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Neck Pain Physiotherapy

Neck Pain Physiotherapy

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A clinical guideline about neck pain physiotherapy, helpfull for physio's.
A clinical guideline about neck pain physiotherapy, helpfull for physio's.

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C l i n i c a l G u i d e l i n e s

JOHN D. CHILDS, PT, PhD · J0$huA A. 6L£LAN0, PT, PhD · JAN£$ N. £LL|0II, PT, PhD · 0£Y0k£ $. I£Yh£N, PT, PhD
k08£kI $. wA|NN£k, PT, PhD · JuL|£ N. wh|INAN, PT, DSc · 8£kNAk0 J. $0PkY, MD
J0$£Ph J. 6006£$, DPT · I|N0IhY w. FLYNN, PT, PhD
Neck Pain:
Clinical Practice Guidelines Linked to
the International Classification of
Functioning, Disability, and Health From
the Orthopaedic Section of the American
Physical Therapy Association
J Orthop Sports Phys Ther 2008;38(9):A1-A34. doi:10.2519/jospt.2008.0303
k£¥|£w£k$: Anthonv 0e|itto, PT, Ph0 · Ceor¤e V. 0vriW, 0PT · Amanda ler|and, PT, · le|ene learon, PT · 1ov Vac0ermid, PT, Ph0
1ames \. Vatheson, 0PT · Phi|ip VcC|ure, PT, Ph0 · Pau| She|e||e, V0, Ph0 · A. Russe|| Smith, 1r, PT, Ed0 · les|ie Torburn, 0PT
lor author, coordinator, and revieWer aN|iations, see end ot te·t. O2OO8 0rthopaedic Section American Phvsica| Therapv Association (APTA), lnc, and the 1ourna| ot
0rthopaedic ò Sports Phvsica| Therapv. The 0rthopaedic Section, APTA, lnc., and the 1ourna| ot 0rthopaedic ò Sports Phvsica| Therapv consent to the photocopvin¤ ot
this ¤uide|ine tor educationa| purposes. Address correspondence to. 1oseph 1. Cod¤es, 0PT, lCl Practice Cuide|ines Coordinator, 0rthopaedic Section, APTA lnc., 292O
East Avenue South, Suite 2OO, la Crosse, \l 54GOI. Emai|. ict@orthopt.or¤
RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AZ
INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A4
CLINICAL GUIDELINES:
Impairment/Function-Based Diagnosis . . . . . . . . . . . . . . . . . . A9
CLINICAL GUIDELINES:
Examinations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AI4
CLINICAL GUIDELINES:
Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AI9
SUMMARY OF RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AZ8
AUTHOR/REVIEWER AFFILIATIONS & CONTACTS . . . . . . . . . . AZ9
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A30
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a2 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
PAIh0ANAI0N|6AL F£AIuk£$: Although the cause of neck pain
may be associated with degenerative processes or pathology
identified during diagnostic imaging, the tissue that is causing
a patient’s neck pain is most often unknown. Thus, clinicians
should assess for impaired function of muscle, connective, and
nerve tissues associated with the identified pathological tissues
when a patient presents with neck pain. (Recommendation
based on theoretical/foundational evidence.)
k|$k FA6I0k$: Clinicians should consider age greater than 40,
coexisting low back pain, a long history of neck pain, cycling as
a regular activity, loss of strength in the hands, worrisome atti-
tude, poor quality of life, and less vitality as predisposing factors
for the development of chronic neck pain. (Recommendation
based on moderate evidence.)
0|A6N0$|$í6LA$$|F|6AI|0N: 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 one of the following International
Statistical Classification of Diseases and Related Health Prob-
lems (ICD) categories: cervicalgia, pain in thoracic spine, head-
aches, cervicocranial syndrome, sprain and strain of cervical
spine, spondylosis with radiculopathy, and cervical disc disorder
with radiculopathy; and the associated International Classifica-
tion of Functioning, Disability, and Health (ICF) impairment-
based category of neck pain with the following impairments of
body function:
· Neck pain wilh mobiIilv deñcils (b,1u1 MobiIilv of
several joints)
· Neck pain wilh headaches (28u1u Pain in head and neck)
· Neck pain wilh movemenl coordinalion impairmenls
(b,6u1 ConlroI of compIex voIunlarv movemenls)
· Neck pain wilh radialing pain (b28u4 Radialing pain in a
segment or region)
The following physical examination measures may be useful in
classifying a patient in the ICF impairment-based category of
neck pain with mobility deficits and the associated ICD catego-
ries of cervicalgia or pain in thoracic spine. (Recommendation
based on moderate evidence.)
· CervicaI aclive range of molion
· CervicaI and lhoracic segmenlaI mobiIilv
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. (Recommendation
based on moderate evidence.)
· CervicaI aclive range of molion
· CervicaI segmenlaI mobiIilv
· CraniaI cervicaI ßexion lesl
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.)
· CraniaI cervicaI ßexion lesl
· Deep neck ßexor endurance lesl
The following physical examination measures may be useful in
classifying a patient in the ICF impairment-based category of
neck pain with radiating pain and the associated ICD categories
of spondylosis with radiculopathy or cervical disc disorder with
radiculopathy. (Recommendation based on moderate evidence.)
· Upper Iimb lension lesl
· SpurIing`s lesl
· Dislraclion lesl
0|FF£k£NI|AL 0|A6N0$|$: 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/classifica-
tion 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. (Recommendation
based on moderate evidence.)
£XAN|NAI|0N - 0uI60N£ N£A$uk£$: 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 a patient’s status throughout the course
of treatment. (Recommendation based on strong evidence.)
£XAN|NAI|0N - A6I|¥|IY L|N|IAI|0N AN0 PAkI|6|PAI|0N k£$Ik|6-
I|0N N£A$uk£$: Clinicians should utilize easily reproducible
activity limitation and participation restriction measures associ-
ated with their patient’s neck pain to assess the changes in the
patient’s level of function over the episode of care. (Recommen-
dation based on expert opinion.)
|NI£k¥£NI|0N$ - 6£k¥|6AL N08|L|ZAI|0NíNAN|PuLAI|0N:
Clinicians should consider utilizing cervical manipulation and
mobilization procedures, thrust and non-thrust, to reduce neck
pain and headache. Combining cervical manipulation and mo-
bilization with exercise is more efective for reducing neck pain,
headache, and disability than manipulation and mobilization
alone. (Recommendation based on strong evidence.)
|NI£k¥£NI|0N$ - Ih0kA6|6 N08|L|ZAI|0NíNAN|PuLAI|0N:
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. (Recommen-
dation based on weak evidence.)
Recommendations*
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a3
A|N 0F Ih£ 6u|0£L|N£
The Orthopaedic Section of the American Physical Therapy As-
sociation (APTA) has an ongoing efort to create evidence-based
practice guidelines for orthopaedic physical therapy manage-
ment of patients with musculoskeletal impairments described
in the World Health Organization’s International Classification
of Functioning, Disability, and Health (ICF).
86
The purposes of these clinical guidelines are to:
· Describe evidence-based phvsicaI lherapv praclice incIud-
ing diagnosis, prognosis, intervention, and assessment of
outcome for musculoskeletal disorders commonly managed
by orthopaedic physical therapists
· CIassifv and deñne common muscuIoskeIelaI condilions
using the World Health Organization’s terminology related
to impairments of body function and body structure, activity
limitations, and participation restrictions
· Idenlifv inlervenlions supporled bv currenl besl evidence lo
address impairments of body function and structure, activ-
ity limitations, and participation restrictions associated with
common musculoskeletal conditions
· Idenlifv appropriale oulcome measures lo assess changes
resulting from physical therapy interventions in body func-
tion and structure as well as in activity and participation of
the individual
· Provide a descriplion lo poIicv makers, using inlernalionaIIv
accepted terminology, of the practice of orthopaedic physi-
cal therapists
· Provide informalion for pavers and cIaims reviewers regard-
ing the practice of orthopaedic physical therapy for common
musculoskeletal conditions
· Creale a reference pubIicalion for orlhopaedic phvsicaI
therapy clinicians, academic instructors, clinical instructors,
students, interns, residents, and fellows regarding the best
current practice of orthopaedic physical therapy
$IAI£N£NI 0F |NI£NI
This guideline is not intended to be construed or to serve as a
standard of medical care. Standards of care are determined on
the basis of all clinical data available for an individual patient
and are subject to change as scientific knowledge and technol-
ogy advance and patterns of care evolve. These parameters of
practice should be considered guidelines only. Adherence to
them will not ensure a successful outcome in every patient, nor
should they be construed as including all proper methods of care
or excluding other acceptable methods of care aimed at the same
results. The ultimate judgment regarding a particular clinical
procedure or treatment plan must be made in light of the clinical
data presented by the patient, the diagnostic and treatment op-
tions available, and the patient’s values, expectations, and prefer-
ences. However, we suggest that significant departures from ac-
cepted guidelines should be documented in the patient’s medical
records at the time the relevant clinical decision is made.
Recommendations* (continued)
Introduction
|NI£k¥£NI|0N$ - $Ik£I6h|N6 £X£k6|$£$: Flexibility exercises
can be used for patients with neck symptoms. Examination
and largeled ßexibiIilv exercises for lhe foIIowing muscIes are
suggested: anterior/medial/posterior scalenes, upper trapezius,
levator scapulae, pectoralis minor, and pectoralis major. (Rec-
ommendation based on weak evidence.)
|NI£k¥£NI|0N$ - 600k0|NAI|0N, $Ik£N6Ih£N|N6, AN0 £N0uk-
AN6£ £X£k6|$£$: Clinicians should consider the use of coor-
dination, strengthening, and endurance exercises to reduce
neck pain and headache. (Recommendation based on strong
evidence.)
|NI£k¥£NI|0N$ - 6£NIkAL|ZAI|0N Pk06£0uk£$ AN0 £X£k6|$£$:
Specific repeated movements or procedures to promote cen-
tralization are not more beneficial in reducing disability when
compared to other forms of interventions. (Recommendation
based on weak evidence.)
|NI£k¥£NI|0N$ - uPP£k 0uAkI£k AN0 N£k¥£ N08|L|ZAI|0N Pk0-
6£0uk£$: 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 based
on moderate evidence.)
|NI£k¥£NI|0N$ - IkA6I|0N: 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 moder-
ate evidence.)
|NI£k¥£NI|0N$ - PAI|£NI £0u6AI|0N AN0 60uN$£L|N6: 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.)
`These recommendations and c|inica| practice ¤uide|ines are based on the
scientihc |iterature pub|ished prior to 1une 2OO/.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a4 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
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 restric-
tions, 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 inter-
ventions 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 ex-
perts that a systematic search and review of the evidence solely
related to diagnostic categories based on International Statis-
tical Classification of Diseases and Health Related Problems
(ICD)
8,
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 homoge-
neous populations is not readily searchable using the ICD termi-
nology. Thus, the authors of this clinical practice guideline sys-
lemalicaIIv searched MEDLINE, CINAHL, and lhe Cochrane
Dalabase of Svslemalic Reviews (1066 lhrough June 2uu,) for
any relevant articles related to classification, outcome measures,
and intervention strategies for musculoskeletal conditions of the
neck region commonly treated by physical therapists. Each con-
tent expert was assigned a specific subcategory (classification,
outcome measures, and intervention strategies for musculoskel-
etal conditions of the neck region) to search by the lead author
(JDC) based upon lheir speciñc area of experlise. Two conlenl
experts were assigned to each subcategory and both individuals
performed a separate search, including but not limited to the
3 databases listed above, to identify articles to assure that no
studies of relevance were omitted. Additionally, when relevant
articles were identified, their reference lists were hand-searched
in an attempt to identify other articles that might have contrib-
uted to the outcome of these clinical practice guidelines.
This guideIine was issued in 2uu8 based upon pubIicalions in
lhe scienliñc Iileralure prior lo June 2uu,. This guideIine wiII
be considered for review in 2012, or sooner if substantive new
evidence becomes available. Any updates to the guideline in the
interim period will be noted on the Orthopaedic Section of the
APTA website: www.orthopt.org
L£¥£L$ 0F £¥|0£N6£
Once the content experts of each subcategory had identified all
relevant articles, they independently graded each article accord-
ing lo crileria described bv lhe Cenler for Evidence-Based Medi-
cine, Oxford, Uniled Kingdom (TabIe 1 beIow). If lhe 2 conlenl
experts did not agree on a grade of evidence for a particular
article, a third content expert was used to resolve the issue.
Methods
I
Evidence obtained trom hi¤h·qua|itv randomized contro||ed
tria|s, prospective studies, or dia¤nostic studies
II
Evidence obtained trom |esser·qua|itv randomized
contro||ed tria|s, prospective studies, or dia¤nostic
studies (e¤, improper randomization, no b|indin¤, · 8O%
to||oW·up)
III Case contro||ed studies or retrospective studies
IV Case series
V
E·pert opinion
6kA0£$ 0F £¥|0£N6£
The overall strength of the evidence supporting recom-
mendations made in this guideline will be graded accord-
ing to guidelines described by Guyatt et al,
,1
as modified by
MacDermid and adopled bv lhe coordinalor and reviewers of
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
A
Stron¤ evidence A preponderance ot |eve| l and/or |eve|
ll studies support the recommendation.
This must inc|ude at |east I |eve| l studv
B
Voderate evidence A sin¤|e hi¤h·qua|itv randomized con·
tro||ed tria| or a preponderance ot |eve|
ll studies support the recommendation
C
\ea| evidence A sin¤|e |eve| ll studv or a preponder·
ance ot |eve| lll and lV studies inc|udin¤
statements ot consensus bv content
e·perts support the recommendation
D
Conhictin¤ evidence li¤her·qua|itv studies conducted on
this topic disa¤ree With respect to their
conc|usions. The recommendation is
based on these conhictin¤ studies
E
Theoretica|/
toundationa| evidence
A preponderance ot evidence trom
anima| or cadaver studies, trom
conceptua| mode|s/princip|es, or trom
basic sciences/bench research support
this conc|usion
F
E·pert opinion Best practice based on the c|inica|
e·perience ot the ¤uide|ines deve|op·
ment team
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a5
ICD-10 and ICF Codes Associated With Neck Pain
these clinical guidelines that provides a summary of symptoms,
impairment findings, and matched interventions for each di-
agnostic category. This recommendation led the authors to add
Table 4 to these clinical guidelines.
6LA$$|F|6AI|0N
The primary ICD-10 codes and conditions associated with neck
pain are: Mõ4.2 CervicaIgia, Mõ4.6 Pain in lhoracic spine, Rõ1
Headache, Mõ3.u CervicocraniaI svndrome, S13.4 Sprain and
slrain of cervicaI spine, M4,.2 SpondvIosis wilh radicuIopalhv,
and Mõu.1 CervicaI disc disorder wilh radicuIopalhv.
8,
The
corresponding ICD-0 CM codes and condilions, which are used
in lhe USA, are ,23.1 CervicaIgia, ,24.1 Pain in lhoracic spine,
,84.u Headache, ,23.2 CervicocraniaI svndrome, 84,.u Sprains
and slrains of lhe neck, and ,23.4 BrachiaI neurilis or radicu-
litis, not otherwise specified (Cervical radiculitis/Radicular
syndrome of upper limbs).
The primary ICF body function codes associated with the above
noted ICD-10 conditions are the sensory functions related to
pain and the movement functions related to joint motion and
control of voluntary movements. These body function codes are
b7I0I Nob|||ty oI severz| |o|ots, bZ80I0 Pz|o |o hezd zod oeck, b760I
6ootro| oI comp|ex vo|uotzry movemeots, zod bZ803 kzd|zt|og pz|o |o
z dermztome.
The primary ICF body structure codes associated with neck
pain are s7I03 Jo|ots oI hezd zod oeck reg|oo, s7I04 Nusc|es oI hezd
zod oeck reg|oo, s7I05 L|gzmeots zod Izsc|ze oI hezd zod oeck reg|oo,
s76000 6erv|cz| vertebrz| co|umo, zod sIZ0I $p|oz| oerves.
The primary ICF activities and participation codes associated
with neck pain are d4I08 6hzog|og z bzs|c body pos|t|oo, d4I58
Nz|otz|o|og z body pos|t|oo, zod d445Z kezch|og.
The ICD-10 and primary and secondary ICF codes associated
with neck pain are provided in Table 3 (below).
k£¥|£w Pk06£$$
The Orthopaedic Section, APTA also selected consultants from
the following areas to serve as reviewers of the early drafts of
this clinical practice guideline:
· CIaims review
· Coding
· EpidemioIogv
· MedicaI praclice guideIines
· Orlhopaedic phvsicaI lherapv residencv educalion
· PhvsicaI lherapv academic educalion
· Sporls phvsicaI lherapv residencv educalion
Comments from these reviewers were utilized by the authors
to edit this clinical practice guideline prior to submitting it for
pubIicalion lo lhe JournaI of Orlhopaedic & Sporls PhvsicaI
Therapy
In addition, several physical therapists practicing in orthopae-
dic 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:
· ¯ModeraleIv usefuI" or ¯exlremeIv usefuI"
· An ¯accurale represenlalion of lhe peer-reviewed
Iileralure"
· A guideIine lhal wiII have a ¯subslanliaI posilive impacl on
orlhopaedic phvsicaI lherapv palienl care"
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 diagnos-
tic classification and intervention. To assist in clarifying these
links, it was recommended that the authors add a table to
Methods (continued)
INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS
Neck Pz|o w|th Nob|||ty 0ehc|ts
Primary ICD-10 V54.2
V54.G
Cervica|¤ia
Pain in thoracic spine
Neck Pz|o w|th hezdzches
Primary ICD-10 R5I
V5J.O
leadache
Cervicocrania| svndrome
Neck Pz|o w|th Novemeot 6oord|ozt|oo |mpz|rmeots
Primary ICD-10 SIJ.4 Sprain and strain ot cervica| spine
Neck Pz|o w|th kzd|zt|og Pz|o
Primary ICD-10 V4/.2
V5O.I
Spondv|osis With radicu|opathv
Cervica| disc disorder With radicu|opathv
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a6 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH
PRIMARY ICF CODES
Neck Pz|o w|th Nob|||ty 0ehc|ts
Body functions b/IOI Vobi|itv ot severa| joints
Body structure s/GOOO Cervica| vertebra| co|umn
Activities and participation d4IO8 Chan¤in¤ a basic bodv position, specihed as movin¤ the head and nec| Whi|e |oo|·
in¤ to the |ett or to the ri¤ht
Neck Pz|o w|th hezdzches
Body functions 28OIO Pain in head and nec|
Body structure s/IOJ
s/IO4
1oints ot head and nec| re¤ion
Vusc|es ot head and nec| re¤ion
Activities and participation d4I58 Vaintainin¤ a bodv position, specihed as maintainin¤ the head in a he·ed position,
such as When readin¤ a boo|, or, maintainin¤ the head in an e·tended position, such
as When |oo|in¤ up at a video monitor
Neck Pz|o w|th Novemeot 6oord|ozt|oo |mpz|rmeots
Body functions b/GOI Contro| ot comp|e· vo|untarv movements
Body structure s/IO5 li¤aments and tasciae ot head and nec| re¤ion
Activities and participation d4I58 Vaintainin¤ a bodv position, specihed as maintainin¤ a|i¤nment ot the head, nec|, and tho·
ra· such that the cervica| vertebra| se¤ments tunction in a neutra|, or mid·ran¤e, position
Neck Pz|o w|th kzd|zt|og Pz|o
Body functions b28O4 Radiatin¤ pain in a se¤ment or re¤ion
Body structure sI2OI Spina| nerves
Activities and participation d4452 Reachin¤
SECONDARY ICF CODES
Neck Pz|o w|th Nob|||ty 0ehc|ts
Body functions b28OIO
b28OIJ
b28OI4
b/IOI
b/I5I
b/JO5
b/J5O
b/4OO
b/GOI
Pain in head and nec|
Pain in bac|
Pain in upper |imb
Vobi|itv ot severa| joints
Stabi|itv ot severa| joints
PoWer ot musc|es ot the trun|
Tone ot iso|ated musc|es and musc|e ¤roups
Endurance ot iso|ated musc|es
Contro| ot comp|e· vo|untarv movements
Body structure sI2OOI
sIJO
s/IOJ
s/IO4
s/IO5
s/GOOO
s/GOOI
s/GOI
s/GO2
Thoracic spina| cord
Structure ot menin¤es
1oints ot head and nec| re¤ion
Vusc|es ot head and nec| re¤ion
li¤aments and tasciae ot head and nec| re¤ion
Cervica| vertebra| co|umn
Thoracic vertebra| co|umn
Vusc|es ot trun|
li¤aments and tasciae ot trun|
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a7
INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH (CONTINUED)
Activities and participation d2JO2
d24OO
d4IOO
d4IO5
d4I5O
d4/5O
Comp|etin¤ the dai|v routine
land|in¤ responsibi|ities
lvin¤ doWn
Bendin¤
Vaintainin¤ a |vin¤ position
0rivin¤ human·poWered transportation
d4/5O
d4/5O
d4554
dG4O9
d9IO9
d92O9
0rivin¤ motorized vehic|es
0rivin¤ anima|·poWered transportation
SWimmin¤
0oin¤ houseWor|, unspecihed
Communitv |ite, unspecihed
Recreation and |eisure, unspecihed
Neck Pz|o w|th hezdzches
Body functions b28OJ
b28O4
b/IOI
b/I5I
b/JO5
b/J5O
b/4OO
b/GOI
b2J59
b24O9
Radiatin¤ pain in a dermatome
Radiatin¤ pain in a se¤ment or re¤ion
Vobi|itv ot severa| joints
Stabi|itv ot severa| joints
PoWer ot musc|es ot the trun|
Tone ot iso|ated musc|es and musc|e ¤roups
Endurance ot iso|ated musc|es
Contro| ot comp|e· vo|untarv movements
Vestibu|ar tunctions, unspecihed
Sensations associated With hearin¤ and vestibu|ar tunction, unspecihed
Body structure sI2OOO
sI2OOI
sI2OI
sIJO
s/IO5
s/GOOI
s/GOOO
s/GOI
Cervica| spina| cord
Thoracic spina| cord
Spina| nerves
Structure ot menin¤es
li¤aments and tasciae ot head and nec| re¤ion
Thoracic vertebra| co|umn
Cervica| vertebra| co|umn
Vusc|es ot trun|
Activities and participation dIGJ
dIGG
d2JO2
d24OO
d4I5O
d4I5J
d4I5O
d4/5O
d4/5O
d4/5O
dG4O9
d9IO9
d92O9
Thin|in¤
Readin¤
Comp|etin¤ the dai|v routine
land|in¤ responsibi|ities
Vaintainin¤ a |vin¤ position
Vaintainin¤ a sittin¤ position
Vaintainin¤ a standin¤ position
0rivin¤ human·poWered transportation
0rivin¤ motorized vehic|es
0rivin¤ anima|·poWered transportation
0oin¤ houseWor|, unspecihed
Communitv |ite, unspecihed
Recreation and |eisure, unspecihed
Neck Pz|o w|th Novemeot 6oord|ozt|oo |mpz|rmeots
Body functions b28OIO
b28OIJ
b28OI4
b/I5I
b/JO5
b/4OO
b/GO2
Pain in head and nec|
Pain in bac|
Pain in upper |imb
Stabi|itv ot severa| joints
PoWer ot musc|es ot the trun|
Endurance ot iso|ated musc|es
Coordination ot vo|untarv movements
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a8 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY, AND HEALTH (CONTINUED)
Body structure s/IOJ
s/IO4
s/GOOO
s/GOOI
s/GOI
s/GO2
1oints ot head and nec| re¤ion
Vusc|es ot head and nec| re¤ion
Cervica| vertebra| co|umn
Thoracic vertebra| co|umn
Vusc|es ot trun|
li¤aments and tasciae ot trun|
Activities and participation d2JO2
d24OO
d4IO5
d4I5J
d4I54
d4/5O
d4/5O
d4/5O
dG4O9
d9IO9
d92O9
Comp|etin¤ the dai|v routine
land|in¤ responsibi|ities
Bendin¤
Vaintainin¤ a sittin¤ position
Vaintainin¤ a standin¤ position
0rivin¤ human·poWered transportation
0rivin¤ motorized vehic|es
0rivin¤ anima|·poWered transportation
0oin¤ houseWor|, unspecihed
Communitv |ite, unspecihed
Recreation and |eisure, unspecihed
Neck Pz|o w|th kzd|zt|og Pz|o
Body functions b28OIJ
b28OI4
b28OJ
b/IOI
b/I5I
b/JO5
b/J5O
b/4OO
b/GOI
Pain in bac|
Pain in upper |imb
Radiatin¤ pain in a dermatome
Vobi|itv ot severa| joints
Stabi|itv ot severa| joints
PoWer ot musc|es ot the trun|
Tone ot iso|ated musc|es and musc|e ¤roups
Endurance ot iso|ated musc|es
Contro| ot comp|e· vo|untarv movements
Body structure sI2OOO
sI2OOI
sI2OI
sIJO
s/IO5
s/GOOO
s/GOOI
s/GOI
s/GO2
Cervica| spina| cord
Thoracic spina| cord
Spina| nerves
Structure ot menin¤es
li¤aments and tasciae ot head and nec| re¤ion
Cervica| vertebra| co|umn
Thoracic vertebra| co|umn
Vusc|es ot trun|
li¤aments and tasciae ot trun|
Activities and participation d2JO2
d24OO
d4I5O
d4I5J
d4I5O
d4JOO
d4JOI
d4JO2
d4JOJ
d4JO4
d4JO5
d4/5O
d4/5O
d4/5O
dG4O9
d9IO9
d92O9
Comp|etin¤ the dai|v routine
land|in¤ responsibi|ities
Vaintainin¤ a |vin¤ position
Vaintainin¤ a sittin¤ position
Vaintainin¤ a standin¤ position
littin¤
Carrvin¤ in the hands
Carrvin¤ in the arms
Carrvin¤ on shou|ders, hip, and bac|
Carrvin¤ on the head
Puttin¤ doWn objects
0rivin¤ human·poWered transportation
0rivin¤ motorized vehic|es
0rivin¤ anima|·poWered transportation
0oin¤ houseWor|, unspecihed
Communitv |ite, unspecihed
Recreation and |eisure, unspecihed
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a9
Pk£¥AL£N6£
Pain and impairment of the neck is common. It is esti-
maled lhal 22% lo ,u% of lhe popuIalion wiII have neck pain
some time in their lives.
10,2u,42,43,õõ,11õ,120
In addition, it has been
suggested that the incidence of neck pain is increasing.
126,181
At any given time, 10% to 20% of the population reports neck
problems,
10,44,,8,16,
wilh õ4% of individuaIs having experienced
neck pain wilhin lhe Iasl 6 monlhs.
42
Prevalence of neck pain
increases with age and is most common in women around the
fifth decade of life.
4,10,46,116,163
Although the natural history of neck pain appears to be fa-
vorable,
õ1,02
rates of recurrence and chronicity are high.
1õ,81
One study reported that 30% of patients with neck pain
will develop chronic symptoms, with neck pain of greater
lhan 6 monlhs duralion aßecling 14% of aII individuaIs who
experience an episode of neck pain.
19
Additionally, a recent
survev demonslraled lhal 3,% of individuaIs who experi-
ence 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.
10,88
In a survey of workers with injuries to
the neck and upper extremity, Pransky et al
13õ
reported that
42% missed more lhan 1 week of work and 26% experienced
recurrence within 1 year. The economic burden due to dis-
orders of the neck is high, and includes costs of treatment,
lost wages, and compensation expenditures.
16,138
Neck pain is
second only to low back pain in annual workers’ compensa-
lion cosls in lhe Uniled Slales.
181
In Sweden, neck and shoul-
der probIems accounl for 18% of aII disabiIilv pavmenls.
126
Jelle el aI
91
reported that patients with neck pain make up
approximaleIv 2õ% of palienls receiving oulpalienl phvsi-
cal therapy. Additionally, patients with neck pain frequently
are treated without surgery by primary care and physical
therapy providers.
1,,õ1,02
PAIh0ANAI0N|6AL F£AIuk£$
A variety of causes of neck pain have been described
and include osteoarthritis, discogenic disorders, trauma, tu-
mors, infection, myofascial pain syndrome, torticollis, and
whiplash.
121
UnforlunaleIv, cIearIv deñned diagnoslic crileria
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
compromise or a ¯mechanicaI neck disorder."
In some conditions, particularly those that are de-
generative in nature or involve abnormalities of the
vertebral motion segment, abnormal findings are
not always associated with symploms. Iourleen lo 18% of
people without neck pain demonstrate a wide range of ab-
normalities 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.
168
Disorders such as cervi-
cal radiculopathy and cervical compressive myelopathy are
reported to be caused by space-occupying lesions (osteophy-
tosis or herniated cervical disc). These may be secondary to
degenerative processes and can give rise to neck and/or up-
per quarter pain as well as neurologic signs and symptoms.
136
While cervical disc herniation and spondylosis are most com-
monly linked to cervical radiculopathy and myelopathy,
1u,136
the bony and ligamentous tissues afected 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
Because most patients with neck pain usually lack
an identifiable pathoanatomic cause for their prob-
lem, the majority are classified as having mechani-
cal neck disorders.
82
Although the cause of neck pain may be associ-
ated with degenerative processes or pathology
identified during diagnostic imaging, the tissue
that is causing a patient’s neck pain is most often un-
known. Thus, clinicians should assess for impaired func-
tion of muscle, connective, and nerve tissues associated
with the identified pathological tissues when a patient
presents with neck pain.
CLINICAL GUIDELINES
Impairment/Function-based
Diagnosis
II
II
E
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a10 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
k|$k FA6I0k$
Bot and colleagues
18
investigated the clini-
cal 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 recov-
ered. 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.
Hill and colleagues
,6
investigated the course of
neck pain in an adult population over a 12 month
period. Significant baseline characteristics, which
predicled persislenl neck pain were age (4õ-õ0 vears), being
of work at the time of the baseline survey (odds ratio [OR]
= 1.6), comorbid Iow back pain (OR = 1.6), and bicvcIing as a
regular activity (OR = 2.4).
In a prospective cohort study, Hoving et al
8u
ex-
amined the predictors of outcome in a patient
popuIalion wilh neck pain. A lolaI of 183 palienls
parlicipaled in lhe sludv of which 63% had improved al a
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 dura-
tion of neck pain, stable neck pain during the 2 weeks prior
to baseline measurement, and previous neck pain predicted
poor prognosis.
Clinicians should consider age greater than 40, co-
existing 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 vital-
ity as predisposing factors for the development of chronic
neck pain.
6L|N|6AL 60uk$£
Approximately 44% of patients experiencing neck pain
will go on to develop chronic symptoms,

and many will con-
tinue to exhibit moderate disability at long-term follow-up.
66
A recent systematic review examined the outcomes of non-
treatment control groups in clinical trials for the conserva-
tive management of chronic mechanical neck pain - not due
to whiplash.
1,1
The outcomes of patients receiving a control
or placebo intervention were analyzed and efect sizes were
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.
1,1
Conversely, there is substantial evidence that favorable out-
comes are attained following treatment of patients with cer-
vical radiculopathy.
,0,136
For example, Radhakrishnan and
colleagues
136
reported that nearly 90% of patients with cer-
vical radiculopathy presented with only mild symptoms at a
median follow-up of 4.9 years. Honet and Puri
,0
found that
,u% of palienls wilh cervicaI radicuIopalhv exhibiled good or
excellent outcomes after a 2-year follow-up. Outcomes for the
patients in the aforementioned studies
,0,136
appeared favor-
abIe and suggesl lhal ,u-0u% of lhis popuIalion can experi-
ence improvement without surgical intervention. In contrast,
the clinical prognosis of patients with whiplash-associated
disorder is Iess favorabIe. A survev of 1u8 palienls wilh a his-
tory of whiplash requiring care at an emergency department
found lhal õõ% had residuaI pain]disabiIilv referabIe lo lhe
originaI accidenl al a mean foIIow-up of 1, vears Ialer. Neck
pain, radiating pain, and headache were the most common
symptoms. Thirty-three percent of the respondents with re-
sidual symptoms sufered from work disability, compared to
6% in lhe group of palienls wilhoul residuaI disorders.

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Strategies for the classification of patients
with neck pain have been recently proposed by
Wang et al,
1,,
Childs et al,
2,
and Fritz and Bren-
nan.
62
The underlying premise is that classifying patients
into groups based on clinical characteristics and matching
these patient subgroups to management strategies likely to
benefit them will improve the outcome of physical therapy
interventions.
2,
The classification system described by Wang
et al
1,,
categorized patients into 1 of 4 subgroups based on
the area of symptoms and the presumed source of the symp-
toms. The labels of these 4 categories were neck pain only,
headaches, referred arm pain and neck pain, and radicular
arm pain and neck pain. Distinct treatment approaches were
linked to each of the 4 categories. Wang et al
1,,
reported the
results of 30 patients treated using this classification strat-
egv as weII as 2, palienls who were nol lrealed. SlalislicaIIv
and clinically significant reductions in pain and disability
were reported for the classification group only.
1,,
It is dif-
cult to draw conclusions regarding the potential usefulness
of the Wang et al
1,,
classification system because patients in
lhe conlroI group were nol lrealed, which is nol reßeclive of
physical therapy practice. The classification system described
by Childs et al
2,
and Fritz and Brennan
62
uses information
from the history and physical examination to place patients
inlo 1 of õ separale lrealmenl subgroups. The IabeIs of lhese
õ subgroups, which are mobiIilv, cenlraIizalion, exercise and
II
II
II
B
III
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a11
conditioning, pain control, and headache, intend to capture
the primary focus or goal of treatment. Fritz and Brennan,
62
uliIizing a prospeclive, observalionaI sludv of 2,4 palienls,
reported that patients who received interventions matched
with their treatment subgroup had better outcomes than pa-
tients 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
2,
and Fritz and Brennan
62
classification with 2 noteworthy dif-
ferences. The first diference is that the labels in this clinical
practice guideline incorporate the following ICF impairments
of body functions terminology: Neck pain with mobility defi-
cits, neck pain with headaches, neck pain with movement co-
ordination impairments, and neck pain with radiating pain.
The second diference is that Fritz and Brennan’s
62
¯pain con-
lroI" calegorv, which was Iinked lo mobiIizalion and range
of motion exercises following an acute cervical sprain, was
divided inlo lhe ¯neck pain wilh movemenl coordinalion im-
pairmenls," and ¯neck pain wilh mobiIilv deñcils" calegories,
where the patient would receive interventions linked to the
most relevant impairment(s) exhibited at a given period dur-
ing 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 lev-
el of certainty when the patient presents with the following
clinical findings
33,62,82,166
:
· Younger individuaI (age <õu vears)
· Acule neck pain (duralion <12 weeks)
· Svmploms isoIaled lo lhe neck
· Reslricled cervicaI range of molion
The ICD diagnosis of headaches, or cervicocranial
syndrome and the associated ICF diagnosis of neck
pain with headaches is made with a reasonable lev-
el of certainty when the patient presents with the following
clinical findings
6,62,00,18õ
:
· UniIaleraI headache associaled wilh neck]suboccipilaI
area symptoms that are aggravated by neck movements or
positions
· Headache produced or aggravaled wilh provocalion of lhe
ipsilateral posterior cervical myofascia and joints
· Reslricled cervicaI range of molion
· Reslricled cervicaI segmenlaI mobiIilv
· AbnormaI]subslandard performance on lhe craniaI cervi-
caI ßexion lesl
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
22,20,14õ,162,182,184
:
· Longslanding neck pain (duralion >12 weeks)
· AbnormaI]subslandard performance on lhe craniaI cervi-
caI ßexion lesl
· AbnormaI]subslandard performance on lhe deep ßexor
endurance test
· Coordinalion, slrenglh, and endurance deñcils of neck
and upper quarter muscles (longus colli, middle trapezius,
lower trapezius, serratus anterior)
· IIexibiIilv deñcils of upper quarler muscIes (anlerior]mid-
dle/posterior scalenes, upper trapezius, levator scapulae,
pectoralis minor, pectoralis major)
· Ergonomic ineßciencies wilh performing repelilive
activities
The ICD diagnosis of spondylosis with radiculopa-
thy or cervical disc disorder with radiculopathy and
the associated ICF diagnosis of neck pain with radi-
ating pain is made with a reasonable level of certainty when
the patient presents with the following clinical findings
1,õ
:
· Upper exlremilv svmploms, usuaIIv radicuIar or referred
pain, that are produced or aggravated with Spurling’s ma-
neuver and upper limb tension tests, and reduced with the
neck distraction test
· Decreased cervicaI rolalion (<6u°) loward lhe invoIved
side
· Signs of nerve rool compression
· Success wilh reducing upper exlremilv svmploms wilh ini-
tial examination and intervention procedures
Neck pain, without symptoms or signs of serious
medical or psychological conditions, associated
with (1) motion limitations in the cervical and up-
per thoracic regions, (2) headaches, and (3) referred or radi-
ating pain into an upper extremity are useful clinical findings
for classifying a patient with neck pain into the following In-
ternational Statistical Classification of Diseases and Related
Health Problems (ICD) categories: cervicalgia, pain in tho-
racic 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:
· Neck pain wilh mobiIilv deñcils (b,1u1 MobiIilv of severaI
joints)
· Neck pain wilh headaches (28u1u Pain in head and neck)
· Neck pain wilh movemenl coordinalion impairmenls
(b,6u1 ConlroI of compIex voIunlarv movemenls)
· Neck pain wilh radialing pain (b28u4 Radialing pain in a
segment or region)
The following physical examination measures may be useful
in classifying a patient in the ICF impairment-based category
II
II
B
I
I
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a12 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
of neck pain with mobility deficits and the associated ICD
categories of cervicalgia or pain in thoracic spine:
· CervicaI aclive range of molion
· CervicaI and lhoracic segmenlaI mobiIilv
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 catego-
ries of headaches or cervicocranial syndrome:
· CervicaI aclive range of molion
· CervicaI segmenlaI mobiIilv
· CraniaI cervicaI ßexion lesl
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:
· CraniaI cervicaI ßexion lesl
· Deep neck ßexor endurance
The following physical examination measures may be useful
in classifying a patient in the ICF impairment-based catego-
ry of neck pain with radiating pain and the associated ICD
categories of spondylosis with radiculopathy or cervical disc
disorder with radiculopathy:
· Upper Iimb lension lesl
· SpurIing`s lesl
· Dislraclion lesl
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A primary goal of diagnosis is to match the pa-
tient’s clinical presentation with the most efcacious
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,
,,
neoplastic
conditions,
0u,14u,1õ2,1õ4
vascular compromise,
1õ1
or systemic dis-
ease.
8,24
Clinicians must be aware of the key signs and symp-
toms 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.
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 frac-
ture, and the presence of or potential for spinal cord or brain
stem injury. A clinical prediction rule has been developed to
assist clinicians in determining when to order radiographs in
individuals who have experienced trauma.
1õ0
In addition to medical conditions, clinicians should
be aware of psychosocial factors that may be con-
tributing to a patient’s persistent pain and dis-
ability, 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.
63,64,114,1õu
When
relevant psychosocial factors are identified, the rehabilitation
approach may need to be modified to emphasize active reha-
bilitation, graded exercise programs, positive reinforcement
of functional accomplishments, and/or graduated exposure
to specific activities that a patient fears as potentially painful
or difcult to perform.

Clinicians should consider diagnostic classifications
associated with serious pathological conditions or
psychosocial factors when the patient’s reported ac-
tivity limitations or impairments of body function and struc-
ture 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 nor-
malization of the patient’s impairments of body function.
|NA6|N6 $Iu0|£$
Adults with cervical pain precipitated by trauma
should be classified as low risk or high risk based on the Ca-
nadian Cervical Spine Rule (CCR) for radiography in alert
and stable trauma patients
1õ0
and the 2001 American College
of Radiology (ACR) suspected Spine Trauma Appropriate-
ness 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 ambula-
tory at any time; or (4) have had a delayed onset of neck pain;
or (õ) do nol have midIine cervicaI spine lenderness; and (6)
are abIe lo acliveIv rolale lheir head 4õ° in each direclion, are
classified as low risk. Those who are classified as low risk do
not require imaging for acute conditions. Patients who are
(1) grealer lhan 6õ vears of age; or (2) have had a dangerous
mechanism of injury; or (3) have paresthesias in the extremi-
ties, are classified as high risk.
1õ0
Those classified as high risk
should undergo cervical radiography.
0,4,
There is a paucity of available literature regarding the pediat-
ric 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
pIain radiographv (3 views) in lhose under 16 vears of age
regardless of mental status.
3
III
I
II
B
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a13
There is no consensus for routine investigation of patients with
chronic neck pain with imaging beyond plain radiographs.
3,48
Routine use of ultrasonography, CT, and magnetic resonance
imaging (MRI) in palienls wilhoul neuroIogic insuIl or olher
disease has not been justified in view of the infrequency of
abnormalities detected, the lack of prognostic value, inacces-
sibility, and the high cost of the procedures.
14,,3,110,133,141,146,1,4
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.
RecenlIv, Krisljansson
111
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
molion. LaleraI radiographic anaIvsis reveaIed signiñcanlIv
increased rolalionaI molion al C3-4 and C4-õ for individu-
als 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
molion al Cõ-6 for individuaIs in lhe WAD group when com-
pared to normal subjects.
UIlrasonographv has been used lo accuraleIv measure lhe
size of the cervical multifidus muscle at the C4 level in as-
ymptomatic 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
High resoIulion prolon densilv-weighled MRI has recenlIv
demonstrated abnormal signal intensity (indicative of tissue
damage) in both the alar and transverse ligaments in some
subjects with chronic WAD.
1u8
Laler foIIow-up sludies indi-
cated a strong relationship between alar ligament damage,
head position (turned) at time of impact, and disability levels
(as measured with the Neck Disability Index).
1u1,1u2,1u,
Elliott et al
õ3
have demonslraled lhal femaIe palienls (18-4õ
vears oId) wilh persislenl WAD (grade II) show MRI changes
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
lrauma causing a generaI inßammalorv response, a speciñc
nerve injury or insult, or a generalized disuse phenomenon.
Further, as the muscular changes were observed in the chron-
ic 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
õ4
have identified
changes in the relative cross-sectional area (rCSA) of the cer-
vical paraspinal musculature in patients with chronic WAD
relative to control subjects with no history of neck pain. Spe-
cifically, the WAD group demonstrated a consistent pattern
of larger rCSA in the multifidii muscles at each segment (C3-
C,). Inference can be drawn lhal lhe 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. How-
ever, emerging evidence into upper cervical ligamentous
disruption, altered segmental motion, and muscular de-
generation has been demonstrated with radiographs, ul-
lrasonographv, and MRI sludies. Il remains unknown if
(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 ofer prognostic
information and provide the foundation for interventional
based studies.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a14 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
0uI60N£ N£A$uk£$
The Neck Disability Index (NDI) is a commonly
utilized outcome measure to capture perceived dis-
ability in patients with neck pain.
134
The NDI con-
lains 1u ilems, , reIaled lo aclivilies of daiIv Iiving, 2 reIaled
to pain, and 1 related to concentration.
1,2
Each item is scored
from u-õ and lhe lolaI score is expressed as a percenlage, wilh
higher scores corresponding to greater disability. Riddle and
Stratford
139
identified a significant association between the
NDI and both the physical and mental health components
of lhe SI-36. The aulhors aIso idenliñed lhal lhe NDI pos-
sesses 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 litiga-
tion.
139
Jelle and Jelle
92
further substantiated the sensitivity
to change by calculating the efect sizes for change scores of
bolh lhe NDI and SI-36.
Two studies
161,1,0
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
1,0
idenliñed lhe minimaI deleclabIe change as õ (1u percenlage
points) in a group of 31 patients with neck pain. Stratford
and colleagues
161
identified the minimal detectable change
aIso lo be õ (1u percenlage poinls) in a group of 48 palienls
with neck pain. However, the minimum clinically important
diference, the smallest diference which patients perceive as
beneficial, may be more useful to clinicians.
80
Stratford and
colleagues
161
identified the minimal clinically important dif-
ference as õ poinls (1u percenlage poinls). More recenlIv,
Cleland and colleagues,

described the minimum clinically
imporlanl dißerence for lhe NDI lo be 0.õ (10 percenlage
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.
3,
In this
group, the intraclass correlation coefcient (ICC) for test re-
lesl reIiabiIilv was u.68 for lhe NDI and lhe minimum cIini-
caIIv imporlanl dißerence was , (14 percenlage poinls).
3,
The Patient-Specific Functional Scale (PSFS) is a
practical alternative or supplement to generic and
condition-specific measures.
1,0
The PSFS asks pa-
tients to list 3 activities that are difcult 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 ac-
tivity as well as they could prior to the onset of symptoms.
16u
The final PSFS score is the average of the 3 activity scores.
The PSFS was developed by Stratford et al
16u
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.
1,0
The ICC value for test retest reli-
abiIilv in palienls wilh cervicaI radicuIopalhv was u.82.
3,
The
minimal detectable change in that population was identified
to be 2.1 points with a minimum clinically important difer-
ence of 2.0.
3,
Clinicians should use validated self-report ques-
tionnaires, such as the Neck Disability Index and
the Patient-Specific Functional Scale for patients
with neck pain. These tools are useful for identifying a pa-
tient’s baseline status relative to pain, function, and disability
and for monitoring a change in patient’s status throughout
the course of treatment.
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There are no activity limitation and partici-
pation restriction measures specifically reported in
the literature associated with neck pain - other than
those that are part of the self-report questionnaire noted in
lhis guideIine`s seclion on Oulcome Measures. However, lhe
following measures are options that a clinician may use to
assess changes in a patient’s level of function over an episode
of care.
· Pain IeveI al end ranges of Iooking over shouIder
· Pain IeveI al end ranges of Iooking down
· Pain IeveI al end ranges of Iooking up
· Pain IeveI afler silling for 2 hours
· Number of limes per nighl lhal pain disrupls sIeep
· Deskwork loIerance (in number of minules or hours)
· Percenl of lime experiencing neck pain over lhe previous
24 hours
· Percenl of lime experiencing headache(s) over lhe previ-
ous month
CLINICAL GUIDELINES
Examination
I
I
A
V
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a15
In addition, the Patient-Specific Functional Scale is a
questionnaire that can be used to quantify changes in
activity limitations and participation restrictions for pa-
tients with neck pain.
16u
This scale enables the clinician to
collect measures related to function that may be different
then the measures that are components of the region-
specific outcome measures section such as the Neck Dis-
ability Index.
1,0
Clinicians should utilize easily reproducible activ-
ity limitation and participation restriction mea-
sures associated with their patient’s neck pain to
assess the changes in the patient’s level of function over the
episode of care.
Cervical Active Range of Motion
ICF category Veasurement ot impairment ot bodv tunction - mobi|itv ot severa| joints
Description The amount ot active nec| he·ion, e·tension, rotation, and sidebendin¤ motion measured usin¤ an inc|inometer
Measurement method A|| cervica| ran¤e ot motion (R0V) measures are pertormed in the upri¤ht sittin¤ position. Care shou|d be ta|en to ensure the
patient maintains an upri¤ht sittin¤ position throu¤hout the e·amination and durin¤ subsequent to||oW·up e·aminations. The
to||oWin¤ procedures are used to measure the R0V tor the cervica| spine.
Neck F|ex|ooí£xteos|oo: lor nec| he·ion, the inc|inometer is p|aced on the top ot the patient's head a|i¤ned With the e·terna|
auditorv meatus and then zeroed. The patient is as|ed to he· the head torWard as tar as possib|e, brin¤in¤ the chin to the chest.
The amount ot nec| he·ion is recorded trom the inc|inometer. lor e·tension R0V, the inc|inometer is positioned in the same
manner, and the patient is as|ed to e·tend the nec| bac|Wards as tar as possib|e. The amount ot nec| e·tension is recorded With
the inc|inometer.
Neck $|debeod|og: The inc|inometer is positioned in the tronta| p|ane on the top ot the patient's head in a|i¤nment With the e·terna|
auditorv meatus. To measure ri¤ht sidebendin¤, the patient is as|ed to move the ri¤ht ear to the ri¤ht shou|der. The amount ot
sidebendin¤ is recorded With the inc|inometer. The opposite is pertormed to measure |ett sidebendin¤. Care shou|d be ta|en to
avoid concomitant rotation or he·ion With the sidebendin¤ movement.
Neck kotzt|oo: Rotation can be measured With a universa|/standard ¤oniometer. The patient is seated, |oo|in¤ direct|v torWard
With the nec| in neutra| position. The tu|crum ot the ¤oniometer is p|aced over the top ot the head With the stationarv arm a|i¤ned
With the acromion process ot the shou|der, and the moveab|e arm bisectin¤ the patient's nose. The patient is as|ed to rotate in each
direction as tar as possib|e.
Nature of variable Continuous
Units of measurement 0e¤rees
Measurement properties Cervica| R0V measurements tor he·ion, e·tension, and sidebendin¤ usin¤ a bubb|e inc|inometer have e·hibited re|iabi|itv
coeNcients ran¤in¤ trom O.GG to O.84 (lCC
2,I
).
J2,I/5
Instrument variations ln addition to usin¤ an inc|inometer,
5,8J,I28,I8O
cervica| R0V can a|so be measured tor c|inica| purposes usin¤ a cervica| ran¤e ot motion
(CR0V) device
IIJ,IG5
or a tape measure. A|| methods are moderate|v corre|ated With more dehnitive radio¤raphic and J0 |inematic
measurement.
4,5
F
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Cervical And Thoracic Segmental Mobility
ICF category Veasurement ot impairment ot bodv tunction - mobi|itv ot sin¤|e joints
Description \ith the patient prone, cervica| and thoracic spine se¤menta| movement and pain response are assessed
Measurement method The patient is prone. The e·aminer contacts each cervica| spinous process With the thumbs. The |atera| nec| muscu|ature is ¤ent|v
pu||ed s|i¤ht|v posterior With the hn¤ers. The e·aminer shou|d be direct|v over the contact area |eepin¤ e|boWs e·tended, then he/
she uses the upper trun| to impart a posterior to anterior torce in a pro¤ressive osci||atorv tashion over the spinous process. This
is repeated tor each cervica| se¤ment. The e·aminer then chan¤es his/her contact position and p|aces the hvpothenar eminence
(just dista| to the pisitorm) ot one hand over the spinous process ot each thoracic spinous process and repeats the same posterior
to anterior torces in a pro¤ressive osci||atorv tashion. The test resu|t is considered to be positive it the patient reports reproduction
ot pain. The mobi|itv ot the se¤ment is jud¤ed to be norma|, hvpermobi|e, or hvpomobi|e. lnterpretation ot mobi|itv is based on the
e·aminer's perception ot the mobi|itv at each spina| se¤ment re|ative to those above and be|oW the tested se¤ment, and based on
the e·aminer's e·perience and perception ot norma| mobi|itv.
Nature of variable |omina| (pain response) and ordina| (mobi|itv jud¤ment)
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a16 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
Cervical And Thoracic Segmental Mobility (continued)
Units of measurement None
Diagnostic accuracy and
measurement properties
0ia¤nostic Accuracv
I44
.
Pain durin¤ se¤menta| testin¤ associated With reports ot nec| pain.
Sensitivitv - O.82, ne¤ative |i|e|ihood ratio (·lR) - O.2J
Specihcitv - O./9, positive |i|e|ihood ratio (+lR) - J.9
Re|iabi|itv tor cervica| spine assessment.
lappa - O.I4 to O.J/ (pain)
IG9
lCC - O.42 to O./9 (pain)
II
lCC - O./8 to I.O (presence ot joint dvstunction in upper J cervica| spine se¤ments)
IOO
\ei¤hted |appa. ·O.2G to O./4 (mobi|itv), ·O.52 to O.9O (pain)
J2
Re|iabi|itv tor thoracic spine assessment.
\ei¤hted |appa. O.IJ to O.82 (mobi|itv), ·O.II to O.9O (pain)
J2
Cranial Cervical Flexion Test
ICF category Veasurement ot impairment ot bodv tunction - contro| ot simp|e vo|untarv movements and endurance ot iso|ated musc|es
Description ln supine, the abi|itv to initiate and maintain iso|ated crania| and cervica| he·ion
Measurement method Patient is positioned supine in hoo| |vin¤ and the head and nec| in mid·ran¤e neutra| (ima¤inarv |ine betWeen torehead and chin and
ima¤inarv |ine betWeen the tra¤us ot the ear and the nec| |on¤itudina||v shou|d be para||e| to each other and the surtace ot the
treatment tab|e). ToWe|s mav be needed under the occiput to achieve this neutra| position. A pneumatic pressure device, such as a
pressure bioteedbac| unit, is inhated to 2O mml¤ to h|| the space betWeen the cervica| |ordotic curve and the surtace ot the tab|e
(behind the suboccipita| re¤ion, not be|oW the |oWer cervica| area).
\hi|e |eepin¤ the posterior head/occiput stationarv (do not |itt, do not push doWn), the patient pertorms crania| cervica| he·ion
(CCl) in a ¤raded tashion in 5 increments (22, 24, 2G, 28, and JO mml¤) and aims to ho|d each position tor IO seconds. Ten seconds
rest is provided betWeen sta¤es. To pertorm CCl, the patient is instructed to ¤ent|v nod the head as thou¤h thev Were savin¤ "ves¨
With the upper nec|. This motion Wi|| hatten the cervica| |ordosis, thus chan¤in¤ the pressure in the pneumatic pressure device. \hi|e
the patient is pertormin¤ the test movement, the therapist pa|pates the nec| to monitor tor unWanted activation ot the superhcia|
cervica| musc|es, such as the sternoc|eidomastoid. The patient can p|ace his/her ton¤ue on the root ot the mouth, With |ips to¤ether
but the teeth s|i¤ht|v separated, to he|p decrease p|atvsma and/or hvoid activation. The test is ¤raded accordin¤ to the pressure |eve|
the patient can achieve With concentric contractions and accurate|v sustain isometrica||v. The test is terminated When the pressure
is decreased bv more than 2O% or When the patient cannot pertorm the proper CCl movement Without substitution strate¤ies.
A norma| response is tor the pressure to increase to betWeen 2G·JO mml¤ and be maintained tor IO seconds Without uti|izin¤
superhcia| cervica| musc|e substitution strate¤ies.
An abnorma| response is Where the patient.
I. ls unab|e to ¤enerate an increase in pressure ot at |east G mml¤,
2. ls unab|e to ho|d the ¤enerated pressure tor IO seconds,
J. uses superhcia| nec| musc|es to accomp|ish the cervica| he·ion motion, or
4. uses a sudden movement ot the chin or pushin¤ (e·tendin¤) the nec| torcetu||v a¤ainst the pressure device
Scorin¤.
· Activation Score. Pressure achieved and he|d tor IO second
· Pertormance lnde·. lncrease in Pressure number ot repetitions
Nature of variable Continuous
Units of measurement mml¤ tor the activation score
Measurement properties Re|iabi|itv assessment tor 5O asvmptomatic subjects, tested tWice (I Wee| apart). Activation score. lCC-O.8I, Pertormance lnde·. lCC-.9J
9G
Neck Flexor Muscle Endurance Test
ICF category Veasurement ot impairment ot bodv tunction - endurance ot iso|ated musc|es
Description ln supine, the abi|itv to |itt the head and nec| a¤ainst ¤ravitv tor an e·tended period
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a17
Neck Flexor Muscle Endurance Test ( continued)
Measurement method The test is pertormed in a supine, hoo|·|vin¤ position. \ith the chin ma·ima||v retracted and maintained isometrica||v, the patient
|itts the head and nec| unti| the head is appro·imate|v 2.5 cm (I in) above the p|inth Whi|e |eepin¤ the chin retracted to the chest.
The c|inician tocuses on the s|in to|ds a|on¤ the patient's nec| and p|aces a hand on the tab|e just be|oW the occipita| bone ot the
patient's head. Verba| commands (ie, "Tuc| vour chin¨ or "lo|d vour head up¨) are ¤iven When either the s|in to|d(s) be¤ins to
separate or the patient's occiput touches the c|inician's hand. The test is terminated it the s|in to|d(s) is separated due to |oss ot
chin tuc| or the patient's head touches the c|inician's hand tor more than I second.
/5
Nature of variable Continuous
Units of measurement Seconds
Measurement properties ln a studv bv larris et a|,
/5
4I subjects With and Without nec| pain pertormed this test. TWo raters tested a|| subjects at base|ine, and
subjects Without nec| pain Were tested a¤ain I Wee| |ater.
Re|iabi|itv.
Subjects Without nec| pain.
lCC (J,I) - O.82 to O.9I, SEV 8.O · II.O seconds
lCC (2,I) - O.G/ to O./8, SEV I2.G · I5.J seconds
Subjects With nec| pain.
lCC (2,I) - O.G/, SEV II.5 seconds
Test resu|ts.
Subjects Without nec| pain. Vean J8.95 seconds (S0-2G.4)
Subjects With nec| pain. Vean 24.I seconds (S0-I2.8)
Upper Limb Tension Test
ICF category Veasurement ot impairment ot structure ot the nervous svstem, other specihed
Description ln non·Wei¤ht bearin¤, the amount ot mobi|itv ot the neura| e|ements ot the upper |imb are assessed Whi|e determinin¤ Whether the
patient's upper quarter svmptoms are e|icited durin¤ pertormance ot the test
Measurement method upper |imb tension tests are pertormed With the patient supine. 0urin¤ pertormance ot the upper |imb tension test that p|aces a
bias toWard testin¤ the patient's response to tension p|aced on the median nerve, the e·aminer sequentia||v introduces the
to||oWin¤ movements to the svmptomatic upper e·tremitv.
· Scapu|ar depression
· Shou|der abduction to about 9O° With the e|boW he·ed
· lorearm supination, Wrist and hn¤er e·tension
· Shou|der |atera| rotation
· E|boW e·tension
· Contra|atera| then ipsi|atera| cervica| side·bendin¤
A positive test occurs When anv ot the to||oWin¤ hndin¤s are present.
I. reproduction ot a|| or part ot the patient's svmptoms
2. side·to·side diterences ot ¤reater than IO° ot e|boW e·tension or Wrist e·tension
J. on the svmptomatic side, contra|atera| cervica| side·bendin¤ increases the patient's svmptoms, or ipsi|atera| side·bendin¤
decreases the patient's svmptoms
Nature of variable |omina|
Units of measurement None
Diagnostic accuracy indices for
the upper limb tension test, based
on the study by Wainner et al
175
95% Conhdence lnterva|
lappa O./G O.5I·I.O
Sensitivitv O.9/ O.9O·I.O
Specihcitv O.22 O.I2·O.JJ
Positive |i|e|ihood ratio I.JO I.IO·I.5
|e¤ative |i|e|ihood ratio O.I2 O.OI·I.9
Spurling’ s Test
ICF category Veasurement ot impairment ot structure ot the nervous svstem, other specihed
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a18 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
Distraction Test
ICF category Veasurement ot impairment ot structure ot the nervous svstem, other specihed
Description 0istraction ot the cervica| spine to ma·imize the diameter ot the neura| toramen and reduce or e|iminate the patient's svmptoms
Measurement method The distraction test is used to identitv cervica| radicu|opathv and is pertormed With the patient supine. The e·aminer ¤rasps under
the chin and occiput, he·es the patient's nec| to a position ot comtort, and ¤radua||v app|ies a distraction torce ot up to
appro·imate|v I4 |¤. A positive test occurs With the reduction or e|imination ot the patient's upper e·tremitv or scapu|ar svmptoms.
This test is not indicated it the patient has no upper e·tremitv or scapu|ar re¤ion svmptoms.
Nature of variable |omina|
Units of measurement None
Diagnostic accuracy indices for
the upper limb tension test, based
on the study by Wainner et al
175
95% Conhdence lnterva|
lappa O.88 O.G4 · I.O
Sensitivitv O.44 O.2I · O.G/
Specihcitv O.9O O.82 · O.98
Positive |i|e|ihood ratio 4.4O I.8O · II.I
|e¤ative |i|e|ihood ratio O.G2 O.4O · O.9O
Spurling’ s Test ( continued)
Description Combination ot sidebendin¤ to the svmptomatic side coup|ed With compression to reduce the diameter ot the neura| toramen and
e|icit the patient's svmptoms
Measurement method The patient is seated and is as|ed to sidebend and s|i¤ht|v rotate the head to the paintu| side. The e·aminer p|aces a compression torce
ot appro·imate|v / |¤ throu¤h the top ot the head in an etort to turther narroW the intervertebra| toramen. The test is considered positive
When it reproduces the patient's svmptoms. The test is not indicated it the patient has no upper e·tremitv or scapu|ar re¤ion svmptoms.
Nature of variable |omina|/dichotomous
Units of measurement None
Diagnostic accuracy indices for
Spurling’s test, based on the
study by Wainner et al
175
95% Conhdence lnterva|
lappa O.GO O.J2 · O.8/
Sensitivitv O.5O O.2/ · O./J
Specihcitv O.8G O.// · O.94
Positive |i|e|ihood ratio J.5O I.GO · /.5O
|e¤ative |i|e|ihood ratio O.58 O.JG · O.94
Valsalva Test
ICF category Veasurement ot impairment ot structure ot the nervous svstem, other specihed
Description Vaneuver in Which the patient bears doWn Without e·ha|in¤ to increase intratheca| pressure and e|icit upper quarter svmptoms
Measurement method The patient is seated and instructed to ta|e a deep breath and ho|d it Whi|e attemptin¤ to e·ha|e tor 2·J seconds. A positive
response occurs With reproduction ot svmptoms.
Nature of variable |omina|/dichotomous
Units of measurement None
Diagnostic accuracy indices for
the valsalva test, based on the
study by Wainner et al
175
95% Conhdence lnterva|
lappa O.G9 O.JG · I.O
Sensitivitv O.22 O.OJ · O.4I
Specihcitv O.94 O.88 · I.O
Positive |i|e|ihood ratio J.5O O.9/ · I2.G
|e¤ative |i|e|ihood ratio O.8J O.G4 · I.I
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a19
A variety of interventions have been described for the treat-
ment of neck pain and there is good evidence from high-
quality 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
Review
69
of mobilization and manipulation for
mechanical neck disorders included 33 randomized
controlled trials of which 42% were considered high qual-
ity. 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) inter-
vention alone were determined to be less efective than when
combined with exercise (combined intervention).
69
A recently
published clinical practice guideline concluded that the evi-
dence for combined intervention was relatively strong, while
the evidence for the efectiveness of thrust or non-thrust ma-
nipulation in isolation was weaker.
68
The recommendations of the Cochrane Review
69
and the re-
cently published clinical practice guideline
68
were based on
key findings that warrant further discussion. Studies cited
included patients with both acute
82
and chronic neck pain
22
and interventions consisted of soft-tissue mobilization and
manual stretching procedures, as well as thrust,
17,83
and non-
thrust manipulative procedures
82
directed at spinal motion
segments. Number of visits ranged from 6 over a 3 week
period
82
to 20 over an 11 week period
22
and the duration of
sessions ranged from 30 minutes
99
to 60 minutes.
22
Com-
bined 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 (medica-
tion, advice, education),
82
and no treatment.
99
The majority
of studies report either clinically or statistically important
diferences in pain in favor of combined intervention when
compared to competing single interventions.
69
Diferences in
muscle performance
22,99
as well as patient satisfaction have
also been reported for both short-term
22,82,99
as well as long-
term outcomes 1
22
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 al
166
reported 6 predictors for patients who experienced an
immediate improvement in either pain, satisfaction, or per-
ception of condition following manipulation of the cervical
spine. These predictors included
166
:
· IniliaI scores on Neck DisabiIilv Index Iess lhan 11.õ
· Having biIaleraI invoIvemenl pallern
· Nol performing sedenlarv work more lhan õ hours per
day
· IeeIing beller whiIe moving lhe neck
· Did nol feeI worse whiIe exlending lhe neck
· The diagnosis of spondvIosis wilhoul radicuIopalhv
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 inter-
vention have not been reported.
Nilsson et al
125
conducted a randomized, clinical tri-
al (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
group and 3,% in lhe Iaser]massage group. Headache inlen-
sity per episode decreased by 36% for those in the manipula-
tion group and 17% in the laser/massage group.
A systematic review by Vernon et al,
171
which includ-
ed studies published through 2005, concluded that
there is moderate- to high-quality evidence that sub-
jects with chronic neck pain and headaches show clinically im-
portant improvements from a course of spinal mobilization or
manipulation at 6, 12, and up to 104 weeks post-treatment.
Despite good evidence to support the benefits of cervical
mobilization/manipulation, it is important that physical
CLINICAL GUIDELINES
Interventions
I
I
II
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a20 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
therapists be aware of the potential risks in using these tech-
niques.
68,60
However, it is impossible to determine the pre-
cise risk because (1) it is extremely difcult to quantify the
number of cervical spine mobilization/manipulative inter-
ventions 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 ac-
cepted standard for reporting these injuries. Reported risk
factors include hypertension, migraines, oral contraceptive
use, and smoking.
,2
However, the prevalence of these factors
in the study by Haldeman et al
,2
is largely the same or lower
than that which occurs in the general population.
Although the true risk for complications remains unknown,
lhe risk for serious compIicalions is eslimaled lo be 6 in 1u
miIIion (u.uuuu6%) manipuIalions, wilh lhe risk of dealh be-
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.
84
Gross et al
,u
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
from 1 in 2u,uuu (u.u1%) lo õ in 1u miIIion (u.uuuõ%).
,u
The risk estimate for patients experiencing non-serious
side efects such as increased symptoms, ranges from 1% to
2%.
149
The most common side efects included local discom-
forl (õ3%), IocaI headache (12%), faligue (11%), or radialing
discomforl (1u%). Palienls characlerized 8õ% of lhese com-
pIainls as miId or moderale, wilh 64% of side eßecls appear-
ing within 4 hours after manipulation. Within 24 hours after
manipuIalion, ,4% of lhe compIainls had resoIved. Less lhan
õ% of side eßecls were characlerized as dizziness, nausea, hol
skin, or other complaints. Side efects were rarely still noted
on the day after manipulation, and very few patients reported
the side efects as being severe.
Due the potential risk of serious adverse efects associated
with cervical manipulation, such as vertebrobasilar artery
stroke,
õ6
it has been recommended that non-thrust cervi-
cal mobilization/manipulation be utilized in favor of thrust
manipulation.
õu,8õ
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 cer-
vical segmental mobility deficits, has not been reported. In
addition, the case reports in the literature describing serious
adverse efects associated with cervical thrust manipulation
do not provide information regarding either the presence of
impairmenls of bodv funclions, or lhe presence of red ßags
for vertebrobasilar insufciency,
,
prior to the application of
the manipulative procedure suspected to be linked with the
reported harmful efects.
Recommendation: Clinicians should consider utiliz-
ing cervical manipulation and mobilization proce-
dures, thrust and non-thrust, to reduce neck pain and
headache. Combining cervical manipulation and mobilization
with exercise is more efective for reducing neck pain, headache,
and disability than manipulation and mobilization alone.
Th0kA6|6 N08|L|ZAI|0NíNAN|PuLAI|0N
A survey among clinicians that practice manual physi-
cal 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 efectiveness of thoracic
spine lhrusl manipuIalion (TSM) for palienls wilh neck
pain, patients in these studies also received cervical manipu-
lation.
2,22,õ,
The rationale to include thoracic spine mobiliza-
tion/manipulation in the treatment of patients with neck
pain stems from the theory that disturbances in joint mobil-
ity in the thoracic spine may be an underlying contributor to
musculoskeletal disorders in the neck.
04,1uõ
Cleland et al
34
compared lhe eßecliveness of TSM in
a trial in which patients were randomized to either a
singIe session of TSM or sham manipuIalion. Palienls
who received TSM experienced a cIinicaIIv meaningfuI and sla-
tistically significant reduction in pain on the visual analogue
scale (VAS) compared to patients who received the sham inter-
vention (P.001).
34
A similar finding (reduction of pain) was
aIso reporled in a randomized lriaI lhal compared TSM inler-
vention to an active exercise program.
14,
A subsequent random-
ized trial by Cleland et al
38
which compared TSM lo non-lhrusl
manipulation (mobilization) found significant diferences in fa-
vor of lhe TSM group in pain, disabiIilv, and palienl perceived
improvemenl upon re-evaIualion 48 hours Ialer.
While preliminary reports indicate that patients
with complaints of primary neck pain experience a
signiñcanl beneñl when lrealed wilh TSM, il is sliII
unclear which patients benefit most. Cleland et al
33
reported a
preliminary clinical prediction rule for patients with primary
neck pain who experience short-term improvement (1-week)
wilh TSM. Each subjecl received a lolaI of 3 lhoracic manipu-
lations directed at the upper and middle thoracic spine for up
lo 2 sessions. Using a gIobaI raling of change score lõ as a
reference crilerion, 6 variabIes were reporled as prediclors of
improvement and included
33
:
· Svmplom duralion of Iess lhan 3u davs
· No svmploms dislaI lo lhe shouIder
· Subjecl reporls lhal Iooking up does nol aggravale
symptoms
· Iear-avoidance BeIiefs Oueslionnaire-PhvsicaI Aclivilv
Scale score less than 12
A
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Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a21
· Diminished upper lhoracic spine kvphosis (T3-Tõ)
· CervicaI exlension of Iess lhan 3u°
Interestingly, the lack of symptom aggravation with looking
up was also one of the predictors reported by Tseng et al
166
in
the cervical manipulation clinical prediction rule. Validation
of bolh lhe cervicaI and TSM cIinicaI ruIes is required before
they can be recommended for widespread clinical use.
In a randomized clinical trial Fernández de las Pe-
ñas et al
õ0
demonstrated that patients with neck
pain related to a whiplash-associated disorder re-
ceiving TSM experienced a signiñcanlIv grealer (P<.uu3)
reduction in pain as measured by the visual analogue scale,
than those who did not receive the thoracic manipulation.
The mean change in pain IeveIs in lhe group receiving TSM
was õ4.1 mm (SD 18.8 mm) compared lo a mean change of
13.4 mm (SD 8.0 mm) in lhe group nol receiving lhoracic ma-
nipulation. The length of follow-up was not clearly defined.
Self-reported levels of pain and cervical active
ROM were assessed before and immedialeIv afler
TSM in 26 palienls wilh a primarv compIainl of
neck pain. The mean reduction in pain on an 11-point nu-
meric 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
aclive ROM were aIso observed in aII direclions excepl exlen-
sion (P<.uu1). This sludv did nol incIude a conlroI group and
only consisted of an immediate follow-up, but the immediate
improvemenls in pain and cervicaI aclive ROM suggesl lhal
TSM mav have some meril in palienls wilh neck pain.
61
There have been 4 case series that have incorpo-
rated thoracic spine thrust manipulation in the
multi-modal management of patients with cervi-
cal radiculopathy.
23,30,12u,1,6
In the first case series,
39
10 of the
11 patients (91%) demonstrated a clinically meaningful im-
provemenl in pain and funclion al lhe 6-monlh foIIow-up
afler a mean of ,.1 phvsicaI lherapv visils. In lhe second case
series
1,6
all patients except for 1 exhibited a significant reduc-
tion in disability. In the third case series,
120
full resolution of
pain was reporled in 8 of 1õ (õ3%) palienls, where aII 6 of lhe
patients receiving mobilization and manipulation achieved
full resolution of pain. In addition, there has been 1 case se-
ries
23
that included thoracic spine thrust manipulation in the
managemenl of , palienls wilh grade I cervicaI compressive
myelopathy. All patients exhibited a reduction in pain and
improvement in function at the time of discharge.
Recommendation: Thoracic spine thrust ma-
nipulation 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.
$Ik£I6h|N6 £X£k6|$£$
In a randomized controlled trial, Ylinen et
al
183
assessed the efectiveness of manual therapy
procedures implemented twice a week compared
wilh a slrelching regimen performed õ limes a week in lhose
with non-specific neck pain. At the 4 and 12 week follow-up
both groups improved but there were no significant diferenc-
es between the groups related to pain. Neck pain and disabil-
ity outcome measures, shoulder pain and disability outcome
measures, and neck stifness were reduced significantly more
in those receiving manual therapy, but the clinical diference
was minimal. The authors concluded that the low-cost of
stretching exercises should be included in the initial treat-
ment plan for patients with neck pain.
The authors of this clinical practice guideline have
observed that patients with neck pain often pres-
enl wilh impairmenls of ßexibiIilv of kev muscIes
related to the lower cervical and upper thoracic spine, such
as the anterior, medial, and posterior scalenes, upper trape-
zius, levator scapulae, pectoralis minor, and pectoralis major,
that should be addressed with stretching exercises. One study
reporled lhal upper quarler muscIe ßexibiIilv deñcils were
common in dental hygienists,

an occupation that requires
frequent repetitive activities involving the shoulders, arms,
and hands. Although research generally does not support the
efectiveness of interventions that focus on stretching and
ßexibiIilv, cIinicaI experience suggesls lhal addressing spe-
cific impairments of muscle length for an individual patient
may be a beneficial addition to a comprehensive treatment
program.
Recommendation: Flexibility exercises can be used
for patients with neck symptoms. Examination and
largeled ßexibiIilv exercises for lhe foIIowing mus-
cles are suggested: anterior/medial/posterior scalenes, upper
trapezius, levator scapulae, pectoralis minor, and pectoralis
major.
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£X£k6|$£$
Jull et al
99
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 tender-
ness in at least 1 of the upper 3 cervical joints as detected by
I
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IV
IV
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Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a22 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
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 out-
come was a change in headache frequency. At the 12-month
follow-up, the mobilization/manipulation, combined mobi-
lization/manipulation and exercise, and the specific exercise
groups had significantly reduced headache frequency and in-
tensity. Additionally 10% more patients experienced a com-
plete reduction in headache frequency when treated with
mobilization/manipulation and exercise than those treated
with the alternative approaches.
99
The exercise program in lhis cIinicaI lriaI bv JuII el aI
99
used
low load endurance exercises to train muscle control of the
cervicoscapular region. The first stage consisted of specific
craniocervicaI ßexion exercises, performed in supine Iving,
aimed lo largel lhe deep neck ßexor muscIes, which are lhe
longus capitis and longus colli. Subsequently, isometric exer-
cises using a low level of rotatory resistance were used to train
lhe co-conlraclion of lhe neck ßexors and exlensors. The ex-
ercise groups had significantly reduced headache frequency
and intensity when compared to the controls.
Chiu et al
28
assessed the benefits of an exercise pro-
gram that focused both on motor control training of
lhe deep neck ßexors and dvnamic slrenglhening. A
lolaI of 14õ palienls wilh chronic neck pain were randomized
to either an exercise or a non-exercise control group. At week
6, lhe exercise group had signiñcanlIv beller improvemenls
in disability scores, pain levels, and isometric neck muscle
strength. However, significant diferences between the 2
groups were found only in pain and patient satisfaction at
lhe 6-monlh foIIow-up.
In a randomized, cIinicaI lriaI, YIinen el aI
184
dem-
onstrated the efectiveness of both strengthening
exercises and endurance training of the deep neck
ßexor muscIes in reducing pain and disabiIilv al lhe 1-vear
foIIow-up in women (n = 18u) wilh chronic, nonspeciñc neck
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 stabiliza-
tion 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
3-vear foIIow-up sludv, YIinen el aI
182
found that women (n =
118) in bolh lhe slrenglhening exercise and endurance lrain-
ing groups achieved long-term benefits from the 12-month
programs.
O`Learv el aI
12,
compared the efect of 2 specific
cervicaI ßexor muscIe exercise prolocoIs on im-
mediate pain relief in the cervical spine of people
with chronic neck pain. They found that those performing
lhe speciñc craniocervicaI ßexion exercise demonslraled
greater improvements in pressure pain thresholds, me-
chanical hyperalgesia, and perceived pain relief during ac-
tive movement.
In a cross-sectional comparative study, Chiu et al
29
compared the performance of the deep cervical
ßexor muscIes on lhe craniocervicaI ßexion lesl in
individuals with (n = 20) and without (n = 20) chronic neck
pain. Those with chronic neck pain had significantly poorer
performance on lhe craniocervicaI ßexion lesl (median pres-
sure achieved, 24 mmHg when starting at 20 mmHg) when
compared with those in the asymptomatic group (median
pressure achieved, 28 mmHg when slarling al 2u mmHg).
JuII el aI
0,
compared the efects of conventional
proprioceplive lraining and craniocervicaI ßexion
training on cervical joint position error in people
with persistent neck pain. The aim was to evaluate whether
proprioceptive training was superior in improving proprio-
ceptive acuity compared to a form of exercise that has been
shown to be efective 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:
proprioceplive lraining or craniocervicaI ßexion lraining.
Exercise regimens were conducled over a 6-week period.
The results demonstrated that both proprioceptive training
and craniocervicaI ßexion lraining have a demonslrabIe ben-
efit on impaired cervical joint position error in people with
neck pain, with marginally more benefit gained from prop-
rioceptive training. The results suggest that improved prop-
rioceptive acuity following intervention with either exercise
protocol may occur through an improved quality of cervical
aferent input or by addressing input through direct training
of relocation sense.
0,
In a randomized, clinical trial, Taimela et al
162
com-
pared the efcacy of a multimodal treatment em-
phasizing proprioceptive training in patients with
non-speciñc chronic neck pain (n = ,6). The proprioceplive
treatment, which consisted of exercises, relaxation, and be-
havioral support was more efcacious than comparison in-
terventions 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.
III
III
I
I
I
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Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a23
In a randomized clinical trial, Viljanen et al
1,3
as-
sessed the efectiveness of dynamic muscle training
(n= 13õ), reIaxalion lraining (n = 128), or ordinarv
aclivilv (n = 13õ) for femaIe oßce workers wilh chronic neck
pain. Dynamic muscle training and relaxation training did
not lead to better improvements in neck pain compared with
ordinary activity.
In a randomized clinical trial, Bronfort et al
22
found
that a combined program of strengthening and en-
durance exercises combined with manual therapy
resulted in greater gains in strength, endurance, range of mo-
tion, and long-term patient pain ratings in those with chron-
ic neck pain than programs that only incorporated manual
therapy. Additionally, Evans et al
õ8
found that these results
were maintained at a 2-year follow-up.
In a prospective case series, Nelson et al
124
followed
patients with cervical and lumbar pain and found
that an aggressive strengthening program was able
lo prevenl surgerv in 3õ of lhe 6u palienls (46 of lhe 6u com-
pIeled lhe program, 38 were avaiIabIe for foIIow-up, and onIv
3 reported having surgery). Despite the methodological limi-
tations 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.
In a systematic review of 9 randomized clinical tri-
aIs and , comparalive lriaIs wilh moderale melhod-
ological quality for patients with mechanical neck
disorders, Sarig-Bahat
14õ
reported relatively strong evidence
supporting the efectiveness of proprioceptive exercises and
dynamic resisted strengthening exercises of the neck-shoul-
der musculature for patients with chronic or frequent neck
disorders. The evidence identified could not support the ef-
fectiveness of group exercise, neck schools, or single sessions
of extension-retraction exercises.
In a randomized clinical trial, Chiu et al
30
found
in palienls wilh chronic neck pain (n = 218), lhal
a 6-week lrealmenl of lransculaneous eIeclri-
cal 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 im-
provements in the intervention groups were maintained at
lhe 6-monlh foIIow-up.
Hammill et al
,4
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 main-
tained at a 12-month follow-up.
In a svslemalic review, Kav el aI
103
concluded that
specific exercises may be efective for the treatment
of acute and chronic mechanical neck pain, with or
without headache.
A recent Cochrane review
60
concluded that mo-
bilization and/or manipulation when used with
exercise are beneficial for patients with persistent
mechanical neck disorders with or without headache. How-
ever, manual therapy without exercise or exercise alone were
not superior to one another.
Although evidence is generally lacking, postural
correction and body mechanics education and
training may also be indicated if clinicians identify
ergonomic inefciencies during either the examination or
treatment of patients with motor control, movement coordi-
nation, muscle power, or endurance impairments.
Recommendation: Clinicians should consider the
use of coordination, strengthening, and endurance
exercises to reduce neck pain and headache.
6£NIkAL|ZAI|0N Pk06£0uk£$ AN0 £X£k6|$£$
Kjellman and colleagues
104
randomly assigned
,, palienls wilh neck pain (20 of which presenled
with cervical radiculopathy) to general exercise,
McKenzie melhod of examinalion and lrealmenl, or a conlroI
group (Iow inlensilv uIlrasound and educalion). The McKen-
zie method of treatment consists of patient positioning, spe-
cific repeated movements, manual procedures, and patient
education in self management in case of recurrence.
1u4,118
The
repealed speciñc movemenls wilh lhe McKenzie melhod in-
tend to centralize (promote the migration of symptoms from
an area more distal to location more proximal) or reduce
pain.
118
At the 12 month follow-up all groups showed signifi-
cant reductions in pain intensity and disability but no signifi-
cant diference between groups existed. Seventy-nine percent
of patients reported that they were better or completely re-
slored afler lrealmenl, aIlhough õ1% reporled conslanl]daiIv
pain. All 3 groups had similar recurrence rates.
Murphv el aI
122
incorporaled McKenzie procedures
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 im-
portant improvement in disability. However, specific details
regarding the number of patients receiving procedures to
promote centralization was not reported.
III
A
I I
I
I
I
I
II
V
IV
IV
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a24 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
There has not been a clinical trial that recruited patients with
only cervical radiculopathy. Therefore, it is not possible to
commenl on lhe eßcacv of lhe McKenzie melhod or lhe use
of centralization procedures and exercises for this particular
subgroup of patients.
31
Recommendation: Specific repeated movements or
procedures to promote centralization are not more
beneficial in reducing disability when compared to
other forms of interventions.
uPP£k 0uAkI£k AN0 N£k¥£ N08|L|ZAI|0N
Pk06£0uk£$
Allison et al
2
examined the efectiveness of
2 diferent manual therapy techniques (neural
mobilization and cervical/upper quadrant mobi-
lization) in the management of cervico-brachial syndrome.
AII palienls received lrealmenl for 8 weeks in addilion lo
a home exercise program. The results demonstrated that
both manual therapy groups exhibited improvements in
pain and function. At the final data collection there ex-
isted no diference between the manual therapy groups
for function but a significant diference between groups
for reduction in pain was identified in favor of the neural
mobilization group.
In a randomized clinical trial, Coppieters et al
41
assigned 20 patients with cervico-brachial pain to
receive either cervical mobilization with the upper
extremity in an upper limb neurodynamic position or thera-
peutic ultrasound. The group receiving the mobilizations
exhibited significantly greater improvements in elbow range
of motion during neurodynamic testing as well as greater re-
ductions in pain compared to the ultrasound group.
Murphv el aI
122
incorporated neural mobilization in
the management of a cohort of patients with cervi-
cal 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.
Cleland et al
39
described the outcomes of a con-
secutive series of patients presenting to physical
therapy who received cervical mobilization (cer-
vical lateral glides) with the upper extremity in a neuro-
dynamic position as well as thoracic spine manipulation,
cervical traction, and strengthening exercises. Ten of the
11 patients (91%) demonstrated a clinically meaningful
improvemenl in pain and funclion foIIowing a mean of ,.1
physical therapy visits.
Recommendation: Clinicians should consider the
use of upper quarter and nerve mobilization proce-
dures to reduce pain and disability in patients with
neck and arm pain.
IkA6I|0N
A systematic review by Graham and col-
leagues
6,
reported that there is moderate evidence
to support the use of mechanical intermittent cervi-
cal traction.
Taghi Joghalaei el aI
93
randomly assigned 30 pa-
tients to receive a treatment program consisting
of ultrasound and exercise with or without me-
chanical intermittent cervical traction for 10 sessions. The
group receiving traction exhibited greater improvements
in grip slrenglh, lhe primarv oulcome measure, afler õ ses-
sions. However, no statistically significant diference be-
tween groups existed at the time of discharge from physical
therapy.
93
Saal et al
143
invesligaled lhe oulcomes of 26 con-
secutive patients who fit the diagnostic criteria for
herniated cervical disc with radiculopathy who re-
ceived a rehabilitation program consisting of cervical traction
and exercise. Twenty-four patients avoided surgical interven-
tion and 20 exhibited good or excellent outcomes.
In a prospective cohort design Cleland et al
36
iden-
tified predictor variables of short-term success for
patients presenting to physical therapy with cervi-
cal radiculopathy. One of the predictor variables for patients
who exhibited a short-term success included a multimodal
physical therapy approach consisting of manual or mechani-
cal traction, manual therapy (cervical or thoracic mobiliza-
lion]manipuIalion), and deep neck ßexor slrenglhening. The
pretest probability for the likelihood of short-term success
was õ3%. The mean duralion of mechanicaI lraclion used on
palienls in lhis sludv was 1,.8 minules wilh an average force
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
posl-lesl probabiIilv of success of ,1%.
36
Raney et al
13,
recently developed a clinical predic-
tion rule to identify patients with neck pain likely
to benefit from cervical mechanical traction. Sixty-
eighl palienls (38 femaIe) were incIuded in dala anaIvsis of
which 3u had a successfuI oulcome. AII palienls received 6
sessions of mechanical intermittent cervical traction start-
ing wilh a force of puII belween 4.õ-õ.4 kg (1u-12 pounds)
for a duralion of 1õ minules. The force of puII progressiveIv
I
III
III
II
II
II
II
II
IV
C
B
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a25
increased based on centralization of symptoms at each sub-
sequenl session. A cIinicaI prediclion ruIe wilh õ variabIes
was identified:
· Palienl reporled peripheraIizalion wilh Iower cervicaI spine
(C4-,) mobiIilv lesling
· Posilive shouIder abduclion sign
· Age lõõ vears
· Posilive upper Iimb lension lesl (median nerve bias uliIiz-
ing shouIder abduclion lo 0u°)
· ReIief of svmploms wilh manuaI dislraclion lesl
Having al Ieasl 3 oul of õ variabIes presenl resuIled in a
posilive IikeIihood ralio equaI lo 4.81 (0õ% CI = 2.1,-11.4),
increasing the likelihood of success with cervical traction
from 44% lo ,0.2%. If al Ieasl 4 oul of õ variabIes were pres-
enl, lhe posilive IikeIihood ralio was equaI lo 11., (0õ% CI
= 2.u0-60.õ8), increasing lhe posl-lesl probabiIilv of having
improvement with cervical traction to 90.2%.
Three separate case series
30,12u,1,6
describe the man-
agement of patients with cervical radiculopathy,
where the interventions included traction. In these
case series, the patients were treated with a multimodal treat-
ment approach and the vast majority of patients exhibited
improved outcomes. In the first report, Cleland et al
39
de-
scribed 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-
caI lraclion, and slrenglhening exercises. Al 6 monlh foIIow-
up, 91% demonstrated a clinically meaningful improvement
in pain and funclion foIIowing a mean of ,.1 phvsicaI lherapv
visits. Similarly, Waldrop
1,6
lrealed 6 palienls wilh cervicaI
radiculopathy with mechanical intermittent cervical traction,
thoracic thrust joint manipulation, and range of motion and
slrenglhening exercises for lhe cervicaI spine. Upon discharge
(mean lrealmenl 1u visils, range õ-18 visils; duralion 33 davs,
range 10-õ6 davs), lhere was a reduclion in disabiIilv belween
13% and 88%. In lhe lhird case series, Moeli and Marchelli
120
investigated the outcomes associated with cervical traction,
neck retraction exercises, scapular muscle strengthening,
and mobilization/manipulation techniques (used for some
palienls) for 1õ palienls wilh cervicaI radicuIopalhv. These
aulhors reporled fuII resoIulion of pain in õ3% of palienls al
the time of discharge.
Browder and colleagues
23
investigated the efec-
tiveness of a multimodal treatment approach in
lhe managemenl of , femaIe palienls wilh grade I
cervical compressive myelopathy. Patients were treated with
intermittent mechanical cervical traction and thoracic ma-
nipuIalion for a median of 0 sessions over a median of õ6
davs. The median decrease in pain scores was õ from a base-
Iine of 6 (using a u-1u pain scaIe), and median improvemenl
in IunclionaI Raling Index scores was 26% from a baseIine
of 44%.
Recommendation: Clinicians should consider
the use of mechanical intermittent cervical trac-
tion, 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.
PAI|£NI £0u6AI|0N AN0 60uN$£L|N6
There is a paucity of high quality evidence
surrounding efcacy of treatments for whiplash-
associated disorder (WAD). However, existing re-
search supports instructing patients in active interventions,
such as exercises, and early return to regular activities as a
means of pain control. Rosenfeld et al
142
compared the long-
term efcacy of active intervention with that of standard in-
tervention and the efect of early versus delayed initiation
of intervention. Patients were randomized to an interven-
tion using frequent active cervical rotation range of motion
exercises complemented by assessment and treatment ac-
cording lo McKenzie`s principIes or lo an inlervenlion lhal
promoted initial rest, soft collar utilization, and gradual self-
mobilization. In patients with WAD, early active interven-
tion was more efective 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 ap-
proach can be carried out as home exercises and progressive
return to activities initiated and supported by appropriately
trained health professionals.
An often prescribed intervention for acute whiplash
injury is the use of a soft cervical collar. Crawford
et al

prospecliveIv invesligaled 1u8 conseculive
patients following a soft tissue injury of the neck that result-
ed from motor vehicle accidents. Each patient was random-
ized 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,
and õ2 week inlervaIs from injurv. Inlervenlion lhal uliIized
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 of work. Other investigations
have reported similar results.
148,1,u
Interventions that instruct
patients to perform exercises early in their recovery from
whiplash type injuries have been reported to be more ef-
fective in reducing pain intensity and disability following
whiplash injury than interventions that instruct patients to
use cervical collars.
148,1,u
I
I
IV
IV
B
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a26 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
Existing research supports active interventions and
early return to regular activities but it has largely
been unknown as to which type of active interven-
tion would yield the most benefit. Brison et al
21
assessed the
efcacy of an educational video in the prevention of persis-
tent WAD symptoms following rear-end motor vehicle colli-
sions. The video provided reassurance, and education about
posture, return to regular activities, specific exercises, and
pain management. Patients were randomized to receive ei-
ther an educational video plus usual care or usual care alone.
The primary outcome was presence of persistent WAD symp-
toms at 24 weeks post injury, based on the frequency and
severity of neck, shoulder, or upper back pain. The group re-
ceiving 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 sufcient and, in fact,
may exacerbate their symptoms if such activities are provoca-
tive of pain.
21
A reduction in pain alone is not sufcient to ad-
dress the neuromuscular control deficits in patients
with chronic symptoms,
1õ,
as these deficits require
specific rehabilitation techniques.
99
For example, persistent
sensory and motor deficits may render the patient at risk for
symptom persistence.
1õõ,1õ6
Support for specificity in reha-
bilitation can be indirectly found from a recent population-
based, incidence cohort study evaluating a government policy
of funding community and hospital-based fitness training and
multidisciplinary rehabilitation for whiplash.
26
No supportive
evidence was found for the efectiveness of this general reha-
bilitation approach. Therefore, only addressing the lack of
fitness and conditioning in this patient population may not
be the most efcacious approach to treatment.
Ferrari et al
6u
studied whether an educational in-
tervention using a pamphlet provided to patients
in the acute stage of whiplash injury might im-
prove the recovery rate. One hundred twelve consecutive
subjects were randomized to 1 of 2 treatment groups: edu-
cational intervention or usual care. The education interven-
tion group received an educational pamphlet based on the
current evidence, whereas the control group only received
usual emergency department care and a standard non-di-
rected 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
response lo lhe queslion, ¯How weII do vou feeI vou are recov-
ering from vour injuries?" Al 3 monlhs posl coIIision, 21.8%
in the education intervention group reported complete recov-
ery compared with 21.0% in the control group (absolute risk
dißerence, u.8%; 0õ% CI = -14.4% lo 16.u%). Al 3 monlhs,
there were no clinically or statistically significant diferences
between groups in severity of remaining symptoms, limita-
tions 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 efec-
tive than usual care for patients with grade I or II WAD.
6u
JuII el aI
99
conducted a preliminary randomized
conlroIIed lriaI wilh ,1 parlicipanls wilh persislenl
neck pain following a motor vehicle accident to ex-
plore whether a multimodal program of physical therapies
was an appropriate management strategy compared to a self-
management approach. Participants were randomly allocated
to receive either a multimodal physical therapy program or
a self-management program (advice and exercise). Further-
more, participants were stratified according to the presence
or absence of widespread mechanical or cold hyperalgesia.
The intervention period was 10 weeks and outcomes were as-
sessed immediately following treatment. Even with the pres-
ence of sensorv hvpersensilivilv in ,2.õ% of subjecls, bolh
groups reported some relief of neck pain and disability, mea-
sured using Neck Disability Index scores, and it was superior
in the group receiving multimodal physical therapy (P=.04).
However, the overall efects 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.
08
A comprehensive review
11,
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 whiplash-
associated disorders.
11,
In a smaII case series, SoderIund and Lindberg
1õ3
reported that physical therapy integrated with
cognitive behavioral components decreased pain
intensity in problematic daily activities in 3 individuals with
chronic WAD.
Predictors of outcome following whiplash injury
have been limited to socio-demographic and fac-
tors of symptom location and severity, which are
not readily amenable to intervention. However, evidence
exists to demonstrate that psychological factors are pres-
ent soon following injury and play a role in recovery from
whiplash injury.
08,1õõ,1õ8
These factors can be as diverse as
the physical presentation and can include afective distur-
bances, anxiety, depression, and fear of movement.
123,132,1,8
Furthermore, post-traumatic stress disorder
112
has also been
I
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I
II
II
IV
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a27
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
observed in both the acute
õ2
and chronic conditions and has
been shown to be prognostic.
1,1
Identifying these factors in
patients may assist in the development of relevant subgroups
and appropriately matched education and counseling strate-
gies that practitioners should utilize in management of pa-
tients with WAD.
Recommendation: To improve the recovery in pa-
tients 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 progno-
sis and full recovery commonly occurs.
A
IA8L£ 4
Neck Pain Impairment/Function-based Diagnosis, Examination and
Intervention Recommended Classification Criteria*
|mpz|rmeot·8zsed 6ztegory
(w|th |60·I0 Assoc|zt|oos) $ymptoms |mpz|rmeots oI 8ody Fuoct|oo |oterveot|oos
|ec| pain With mobi|itv dehcit
· Cervica|¤ia
· Pain in thoracic spine
· uni|atera| nec| pain
· |ec| motion |imitations
· 0nset ot svmptoms is otten
|in|ed to a recent un¤uarded /
aW|Ward movement or position
· Associated (reterred) upper
e·tremitv pain mav be present
· limited cervica| ran¤e ot motion
· |ec| pain reproduced at end
ran¤es ot active and passive
motions
· Restricted cervica| and thoracic
se¤menta| mobi|itv
· |ec| and nec|·re|ated upper
e·tremitv pain reproduced With
provocation ot the invo|ved cervica|
or upper thoracic se¤ments
· Cervica| mobi|ization /
manipu|ation
· Thoracic mobi|ization /
manipu|ation
· Stretchin¤ e·ercises
· Coordination, stren¤thenin¤, and
endurance e·ercises
|ec| Pain With leadache
· leadache
· Cervicocrania| svndrome
· |oncontinuous, uni|atera| nec|
pain and associated (reterred)
headache
· leadache is precipitated or
a¤¤ravated bv nec| movements or
sustained positions
· leadache reproduced With
provocation ot the invo|ved upper
cervica| se¤ments
· limited cervica| ran¤e ot motion
· Restricted upper cervica| se¤menta|
mobi|itv
· Stren¤th and endurance dehcits ot
the deep nec| he·or musc|es
· Cervica| mobi|ization /
manipu|ation
· Stretchin¤ e·ercises
· Coordination, stren¤thenin¤, and
endurance e·ercises
|ec| Pain With Vovement
Coordination lmpairments
· Sprain and strain ot cervica| spine
· |ec| pain and associated (reterred)
upper e·tremitv pain
· Svmptoms are otten |in|ed to a
precipitatin¤ trauma/Whip|ash
and mav be present tor an e·tended
period ot time
· Stren¤th, endurance, and
coordination dehcits ot the deep
nec| he·or musc|es
· |ec| pain With mid·ran¤e motion
that Worsens With end ran¤e
movements or positions
· |ec| and nec|·re|ated upper
e·tremitv pain reproduced With
provocation ot the invo|ved cervica|
se¤ment(s)
· Cervica| instabi|itv mav be present
(note that musc|e spasm adjacent
to the invo|ved cervica| se¤ment(s)
mav prohibit accurate testin¤)
· Coordination, stren¤thenin¤,
and endurance e·ercises
· Patient education and counse|in¤
· Stretchin¤ e·ercises
|ec| Pain With Radiatin¤ Pain
· Spondv|osis With radicu|opathv
· Cervica| disc disorder With
radicu|opathv
· |ec| pain With associated radiatin¤
(narroW band ot |ancinatin¤) pain in
the invo|ved upper e·tremitv
· upper e·tremitv paresthesias,
numbness, and Wea|ness mav be
present
· |ec| and nec|·re|ated radiatin¤
pain reproduced With.
I. Cervica| e·tension, sidebendin¤,
and rotation toWard the invo|ved
side (Spur|in¤'s test)
2. upper |imb tension testin¤
· |ec| and nec|·re|ated radiatin¤
pain re|ieved With cervica|
distraction
· Vav have upper e·tremitv sensorv,
stren¤th, or rehe· dehcits
associated With the invo|ved nerve(s)
· upper quarter and nerve
mobi|ization procedures
· Traction
· Thoracic mobi|ization /
manipu|ation
* Recommendation based on expert opinion.
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a28 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
E PAIh0ANAI0N|6AL F£AIuk£$
A|thou¤h the cause ot nec| pain mav be associated With de¤enera·
tive processes or patho|o¤v identihed durin¤ dia¤nostic ima¤in¤, the
tissue that is causin¤ a patient's nec| pain is most otten un|noWn.
Thus, c|inicians shou|d assess tor impaired tunction ot musc|e, con·
nective, and nerve tissues associated With the identihed patho|o¤ica|
tissues When a patient presents With nec| pain.
B k|$k FA6I0k$
C|inicians shou|d consider a¤e ¤reater than 4O, coe·istin¤ |oW bac|
pain, a |on¤ historv ot nec| pain, cvc|in¤ as a re¤u|ar activitv, |oss ot
stren¤th in the hands, Worrisome attitude, poor qua|itv ot |ite, and
|ess vita|itv as predisposin¤ tactors tor the deve|opment ot chronic
nec| pain.
B 0|A6N0$|$í6LA$$|F|6AI|0N
|ec| pain, Without svmptoms or si¤ns ot serious medica| or psvcho·
|o¤ica| conditions, associated With (I) motion |imitations in the cervi·
ca| and upper thoracic re¤ions, (2) headaches, and (J) reterred or
radiatin¤ pain into an upper e·tremitv are usetu| c|inica| hndin¤s tor
c|assitvin¤ a patient into one ot the to||oWin¤ lnternationa| Statistica|
C|assihcation ot 0iseases and Re|ated lea|th Prob|ems (lC0) cat·
e¤ories. cervica|¤ia, pain in thoracic spine, headaches, cervicocrania|
svndrome, sprain and strain ot cervica| spine, spondv|osis With
radicu|opathv, and cervica| disc disorder With radicu|opathv, and the
associated lnternationa| C|assihcation ot lunctionin¤, 0isabi|itv, and
lea|th (lCl) impairment·based cate¤orv nec| pain With the to||oWin¤
impairments ot bodv tunction.
|ec| pain With mobi|itv impairments (b/IOI Vobi|itv ot severa| joints)
|ec| pain With headaches (28OIO Pain in head and nec|)
|ec| pain With movement coordination impairments (b/GOI Contro|
ot comp|e· vo|untarv movements)
|ec| pain With radiatin¤ pain (b28O4 Radiatin¤ pain in a se¤ment or re¤ion)
The to||oWin¤ phvsica| e·amination measures mav be usetu| in c|as·
sitvin¤ a patient in the lCl impairment·based cate¤orv ot nec| pain
With mobi|itv impairments and the associated lC0 cate¤ories ot cer·
vica|¤ia or pain in thoracic spine.
· Cervica| active ran¤e ot motion
· Cervica| and thoracic se¤menta| mobi|itv
The to||oWin¤ phvsica| e·amination measures mav be usetu| in c|as·
sitvin¤ a patient in the lCl impairment·based cate¤orv ot nec| pain
With headaches and the associated lC0 cate¤ories ot headaches or
cervicocrania| svndrome.
· Cervica| active ran¤e ot motion
· Cervica| se¤menta| mobi|itv
· Crania| cervica| he·ion test
The to||oWin¤ phvsica| e·amination measures mav be usetu| in c|as·
sitvin¤ a patient in the lCl impairment·based cate¤orv ot nec| pain
With movement coordination impairments and the associated lC0
cate¤orv ot sprain and strain ot cervica| spine.
· Crania| cervica| he·ion test
· 0eep nec| he·or endurance
The to||oWin¤ phvsica| e·amination measures mav be usetu| in c|as·
sitvin¤ a patient in the lCl impairment·based cate¤orv ot nec| pain
With radiatin¤ pain and the associated lC0 cate¤ories ot spondv|osis
With radicu|opathv or cervica| disc disorder With radicu|opathv.
· upper |imb tension test
· Spur|in¤'s test
· 0istraction test
B 0|FF£k£NI|AL 0|A6N0$|$
C|inicians shou|d consider dia¤nostic c|assihcations associated With
serious patho|o¤ica| conditions or psvchosocia| tactors When the
patient's reported activitv |imitations or impairments ot bodv tunc·
tion and structure are not consistent With those presented in the di·
a¤nosis/c|assihcation section ot this ¤uide|ine, or, When the patient's
svmptoms are not reso|vin¤ With interventions aimed at norma|iza·
tion ot the patient's impairments ot bodv tunction.
A £XAN|NAI|0N - 0uI60N£ N£A$uk£$
C|inicians shou|d use va|idated se|t·report questionnaires, such as
the |ec| 0isabi|itv lnde· and the Patient·Specihc lunctiona| Sca|e
tor patients With nec| pain. These too|s are usetu| tor identitvin¤ a
patient's base|ine status re|ative to pain, tunction, and disabi|itv and
tor monitorin¤ a chan¤e in patient's status throu¤hout the course ot
treatment.
F £XAN|NAI|0N - A6I|¥|IY L|N|IAI|0N N£A$uk£$
C|inicians shou|d uti|ize easi|v reproducib|e activitv |imitation and
participation restriction measures associated With their patient's
nec| pain to assess the chan¤es in the patient's |eve| ot tunction over
the episode ot care.
A |NI£k¥£NI|0N$ - 6£k¥|6AL N08|L|ZAI|0Ní
NAN|PuLAI|0N
C|inicians shou|d consider uti|izin¤ cervica| manipu|ation and mobi·
|ization procedures, thrust and non·thrust, to reduce nec| pain and
headache. Combinin¤ cervica| manipu|ation and mobi|ization With
e·ercise is more etective tor reducin¤ nec| pain, headache, and dis·
abi|itv than manipu|ation and mobi|ization a|one.
C |NI£k¥£NI|0N$ - Ih0kA6|6 N08|L|ZAI|0Ní
NAN|PuLAI|0N
Thoracic spine thrust manipu|ation can be used tor patients With
primarv comp|aints ot nec| pain. Thoracic spine thrust manipu|ation
can a|so be used tor reducin¤ pain and disabi|itv in patients With
nec| and nec|·re|ated arm pain.
CLINICAL GUIDELINES
Summary of Recommendations
Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a29
C |NI£k¥£NI|0N$ - $Ik£I6h|N6 £X£k6|$£$
l|e·ibi|itv e·ercises can be used tor patients With nec| svmptoms. E··
amination and tar¤eted he·ibi|itv e·ercises tor the to||oWin¤ musc|es
are su¤¤ested bv the authors. anterior/media|/posterior sca|enes, up·
per trapezius, |evator scapu|ae, pectora|is minor, and pectora|is major.
A |NI£k¥£NI|0N$ - 600k0|NAI|0N, $Ik£N6Ih£N|N6,
AN0 £N0ukAN6£ £X£k6|$£$
C|inicians shou|d consider the use ot coordination, stren¤thenin¤,
and endurance e·ercises to reduce nec| pain and headache.
C |NI£k¥£NI|0N$ - 6£NIkAL|ZAI|0N Pk06£0uk£$ AN0
£X£k6|$£$
Specihc repeated movements or procedures to promote centra|iza·
tion are not more benehcia| in reducin¤ disabi|itv When compared to
other torms ot interventions.
B |NI£k¥£NI|0N$ - uPP£k 0uAkI£k AN0 N£k¥£ N08|L|ZA-
I|0N Pk06£0uk£$
C|inicians shou|d consider the use ot upper quarter and nerve mobi|i·
zation procedures to reduce pain and disabi|itv in patients With nec|
and arm pain.
B |NI£k¥£NI|0N$ - IkA6I|0N
C|inicians shou|d consider the use ot mechanica| intermittent cervi·
ca| traction, combined With other interventions such as manua|
therapv and stren¤thenin¤ e·ercises, tor reducin¤ pain and disabi|itv
in patients With nec| and nec|·re|ated arm pain.
A |NI£k¥£NI|0N$ - PAI|£NI £0u6AI|0N AN0
60uN$£L|N6
To improve the recoverv in patients With Whip|ash·associated dis·
order, c|inicians shou|d (I) educate the patient that ear|v return to
norma|, non·provocative pre·accident activities is important, and
(2) provide reassurance to the patient that ¤ood pro¤nosis and tu||
recoverv common|v occurs.
Summary of
Recommendations (continued)
AuIh0k$
Joho 0. 6h||ds, PT, PhD
Associate Protessor ò 0irector ot
Research
uS Armv·Bav|or universitv 0octora|
Pro¤ram in Phvsica| Therapv
San Antonio, Te·as
chi|dsjd@sbc¤|oba|.net
Joshuz A. 6|e|zod, PI, Ph0
Associate Protessor
lran||in Pierce universitv
Concord, |eW lampshire
joshc|e|and@comcast.net
Jzmes N. £|||ott, PT, PhD
Post·0octora| Research le||oW
Centre tor C|inica| Research E·ce|·
|ence in Spina| Pain, lnjurv and
lea|th
The universitv ot 0ueens|and
Brisbane, Austra|ia
j.e||iott2@uq.edu.au
8erozrd J. $opky, MD
0epartment ot lami|v Vedicine
Ca|itornia Permanente Vedica| Croup
Rosevi||e, Ca|itornia
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uS Armv·Bav|or universitv 0octora|
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San Antonio, Te·as
dtevhen@sbc¤|oba|.net
kobert $. wz|ooer, PT, PhD
Associate Protessor
0epartment ot Phvsica| Therapv
Te·as State universitv
Vice President and 0irector ot
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Ju||e N. wh|tmzo, PT, DSc
Assistant Protessor
Schoo| ot Phvsica| Therapv
Re¤is universitv
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apv le||oWship Pro¤ram, Evidence
in Motion
jWhitman@re¤is.edu
Joseph J. 6odges, DPT
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la Crosse, \isconsin
ict@orthopt.or¤
I|mothy w. F|yoo, PT, PhD
Associate Protessor ò Vanua| Thera·
pv le||oWship Coordinator
0epartment ot Phvsica| Therapv
Re¤is universitv
0enver, Co|orado
thvnn@re¤is.edu
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Pittsbur¤h, Pennsv|vania
de|ittoa@upmc.edu
6eorge N. 0yr|w, DPT
C|inica| lacu|tv
0rthopaedic Phvsica| Therapv and Sports
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The 0hio State universitv Sports
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Co|umbus, 0hio
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Amzodz Fer|zod, PT
C|inic 0irector
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he|eoe Fezroo, PT
Principa| and Consu|tant
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Joy Nzc0erm|d, PT, PhD
Associate Protessor
Schoo| ot Rehabi|itation Science
VcVaster universitv
lami|ton, 0ntario, Canada
macderj@mcmaster.ca
Jzmes w. Nzthesoo, DPT
C|inica| Research 0irector
Therapv Partners, lnc
Burnsvi||e, Vinnesota
jmatheson@therapvpartners.com
Ph|||p Nc6|ure, PT, PhD
Protessor
0epartment ot Phvsica| Therapv
Arcadia universitv
C|enside, Pennsv|vania
mcc|ure@arcadia.edu
Pzu| $heke||e, MD, PhD
0irector
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Practice Center
Rand Corporation
Santa Vonica, Ca|itornia
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A. kusse|| $m|th, Jr, PT, Ed0
Chair
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universitv ot |orth l|orida
1ac|sonvi||e, l|orida
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Les||e Iorburo, DPT
Principa| and Consu|tant
Si|houette Consu|tin¤, lnc.
San Car|os, Ca|itornia
torburn@vahoo.com
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Ne c k Pa i n : C l i n i c a l P r a c t i c e Gu i d e l i n e s
a30 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
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