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Proposal of A Classification System For
Proposal of A Classification System For
Official Publication of the Orthopeadic and Sports Physical Therapy Sections of the American Physical Therapy Association
It is likely that patients with neck pain are not a homogeneous group, but, instead, consist of a The ‘‘Guide to Physical Thera-
variety of subgroups, each of which may benefit from a specific intervention matched to the pist Practice’’5 indicates that inter-
patient’s signs and symptoms. Studies to date have largely failed to account for this possibility, ventions, such as mobilization/
which may compromise the statistical power of research and ultimately fail to provide guidance
manipulation, therapeutic exer-
for clinical decision making. Classification provides a means of breaking down a larger entity into
more homogeneous subgroups of patients, based on examination data. Classification can guide the
cise, traction, and a variety of mo-
determination of a patient’s prognosis, and the selection of the most appropriate intervention dalities, are utilized by physical
strategy. Classification has received considerable attention in the management of patients with low therapists to manage patients with
back pain, and evidence is emerging regarding its benefits. There has been considerably less effort neck pain. Although these inter-
made towards examining classification as it pertains to patients with neck pain. The purpose of ventions are largely accepted as
this clinical commentary is to examine the current literature and to propose a classification system the standard of care for patients
for patients with neck pain, based on the overall goal of treatment. The approach is based on with neck pain,74 high-quality evi-
published evidence when possible and is also informed by clinical experience and expert opinion.
dence from randomized controlled
Classification decisions are based on the integration of data from a variety of information from the
history and physical examination. The end result of the classification process is to determine the trials (RCTs) that investigate these
treatment approach believed to be most likely to maximize the clinical outcome for an individual interventions is frequently absent
patient with neck pain. J Orthop Sports Phys Ther 2004;34:686-700. or inconclusive.2,17,32-34,39,51 For
Key Words: conservative treatment, decision making, diagnosis, neck pain, example, the Philadelphia Panel
staging Clinical Practice Guidelines con-
cluded that many commonly used
interventions for patients with
A
pproximately 54% of individuals have experienced neck
neck pain lack sufficient evidence
pain within the last 6 months,21 and the incidence of neck
for their use.17 Furthermore, guid-
pain may be increasing.68 The economic burden associated
ance in selecting the most benefi-
with the management of patients with neck pain is high,
second only to low back pain (LBP) in annual workers’ cial interventions for an individual
compensation costs in the United States.99 Patients with neck pain are patient is also lacking, potentially
frequently encountered in outpatient physical therapy practice. Jette et resulting in less effective interven-
al43 reported that patients with neck pain make up approximately 25% tion strategies for these patients.
of all patients receiving outpatient physical therapy. In a review of over 4500 patients
receiving physical therapy, Di
1
Senior Physical Therapist and Director of Research, Department of Physical Therapy, Wilford Hall
Fabio and Boissonnault23 found
Medical Center, Lackland AFB, San Antonio, TX; Postdoctoral Research Fellow, Department of Physical that patients with neck pain expe-
Therapy, University of Pittsburgh, Pittsburgh, PA. rienced smaller improvements in
2
Assistant Professor, Department of Physical Therapy, University of Utah, Salt Lake City, UT; Clinical
Outcomes Research Scientist, Intermountain Health Care, Salt Lake City, UT. physical function than patients
3
Doctoral Candidate and Research Associate, Department of Physical Therapy, University of Pittsburgh, with low back or knee pain.
Pittsburgh, PA. One explanation for the scarcity
4
Affiliate Faculty, Department of Physical Therapy, Regis University, Denver, CO.
The opinions or assertions contained herein are the private views of the authors and are not to be of evidence for interventions for
construed as official or as reflecting the views of the US Air Force, US Army, or Department of Defense. patients with neck pain and lack of
This manuscript was exempt from review by the Wilford Hall Medical Center Institutional Review Board guidance for decision making is
based on its being a clinical commentary.
Address correspondence to John D. Childs, 508 Thurber Dr, Schertz, TX 78154-1146. E-mail: the absence of a mechanism for
childsjd@sbcglobal.net classifying patients.72 Classification
treatment approach. The authors examined the re- more serious, such as cervical myelopathy, ligamen-
sults of 30 patients treated on the basis of this tous instability, fracture, neoplastic condition, vascular
classification approach, and 27 patients who received compromise, etc. Therapists must also be aware of
no treatment. Statistically and clinically significant other nonmusculoskeletal causes of neck symptoms
reductions in pain and disability were reported in the that may mimic the presence of mechanical neck
classification group only.95 pain. For example, an apical (pancoast) tumor of the
The sparse and preliminary nature of existing lung can create pain in the shoulder region and
classification systems22,28 suggests that further re- neurologic deficits due to compression of the
search in this area is needed and that no single brachial plexus.10 Heart disease can present with pain
optimal system has been established. For example, it in a C3 dermatome and/or extending into the upper
is difficult to draw conclusions regarding the poten- extremity.
TABLE 3. Overview of classification categories with key examination findings and proposed matched interventions.
Proposed Matched
Classification Examination Findings Interventions
Mobility • Recent onset of symptoms • Cervical and thoracic spine mobilization/
• No radicular/referred symptoms in the upper quar- manipulation
ter • Active range of motion exercises
• Restricted range of motion with side-to-side rota-
tion and/or discrepancy in lateral flexion range of
motion
• No signs of nerve root compression or
peripheralization of symptoms in the upper quar-
ter with cervical range of motion
Centralization • Radicular/referred symptoms in the upper quarter • Mechanical/manual cervical traction
• Peripheralization and/or centralization of symp- • Repeated movements to centralize symptoms
toms with range of motion
• Signs of nerve root compression present
• May have pathoanatomic diagnosis of cervical
radiculopathy
Conditioning • Lower pain and disability scores • Strengthening and endurance exercises for the CLINICAL
and • Longer duration of symptoms muscles of the neck and upper quarter
increase • No signs of nerve root compression • Aerobic conditioning exercises
exercise • No peripheralization/centralization during range
tolerance of motion
Pain control • High pain and disability scores • Gentle active range of motion within pain toler-
• Very recent onset of symptoms ance
COMMENTARY
CLINICAL
exercise group, or a control group. Patients in the treatment program; however, it appears that the
McKenzie group generally had better outcomes than emphasis should be placed on strengthening and
those in the control group, but did not show any conditioning activities. Experience also suggests that
superiority over patients receiving general exercise. many patients in this classification may benefit from
The extent to which chin retractions were used in the interventions designed to decrease stress on the
McKenzie group was not clear, and the study in- cervical spine during daily activities or while at work.
cluded any patient with chronic neck pain, without Research focusing on ergonomic interventions is
attempting to identify a priori those most likely to lacking for patients with neck pain57; however, for a
COMMENTARY
respond to a McKenzie approach.49 Further research patient whose symptoms are provoked by repetitive
is clearly needed on interventions such as repeated activities, modifications may be useful.
movements and traction, which are often used with
the intent to centralize symptoms. Reduce Headache Classification
Some patients with neck pain present with a chief
Conditioning and Increased Exercise Tolerance complaint of headache that appears to be of cervical
Classification origin. When this is the case, the goal of treatment
focuses on reducing the headache symptoms. Diag-
Some patients with neck pain do not present with nostic criteria for cervicogenic headaches have been
significant mobility restrictions or a need for central- the subject of much debate.60 It has been suggested
CLINICAL
characteristics of patients likely to respond to particu- and scrutiny.17 Various aspects of a system need to be
assessed, including the reliability of individual exami-
lar interventions. Based on the literature and current
nation components as well as the overall reliability of
practice patterns, it appears that there are at least
the classification decision. Most important, however,
some patients with neck pain who will respond to
is an assessment of the impact of the use of the
inter ventions that include mobilization/
classification system on patient outcomes. An effective
manipulation, exercise, and possibly traction. By fur-
classification system must improve the outcomes of
ther examining the literature and considering clinical
care. Ultimately this is demonstrated by showing that
COMMENTARY
CLINICAL
cussion 1843. Physical Therapy: A Case Study Approach. New York,
46. Karas R, McIntosh G, Hall H, Wilson L, Melles T. The NY: McGraw-Hill; 1999.
relationship between nonorganic signs and centraliza- 65. Moeti P, Marchetti G. Clinical outcome from mechani-
tion of symptoms in the prediction of return to work for cal intermittent cervical traction for the treatment of
patients with low back pain. Phys Ther. 1997;77:354- cervical radiculopathy: a case series. J Orthop Sports
360; discussion 361-359. Phys Ther. 2001;31:207-213.
47. Katz JN, Buchbinder R. Soft tissue syndromes. Baillieres 66. Moore JE, Von Korff M, Cherkin D, Saunders K, Lorig K.
Clin Rheumatol. 1995;9:585-598. A randomized trial of a cognitive-behavioral program
48. Kendall NAS, Linton SJ, Main CJ. Guide to assessing for enhancing back pain self care in a primary care
COMMENTARY
psychosocial yellow flags in acute low back pain: risk setting. Pain. 2000;88:145-153.
factors for long-term disability and work loss. 67. Nilsson N, Christensen HW, Hartvigsen J. The effect of
Wellington, New Zealand: Accident Rehabilitation and spinal manipulation in the treatment of cervicogenic
Compensation Insurance Corporation of New Zealand headache. J Manipulative Physiol Ther. 1997;20:326-
and the National Health Committee; 2002. 330.
49. Kjellman G, Oberg B. A randomized clinical trial 68. Nygren A, Berglund A, von Koch M. Neck-and-shoulder
comparing general exercise, McKenzie treatment and a pain, an increasing problem. Strategies for using insur-
control group in patients with neck pain. J Rehabil ance material to follow trends. Scand J Rehabil Med
Med. 2002;34:183-190. Suppl. 1995;32:107-112.
50. Kjellman G, Skargren E, Oberg B. Prognostic factors for 69. Pincus T, Vlaeyen JW, Kendall NA, Von Korff MR,
perceived pain and function at one-year follow-up in Kalauokalani DA, Reis S. Cognitive-behavioral therapy
primary care patients with neck pain. Disabil Rehabil. and psychosocial factors in low back pain: directions
2002;24:364-370. for the future. Spine. 2002;27:E133-138.
Authors’ Response
We appreciate Dr Sterling’s insightful commentary is used for patients in each category. In fact, patients
on our proposed classification system for patients are expected to shift from one classification to
with neck pain. We would like to provide additional another, because of underlying changes in the pa-
comment on a few of the issues she has raised. First, tient’s clinical presentation over time, which necessi-
we agree with Dr Sterling’s suggestion that it may be tates accompanying changes in management strategy.
useful to differentiate whiplash injury from idiopathic Dr Sterling gives the example of patients initially
neck pain altogether, and we readily acknowledge the categorized in the ‘‘mobility’’ group as being ex-
existence of the subgroup of patients with whiplash- pected to have other impairments, such as alterations
associated disorder (WAD) in our paper. However, in muscle recruitment strategies, which indeed re-
given that entire classification systems have been quires attention during rehabilitation. Nevertheless,
previously proposed unique to this subgroup (includ- we contend that each patient will have a primary goal
ing Dr Sterling’s own work),4,5 we intentionally omit- of treatment at a given point during an episode of
ted a detailed discussion of these patients here in care, attesting to the importance of ongoing assess-
deference to the existing literature. We also agree ment throughout the episode of care. Clearly, the
with Dr Sterling that patients suspected to have WAD goal for most patients with neck pain is to arrive at
may include more than just patients with acute the conditioning and increased exercise tolerance
injuries, based on the poor prognosis associated with classification, where muscle recruitment consider-
patients who have persistent physical and/or psycho- ations and strength and endurance issues can be
logical factors known to interfere with recovery. examined in more detail. Interventions, such as
Secondly, we readily agree with Dr Sterling’s asser- aerobic conditioning and strengthening and endur-
tion that psychosocial and psychological factors be ance exercises, can then be matched to these impair-
considered in any classification system for patients ments to optimize muscle function and overall
with neck pain, and we examine the importance of functional recovery.
these considerations for both prognostic and treat- Finally, Dr Sterling suggests that one difficulty with
ment purposes in our paper. However, we elected not this approach is that some of the suggested interven-
CLINICAL
to more specifically elaborate on detailed screening tions within each category lack evidence for their use.
and management strategies, because the effectiveness Although we generally agree with this assertion,
of biopsychosocial interventions for patients with attempts to identify subgroups of patients will result
neck pain has not been sufficiently studied (com- in more homogeneous subsets of patients with neck
pared to the proliferation of evidence supporting the pain, increasing the power of clinical research to
use of these interventions in patients with low back identify effective interventions for patients with neck
pain). Furthermore, evidence in patients with low pain. Ultimately, these efforts should improve deci-
COMMENTARY
back pain suggests that individuals who present with sion making for clinicians in matching patients to
relevant psychosocial issues may not need to be specific interventions from which they are likely to
considered a unique classification. Rather, these is- receive the most benefit. We thank Dr Sterling for
sues can be addressed within the context of an her valuable insight and look forward to future
existing classification system,1 using rehabilitation research that will more specifically develop and refine
strategies that emphasize active rehabilitation, positive the framework proposed here.
reinforcement of functional accomplishments, graded
exercise programs, gradual exposure to specific activi- Maj John D. Childs, PT, PhD, MBA, OCS, FAAOMPT
ties that a patient fears, etc.2,3,6 Senior Physical Therapist and Director of Research
Dr Sterling correctly recognizes the potential for Department of Physical Therapy, Wilford Hall
some overlap to occur in the treatment approach that Medical Center