’s persistent pain and disability, or that may contribute to the transition of an acute condition to a chronic, disabling condition. Researchers have recently shown that psychosocial factors are an important prognostic indicator of prolonged disability./,%/-%**-%*.) When relevant psychosocial factors are identified, the rehabilitation approach may need to be modified to emphasize active rehabilitation, graded exercise programs, positive reinforcement of functional accomplishments, and/or graduated exposure to specific activities that a patient fears as potentially painful or difficult to perform./.
II
Clinicians should consider diagnostic classifications associated with serious pathological conditions or psychosocial factors when the patient’s reported activity limitations or impairments of body function and structure are not consistent with those presented in the diagnosis/ classification section of this guideline, or, when the patient’s symptoms are not resolving with interventions aimed at normalization of the patient’s impairments of body function.
B
?C7=?D=IJK:?;I Adults with cervical pain precipitated by trauma should be classified as low risk or high risk based on the Canadian Cervical Spine Rule (CCR) for radiography in alert and stable trauma patients*.2 and the 2001 American College of Radiology (ACR) suspected Spine Trauma Appropriateness Criteria.3 According to the CCR, patients who (1) are able to sit in the emergency department; or (2) have had a simple rear-end motor vehicle collision; or (3) are ambulatory at any time; or (4) have had a delayed onset of neck pain; hk!."]hghmaZo^fb]ebg^\^kob\Zelibg^m^g]^kg^ll4Zg]!/" Zk^Z[e^mhZ\mbo^erkhmZm^ma^bka^Z]-.bg^Z\a]bk^\mbhg%Zk^ classified as low risk. Those who are classified as low risk do not require imaging for acute conditions. Patients who are !*"`k^Zm^kmaZg/.r^Zklh_Z`^4hk!+"aZo^aZ]Z]Zg`^khnl mechanism of injury; or (3) have paresthesias in the extremities, are classified as high risk.*.2 Those classified as high risk should undergo cervical radiography.2%-0 There is a paucity of available literature regarding the pediatric population to help guide decision making on the need for imaging. Adult risk classification features should be applied in children greater than age 14. Due to the added radiation exposure of computed tomography the ACR recommends ieZbg kZ]bh`kZiar !, ob^pl" bg mahl^ ng]^k */ r^Zkl h_ Z`^ regardless of mental status.3
september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s There is no consensus for routine investigation of patients with chronic neck pain with imaging beyond plain radiographs. ,%-1 Routine use of ultrasonography, CT, and magnetic resonance bfZ`bg`!FKB"bgiZmb^gmlpbmahnmg^nkheh`b\bglnemhkhma^k disease has not been justified in view of the infrequency of abnormalities detected, the lack of prognostic value, inaccessibility, and the high cost of the procedures.*-%0,%**2%*,,%*-*%*-/%*0- A major limitation is the lack of specific findings in patients with neck disorder and no definite correlation between the patient’s subjective symptoms and abnormal findings seen on imaging studies. As a result, debate continues as to whether persistent pain is attributable to structural pathology or to other underlying causes. K^\^gmer%DkblmcZgllhg111 compared sagittal plane, rotational, and translational cervical segmental motion in women with (1) persistent whiplash-associated disorder (WAD) (grades I and II), (2) persistent non-traumatic, insidious onset of neck pain, and (3) normal values of rotational and translational fhmbhg'EZm^kZekZ]bh`kZiab\ZgZerlblk^o^Ze^]lb`gbÖ\Zgmer bg\k^Zl^]khmZmbhgZefhmbhgZm<,&-Zg]<-&._hkbg]bob]nals in the WAD and insidious groups, significantly excessive translational motion at C3-4 for individuals in the WAD and insidious groups, and significantly excessive translational fhmbhgZm<.&/_hkbg]bob]nZelbgma^P:=`khnipa^g\hfpared to normal subjects. NemkZlhgh`kZiar aZl [^^g nl^] mh Z\\nkZm^er f^Zlnk^ ma^ size of the cervical multifidus muscle at the C4 level in asymptomatic female subjects. For those with chronic WAD, ultrasonography did not accurately measure the cervical multifidus because the fascial borders of the multifidus were largely indistinguishable, indicating possible pathological conditions.110 Ab`ak^lhenmbhgikhmhg]^glbmr&p^b`am^]FKBaZlk^\^gmer demonstrated abnormal signal intensity (indicative of tissue damage) in both the alar and transverse ligaments in some subjects with chronic WAD.*)1EZm^k_heehp&nilmn]b^lbg]bcated a strong relationship between alar ligament damage,
head position (turned) at time of impact, and disability levels (as measured with the Neck Disability Index).*)*%*)+%*)0 Elliott et al.,aZo^]^fhglmkZm^]maZm_^fZe^iZmb^gml!*1&-. r^Zklhe]"pbmai^klblm^gmP:=!`kZ]^BB"lahpFKB\aZg`^l in the fat content of the cervical extensor musculature that were not present in subjects with chronic insidious onset neck pain or healthy controls. It is currently unclear whether the patterns of fatty infiltration are the result of local structural mkZnfZ\Znlbg`Z`^g^kZebg×ZffZmhkrk^lihgl^%Zli^\bÖ\ nerve injury or insult, or a generalized disuse phenomenon. Further, as the muscular changes were observed in the chronic state, it is not yet known whether they occur uniformly in all people who have sustained whiplash injury irrespective of recovery or are unique to only those who develop chronic symptoms. In addition to fatty infiltration, Elliott et al.- have identified changes in the relative cross-sectional area (rCSA) of the cervical paraspinal musculature in patients with chronic WAD relative to control subjects with no history of neck pain. Specifically, the WAD group demonstrated a consistent pattern of larger rCSA in the multifidii muscles at each segment (C3<0"'Bg_^k^g\^\Zg[^]kZpgmaZmma^larger rCSAs recorded in the multifidii muscles of those with chronic WAD are the result of larger amounts of fatty infiltrate. In summary, imaging studies often fail to identify any structural pathology related to symptoms in patients with neck disorder and in particular, whiplash injury. However, emerging evidence into upper cervical ligamentous disruption, altered segmental motion, and muscular degeneration has been demonstrated with radiographs, ulmkZlhgh`kZiar% Zg] FKB lmn]b^l' Bm k^fZbgl ngdghpg b_ (1) these findings are unique to chronic WAD; (2) whether they relate to patients’ physical signs and symptoms, and (3) whether specific physical therapy intervention can alter such degeneration. Such knowledge may offer prognostic information and provide the foundation for interventional based studies.
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a13
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
CLINICAL GUIDELINES
Examination EKJ9EC;C;7IKH;I The Neck Disability Index (NDI) is a commonly utilized outcome measure to capture perceived disability in patients with neck pain.134 The NDI conmZbgl*)bm^fl%0k^eZm^]mhZ\mbobmb^lh_]Zberebobg`%+k^eZm^] to pain, and 1 related to concentration.*0+ Each item is scored _khf)&.Zg]ma^mhmZel\hk^bl^qik^ll^]ZlZi^k\^gmZ`^%pbma higher scores corresponding to greater disability. Riddle and Stratford139 identified a significant association between the NDI and both the physical and mental health components h_ma^L?&,/'Ma^ZnmahklZelhb]^gmbÖ^]maZmma^G=Bihlsesses adequate sensitivity as compared to the magnitude of change that occurred for patients reaching their functional goals, work status, and if the patient was currently in litigation.139C^mm^Zg]C^mm^92 further substantiated the sensitivity to change by calculating the effect sizes for change scores of [hmama^G=BZg]L?&,/'
I
Two studies*/*%*02 with small sample sizes have identified the minimal detectable change, or the amount of change that must be observed before the change can be considered to exceed the measurement error, for the NDI. Westaway*02 b]^gmbÖ^]ma^fbgbfZe]^m^\mZ[e^\aZg`^Zl.!*)i^k\^gmZ`^ points) in a group of 31 patients with neck pain. Stratford and colleagues*/* identified the minimal detectable change Zelhmh[^.!*)i^k\^gmZ`^ihbgml"bgZ`khnih_-1iZmb^gml with neck pain. However, the minimum clinically important difference, the smallest difference which patients perceive as beneficial, may be more useful to clinicians.12 Stratford and colleagues*/* identified the minimal clinically important dif_^k^g\^ Zl . ihbgml !*) i^k\^gmZ`^ ihbgml"' Fhk^ k^\^gmer% Cleland and colleagues,,. described the minimum clinically bfihkmZgm ]bü^k^g\^ _hk ma^ G=B mh [^ 2'. !*2 i^k\^gmZ`^ points) for patients with mechanical neck disorders. The NDI has demonstrated moderate test re-test reliability and has been shown to be a valid health outcome measure in a patient population with cervical radiculopathy. ,0 In this group, the intraclass correlation coefficient (ICC) for test rem^lmk^ebZ[bebmrpZl)'/1_hkma^G=BZg]ma^fbgbfnf\ebgb\ZeerbfihkmZgm]bü^k^g\^pZl0!*-i^k\^gmZ`^ihbgml"' ,0
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The Patient-Specific Functional Scale (PSFS) is a practical alternative or supplement to generic and condition-specific measures.*02 The PSFS asks pa-
tients to list 3 activities that are difficult as a result of their symptoms, injury, or disorder. The patient rates each activity on a 0-10 scale, with 0 representing the inability to perform the activity, and 10 representing the ability to perform the activity as well as they could prior to the onset of symptoms.*/) The final PSFS score is the average of the 3 activity scores. The PSFS was developed by Stratford et al*/) in an attempt to present a standardized measure for recording a patient’s perceived level of disability across a variety of conditions. The PSFS has been evaluated for reliability and validity in patients with neck pain.*02 The ICC value for test retest reliZ[bebmrbgiZmb^gmlpbma\^kob\ZekZ]b\nehiZmarpZl)'1+',0 The minimal detectable change in that population was identified to be 2.1 points with a minimum clinically important difference of 2.0.,0 Clinicians should use validated self-report questionnaires, such as the Neck Disability Index and the Patient-Specific Functional Scale for patients with neck pain. These tools are useful for identifying a patient’s baseline status relative to pain, function, and disability and for monitoring a change in patient’s status throughout the course of treatment.
A
79J?L?JOB?C?J7J?ED7D:F7HJ?9?F7J?EDH;IJH?9J?EDC;7IKH;I There are no activity limitation and participation restriction measures specifically reported in the literature associated with neck pain - other than those that are part of the self-report questionnaire noted in mabl`nb]^ebg^Íll^\mbhghgHnm\hf^F^Zlnk^l'Ahp^o^k%ma^ following measures are options that a clinician may use to assess changes in a patient’s level of function over an episode of care. IZbge^o^eZm^g]kZg`^lh_ehhdbg`ho^klahne]^k IZbge^o^eZm^g]kZg`^lh_ehhdbg`]hpg IZbge^o^eZm^g]kZg`^lh_ehhdbg`ni IZbge^o^eZ_m^klbmmbg`_hk+ahnkl Gnf[^kh_mbf^li^kgb`ammaZmiZbg]blknimlle^^i =^ldphkdmhe^kZg\^!bggnf[^kh_fbgnm^lhkahnkl" I^k\^gmh_mbf^^qi^kb^g\bg`g^\diZbgho^kma^ik^obhnl 24 hours I^k\^gmh_mbf^^qi^kb^g\bg`a^Z]Z\a^!l"ho^kma^ik^obous month
V
september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s In addition, the Patient-Specific Functional Scale is a questionnaire that can be used to quantify changes in activity limitations and participation restrictions for patients with neck pain.*/) This scale enables the clinician to collect measures related to function that may be different then the measures that are components of the regionspecific outcome measures section such as the Neck Dis-
ability Index. *02 Clinicians should utilize easily reproducible activity limitation and participation restriction measures associated with their patient’s neck pain to assess the changes in the patient’s level of function over the episode of care.
F
F>OI?97B?CF7?HC;DJC;7IKH;I Cervical Active Range of Motion ICF category
C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅceX_b_joe\i[l[hWb`e_dji
Description
J^[Wcekdje\WYj_l[d[YaÔ[n_ed"[nj[di_ed"hejWj_ed"WdZi_Z[X[dZ_d]cej_edc[Wikh[Zki_d]Wd_dYb_dec[j[h
Measurement method
7bbY[hl_YWbhWd][e\cej_ed HEC c[Wikh[iWh[f[h\ehc[Z_dj^[kfh_]^ji_jj_d]fei_j_ed$9Wh[i^ekbZX[jWa[dje[dikh[j^[ fWj_[djcW_djW_diWdkfh_]^ji_jj_d]fei_j_edj^hek]^ekjj^[[nWc_dWj_edWdZZkh_d]ikXi[gk[dj\ebbem#kf[nWc_dWj_edi$J^[ \ebbem_d]fheY[Zkh[iWh[ki[Zjec[Wikh[j^[HEC\ehj^[Y[hl_YWbif_d[$ D[Ya
Nature of variable
9edj_dkeki
Units of measurement
:[]h[[i
Measurement properties
9[hl_YWb HEC c[Wikh[c[dji \eh Ô[n_ed" [nj[di_ed" WdZ i_Z[X[dZ_d] ki_d] W XkXXb[ _dYb_dec[j[h ^Wl[ [n^_X_j[Z h[b_WX_b_jo Ye[øY_[djihWd]_d]\hec&$,,je&$.* ?99("' $)("'-+
Instrument variations
?dWZZ_j_edjeki_d]Wd_dYb_dec[j[h"+".)"'(."'.&Y[hl_YWbHECYWdWbieX[c[Wikh[Z\ehYb_d_YWbfkhfei[iki_d]WY[hl_YWbhWd][e\cej_ed 9HEC Z[l_Y['')"',+ehWjWf[c[Wikh[$7bbc[j^eZiWh[ceZ[hWj[boYehh[bWj[Zm_j^ceh[Z[Ód_j_l[hWZ_e]hWf^_YWdZ):a_d[cWj_Y c[Wikh[c[dj$*"+
Cervical And Thoracic Segmental Mobility ICF category
C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅceX_b_joe\i_d]b[`e_dji
Description
M_j^j^[fWj_[djfhed["Y[hl_YWbWdZj^ehWY_Yif_d[i[]c[djWbcel[c[djWdZfW_dh[ifedi[Wh[Wii[ii[Z
Measurement method
J^[fWj_[dj_ifhed[$J^[[nWc_d[hYedjWYji[WY^Y[hl_YWbif_dekifheY[iim_j^j^[j^kcXi$J^[bWj[hWbd[YackiYkbWjkh[_i][djbo fkbb[Zib_]^jbofeij[h_ehm_j^j^[Ód][hi$J^[[nWc_d[hi^ekbZX[Z_h[Yjboel[hj^[YedjWYjWh[Wa[[f_d][bXemi[nj[dZ[Z"j^[d^[% i^[ki[ij^[kff[hjhkdaje_cfWhjWfeij[h_ehjeWdj[h_eh\ehY[_dWfhe]h[ii_l[eiY_bbWjeho\Wi^_edel[hj^[if_dekifheY[ii$J^_i _ih[f[Wj[Z\eh[WY^Y[hl_YWbi[]c[dj$J^[[nWc_d[hj^[dY^Wd][i^_i%^[hYedjWYjfei_j_edWdZfbWY[ij^[^ofej^[dWh[c_d[dY[ `kijZ_ijWbjej^[f_i_\ehc e\ed[^WdZel[hj^[if_dekifheY[iie\[WY^j^ehWY_Yif_dekifheY[iiWdZh[f[Wjij^[iWc[feij[h_eh jeWdj[h_eh\ehY[i_dWfhe]h[ii_l[eiY_bbWjeho\Wi^_ed$J^[j[ijh[ikbj_iYedi_Z[h[ZjeX[fei_j_l[_\j^[fWj_[djh[fehjih[fheZkYj_ed e\fW_d$J^[ceX_b_joe\j^[i[]c[dj_i`kZ][ZjeX[dehcWb"^of[hceX_b["eh^ofeceX_b[$?dj[hfh[jWj_ede\ceX_b_jo_iXWi[Zedj^[ [nWc_d[hÊif[hY[fj_ede\j^[ceX_b_joWj[WY^if_dWbi[]c[djh[bWj_l[jej^ei[WXel[WdZX[bemj^[j[ij[Zi[]c[dj"WdZXWi[Zed j^[[nWc_d[hÊi[nf[h_[dY[WdZf[hY[fj_ede\dehcWbceX_b_jo$
Nature of variable
Dec_dWb fW_dh[ifedi[ WdZehZ_dWb ceX_b_jo`kZ]c[dj
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a15
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Cervical And Thoracic Segmental Mobility (continued) Units of measurement
None
Diagnostic accuracy and measurement properties
:_W]deij_Y7YYkhWYo'**0 FW_dZkh_d]i[]c[djWbj[ij_d]WiieY_Wj[Zm_j^h[fehjie\d[YafW_d$ I[di_j_l_jo3&$.(1d[]Wj_l[b_a[b_^eeZhWj_e #BH 3&$() If[Y_ÓY_jo3&$-/1fei_j_l[b_a[b_^eeZhWj_e !BH 3)$/ H[b_WX_b_jo\ehY[hl_YWbif_d[Wii[iic[dj0 AWffW3&$'*je&$)- fW_d ',/ ?993&$*(je&$-/ fW_d '' ?993&$-.je'$& fh[i[dY[e\`e_djZoi\kdYj_ed_dkff[h)Y[hl_YWbif_d[i[]c[dji '&& M[_]^j[ZaWffW0#&$(,je&$-* ceX_b_jo "#&$+(je&$/& fW_d )( H[b_WX_b_jo\ehj^ehWY_Yif_d[Wii[iic[dj0 M[_]^j[ZaWffW0&$')je&$.( ceX_b_jo "#&$''je&$/& fW_d )(
Cranial Cervical Flexion Test ICF category
C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅYedjhebe\i_cfb[lebkdjWhocel[c[djiWdZ[dZkhWdY[e\_iebWj[ZckiYb[i
Description
?dikf_d["j^[WX_b_joje_d_j_Wj[WdZcW_djW_d_iebWj[ZYhWd_WbWdZY[hl_YWbÔ[n_ed
Measurement method
FWj_[dj_ifei_j_ed[Zikf_d[_d^eeabo_d]WdZj^[^[WZWdZd[Ya_dc_Z#hWd][d[kjhWb _cW]_dWhob_d[X[jm[[d\eh[^[WZWdZY^_dWdZ _cW]_dWhob_d[X[jm[[dj^[jhW]kie\j^[[WhWdZj^[d[Yabed]_jkZ_dWbboi^ekbZX[fWhWbb[bje[WY^ej^[hWdZj^[ikh\WY[e\j^[ jh[Wjc[djjWXb[ $Jem[bicWoX[d[[Z[ZkdZ[hj^[eYY_fkjjeWY^_[l[j^_id[kjhWbfei_j_ed$7fd[kcWj_Yfh[iikh[Z[l_Y["ikY^WiW fh[iikh[X_e\[[ZXWYakd_j"_i_dÔWj[Zje(&cc>]jeÓbbj^[ifWY[X[jm[[dj^[Y[hl_YWbbehZej_YYkhl[WdZj^[ikh\WY[e\j^[jWXb[ X[^_dZj^[ikXeYY_f_jWbh[]_ed"dejX[bemj^[bem[hY[hl_YWbWh[W $ M^_b[a[[f_d]j^[feij[h_eh^[WZ%eYY_fkjijWj_edWho Zedejb_\j"Zedejfki^Zemd "j^[fWj_[djf[h\ehciYhWd_WbY[hl_YWbÔ[n_ed 99< _dW]hWZ[Z\Wi^_ed_d+_dYh[c[dji (("(*"(,"(."WdZ)&cc>] WdZW_cije^ebZ[WY^fei_j_ed\eh'&i[YedZi$J[di[YedZi h[ij_ifhel_Z[ZX[jm[[dijW][i$Jef[h\ehc99<"j^[fWj_[dj_i_dijhkYj[Zje][djbodeZj^[^[WZWij^ek]^j^[om[h[iWo_d]Ço[iÈ m_j^j^[kff[hd[Ya$J^_icej_edm_bbÔWjj[dj^[Y[hl_YWbbehZei_i"j^kiY^Wd]_d]j^[fh[iikh[_dj^[fd[kcWj_Yfh[iikh[Z[l_Y[$M^_b[ j^[fWj_[dj_if[h\ehc_d]j^[j[ijcel[c[dj"j^[j^[hWf_ijfWbfWj[ij^[d[Yajeced_jeh\ehkdmWdj[ZWYj_lWj_ede\j^[ikf[hÓY_Wb Y[hl_YWbckiYb[i"ikY^Wij^[ij[hdeYb[_ZecWije_Z$J^[fWj_[djYWdfbWY[^_i%^[hjed]k[edj^[hee\e\j^[cekj^"m_j^b_fije][j^[h Xkjj^[j[[j^ib_]^jboi[fWhWj[Z"je^[bfZ[Yh[Wi[fbWjoicWWdZ%eh^oe_ZWYj_lWj_ed$J^[j[ij_i]hWZ[ZWYYehZ_d]jej^[fh[iikh[b[l[b j^[fWj_[djYWdWY^_[l[m_j^YedY[djh_YYedjhWYj_ediWdZWYYkhWj[boikijW_d_iec[jh_YWbbo$J^[j[ij_ij[hc_dWj[Zm^[dj^[fh[iikh[ _iZ[Yh[Wi[ZXoceh[j^Wd(&ehm^[dj^[fWj_[djYWddejf[h\ehcj^[fhef[h99<cel[c[djm_j^ekjikXij_jkj_edijhWj[]_[i$ 7dehcWbh[ifedi[_i\ehj^[fh[iikh[je_dYh[Wi[jeX[jm[[d(,#)&cc>]WdZX[cW_djW_d[Z\eh'&i[YedZim_j^ekjkj_b_p_d] ikf[hÓY_WbY[hl_YWbckiYb[ikXij_jkj_edijhWj[]_[i$ 7dWXdehcWbh[ifedi[_im^[h[j^[fWj_[dj0 '$?ikdWXb[je][d[hWj[Wd_dYh[Wi[_dfh[iikh[e\Wjb[Wij,cc>]" ($?ikdWXb[je^ebZj^[][d[hWj[Zfh[iikh[\eh'&i[YedZi" )$Ki[iikf[hÓY_Wbd[YackiYb[ijeWYYecfb_i^j^[Y[hl_YWbÔ[n_edcej_ed"eh *$Ki[iWikZZ[dcel[c[dje\j^[Y^_dehfki^_d] [nj[dZ_d] j^[d[Ya\ehY[\kbboW]W_dijj^[fh[iikh[Z[l_Y[ IYeh_d]0 7Yj_lWj_edIYeh[0Fh[iikh[WY^_[l[ZWdZ^[bZ\eh'&i[YedZ F[h\ehcWdY[?dZ[n0?dYh[Wi[_dFh[iikh[dkcX[he\h[f[j_j_edi
Nature of variable
9edj_dkeki
Units of measurement
cc>]\ehj^[WYj_lWj_ediYeh[
Measurement properties
H[b_WX_b_joWii[iic[dj\eh+&WiocfjecWj_YikX`[Yji"j[ij[Zjm_Y[ 'm[[aWfWhj 07Yj_lWj_ediYeh[0?993&$.'1F[h\ehcWdY[?dZ[n0?993$/)/,
Neck Flexor Muscle Endurance Test
a16
ICF category
C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅ[dZkhWdY[e\_iebWj[ZckiYb[i
Description
?dikf_d["j^[WX_b_jojeb_\jj^[^[WZWdZd[YaW]W_dij]hWl_jo\ehWd[nj[dZ[Zf[h_eZ
|
september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Neck Flexor Muscle Endurance Test (continued) Measurement method
J^[j[ij_if[h\ehc[Z_dWikf_d["^eea#bo_d]fei_j_ed$M_j^j^[Y^_dcWn_cWbboh[jhWYj[ZWdZcW_djW_d[Z_iec[jh_YWbbo"j^[fWj_[dj b_\jij^[^[WZWdZd[Yakdj_bj^[^[WZ_iWffhen_cWj[bo($+Yc '_d WXel[j^[fb_dj^m^_b[a[[f_d]j^[Y^_dh[jhWYj[Zjej^[Y^[ij$ J^[Yb_d_Y_Wd\eYki[iedj^[ia_d\ebZiWbed]j^[fWj_[djÊid[YaWdZfbWY[iW^WdZedj^[jWXb[`kijX[bemj^[eYY_f_jWbXed[e\j^[ fWj_[djÊi^[WZ$L[hXWbYeccWdZi _["ÇJkYaoekhY^_dÈehÇ>ebZoekh^[WZkfÈ Wh[]_l[dm^[d[_j^[hj^[ia_d\ebZ i X[]_dije i[fWhWj[ehj^[fWj_[djÊieYY_fkjjekY^[ij^[Yb_d_Y_WdÊi^WdZ$J^[j[ij_ij[hc_dWj[Z_\j^[ia_d\ebZ i _ii[fWhWj[ZZk[jebeiie\ Y^_djkYaehj^[fWj_[djÊi^[WZjekY^[ij^[Yb_d_Y_WdÊi^WdZ\ehceh[j^Wd'i[YedZ$-+
Nature of variable
9edj_dkeki
Units of measurement
I[YedZi
Measurement properties
?dWijkZoXo>Whh_i[jWb"-+*'ikX`[Yjim_j^WdZm_j^ekjd[YafW_df[h\ehc[Zj^_ij[ij$JmehWj[hij[ij[ZWbbikX`[YjiWjXWi[b_d["WdZ ikX`[Yjim_j^ekjd[YafW_dm[h[j[ij[ZW]W_d'm[[abWj[h$ H[b_WX_b_jo0 IkX`[Yjim_j^ekjd[YafW_d0 ?99 )"' 3&$.(je&$/'"I;C.$&#''$&i[YedZi ?99 ("' 3&$,-je&$-."I;C'($,#'+$)i[YedZi IkX`[Yjim_j^d[YafW_d0 ?99 ("' 3&$,-"I;C''$+i[YedZi J[ijh[ikbji0 IkX`[Yjim_j^ekjd[YafW_d0C[Wd).$/+i[YedZi I:3(,$* IkX`[Yjim_j^d[YafW_d0C[Wd(*$'i[YedZi I:3'($.
Upper Limb Tension Test ICF category
C[Wikh[c[dje\_cfW_hc[dje\ijhkYjkh[e\j^[d[hlekiioij[c"ej^[hif[Y_Ó[Z
Description
?dded#m[_]^jX[Wh_d]"j^[Wcekdje\ceX_b_joe\j^[d[khWb[b[c[djie\j^[kff[hb_cXWh[Wii[ii[Zm^_b[Z[j[hc_d_d]m^[j^[hj^[ fWj_[djÊikff[hgkWhj[hiocfjeciWh[[b_Y_j[ZZkh_d]f[h\ehcWdY[e\j^[j[ij
Measurement method
Kff[hb_cXj[di_edj[ijiWh[f[h\ehc[Zm_j^j^[fWj_[djikf_d[$:kh_d]f[h\ehcWdY[e\j^[kff[hb_cXj[di_edj[ijj^WjfbWY[iW X_Wi jemWhZ j[ij_d] j^[ fWj_[djÊi h[ifedi[ je j[di_ed fbWY[Z ed j^[ c[Z_Wd d[hl[" j^[ [nWc_d[h i[gk[dj_Wbbo _djheZkY[i j^[ \ebbem_d]cel[c[djijej^[iocfjecWj_Ykff[h[njh[c_jo0 IYWfkbWhZ[fh[ii_ed I^ekbZ[hWXZkYj_edjeWXekj/&m_j^j^[[bXemÔ[n[Z <eh[Whcikf_dWj_ed"mh_ijWdZÓd][h[nj[di_ed I^ekbZ[hbWj[hWbhejWj_ed ;bXem[nj[di_ed 9edjhWbWj[hWbj^[d_fi_bWj[hWbY[hl_YWbi_Z[#X[dZ_d] 7fei_j_l[j[ijeYYkhim^[dWdoe\j^[\ebbem_d]ÓdZ_d]iWh[fh[i[dj0 '$h[fheZkYj_ede\WbbehfWhje\j^[fWj_[djÊiiocfjeci ($i_Z[#je#i_Z[Z_÷[h[dY[ie\]h[Wj[hj^Wd'&e\[bXem[nj[di_edehmh_ij[nj[di_ed )$edj^[iocfjecWj_Yi_Z["YedjhWbWj[hWbY[hl_YWbi_Z[#X[dZ_d]_dYh[Wi[ij^[fWj_[djÊiiocfjeci"eh_fi_bWj[hWbi_Z[#X[dZ_d] Z[Yh[Wi[ij^[fWj_[djÊiiocfjeci
Nature of variable
Dec_dWb
Units of measurement
None
Diagnostic accuracy indices for the upper limb tension test, based on the study by Wainner et al175
AWffW I[di_j_l_jo If[Y_ÓY_jo Fei_j_l[b_a[b_^eeZhWj_e D[]Wj_l[b_a[b_^eeZhWj_e
&$-, &$/- &$(( '$)& &$'(
/+9edÓZ[dY[?dj[hlWb &$+'#'$& &$/&#'$& &$'(#&$)) '$'&#'$+ &$&'#'$/
Spurling’s Test ICF category
C[Wikh[c[dje\_cfW_hc[dje\ijhkYjkh[e\j^[d[hlekiioij[c"ej^[hif[Y_Ó[Z
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a17
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Spurling’s Test (continued) Description
9ecX_dWj_ede\i_Z[X[dZ_d]jej^[iocfjecWj_Yi_Z[Yekfb[Zm_j^Yecfh[ii_edjeh[ZkY[j^[Z_Wc[j[he\j^[d[khWb\ehWc[dWdZ [b_Y_jj^[fWj_[djÊiiocfjeci
Measurement method
J^[fWj_[dj_ii[Wj[ZWdZ_iWia[Zjei_Z[X[dZWdZib_]^jbohejWj[j^[^[WZjej^[fW_d\kbi_Z[$J^[[nWc_d[hfbWY[iWYecfh[ii_ed\ehY[ e\Wffhen_cWj[bo-a]j^hek]^j^[jefe\j^[^[WZ_dWd[÷ehjje\khj^[hdWhhemj^[_dj[hl[hj[XhWb\ehWc[d$J^[j[ij_iYedi_Z[h[Zfei_j_l[ m^[d_jh[fheZkY[ij^[fWj_[djÊiiocfjeci$J^[j[ij_idej_dZ_YWj[Z_\j^[fWj_[dj^Widekff[h[njh[c_joehiYWfkbWhh[]_ediocfjeci$
Nature of variable
Dec_dWb%Z_Y^ejeceki
Units of measurement
None
Diagnostic accuracy indices for Spurling’s test, based on the study by Wainner et al175
AWffW I[di_j_l_jo If[Y_ÓY_jo Fei_j_l[b_a[b_^eeZhWj_e D[]Wj_l[b_a[b_^eeZhWj_e
&$,& &$+& &$., )$+& &$+.
/+9edÓZ[dY[?dj[hlWb &$)(#&$.&$(-#&$-) &$--#&$/* '$,&#-$+& &$),#&$/*
D istraction Test ICF category
C[Wikh[c[dje\_cfW_hc[dje\ijhkYjkh[e\j^[d[hlekiioij[c"ej^[hif[Y_Ó[Z
Description
:_ijhWYj_ede\j^[Y[hl_YWbif_d[jecWn_c_p[j^[Z_Wc[j[he\j^[d[khWb\ehWc[dWdZh[ZkY[eh[b_c_dWj[j^[fWj_[djÊiiocfjeci
Measurement method
J^[Z_ijhWYj_edj[ij_iki[Zje_Z[dj_\oY[hl_YWbhWZ_YkbefWj^oWdZ_if[h\ehc[Zm_j^j^[fWj_[djikf_d[$J^[[nWc_d[h]hWifikdZ[h j^[ Y^_d WdZ eYY_fkj" Ô[n[i j^[ fWj_[djÊi d[Ya je W fei_j_ed e\ Yec\ehj" WdZ ]hWZkWbbo Wffb_[i W Z_ijhWYj_ed \ehY[ e\ kf je Wffhen_cWj[bo'*a]$7fei_j_l[j[ijeYYkhim_j^j^[h[ZkYj_edeh[b_c_dWj_ede\j^[fWj_[djÊikff[h[njh[c_joehiYWfkbWhiocfjeci$ J^_ij[ij_idej_dZ_YWj[Z_\j^[fWj_[dj^Widekff[h[njh[c_joehiYWfkbWhh[]_ediocfjeci$
Nature of variable
Dec_dWb
Units of measurement
None
Diagnostic accuracy indices for the upper limb tension test, based on the study by Wainner et al175
AWffW I[di_j_l_jo If[Y_ÓY_jo Fei_j_l[b_a[b_^eeZhWj_e D[]Wj_l[b_a[b_^eeZhWj_e
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Valsalva Test ICF category
C[Wikh[c[dje\_cfW_hc[dje\ijhkYjkh[e\j^[d[hlekiioij[c"ej^[hif[Y_Ó[Z
Description
CWd[kl[h_dm^_Y^j^[fWj_[djX[WhiZemdm_j^ekj[n^Wb_d]je_dYh[Wi[_djhWj^[YWbfh[iikh[WdZ[b_Y_jkff[hgkWhj[hiocfjeci
Measurement method
J^[fWj_[dj_ii[Wj[ZWdZ_dijhkYj[ZjejWa[WZ[[fXh[Wj^WdZ^ebZ_jm^_b[Wjj[cfj_d]je[n^Wb[\eh(#)i[YedZi$7fei_j_l[ h[ifedi[eYYkhim_j^h[fheZkYj_ede\iocfjeci$
Nature of variable
Dec_dWb%Z_Y^ejeceki
Units of measurement
None
Diagnostic accuracy indices for the valsalva test, based on the study by Wainner et al175
a18
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AWffW I[di_j_l_jo If[Y_ÓY_jo Fei_j_l[b_a[b_^eeZhWj_e D[]Wj_l[b_a[b_^eeZhWj_e
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
CLINICAL GUIDELINES
Interventions A variety of interventions have been described for the treatment of neck pain and there is good evidence from highquality randomized, controlled trials and systematic reviews to support the benefits of physical therapy intervention in these patients.
CERVICAL MOBILIZATION/MANIPULATION The most recent Cochrane Collaboration Review69 of mobilization and manipulation for mechanical neck disorders included 33 randomized controlled trials of which 42% were considered high quality. They concluded that the most beneficial manipulative interventions for patients with mechanical neck pain with or without headaches should be combined with exercise to reduce pain and improve patient satisfaction. Manipulation (thrust) and mobilization (non-thrust manipulation) intervention alone were determined to be less effective than when combined with exercise (combined intervention).69 A recently published clinical practice guideline concluded that the evidence for combined intervention was relatively strong, while the evidence for the effectiveness of thrust or non-thrust manipulation in isolation was weaker.68
I
The recommendations of the Cochrane Review69 and the recently published clinical practice guideline68 were based on key findings that warrant further discussion. Studies cited included patients with both acute82and chronic neck pain22 and interventions consisted of soft-tissue mobilization and manual stretching procedures, as well as thrust,17,83 and nonthrust manipulative procedures82 directed at spinal motion segments. Number of visits ranged from 6 over a 3 week period82 to 20 over an 11 week period22 and the duration of sessions ranged from 30 minutes99 to 60 minutes.22 Combined intervention was compared with various competing interventions that included manipulation alone,22,99 various non-manual physical therapy interventions,82 high-tech and low-tech exercises,22,82,99 general practitioner care (medication, advice, education),82 and no treatment.99 The majority of studies report either clinically or statistically important differences in pain in favor of combined intervention when compared to competing single interventions.69 Differences in muscle performance22,99 as well as patient satisfaction have also been reported for both short-term22,82,99 as well as longterm outcomes 122 and 2 years later.58 When compared to care
rendered by a general practitioner and non-manual physical therapy interventions, the combination of manipulation and exercise resulted in significant cost-savings of up to 68%.106 Although many patients experience a significant benefit when treated with thrust manipulation, it is still unclear which patients benefit most. Tseng et al166 reported 6 predictors for patients who experienced an immediate improvement in either pain, satisfaction, or perception of condition following manipulation of the cervical spine. These predictors included166: BgbmbZel\hk^lhgG^\d=blZ[bebmrBg]^qe^llmaZg**'. AZobg`[beZm^kZebgoheo^f^gmiZmm^kg Ghm i^k_hkfbg` l^]^gmZkr phkd fhk^ maZg . ahnkl i^k day ?^^ebg`[^mm^kpabe^fhobg`ma^g^\d =b]ghm_^^ephkl^pabe^^qm^g]bg`ma^g^\d Ma^]bZ`ghlblh_lihg]rehlblpbmahnmkZ]b\nehiZmar
II
The presence of 4 or more of these predictors increased the probability of success with manipulation from 60% to 89%.166 Predictors of which patients respond best to combined intervention have not been reported. Nilsson et al125 conducted a randomized, clinical trial (n=53) in individuals with cervicogenic headache. Subjects were randomized to receive high velocity low amplitude spinal manipulation or low level laser and deep friction massage. The use of analgesics were reduced by 36% in the manipulation group but were unchanged in the laser/massage group. The number of headache hours per day decreased by 69% for the individuals in the manipulation `khniZg],0 bgma^eZl^k(fZllZ`^`khni'A^Z]Z\a^bgm^gsity per episode decreased by 36% for those in the manipulation group and 17% in the laser/massage group.
I
A systematic review by Vernon et al,171 which included studies published through 2005, concluded that there is moderate- to high-quality evidence that subjects with chronic neck pain and headaches show clinically important improvements from a course of spinal mobilization or manipulation at 6, 12, and up to 104 weeks post-treatment.
II
Despite good evidence to support the benefits of cervical mobilization/manipulation, it is important that physical
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a19
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s therapists be aware of the potential risks in using these techniques./1%/2 However, it is impossible to determine the precise risk because (1) it is extremely difficult to quantify the number of cervical spine mobilization/manipulative interventions performed each year, and (2) not all adverse events occurring after mobilization/manipulation interventions are published in the peer-reviewed literature, and there is no accepted standard for reporting these injuries. Reported risk factors include hypertension, migraines, oral contraceptive use, and smoking.0+ However, the prevalence of these factors in the study by Haldeman et al0+ is largely the same or lower than that which occurs in the general population. Although the true risk for complications remains unknown, ma^kbld_hkl^kbhnl\hfieb\Zmbhglbl^lmbfZm^]mh[^/bg*) fbeebhg!)'))))/ "fZgbineZmbhgl%pbmama^kbldh_]^Zma[^ing 3 in 10 million (0.000003%). Importantly, these rates are adjusted assuming that only 1 in 10 complications is actually reported in the literature.1- Gross et al0) recently reported, in a clinical practice guideline on the use of mobilization/ manipulation in patients with mechanical neck pain, that estimates for serious complication for manipulation ranged _khf*bg+)%)))!)')* "mh.bg*)fbeebhg!)'))). "'0) The risk estimate for patients experiencing non-serious side effects such as increased symptoms, ranges from 1% to 2%.149 The most common side effects included local discom_hkm!., "%eh\Zea^Z]Z\a^!*+ "%_Zmb`n^!** "%hkkZ]bZmbg` ]bl\hf_hkm!*) "'IZmb^gml\aZkZ\m^kbs^]1. h_ma^l^\hfieZbgmlZlfbe]hkfh]^kZm^%pbma/- h_lb]^^ü^\mlZii^Zking within 4 hours after manipulation. Within 24 hours after fZgbineZmbhg%0- h_ma^\hfieZbgmlaZ]k^lheo^]'E^llmaZg . h_lb]^^ü^\mlp^k^\aZkZ\m^kbs^]Zl]bssbg^ll%gZnl^Z%ahm skin, or other complaints. Side effects were rarely still noted on the day after manipulation, and very few patients reported the side effects as being severe. Due the potential risk of serious adverse effects associated with cervical manipulation, such as vertebrobasilar artery stroke,./ it has been recommended that non-thrust cervical mobilization/manipulation be utilized in favor of thrust manipulation..)%1. However, information regarding the risk/ benefit ratio of providing cervical thrust manipulation to patients with impairments of body function purported to benefit from cervical mobilization/manipulation, such as cervical segmental mobility deficits, has not been reported. In addition, the case reports in the literature describing serious adverse effects associated with cervical thrust manipulation do not provide information regarding either the presence of bfiZbkf^gmlh_[h]r_ng\mbhgl%hkma^ik^l^g\^h_k^]×Z`l for vertebrobasilar insufficiency,0 prior to the application of the manipulative procedure suspected to be linked with the reported harmful effects. a20
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Recommendation: Clinicians should consider utilizing cervical manipulation and mobilization procedures, thrust and non-thrust, to reduce neck pain and headache. Combining cervical manipulation and mobilization with exercise is more effective for reducing neck pain, headache, and disability than manipulation and mobilization alone.
A
T>EH79?9CE8?B?P7J?ED%C7D?FKB7J?ED A survey among clinicians that practice manual physical therapy reported that the thoracic spine is the region of the spine most often manipulated, despite the fact that more patients complain of neck pain.1 While several randomized clinical trials have examined the effectiveness of thoracic libg^ maknlm fZgbineZmbhg !MLF" _hk iZmb^gml pbma g^\d pain, patients in these studies also received cervical manipulation.+%++%.0 The rationale to include thoracic spine mobilization/manipulation in the treatment of patients with neck pain stems from the theory that disturbances in joint mobility in the thoracic spine may be an underlying contributor to musculoskeletal disorders in the neck. 2-%*). Cleland et al34\hfiZk^]ma^^ü^\mbo^g^llh_MLFbg a trial in which patients were randomized to either a lbg`e^l^llbhgh_MLFhklaZffZgbineZmbhg'IZmb^gml pahk^\^bo^]MLF^qi^kb^g\^]Z\ebgb\Zeerf^Zgbg`_neZg]lmZtistically significant reduction in pain on the visual analogue scale (VAS) compared to patients who received the sham intervention (P .001).34 A similar finding (reduction of pain) was Zelhk^ihkm^]bgZkZg]hfbs^]mkbZemaZm\hfiZk^]MLFbgm^kvention to an active exercise program.*-0 A subsequent randomized trial by Cleland et al,1pab\a\hfiZk^]MLFmhghg&maknlm manipulation (mobilization) found significant differences in faohkh_ma^MLF`khnibgiZbg%]blZ[bebmr%Zg]iZmb^gmi^k\^bo^] bfikho^f^gmnihgk^&^oZenZmbhg-1ahnkleZm^k'
I
While preliminary reports indicate that patients with complaints of primary neck pain experience a lb`gbÖ\Zgm[^g^Ömpa^gmk^Zm^]pbmaMLF%bmbllmbee unclear which patients benefit most. Cleland et al33 reported a preliminary clinical prediction rule for patients with primary neck pain who experience short-term improvement (1-week) pbmaMLF'>Z\aln[c^\mk^\^bo^]ZmhmZeh_,mahkZ\b\fZgbinlations directed at the upper and middle thoracic spine for up mh+l^llbhgl'Nlbg`Z`eh[ZekZmbg`h_\aZg`^l\hk^l.ZlZ k^_^k^g\^\kbm^kbhg%/oZkbZ[e^lp^k^k^ihkm^]Zlik^]b\mhklh_ improvement and included33: Lrfimhf]nkZmbhgh_e^llmaZg,)]Zrl Ghlrfimhfl]blmZemhma^lahne]^k Ln[c^\m k^ihkml maZm ehhdbg` ni ]h^l ghm Z``kZoZm^ symptoms ?^Zk&Zohb]Zg\^ ;^eb^_l Jn^lmbhggZbk^&Iarlb\Ze :\mbobmr Scale score less than 12
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s =bfbgbla^]nii^kmahkZ\b\libg^driahlbl!M,ÈM." <^kob\Ze^qm^glbhgh_e^llmaZg,) Interestingly, the lack of symptom aggravation with looking up was also one of the predictors reported by Tseng et al*// in the cervical manipulation clinical prediction rule. Validation h_[hmama^\^kob\ZeZg]MLF\ebgb\Zekne^lblk^jnbk^][^_hk^ they can be recommended for widespread clinical use. In a randomized clinical trial Fernández de las Peñas et al.2 demonstrated that patients with neck pain related to a whiplash-associated disorder receiobg` MLF ^qi^kb^g\^] Z lb`gbÖ\Zgmer `k^Zm^k !I5'))," reduction in pain as measured by the visual analogue scale, than those who did not receive the thoracic manipulation. Ma^f^Zg\aZg`^bgiZbge^o^elbgma^`khnik^\^bobg`MLF pZl.-'*ff!L=*1'1ff"\hfiZk^]mhZf^Zg\aZg`^h_ *,'-ff!L=1'2ff"bgma^`khnighmk^\^bobg`mahkZ\b\fZnipulation. The length of follow-up was not clearly defined.
I
Self-reported levels of pain and cervical active KHFp^k^Zll^ll^][^_hk^Zg]bff^]bZm^erZ_m^k MLF bg +/ iZmb^gml pbma Z ikbfZkr \hfieZbgm h_ neck pain. The mean reduction in pain on an 11-point numeric pain rating scale was approximately 2 points (P .01), which has been shown to indicate that a clinically meaningful improvement has occurred. Significant increases in cervical Z\mbo^KHFp^k^Zelhh[l^ko^]bgZee]bk^\mbhgl^q\^im^qm^glbhg!I5'))*"'Mabllmn]r]b]ghmbg\en]^Z\hgmkhe`khniZg] only consisted of an immediate follow-up, but the immediate bfikho^f^gmlbgiZbgZg]\^kob\ZeZ\mbo^KHFln``^lmmaZm MLFfZraZo^lhf^f^kbmbgiZmb^gmlpbmag^\diZbg'/*
IV
There have been 4 case series that have incorporated thoracic spine thrust manipulation in the multi-modal management of patients with cervical radiculopathy.+,%,2%*+)%*0/ In the first case series,39 10 of the 11 patients (91%) demonstrated a clinically meaningful imikho^f^gm bg iZbg Zg] _ng\mbhg Zm ma^ /&fhgma _heehp&ni Z_m^kZf^Zgh_0'*iarlb\Zema^kZiroblbml'Bgma^l^\hg]\Zl^ series*0/ all patients except for 1 exhibited a significant reduction in disability. In the third case series,120 full resolution of iZbgpZlk^ihkm^]bg1h_*.!., "iZmb^gml%pa^k^Zee/h_ma^ patients receiving mobilization and manipulation achieved full resolution of pain. In addition, there has been 1 case series23 that included thoracic spine thrust manipulation in the fZgZ`^f^gmh_0iZmb^gmlpbma`kZ]^B\^kob\Ze\hfik^llbo^ myelopathy. All patients exhibited a reduction in pain and improvement in function at the time of discharge.
IV
C
Recommendation: Thoracic spine thrust manipulation can be used for patients with primary complaints of neck pain. Thoracic spine thrust ma-
nipulation can also be used for reducing pain and disability in patients with neck and neck-related arm pain.
IJH;J9>?D=;N;H9?I;I In a randomized controlled trial, Ylinen et al*1, assessed the effectiveness of manual therapy procedures implemented twice a week compared pbmaZlmk^m\abg`k^`bf^gi^k_hkf^].mbf^lZp^^dbgmahl^ with non-specific neck pain. At the 4 and 12 week follow-up both groups improved but there were no significant differences between the groups related to pain. Neck pain and disability outcome measures, shoulder pain and disability outcome measures, and neck stiffness were reduced significantly more in those receiving manual therapy, but the clinical difference was minimal. The authors concluded that the low-cost of stretching exercises should be included in the initial treatment plan for patients with neck pain.
I
The authors of this clinical practice guideline have observed that patients with neck pain often pres^gmpbmabfiZbkf^gmlh_×^qb[bebmrh_d^rfnl\e^l related to the lower cervical and upper thoracic spine, such as the anterior, medial, and posterior scalenes, upper trapezius, levator scapulae, pectoralis minor, and pectoralis major, that should be addressed with stretching exercises. One study k^ihkm^]maZmnii^kjnZkm^kfnl\e^×^qb[bebmr]^Ö\bmlp^k^ common in dental hygienists,2. an occupation that requires frequent repetitive activities involving the shoulders, arms, and hands. Although research generally does not support the effectiveness of interventions that focus on stretching and ×^qb[bebmr%\ebgb\Ze^qi^kb^g\^ln``^lmlmaZmZ]]k^llbg`li^cific impairments of muscle length for an individual patient may be a beneficial addition to a comprehensive treatment program.
V
Recommendation: Flexibility exercises can be used for patients with neck symptoms. Examination and mZk`^m^]×^qb[bebmr^q^k\bl^l_hkma^_heehpbg`fnlcles are suggested: anterior/medial/posterior scalenes, upper trapezius, levator scapulae, pectoralis minor, and pectoralis major.
C
9EEH:?D7J?ED"IJH;D=J>;D?D="7D:;D:KH7D9; ;N;H9?I;I Jull et al99 conducted a multi-centered, randomized clinical trial (n=200) in participants who met the diagnostic criteria for cervicogenic headache. The inclusion criteria were unilateral or unilateral dominant side-consistent headache associated with neck pain and aggravated by neck postures or movement, joint tenderness in at least 1 of the upper 3 cervical joints as detected by
I
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a21
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s manual palpation, and a headache frequency of at least 1 per week over a period of 2 months to 10 years. Subjects were randomized into 4 groups: mobilization/manipulation group, exercise therapy group, combined mobilization/manipulation and exercise group, and a control group. The primary outcome was a change in headache frequency. At the 12-month follow-up, the mobilization/manipulation, combined mobilization/manipulation and exercise, and the specific exercise groups had significantly reduced headache frequency and intensity. Additionally 10% more patients experienced a complete reduction in headache frequency when treated with mobilization/manipulation and exercise than those treated with the alternative approaches. 99 Ma^^q^k\bl^ikh`kZfbgmabl\ebgb\ZemkbZe[rCnee^mZe99 used low load endurance exercises to train muscle control of the cervicoscapular region. The first stage consisted of specific \kZgbh\^kob\Ze ×^qbhg ^q^k\bl^l% i^k_hkf^] bg lnibg^ erbg`% Zbf^]mhmZk`^mma^]^^ig^\d×^qhkfnl\e^l%pab\aZk^ma^ longus capitis and longus colli. Subsequently, isometric exercises using a low level of rotatory resistance were used to train ma^\h&\hgmkZ\mbhgh_ma^g^\d×^qhklZg]^qm^glhkl'Ma^^qercise groups had significantly reduced headache frequency and intensity when compared to the controls. Chiu et al+1 assessed the benefits of an exercise program that focused both on motor control training of ma^]^^ig^\d×^qhklZg]]rgZfb\lmk^g`ma^gbg`': mhmZeh_*-.iZmb^gmlpbma\akhgb\g^\diZbgp^k^kZg]hfbs^] to either an exercise or a non-exercise control group. At week /%ma^^q^k\bl^`khniaZ]lb`gbÖ\Zgmer[^mm^kbfikho^f^gml in disability scores, pain levels, and isometric neck muscle strength. However, significant differences between the 2 groups were found only in pain and patient satisfaction at ma^/&fhgma_heehp&ni'
I
BgZkZg]hfbs^]%\ebgb\ZemkbZe%Rebg^g^mZe*1- demonstrated the effectiveness of both strengthening exercises and endurance training of the deep neck ×^qhkfnl\e^lbgk^]n\bg`iZbgZg]]blZ[bebmrZmma^*&r^Zk _heehp&nibgphf^g!g6*1)"pbma\akhgb\%ghgli^\bÖ\g^\d pain. The endurance training group performed dynamic neck exercises, which included lifting the head up from the supine and prone positions. The strength training group performed high-intensity isometric neck strengthening and stabilization exercises with an elastic band. Both training groups performed dynamic exercises for the shoulders and upper extremities with dumbbells. Both groups were advised to also do aerobic and stretching exercises 3 times a week. In a ,&r^Zk_heehp&nilmn]r%Rebg^g^mZe*1+ found that women (n = **1"bg[hmama^lmk^g`ma^gbg`^q^k\bl^Zg]^g]nkZg\^mkZbging groups achieved long-term benefits from the 12-month programs.
I
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HÍE^Zkr ^m Ze*+0 compared the effect of 2 specific \^kob\Ze ×^qhk fnl\e^ ^q^k\bl^ ikhmh\hel hg bfmediate pain relief in the cervical spine of people with chronic neck pain. They found that those performing ma^ li^\bÖ\ \kZgbh\^kob\Ze ×^qbhg ^q^k\bl^ ]^fhglmkZm^] greater improvements in pressure pain thresholds, mechanical hyperalgesia, and perceived pain relief during active movement.
III
In a cross-sectional comparative study, Chiu et al29 compared the performance of the deep cervical ×^qhkfnl\e^lhgma^\kZgbh\^kob\Ze×^qbhgm^lmbg individuals with (n = 20) and without (n = 20) chronic neck pain. Those with chronic neck pain had significantly poorer i^k_hkfZg\^hgma^\kZgbh\^kob\Ze×^qbhgm^lm!f^]bZgik^lsure achieved, 24 mmHg when starting at 20 mmHg) when compared with those in the asymptomatic group (median ik^llnk^Z\ab^o^]%+1ffA`pa^glmZkmbg`Zm+)ffA`"'
III
Cnee ^m Ze20 compared the effects of conventional ikhikbh\^imbo^mkZbgbg`Zg]\kZgbh\^kob\Ze×^qbhg training on cervical joint position error in people with persistent neck pain. The aim was to evaluate whether proprioceptive training was superior in improving proprioceptive acuity compared to a form of exercise that has been shown to be effective in reducing neck pain. Sixty-four female subjects with persistent neck pain and deficits in cervical joint position error were randomized into 2 exercise groups: ikhikbh\^imbo^ mkZbgbg` hk \kZgbh\^kob\Ze ×^qbhg mkZbgbg`' >q^k\bl^ k^`bf^gl p^k^ \hg]n\m^] ho^k Z /&p^^d i^kbh]' The results demonstrated that both proprioceptive training Zg]\kZgbh\^kob\Ze×^qbhgmkZbgbg`aZo^Z]^fhglmkZ[e^[^gefit on impaired cervical joint position error in people with neck pain, with marginally more benefit gained from proprioceptive training. The results suggest that improved proprioceptive acuity following intervention with either exercise protocol may occur through an improved quality of cervical afferent input or by addressing input through direct training of relocation sense.20
I
In a randomized, clinical trial, Taimela et al*/+ compared the efficacy of a multimodal treatment emphasizing proprioceptive training in patients with ghg&li^\bÖ\\akhgb\g^\diZbg!g60/"'Ma^ikhikbh\^imbo^ treatment, which consisted of exercises, relaxation, and behavioral support was more efficacious than comparison interventions that consisted of (1) attending a lecture on the neck and 2 sessions of practical training for a home exercise program, and (2) a lecture regarding care of the neck with a recommendation to exercise. Specifically, the proprioceptive treatment group had greater reductions in neck symptoms, improvements in general health, and improvements in the ability to work.
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s In a randomized clinical trial, Viljanen et al*0, assessed the effectiveness of dynamic muscle training !g6*,."%k^eZqZmbhgmkZbgbg`!g6*+1"%hkhk]bgZkr Z\mbobmr!g6*,."_hk_^fZe^hú\^phkd^klpbma\akhgb\g^\d pain. Dynamic muscle training and relaxation training did not lead to better improvements in neck pain compared with ordinary activity.
I
In a randomized clinical trial, Bronfort et al22 found that a combined program of strengthening and endurance exercises combined with manual therapy resulted in greater gains in strength, endurance, range of motion, and long-term patient pain ratings in those with chronic neck pain than programs that only incorporated manual therapy. Additionally, Evans et al.1 found that these results were maintained at a 2-year follow-up.
I
In a prospective case series, Nelson et al124 followed patients with cervical and lumbar pain and found that an aggressive strengthening program was able mhik^o^gmlnk`^krbg,.h_ma^/)iZmb^gml!-/h_ma^/)\hfie^m^]ma^ikh`kZf%,1p^k^ZoZbeZ[e^_hk_heehp&ni%Zg]hger 3 reported having surgery). Despite the methodological limitations of this study, some patients that were originally given the option of surgery were able to successfully avoid surgery in the short term following participation in an aggressive strengthening exercise program.
IV
In a systematic review of 9 randomized clinical triZelZg]0\hfiZkZmbo^mkbZelpbmafh]^kZm^f^mah]ological quality for patients with mechanical neck disorders, Sarig-Bahat*-. reported relatively strong evidence supporting the effectiveness of proprioceptive exercises and dynamic resisted strengthening exercises of the neck-shoulder musculature for patients with chronic or frequent neck disorders. The evidence identified could not support the effectiveness of group exercise, neck schools, or single sessions of extension-retraction exercises.
II
In a randomized clinical trial, Chiu et al30 found bgiZmb^gmlpbma\akhgb\g^\diZbg!g6+*1"%maZm Z /&p^^d mk^Zmf^gm h_ mkZgl\nmZg^hnl ^e^\mkbcal nerve stimulation or exercise had a better and clinically relevant improvement in disability, isometric neck muscle strength, and pain compared to a control group. All the improvements in the intervention groups were maintained at ma^/&fhgma_heehp&ni'
I
Hammill et al0- used a combination of postural education, stretching, and strengthening exercises to reduce the frequency of headaches and improve disability in a series of 20 patients, with results being maintained at a 12-month follow-up.
IV
BgZlrlm^fZmb\k^ob^p%DZr^mZe103 concluded that specific exercises may be effective for the treatment of acute and chronic mechanical neck pain, with or without headache.
I
A recent Cochrane review/2 concluded that mobilization and/or manipulation when used with exercise are beneficial for patients with persistent mechanical neck disorders with or without headache. However, manual therapy without exercise or exercise alone were not superior to one another.
I
Although evidence is generally lacking, postural correction and body mechanics education and training may also be indicated if clinicians identify ergonomic inefficiencies during either the examination or treatment of patients with motor control, movement coordination, muscle power, or endurance impairments.
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A
Recommendation: Clinicians should consider the use of coordination, strengthening, and endurance exercises to reduce neck pain and headache.
9;DJH7B?P7J?EDFHE9;:KH;I7D:;N;H9?I;I Kjellman and colleagues104 randomly assigned 00iZmb^gmlpbmag^\diZbg!+2h_pab\aik^l^gm^] with cervical radiculopathy) to general exercise, F\D^gsb^f^mah]h_^qZfbgZmbhgZg]mk^Zmf^gm%hkZ\hgmkhe `khni!ehpbgm^glbmrnemkZlhng]Zg]^]n\Zmbhg"'Ma^F\D^gzie method of treatment consists of patient positioning, specific repeated movements, manual procedures, and patient education in self management in case of recurrence.*)-%**1 The k^i^Zm^]li^\bÖ\fho^f^gmlpbmama^F\D^gsb^f^mah]bgtend to centralize (promote the migration of symptoms from an area more distal to location more proximal) or reduce pain.**1 At the 12 month follow-up all groups showed significant reductions in pain intensity and disability but no significant difference between groups existed. Seventy-nine percent of patients reported that they were better or completely relmhk^]Z_m^kmk^Zmf^gm%Zemahn`a.* k^ihkm^]\hglmZgm(]Zber pain. All 3 groups had similar recurrence rates.
I
Fnkiar^mZe122bg\hkihkZm^]F\D^gsb^ikh\^]nk^l to promote centralization in the management of a cohort of 31 patients with cervical radiculopathy. These patients also received cervical manipulation or muscle energy techniques and neural mobilization. Seventy-seven percent of patients at the short-term follow-up and 93% of patients at the long-term follow-up exhibited a clinically important improvement in disability. However, specific details regarding the number of patients receiving procedures to promote centralization was not reported.
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journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a23
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s There has not been a clinical trial that recruited patients with only cervical radiculopathy. Therefore, it is not possible to \hff^gmhgma^^ú\Z\rh_ma^F\D^gsb^f^mah]hkma^nl^ of centralization procedures and exercises for this particular subgroup of patients.31
Recommendation: Clinicians should consider the use of upper quarter and nerve mobilization procedures to reduce pain and disability in patients with neck and arm pain.
Recommendation: Specific repeated movements or procedures to promote centralization are not more beneficial in reducing disability when compared to other forms of interventions.
JH79J?ED
KFF;HGK7HJ;H7D:D;HL;CE8?B?P7J?ED FHE9;:KH;I
MZ`ab Ch`aZmZ^b ^m Ze93 randomly assigned 30 patients to receive a treatment program consisting of ultrasound and exercise with or without mechanical intermittent cervical traction for 10 sessions. The group receiving traction exhibited greater improvements bg`kbilmk^g`ma%ma^ikbfZkrhnm\hf^f^Zlnk^%Z_m^k.l^lsions. However, no statistically significant difference between groups existed at the time of discharge from physical therapy.93
C
Allison et al2 examined the effectiveness of 2 different manual therapy techniques (neural mobilization and cervical/upper quadrant mobilization) in the management of cervico-brachial syndrome. :eeiZmb^gmlk^\^bo^]mk^Zmf^gm_hk1p^^dlbgZ]]bmbhgmh a home exercise program. The results demonstrated that both manual therapy groups exhibited improvements in pain and function. At the final data collection there existed no difference between the manual therapy groups for function but a significant difference between groups for reduction in pain was identified in favor of the neural mobilization group.
II
In a randomized clinical trial, Coppieters et al41 assigned 20 patients with cervico-brachial pain to receive either cervical mobilization with the upper extremity in an upper limb neurodynamic position or therapeutic ultrasound. The group receiving the mobilizations exhibited significantly greater improvements in elbow range of motion during neurodynamic testing as well as greater reductions in pain compared to the ultrasound group.
II
Fnkiar^mZe122 incorporated neural mobilization in the management of a cohort of patients with cervical radiculopathy. Seventy seven percent of patients at the short-term follow-up and 93% of patients at the long term follow-up exhibited a clinically important decrease in disability. However, no specifics were provided relative to which patients received neural mobilization procedures.
III
Cleland et al39 described the outcomes of a consecutive series of patients presenting to physical therapy who received cervical mobilization (cervical lateral glides) with the upper extremity in a neurodynamic position as well as thoracic spine manipulation, cervical traction, and strengthening exercises. Ten of the 11 patients (91%) demonstrated a clinically meaningful bfikho^f^gmbgiZbgZg]_ng\mbhg_heehpbg`Zf^Zgh_0'* physical therapy visits.
IV
a24
|
B
A systematic review by Graham and colleagues/0 reported that there is moderate evidence to support the use of mechanical intermittent cervical traction.
I
II
Saal et al143 bgo^lmb`Zm^] ma^ hnm\hf^l h_ +/ \hgsecutive patients who fit the diagnostic criteria for herniated cervical disc with radiculopathy who received a rehabilitation program consisting of cervical traction and exercise. Twenty-four patients avoided surgical intervention and 20 exhibited good or excellent outcomes.
III
In a prospective cohort design Cleland et al,/ identified predictor variables of short-term success for patients presenting to physical therapy with cervical radiculopathy. One of the predictor variables for patients who exhibited a short-term success included a multimodal physical therapy approach consisting of manual or mechanical traction, manual therapy (cervical or thoracic mobilizambhg(fZgbineZmbhg"%Zg]]^^ig^\d×^qhklmk^g`ma^gbg`'Ma^ pretest probability for the likelihood of short-term success pZl., 'Ma^f^Zg]nkZmbhgh_f^\aZgb\ZemkZ\mbhgnl^]hg iZmb^gmlbgmabllmn]rpZl*0'1fbgnm^lpbmaZgZo^kZ`^_hk\^ of pull of 11 kg (24.3 pounds). The positive likelihood ratio for patients receiving the multimodal treatment approach (excluding other predictor variables) was 2.2, resulting in a ihlm&m^lmikh[Z[bebmrh_ln\\^llh_0* ' ,/
II
Raney et al*,0 recently developed a clinical prediction rule to identify patients with neck pain likely to benefit from cervical mechanical traction. Sixty^b`amiZmb^gml!,1_^fZe^"p^k^bg\en]^]bg]ZmZZgZerlblh_ pab\a,)aZ]Zln\\^ll_nehnm\hf^':eeiZmb^gmlk^\^bo^]/ sessions of mechanical intermittent cervical traction startbg`pbmaZ_hk\^h_inee[^mp^^g-'.&.'-d`!*)&*+ihng]l" _hkZ]nkZmbhgh_*.fbgnm^l'Ma^_hk\^h_ineeikh`k^llbo^er
II
september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s increased based on centralization of symptoms at each subl^jn^gm l^llbhg' : \ebgb\Ze ik^]b\mbhg kne^ pbma . oZkbZ[e^l was identified: IZmb^gmk^ihkm^]i^kbia^kZebsZmbhgpbmaehp^k\^kob\Zelibg^ !<-&0"fh[bebmrm^lmbg` Ihlbmbo^lahne]^kZ[]n\mbhglb`g :`^l..r^Zkl Ihlbmbo^nii^kebf[m^glbhgm^lm!f^]bZgg^ko^[bZlnmbebsbg`lahne]^kZ[]n\mbhgmh2)" K^eb^_h_lrfimhflpbmafZgnZe]blmkZ\mbhgm^lm
bg?ng\mbhgZeKZmbg`Bg]^ql\hk^lpZl+/ _khfZ[Zl^ebg^ of 44%.
AZobg` Zm e^Zlm , hnm h_ . oZkbZ[e^l ik^l^gm k^lnem^] bg Z ihlbmbo^ebd^ebahh]kZmbh^jnZemh-'1*!2.
F7J?;DJ;:K97J?ED7D:9EKDI;B?D=
Three separate case series,2%*+)%*0/ describe the management of patients with cervical radiculopathy, where the interventions included traction. In these case series, the patients were treated with a multimodal treatment approach and the vast majority of patients exhibited improved outcomes. In the first report, Cleland et al39 described the outcomes of a consecutive series of 11 patients presenting to physical therapy with cervical radiculopathy and managed with the use of manual physical therapy, cervi\ZemkZ\mbhg%Zg]lmk^g`ma^gbg`^q^k\bl^l':m/fhgma_heehp& up, 91% demonstrated a clinically meaningful improvement bgiZbgZg]_ng\mbhg_heehpbg`Zf^Zgh_0'*iarlb\Zema^kZir visits. Similarly, Waldrop*0/mk^Zm^]/iZmb^gmlpbma\^kob\Ze radiculopathy with mechanical intermittent cervical traction, thoracic thrust joint manipulation, and range of motion and lmk^g`ma^gbg`^q^k\bl^l_hkma^\^kob\Zelibg^'Nihg]bl\aZk`^ !f^Zgmk^Zmf^gm*)oblbml%kZg`^.&*1oblbml4]nkZmbhg,,]Zrl% kZg`^*2&./]Zrl"%ma^k^pZlZk^]n\mbhgbg]blZ[bebmr[^mp^^g *, Zg]11 'Bgma^mabk]\Zl^l^kb^l%Fh^mbZg]FZk\a^mmb120 investigated the outcomes associated with cervical traction, neck retraction exercises, scapular muscle strengthening, and mobilization/manipulation techniques (used for some iZmb^gml"_hk*.iZmb^gmlpbma\^kob\ZekZ]b\nehiZmar'Ma^l^ Znmahklk^ihkm^]_neek^lhenmbhgh_iZbgbg., h_iZmb^gmlZm the time of discharge.
IV
Browder and colleagues23 investigated the effectiveness of a multimodal treatment approach in ma^fZgZ`^f^gmh_0_^fZe^iZmb^gmlpbma`kZ]^B cervical compressive myelopathy. Patients were treated with intermittent mechanical cervical traction and thoracic magbineZmbhg _hk Z f^]bZg h_ 2 l^llbhgl ho^k Z f^]bZg h_ ./ ]Zrl'Ma^f^]bZg]^\k^Zl^bgiZbgl\hk^lpZl._khfZ[Zl^ebg^h_/!nlbg`Z)&*)iZbgl\Ze^"%Zg]f^]bZgbfikho^f^gm
IV
Recommendation: Clinicians should consider the use of mechanical intermittent cervical traction, combined with other interventions such as manual therapy and strengthening exercises, for reducing pain and disability in patients with neck and neck-related arm pain.
B
There is a paucity of high quality evidence surrounding efficacy of treatments for whiplashassociated disorder (WAD). However, existing research supports instructing patients in active interventions, such as exercises, and early return to regular activities as a means of pain control. Rosenfeld et al142 compared the longterm efficacy of active intervention with that of standard intervention and the effect of early versus delayed initiation of intervention. Patients were randomized to an intervention using frequent active cervical rotation range of motion exercises complemented by assessment and treatment ac\hk]bg`mhF\D^gsb^Ílikbg\bie^lhkmhZgbgm^ko^gmbhgmaZm promoted initial rest, soft collar utilization, and gradual selfmobilization. In patients with WAD, early active intervention was more effective in reducing pain intensity and sick leave, and in retaining/regaining total range of motion than intervention that promoted rest, collar usage, and gradual self-mobilization. Patient education promoting an active approach can be carried out as home exercises and progressive return to activities initiated and supported by appropriately trained health professionals.
I
An often prescribed intervention for acute whiplash injury is the use of a soft cervical collar. Crawford et al-.ikhli^\mbo^erbgo^lmb`Zm^]*)1\hgl^\nmbo^ patients following a soft tissue injury of the neck that resulted from motor vehicle accidents. Each patient was randomized to a group instructed to engage in early mobilization using an exercise regime or to a group that was instructed to utilize a soft cervical collar for 3 weeks followed by the same exercise regime. Patients were assessed clinically at 3, 12, Zg].+p^^dbgm^koZel_khfbgcnkr'Bgm^ko^gmbhgmaZmnmbebs^] a soft collar was found to have no obvious benefit in terms of functional recovery after neck injury and was associated with a prolonged time period off work. Other investigations have reported similar results.*-1%*0) Interventions that instruct patients to perform exercises early in their recovery from whiplash type injuries have been reported to be more effective in reducing pain intensity and disability following whiplash injury than interventions that instruct patients to use cervical collars.*-1%*0)
I
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a25
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s Existing research supports active interventions and early return to regular activities but it has largely been unknown as to which type of active intervention would yield the most benefit. Brison et al21 assessed the efficacy of an educational video in the prevention of persistent WAD symptoms following rear-end motor vehicle collisions. The video provided reassurance, and education about posture, return to regular activities, specific exercises, and pain management. Patients were randomized to receive either an educational video plus usual care or usual care alone. The primary outcome was presence of persistent WAD symptoms at 24 weeks post injury, based on the frequency and severity of neck, shoulder, or upper back pain. The group receiving the instructional video demonstrated a trend toward less severe WAD symptoms suggesting that the ‘act as usual’ recommendation that is often prescribed as a management strategy for patients with WAD is not sufficient and, in fact, may exacerbate their symptoms if such activities are provocative of pain.21
I
A reduction in pain alone is not sufficient to address the neuromuscular control deficits in patients with chronic symptoms,*.0 as these deficits require specific rehabilitation techniques.99 For example, persistent sensory and motor deficits may render the patient at risk for symptom persistence.*..%*./ Support for specificity in rehabilitation can be indirectly found from a recent populationbased, incidence cohort study evaluating a government policy of funding community and hospital-based fitness training and multidisciplinary rehabilitation for whiplash.+/ No supportive evidence was found for the effectiveness of this general rehabilitation approach. Therefore, only addressing the lack of fitness and conditioning in this patient population may not be the most efficacious approach to treatment.
III
Ferrari et al/) studied whether an educational intervention using a pamphlet provided to patients in the acute stage of whiplash injury might improve the recovery rate. One hundred twelve consecutive subjects were randomized to 1 of 2 treatment groups: educational intervention or usual care. The education intervention group received an educational pamphlet based on the current evidence, whereas the control group only received usual emergency department care and a standard non-directed discharge information sheet. Both groups underwent follow-up by telephone interview at 2 weeks and 3 months. The primary outcome measure of recovery was the patient’s k^lihgl^mhma^jn^lmbhg%ÊAhpp^ee]hrhn_^^erhnZk^k^\ho^kbg`_khfrhnkbgcnkb^l8Ë:m,fhgmalihlm\heeblbhg%+*'1 in the education intervention group reported complete recovery compared with 21.0% in the control group (absolute risk ]bü^k^g\^%)'1 42.
I
a26
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between groups in severity of remaining symptoms, limitations in daily activities, therapy use, medications used, lost time from work, or litigation. This study concluded that an evidence-based educational pamphlet provided to patients at discharge from the emergency department is no more effective than usual care for patients with grade I or II WAD./) Cnee ^m Ze99 conducted a preliminary randomized \hgmkhee^]mkbZepbma0*iZkmb\biZgmlpbmai^klblm^gm neck pain following a motor vehicle accident to explore whether a multimodal program of physical therapies was an appropriate management strategy compared to a selfmanagement approach. Participants were randomly allocated to receive either a multimodal physical therapy program or a self-management program (advice and exercise). Furthermore, participants were stratified according to the presence or absence of widespread mechanical or cold hyperalgesia. The intervention period was 10 weeks and outcomes were assessed immediately following treatment. Even with the pres^g\^ h_ l^glhkr ari^kl^glbmbobmr bg 0+'. h_ ln[c^\ml% [hma groups reported some relief of neck pain and disability, measured using Neck Disability Index scores, and it was superior in the group receiving multimodal physical therapy (P=.04). However, the overall effects of both programs were mitigated in the group presenting with both widespread mechanical and cold hyperalgesia. Further research aimed at testing the validity of this sub-group observation is warranted. 21
I
A comprehensive review**0 of the available scientific evidence produced a set of unambiguous patient centered messages that challenge unhelpful beliefs about whiplash, promoting an active approach to recovery. The use of this rigorously developed educational booklet (The Whiplash Book) was capable of improving beliefs about whiplash and its management for patients with whiplashassociated disorders.**0
II
BgZlfZee \Zl^l^kb^l% Lh]^keng] Zg]Ebg][^k`*., reported that physical therapy integrated with cognitive behavioral components decreased pain intensity in problematic daily activities in 3 individuals with chronic WAD.
IV
Predictors of outcome following whiplash injury have been limited to socio-demographic and factors of symptom location and severity, which are not readily amenable to intervention. However, evidence exists to demonstrate that psychological factors are present soon following injury and play a role in recovery from whiplash injury.21%*..%*.1 These factors can be as diverse as the physical presentation and can include affective disturbances, anxiety, depression, and fear of movement.*+,%*,+%*01 Furthermore, post-traumatic stress disorder112 has also been
II
september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s observed in both the acute.+ and chronic conditions and has been shown to be prognostic.*0* Identifying these factors in patients may assist in the development of relevant subgroups and appropriately matched education and counseling strategies that practitioners should utilize in management of patients with WAD.
J78B;* ?cfW_hc[dj#8Wi[Z9Wj[]eho M_j^?9:#'&7iieY_Wj_edi
Recommendation: To improve the recovery in patients with whiplash-associated disorder, clinicians should (1) educate the patient that early return to normal, non-provocative pre-accident activities is important, and (2) provide reassurance to the patient that good prognosis and full recovery commonly occurs.
A
Neck Pain Impairment/Function-based Diagnosis, Examination and Intervention Recommended Classification Criteria*
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* Recommendation based on expert opinion.
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a27
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
CLINICAL GUIDELINES
Summary of Recommendations E
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B
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B
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
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journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a29
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
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journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a31
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
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journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a33
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association J Orthop Sports Phys Ther 2008;38(9):A1-A34. doi:10.2519/jospt.2008.0303
RECOMMENDATIONS$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7( INTRODUCTION$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7) METHODS$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7* CLINICAL GUIDELINES: Impairment/Function-Based Diagnosis$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7/ CLINICAL GUIDELINES: Examinations$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7'* CLINICAL GUIDELINES: Interventions$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7'/ SUMMARY OF RECOMMENDATIONS$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7(. AUTHOR/REVIEWER AFFILIATIONS & CONTACTS$ $ $ $ $ $ $ $ $ $ 7(/ REFERENCES$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7)&
H;L?;M;HI07dj^edo:[b_jje"FJ"F^:=[eh][C$:oh_m":FJ7cWdZW<[hbWdZ"FJ">[b[d[<[Whed"FJ@eoCWY:[hc_Z"FJ"F^: @Wc[iM$CWj^[ied":FJF^_b_fCY9bkh["FJ"F^:FWkbI^[a[bb["C:"F^:7$Hkii[bbIc_j^"@h"FJ";Z:B[ib_[JehXkhd":FJ <ehWkj^eh"YeehZ_dWjeh"WdZh[l_[m[hWøb_Wj_edi"i[[[dZe\j[nj$(&&.Ehj^efW[Z_YI[Yj_ed7c[h_YWdF^oi_YWbJ^[hWfo7iieY_Wj_ed 7FJ7 "?dY"WdZj^[@ekhdWbe\ Ehj^efW[Z_Y IfehjiF^oi_YWbJ^[hWfo$J^[Ehj^efW[Z_YI[Yj_ed"7FJ7"?dY$"WdZj^[@ekhdWbe\Ehj^efW[Z_Y IfehjiF^oi_YWbJ^[hWfoYedi[djjej^[f^ejeYefo_d]e\ j^_i]k_Z[b_d[\eh[ZkYWj_edWbfkhfei[i$7ZZh[iiYehh[ifedZ[dY[je0@ei[f^@$=eZ][i":FJ"?9<FhWYj_Y[=k_Z[b_d[i9eehZ_dWjeh"Ehj^efW[Z_YI[Yj_ed"7FJ7?dY$"(/(& ;Wij7l[dk[Iekj^"Ik_j[(&&1BW9heii["M?+*,&'$;cW_b0_Y\6ehj^efj$eh]
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Recommendations* F7J>E7D7JEC?97B<;7JKH;I0 Although the cause of neck pain may be associated with degenerative processes or pathology identified during diagnostic imaging, the tissue that is causing a patient’s neck pain is most often unknown. Thus, clinicians should assess for impaired function of muscle, connective, and nerve tissues associated with the identified pathological tissues when a patient presents with neck pain. (Recommendation based on theoretical/foundational evidence.) H?IA<79JEHI0 Clinicians should consider age greater than 40, coexisting low back pain, a long history of neck pain, cycling as a regular activity, loss of strength in the hands, worrisome attitude, poor quality of life, and less vitality as predisposing factors for the development of chronic neck pain. (Recommendation based on moderate evidence.) :?7=DEI?I%9B7II?
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The following physical examination measures may be useful in classifying a patient in the ICF impairment-based category of neck pain with movement coordination impairments and the associated ICD category of sprain and strain of cervical spine. (Recommendation based on moderate evidence.)
september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Recommendations* (continued) ?DJ;HL;DJ?EDIÅIJH;J9>?D=;N;H9?I;I0 Flexibility exercises can be used for patients with neck symptoms. Examination Zg]mZk`^m^]×^qb[bebmr^q^k\bl^l_hkma^_heehpbg`fnl\e^lZk^ suggested: anterior/medial/posterior scalenes, upper trapezius, levator scapulae, pectoralis minor, and pectoralis major. (Recommendation based on weak evidence.) ?DJ;HL;DJ?EDIÅ9EEH:?D7J?ED"IJH;D=J>;D?D="7D:;D:KH7D9;;N;H9?I;I0 Clinicians should consider the use of coordination, strengthening, and endurance exercises to reduce neck pain and headache. (Recommendation based on strong evidence.)
and nerve mobilization procedures to reduce pain and disability in patients with neck and arm pain. (Recommendation based on moderate evidence.) ?DJ;HL;DJ?EDIÅJH79J?ED0 Clinicians should consider the use of mechanical intermittent cervical traction, combined with other interventions such as manual therapy and strengthening exercises, for reducing pain and disability in patients with neck and neck-related arm pain. (Recommendation based on moderate evidence.)
?DJ;HL;DJ?EDIÅ9;DJH7B?P7J?EDFHE9;:KH;I7D:;N;H9?I;I0 Specific repeated movements or procedures to promote centralization are not more beneficial in reducing disability when compared to other forms of interventions. (Recommendation based on weak evidence.)
?DJ;HL;DJ?EDIÅF7J?;DJ;:K97J?ED7D:9EKDI;B?D=0 To improve recovery in patients with whiplash-associated disorder, clinicians should (1) educate the patient that early return to normal, non-provocative pre-accident activities is important, and (2) provide reassurance to the patient that good prognosis and full recovery commonly occurs. (Recommendation based on strong evidence.)
?DJ;HL;DJ?EDIÅKFF;HGK7HJ;H7D:D;HL;CE8?B?P7J?EDFHE9;:KH;I0 Clinicians should consider the use of upper quarter
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Introduction 7?CE<J>;=K?:;B?D; The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF).1/ The purposes of these clinical guidelines are to: =^l\kb[^^ob]^g\^&[Zl^]iarlb\Zema^kZirikZ\mb\^bg\en]ing diagnosis, prognosis, intervention, and assessment of outcome for musculoskeletal disorders commonly managed by orthopaedic physical therapists <eZllb_rZg]]^Ög^\hffhgfnl\nehld^e^mZe\hg]bmbhgl using the World Health Organization’s terminology related to impairments of body function and body structure, activity limitations, and participation restrictions B]^gmb_rbgm^ko^gmbhgllniihkm^][r\nkk^gm[^lm^ob]^g\^mh address impairments of body function and structure, activity limitations, and participation restrictions associated with common musculoskeletal conditions B]^gmb_rZiikhikbZm^hnm\hf^f^Zlnk^lmhZll^ll\aZg`^l resulting from physical therapy interventions in body function and structure as well as in activity and participation of the individual
Ikhob]^Z]^l\kbimbhgmhiheb\rfZd^kl%nlbg`bgm^kgZmbhgZeer accepted terminology, of the practice of orthopaedic physical therapists Ikhob]^bg_hkfZmbhg_hkiZr^klZg]\eZbflk^ob^p^klk^`Zk]ing the practice of orthopaedic physical therapy for common musculoskeletal conditions
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a3
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Methods Content experts were appointed by the Orthopaedic Section, APTA as developers and authors of clinical practice guidelines for musculoskeletal conditions of the cervical region that are commonly treated by physical therapists. These content experts were given the task to identify impairments of body function and structure, activity limitations, and participation restrictions, described using ICF terminology, that could (1) categorize patients into mutually exclusive impairment patterns upon which to base intervention strategies, and (2) serve as measures of changes in function over the course of an episode of care. The second task given to the content experts was to describe interventions and supporting evidence for specific subsets of patients based upon the previously chosen patient categories. It was also acknowledged by the Orthopaedic Section, APTA content experts that a systematic search and review of the evidence solely related to diagnostic categories based on International Statistical Classification of Diseases and Health Related Problems (ICD)10 terminology would not be useful for these ICF-based clinical practice guidelines as most of the evidence associated with changes in levels of impairment or function in homogeneous populations is not readily searchable using the ICD terminology. Thus, the authors of this clinical practice guideline sysm^fZmb\Zeerl^Zk\a^]F>=EBG>%
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=H7:;IE<;L?:;D9; The overall strength of the evidence supporting recommendations made in this guideline will be graded according to guidelines described by Guyatt et al,0* as modified by FZ\=^kfb]Zg]Z]him^][rma^\hhk]bgZmhkZg]k^ob^p^klh_ this project. In this modified system, the typical A, B, C, and D grades of evidence have been modified to include the role of consensus expert opinion and basic science research to demonstrate biological or biomechanical plausibility (Table 2 below).
GRADES OF RECOMMENDATION
STRENGTH OF EVIDENCE
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Methods (continued) H;L?;MFHE9;II The Orthopaedic Section, APTA also selected consultants from the following areas to serve as reviewers of the early drafts of this clinical practice guideline: <eZbflk^ob^p
these clinical guidelines that provides a summary of symptoms, impairment findings, and matched interventions for each diagnostic category. This recommendation led the authors to add Table 4 to these clinical guidelines. 9B7II?
ICD-10 and ICF Codes Associated With Neck Pain INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS D[YaFW_dM_j^CeX_b_jo:[ÓY_ji Primary ICD-10
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journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a5
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH PRIMARY ICF CODES
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH (CONTINUED) Z()&( Z(*&& Z*'&& Z*'&+ Z*'+& Z*-+&
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journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a7
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH (CONTINUED) Body structure
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Z()&( Z(*&& Z*'+& Z*'+) Z*'+& Z*)&& Z*)&' Z*)&( Z*)&) Z*)&* Z*)&+ Z*-+& Z*-+& Z*-+& Z,*&/ Z/'&/ Z/(&/
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a8
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
CLINICAL GUIDELINES
Impairment/Function-based Diagnosis FH;L7B;D9; Pain and impairment of the neck is common. It is estifZm^]maZm++ mh0) h_ma^ihineZmbhgpbeeaZo^g^\diZbg some time in their lives.*2%+)%-+%-,%..%**.%*+2 In addition, it has been suggested that the incidence of neck pain is increasing.*+/%*1* At any given time, 10% to 20% of the population reports neck problems,*2%--%01%*/0pbma.- h_bg]bob]nZelaZobg`^qi^kb^g\^] g^\diZbgpbmabgma^eZlm/fhgmal'42 Prevalence of neck pain increases with age and is most common in women around the fifth decade of life.-%*2%-/%**/%*/, Although the natural history of neck pain appears to be favorable,.*%2+ rates of recurrence and chronicity are high.*.%1* One study reported that 30% of patients with neck pain will develop chronic symptoms, with neck pain of greater maZg/fhgmal]nkZmbhgZü^\mbg`*- h_Zeebg]bob]nZelpah experience an episode of neck pain.19 Additionally, a recent lnko^r ]^fhglmkZm^] maZm ,0 h_ bg]bob]nZel pah ^qi^kbence neck pain will report persistent problems for at least 12 months.44 Five percent of the adult population with neck pain will be disabled by the pain, representing a serious health concern.*2%11 In a survey of workers with injuries to the neck and upper extremity, Pransky et al*,. reported that -+ fbll^]fhk^maZg*p^^dh_phkdZg]+/ ^qi^kb^g\^] recurrence within 1 year. The economic burden due to disorders of the neck is high, and includes costs of treatment, lost wages, and compensation expenditures.*/%*,1 Neck pain is second only to low back pain in annual workers’ compensambhg\hlmlbgma^Ngbm^]LmZm^l'*1* In Sweden, neck and shoul]^kikh[e^flZ\\hngm_hk*1 h_Zee]blZ[bebmriZrf^gml'*+/ C^mm^^mZe91 reported that patients with neck pain make up ZiikhqbfZm^er+. h_iZmb^gmlk^\^bobg`hnmiZmb^gmiarlbcal therapy. Additionally, patients with neck pain frequently are treated without surgery by primary care and physical therapy providers.*0%.*%2+
F7J>E7D7JEC?97B<;7JKH;I A variety of causes of neck pain have been described and include osteoarthritis, discogenic disorders, trauma, tumors, infection, myofascial pain syndrome, torticollis, and whiplash.121Ng_hkmngZm^er%\e^Zker]^Ög^]]bZ`ghlmb\\kbm^kbZ have not been established for many of these entities. Similar to low back pain, a pathoanatomical cause is not identifiable
in the majority of patients who present with complaints of neck pain and neck related symptoms of the upper quarter.*. Therefore, once serious medical pathology (such as cervical fracture or myelopathy) has been ruled out, patients with neck pain are often classified as having either a nerve root \hfikhfbl^hkZÊf^\aZgb\Zeg^\d]blhk]^k'Ë In some conditions, particularly those that are degenerative in nature or involve abnormalities of the vertebral motion segment, abnormal findings are not always associated with symimhfl' ?hnkm^^g mh *1 h_ people without neck pain demonstrate a wide range of abnormalities with imaging studies, including disc protrusion or extrusion and impingement of the thecal sac on the nerve root and spinal cord.12 However, degenerative changes are still suggested to be a possible cause of mechanical neck pain in some cases,109,130,131 despite the fact that these changes are present in asymptomatic individuals, are non-specific, and are highly prevalent in the elderly.*/1 Disorders such as cervical radiculopathy and cervical compressive myelopathy are reported to be caused by space-occupying lesions (osteophytosis or herniated cervical disc). These may be secondary to degenerative processes and can give rise to neck and/or upper quarter pain as well as neurologic signs and symptoms.*,/ While cervical disc herniation and spondylosis are most commonly linked to cervical radiculopathy and myelopathy,*)%*,/ the bony and ligamentous tissues affected by these conditions are themselves pain generators and are capable of giving rise to some of the referred symptoms observed in patients with these disorders.13,40
II
Because most patients with neck pain usually lack an identifiable pathoanatomic cause for their problem, the majority are classified as having mechanical neck disorders.1+
II
Although the cause of neck pain may be associated with degenerative processes or pathology identified during diagnostic imaging, the tissue that is causing a patient’s neck pain is most often unknown. Thus, clinicians should assess for impaired function of muscle, connective, and nerve tissues associated with the identified pathological tissues when a patient presents with neck pain.
E
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N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s H?IA<79JEHI Bot and colleagues18 investigated the clinical course and predictors of recovery for patients with neck and shoulder pain. Four hundred forty three patients who consulted their primary care physician with neck or shoulder symptoms were followed for 12 months. At 12 months, 32% of patients reported that they had recovered. Predictors of poor pain-related outcome at 12 months included less intense pain at baseline, a history of neck and shoulder symptoms, more worrying, worse perceived health, and a moderate or bad quality of life. The predictors for a poor disability-related response at 12 months included older age, less disability at baseline, longer duration of symptoms, loss of strength in hands, having multiple symptoms, more worrying, moderate or bad quality of life, and less vitality.
II
Hill and colleagues0/ investigated the course of neck pain in an adult population over a 12 month period. Significant baseline characteristics, which ik^]b\m^]i^klblm^gmg^\diZbgp^k^Z`^!-.&.2r^Zkl"%[^bg` off work at the time of the baseline survey (odds ratio [OR] 6*'/"%\hfhk[b]ehp[Z\diZbg!HK6*'/"%Zg][b\r\ebg`ZlZ regular activity (OR = 2.4).
II
In a prospective cohort study, Hoving et al1) examined the predictors of outcome in a patient ihineZmbhgpbmag^\diZbg':mhmZeh_*1,iZmb^gml iZkmb\biZm^]bgma^lmn]rh_pab\a/, aZ]bfikho^]ZmZ 12-month follow-up. In the short term, older age (l40), concomitant low back pain, and headache were associated with poor outcome. In the long-term, in addition to age and concomitant low back pain, previous trauma, a long duration of neck pain, stable neck pain during the 2 weeks prior to baseline measurement, and previous neck pain predicted poor prognosis.
II
Clinicians should consider age greater than 40, coexisting low back pain, a long history of neck pain, bicycling as a regular activity, loss of strength in the hands, worrisome attitude, poor quality of life, and less vitality as predisposing factors for the development of chronic neck pain.
B
9B?D?97B9EKHI; Approximately 44% of patients experiencing neck pain will go on to develop chronic symptoms,*. and many will continue to exhibit moderate disability at long-term follow-up.// A recent systematic review examined the outcomes of nontreatment control groups in clinical trials for the conservative management of chronic mechanical neck pain - not due to whiplash.*0* The outcomes of patients receiving a control or placebo intervention were analyzed and effect sizes were a10
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calculated. The changes in pain scores over the varying trial periods in these untreated subjects with chronic mechanical neck pain were consistently small and not significant.*0* Conversely, there is substantial evidence that favorable outcomes are attained following treatment of patients with cervical radiculopathy.02%*,/ For example, Radhakrishnan and colleagues*,/ reported that nearly 90% of patients with cervical radiculopathy presented with only mild symptoms at a median follow-up of 4.9 years. Honet and Puri02 found that 0) h_iZmb^gmlpbma\^kob\ZekZ]b\nehiZmar^qab[bm^]`hh]hk excellent outcomes after a 2-year follow-up. Outcomes for the patients in the aforementioned studies02%*,/ appeared favorZ[e^Zg]ln``^lmmaZm0)&2) h_mablihineZmbhg\Zg^qi^kbence improvement without surgical intervention. In contrast, the clinical prognosis of patients with whiplash-associated ]blhk]^kble^ll_ZohkZ[e^':lnko^rh_*)1iZmb^gmlpbmaZabltory of whiplash requiring care at an emergency department _hng]maZm.. aZ]k^lb]nZeiZbg(]blZ[bebmrk^_^kZ[e^mhma^ hkb`bgZeZ\\b]^gmZmZf^Zg_heehp&nih_*0r^ZkleZm^k'G^\d pain, radiating pain, and headache were the most common symptoms. Thirty-three percent of the respondents with residual symptoms suffered from work disability, compared to / bgma^`khnih_iZmb^gmlpbmahnmk^lb]nZe]blhk]^kl'+.
:?7=DEI?I%9B7II?
III
september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s conditioning, pain control, and headache, intend to capture the primary focus or goal of treatment. Fritz and Brennan,/+ nmbebsbg`Zikhli^\mbo^%h[l^koZmbhgZelmn]rh_+0-iZmb^gml% reported that patients who received interventions matched with their treatment subgroup had better outcomes than patients who received interventions that were not matched with their subgroup. The classification system described in this practice guideline linked to the ICF, parallels the Childs et al+0 and Fritz and Brennan/+ classification with 2 noteworthy differences. The first difference is that the labels in this clinical practice guideline incorporate the following ICF impairments of body functions terminology: Neck pain with mobility deficits, neck pain with headaches, neck pain with movement coordination impairments, and neck pain with radiating pain. The second difference is that Fritz and Brennan’s/+ÊiZbg\hgmkheË\Zm^`hkr%pab\apZlebgd^]mhfh[bebsZmbhgZg]kZg`^ of motion exercises following an acute cervical sprain, was ]bob]^]bgmhma^Êg^\diZbgpbmafho^f^gm\hhk]bgZmbhgbfiZbkf^gml%ËZg]Êg^\diZbgpbmafh[bebmr]^Ö\bmlË\Zm^`hkb^l% where the patient would receive interventions linked to the most relevant impairment(s) exhibited at a given period during the patient’s episode of care. The ICD diagnosis of cervicalgia, or pain in thoracic spine and the associated ICF diagnosis of neck pain with mobility deficits is made with a reasonable level of certainty when the patient presents with the following clinical findings,,%/+%1+%*//: Rhng`^kbg]bob]nZe!Z`^5.)r^Zkl" :\nm^g^\diZbg!]nkZmbhg5*+p^^dl" LrfimhflblheZm^]mhma^g^\d K^lmkb\m^]\^kob\ZekZg`^h_fhmbhg
I
The ICD diagnosis of headaches, or cervicocranial syndrome and the associated ICF diagnosis of neck pain with headaches is made with a reasonable level of certainty when the patient presents with the following clinical findings/%/+%22%*1.: NgbeZm^kZe a^Z]Z\a^ Zllh\bZm^] pbma g^\d(ln[h\\bibmZe area symptoms that are aggravated by neck movements or positions A^Z]Z\a^ikh]n\^]hkZ``kZoZm^]pbmaikhoh\Zmbhgh_ma^ ipsilateral posterior cervical myofascia and joints K^lmkb\m^]\^kob\ZekZg`^h_fhmbhg K^lmkb\m^]\^kob\Zel^`f^gmZefh[bebmr :[ghkfZe(ln[lmZg]Zk]i^k_hkfZg\^hgma^\kZgbZe\^kob\Ze×^qbhgm^lm
II
The ICD diagnosis of sprain and strain of cervical spine and the associated ICF diagnosis of neck pain with movement coordination impairments is made with a reasonable level of certainty when the patient presents with the following clinical findings++%+2%*-.%*/+%*1+%*1-:
I
Ehg`lmZg]bg`g^\diZbg!]nkZmbhg7*+p^^dl" :[ghkfZe(ln[lmZg]Zk]i^k_hkfZg\^hgma^\kZgbZe\^kob\Ze×^qbhgm^lm :[ghkfZe(ln[lmZg]Zk] i^k_hkfZg\^ hg ma^ ]^^i ×^qhk endurance test
II
Neck pain, without symptoms or signs of serious medical or psychological conditions, associated with (1) motion limitations in the cervical and upper thoracic regions, (2) headaches, and (3) referred or radiating pain into an upper extremity are useful clinical findings for classifying a patient with neck pain into the following International Statistical Classification of Diseases and Related Health Problems (ICD) categories: cervicalgia, pain in thoracic spine, headaches, cervicocranial syndrome, sprain and strain of cervical spine, spondylosis with radiculopathy, and cervical disc disorder with radiculopathy; and the associated International Classification of Functioning, Disability, and Health (ICF) impairment-based category of neck pain with the following impairments of body function: G^\diZbgpbmafh[bebmr]^Ö\bml([0*)*Fh[bebmrh_l^o^kZe joints) G^\diZbgpbmaa^Z]Z\a^l(+1)*)IZbgbga^Z]Zg]g^\d" G^\d iZbg pbma fho^f^gm \hhk]bgZmbhg bfiZbkf^gml ([0/)*
B
The following physical examination measures may be useful in classifying a patient in the ICF impairment-based category
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a11
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s of neck pain with mobility deficits and the associated ICD categories of cervicalgia or pain in thoracic spine: <^kob\ZeZ\mbo^kZg`^h_fhmbhg <^kob\ZeZg]mahkZ\b\l^`f^gmZefh[bebmr The following physical examination measures may be useful in classifying a patient in the ICF impairment-based category of neck pain with headaches and the associated ICD categories of headaches or cervicocranial syndrome: <^kob\ZeZ\mbo^kZg`^h_fhmbhg <^kob\Zel^`f^gmZefh[bebmr
:?<<;H;DJ?7B:?7=DEI?I A primary goal of diagnosis is to match the patient’s clinical presentation with the most efficacious treatment approach. A component of this decision is determining whether the patient is, in fact, appropriate for physical therapy management. In the vast majority of patients with neck pain, symptoms can be attributed to mechanical factors. However, in a much smaller percentage of patients, the cause of neck pain may be something more serious, such as cervical myelopathy, cervical instability,49 fracture,00 neoplastic conditions,2)%*-)%*.+%*.- vascular compromise,*.* or systemic disease.1%+- Clinicians must be aware of the key signs and symptoms associated with serious pathological neck conditions, continually screen for the presence of these conditions, and initiate referral to the appropriate medical practitioner when a potentially serious medical condition is suspected.
III
When a patient with neck pain reports a history of trauma, the therapist needs to be particularly alert for the presence of cervical instability, spinal fracture, and the presence of or potential for spinal cord or brain stem injury. A clinical prediction rule has been developed to
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assist clinicians in determining when to order radiographs in individuals who have experienced trauma.*.2 In addition to medical conditions, clinicians should be aware of psychosocial factors that may be contributing to a patient’s persistent pain and disability, or that may contribute to the transition of an acute condition to a chronic, disabling condition. Researchers have recently shown that psychosocial factors are an important prognostic indicator of prolonged disability./,%/-%**-%*.) When relevant psychosocial factors are identified, the rehabilitation approach may need to be modified to emphasize active rehabilitation, graded exercise programs, positive reinforcement of functional accomplishments, and/or graduated exposure to specific activities that a patient fears as potentially painful or difficult to perform./.
II
Clinicians should consider diagnostic classifications associated with serious pathological conditions or psychosocial factors when the patient’s reported activity limitations or impairments of body function and structure are not consistent with those presented in the diagnosis/ classification section of this guideline, or, when the patient’s symptoms are not resolving with interventions aimed at normalization of the patient’s impairments of body function.
B
?C7=?D=IJK:?;I Adults with cervical pain precipitated by trauma should be classified as low risk or high risk based on the Canadian Cervical Spine Rule (CCR) for radiography in alert and stable trauma patients*.2 and the 2001 American College of Radiology (ACR) suspected Spine Trauma Appropriateness Criteria.3 According to the CCR, patients who (1) are able to sit in the emergency department; or (2) have had a simple rear-end motor vehicle collision; or (3) are ambulatory at any time; or (4) have had a delayed onset of neck pain; hk!."]hghmaZo^fb]ebg^\^kob\Zelibg^m^g]^kg^ll4Zg]!/" Zk^Z[e^mhZ\mbo^erkhmZm^ma^bka^Z]-.bg^Z\a]bk^\mbhg%Zk^ classified as low risk. Those who are classified as low risk do not require imaging for acute conditions. Patients who are !*"`k^Zm^kmaZg/.r^Zklh_Z`^4hk!+"aZo^aZ]Z]Zg`^khnl mechanism of injury; or (3) have paresthesias in the extremities, are classified as high risk.*.2 Those classified as high risk should undergo cervical radiography.2%-0 There is a paucity of available literature regarding the pediatric population to help guide decision making on the need for imaging. Adult risk classification features should be applied in children greater than age 14. Due to the added radiation exposure of computed tomography the ACR recommends ieZbg kZ]bh`kZiar !, ob^pl" bg mahl^ ng]^k */ r^Zkl h_ Z`^ regardless of mental status.3
september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s There is no consensus for routine investigation of patients with chronic neck pain with imaging beyond plain radiographs. ,%-1 Routine use of ultrasonography, CT, and magnetic resonance bfZ`bg`!FKB"bgiZmb^gmlpbmahnmg^nkheh`b\bglnemhkhma^k disease has not been justified in view of the infrequency of abnormalities detected, the lack of prognostic value, inaccessibility, and the high cost of the procedures.*-%0,%**2%*,,%*-*%*-/%*0- A major limitation is the lack of specific findings in patients with neck disorder and no definite correlation between the patient’s subjective symptoms and abnormal findings seen on imaging studies. As a result, debate continues as to whether persistent pain is attributable to structural pathology or to other underlying causes. K^\^gmer%DkblmcZgllhg111 compared sagittal plane, rotational, and translational cervical segmental motion in women with (1) persistent whiplash-associated disorder (WAD) (grades I and II), (2) persistent non-traumatic, insidious onset of neck pain, and (3) normal values of rotational and translational fhmbhg'EZm^kZekZ]bh`kZiab\ZgZerlblk^o^Ze^]lb`gbÖ\Zgmer bg\k^Zl^]khmZmbhgZefhmbhgZm<,&-Zg]<-&._hkbg]bob]nals in the WAD and insidious groups, significantly excessive translational motion at C3-4 for individuals in the WAD and insidious groups, and significantly excessive translational fhmbhgZm<.&/_hkbg]bob]nZelbgma^P:=`khnipa^g\hfpared to normal subjects. NemkZlhgh`kZiar aZl [^^g nl^] mh Z\\nkZm^er f^Zlnk^ ma^ size of the cervical multifidus muscle at the C4 level in asymptomatic female subjects. For those with chronic WAD, ultrasonography did not accurately measure the cervical multifidus because the fascial borders of the multifidus were largely indistinguishable, indicating possible pathological conditions.110 Ab`ak^lhenmbhgikhmhg]^glbmr&p^b`am^]FKBaZlk^\^gmer demonstrated abnormal signal intensity (indicative of tissue damage) in both the alar and transverse ligaments in some subjects with chronic WAD.*)1EZm^k_heehp&nilmn]b^lbg]bcated a strong relationship between alar ligament damage,
head position (turned) at time of impact, and disability levels (as measured with the Neck Disability Index).*)*%*)+%*)0 Elliott et al.,aZo^]^fhglmkZm^]maZm_^fZe^iZmb^gml!*1&-. r^Zklhe]"pbmai^klblm^gmP:=!`kZ]^BB"lahpFKB\aZg`^l in the fat content of the cervical extensor musculature that were not present in subjects with chronic insidious onset neck pain or healthy controls. It is currently unclear whether the patterns of fatty infiltration are the result of local structural mkZnfZ\Znlbg`Z`^g^kZebg×ZffZmhkrk^lihgl^%Zli^\bÖ\ nerve injury or insult, or a generalized disuse phenomenon. Further, as the muscular changes were observed in the chronic state, it is not yet known whether they occur uniformly in all people who have sustained whiplash injury irrespective of recovery or are unique to only those who develop chronic symptoms. In addition to fatty infiltration, Elliott et al.- have identified changes in the relative cross-sectional area (rCSA) of the cervical paraspinal musculature in patients with chronic WAD relative to control subjects with no history of neck pain. Specifically, the WAD group demonstrated a consistent pattern of larger rCSA in the multifidii muscles at each segment (C3<0"'Bg_^k^g\^\Zg[^]kZpgmaZmma^larger rCSAs recorded in the multifidii muscles of those with chronic WAD are the result of larger amounts of fatty infiltrate. In summary, imaging studies often fail to identify any structural pathology related to symptoms in patients with neck disorder and in particular, whiplash injury. However, emerging evidence into upper cervical ligamentous disruption, altered segmental motion, and muscular degeneration has been demonstrated with radiographs, ulmkZlhgh`kZiar% Zg] FKB lmn]b^l' Bm k^fZbgl ngdghpg b_ (1) these findings are unique to chronic WAD; (2) whether they relate to patients’ physical signs and symptoms, and (3) whether specific physical therapy intervention can alter such degeneration. Such knowledge may offer prognostic information and provide the foundation for interventional based studies.
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a13
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
CLINICAL GUIDELINES
Examination EKJ9EC;C;7IKH;I The Neck Disability Index (NDI) is a commonly utilized outcome measure to capture perceived disability in patients with neck pain.134 The NDI conmZbgl*)bm^fl%0k^eZm^]mhZ\mbobmb^lh_]Zberebobg`%+k^eZm^] to pain, and 1 related to concentration.*0+ Each item is scored _khf)&.Zg]ma^mhmZel\hk^bl^qik^ll^]ZlZi^k\^gmZ`^%pbma higher scores corresponding to greater disability. Riddle and Stratford139 identified a significant association between the NDI and both the physical and mental health components h_ma^L?&,/'Ma^ZnmahklZelhb]^gmbÖ^]maZmma^G=Bihlsesses adequate sensitivity as compared to the magnitude of change that occurred for patients reaching their functional goals, work status, and if the patient was currently in litigation.139C^mm^Zg]C^mm^92 further substantiated the sensitivity to change by calculating the effect sizes for change scores of [hmama^G=BZg]L?&,/'
I
Two studies*/*%*02 with small sample sizes have identified the minimal detectable change, or the amount of change that must be observed before the change can be considered to exceed the measurement error, for the NDI. Westaway*02 b]^gmbÖ^]ma^fbgbfZe]^m^\mZ[e^\aZg`^Zl.!*)i^k\^gmZ`^ points) in a group of 31 patients with neck pain. Stratford and colleagues*/* identified the minimal detectable change Zelhmh[^.!*)i^k\^gmZ`^ihbgml"bgZ`khnih_-1iZmb^gml with neck pain. However, the minimum clinically important difference, the smallest difference which patients perceive as beneficial, may be more useful to clinicians.12 Stratford and colleagues*/* identified the minimal clinically important dif_^k^g\^ Zl . ihbgml !*) i^k\^gmZ`^ ihbgml"' Fhk^ k^\^gmer% Cleland and colleagues,,. described the minimum clinically bfihkmZgm ]bü^k^g\^ _hk ma^ G=B mh [^ 2'. !*2 i^k\^gmZ`^ points) for patients with mechanical neck disorders. The NDI has demonstrated moderate test re-test reliability and has been shown to be a valid health outcome measure in a patient population with cervical radiculopathy. ,0 In this group, the intraclass correlation coefficient (ICC) for test rem^lmk^ebZ[bebmrpZl)'/1_hkma^G=BZg]ma^fbgbfnf\ebgb\ZeerbfihkmZgm]bü^k^g\^pZl0!*-i^k\^gmZ`^ihbgml"' ,0
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The Patient-Specific Functional Scale (PSFS) is a practical alternative or supplement to generic and condition-specific measures.*02 The PSFS asks pa-
tients to list 3 activities that are difficult as a result of their symptoms, injury, or disorder. The patient rates each activity on a 0-10 scale, with 0 representing the inability to perform the activity, and 10 representing the ability to perform the activity as well as they could prior to the onset of symptoms.*/) The final PSFS score is the average of the 3 activity scores. The PSFS was developed by Stratford et al*/) in an attempt to present a standardized measure for recording a patient’s perceived level of disability across a variety of conditions. The PSFS has been evaluated for reliability and validity in patients with neck pain.*02 The ICC value for test retest reliZ[bebmrbgiZmb^gmlpbma\^kob\ZekZ]b\nehiZmarpZl)'1+',0 The minimal detectable change in that population was identified to be 2.1 points with a minimum clinically important difference of 2.0.,0 Clinicians should use validated self-report questionnaires, such as the Neck Disability Index and the Patient-Specific Functional Scale for patients with neck pain. These tools are useful for identifying a patient’s baseline status relative to pain, function, and disability and for monitoring a change in patient’s status throughout the course of treatment.
A
79J?L?JOB?C?J7J?ED7D:F7HJ?9?F7J?EDH;IJH?9J?EDC;7IKH;I There are no activity limitation and participation restriction measures specifically reported in the literature associated with neck pain - other than those that are part of the self-report questionnaire noted in mabl`nb]^ebg^Íll^\mbhghgHnm\hf^F^Zlnk^l'Ahp^o^k%ma^ following measures are options that a clinician may use to assess changes in a patient’s level of function over an episode of care. IZbge^o^eZm^g]kZg`^lh_ehhdbg`ho^klahne]^k IZbge^o^eZm^g]kZg`^lh_ehhdbg`]hpg IZbge^o^eZm^g]kZg`^lh_ehhdbg`ni IZbge^o^eZ_m^klbmmbg`_hk+ahnkl Gnf[^kh_mbf^li^kgb`ammaZmiZbg]blknimlle^^i =^ldphkdmhe^kZg\^!bggnf[^kh_fbgnm^lhkahnkl" I^k\^gmh_mbf^^qi^kb^g\bg`g^\diZbgho^kma^ik^obhnl 24 hours I^k\^gmh_mbf^^qi^kb^g\bg`a^Z]Z\a^!l"ho^kma^ik^obous month
V
september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s In addition, the Patient-Specific Functional Scale is a questionnaire that can be used to quantify changes in activity limitations and participation restrictions for patients with neck pain.*/) This scale enables the clinician to collect measures related to function that may be different then the measures that are components of the regionspecific outcome measures section such as the Neck Dis-
ability Index. *02 Clinicians should utilize easily reproducible activity limitation and participation restriction measures associated with their patient’s neck pain to assess the changes in the patient’s level of function over the episode of care.
F
F>OI?97B?CF7?HC;DJC;7IKH;I Cervical Active Range of Motion ICF category
C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅceX_b_joe\i[l[hWb`e_dji
Description
J^[Wcekdje\WYj_l[d[YaÔ[n_ed"[nj[di_ed"hejWj_ed"WdZi_Z[X[dZ_d]cej_edc[Wikh[Zki_d]Wd_dYb_dec[j[h
Measurement method
7bbY[hl_YWbhWd][e\cej_ed HEC c[Wikh[iWh[f[h\ehc[Z_dj^[kfh_]^ji_jj_d]fei_j_ed$9Wh[i^ekbZX[jWa[dje[dikh[j^[ fWj_[djcW_djW_diWdkfh_]^ji_jj_d]fei_j_edj^hek]^ekjj^[[nWc_dWj_edWdZZkh_d]ikXi[gk[dj\ebbem#kf[nWc_dWj_edi$J^[ \ebbem_d]fheY[Zkh[iWh[ki[Zjec[Wikh[j^[HEC\ehj^[Y[hl_YWbif_d[$ D[Ya
Nature of variable
9edj_dkeki
Units of measurement
:[]h[[i
Measurement properties
9[hl_YWb HEC c[Wikh[c[dji \eh Ô[n_ed" [nj[di_ed" WdZ i_Z[X[dZ_d] ki_d] W XkXXb[ _dYb_dec[j[h ^Wl[ [n^_X_j[Z h[b_WX_b_jo Ye[øY_[djihWd]_d]\hec&$,,je&$.* ?99("' $)("'-+
Instrument variations
?dWZZ_j_edjeki_d]Wd_dYb_dec[j[h"+".)"'(."'.&Y[hl_YWbHECYWdWbieX[c[Wikh[Z\ehYb_d_YWbfkhfei[iki_d]WY[hl_YWbhWd][e\cej_ed 9HEC Z[l_Y['')"',+ehWjWf[c[Wikh[$7bbc[j^eZiWh[ceZ[hWj[boYehh[bWj[Zm_j^ceh[Z[Ód_j_l[hWZ_e]hWf^_YWdZ):a_d[cWj_Y c[Wikh[c[dj$*"+
Cervical And Thoracic Segmental Mobility ICF category
C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅceX_b_joe\i_d]b[`e_dji
Description
M_j^j^[fWj_[djfhed["Y[hl_YWbWdZj^ehWY_Yif_d[i[]c[djWbcel[c[djWdZfW_dh[ifedi[Wh[Wii[ii[Z
Measurement method
J^[fWj_[dj_ifhed[$J^[[nWc_d[hYedjWYji[WY^Y[hl_YWbif_dekifheY[iim_j^j^[j^kcXi$J^[bWj[hWbd[YackiYkbWjkh[_i][djbo fkbb[Zib_]^jbofeij[h_ehm_j^j^[Ód][hi$J^[[nWc_d[hi^ekbZX[Z_h[Yjboel[hj^[YedjWYjWh[Wa[[f_d][bXemi[nj[dZ[Z"j^[d^[% i^[ki[ij^[kff[hjhkdaje_cfWhjWfeij[h_ehjeWdj[h_eh\ehY[_dWfhe]h[ii_l[eiY_bbWjeho\Wi^_edel[hj^[if_dekifheY[ii$J^_i _ih[f[Wj[Z\eh[WY^Y[hl_YWbi[]c[dj$J^[[nWc_d[hj^[dY^Wd][i^_i%^[hYedjWYjfei_j_edWdZfbWY[ij^[^ofej^[dWh[c_d[dY[ `kijZ_ijWbjej^[f_i_\ehc e\ed[^WdZel[hj^[if_dekifheY[iie\[WY^j^ehWY_Yif_dekifheY[iiWdZh[f[Wjij^[iWc[feij[h_eh jeWdj[h_eh\ehY[i_dWfhe]h[ii_l[eiY_bbWjeho\Wi^_ed$J^[j[ijh[ikbj_iYedi_Z[h[ZjeX[fei_j_l[_\j^[fWj_[djh[fehjih[fheZkYj_ed e\fW_d$J^[ceX_b_joe\j^[i[]c[dj_i`kZ][ZjeX[dehcWb"^of[hceX_b["eh^ofeceX_b[$?dj[hfh[jWj_ede\ceX_b_jo_iXWi[Zedj^[ [nWc_d[hÊif[hY[fj_ede\j^[ceX_b_joWj[WY^if_dWbi[]c[djh[bWj_l[jej^ei[WXel[WdZX[bemj^[j[ij[Zi[]c[dj"WdZXWi[Zed j^[[nWc_d[hÊi[nf[h_[dY[WdZf[hY[fj_ede\dehcWbceX_b_jo$
Nature of variable
Dec_dWb fW_dh[ifedi[ WdZehZ_dWb ceX_b_jo`kZ]c[dj
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a15
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Cervical And Thoracic Segmental Mobility (continued) Units of measurement
None
Diagnostic accuracy and measurement properties
:_W]deij_Y7YYkhWYo'**0 FW_dZkh_d]i[]c[djWbj[ij_d]WiieY_Wj[Zm_j^h[fehjie\d[YafW_d$ I[di_j_l_jo3&$.(1d[]Wj_l[b_a[b_^eeZhWj_e #BH 3&$() If[Y_ÓY_jo3&$-/1fei_j_l[b_a[b_^eeZhWj_e !BH 3)$/ H[b_WX_b_jo\ehY[hl_YWbif_d[Wii[iic[dj0 AWffW3&$'*je&$)- fW_d ',/ ?993&$*(je&$-/ fW_d '' ?993&$-.je'$& fh[i[dY[e\`e_djZoi\kdYj_ed_dkff[h)Y[hl_YWbif_d[i[]c[dji '&& M[_]^j[ZaWffW0#&$(,je&$-* ceX_b_jo "#&$+(je&$/& fW_d )( H[b_WX_b_jo\ehj^ehWY_Yif_d[Wii[iic[dj0 M[_]^j[ZaWffW0&$')je&$.( ceX_b_jo "#&$''je&$/& fW_d )(
Cranial Cervical Flexion Test ICF category
C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅYedjhebe\i_cfb[lebkdjWhocel[c[djiWdZ[dZkhWdY[e\_iebWj[ZckiYb[i
Description
?dikf_d["j^[WX_b_joje_d_j_Wj[WdZcW_djW_d_iebWj[ZYhWd_WbWdZY[hl_YWbÔ[n_ed
Measurement method
FWj_[dj_ifei_j_ed[Zikf_d[_d^eeabo_d]WdZj^[^[WZWdZd[Ya_dc_Z#hWd][d[kjhWb _cW]_dWhob_d[X[jm[[d\eh[^[WZWdZY^_dWdZ _cW]_dWhob_d[X[jm[[dj^[jhW]kie\j^[[WhWdZj^[d[Yabed]_jkZ_dWbboi^ekbZX[fWhWbb[bje[WY^ej^[hWdZj^[ikh\WY[e\j^[ jh[Wjc[djjWXb[ $Jem[bicWoX[d[[Z[ZkdZ[hj^[eYY_fkjjeWY^_[l[j^_id[kjhWbfei_j_ed$7fd[kcWj_Yfh[iikh[Z[l_Y["ikY^WiW fh[iikh[X_e\[[ZXWYakd_j"_i_dÔWj[Zje(&cc>]jeÓbbj^[ifWY[X[jm[[dj^[Y[hl_YWbbehZej_YYkhl[WdZj^[ikh\WY[e\j^[jWXb[ X[^_dZj^[ikXeYY_f_jWbh[]_ed"dejX[bemj^[bem[hY[hl_YWbWh[W $ M^_b[a[[f_d]j^[feij[h_eh^[WZ%eYY_fkjijWj_edWho Zedejb_\j"Zedejfki^Zemd "j^[fWj_[djf[h\ehciYhWd_WbY[hl_YWbÔ[n_ed 99< _dW]hWZ[Z\Wi^_ed_d+_dYh[c[dji (("(*"(,"(."WdZ)&cc>] WdZW_cije^ebZ[WY^fei_j_ed\eh'&i[YedZi$J[di[YedZi h[ij_ifhel_Z[ZX[jm[[dijW][i$Jef[h\ehc99<"j^[fWj_[dj_i_dijhkYj[Zje][djbodeZj^[^[WZWij^ek]^j^[om[h[iWo_d]Ço[iÈ m_j^j^[kff[hd[Ya$J^_icej_edm_bbÔWjj[dj^[Y[hl_YWbbehZei_i"j^kiY^Wd]_d]j^[fh[iikh[_dj^[fd[kcWj_Yfh[iikh[Z[l_Y[$M^_b[ j^[fWj_[dj_if[h\ehc_d]j^[j[ijcel[c[dj"j^[j^[hWf_ijfWbfWj[ij^[d[Yajeced_jeh\ehkdmWdj[ZWYj_lWj_ede\j^[ikf[hÓY_Wb Y[hl_YWbckiYb[i"ikY^Wij^[ij[hdeYb[_ZecWije_Z$J^[fWj_[djYWdfbWY[^_i%^[hjed]k[edj^[hee\e\j^[cekj^"m_j^b_fije][j^[h Xkjj^[j[[j^ib_]^jboi[fWhWj[Z"je^[bfZ[Yh[Wi[fbWjoicWWdZ%eh^oe_ZWYj_lWj_ed$J^[j[ij_i]hWZ[ZWYYehZ_d]jej^[fh[iikh[b[l[b j^[fWj_[djYWdWY^_[l[m_j^YedY[djh_YYedjhWYj_ediWdZWYYkhWj[boikijW_d_iec[jh_YWbbo$J^[j[ij_ij[hc_dWj[Zm^[dj^[fh[iikh[ _iZ[Yh[Wi[ZXoceh[j^Wd(&ehm^[dj^[fWj_[djYWddejf[h\ehcj^[fhef[h99<cel[c[djm_j^ekjikXij_jkj_edijhWj[]_[i$ 7dehcWbh[ifedi[_i\ehj^[fh[iikh[je_dYh[Wi[jeX[jm[[d(,#)&cc>]WdZX[cW_djW_d[Z\eh'&i[YedZim_j^ekjkj_b_p_d] ikf[hÓY_WbY[hl_YWbckiYb[ikXij_jkj_edijhWj[]_[i$ 7dWXdehcWbh[ifedi[_im^[h[j^[fWj_[dj0 '$?ikdWXb[je][d[hWj[Wd_dYh[Wi[_dfh[iikh[e\Wjb[Wij,cc>]" ($?ikdWXb[je^ebZj^[][d[hWj[Zfh[iikh[\eh'&i[YedZi" )$Ki[iikf[hÓY_Wbd[YackiYb[ijeWYYecfb_i^j^[Y[hl_YWbÔ[n_edcej_ed"eh *$Ki[iWikZZ[dcel[c[dje\j^[Y^_dehfki^_d] [nj[dZ_d] j^[d[Ya\ehY[\kbboW]W_dijj^[fh[iikh[Z[l_Y[ IYeh_d]0 7Yj_lWj_edIYeh[0Fh[iikh[WY^_[l[ZWdZ^[bZ\eh'&i[YedZ F[h\ehcWdY[?dZ[n0?dYh[Wi[_dFh[iikh[dkcX[he\h[f[j_j_edi
Nature of variable
9edj_dkeki
Units of measurement
cc>]\ehj^[WYj_lWj_ediYeh[
Measurement properties
H[b_WX_b_joWii[iic[dj\eh+&WiocfjecWj_YikX`[Yji"j[ij[Zjm_Y[ 'm[[aWfWhj 07Yj_lWj_ediYeh[0?993&$.'1F[h\ehcWdY[?dZ[n0?993$/)/,
Neck Flexor Muscle Endurance Test
a16
ICF category
C[Wikh[c[dje\_cfW_hc[dje\XeZo\kdYj_edÅ[dZkhWdY[e\_iebWj[ZckiYb[i
Description
?dikf_d["j^[WX_b_jojeb_\jj^[^[WZWdZd[YaW]W_dij]hWl_jo\ehWd[nj[dZ[Zf[h_eZ
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Neck Flexor Muscle Endurance Test (continued) Measurement method
J^[j[ij_if[h\ehc[Z_dWikf_d["^eea#bo_d]fei_j_ed$M_j^j^[Y^_dcWn_cWbboh[jhWYj[ZWdZcW_djW_d[Z_iec[jh_YWbbo"j^[fWj_[dj b_\jij^[^[WZWdZd[Yakdj_bj^[^[WZ_iWffhen_cWj[bo($+Yc '_d WXel[j^[fb_dj^m^_b[a[[f_d]j^[Y^_dh[jhWYj[Zjej^[Y^[ij$ J^[Yb_d_Y_Wd\eYki[iedj^[ia_d\ebZiWbed]j^[fWj_[djÊid[YaWdZfbWY[iW^WdZedj^[jWXb[`kijX[bemj^[eYY_f_jWbXed[e\j^[ fWj_[djÊi^[WZ$L[hXWbYeccWdZi _["ÇJkYaoekhY^_dÈehÇ>ebZoekh^[WZkfÈ Wh[]_l[dm^[d[_j^[hj^[ia_d\ebZ i X[]_dije i[fWhWj[ehj^[fWj_[djÊieYY_fkjjekY^[ij^[Yb_d_Y_WdÊi^WdZ$J^[j[ij_ij[hc_dWj[Z_\j^[ia_d\ebZ i _ii[fWhWj[ZZk[jebeiie\ Y^_djkYaehj^[fWj_[djÊi^[WZjekY^[ij^[Yb_d_Y_WdÊi^WdZ\ehceh[j^Wd'i[YedZ$-+
Nature of variable
9edj_dkeki
Units of measurement
I[YedZi
Measurement properties
?dWijkZoXo>Whh_i[jWb"-+*'ikX`[Yjim_j^WdZm_j^ekjd[YafW_df[h\ehc[Zj^_ij[ij$JmehWj[hij[ij[ZWbbikX`[YjiWjXWi[b_d["WdZ ikX`[Yjim_j^ekjd[YafW_dm[h[j[ij[ZW]W_d'm[[abWj[h$ H[b_WX_b_jo0 IkX`[Yjim_j^ekjd[YafW_d0 ?99 )"' 3&$.(je&$/'"I;C.$&#''$&i[YedZi ?99 ("' 3&$,-je&$-."I;C'($,#'+$)i[YedZi IkX`[Yjim_j^d[YafW_d0 ?99 ("' 3&$,-"I;C''$+i[YedZi J[ijh[ikbji0 IkX`[Yjim_j^ekjd[YafW_d0C[Wd).$/+i[YedZi I:3(,$* IkX`[Yjim_j^d[YafW_d0C[Wd(*$'i[YedZi I:3'($.
Upper Limb Tension Test ICF category
C[Wikh[c[dje\_cfW_hc[dje\ijhkYjkh[e\j^[d[hlekiioij[c"ej^[hif[Y_Ó[Z
Description
?dded#m[_]^jX[Wh_d]"j^[Wcekdje\ceX_b_joe\j^[d[khWb[b[c[djie\j^[kff[hb_cXWh[Wii[ii[Zm^_b[Z[j[hc_d_d]m^[j^[hj^[ fWj_[djÊikff[hgkWhj[hiocfjeciWh[[b_Y_j[ZZkh_d]f[h\ehcWdY[e\j^[j[ij
Measurement method
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Nature of variable
Dec_dWb
Units of measurement
None
Diagnostic accuracy indices for the upper limb tension test, based on the study by Wainner et al175
AWffW I[di_j_l_jo If[Y_ÓY_jo Fei_j_l[b_a[b_^eeZhWj_e D[]Wj_l[b_a[b_^eeZhWj_e
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Spurling’s Test ICF category
C[Wikh[c[dje\_cfW_hc[dje\ijhkYjkh[e\j^[d[hlekiioij[c"ej^[hif[Y_Ó[Z
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a17
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Spurling’s Test (continued) Description
9ecX_dWj_ede\i_Z[X[dZ_d]jej^[iocfjecWj_Yi_Z[Yekfb[Zm_j^Yecfh[ii_edjeh[ZkY[j^[Z_Wc[j[he\j^[d[khWb\ehWc[dWdZ [b_Y_jj^[fWj_[djÊiiocfjeci
Measurement method
J^[fWj_[dj_ii[Wj[ZWdZ_iWia[Zjei_Z[X[dZWdZib_]^jbohejWj[j^[^[WZjej^[fW_d\kbi_Z[$J^[[nWc_d[hfbWY[iWYecfh[ii_ed\ehY[ e\Wffhen_cWj[bo-a]j^hek]^j^[jefe\j^[^[WZ_dWd[÷ehjje\khj^[hdWhhemj^[_dj[hl[hj[XhWb\ehWc[d$J^[j[ij_iYedi_Z[h[Zfei_j_l[ m^[d_jh[fheZkY[ij^[fWj_[djÊiiocfjeci$J^[j[ij_idej_dZ_YWj[Z_\j^[fWj_[dj^Widekff[h[njh[c_joehiYWfkbWhh[]_ediocfjeci$
Nature of variable
Dec_dWb%Z_Y^ejeceki
Units of measurement
None
Diagnostic accuracy indices for Spurling’s test, based on the study by Wainner et al175
AWffW I[di_j_l_jo If[Y_ÓY_jo Fei_j_l[b_a[b_^eeZhWj_e D[]Wj_l[b_a[b_^eeZhWj_e
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D istraction Test ICF category
C[Wikh[c[dje\_cfW_hc[dje\ijhkYjkh[e\j^[d[hlekiioij[c"ej^[hif[Y_Ó[Z
Description
:_ijhWYj_ede\j^[Y[hl_YWbif_d[jecWn_c_p[j^[Z_Wc[j[he\j^[d[khWb\ehWc[dWdZh[ZkY[eh[b_c_dWj[j^[fWj_[djÊiiocfjeci
Measurement method
J^[Z_ijhWYj_edj[ij_iki[Zje_Z[dj_\oY[hl_YWbhWZ_YkbefWj^oWdZ_if[h\ehc[Zm_j^j^[fWj_[djikf_d[$J^[[nWc_d[h]hWifikdZ[h j^[ Y^_d WdZ eYY_fkj" Ô[n[i j^[ fWj_[djÊi d[Ya je W fei_j_ed e\ Yec\ehj" WdZ ]hWZkWbbo Wffb_[i W Z_ijhWYj_ed \ehY[ e\ kf je Wffhen_cWj[bo'*a]$7fei_j_l[j[ijeYYkhim_j^j^[h[ZkYj_edeh[b_c_dWj_ede\j^[fWj_[djÊikff[h[njh[c_joehiYWfkbWhiocfjeci$ J^_ij[ij_idej_dZ_YWj[Z_\j^[fWj_[dj^Widekff[h[njh[c_joehiYWfkbWhh[]_ediocfjeci$
Nature of variable
Dec_dWb
Units of measurement
None
Diagnostic accuracy indices for the upper limb tension test, based on the study by Wainner et al175
AWffW I[di_j_l_jo If[Y_ÓY_jo Fei_j_l[b_a[b_^eeZhWj_e D[]Wj_l[b_a[b_^eeZhWj_e
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Valsalva Test ICF category
C[Wikh[c[dje\_cfW_hc[dje\ijhkYjkh[e\j^[d[hlekiioij[c"ej^[hif[Y_Ó[Z
Description
CWd[kl[h_dm^_Y^j^[fWj_[djX[WhiZemdm_j^ekj[n^Wb_d]je_dYh[Wi[_djhWj^[YWbfh[iikh[WdZ[b_Y_jkff[hgkWhj[hiocfjeci
Measurement method
J^[fWj_[dj_ii[Wj[ZWdZ_dijhkYj[ZjejWa[WZ[[fXh[Wj^WdZ^ebZ_jm^_b[Wjj[cfj_d]je[n^Wb[\eh(#)i[YedZi$7fei_j_l[ h[ifedi[eYYkhim_j^h[fheZkYj_ede\iocfjeci$
Nature of variable
Dec_dWb%Z_Y^ejeceki
Units of measurement
None
Diagnostic accuracy indices for the valsalva test, based on the study by Wainner et al175
a18
|
AWffW I[di_j_l_jo If[Y_ÓY_jo Fei_j_l[b_a[b_^eeZhWj_e D[]Wj_l[b_a[b_^eeZhWj_e
&$,/ &$(( &$/* )$+& &$.)
/+9edÓZ[dY[?dj[hlWb &$),#'$& &$&)#&$*' &$..#'$& &$/-#'($, &$,*#'$'
september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
CLINICAL GUIDELINES
Interventions A variety of interventions have been described for the treatment of neck pain and there is good evidence from highquality randomized, controlled trials and systematic reviews to support the benefits of physical therapy intervention in these patients.
CERVICAL MOBILIZATION/MANIPULATION The most recent Cochrane Collaboration Review69 of mobilization and manipulation for mechanical neck disorders included 33 randomized controlled trials of which 42% were considered high quality. They concluded that the most beneficial manipulative interventions for patients with mechanical neck pain with or without headaches should be combined with exercise to reduce pain and improve patient satisfaction. Manipulation (thrust) and mobilization (non-thrust manipulation) intervention alone were determined to be less effective than when combined with exercise (combined intervention).69 A recently published clinical practice guideline concluded that the evidence for combined intervention was relatively strong, while the evidence for the effectiveness of thrust or non-thrust manipulation in isolation was weaker.68
I
The recommendations of the Cochrane Review69 and the recently published clinical practice guideline68 were based on key findings that warrant further discussion. Studies cited included patients with both acute82and chronic neck pain22 and interventions consisted of soft-tissue mobilization and manual stretching procedures, as well as thrust,17,83 and nonthrust manipulative procedures82 directed at spinal motion segments. Number of visits ranged from 6 over a 3 week period82 to 20 over an 11 week period22 and the duration of sessions ranged from 30 minutes99 to 60 minutes.22 Combined intervention was compared with various competing interventions that included manipulation alone,22,99 various non-manual physical therapy interventions,82 high-tech and low-tech exercises,22,82,99 general practitioner care (medication, advice, education),82 and no treatment.99 The majority of studies report either clinically or statistically important differences in pain in favor of combined intervention when compared to competing single interventions.69 Differences in muscle performance22,99 as well as patient satisfaction have also been reported for both short-term22,82,99 as well as longterm outcomes 122 and 2 years later.58 When compared to care
rendered by a general practitioner and non-manual physical therapy interventions, the combination of manipulation and exercise resulted in significant cost-savings of up to 68%.106 Although many patients experience a significant benefit when treated with thrust manipulation, it is still unclear which patients benefit most. Tseng et al166 reported 6 predictors for patients who experienced an immediate improvement in either pain, satisfaction, or perception of condition following manipulation of the cervical spine. These predictors included166: BgbmbZel\hk^lhgG^\d=blZ[bebmrBg]^qe^llmaZg**'. AZobg`[beZm^kZebgoheo^f^gmiZmm^kg Ghm i^k_hkfbg` l^]^gmZkr phkd fhk^ maZg . ahnkl i^k day ?^^ebg`[^mm^kpabe^fhobg`ma^g^\d =b]ghm_^^ephkl^pabe^^qm^g]bg`ma^g^\d Ma^]bZ`ghlblh_lihg]rehlblpbmahnmkZ]b\nehiZmar
II
The presence of 4 or more of these predictors increased the probability of success with manipulation from 60% to 89%.166 Predictors of which patients respond best to combined intervention have not been reported. Nilsson et al125 conducted a randomized, clinical trial (n=53) in individuals with cervicogenic headache. Subjects were randomized to receive high velocity low amplitude spinal manipulation or low level laser and deep friction massage. The use of analgesics were reduced by 36% in the manipulation group but were unchanged in the laser/massage group. The number of headache hours per day decreased by 69% for the individuals in the manipulation `khniZg],0 bgma^eZl^k(fZllZ`^`khni'A^Z]Z\a^bgm^gsity per episode decreased by 36% for those in the manipulation group and 17% in the laser/massage group.
I
A systematic review by Vernon et al,171 which included studies published through 2005, concluded that there is moderate- to high-quality evidence that subjects with chronic neck pain and headaches show clinically important improvements from a course of spinal mobilization or manipulation at 6, 12, and up to 104 weeks post-treatment.
II
Despite good evidence to support the benefits of cervical mobilization/manipulation, it is important that physical
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a19
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s therapists be aware of the potential risks in using these techniques./1%/2 However, it is impossible to determine the precise risk because (1) it is extremely difficult to quantify the number of cervical spine mobilization/manipulative interventions performed each year, and (2) not all adverse events occurring after mobilization/manipulation interventions are published in the peer-reviewed literature, and there is no accepted standard for reporting these injuries. Reported risk factors include hypertension, migraines, oral contraceptive use, and smoking.0+ However, the prevalence of these factors in the study by Haldeman et al0+ is largely the same or lower than that which occurs in the general population. Although the true risk for complications remains unknown, ma^kbld_hkl^kbhnl\hfieb\Zmbhglbl^lmbfZm^]mh[^/bg*) fbeebhg!)'))))/ "fZgbineZmbhgl%pbmama^kbldh_]^Zma[^ing 3 in 10 million (0.000003%). Importantly, these rates are adjusted assuming that only 1 in 10 complications is actually reported in the literature.1- Gross et al0) recently reported, in a clinical practice guideline on the use of mobilization/ manipulation in patients with mechanical neck pain, that estimates for serious complication for manipulation ranged _khf*bg+)%)))!)')* "mh.bg*)fbeebhg!)'))). "'0) The risk estimate for patients experiencing non-serious side effects such as increased symptoms, ranges from 1% to 2%.149 The most common side effects included local discom_hkm!., "%eh\Zea^Z]Z\a^!*+ "%_Zmb`n^!** "%hkkZ]bZmbg` ]bl\hf_hkm!*) "'IZmb^gml\aZkZ\m^kbs^]1. h_ma^l^\hfieZbgmlZlfbe]hkfh]^kZm^%pbma/- h_lb]^^ü^\mlZii^Zking within 4 hours after manipulation. Within 24 hours after fZgbineZmbhg%0- h_ma^\hfieZbgmlaZ]k^lheo^]'E^llmaZg . h_lb]^^ü^\mlp^k^\aZkZ\m^kbs^]Zl]bssbg^ll%gZnl^Z%ahm skin, or other complaints. Side effects were rarely still noted on the day after manipulation, and very few patients reported the side effects as being severe. Due the potential risk of serious adverse effects associated with cervical manipulation, such as vertebrobasilar artery stroke,./ it has been recommended that non-thrust cervical mobilization/manipulation be utilized in favor of thrust manipulation..)%1. However, information regarding the risk/ benefit ratio of providing cervical thrust manipulation to patients with impairments of body function purported to benefit from cervical mobilization/manipulation, such as cervical segmental mobility deficits, has not been reported. In addition, the case reports in the literature describing serious adverse effects associated with cervical thrust manipulation do not provide information regarding either the presence of bfiZbkf^gmlh_[h]r_ng\mbhgl%hkma^ik^l^g\^h_k^]×Z`l for vertebrobasilar insufficiency,0 prior to the application of the manipulative procedure suspected to be linked with the reported harmful effects. a20
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Recommendation: Clinicians should consider utilizing cervical manipulation and mobilization procedures, thrust and non-thrust, to reduce neck pain and headache. Combining cervical manipulation and mobilization with exercise is more effective for reducing neck pain, headache, and disability than manipulation and mobilization alone.
A
T>EH79?9CE8?B?P7J?ED%C7D?FKB7J?ED A survey among clinicians that practice manual physical therapy reported that the thoracic spine is the region of the spine most often manipulated, despite the fact that more patients complain of neck pain.1 While several randomized clinical trials have examined the effectiveness of thoracic libg^ maknlm fZgbineZmbhg !MLF" _hk iZmb^gml pbma g^\d pain, patients in these studies also received cervical manipulation.+%++%.0 The rationale to include thoracic spine mobilization/manipulation in the treatment of patients with neck pain stems from the theory that disturbances in joint mobility in the thoracic spine may be an underlying contributor to musculoskeletal disorders in the neck. 2-%*). Cleland et al34\hfiZk^]ma^^ü^\mbo^g^llh_MLFbg a trial in which patients were randomized to either a lbg`e^l^llbhgh_MLFhklaZffZgbineZmbhg'IZmb^gml pahk^\^bo^]MLF^qi^kb^g\^]Z\ebgb\Zeerf^Zgbg`_neZg]lmZtistically significant reduction in pain on the visual analogue scale (VAS) compared to patients who received the sham intervention (P .001).34 A similar finding (reduction of pain) was Zelhk^ihkm^]bgZkZg]hfbs^]mkbZemaZm\hfiZk^]MLFbgm^kvention to an active exercise program.*-0 A subsequent randomized trial by Cleland et al,1pab\a\hfiZk^]MLFmhghg&maknlm manipulation (mobilization) found significant differences in faohkh_ma^MLF`khnibgiZbg%]blZ[bebmr%Zg]iZmb^gmi^k\^bo^] bfikho^f^gmnihgk^&^oZenZmbhg-1ahnkleZm^k'
I
While preliminary reports indicate that patients with complaints of primary neck pain experience a lb`gbÖ\Zgm[^g^Ömpa^gmk^Zm^]pbmaMLF%bmbllmbee unclear which patients benefit most. Cleland et al33 reported a preliminary clinical prediction rule for patients with primary neck pain who experience short-term improvement (1-week) pbmaMLF'>Z\aln[c^\mk^\^bo^]ZmhmZeh_,mahkZ\b\fZgbinlations directed at the upper and middle thoracic spine for up mh+l^llbhgl'Nlbg`Z`eh[ZekZmbg`h_\aZg`^l\hk^l.ZlZ k^_^k^g\^\kbm^kbhg%/oZkbZ[e^lp^k^k^ihkm^]Zlik^]b\mhklh_ improvement and included33: Lrfimhf]nkZmbhgh_e^llmaZg,)]Zrl Ghlrfimhfl]blmZemhma^lahne]^k Ln[c^\m k^ihkml maZm ehhdbg` ni ]h^l ghm Z``kZoZm^ symptoms ?^Zk&Zohb]Zg\^ ;^eb^_l Jn^lmbhggZbk^&Iarlb\Ze :\mbobmr Scale score less than 12
II
september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s =bfbgbla^]nii^kmahkZ\b\libg^driahlbl!M,ÈM." <^kob\Ze^qm^glbhgh_e^llmaZg,) Interestingly, the lack of symptom aggravation with looking up was also one of the predictors reported by Tseng et al*// in the cervical manipulation clinical prediction rule. Validation h_[hmama^\^kob\ZeZg]MLF\ebgb\Zekne^lblk^jnbk^][^_hk^ they can be recommended for widespread clinical use. In a randomized clinical trial Fernández de las Peñas et al.2 demonstrated that patients with neck pain related to a whiplash-associated disorder receiobg` MLF ^qi^kb^g\^] Z lb`gbÖ\Zgmer `k^Zm^k !I5'))," reduction in pain as measured by the visual analogue scale, than those who did not receive the thoracic manipulation. Ma^f^Zg\aZg`^bgiZbge^o^elbgma^`khnik^\^bobg`MLF pZl.-'*ff!L=*1'1ff"\hfiZk^]mhZf^Zg\aZg`^h_ *,'-ff!L=1'2ff"bgma^`khnighmk^\^bobg`mahkZ\b\fZnipulation. The length of follow-up was not clearly defined.
I
Self-reported levels of pain and cervical active KHFp^k^Zll^ll^][^_hk^Zg]bff^]bZm^erZ_m^k MLF bg +/ iZmb^gml pbma Z ikbfZkr \hfieZbgm h_ neck pain. The mean reduction in pain on an 11-point numeric pain rating scale was approximately 2 points (P .01), which has been shown to indicate that a clinically meaningful improvement has occurred. Significant increases in cervical Z\mbo^KHFp^k^Zelhh[l^ko^]bgZee]bk^\mbhgl^q\^im^qm^glbhg!I5'))*"'Mabllmn]r]b]ghmbg\en]^Z\hgmkhe`khniZg] only consisted of an immediate follow-up, but the immediate bfikho^f^gmlbgiZbgZg]\^kob\ZeZ\mbo^KHFln``^lmmaZm MLFfZraZo^lhf^f^kbmbgiZmb^gmlpbmag^\diZbg'/*
IV
There have been 4 case series that have incorporated thoracic spine thrust manipulation in the multi-modal management of patients with cervical radiculopathy.+,%,2%*+)%*0/ In the first case series,39 10 of the 11 patients (91%) demonstrated a clinically meaningful imikho^f^gm bg iZbg Zg] _ng\mbhg Zm ma^ /&fhgma _heehp&ni Z_m^kZf^Zgh_0'*iarlb\Zema^kZiroblbml'Bgma^l^\hg]\Zl^ series*0/ all patients except for 1 exhibited a significant reduction in disability. In the third case series,120 full resolution of iZbgpZlk^ihkm^]bg1h_*.!., "iZmb^gml%pa^k^Zee/h_ma^ patients receiving mobilization and manipulation achieved full resolution of pain. In addition, there has been 1 case series23 that included thoracic spine thrust manipulation in the fZgZ`^f^gmh_0iZmb^gmlpbma`kZ]^B\^kob\Ze\hfik^llbo^ myelopathy. All patients exhibited a reduction in pain and improvement in function at the time of discharge.
IV
C
Recommendation: Thoracic spine thrust manipulation can be used for patients with primary complaints of neck pain. Thoracic spine thrust ma-
nipulation can also be used for reducing pain and disability in patients with neck and neck-related arm pain.
IJH;J9>?D=;N;H9?I;I In a randomized controlled trial, Ylinen et al*1, assessed the effectiveness of manual therapy procedures implemented twice a week compared pbmaZlmk^m\abg`k^`bf^gi^k_hkf^].mbf^lZp^^dbgmahl^ with non-specific neck pain. At the 4 and 12 week follow-up both groups improved but there were no significant differences between the groups related to pain. Neck pain and disability outcome measures, shoulder pain and disability outcome measures, and neck stiffness were reduced significantly more in those receiving manual therapy, but the clinical difference was minimal. The authors concluded that the low-cost of stretching exercises should be included in the initial treatment plan for patients with neck pain.
I
The authors of this clinical practice guideline have observed that patients with neck pain often pres^gmpbmabfiZbkf^gmlh_×^qb[bebmrh_d^rfnl\e^l related to the lower cervical and upper thoracic spine, such as the anterior, medial, and posterior scalenes, upper trapezius, levator scapulae, pectoralis minor, and pectoralis major, that should be addressed with stretching exercises. One study k^ihkm^]maZmnii^kjnZkm^kfnl\e^×^qb[bebmr]^Ö\bmlp^k^ common in dental hygienists,2. an occupation that requires frequent repetitive activities involving the shoulders, arms, and hands. Although research generally does not support the effectiveness of interventions that focus on stretching and ×^qb[bebmr%\ebgb\Ze^qi^kb^g\^ln``^lmlmaZmZ]]k^llbg`li^cific impairments of muscle length for an individual patient may be a beneficial addition to a comprehensive treatment program.
V
Recommendation: Flexibility exercises can be used for patients with neck symptoms. Examination and mZk`^m^]×^qb[bebmr^q^k\bl^l_hkma^_heehpbg`fnlcles are suggested: anterior/medial/posterior scalenes, upper trapezius, levator scapulae, pectoralis minor, and pectoralis major.
C
9EEH:?D7J?ED"IJH;D=J>;D?D="7D:;D:KH7D9; ;N;H9?I;I Jull et al99 conducted a multi-centered, randomized clinical trial (n=200) in participants who met the diagnostic criteria for cervicogenic headache. The inclusion criteria were unilateral or unilateral dominant side-consistent headache associated with neck pain and aggravated by neck postures or movement, joint tenderness in at least 1 of the upper 3 cervical joints as detected by
I
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a21
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s manual palpation, and a headache frequency of at least 1 per week over a period of 2 months to 10 years. Subjects were randomized into 4 groups: mobilization/manipulation group, exercise therapy group, combined mobilization/manipulation and exercise group, and a control group. The primary outcome was a change in headache frequency. At the 12-month follow-up, the mobilization/manipulation, combined mobilization/manipulation and exercise, and the specific exercise groups had significantly reduced headache frequency and intensity. Additionally 10% more patients experienced a complete reduction in headache frequency when treated with mobilization/manipulation and exercise than those treated with the alternative approaches. 99 Ma^^q^k\bl^ikh`kZfbgmabl\ebgb\ZemkbZe[rCnee^mZe99 used low load endurance exercises to train muscle control of the cervicoscapular region. The first stage consisted of specific \kZgbh\^kob\Ze ×^qbhg ^q^k\bl^l% i^k_hkf^] bg lnibg^ erbg`% Zbf^]mhmZk`^mma^]^^ig^\d×^qhkfnl\e^l%pab\aZk^ma^ longus capitis and longus colli. Subsequently, isometric exercises using a low level of rotatory resistance were used to train ma^\h&\hgmkZ\mbhgh_ma^g^\d×^qhklZg]^qm^glhkl'Ma^^qercise groups had significantly reduced headache frequency and intensity when compared to the controls. Chiu et al+1 assessed the benefits of an exercise program that focused both on motor control training of ma^]^^ig^\d×^qhklZg]]rgZfb\lmk^g`ma^gbg`': mhmZeh_*-.iZmb^gmlpbma\akhgb\g^\diZbgp^k^kZg]hfbs^] to either an exercise or a non-exercise control group. At week /%ma^^q^k\bl^`khniaZ]lb`gbÖ\Zgmer[^mm^kbfikho^f^gml in disability scores, pain levels, and isometric neck muscle strength. However, significant differences between the 2 groups were found only in pain and patient satisfaction at ma^/&fhgma_heehp&ni'
I
BgZkZg]hfbs^]%\ebgb\ZemkbZe%Rebg^g^mZe*1- demonstrated the effectiveness of both strengthening exercises and endurance training of the deep neck ×^qhkfnl\e^lbgk^]n\bg`iZbgZg]]blZ[bebmrZmma^*&r^Zk _heehp&nibgphf^g!g6*1)"pbma\akhgb\%ghgli^\bÖ\g^\d pain. The endurance training group performed dynamic neck exercises, which included lifting the head up from the supine and prone positions. The strength training group performed high-intensity isometric neck strengthening and stabilization exercises with an elastic band. Both training groups performed dynamic exercises for the shoulders and upper extremities with dumbbells. Both groups were advised to also do aerobic and stretching exercises 3 times a week. In a ,&r^Zk_heehp&nilmn]r%Rebg^g^mZe*1+ found that women (n = **1"bg[hmama^lmk^g`ma^gbg`^q^k\bl^Zg]^g]nkZg\^mkZbging groups achieved long-term benefits from the 12-month programs.
I
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HÍE^Zkr ^m Ze*+0 compared the effect of 2 specific \^kob\Ze ×^qhk fnl\e^ ^q^k\bl^ ikhmh\hel hg bfmediate pain relief in the cervical spine of people with chronic neck pain. They found that those performing ma^ li^\bÖ\ \kZgbh\^kob\Ze ×^qbhg ^q^k\bl^ ]^fhglmkZm^] greater improvements in pressure pain thresholds, mechanical hyperalgesia, and perceived pain relief during active movement.
III
In a cross-sectional comparative study, Chiu et al29 compared the performance of the deep cervical ×^qhkfnl\e^lhgma^\kZgbh\^kob\Ze×^qbhgm^lmbg individuals with (n = 20) and without (n = 20) chronic neck pain. Those with chronic neck pain had significantly poorer i^k_hkfZg\^hgma^\kZgbh\^kob\Ze×^qbhgm^lm!f^]bZgik^lsure achieved, 24 mmHg when starting at 20 mmHg) when compared with those in the asymptomatic group (median ik^llnk^Z\ab^o^]%+1ffA`pa^glmZkmbg`Zm+)ffA`"'
III
Cnee ^m Ze20 compared the effects of conventional ikhikbh\^imbo^mkZbgbg`Zg]\kZgbh\^kob\Ze×^qbhg training on cervical joint position error in people with persistent neck pain. The aim was to evaluate whether proprioceptive training was superior in improving proprioceptive acuity compared to a form of exercise that has been shown to be effective in reducing neck pain. Sixty-four female subjects with persistent neck pain and deficits in cervical joint position error were randomized into 2 exercise groups: ikhikbh\^imbo^ mkZbgbg` hk \kZgbh\^kob\Ze ×^qbhg mkZbgbg`' >q^k\bl^ k^`bf^gl p^k^ \hg]n\m^] ho^k Z /&p^^d i^kbh]' The results demonstrated that both proprioceptive training Zg]\kZgbh\^kob\Ze×^qbhgmkZbgbg`aZo^Z]^fhglmkZ[e^[^gefit on impaired cervical joint position error in people with neck pain, with marginally more benefit gained from proprioceptive training. The results suggest that improved proprioceptive acuity following intervention with either exercise protocol may occur through an improved quality of cervical afferent input or by addressing input through direct training of relocation sense.20
I
In a randomized, clinical trial, Taimela et al*/+ compared the efficacy of a multimodal treatment emphasizing proprioceptive training in patients with ghg&li^\bÖ\\akhgb\g^\diZbg!g60/"'Ma^ikhikbh\^imbo^ treatment, which consisted of exercises, relaxation, and behavioral support was more efficacious than comparison interventions that consisted of (1) attending a lecture on the neck and 2 sessions of practical training for a home exercise program, and (2) a lecture regarding care of the neck with a recommendation to exercise. Specifically, the proprioceptive treatment group had greater reductions in neck symptoms, improvements in general health, and improvements in the ability to work.
I
september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s In a randomized clinical trial, Viljanen et al*0, assessed the effectiveness of dynamic muscle training !g6*,."%k^eZqZmbhgmkZbgbg`!g6*+1"%hkhk]bgZkr Z\mbobmr!g6*,."_hk_^fZe^hú\^phkd^klpbma\akhgb\g^\d pain. Dynamic muscle training and relaxation training did not lead to better improvements in neck pain compared with ordinary activity.
I
In a randomized clinical trial, Bronfort et al22 found that a combined program of strengthening and endurance exercises combined with manual therapy resulted in greater gains in strength, endurance, range of motion, and long-term patient pain ratings in those with chronic neck pain than programs that only incorporated manual therapy. Additionally, Evans et al.1 found that these results were maintained at a 2-year follow-up.
I
In a prospective case series, Nelson et al124 followed patients with cervical and lumbar pain and found that an aggressive strengthening program was able mhik^o^gmlnk`^krbg,.h_ma^/)iZmb^gml!-/h_ma^/)\hfie^m^]ma^ikh`kZf%,1p^k^ZoZbeZ[e^_hk_heehp&ni%Zg]hger 3 reported having surgery). Despite the methodological limitations of this study, some patients that were originally given the option of surgery were able to successfully avoid surgery in the short term following participation in an aggressive strengthening exercise program.
IV
In a systematic review of 9 randomized clinical triZelZg]0\hfiZkZmbo^mkbZelpbmafh]^kZm^f^mah]ological quality for patients with mechanical neck disorders, Sarig-Bahat*-. reported relatively strong evidence supporting the effectiveness of proprioceptive exercises and dynamic resisted strengthening exercises of the neck-shoulder musculature for patients with chronic or frequent neck disorders. The evidence identified could not support the effectiveness of group exercise, neck schools, or single sessions of extension-retraction exercises.
II
In a randomized clinical trial, Chiu et al30 found bgiZmb^gmlpbma\akhgb\g^\diZbg!g6+*1"%maZm Z /&p^^d mk^Zmf^gm h_ mkZgl\nmZg^hnl ^e^\mkbcal nerve stimulation or exercise had a better and clinically relevant improvement in disability, isometric neck muscle strength, and pain compared to a control group. All the improvements in the intervention groups were maintained at ma^/&fhgma_heehp&ni'
I
Hammill et al0- used a combination of postural education, stretching, and strengthening exercises to reduce the frequency of headaches and improve disability in a series of 20 patients, with results being maintained at a 12-month follow-up.
IV
BgZlrlm^fZmb\k^ob^p%DZr^mZe103 concluded that specific exercises may be effective for the treatment of acute and chronic mechanical neck pain, with or without headache.
I
A recent Cochrane review/2 concluded that mobilization and/or manipulation when used with exercise are beneficial for patients with persistent mechanical neck disorders with or without headache. However, manual therapy without exercise or exercise alone were not superior to one another.
I
Although evidence is generally lacking, postural correction and body mechanics education and training may also be indicated if clinicians identify ergonomic inefficiencies during either the examination or treatment of patients with motor control, movement coordination, muscle power, or endurance impairments.
V
A
Recommendation: Clinicians should consider the use of coordination, strengthening, and endurance exercises to reduce neck pain and headache.
9;DJH7B?P7J?EDFHE9;:KH;I7D:;N;H9?I;I Kjellman and colleagues104 randomly assigned 00iZmb^gmlpbmag^\diZbg!+2h_pab\aik^l^gm^] with cervical radiculopathy) to general exercise, F\D^gsb^f^mah]h_^qZfbgZmbhgZg]mk^Zmf^gm%hkZ\hgmkhe `khni!ehpbgm^glbmrnemkZlhng]Zg]^]n\Zmbhg"'Ma^F\D^gzie method of treatment consists of patient positioning, specific repeated movements, manual procedures, and patient education in self management in case of recurrence.*)-%**1 The k^i^Zm^]li^\bÖ\fho^f^gmlpbmama^F\D^gsb^f^mah]bgtend to centralize (promote the migration of symptoms from an area more distal to location more proximal) or reduce pain.**1 At the 12 month follow-up all groups showed significant reductions in pain intensity and disability but no significant difference between groups existed. Seventy-nine percent of patients reported that they were better or completely relmhk^]Z_m^kmk^Zmf^gm%Zemahn`a.* k^ihkm^]\hglmZgm(]Zber pain. All 3 groups had similar recurrence rates.
I
Fnkiar^mZe122bg\hkihkZm^]F\D^gsb^ikh\^]nk^l to promote centralization in the management of a cohort of 31 patients with cervical radiculopathy. These patients also received cervical manipulation or muscle energy techniques and neural mobilization. Seventy-seven percent of patients at the short-term follow-up and 93% of patients at the long-term follow-up exhibited a clinically important improvement in disability. However, specific details regarding the number of patients receiving procedures to promote centralization was not reported.
III
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a23
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s There has not been a clinical trial that recruited patients with only cervical radiculopathy. Therefore, it is not possible to \hff^gmhgma^^ú\Z\rh_ma^F\D^gsb^f^mah]hkma^nl^ of centralization procedures and exercises for this particular subgroup of patients.31
Recommendation: Clinicians should consider the use of upper quarter and nerve mobilization procedures to reduce pain and disability in patients with neck and arm pain.
Recommendation: Specific repeated movements or procedures to promote centralization are not more beneficial in reducing disability when compared to other forms of interventions.
JH79J?ED
KFF;HGK7HJ;H7D:D;HL;CE8?B?P7J?ED FHE9;:KH;I
MZ`ab Ch`aZmZ^b ^m Ze93 randomly assigned 30 patients to receive a treatment program consisting of ultrasound and exercise with or without mechanical intermittent cervical traction for 10 sessions. The group receiving traction exhibited greater improvements bg`kbilmk^g`ma%ma^ikbfZkrhnm\hf^f^Zlnk^%Z_m^k.l^lsions. However, no statistically significant difference between groups existed at the time of discharge from physical therapy.93
C
Allison et al2 examined the effectiveness of 2 different manual therapy techniques (neural mobilization and cervical/upper quadrant mobilization) in the management of cervico-brachial syndrome. :eeiZmb^gmlk^\^bo^]mk^Zmf^gm_hk1p^^dlbgZ]]bmbhgmh a home exercise program. The results demonstrated that both manual therapy groups exhibited improvements in pain and function. At the final data collection there existed no difference between the manual therapy groups for function but a significant difference between groups for reduction in pain was identified in favor of the neural mobilization group.
II
In a randomized clinical trial, Coppieters et al41 assigned 20 patients with cervico-brachial pain to receive either cervical mobilization with the upper extremity in an upper limb neurodynamic position or therapeutic ultrasound. The group receiving the mobilizations exhibited significantly greater improvements in elbow range of motion during neurodynamic testing as well as greater reductions in pain compared to the ultrasound group.
II
Fnkiar^mZe122 incorporated neural mobilization in the management of a cohort of patients with cervical radiculopathy. Seventy seven percent of patients at the short-term follow-up and 93% of patients at the long term follow-up exhibited a clinically important decrease in disability. However, no specifics were provided relative to which patients received neural mobilization procedures.
III
Cleland et al39 described the outcomes of a consecutive series of patients presenting to physical therapy who received cervical mobilization (cervical lateral glides) with the upper extremity in a neurodynamic position as well as thoracic spine manipulation, cervical traction, and strengthening exercises. Ten of the 11 patients (91%) demonstrated a clinically meaningful bfikho^f^gmbgiZbgZg]_ng\mbhg_heehpbg`Zf^Zgh_0'* physical therapy visits.
IV
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B
A systematic review by Graham and colleagues/0 reported that there is moderate evidence to support the use of mechanical intermittent cervical traction.
I
II
Saal et al143 bgo^lmb`Zm^] ma^ hnm\hf^l h_ +/ \hgsecutive patients who fit the diagnostic criteria for herniated cervical disc with radiculopathy who received a rehabilitation program consisting of cervical traction and exercise. Twenty-four patients avoided surgical intervention and 20 exhibited good or excellent outcomes.
III
In a prospective cohort design Cleland et al,/ identified predictor variables of short-term success for patients presenting to physical therapy with cervical radiculopathy. One of the predictor variables for patients who exhibited a short-term success included a multimodal physical therapy approach consisting of manual or mechanical traction, manual therapy (cervical or thoracic mobilizambhg(fZgbineZmbhg"%Zg]]^^ig^\d×^qhklmk^g`ma^gbg`'Ma^ pretest probability for the likelihood of short-term success pZl., 'Ma^f^Zg]nkZmbhgh_f^\aZgb\ZemkZ\mbhgnl^]hg iZmb^gmlbgmabllmn]rpZl*0'1fbgnm^lpbmaZgZo^kZ`^_hk\^ of pull of 11 kg (24.3 pounds). The positive likelihood ratio for patients receiving the multimodal treatment approach (excluding other predictor variables) was 2.2, resulting in a ihlm&m^lmikh[Z[bebmrh_ln\\^llh_0* ' ,/
II
Raney et al*,0 recently developed a clinical prediction rule to identify patients with neck pain likely to benefit from cervical mechanical traction. Sixty^b`amiZmb^gml!,1_^fZe^"p^k^bg\en]^]bg]ZmZZgZerlblh_ pab\a,)aZ]Zln\\^ll_nehnm\hf^':eeiZmb^gmlk^\^bo^]/ sessions of mechanical intermittent cervical traction startbg`pbmaZ_hk\^h_inee[^mp^^g-'.&.'-d`!*)&*+ihng]l" _hkZ]nkZmbhgh_*.fbgnm^l'Ma^_hk\^h_ineeikh`k^llbo^er
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s increased based on centralization of symptoms at each subl^jn^gm l^llbhg' : \ebgb\Ze ik^]b\mbhg kne^ pbma . oZkbZ[e^l was identified: IZmb^gmk^ihkm^]i^kbia^kZebsZmbhgpbmaehp^k\^kob\Zelibg^ !<-&0"fh[bebmrm^lmbg` Ihlbmbo^lahne]^kZ[]n\mbhglb`g :`^l..r^Zkl Ihlbmbo^nii^kebf[m^glbhgm^lm!f^]bZgg^ko^[bZlnmbebsbg`lahne]^kZ[]n\mbhgmh2)" K^eb^_h_lrfimhflpbmafZgnZe]blmkZ\mbhgm^lm
bg?ng\mbhgZeKZmbg`Bg]^ql\hk^lpZl+/ _khfZ[Zl^ebg^ of 44%.
AZobg` Zm e^Zlm , hnm h_ . oZkbZ[e^l ik^l^gm k^lnem^] bg Z ihlbmbo^ebd^ebahh]kZmbh^jnZemh-'1*!2.
F7J?;DJ;:K97J?ED7D:9EKDI;B?D=
Three separate case series,2%*+)%*0/ describe the management of patients with cervical radiculopathy, where the interventions included traction. In these case series, the patients were treated with a multimodal treatment approach and the vast majority of patients exhibited improved outcomes. In the first report, Cleland et al39 described the outcomes of a consecutive series of 11 patients presenting to physical therapy with cervical radiculopathy and managed with the use of manual physical therapy, cervi\ZemkZ\mbhg%Zg]lmk^g`ma^gbg`^q^k\bl^l':m/fhgma_heehp& up, 91% demonstrated a clinically meaningful improvement bgiZbgZg]_ng\mbhg_heehpbg`Zf^Zgh_0'*iarlb\Zema^kZir visits. Similarly, Waldrop*0/mk^Zm^]/iZmb^gmlpbma\^kob\Ze radiculopathy with mechanical intermittent cervical traction, thoracic thrust joint manipulation, and range of motion and lmk^g`ma^gbg`^q^k\bl^l_hkma^\^kob\Zelibg^'Nihg]bl\aZk`^ !f^Zgmk^Zmf^gm*)oblbml%kZg`^.&*1oblbml4]nkZmbhg,,]Zrl% kZg`^*2&./]Zrl"%ma^k^pZlZk^]n\mbhgbg]blZ[bebmr[^mp^^g *, Zg]11 'Bgma^mabk]\Zl^l^kb^l%Fh^mbZg]FZk\a^mmb120 investigated the outcomes associated with cervical traction, neck retraction exercises, scapular muscle strengthening, and mobilization/manipulation techniques (used for some iZmb^gml"_hk*.iZmb^gmlpbma\^kob\ZekZ]b\nehiZmar'Ma^l^ Znmahklk^ihkm^]_neek^lhenmbhgh_iZbgbg., h_iZmb^gmlZm the time of discharge.
IV
Browder and colleagues23 investigated the effectiveness of a multimodal treatment approach in ma^fZgZ`^f^gmh_0_^fZe^iZmb^gmlpbma`kZ]^B cervical compressive myelopathy. Patients were treated with intermittent mechanical cervical traction and thoracic magbineZmbhg _hk Z f^]bZg h_ 2 l^llbhgl ho^k Z f^]bZg h_ ./ ]Zrl'Ma^f^]bZg]^\k^Zl^bgiZbgl\hk^lpZl._khfZ[Zl^ebg^h_/!nlbg`Z)&*)iZbgl\Ze^"%Zg]f^]bZgbfikho^f^gm
IV
Recommendation: Clinicians should consider the use of mechanical intermittent cervical traction, combined with other interventions such as manual therapy and strengthening exercises, for reducing pain and disability in patients with neck and neck-related arm pain.
B
There is a paucity of high quality evidence surrounding efficacy of treatments for whiplashassociated disorder (WAD). However, existing research supports instructing patients in active interventions, such as exercises, and early return to regular activities as a means of pain control. Rosenfeld et al142 compared the longterm efficacy of active intervention with that of standard intervention and the effect of early versus delayed initiation of intervention. Patients were randomized to an intervention using frequent active cervical rotation range of motion exercises complemented by assessment and treatment ac\hk]bg`mhF\D^gsb^Ílikbg\bie^lhkmhZgbgm^ko^gmbhgmaZm promoted initial rest, soft collar utilization, and gradual selfmobilization. In patients with WAD, early active intervention was more effective in reducing pain intensity and sick leave, and in retaining/regaining total range of motion than intervention that promoted rest, collar usage, and gradual self-mobilization. Patient education promoting an active approach can be carried out as home exercises and progressive return to activities initiated and supported by appropriately trained health professionals.
I
An often prescribed intervention for acute whiplash injury is the use of a soft cervical collar. Crawford et al-.ikhli^\mbo^erbgo^lmb`Zm^]*)1\hgl^\nmbo^ patients following a soft tissue injury of the neck that resulted from motor vehicle accidents. Each patient was randomized to a group instructed to engage in early mobilization using an exercise regime or to a group that was instructed to utilize a soft cervical collar for 3 weeks followed by the same exercise regime. Patients were assessed clinically at 3, 12, Zg].+p^^dbgm^koZel_khfbgcnkr'Bgm^ko^gmbhgmaZmnmbebs^] a soft collar was found to have no obvious benefit in terms of functional recovery after neck injury and was associated with a prolonged time period off work. Other investigations have reported similar results.*-1%*0) Interventions that instruct patients to perform exercises early in their recovery from whiplash type injuries have been reported to be more effective in reducing pain intensity and disability following whiplash injury than interventions that instruct patients to use cervical collars.*-1%*0)
I
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a25
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s Existing research supports active interventions and early return to regular activities but it has largely been unknown as to which type of active intervention would yield the most benefit. Brison et al21 assessed the efficacy of an educational video in the prevention of persistent WAD symptoms following rear-end motor vehicle collisions. The video provided reassurance, and education about posture, return to regular activities, specific exercises, and pain management. Patients were randomized to receive either an educational video plus usual care or usual care alone. The primary outcome was presence of persistent WAD symptoms at 24 weeks post injury, based on the frequency and severity of neck, shoulder, or upper back pain. The group receiving the instructional video demonstrated a trend toward less severe WAD symptoms suggesting that the ‘act as usual’ recommendation that is often prescribed as a management strategy for patients with WAD is not sufficient and, in fact, may exacerbate their symptoms if such activities are provocative of pain.21
I
A reduction in pain alone is not sufficient to address the neuromuscular control deficits in patients with chronic symptoms,*.0 as these deficits require specific rehabilitation techniques.99 For example, persistent sensory and motor deficits may render the patient at risk for symptom persistence.*..%*./ Support for specificity in rehabilitation can be indirectly found from a recent populationbased, incidence cohort study evaluating a government policy of funding community and hospital-based fitness training and multidisciplinary rehabilitation for whiplash.+/ No supportive evidence was found for the effectiveness of this general rehabilitation approach. Therefore, only addressing the lack of fitness and conditioning in this patient population may not be the most efficacious approach to treatment.
III
Ferrari et al/) studied whether an educational intervention using a pamphlet provided to patients in the acute stage of whiplash injury might improve the recovery rate. One hundred twelve consecutive subjects were randomized to 1 of 2 treatment groups: educational intervention or usual care. The education intervention group received an educational pamphlet based on the current evidence, whereas the control group only received usual emergency department care and a standard non-directed discharge information sheet. Both groups underwent follow-up by telephone interview at 2 weeks and 3 months. The primary outcome measure of recovery was the patient’s k^lihgl^mhma^jn^lmbhg%ÊAhpp^ee]hrhn_^^erhnZk^k^\ho^kbg`_khfrhnkbgcnkb^l8Ë:m,fhgmalihlm\heeblbhg%+*'1 in the education intervention group reported complete recovery compared with 21.0% in the control group (absolute risk ]bü^k^g\^%)'1 42.
I
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between groups in severity of remaining symptoms, limitations in daily activities, therapy use, medications used, lost time from work, or litigation. This study concluded that an evidence-based educational pamphlet provided to patients at discharge from the emergency department is no more effective than usual care for patients with grade I or II WAD./) Cnee ^m Ze99 conducted a preliminary randomized \hgmkhee^]mkbZepbma0*iZkmb\biZgmlpbmai^klblm^gm neck pain following a motor vehicle accident to explore whether a multimodal program of physical therapies was an appropriate management strategy compared to a selfmanagement approach. Participants were randomly allocated to receive either a multimodal physical therapy program or a self-management program (advice and exercise). Furthermore, participants were stratified according to the presence or absence of widespread mechanical or cold hyperalgesia. The intervention period was 10 weeks and outcomes were assessed immediately following treatment. Even with the pres^g\^ h_ l^glhkr ari^kl^glbmbobmr bg 0+'. h_ ln[c^\ml% [hma groups reported some relief of neck pain and disability, measured using Neck Disability Index scores, and it was superior in the group receiving multimodal physical therapy (P=.04). However, the overall effects of both programs were mitigated in the group presenting with both widespread mechanical and cold hyperalgesia. Further research aimed at testing the validity of this sub-group observation is warranted. 21
I
A comprehensive review**0 of the available scientific evidence produced a set of unambiguous patient centered messages that challenge unhelpful beliefs about whiplash, promoting an active approach to recovery. The use of this rigorously developed educational booklet (The Whiplash Book) was capable of improving beliefs about whiplash and its management for patients with whiplashassociated disorders.**0
II
BgZlfZee \Zl^l^kb^l% Lh]^keng] Zg]Ebg][^k`*., reported that physical therapy integrated with cognitive behavioral components decreased pain intensity in problematic daily activities in 3 individuals with chronic WAD.
IV
Predictors of outcome following whiplash injury have been limited to socio-demographic and factors of symptom location and severity, which are not readily amenable to intervention. However, evidence exists to demonstrate that psychological factors are present soon following injury and play a role in recovery from whiplash injury.21%*..%*.1 These factors can be as diverse as the physical presentation and can include affective disturbances, anxiety, depression, and fear of movement.*+,%*,+%*01 Furthermore, post-traumatic stress disorder112 has also been
II
september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s observed in both the acute.+ and chronic conditions and has been shown to be prognostic.*0* Identifying these factors in patients may assist in the development of relevant subgroups and appropriately matched education and counseling strategies that practitioners should utilize in management of patients with WAD.
J78B;* ?cfW_hc[dj#8Wi[Z9Wj[]eho M_j^?9:#'&7iieY_Wj_edi
Recommendation: To improve the recovery in patients with whiplash-associated disorder, clinicians should (1) educate the patient that early return to normal, non-provocative pre-accident activities is important, and (2) provide reassurance to the patient that good prognosis and full recovery commonly occurs.
A
Neck Pain Impairment/Function-based Diagnosis, Examination and Intervention Recommended Classification Criteria*
Iocfjeci
?cfW_hc[djie\8eZo
?dj[hl[dj_edi
D[YafW_dm_j^ceX_b_joZ[ÓY_j 9[hl_YWb]_W FW_d_dj^ehWY_Yif_d[
Kd_bWj[hWbd[YafW_d D[Yacej_edb_c_jWj_edi Edi[je\iocfjeci_ie\j[d b_da[ZjeWh[Y[djkd]kWhZ[Z% WmamWhZcel[c[djehfei_j_ed 7iieY_Wj[Z h[\[hh[Z kff[h [njh[c_jofW_dcWoX[fh[i[dj
B_c_j[ZY[hl_YWbhWd][e\cej_ed D[YafW_dh[fheZkY[ZWj[dZ hWd][ie\WYj_l[WdZfWii_l[ cej_edi H[ijh_Yj[ZY[hl_YWbWdZj^ehWY_Y i[]c[djWbceX_b_jo D[YaWdZd[Ya#h[bWj[Zkff[h [njh[c_jofW_dh[fheZkY[Zm_j^ fheleYWj_ede\j^[_dlebl[ZY[hl_YWb ehkff[hj^ehWY_Yi[]c[dji
9[hl_YWbceX_b_pWj_ed% cWd_fkbWj_ed J^ehWY_YceX_b_pWj_ed% cWd_fkbWj_ed Ijh[jY^_d][n[hY_i[i 9eehZ_dWj_ed"ijh[d]j^[d_d]"WdZ [dZkhWdY[[n[hY_i[i
D[YaFW_dm_j^>[WZWY^[ >[WZWY^[ 9[hl_YeYhWd_WbiodZhec[
DedYedj_dkeki"kd_bWj[hWbd[Ya fW_dWdZWiieY_Wj[Z h[\[hh[Z ^[WZWY^[ >[WZWY^[_ifh[Y_f_jWj[Zeh W]]hWlWj[ZXod[Yacel[c[djieh ikijW_d[Zfei_j_edi
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* Recommendation based on expert opinion.
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a27
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
CLINICAL GUIDELINES
Summary of Recommendations E
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Summary of Recommendations (continued) C
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journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a29
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s H;<;H;D9;I '$7ZWci="I_c@$7ikhl[oe\KAcWdkWbj^[hWf_ijiÊfhWYj_Y[e\WdZWj# j_jkZ[ijemWhZicWd_fkbWj_edWdZ_jiYecfb_YWj_edi$Physiother Res Int. '//.1)0(&,#((-$ ($7bb_ied=J"DW]o8C">WbbJ$7hWdZec_p[ZYb_d_YWbjh_Wbe\cWdkWbj^[hWfo \ehY[hl_Ye#XhWY^_WbfW_diodZhec[##Wf_bejijkZo$Man Ther.(&&(1-0/+# '&($ )$7c[h_YWd9ebb[][e\HWZ_ebe]o;nf[hjFWd[bedCkiYkbeia[b[jWb?cW]_d]$ 79H7ffhefh_Wj[d[ii9h_j[h_W0Ikif[Yj[Z9[hl_YWbIf_d[JhWkcW$H[ijed" L707c[h_YWd9ebb[][e\HWZ_ebe]o1(&&'$ *$7dZ[hiied>?$J^[[f_Z[c_ebe]oe\Y^hed_YfW_d_dWIm[Z_i^hkhWbWh[W$ Qual Life Res. '//*1)Ikffb'0I'/#(,$ +$7djedWY_<"=^_hcW_I"8ede="DWff_=$9khh[djc[j^eZi\ehY[hl_YWbif_d[ cel[c[dj[lWbkWj_ed0Wh[l_[m$Clin Exp Rheumatol.(&&&1'.0I*+#+($ ,$7djedWY_<"=^_hcW_I"8ede="IWdZh_d_="DWff_=$9[hl_Ye][d_Y ^[WZWY^[0[lWbkWj_ede\j^[eh_]_dWbZ_W]deij_YYh_j[h_W$Cephalalgia$ (&&'1('0+-)#+.)$ 7.7iWlWiefedI"@Wdaeia_@"=eZ][i@@$9b_d_YWbZ_W]dei_ie\l[hj[XheXWi_# bWh_dikøY_[dYo0h[i_Z[djÊiYWi[fheXb[c$ J Orthop Sports Phys Ther. (&&+1)+0,*+#,+&$^jjf0%%Zn$Ze_$eh]%'&$(+'/%`eifj$(&&+$'-)( .$7jj_W@">WjWbWH"9eea:@"Med]@=$J^[hWj_edWbYb_d_YWb[nWc_dWj_ed$:e[i j^_iWZkbjfWj_[dj^Wl[WYkj[c[d_d]_j_i5JAMA$'///1(.(0'-+#'.'$ /$8[hd[@:"DehmeeZI>"CY7kb[o9;"L_bbWh[Wb:>$>[b_YWbYecfkj[Zjece# ]hWf^_YWd]_e]hWf^o0Wd[nY[bb[djiYh[[d_d]j[ij\ehXbkdjY[h[XhelWiYkbWh _d`kho$ J Trauma.(&&*1+-0''#'-1Z_iYkii_ed'-#'/$ '&$8[hd^WhZjC">od[iH7"8bkc[>M"M^_j[77")hZ$9[hl_YWbifedZobej_Y co[befWj^o$J Bone Joint Surg Am.'//)1-+0''/#'(.$ ''$8[hj_bied89"=hkdd[i`eC"Ijh[dZ[hB;$H[b_WX_b_joe\Yb_d_YWbj[iji _dj^[Wii[iic[dje\fWj_[djim_j^d[Ya%i^ekbZ[hfheXb[ci#_cfWYj e\^_ijeho$Spine$(&&)1(.0((((#(()'$^jjf0%%Zn$Ze_$eh]%'&$'&/-%&'$ 8HI$&&&&&./,.+$++,(/$(; '($8eZ[dI:":Wl_i:E":_dWJI"FWjhedWiD@"M_[i[bIM$7XdehcWbcW]d[j_Y# h[iedWdY[iYWdie\j^[bkcXWhif_d[_dWiocfjecWj_YikX`[Yji$7fheif[Y# j_l[_dl[ij_]Wj_ed$J Bone Joint Surg Am.'//&1-(0*&)#*&.$ ')$8e]ZkaD"CWhibWdZ7$J^[Y[hl_YWbpo]Wfef^oi_Wb`e_djiWiWiekhY[e\ d[YafW_d$Spine$'/..1')0,'&#,'-$ '*$8ehY^]h[l_da="Ic[l_aE">WWl[?">WhWbZi[j^E"DehZXo7"B[h[_c?$CH? e\Y[h[XhkcWdZY[hl_YWbYebkcdWm_j^_djmeZWoiW\j[hm^_fbWi^d[Ya ifhW_d_d`kho$Injury$'//-1(.0))'#))+$ '+$8eh]^ekji@7"Ae[i8M"8ekj[hBC$J^[Yb_d_YWbYekhi[WdZfhe]deij_Y\WY# jehie\ded#if[Y_ÓYd[YafW_d0Wioij[cWj_Yh[l_[m$Pain$'//.1--0'#')$ ',$8eh]^ekji@7"Ae[i8M"LedZ[b_d]>"8ekj[hBC$9eij#e\#_bbd[iie\d[Ya fW_d_dJ^[D[j^[hbWdZi_d'//,$Pain$'///1.&0,(/#,),$ '-$8ejI:"lWdZ[hMWWb@C"J[hm[[98"[jWb$?dY_Z[dY[WdZfh[lWb[dY[e\ YecfbW_djie\j^[d[YaWdZkff[h[njh[c_jo_d][d[hWbfhWYj_Y[$Ann Rheum Dis.(&&+1,*0''.#'()$^jjf0%%Zn$Ze_$eh]%'&$''),%WhZ$(&&)$&'/)*/ '.$8ejI:"lWdZ[hMWWb@C"J[hm[[98"[jWb$Fh[Z_Yjehie\ekjYec[_d d[YaWdZi^ekbZ[hiocfjeci0WYe^ehjijkZo_d][d[hWbfhWYj_Y[$Spine$ (&&+1)&0;*+/#*-&$ '/$8el_c="IY^hWZ[h>"IWdZJ$D[YafW_d_dj^[][d[hWbfefkbWj_ed$Spine$ '//*1'/0')&-#')&/$ (&$8hWjjX[h]="J^ehibkdZC"M_acWd7$J^[fh[lWb[dY[e\fW_d_dW][d[hWb fefkbWj_ed$J^[h[ikbjie\WfeijWbikhl[o_dWYekdjoe\Im[Z[d$Pain$ '/./1)-0('+#((($ ('$8h_iedH@">Whjb_d]B":eijWb[hI"[jWb$7hWdZec_p[ZYedjhebb[Zjh_Wbe\Wd [ZkYWj_edWb_dj[hl[dj_edjefh[l[djj^[Y^hed_YfW_de\m^_fbWi^WiieY_Wj[Z
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
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journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a31
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
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journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a33
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september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
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