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Neck Pain CPG
Neck Pain CPG
Neck Pain:
Clinical Practice Guidelines Linked to
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RECOMMENDATIONS$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7(
INTRODUCTION$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7)
Journal of Orthopaedic & Sports Physical Therapy®
METHODS$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7*
CLINICAL GUIDELINES:
Impairment/Function-Based Diagnosis$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7/
CLINICAL GUIDELINES:
Examinations$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7'*
CLINICAL GUIDELINES:
Interventions$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7'/
SUMMARY OF RECOMMENDATIONS$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 7(.
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@Wc[iM$CWj^[ied":FJF^_b_fCY9bkh["FJ"F^:FWkbI^[a[bb["C:"F^:7$Hkii[bbIc_j^"@h"FJ";Z:B[ib_[JehXkhd":FJ
<ehWkj^eh"YeehZ_dWjeh"WdZh[l_[m[hWøb_Wj_edi"i[[[dZe\j[nj$(&&.Ehj^efW[Z_YI[Yj_ed7c[h_YWdF^oi_YWbJ^[hWfo7iieY_Wj_ed7FJ7"?dY"WdZj^[@ekhdWbe\
Ehj^efW[Z_YIfehjiF^oi_YWbJ^[hWfo$J^[Ehj^efW[Z_YI[Yj_ed"7FJ7"?dY$"WdZj^[@ekhdWbe\Ehj^efW[Z_YIfehjiF^oi_YWbJ^[hWfoYedi[djjej^[f^ejeYefo_d]e\
j^_i]k_Z[b_d[\eh[ZkYWj_edWbfkhfei[i$7ZZh[iiYehh[ifedZ[dY[je0@ei[f^@$=eZ][i":FJ"?9<FhWYj_Y[=k_Z[b_d[i9eehZ_dWjeh"Ehj^efW[Z_YI[Yj_ed"7FJ7?dY$"(/(&
;Wij7l[dk[Iekj^"Ik_j[(&&1BW9heii["M?+*,&'$;cW_b0_Y\6ehj^efj$eh]
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Recommendations*
F7J>E7D7JEC?97B<;7JKH;I0 Although the cause of neck pain The following physical examination measures may be useful in
may be associated with degenerative processes or pathology classifying a patient in the ICF impairment-based category of
identified during diagnostic imaging, the tissue that is causing neck pain with movement coordination impairments and the
a patient’s neck pain is most often unknown. Thus, clinicians associated ICD category of sprain and strain of cervical spine.
should assess for impaired function of muscle, connective, and (Recommendation based on moderate evidence.)
nerve tissues associated with the identified pathological tissues <kZgbZe\^kob\Ze×^qbhgm^lm
when a patient presents with neck pain. (Recommendation =^^ig^\d×^qhk^g]nkZg\^m^lm
based on theoretical/foundational evidence.)
The following physical examination measures may be useful in
H?IA<79JEHI0 Clinicians should consider age greater than 40, classifying a patient in the ICF impairment-based category of
coexisting low back pain, a long history of neck pain, cycling as neck pain with radiating pain and the associated ICD categories
a regular activity, loss of strength in the hands, worrisome atti- of spondylosis with radiculopathy or cervical disc disorder with
radiculopathy. (Recommendation based on moderate evidence.)
tude, poor quality of life, and less vitality as predisposing factors
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Nii^kebf[m^glbhgm^lm
for the development of chronic neck pain. (Recommendation
Linkebg`Ílm^lm
based on moderate evidence.)
=blmkZ\mbhgm^lm
:?7=DEI?I%9B7II?<?97J?ED0 Neck pain, without symptoms or
:?<<;H;DJ?7B:?7=DEI?I0 Clinicians should consider diagnostic
signs of serious medical or psychological conditions, associated
classifications associated with serious pathological conditions
with (1) motion limitations in the cervical and upper thoracic or psychosocial factors when the patient’s reported activity
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
regions, (2) headaches, and (3) referred or radiating pain into limitations or impairments of body function and structure are
an upper extremity are useful clinical findings for classifying a not consistent with those presented in the diagnosis/classifica-
patient with neck pain into one of the following International tion section of this guideline, or, when the patient’s symptoms
Statistical Classification of Diseases and Related Health Prob- are not resolving with interventions aimed at normalization of
lems (ICD) categories: cervicalgia, pain in thoracic spine, head- the patient’s impairments of body function. (Recommendation
aches, cervicocranial syndrome, sprain and strain of cervical based on moderate evidence.)
spine, spondylosis with radiculopathy, and cervical disc disorder
with radiculopathy; and the associated International Classifica- ;N7C?D7J?EDÅEKJ9EC;C;7IKH;I0 Clinicians should use
tion of Functioning, Disability, and Health (ICF) impairment- validated self-report questionnaires, such as the Neck Disability
Index and the Patient-Specific Functional Scale for patients
Journal of Orthopaedic & Sports Physical Therapy®
a2 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Recommendations* (continued)
?DJ;HL;DJ?EDIÅIJH;J9>?D=;N;H9?I;I0 Flexibility exercises and nerve mobilization procedures to reduce pain and disability
can be used for patients with neck symptoms. Examination in patients with neck and arm pain. (Recommendation based
Zg]mZk`^m^]×^qb[bebmr^q^k\bl^l_hkma^_heehpbg`fnl\e^lZk^ on moderate evidence.)
suggested: anterior/medial/posterior scalenes, upper trapezius,
levator scapulae, pectoralis minor, and pectoralis major. (Rec- ?DJ;HL;DJ?EDIÅJH79J?ED0 Clinicians should consider the use
ommendation based on weak evidence.) of mechanical intermittent cervical traction, combined with
other interventions such as manual therapy and strengthening
?DJ;HL;DJ?EDIÅ9EEH:?D7J?ED"IJH;D=J>;D?D="7D:;D:KH- exercises, for reducing pain and disability in patients with neck
7D9;;N;H9?I;I0 Clinicians should consider the use of coor- and neck-related arm pain. (Recommendation based on moder-
dination, strengthening, and endurance exercises to reduce ate evidence.)
neck pain and headache. (Recommendation based on strong
evidence.) ?DJ;HL;DJ?EDIÅF7J?;DJ;:K97J?ED7D:9EKDI;B?D=0 To
improve recovery in patients with whiplash-associated disorder,
?DJ;HL;DJ?EDIÅ9;DJH7B?P7J?EDFHE9;:KH;I7D:;N;H9?I;I0 clinicians should (1) educate the patient that early return to
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Specific repeated movements or procedures to promote cen- normal, non-provocative pre-accident activities is important,
tralization are not more beneficial in reducing disability when and (2) provide reassurance to the patient that good prognosis
compared to other forms of interventions. (Recommendation and full recovery commonly occurs. (Recommendation based
based on weak evidence.) on strong evidence.)
?DJ;HL;DJ?EDIÅKFF;HGK7HJ;H7D:D;HL;CE8?B?P7J?EDFHE- J^[i[h[Yecc[dZWj_ediWdZYb_d_YWbfhWYj_Y[]k_Z[b_d[iWh[XWi[Zedj^[
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Introduction
7?CE<J>;=K?:;B?D; Ikhob]^Z]^l\kbimbhgmhiheb\rfZd^kl%nlbg`bgm^kgZmbhgZeer
The Orthopaedic Section of the American Physical Therapy As- accepted terminology, of the practice of orthopaedic physi-
sociation (APTA) has an ongoing effort to create evidence-based cal therapists
Journal of Orthopaedic & Sports Physical Therapy®
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a3
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Methods
=H7:;IE<;L?:;D9;
perts that a systematic search and review of the evidence solely
The overall strength of the evidence supporting recom-
related to diagnostic categories based on International Statis-
mendations made in this guideline will be graded accord-
tical Classification of Diseases and Health Related Problems
ing to guidelines described by Guyatt et al,0* as modified by
(ICD)10 terminology would not be useful for these ICF-based
FZ\=^kfb]Zg]Z]him^][rma^\hhk]bgZmhkZg]k^ob^p^klh_
clinical practice guidelines as most of the evidence associated
this project. In this modified system, the typical A, B, C, and
with changes in levels of impairment or function in homoge-
D grades of evidence have been modified to include the role
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
!C=<"[Zl^]nihgma^bkli^\bÖ\Zk^Zh_^qi^kmbl^'Mph\hgm^gm J^_ickij_dYbkZ[Wjb[Wij'b[l[b?ijkZo
experts were assigned to each subcategory and both individuals CeZ[hWj[[l_Z[dY[ 7i_d]b[^_]^#gkWb_johWdZec_p[ZYed#
performed a separate search, including but not limited to the B jhebb[Zjh_WbehWfh[fedZ[hWdY[e\b[l[b
3 databases listed above, to identify articles to assure that no ??ijkZ_[iikffehjj^[h[Yecc[dZWj_ed
studies of relevance were omitted. Additionally, when relevant
articles were identified, their reference lists were hand-searched M[Wa[l_Z[dY[ 7i_d]b[b[l[b??ijkZoehWfh[fedZ[h#
in an attempt to identify other articles that might have contrib- WdY[e\b[l[b???WdZ?LijkZ_[i_dYbkZ_d]
C
uted to the outcome of these clinical practice guidelines. ijWj[c[djie\Yedi[dikiXoYedj[dj
[nf[hjiikffehjj^[h[Yecc[dZWj_ed
Mabl`nb]^ebg^pZlblln^]bg+))1[Zl^]nihgin[eb\Zmbhglbg 9edÔ_Yj_d][l_Z[dY[ >_]^[h#gkWb_joijkZ_[iYedZkYj[Zed
ma^l\b^gmbÖ\ebm^kZmnk^ikbhkmhCng^+))0'Mabl`nb]^ebg^pbee j^_ijef_YZ_iW]h[[m_j^h[if[Yjjej^[_h
be considered for review in 2012, or sooner if substantive new D
YedYbki_edi$J^[h[Yecc[dZWj_ed_i
evidence becomes available. Any updates to the guideline in the XWi[Zedj^[i[YedÔ_Yj_d]ijkZ_[i
interim period will be noted on the Orthopaedic Section of the
APTA website: www.orthopt.org J^[eh[j_YWb% 7fh[fedZ[hWdY[e\[l_Z[dY[\hec
\ekdZWj_edWb[l_Z[dY[ Wd_cWbehYWZWl[hijkZ_[i"\hec
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Once the content experts of each subcategory had identified all XWi_YiY_[dY[i%X[dY^h[i[WhY^ikffehj
relevant articles, they independently graded each article accord- j^_iYedYbki_ed
bg`mh\kbm^kbZ]^l\kb[^][rma^<^gm^k_hk>ob]^g\^&;Zl^]F^]b-
\bg^%Hq_hk]%Ngbm^]Dbg`]hf!MZ[e^*[^ehp"'B_ma^+\hgm^gm ;nf[hjef_d_ed 8[ijfhWYj_Y[XWi[Zedj^[Yb_d_YWb
experts did not agree on a grade of evidence for a particular F [nf[h_[dY[e\j^[]k_Z[b_d[iZ[l[bef#
article, a third content expert was used to resolve the issue. c[djj[Wc
a4 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a5
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
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Activities and participation Z*'&. 9^Wd]_d]WXWi_YXeZofei_j_ed"if[Y_Ó[ZWicel_d]j^[^[WZWdZd[Yam^_b[beea#
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a6 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Z*-+' :h_l_d]cejeh_p[Zl[^_Yb[i
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X(*&/ I[diWj_ediWiieY_Wj[Zm_j^^[Wh_d]WdZl[ij_XkbWh\kdYj_ed"kdif[Y_Ó[Z
Body structure i'(&&& 9[hl_YWbif_dWbYehZ
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Journal of Orthopaedic & Sports Physical Therapy®
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journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a7
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
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Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
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Journal of Orthopaedic & Sports Physical Therapy®
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a8 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
CLINICAL GUIDELINES
Impairment/Function-based
Diagnosis
FH;L7B;D9; in the majority of patients who present with complaints of
Pain and impairment of the neck is common. It is esti- neck pain and neck related symptoms of the upper quarter.*.
fZm^]maZm++mh0)h_ma^ihineZmbhgpbeeaZo^g^\diZbg Therefore, once serious medical pathology (such as cervical
some time in their lives.*2%+)%-+%-,%..%**.%*+2 In addition, it has been fracture or myelopathy) has been ruled out, patients with
suggested that the incidence of neck pain is increasing.*+/%*1* neck pain are often classified as having either a nerve root
At any given time, 10% to 20% of the population reports neck \hfikhfbl^hkZÊf^\aZgb\Zeg^\d]blhk]^k'Ë
problems,*2%--%01%*/0pbma.-h_bg]bob]nZelaZobg`^qi^kb^g\^]
Downloaded from www.jospt.org at on December 10, 2020. For personal use only. No other uses without permission.
g^\diZbgpbmabgma^eZlm/fhgmal'42 Prevalence of neck pain In some conditions, particularly those that are de-
increases with age and is most common in women around the
fifth decade of life.-%*2%-/%**/%*/,
II generative in nature or involve abnormalities of the
vertebral motion segment, abnormal findings are
not always associated with symimhfl' ?hnkm^^g mh *1 h_
Although the natural history of neck pain appears to be fa- people without neck pain demonstrate a wide range of ab-
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
vorable,.*%2+ rates of recurrence and chronicity are high.*.%1* normalities with imaging studies, including disc protrusion
One study reported that 30% of patients with neck pain or extrusion and impingement of the thecal sac on the nerve
will develop chronic symptoms, with neck pain of greater root and spinal cord.12 However, degenerative changes are
maZg/fhgmal]nkZmbhgZü^\mbg`*-h_Zeebg]bob]nZelpah still suggested to be a possible cause of mechanical neck pain
experience an episode of neck pain.19 Additionally, a recent in some cases,109,130,131 despite the fact that these changes are
lnko^r ]^fhglmkZm^] maZm ,0 h_ bg]bob]nZel pah ^qi^kb- present in asymptomatic individuals, are non-specific, and
ence neck pain will report persistent problems for at least are highly prevalent in the elderly.*/1 Disorders such as cervi-
12 months.44 Five percent of the adult population with neck cal radiculopathy and cervical compressive myelopathy are
pain will be disabled by the pain, representing a serious reported to be caused by space-occupying lesions (osteophy-
Journal of Orthopaedic & Sports Physical Therapy®
health concern.*2%11 In a survey of workers with injuries to tosis or herniated cervical disc). These may be secondary to
the neck and upper extremity, Pransky et al*,. reported that degenerative processes and can give rise to neck and/or up-
-+fbll^]fhk^maZg*p^^dh_phkdZg]+/^qi^kb^g\^] per quarter pain as well as neurologic signs and symptoms.*,/
recurrence within 1 year. The economic burden due to dis- While cervical disc herniation and spondylosis are most com-
orders of the neck is high, and includes costs of treatment, monly linked to cervical radiculopathy and myelopathy,*)%*,/
lost wages, and compensation expenditures.*/%*,1 Neck pain is the bony and ligamentous tissues affected by these conditions
second only to low back pain in annual workers’ compensa- are themselves pain generators and are capable of giving rise
mbhg\hlmlbgma^Ngbm^]LmZm^l'*1* In Sweden, neck and shoul- to some of the referred symptoms observed in patients with
]^kikh[e^flZ\\hngm_hk*1h_Zee]blZ[bebmriZrf^gml'*+/ these disorders.13,40
C^mm^^mZe91 reported that patients with neck pain make up
ZiikhqbfZm^er+.h_iZmb^gmlk^\^bobg`hnmiZmb^gmiarlb- Because most patients with neck pain usually lack
cal therapy. Additionally, patients with neck pain frequently
are treated without surgery by primary care and physical
II an identifiable pathoanatomic cause for their prob-
lem, the majority are classified as having mechani-
therapy providers.*0%.*%2+ cal neck disorders.1+
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a9
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
H?IA<79JEHI calculated. The changes in pain scores over the varying trial
Bot and colleagues18 investigated the clini- periods in these untreated subjects with chronic mechanical
II cal course and predictors of recovery for patients
with neck and shoulder pain. Four hundred forty
neck pain were consistently small and not significant.*0*
three patients who consulted their primary care physician Conversely, there is substantial evidence that favorable out-
with neck or shoulder symptoms were followed for 12 months. comes are attained following treatment of patients with cer-
At 12 months, 32% of patients reported that they had recov- vical radiculopathy.02%*,/ For example, Radhakrishnan and
ered. Predictors of poor pain-related outcome at 12 months colleagues*,/ reported that nearly 90% of patients with cer-
included less intense pain at baseline, a history of neck and vical radiculopathy presented with only mild symptoms at a
shoulder symptoms, more worrying, worse perceived health, median follow-up of 4.9 years. Honet and Puri02 found that
and a moderate or bad quality of life. The predictors for a 0)h_iZmb^gmlpbma\^kob\ZekZ]b\nehiZmar^qab[bm^]`hh]hk
poor disability-related response at 12 months included older excellent outcomes after a 2-year follow-up. Outcomes for the
age, less disability at baseline, longer duration of symptoms, patients in the aforementioned studies02%*,/ appeared favor-
loss of strength in hands, having multiple symptoms, more Z[e^Zg]ln``^lmmaZm0)&2)h_mablihineZmbhg\Zg^qi^kb-
worrying, moderate or bad quality of life, and less vitality. ence improvement without surgical intervention. In contrast,
the clinical prognosis of patients with whiplash-associated
Downloaded from www.jospt.org at on December 10, 2020. For personal use only. No other uses without permission.
/+
with poor outcome. In the long-term, in addition to age and nan. The underlying premise is that classifying patients
concomitant low back pain, previous trauma, a long dura- into groups based on clinical characteristics and matching
tion of neck pain, stable neck pain during the 2 weeks prior these patient subgroups to management strategies likely to
to baseline measurement, and previous neck pain predicted benefit them will improve the outcome of physical therapy
poor prognosis. interventions.+0 The classification system described by Wang
et al*00 categorized patients into 1 of 4 subgroups based on
Clinicians should consider age greater than 40, co- the area of symptoms and the presumed source of the symp-
B existing low back pain, a long history of neck pain,
bicycling as a regular activity, loss of strength in the
toms. The labels of these 4 categories were neck pain only,
headaches, referred arm pain and neck pain, and radicular
hands, worrisome attitude, poor quality of life, and less vital- arm pain and neck pain. Distinct treatment approaches were
ity as predisposing factors for the development of chronic linked to each of the 4 categories. Wang et al*00 reported the
neck pain. results of 30 patients treated using this classification strat-
^`rZlp^eeZl+0iZmb^gmlpahp^k^ghmmk^Zm^]'LmZmblmb\Zeer
and clinically significant reductions in pain and disability
9B?D?97B9EKHI; were reported for the classification group only.*00 It is diffi-
Approximately 44% of patients experiencing neck pain cult to draw conclusions regarding the potential usefulness
will go on to develop chronic symptoms,*. and many will con- of the Wang et al*00 classification system because patients in
tinue to exhibit moderate disability at long-term follow-up.// ma^\hgmkhe`khnip^k^ghmmk^Zm^]%pab\ablghmk^×^\mbo^h_
A recent systematic review examined the outcomes of non- physical therapy practice. The classification system described
treatment control groups in clinical trials for the conserva- by Childs et al+0 and Fritz and Brennan/+ uses information
tive management of chronic mechanical neck pain - not due from the history and physical examination to place patients
to whiplash.*0* The outcomes of patients receiving a control bgmh*h_.l^iZkZm^mk^Zmf^gmln[`khnil'Ma^eZ[^elh_ma^l^
or placebo intervention were analyzed and effect sizes were .ln[`khnil%pab\aZk^fh[bebmr%\^gmkZebsZmbhg%^q^k\bl^Zg]
a10 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
of motion exercises following an acute cervical sprain, was the associated ICF diagnosis of neck pain with radi-
]bob]^]bgmhma^Êg^\diZbgpbmafho^f^gm\hhk]bgZmbhgbf- ating pain is made with a reasonable level of certainty when
iZbkf^gml%ËZg]Êg^\diZbgpbmafh[bebmr]^Ö\bmlË\Zm^`hkb^l% the patient presents with the following clinical findings*0.:
where the patient would receive interventions linked to the Nii^k^qmk^fbmrlrfimhfl%nlnZeerkZ]b\neZkhkk^_^kk^]
most relevant impairment(s) exhibited at a given period dur- pain, that are produced or aggravated with Spurling’s ma-
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ing the patient’s episode of care. neuver and upper limb tension tests, and reduced with the
neck distraction test
The ICD diagnosis of cervicalgia, or pain in thoracic =^\k^Zl^] \^kob\Ze khmZmbhg !5/)" mhpZk] ma^ bgoheo^]
I spine and the associated ICF diagnosis of neck pain
with mobility deficits is made with a reasonable lev-
side
Lb`glh_g^ko^khhm\hfik^llbhg
el of certainty when the patient presents with the following Ln\\^llpbmak^]n\bg`nii^k^qmk^fbmrlrfimhflpbmabgb-
clinical findings,,%/+%1+%*//: tial examination and intervention procedures
Rhng`^kbg]bob]nZe!Z`^5.)r^Zkl"
:\nm^g^\diZbg!]nkZmbhg5*+p^^dl" Neck pain, without symptoms or signs of serious
B
Journal of Orthopaedic & Sports Physical Therapy®
with a reasonable level of certainty when the patient presents The following physical examination measures may be useful
with the following clinical findings++%+2%*-.%*/+%*1+%*1-: in classifying a patient in the ICF impairment-based category
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a11
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
of neck pain with mobility deficits and the associated ICD assist clinicians in determining when to order radiographs in
categories of cervicalgia or pain in thoracic spine: individuals who have experienced trauma.*.2
<^kob\ZeZ\mbo^kZg`^h_fhmbhg
<^kob\ZeZg]mahkZ\b\l^`f^gmZefh[bebmr In addition to medical conditions, clinicians should
The following physical examination measures may be useful ture are not consistent with those presented in the diagnosis/
in classifying a patient in the ICF impairment-based catego- classification section of this guideline, or, when the patient’s
ry of neck pain with radiating pain and the associated ICD symptoms are not resolving with interventions aimed at nor-
categories of spondylosis with radiculopathy or cervical disc malization of the patient’s impairments of body function.
disorder with radiculopathy:
Nii^kebf[m^glbhgm^lm
Linkebg`Ílm^lm ?C7=?D=IJK:?;I
=blmkZ\mbhgm^lm Adults with cervical pain precipitated by trauma
should be classified as low risk or high risk based on the Ca-
Journal of Orthopaedic & Sports Physical Therapy®
a12 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
There is no consensus for routine investigation of patients with head position (turned) at time of impact, and disability levels
chronic neck pain with imaging beyond plain radiographs. ,%-1 (as measured with the Neck Disability Index).*)*%*)+%*)0
Routine use of ultrasonography, CT, and magnetic resonance
bfZ`bg`!FKB"bgiZmb^gmlpbmahnmg^nkheh`b\bglnemhkhma^k Elliott et al.,aZo^]^fhglmkZm^]maZm_^fZe^iZmb^gml!*1&-.
disease has not been justified in view of the infrequency of r^Zklhe]"pbmai^klblm^gmP:=!`kZ]^BB"lahpFKB\aZg`^l
abnormalities detected, the lack of prognostic value, inacces- in the fat content of the cervical extensor musculature that
sibility, and the high cost of the procedures.*-%0,%**2%*,,%*-*%*-/%*0- A were not present in subjects with chronic insidious onset neck
major limitation is the lack of specific findings in patients pain or healthy controls. It is currently unclear whether the
with neck disorder and no definite correlation between the patterns of fatty infiltration are the result of local structural
patient’s subjective symptoms and abnormal findings seen on mkZnfZ\Znlbg`Z`^g^kZebg×ZffZmhkrk^lihgl^%Zli^\bÖ\
imaging studies. As a result, debate continues as to whether nerve injury or insult, or a generalized disuse phenomenon.
persistent pain is attributable to structural pathology or to Further, as the muscular changes were observed in the chron-
other underlying causes. ic state, it is not yet known whether they occur uniformly in
all people who have sustained whiplash injury irrespective
K^\^gmer%DkblmcZgllhg111 compared sagittal plane, rotational, of recovery or are unique to only those who develop chronic
and translational cervical segmental motion in women with symptoms.
Downloaded from www.jospt.org at on December 10, 2020. For personal use only. No other uses without permission.
als in the WAD and insidious groups, significantly excessive cifically, the WAD group demonstrated a consistent pattern
translational motion at C3-4 for individuals in the WAD and of larger rCSA in the multifidii muscles at each segment (C3-
insidious groups, and significantly excessive translational <0"'Bg_^k^g\^\Zg[^]kZpgmaZmma^larger rCSAs recorded
fhmbhgZm<.&/_hkbg]bob]nZelbgma^P:=`khnipa^g\hf- in the multifidii muscles of those with chronic WAD are the
pared to normal subjects. result of larger amounts of fatty infiltrate.
NemkZlhgh`kZiar aZl [^^g nl^] mh Z\\nkZm^er f^Zlnk^ ma^ In summary, imaging studies often fail to identify any
size of the cervical multifidus muscle at the C4 level in as- structural pathology related to symptoms in patients with
ymptomatic female subjects. For those with chronic WAD, neck disorder and in particular, whiplash injury. How-
Journal of Orthopaedic & Sports Physical Therapy®
ultrasonography did not accurately measure the cervical ever, emerging evidence into upper cervical ligamentous
multifidus because the fascial borders of the multifidus were disruption, altered segmental motion, and muscular de-
largely indistinguishable, indicating possible pathological generation has been demonstrated with radiographs, ul-
conditions.110 mkZlhgh`kZiar% Zg] FKB lmn]b^l' Bm k^fZbgl ngdghpg b_
(1) these findings are unique to chronic WAD; (2) whether
Ab`ak^lhenmbhgikhmhg]^glbmr&p^b`am^]FKBaZlk^\^gmer they relate to patients’ physical signs and symptoms, and
demonstrated abnormal signal intensity (indicative of tissue (3) whether specific physical therapy intervention can alter
damage) in both the alar and transverse ligaments in some such degeneration. Such knowledge may offer prognostic
subjects with chronic WAD.*)1EZm^k_heehp&nilmn]b^lbg]b- information and provide the foundation for interventional
cated a strong relationship between alar ligament damage, based studies.
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a13
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
CLINICAL GUIDELINES
Examination
EKJ9EC;C;7IKH;I tients to list 3 activities that are difficult as a result of their
The Neck Disability Index (NDI) is a commonly symptoms, injury, or disorder. The patient rates each activity
I utilized outcome measure to capture perceived dis-
ability in patients with neck pain.134 The NDI con-
on a 0-10 scale, with 0 representing the inability to perform
the activity, and 10 representing the ability to perform the ac-
mZbgl*)bm^fl%0k^eZm^]mhZ\mbobmb^lh_]Zberebobg`%+k^eZm^] tivity as well as they could prior to the onset of symptoms.*/)
to pain, and 1 related to concentration.*0+ Each item is scored The final PSFS score is the average of the 3 activity scores.
_khf)&.Zg]ma^mhmZel\hk^bl^qik^ll^]ZlZi^k\^gmZ`^%pbma The PSFS was developed by Stratford et al*/) in an attempt
higher scores corresponding to greater disability. Riddle and to present a standardized measure for recording a patient’s
Downloaded from www.jospt.org at on December 10, 2020. For personal use only. No other uses without permission.
Stratford139 identified a significant association between the perceived level of disability across a variety of conditions.
NDI and both the physical and mental health components The PSFS has been evaluated for reliability and validity in
h_ma^L?&,/'Ma^ZnmahklZelhb]^gmbÖ^]maZmma^G=Bihl- patients with neck pain.*02 The ICC value for test retest reli-
sesses adequate sensitivity as compared to the magnitude of Z[bebmrbgiZmb^gmlpbma\^kob\ZekZ]b\nehiZmarpZl)'1+',0 The
change that occurred for patients reaching their functional minimal detectable change in that population was identified
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
goals, work status, and if the patient was currently in litiga- to be 2.1 points with a minimum clinically important differ-
tion.139C^mm^Zg]C^mm^92 further substantiated the sensitivity ence of 2.0.,0
to change by calculating the effect sizes for change scores of
[hmama^G=BZg]L?&,/' Clinicians should use validated self-report ques-
a14 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
F>OI?97B?CF7?HC;DJC;7IKH;I
Description J^[Wcekdje\WYj_l[d[YaÔ[n_ed"[nj[di_ed"hejWj_ed"WdZi_Z[X[dZ_d]cej_edc[Wikh[Zki_d]Wd_dYb_dec[j[h
Downloaded from www.jospt.org at on December 10, 2020. For personal use only. No other uses without permission.
j^[_dYb_dec[j[h$
D[YaI_Z[X[dZ_d]0J^[_dYb_dec[j[h_ifei_j_ed[Z_dj^[\hedjWbfbWd[edj^[jefe\j^[fWj_[djÊi^[WZ_dWb_]dc[djm_j^j^[[nj[hdWb
WkZ_jehoc[Wjki$Jec[Wikh[h_]^ji_Z[X[dZ_d]"j^[fWj_[dj_iWia[Zjecel[j^[h_]^j[Whjej^[h_]^ji^ekbZ[h$J^[Wcekdje\
i_Z[X[dZ_d]_ih[YehZ[Zm_j^j^[_dYb_dec[j[h$J^[effei_j[_if[h\ehc[Zjec[Wikh[b[\ji_Z[X[dZ_d]$9Wh[i^ekbZX[jWa[dje
Wle_ZYedYec_jWdjhejWj_edehÔ[n_edm_j^j^[i_Z[X[dZ_d]cel[c[dj$
D[YaHejWj_ed0HejWj_edYWdX[c[Wikh[Zm_j^Wkd_l[hiWb%ijWdZWhZ]ed_ec[j[h$J^[fWj_[dj_ii[Wj[Z"beea_d]Z_h[Yjbo\ehmWhZ
m_j^j^[d[Ya_dd[kjhWbfei_j_ed$J^[\kbYhkce\j^[]ed_ec[j[h_ifbWY[Zel[hj^[jefe\j^[^[WZm_j^j^[ijWj_edWhoWhcWb_]d[Z
m_j^j^[WYhec_edfheY[iie\j^[i^ekbZ[h"WdZj^[cel[WXb[WhcX_i[Yj_d]j^[fWj_[djÊidei[$J^[fWj_[dj_iWia[ZjehejWj[_d[WY^
Z_h[Yj_edWi\WhWifeii_Xb[$
Measurement properties 9[hl_YWb HEC c[Wikh[c[dji \eh Ô[n_ed" [nj[di_ed" WdZ i_Z[X[dZ_d] ki_d] W XkXXb[ _dYb_dec[j[h ^Wl[ [n^_X_j[Z h[b_WX_b_jo
Ye[øY_[djihWd]_d]\hec&$,,je&$.*?99("'$)("'-+
Description M_j^j^[fWj_[djfhed["Y[hl_YWbWdZj^ehWY_Yif_d[i[]c[djWbcel[c[djWdZfW_dh[ifedi[Wh[Wii[ii[Z
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a15
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
H[b_WX_b_jo\ehY[hl_YWbif_d[Wii[iic[dj0
AWffW3&$'*je&$)-fW_d',/
?993&$*(je&$-/fW_d''
?993&$-.je'$&fh[i[dY[e\`e_djZoi\kdYj_ed_dkff[h)Y[hl_YWbif_d[i[]c[dji'&&
M[_]^j[ZaWffW0#&$(,je&$-*ceX_b_jo"#&$+(je&$/&fW_d)(
H[b_WX_b_jo\ehj^ehWY_Yif_d[Wii[iic[dj0
M[_]^j[ZaWffW0&$')je&$.(ceX_b_jo"#&$''je&$/&fW_d)(
Downloaded from www.jospt.org at on December 10, 2020. For personal use only. No other uses without permission.
Description ?dikf_d["j^[WX_b_joje_d_j_Wj[WdZcW_djW_d_iebWj[ZYhWd_WbWdZY[hl_YWbÔ[n_ed
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Y[hl_YWbckiYb[i"ikY^Wij^[ij[hdeYb[_ZecWije_Z$J^[fWj_[djYWdfbWY[^_i%^[hjed]k[edj^[hee\e\j^[cekj^"m_j^b_fije][j^[h
Xkjj^[j[[j^ib_]^jboi[fWhWj[Z"je^[bfZ[Yh[Wi[fbWjoicWWdZ%eh^oe_ZWYj_lWj_ed$J^[j[ij_i]hWZ[ZWYYehZ_d]jej^[fh[iikh[b[l[b
j^[fWj_[djYWdWY^_[l[m_j^YedY[djh_YYedjhWYj_ediWdZWYYkhWj[boikijW_d_iec[jh_YWbbo$J^[j[ij_ij[hc_dWj[Zm^[dj^[fh[iikh[
_iZ[Yh[Wi[ZXoceh[j^Wd(&ehm^[dj^[fWj_[djYWddejf[h\ehcj^[fhef[h99<cel[c[djm_j^ekjikXij_jkj_edijhWj[]_[i$
7dehcWbh[ifedi[_i\ehj^[fh[iikh[je_dYh[Wi[jeX[jm[[d(,#)&cc>]WdZX[cW_djW_d[Z\eh'&i[YedZim_j^ekjkj_b_p_d]
ikf[hÓY_WbY[hl_YWbckiYb[ikXij_jkj_edijhWj[]_[i$
7dWXdehcWbh[ifedi[_im^[h[j^[fWj_[dj0
'$?ikdWXb[je][d[hWj[Wd_dYh[Wi[_dfh[iikh[e\Wjb[Wij,cc>]"
($?ikdWXb[je^ebZj^[][d[hWj[Zfh[iikh[\eh'&i[YedZi"
)$Ki[iikf[hÓY_Wbd[YackiYb[ijeWYYecfb_i^j^[Y[hl_YWbÔ[n_edcej_ed"eh
*$Ki[iWikZZ[dcel[c[dje\j^[Y^_dehfki^_d][nj[dZ_d]j^[d[Ya\ehY[\kbboW]W_dijj^[fh[iikh[Z[l_Y[
IYeh_d]0
7Yj_lWj_edIYeh[0Fh[iikh[WY^_[l[ZWdZ^[bZ\eh'&i[YedZ
F[h\ehcWdY[?dZ[n0?dYh[Wi[_dFh[iikh[dkcX[he\h[f[j_j_edi
Description ?dikf_d["j^[WX_b_jojeb_\jj^[^[WZWdZd[YaW]W_dij]hWl_jo\ehWd[nj[dZ[Zf[h_eZ
a16 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
?99("'3&$,-je&$-."I;C'($,#'+$)i[YedZi
IkX`[Yjim_j^d[YafW_d0
?99("'3&$,-"I;C''$+i[YedZi
J[ijh[ikbji0
IkX`[Yjim_j^ekjd[YafW_d0C[Wd).$/+i[YedZiI:3(,$*
IkX`[Yjim_j^d[YafW_d0C[Wd(*$'i[YedZiI:3'($.
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Description ?dded#m[_]^jX[Wh_d]"j^[Wcekdje\ceX_b_joe\j^[d[khWb[b[c[djie\j^[kff[hb_cXWh[Wii[ii[Zm^_b[Z[j[hc_d_d]m^[j^[hj^[
fWj_[djÊikff[hgkWhj[hiocfjeciWh[[b_Y_j[ZZkh_d]f[h\ehcWdY[e\j^[j[ij
\ebbem_d]cel[c[djijej^[iocfjecWj_Ykff[h[njh[c_jo0
IYWfkbWhZ[fh[ii_ed
I^ekbZ[hWXZkYj_edjeWXekj/&m_j^j^[[bXemÔ[n[Z
<eh[Whcikf_dWj_ed"mh_ijWdZÓd][h[nj[di_ed
I^ekbZ[hbWj[hWbhejWj_ed
;bXem[nj[di_ed
9edjhWbWj[hWbj^[d_fi_bWj[hWbY[hl_YWbi_Z[#X[dZ_d]
7fei_j_l[j[ijeYYkhim^[dWdoe\j^[\ebbem_d]ÓdZ_d]iWh[fh[i[dj0
'$h[fheZkYj_ede\WbbehfWhje\j^[fWj_[djÊiiocfjeci
($i_Z[#je#i_Z[Z_÷[h[dY[ie\]h[Wj[hj^Wd'&e\[bXem[nj[di_edehmh_ij[nj[di_ed
)$edj^[iocfjecWj_Yi_Z["YedjhWbWj[hWbY[hl_YWbi_Z[#X[dZ_d]_dYh[Wi[ij^[fWj_[djÊiiocfjeci"eh_fi_bWj[hWbi_Z[#X[dZ_d]
Z[Yh[Wi[ij^[fWj_[djÊiiocfjeci
Spurling’s Test
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a17
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Description 9ecX_dWj_ede\i_Z[X[dZ_d]jej^[iocfjecWj_Yi_Z[Yekfb[Zm_j^Yecfh[ii_edjeh[ZkY[j^[Z_Wc[j[he\j^[d[khWb\ehWc[dWdZ
[b_Y_jj^[fWj_[djÊiiocfjeci
D istraction Test
Description :_ijhWYj_ede\j^[Y[hl_YWbif_d[jecWn_c_p[j^[Z_Wc[j[he\j^[d[khWb\ehWc[dWdZh[ZkY[eh[b_c_dWj[j^[fWj_[djÊiiocfjeci
Valsalva Test
Description CWd[kl[h_dm^_Y^j^[fWj_[djX[WhiZemdm_j^ekj[n^Wb_d]je_dYh[Wi[_djhWj^[YWbfh[iikh[WdZ[b_Y_jkff[hgkWhj[hiocfjeci
a18 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
CLINICAL GUIDELINES
Interventions
A variety of interventions have been described for the treat- rendered by a general practitioner and non-manual physical
ment of neck pain and there is good evidence from high- therapy interventions, the combination of manipulation and
quality randomized, controlled trials and systematic reviews ^q^k\bl^k^lnem^]bglb`gbÖ\Zgm\hlm&lZobg`lh_nimh/1'*)/
to support the benefits of physical therapy intervention in
these patients. Although many patients experience a significant
II benefit when treated with thrust manipulation, it
is still unclear which patients benefit most. Tseng
9;HL?97BCE8?B?P7J?ED%C7D?FKB7J?ED et al*//k^ihkm^]/ik^]b\mhkl_hkiZmb^gmlpah^qi^kb^g\^]Zg
Downloaded from www.jospt.org at on December 10, 2020. For personal use only. No other uses without permission.
The most recent Cochrane Collaboration immediate improvement in either pain, satisfaction, or per-
I Review/2 of mobilization and manipulation for
mechanical neck disorders included 33 randomized
ception of condition following manipulation of the cervical
spine. These predictors included*//:
controlled trials of which 42% were considered high qual- BgbmbZel\hk^lhgG^\d=blZ[bebmrBg]^qe^llmaZg**'.
ity. They concluded that the most beneficial manipulative AZobg`[beZm^kZebgoheo^f^gmiZmm^kg
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
interventions for patients with mechanical neck pain with Ghm i^k_hkfbg` l^]^gmZkr phkd fhk^ maZg . ahnkl i^k
or without headaches should be combined with exercise to day
k^]n\^iZbgZg]bfikho^iZmb^gmlZmbl_Z\mbhg'FZgbineZmbhg ?^^ebg`[^mm^kpabe^fhobg`ma^g^\d
(thrust) and mobilization (non-thrust manipulation) inter- =b]ghm_^^ephkl^pabe^^qm^g]bg`ma^g^\d
vention alone were determined to be less effective than when Ma^]bZ`ghlblh_lihg]rehlblpbmahnmkZ]b\nehiZmar
combined with exercise (combined intervention)./2 A recently
published clinical practice guideline concluded that the evi- The presence of 4 or more of these predictors increased the
dence for combined intervention was relatively strong, while ikh[Z[bebmrh_ln\\^llpbmafZgbineZmbhg_khf/)mh12'*//
the evidence for the effectiveness of thrust or non-thrust ma- Predictors of which patients respond best to combined inter-
Journal of Orthopaedic & Sports Physical Therapy®
The recommendations of the Cochrane Review/2 and the re- Nilsson et al*+. conducted a randomized, clinical tri-
cently published clinical practice guideline/1 were based on
key findings that warrant further discussion. Studies cited
I Ze!g6.,"bgbg]bob]nZelpbma\^kob\h`^gb\a^Z]Z\a^'
Subjects were randomized to receive high velocity
included patients with both acute1+and chronic neck pain22 low amplitude spinal manipulation or low level laser and
and interventions consisted of soft-tissue mobilization and deep friction massage. The use of analgesics were reduced
manual stretching procedures, as well as thrust,*0%1, and non- [r,/bgma^fZgbineZmbhg`khni[nmp^k^ng\aZg`^]bg
thrust manipulative procedures1+ directed at spinal motion the laser/massage group. The number of headache hours per
l^`f^gml' Gnf[^k h_ oblbml kZg`^] _khf / ho^k Z , p^^d ]Zr]^\k^Zl^][r/2_hkma^bg]bob]nZelbgma^fZgbineZmbhg
period1+ to 20 over an 11 week period22 and the duration of `khniZg],0bgma^eZl^k(fZllZ`^`khni'A^Z]Z\a^bgm^g-
sessions ranged from 30 minutes99 mh /) fbgnm^l'22 Com- lbmri^k^iblh]^]^\k^Zl^][r,/_hkmahl^bgma^fZgbineZ-
bined intervention was compared with various competing mbhg`khniZg]*0bgma^eZl^k(fZllZ`^`khni'
interventions that included manipulation alone,22,99 various
non-manual physical therapy interventions,1+ high-tech and A systematic review by Vernon et al,*0* which includ-
low-tech exercises,++%1+%22 general practitioner care (medica-
tion, advice, education),1+ and no treatment.99 The majority
II ^]lmn]b^lin[ebla^]makhn`a+)).%\hg\en]^]maZm
there is moderate- to high-quality evidence that sub-
of studies report either clinically or statistically important jects with chronic neck pain and headaches show clinically im-
differences in pain in favor of combined intervention when portant improvements from a course of spinal mobilization or
compared to competing single interventions./2 Differences in fZgbineZmbhgZm/%*+%Zg]nimh*)-p^^dlihlm&mk^Zmf^gm'
muscle performance22,99 as well as patient satisfaction have
also been reported for both short-term++%1+%22 as well as long- Despite good evidence to support the benefits of cervical
term outcomes 122 and 2 years later..1 When compared to care mobilization/manipulation, it is important that physical
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a19
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
therapists be aware of the potential risks in using these tech- Recommendation: Clinicians should consider utiliz-
niques./1%/2 However, it is impossible to determine the pre-
cise risk because (1) it is extremely difficult to quantify the
A ing cervical manipulation and mobilization proce-
dures, thrust and non-thrust, to reduce neck pain and
number of cervical spine mobilization/manipulative inter- headache. Combining cervical manipulation and mobilization
ventions performed each year, and (2) not all adverse events with exercise is more effective for reducing neck pain, headache,
occurring after mobilization/manipulation interventions are and disability than manipulation and mobilization alone.
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 T>EH79?9CE8?B?P7J?ED%C7D?FKB7J?ED
use, and smoking.0+ However, the prevalence of these factors A survey among clinicians that practice manual physi-
in the study by Haldeman et al0+ is largely the same or lower cal therapy reported that the thoracic spine is the region of
than that which occurs in the general population. the spine most often manipulated, despite the fact that more
patients complain of neck pain.1 While several randomized
Although the true risk for complications remains unknown, clinical trials have examined the effectiveness of thoracic
ma^kbld_hkl^kbhnl\hfieb\Zmbhglbl^lmbfZm^]mh[^/bg*) libg^ maknlm fZgbineZmbhg !MLF" _hk iZmb^gml pbma g^\d
fbeebhg!)'))))/"fZgbineZmbhgl%pbmama^kbldh_]^Zma[^- pain, patients in these studies also received cervical manipu-
Downloaded from www.jospt.org at on December 10, 2020. For personal use only. No other uses without permission.
ing 3 in 10 million (0.000003%). Importantly, these rates are lation.+%++%.0 The rationale to include thoracic spine mobiliza-
adjusted assuming that only 1 in 10 complications is actually tion/manipulation in the treatment of patients with neck
reported in the literature.1- Gross et al0) recently reported, pain stems from the theory that disturbances in joint mobil-
in a clinical practice guideline on the use of mobilization/ ity in the thoracic spine may be an underlying contributor to
manipulation in patients with mechanical neck pain, that musculoskeletal disorders in the neck. 2-%*).
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ing within 4 hours after manipulation. Within 24 hours after vention to an active exercise program.*-0 A subsequent random-
fZgbineZmbhg%0-h_ma^\hfieZbgmlaZ]k^lheo^]'E^llmaZg ized trial by Cleland et al,1pab\a\hfiZk^]MLFmhghg&maknlm
.h_lb]^^ü^\mlp^k^\aZkZ\m^kbs^]Zl]bssbg^ll%gZnl^Z%ahm manipulation (mobilization) found significant differences in fa-
skin, or other complaints. Side effects were rarely still noted ohkh_ma^MLF`khnibgiZbg%]blZ[bebmr%Zg]iZmb^gmi^k\^bo^]
on the day after manipulation, and very few patients reported bfikho^f^gmnihgk^&^oZenZmbhg-1ahnkleZm^k'
the side effects as being severe.
While preliminary reports indicate that patients
Due the potential risk of serious adverse effects associated
with cervical manipulation, such as vertebrobasilar artery
II with complaints of primary neck pain experience a
lb`gbÖ\Zgm[^g^Ömpa^gmk^Zm^]pbmaMLF%bmbllmbee
stroke,./ it has been recommended that non-thrust cervi- unclear which patients benefit most. Cleland et al33 reported a
cal mobilization/manipulation be utilized in favor of thrust preliminary clinical prediction rule for patients with primary
manipulation..)%1. However, information regarding the risk/ neck pain who experience short-term improvement (1-week)
benefit ratio of providing cervical thrust manipulation to pbmaMLF'>Z\aln[c^\mk^\^bo^]ZmhmZeh_,mahkZ\b\fZgbin-
patients with impairments of body function purported to lations directed at the upper and middle thoracic spine for up
benefit from cervical mobilization/manipulation, such as cer- mh+l^llbhgl'Nlbg`Z`eh[ZekZmbg`h_\aZg`^l\hk^l.ZlZ
vical segmental mobility deficits, has not been reported. In k^_^k^g\^\kbm^kbhg%/oZkbZ[e^lp^k^k^ihkm^]Zlik^]b\mhklh_
addition, the case reports in the literature describing serious improvement and included33:
adverse effects associated with cervical thrust manipulation Lrfimhf]nkZmbhgh_e^llmaZg,)]Zrl
do not provide information regarding either the presence of Ghlrfimhfl]blmZemhma^lahne]^k
bfiZbkf^gmlh_[h]r_ng\mbhgl%hkma^ik^l^g\^h_k^]×Z`l Ln[c^\m k^ihkml maZm ehhdbg` ni ]h^l ghm Z``kZoZm^
for vertebrobasilar insufficiency,0 prior to the application of symptoms
the manipulative procedure suspected to be linked with the ?^Zk&Zohb]Zg\^ ;^eb^_l Jn^lmbhggZbk^&Iarlb\Ze :\mbobmr
reported harmful effects. Scale score less than 12
a20 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
=bfbgbla^]nii^kmahkZ\b\libg^driahlbl!M,ÈM." nipulation can also be used for reducing pain and disability
<^kob\Ze^qm^glbhgh_e^llmaZg,) in patients with neck and neck-related arm pain.
KHFp^k^Zll^ll^][^_hk^Zg]bff^]bZm^erZ_m^k ^gmpbmabfiZbkf^gmlh_×^qb[bebmrh_d^rfnl\e^l
MLF bg +/ iZmb^gml pbma Z ikbfZkr \hfieZbgm h_ related to the lower cervical and upper thoracic spine, such
neck pain. The mean reduction in pain on an 11-point nu- as the anterior, medial, and posterior scalenes, upper trape-
meric pain rating scale was approximately 2 points (P.01), zius, levator scapulae, pectoralis minor, and pectoralis major,
which has been shown to indicate that a clinically meaningful that should be addressed with stretching exercises. One study
improvement has occurred. Significant increases in cervical k^ihkm^]maZmnii^kjnZkm^kfnl\e^×^qb[bebmr]^Ö\bmlp^k^
Z\mbo^KHFp^k^Zelhh[l^ko^]bgZee]bk^\mbhgl^q\^im^qm^g- common in dental hygienists,2. an occupation that requires
lbhg!I5'))*"'Mabllmn]r]b]ghmbg\en]^Z\hgmkhe`khniZg] frequent repetitive activities involving the shoulders, arms,
only consisted of an immediate follow-up, but the immediate and hands. Although research generally does not support the
Journal of Orthopaedic & Sports Physical Therapy®
cal radiculopathy.+,%,2%*+)%*0/ In the first case series,39 10 of the Recommendation: Flexibility exercises can be used
11 patients (91%) demonstrated a clinically meaningful im-
ikho^f^gm bg iZbg Zg] _ng\mbhg Zm ma^ /&fhgma _heehp&ni
C for patients with neck symptoms. Examination and
mZk`^m^]×^qb[bebmr^q^k\bl^l_hkma^_heehpbg`fnl-
Z_m^kZf^Zgh_0'*iarlb\Zema^kZiroblbml'Bgma^l^\hg]\Zl^ cles are suggested: anterior/medial/posterior scalenes, upper
series*0/ all patients except for 1 exhibited a significant reduc- trapezius, levator scapulae, pectoralis minor, and pectoralis
tion in disability. In the third case series,120 full resolution of major.
iZbgpZlk^ihkm^]bg1h_*.!.,"iZmb^gml%pa^k^Zee/h_ma^
patients receiving mobilization and manipulation achieved
full resolution of pain. In addition, there has been 1 case se- 9EEH:?D7J?ED"IJH;D=J>;D?D="7D:;D:KH7D9;
ries23 that included thoracic spine thrust manipulation in the ;N;H9?I;I
fZgZ`^f^gmh_0iZmb^gmlpbma`kZ]^B\^kob\Ze\hfik^llbo^ Jull et al99 conducted a multi-centered,
myelopathy. All patients exhibited a reduction in pain and
improvement in function at the time of discharge.
I randomized clinical trial (n=200) in participants
who met the diagnostic criteria for cervicogenic
headache. The inclusion criteria were unilateral or unilateral
Recommendation: Thoracic spine thrust ma- dominant side-consistent headache associated with neck pain
C nipulation can be used for patients with primary
complaints of neck pain. Thoracic spine thrust ma-
and aggravated by neck postures or movement, joint tender-
ness in at least 1 of the upper 3 cervical joints as detected by
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a21
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
manual palpation, and a headache frequency of at least 1 per HÍE^Zkr ^m Ze*+0 compared the effect of 2 specific
week over a period of 2 months to 10 years. Subjects were
randomized into 4 groups: mobilization/manipulation group,
III \^kob\Ze ×^qhk fnl\e^ ^q^k\bl^ ikhmh\hel hg bf-
mediate pain relief in the cervical spine of people
exercise therapy group, combined mobilization/manipulation with chronic neck pain. They found that those performing
and exercise group, and a control group. The primary out- ma^ li^\bÖ\ \kZgbh\^kob\Ze ×^qbhg ^q^k\bl^ ]^fhglmkZm^]
come was a change in headache frequency. At the 12-month greater improvements in pressure pain thresholds, me-
follow-up, the mobilization/manipulation, combined mobi- chanical hyperalgesia, and perceived pain relief during ac-
lization/manipulation and exercise, and the specific exercise tive movement.
groups had significantly reduced headache frequency and in-
tensity. Additionally 10% more patients experienced a com- In a cross-sectional comparative study, Chiu et al29
plete reduction in headache frequency when treated with
mobilization/manipulation and exercise than those treated
III compared the performance of the deep cervical
×^qhkfnl\e^lhgma^\kZgbh\^kob\Ze×^qbhgm^lmbg
with the alternative approaches. 99 individuals with (n = 20) and without (n = 20) chronic neck
pain. Those with chronic neck pain had significantly poorer
Ma^^q^k\bl^ikh`kZfbgmabl\ebgb\ZemkbZe[rCnee^mZe99 used i^k_hkfZg\^hgma^\kZgbh\^kob\Ze×^qbhgm^lm!f^]bZgik^l-
low load endurance exercises to train muscle control of the sure achieved, 24 mmHg when starting at 20 mmHg) when
Downloaded from www.jospt.org at on December 10, 2020. For personal use only. No other uses without permission.
cervicoscapular region. The first stage consisted of specific compared with those in the asymptomatic group (median
\kZgbh\^kob\Ze ×^qbhg ^q^k\bl^l% i^k_hkf^] bg lnibg^ erbg`% ik^llnk^Z\ab^o^]%+1ffA`pa^glmZkmbg`Zm+)ffA`"'
Zbf^]mhmZk`^mma^]^^ig^\d×^qhkfnl\e^l%pab\aZk^ma^
longus capitis and longus colli. Subsequently, isometric exer- Cnee ^m Ze20 compared the effects of conventional
cises using a low level of rotatory resistance were used to train I ikhikbh\^imbo^mkZbgbg`Zg]\kZgbh\^kob\Ze×^qbhg
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
a22 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
ological quality for patients with mechanical neck zie method of treatment consists of patient positioning, spe-
disorders, Sarig-Bahat*-. reported relatively strong evidence cific repeated movements, manual procedures, and patient
supporting the effectiveness of proprioceptive exercises and education in self management in case of recurrence.*)-%**1 The
dynamic resisted strengthening exercises of the neck-shoul- k^i^Zm^]li^\bÖ\fho^f^gmlpbmama^F\D^gsb^f^mah]bg-
der musculature for patients with chronic or frequent neck tend to centralize (promote the migration of symptoms from
disorders. The evidence identified could not support the ef- an area more distal to location more proximal) or reduce
fectiveness of group exercise, neck schools, or single sessions pain.**1 At the 12 month follow-up all groups showed signifi-
of extension-retraction exercises. cant reductions in pain intensity and disability but no signifi-
cant difference between groups existed. Seventy-nine percent
In a randomized clinical trial, Chiu et al30 found of patients reported that they were better or completely re-
I bgiZmb^gmlpbma\akhgb\g^\diZbg!g6+*1"%maZm
Z /&p^^d mk^Zmf^gm h_ mkZgl\nmZg^hnl ^e^\mkb-
lmhk^]Z_m^kmk^Zmf^gm%Zemahn`a.*k^ihkm^]\hglmZgm(]Zber
pain. All 3 groups had similar recurrence rates.
cal nerve stimulation or exercise had a better and clinically
relevant improvement in disability, isometric neck muscle Fnkiar^mZe122bg\hkihkZm^]F\D^gsb^ikh\^]nk^l
strength, and pain compared to a control group. All the im-
provements in the intervention groups were maintained at
III to promote centralization in the management of a
cohort of 31 patients with cervical radiculopathy.
ma^/&fhgma_heehp&ni' These patients also received cervical manipulation or muscle
energy techniques and neural mobilization. Seventy-seven
Hammill et al0- used a combination of postural percent of patients at the short-term follow-up and 93% of
IV education, stretching, and strengthening exercises
to reduce the frequency of headaches and improve
patients at the long-term follow-up exhibited a clinically im-
portant improvement in disability. However, specific details
disability in a series of 20 patients, with results being main- regarding the number of patients receiving procedures to
tained at a 12-month follow-up. promote centralization was not reported.
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a23
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
There has not been a clinical trial that recruited patients with Recommendation: Clinicians should consider the
only cervical radiculopathy. Therefore, it is not possible to
\hff^gmhgma^^ú\Z\rh_ma^F\D^gsb^f^mah]hkma^nl^
B use of upper quarter and nerve mobilization proce-
dures to reduce pain and disability in patients with
of centralization procedures and exercises for this particular neck and arm pain.
subgroup of patients.31
mobilization and cervical/upper quadrant mobi- group receiving traction exhibited greater improvements
lization) in the management of cervico-brachial syndrome. bg`kbilmk^g`ma%ma^ikbfZkrhnm\hf^f^Zlnk^%Z_m^k.l^l-
:eeiZmb^gmlk^\^bo^]mk^Zmf^gm_hk1p^^dlbgZ]]bmbhgmh sions. However, no statistically significant difference be-
a home exercise program. The results demonstrated that tween groups existed at the time of discharge from physical
both manual therapy groups exhibited improvements in therapy.93
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
extremity in an upper limb neurodynamic position or thera- tified predictor variables of short-term success for
peutic ultrasound. The group receiving the mobilizations patients presenting to physical therapy with cervi-
exhibited significantly greater improvements in elbow range cal radiculopathy. One of the predictor variables for patients
of motion during neurodynamic testing as well as greater re- who exhibited a short-term success included a multimodal
ductions in pain compared to the ultrasound group. physical therapy approach consisting of manual or mechani-
cal traction, manual therapy (cervical or thoracic mobiliza-
Fnkiar^mZe122 incorporated neural mobilization in mbhg(fZgbineZmbhg"%Zg]]^^ig^\d×^qhklmk^g`ma^gbg`'Ma^
III the management of a cohort of patients with cervi-
cal radiculopathy. Seventy seven percent of patients
pretest probability for the likelihood of short-term success
pZl.,'Ma^f^Zg]nkZmbhgh_f^\aZgb\ZemkZ\mbhgnl^]hg
at the short-term follow-up and 93% of patients at the long iZmb^gmlbgmabllmn]rpZl*0'1fbgnm^lpbmaZgZo^kZ`^_hk\^
term follow-up exhibited a clinically important decrease in of pull of 11 kg (24.3 pounds). The positive likelihood ratio
disability. However, no specifics were provided relative to for patients receiving the multimodal treatment approach
which patients received neural mobilization procedures. (excluding other predictor variables) was 2.2, resulting in a
ihlm&m^lmikh[Z[bebmrh_ln\\^llh_0*' ,/
Cleland et al39 described the outcomes of a con-
IV secutive series of patients presenting to physical Raney et al*,0 recently developed a clinical predic-
therapy who received cervical mobilization (cer-
vical lateral glides) with the upper extremity in a neuro-
II tion rule to identify patients with neck pain likely
to benefit from cervical mechanical traction. Sixty-
dynamic position as well as thoracic spine manipulation, ^b`amiZmb^gml!,1_^fZe^"p^k^bg\en]^]bg]ZmZZgZerlblh_
cervical traction, and strengthening exercises. Ten of the pab\a,)aZ]Zln\\^ll_nehnm\hf^':eeiZmb^gmlk^\^bo^]/
11 patients (91%) demonstrated a clinically meaningful sessions of mechanical intermittent cervical traction start-
bfikho^f^gmbgiZbgZg]_ng\mbhg_heehpbg`Zf^Zgh_0'* bg`pbmaZ_hk\^h_inee[^mp^^g-'.&.'-d`!*)&*+ihng]l"
physical therapy visits. _hkZ]nkZmbhgh_*.fbgnm^l'Ma^_hk\^h_ineeikh`k^llbo^er
a24 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
AZobg` Zm e^Zlm , hnm h_ . oZkbZ[e^l ik^l^gm k^lnem^] bg Z F7J?;DJ;:K97J?ED7D:9EKDI;B?D=
ihlbmbo^ebd^ebahh]kZmbh^jnZemh-'1*!2.<B6+'*0&**'-"% There is a paucity of high quality evidence
increasing the likelihood of success with cervical traction
_khf--mh02'+'B_Zme^Zlm-hnmh_.oZkbZ[e^lp^k^ik^l-
I surrounding efficacy of treatments for whiplash-
associated disorder (WAD). However, existing re-
^gm%ma^ihlbmbo^ebd^ebahh]kZmbhpZl^jnZemh**'0!2.<B search supports instructing patients in active interventions,
Downloaded from www.jospt.org at on December 10, 2020. For personal use only. No other uses without permission.
where the interventions included traction. In these tion using frequent active cervical rotation range of motion
case series, the patients were treated with a multimodal treat- exercises complemented by assessment and treatment ac-
ment approach and the vast majority of patients exhibited \hk]bg`mhF\D^gsb^Ílikbg\bie^lhkmhZgbgm^ko^gmbhgmaZm
improved outcomes. In the first report, Cleland et al39 de- promoted initial rest, soft collar utilization, and gradual self-
scribed the outcomes of a consecutive series of 11 patients mobilization. In patients with WAD, early active interven-
presenting to physical therapy with cervical radiculopathy tion was more effective in reducing pain intensity and sick
and managed with the use of manual physical therapy, cervi- leave, and in retaining/regaining total range of motion than
\ZemkZ\mbhg%Zg]lmk^g`ma^gbg`^q^k\bl^l':m/fhgma_heehp& intervention that promoted rest, collar usage, and gradual
up, 91% demonstrated a clinically meaningful improvement self-mobilization. Patient education promoting an active ap-
Journal of Orthopaedic & Sports Physical Therapy®
journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a25
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Existing research supports active interventions and between groups in severity of remaining symptoms, limita-
I early return to regular activities but it has largely
been unknown as to which type of active interven-
tions in daily activities, therapy use, medications used, lost
time from work, or litigation. This study concluded that an
tion would yield the most benefit. Brison et al21 assessed the evidence-based educational pamphlet provided to patients at
efficacy of an educational video in the prevention of persis- discharge from the emergency department is no more effec-
tent WAD symptoms following rear-end motor vehicle colli- tive than usual care for patients with grade I or II WAD./)
sions. The video provided reassurance, and education about
posture, return to regular activities, specific exercises, and Cnee ^m Ze99 conducted a preliminary randomized
pain management. Patients were randomized to receive ei-
ther an educational video plus usual care or usual care alone.
I \hgmkhee^]mkbZepbma0*iZkmb\biZgmlpbmai^klblm^gm
neck pain following a motor vehicle accident to ex-
The primary outcome was presence of persistent WAD symp- plore whether a multimodal program of physical therapies
toms at 24 weeks post injury, based on the frequency and was an appropriate management strategy compared to a self-
severity of neck, shoulder, or upper back pain. The group re- management approach. Participants were randomly allocated
ceiving the instructional video demonstrated a trend toward to receive either a multimodal physical therapy program or
less severe WAD symptoms suggesting that the ‘act as usual’ a self-management program (advice and exercise). Further-
recommendation that is often prescribed as a management more, participants were stratified according to the presence
Downloaded from www.jospt.org at on December 10, 2020. For personal use only. No other uses without permission.
strategy for patients with WAD is not sufficient and, in fact, or absence of widespread mechanical or cold hyperalgesia.
may exacerbate their symptoms if such activities are provoca- The intervention period was 10 weeks and outcomes were as-
tive of pain.21 sessed immediately following treatment. Even with the pres-
^g\^ h_ l^glhkr ari^kl^glbmbobmr bg 0+'. h_ ln[c^\ml% [hma
A reduction in pain alone is not sufficient to ad- groups reported some relief of neck pain and disability, mea-
III
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
dress the neuromuscular control deficits in patients sured using Neck Disability Index scores, and it was superior
with chronic symptoms,*.0 as these deficits require in the group receiving multimodal physical therapy (P=.04).
specific rehabilitation techniques.99 For example, persistent However, the overall effects of both programs were mitigated
sensory and motor deficits may render the patient at risk for in the group presenting with both widespread mechanical
symptom persistence.*..%*./ Support for specificity in reha- and cold hyperalgesia. Further research aimed at testing the
bilitation can be indirectly found from a recent population- validity of this sub-group observation is warranted. 21
based, incidence cohort study evaluating a government policy
of funding community and hospital-based fitness training and A comprehensive review**0 of the available scientific
multidisciplinary rehabilitation for whiplash.+/ No supportive II evidence produced a set of unambiguous patient
Journal of Orthopaedic & Sports Physical Therapy®
evidence was found for the effectiveness of this general reha- centered messages that challenge unhelpful beliefs
bilitation approach. Therefore, only addressing the lack of about whiplash, promoting an active approach to recovery.
fitness and conditioning in this patient population may not The use of this rigorously developed educational booklet
be the most efficacious approach to treatment. (The Whiplash Book) was capable of improving beliefs about
whiplash and its management for patients with whiplash-
Ferrari et al/) studied whether an educational in- associated disorders.**0
I tervention using a pamphlet provided to patients
in the acute stage of whiplash injury might im- BgZlfZee \Zl^l^kb^l% Lh]^keng] Zg]Ebg][^k`*.,
prove the recovery rate. One hundred twelve consecutive
subjects were randomized to 1 of 2 treatment groups: edu-
IV reported that physical therapy integrated with
cognitive behavioral components decreased pain
cational intervention or usual care. The education interven- intensity in problematic daily activities in 3 individuals with
tion group received an educational pamphlet based on the chronic WAD.
current evidence, whereas the control group only received
usual emergency department care and a standard non-di- Predictors of outcome following whiplash injury
rected discharge information sheet. Both groups underwent
follow-up by telephone interview at 2 weeks and 3 months.
II have been limited to socio-demographic and fac-
tors of symptom location and severity, which are
The primary outcome measure of recovery was the patient’s not readily amenable to intervention. However, evidence
k^lihgl^mhma^jn^lmbhg%ÊAhpp^ee]hrhn_^^erhnZk^k^\ho- exists to demonstrate that psychological factors are pres-
^kbg`_khfrhnkbgcnkb^l8Ë:m,fhgmalihlm\heeblbhg%+*'1 ent soon following injury and play a role in recovery from
in the education intervention group reported complete recov- whiplash injury.21%*..%*.1 These factors can be as diverse as
ery compared with 21.0% in the control group (absolute risk the physical presentation and can include affective distur-
]bü^k^g\^%)'142.<B6&*-'-mh*/')"':m,fhgmal% bances, anxiety, depression, and fear of movement.*+,%*,+%*01
there were no clinically or statistically significant differences Furthermore, post-traumatic stress disorder112 has also been
a26 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
observed in both the acute.+ and chronic conditions and has Recommendation: To improve the recovery in pa-
been shown to be prognostic.*0* Identifying these factors in
patients may assist in the development of relevant subgroups
A tients with whiplash-associated disorder, clinicians
should (1) educate the patient that early return to
and appropriately matched education and counseling strate- normal, non-provocative pre-accident activities is important,
gies that practitioners should utilize in management of pa- and (2) provide reassurance to the patient that good progno-
tients with WAD. sis and full recovery commonly occurs.
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journal of orthopaedic & sports physical therapy | volume 38 | number 9 | september 2008 | a27
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
CLINICAL GUIDELINES
Summary of Recommendations
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d[Yj_l["WdZd[hl[j_iik[iWiieY_Wj[Zm_j^j^[_Z[dj_Ó[ZfWj^ebe]_YWb J^[\ebbem_d]f^oi_YWb[nWc_dWj_edc[Wikh[icWoX[ki[\kb_dYbWi#
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fW_d"Wbed]^_ijehoe\d[YafW_d"YoYb_d]WiWh[]kbWhWYj_l_jo"beiie\ :_ijhWYj_edj[ij
ijh[d]j^_dj^[^WdZi"mehh_iec[Wjj_jkZ["feehgkWb_joe\b_\["WdZ
b[iil_jWb_joWifh[Z_ifei_d]\WYjehi\ehj^[Z[l[befc[dje\Y^hed_Y B :?<<;H;DJ?7B:?7=DEI?I
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B :?7=DEI?I%9B7II?<?97J?ED
fWj_[djÊih[fehj[ZWYj_l_job_c_jWj_edieh_cfW_hc[djie\XeZo\kdY#
Copyright © 2008 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
D[YafW_d"m_j^ekjiocfjeciehi_]die\i[h_ekic[Z_YWbehfioY^e# j_edWdZijhkYjkh[Wh[dejYedi_ij[djm_j^j^ei[fh[i[dj[Z_dj^[Z_#
be]_YWbYedZ_j_edi"WiieY_Wj[Zm_j^'cej_edb_c_jWj_edi_dj^[Y[hl_# W]dei_i%YbWii_ÓYWj_edi[Yj_ede\j^_i]k_Z[b_d["eh"m^[dj^[fWj_[djÊi
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hWZ_Wj_d]fW_d_djeWdkff[h[njh[c_joWh[ki[\kbYb_d_YWbÓdZ_d]i\eh j_ede\j^[fWj_[djÊi_cfW_hc[djie\XeZo\kdYj_ed$
YbWii_\o_d]WfWj_[dj_djeed[e\j^[\ebbem_d]?dj[hdWj_edWbIjWj_ij_YWb
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[]eh_[i0Y[hl_YWb]_W"fW_d_dj^ehWY_Yif_d["^[WZWY^[i"Y[hl_YeYhWd_Wb
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Journal of Orthopaedic & Sports Physical Therapy®
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l_YWb]_WehfW_d_dj^ehWY_Yif_d[$ A ?DJ;HL;DJ?EDIÅ9;HL?97BCE8?B?P7J?ED%
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a28 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
Summary of B ?DJ;HL;DJ?EDIÅKFF;HGK7HJ;H7D:D;HL;CE8?B?P7-
Recommendations (continued) J?EDFHE9;:KH;I
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N e c k Pa i n : C l i n i c a l P r a c t i c e G u i d e l i n e s
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a32 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
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a34 | september 2008 | number 9 | volume 38 | journal of orthopaedic & sports physical therapy
ERRATA
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n the September 2008 issue of
Journal of Orthopaedic & Sports Ê=kbobg`fhmhkbs^]o^ab\e^l%Ëikbgm- mZbgbg` Z lmZg]bg` ihlbmbhg%Ë ikbgm^]
Physical Therapy, we make the fol- ^]bg-bglmZg\^lZlÊ]-0.)%Ëlahne] bg + bglmZg\^l Zl Ê]-*.)%Ë lahne] [^
lowing corrections to the “Neck Pain: [^]-0.*' ]-*.-'
Clinical Practice Guidelines”: Ng]^kL^\hg]ZkrB<?<h]^lhgiZ`^l Ie^Zl^ Z\\^im hnk Ziheh`r _hk ma^l^
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164. Firas Mourad, Giuseppe Giovannico, Filippo Maselli, Francesca Bonetti, César Fernández de las Peñas, James Dunning. 2016.
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Neck Pain and Headache in a Patient Following Multiple-Level Anterior Cervical Discectomy and Fusion: A Case Report. Journal
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268. Andrew M. Leaver, Christopher G. Maher, James H. McAuley, Gwendolen Jull, Jane Latimer, Kathryn M. Refshauge. 2013.
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269. Reinhold Klein, Alexa Bareis, Antonius Schneider, Klaus Linde. 2013. Strain–counterstrain to treat restrictions of the mobility
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270. Eric J. Hegedus, Ben Stern, Michael P. Reiman, Dan Tarara, Alexis A. Wright. 2013. A suggested model for physical examination
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271. Kim Dunleavy, Allon Goldberg. 2013. Comparison of cervical range of motion in two seated postural conditions in adults 50 or
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272. Sandra L. Kaplan, Colleen Coulter, Linda Fetters. 2013. Physical Therapy Management of Congenital Muscular Torticollis.
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273. Luiz Alfredo Braun Ferreira, Lucas Cristiano Fath Santos, Wagner Menna Pereira, Hugo Pasini Neto, Luanda André College
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274. Pierre Langevin, Jean-Sébastien Roy, François Desmeules. 2012. Cervical radiculopathy: Study protocol of a randomised clinical
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275. Jessie J Mathers. 2012. Differential diagnosis of a patient referred to physical therapy with neck pain: a case study of a patient
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276. Koji Nakamaru, Howard Vernon, Junya Aizawa, Takayuki Koyama, Osamu Nitta. 2012. Crosscultural Adaptation, Reliability, and
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277. Raquel Martínez-Segura, Ana Isabel de-la-Llave-Rincón, Ricardo Ortega-Santiago, Joshua A. Cleland, César Fernández-de-las-
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278. Manuel Saavedra-Hernández, Adelaida M. Castro-Sánchez, Manuel Arroyo-Morales, Joshua A. Cleland, Inmaculada C. Lara-
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279. Charles R. Hazle, Arthur J. Nitz. 2012. A simulated passive intervertebral motion task: observations of performance in a cross-
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280. Emilio J. Puentedura, Joshua A. Cleland, Merrill R. Landers, Paul Mintken, Adriaan Louw, César Fernández-de-las-Peñas. 2012.
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to the Cervical Spine. Journal of Orthopaedic & Sports Physical Therapy 42:7, 577-592. [Abstract] [Full Text] [PDF] [PDF Plus]
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281. Ismael V Díaz-Llopis, Carmen M Rodríguez-Ruíz, Sandra Mulet-Perry, Francisco J Mondéjar-Gómez, Jose M Climent-Barberá,
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corticosteroids in chronic plantar fasciitis: results at one and six months. Clinical Rehabilitation 26:7, 594-606. [Crossref]
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282. Christopher J. Durall. 2012. Therapeutic Exercise for Athletes With Nonspecific Neck Pain. Sports Health: A Multidisciplinary
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283. Dennis L. Hart, Paul W. Stratford, Mark W. Werneke, Daniel Deutscher, Ying-Chih Wang. 2012. Lumbar Computerized
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of Orthopaedic & Sports Physical Therapy 42:6, 541-551. [Abstract] [Full Text] [PDF] [PDF Plus]
284. Hilla Sarig Bahat, Hilla Eshkol Izrael. 2012. Neck-shoulder pain and weakness: An uncommon presentation. Manual Therapy
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285. Robert J. Nee, Gwendolen A. Jull, Bill Vicenzino, Michel W. Coppieters. 2012. The Validity of Upper-Limb Neurodynamic
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286. Patricia L. Sinnott, Andrew M. Siroka, Andrea C. Shane, Jodie A. Trafton, Todd H. Wagner. 2012. Identifying Neck and Back
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287. Anthony Delitto, Steven Z. George, Linda Van Dillen, Julie M. Whitman, Gwendolyn Sowa, Paul Shekelle, Thomas R. Denninger,
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288. Robert J. Nee, Bill Vicenzino, Gwendolen A. Jull, Joshua A. Cleland, Michel W. Coppieters. 2012. Neural tissue management
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289. Katyana Kowalchuk Horn, Sophie Jennings, Gillian Richardson, Ditte van Vliet, Cheryl Hefford, J. Haxby Abbott. 2012.
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290. Amy Wahlgren, Kerstin Palombaro. 2012. Evidence-Based Physical Therapy for BPPV Using the International Classification of
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291. Jan Pool. 7 Gedragsgeoriënteerde therapie bij patiënten met nekklachten: een optie? 115-125. [Crossref]
292. Lee N. Marinko, Juliann M. Chacko, Diane Dalton, Charles C. Chacko. 2011. The effectiveness of therapeutic exercise for painful
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293. Ana Isabel de-la-Llave-Rincón, Emilio J Puentedura, César Fernández-de-las-Peñas. 2011. Clinical presentation and manual
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294. Steven W. Forbush, Terry Cox, Eric Wilson. 2011. Treatment of Patients With Degenerative Cervical Radiculopathy Using a
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295. Kevin M. Cross, Chris Kuenze, Terry Grindstaff, Jay Hertel. 2011. Thoracic Spine Thrust Manipulation Improves Pain, Range
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297. Rogelio A. Coronado, Meryl J. Alappattu, Dennis L. Hart, Steven Z. George. 2011. Total Number and Severity of Comorbidities
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298. Michael P Reiman, Robert C Manske. 2011. The assessment of function: How is it measured? A clinical perspective. Journal of
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299. Marlon L Wong, Mark D Rossi, Wade Groff, Sonia Castro, Jennifer Powell. 2011. Physical therapy management of a patient with
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303. Manuel A. Domenech, Phil S. Sizer, Gregory S. Dedrick, Michael K. McGalliard, Jean-Michel Brismee. 2011. The Deep Neck
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308. Gert Bronfort, Mitch Haas, Roni Evans, Brent Leininger, Jay Triano. 2010. Effectiveness of manual therapies: the UK evidence
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309. Jonathan D’Sylva, Jordan Miller, Anita Gross, Stephen J. Burnie, Charles H. Goldsmith, Nadine Graham, Ted Haines, Gert
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310. Joshua A. Cleland, Paul E. Mintken, Kristin Carpenter, Julie M. Fritz, Paul Glynn, Julie Whitman, John D. Childs. 2010.
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312. Reuben Escorpizo, Gerold Stucki, Alarcos Cieza, Kandace Davis, Teri Stumbo, Daniel L. Riddle. 2010. Creating an Interface
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313. David S. Logerstedt, Lynn Snyder-Mackler, Richard C. Ritter, Michael J. Axe, Joseph Godges. 2010. Knee Pain and Mobility
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314. Isabel Audette, Jean-Pierre Dumas, Julie N. Côté, Sophie J. De Serres. 2010. Validity and Between-Day Reliability of the Cervical
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315. David S. Logerstedt, Lynn Snyder-Mackler, Richard C. Ritter, Michael J. Axe, Joseph J. Godges. 2010. Knee Stability and
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316. Emmanuel Yung, Skulpan Asavasopon, Joseph J. Godges. 2010. Screening for Head, Neck, and Shoulder Pathology in Patients
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318. Tamara Prushansky, Orly Deryi, Bahaa Jabarreen. 2010. Reproducibility and validity of digital inclinometry for measuring cervical
range of motion in normal subjects. Physiotherapy Research International 15:1, 42-48. [Crossref]
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319. Hilla Sarig-Bahat, Patrice L. (Tamar) Weiss, Yocheved Laufer. 2010. Neck Pain Assessment in a Virtual Environment. Spine
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320. Anita Gross, Jordan Miller, Jonathan D'Sylva, Stephen J Burnie, Charles H Goldsmith, Nadine Graham, Ted Haines, Gert
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Journal of Orthopaedic & Sports Physical Therapy®