Proposal of a Classification System for

Patients With Neck Pain

Maj John D. Childs, PT, PhD, MBA, OCS, FAAOMPT 1
Julie M. Fritz, PT, PhD, ATC 2
Sara R. Piva, PT, MS, OCS, FAAOMPT 3
Julie M. Whitman, PT, DSc, OCS, FAAOMPT 4

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
therapists to manage patients with
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strategy. Classification has received considerable attention in the management of patients with low
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
Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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-
Journal of Orthopaedic & Sports Physical Therapy®

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

686 Journal of Orthopaedic & Sports Physical Therapy

 provides a means of breaking down a larger entity
into more homogeneous subgroups of patients based
on examination data. In the absence of a classifica-
tion method, clinicians and researchers are left with
the perception that any patient with neck pain is
equally likely to succeed or fail with any particular
intervention.47,54 Existing classification systems de-
signed to identify pathoanatomic mechanisms have
largely failed.17 Moreover, classification is likely to be
most helpful for physical therapists when it is based
on signs and symptoms that match interventions to
the subgroup of patients most likely to benefit from
them.72,76 The goal of classification is to improve
decision making in the determination of patient’s
intervention strategy and subsequent prognosis. The
difficulties associated with developing a classification
system that consists of mutually exclusive subgroups
encompassing the spectrum of patients with a particu-
lar condition have been well described by Zimny.101
Nevertheless, the development and application of
classification systems remain a critical step to further
establish the scientific basis for the physical therapy
profession.4
Two groups of researchers have described proposed
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classification schemes for patients with neck pain.
Werneke et al98 described a classification process that
categorized patients with either neck or back pain
into 2 groups (centralizers and noncentralizers),
based on their response to a McKenzie-based evalua-
tion process. The authors reported that patients in
Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
the ‘‘centralizer’’ classification experienced signifi-
cantly greater reductions in pain and disability after a
course of physical therapy; however, the choice of
interventions was left to the discretion of the thera-
pists, and not explicitly linked to the classification. In
addition, only 23% of the subjects had neck pain,
and the results of these subjects were not distin-
guished from the larger sample. Wang et al95 recently
described a classification process designed specifically
Journal of Orthopaedic & Sports Physical Therapy®
for patients with neck pain. The classification process
categorized patients into 1 of 4 groups, based on the
location and presumed source of symptoms (neck
pain only, radicular arm pain and neck pain, referred
arm pain and neck pain, or headaches). Subcatego-
ries within each group are also described. These
subgroups are identified primarily through clinical
signs and symptoms and are linked to a distinct
treatment approach. The authors examined the re-
sults of 30 patients treated on the basis of this
classification approach, and 27 patients who received
no treatment. Statistically and clinically significant
reductions in pain and disability were reported in the
classification group only.95
The sparse and preliminary nature of existing
classification systems22,28 suggests that further re-
search in this area is needed and that no single
optimal system has been established. For example, it
is difficult to draw conclusions regarding the poten-
J Orthop Sports Phys Ther • Volume 34 • Number 11 • November 2004
tial usefulness of the classification system proposed by
Wang et al,95 because patients in the control group
were not treated, which is not reflective of physical
therapy practice. Additionally, little evidence exists to
support the numerous decision-making consider-
ations outlined in the algorithm. Given that the
criteria used to classify patients are likely to change
with more definitive research,28 initially proposing a
less specific framework for patients with neck pain
may be more pragmatic. This general framework can
then be used as the basis for future research, the
results of which can be used to optimize the classifica-
tion decision-making process. Therefore, the purpose
of this clinical commentary is to examine the current
literature on the management of patients with neck
pain and to propose a classification system for these
patients. Effective classification methods are likely to
improve clinical decision making and outcomes of
care, and to enhance the power of clinical research
by permitting researchers to study more homoge-
neous groups of patients.72,76
The system proposed in this commentary primarily
addresses the classification of patients with neck pain
attributable to cervical and upper thoracic spine
dysfunction. Patients with neck pain referred from
other structures (eg, temporomandibular joint) are
not considered. The classification system requires
integration of data from a variety of information from
the history and physical examination. Whenever pos-
sible, the system is based on evidence from the
peer-reviewed literature, but also incorporates clinical
experience and expert opinion in areas where evi-
dence is insufficient. In these instances, we were
intentionally vague to avoid propagating opinion that
may or may not be supported by future research
attempting to more specifically define characteristics
of patients within each classification.
The primary goal of classification is to determine
the treatment approach most likely to yield the best
clinical outcome for an individual patient. However,
before this decision can be made, the clinician must
CLINICAL
first determine if the patient is appropriate for
physical therapy management. Although a specific
pathoanatomic source cannot be identified in most
patients with neck pain,12 the vast majority of cases
can be attributed to mechanical factors. In a much
smaller percentage, the cause may be something
COMMENTARY
more serious, such as cervical myelopathy, ligamen-
tous instability, fracture, neoplastic condition, vascular
compromise, etc. Therapists must also be aware of
other nonmusculoskeletal causes of neck symptoms
that may mimic the presence of mechanical neck
pain. For example, an apical (pancoast) tumor of the
lung can create pain in the shoulder region and
neurologic deficits due to compression of the
brachial plexus.10 Heart disease can present with pain
in a C3 dermatome and/or extending into the upper
extremity.
687
 TABLE 1. Key signs and symptoms associated with serious pathological neck conditions.
Cervical Myelopathy Neoplastic Conditions
• Sensory disturbance of • Age over 50 years
the hands • Previous history of
• Muscle wasting of hand cancer
intrinsic muscles • Unexplained weight
• Unsteady gait loss
• Hoffman’s reflex • Constant pain, no re-
• Hyperreflexia lief with bed rest
• Bowel and bladder dis- • Night pain
turbances
• Multisegmental weak-
ness and/or sensory
changes
TABLE 2. Clinical yellow flags indicating heightened fear-avoidance beliefs.48
Attitudes and Beliefs
• Belief that pain is harmful or disabling, resulting in guarding and
fear of movement
• Belief that all pain must be abolished before returning to activity
• Expectation of increased pain with activity or work, lack of abil-
ity to predict capabilities
• Catastrophizing, expecting the worst
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• Belief that pain is uncontrollable
• Passive attitude to rehabilitation
Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
A comprehensive discussion on how to properly
screen patients with neck pain for potentially serious
pathology is beyond the scope of this commentary.
More detailed information on the differential diagno-
sis of these and other potentially serious neck condi-
tions is contained in other sources.11,64 Nevertheless,
clinicians need to recognize when nonmovement
factors may be playing a significant role in the
Journal of Orthopaedic & Sports Physical Therapy®
patient’s symptoms and disability. For example, a
clinical prediction rule (CPR) was recently devel-
oped83 and validated9,82 to improve decision making
for determining when to obtain cervical spine radio-
graphs for patients who have experienced trauma.
Table 1 provides a summary of signs and symptoms
associated with other conditions that indicate the
potential for serious underlying pathology to exist.
Self-report measures that assess general medical sta-
tus, level of pain and disability, and fear-avoidance
beliefs can also be useful to assist therapists in the
identification of patients with potentially serious pa-
thology. Appropriate referral for medical manage-
ment is important when there is a suspicion that one
of these conditions exists.
The majority of patients with neck pain will re-
cover, but a sizable percentage of individuals will
experience persistent pain and disability.12 The pres-
688
Upper Cervical
Ligamentous Vertebral Artery Inflammatory or
Instability Insufficiency Systemic Disease
• Occipital headache • Drop attacks • Temperature ⬎37°C
and numbness • Dizziness or • BP ⬎ 160/95 mmHg
• Severe limitation dur- lightheadedness related • Resting pulse ⬎ 100
ing neck active range to neck movement bpm
of motion in all direc- • Dysphasia • Resting respiration
tions • Dysarthria ⬎ 25 bpm
• Signs of cervical • Diplopia • Fatigue
myelopathy • Positive cranial nerve
signs
Behaviors
• Use of extended rest
• Reduced activity level with significant withdrawal from daily
activities
• Avoidance of normal activity and progressive substitution of life-
style away from productive activity
• Reports of extremely high pain intensity
• Excessive reliance on aids (braces, crutches, etc)
• Sleep quality reduced following the onset of back pain
• High intake of alcohol or other substances with an increase
since the onset of back pain
• Smoking
ence of abnormal illness behavior or psychosocial
factors may be a contributing factor in these cases
and can interfere with recovery.69 Considerable re-
search has shown that psychosocial factors are an
important prognostic indicator of prolonged disabil-
ity.6,24,50,87 Similar to LBP,55 the literature suggests
that fear-avoidance beliefs may play an important role
in patients with neck pain.29,71,93 Attitudes and behav-
iors that may represent concern for psychosocial
factors to be present are listed in Table 2.48
If relevant psychosocial factors are identified, the
rehabilitation approach may need to be modified. An
emphasis on active rehabilitation and positive rein-
forcement of functional accomplishments is recom-
mended.66 Graded exercise programs that direct
attention towards attaining certain functional goals
and away from the symptom of pain have also been
recommended.56 Finally, graduated exposure to spe-
cific activities that a patient fears as potentially
painful or difficult to perform may be helpful.92
Evidence from patients with LBP suggests that pa-
tients with higher levels of fear-avoidance beliefs do
not need to be considered a unique classification, but
can be effectively managed within an existing classifi-
cation system with the above modifications.31 The
effectiveness of these interventions for patients with
neck pain has not been sufficiently studied.48
J Orthop Sports Phys Ther • Volume 34 • Number 11 • November 2004
 DETERMINING THE MOST EFFECTIVE
INTERVENTION
Once it is determined that a patient is appropriate
for physical therapy management, an intervention
approach must be determined. We propose 5 sub-
groups, or classifications, of patients, each with a
label intended to capture the primary goal of treat-
ment: (1) ‘‘mobility,’’ (2) ‘‘centralization,’’ (3) ‘‘con-
ditioning and increase exercise tolerance,’’ (4) ‘‘pain
control,’’ and (5) ‘‘reduce headache.’’ Assignment of
a patient to a classification depends upon the overall
impression formed from the history and physical
examination (Table 3).
We believe each classification is homogeneous with
respect to the treatment approach most likely to
benefit the patient, and not necessarily homoge-
neous, as based on etiology or pathoanatomy. We
have labeled each classification based on the goal of
the treatment approach, and not on the specific
interventions proposed, because future research may
change our understanding of the most efficacious
interventions to achieve a particular goal. We believe
each patient has a primary goal of treatment at a
given period during the course of management,
making the classification categories mutually exclusive
at a single point in time. We recognize, however, that
the process of classification is ongoing, and it is
anticipated that a patient’s presentation will change
with time and treatment. Ongoing reassessment is,
therefore, necessary to determine the most appropri-
ate intervention at any point in time.
Mobility Classification
Evidence from RCTs16,27,40 and a recent Cochrane
systematic review 35 suggests that mobilization/
manipulation is beneficial for at least some patients
with neck pain. Hoving et al40 reported in a high-
quality randomized clinical trial that manual therapy
consisting of mobilizations performed by a physical
therapist was more effective in improving outcomes
and more cost effective53 than a physical therapy
intervention that did not incorporate a manual
therapy approach, or than continued care by a

TABLE 3. Overview of classification categories with key examination findings and proposed matched interventions.
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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-
Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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
Journal of Orthopaedic & Sports Physical Therapy®

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

• Symptoms precipitated by trauma • Range of motion exercises for adjacent regions

• Referred or radiating symptoms extending into the • Physical modalities as needed
upper quarter • Activity modification to control pain
• Poor tolerance for examination or most interven-
tions
Reduce headache • Unilateral headache with onset preceded by neck • Cervical spine manipulation/mobilization
pain • Strengthening of neck and upper quarter muscles
• Headache pain triggered by neck movement or • Postural education
positions
• Headache pain elicited by pressure on posterior
neck

J Orthop Sports Phys Ther • Volume 34 • Number 11 • November 2004 689

 general practitioner. Limited evidence suggests that
mobilization/manipulation tends to be more benefi-
cial for younger patients with acute neck pain.52
However, a recent Cochrane systematic review on the
benefits of manual therapy interventions for patients
with mechanical neck pain was unable to determine
whether certain subgroups exist.35 Studies comparing
manipulation with other treatments in patients with
chronic neck pain (greater than 12 weeks in dura-
tion) have not found superior outcomes for patients
receiving manipulation,52 whereas 75% of subjects in
the trial by Hoving et al40 had symptoms for less than
12 weeks. It is also suggested that patients with
restricted cervical range of motion and symptoms
isolated to the neck (ie, no upper extremity symp-
toms) may also be more likely to benefit from
mobilization/manipulation.14,41 Evidence also sug-
gests that manual therapy is more effective when used
in combination with exercise.3,27,36
Based on this evidence, patients initially assigned to
a mobility classification tend to be younger individu-
als with a more recent onset of symptoms and a
primary impairment of decreased range of motion
(Table 3). In our experience, active range of motion
testing will often reveal a side-to-side discrepancy in
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lateral flexion or rotation range of motion. Symptoms
are typically localized to the neck and usually do not
peripheralize into the upper quarter during active
range of motion. Signs of nerve root compression are
uncommon.
The primary aim of treatment for this subgroup of
Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
patients is to improve mobility. Initial treatment will
likely include mobilization/manipulation directed to
the cervical, cervicothoracic, and/or thoracic spine,
possibly accompanied by specific active range of
motion, self-mobilization, or stretching exercises de-
signed to increase pain-free range of motion. There is
no evidence to support a preference for manipula-
tion over mobilization for patients with neck pain,
but the inherent risks related to the use of manipula-
Journal of Orthopaedic & Sports Physical Therapy®
tion should be considered in the decision-making
process. Indeed, a recent study found equal improve-
ment in patients with neck pain randomized to
receive either manipulation or mobilization treat-
ments.42 Manual or mechanical cervical traction per-
formed for the purpose of producing passive
mobilization may also be used in this classification,
possibly for older patients who may be experiencing
degenerative conditions of the neck with multilevel
involvement.
Centralization Classification
Many patients with neck pain and limitations in
active range of motion also present with symptoms
into the upper extremity and signs of nerve root
compression. When patients present with radiating or
radicular symptoms, the goal of the initial interven-
tions shifts from improving mobility to achieving
690 J Orthop Sports Phys Ther • Volume 34 • Number 11 • November 2004
centralization of symptoms. Centralization occurs
when movement of the neck results in symptoms
moving from an area more distal in the upper
quarter to a location more central or near the
midline position of the neck.62 Although the mecha-
nism by which centralization occurs is poorly under-
stood, its occurrence is important because of its
potential use in identifying those patients who will
respond to conservative management.25,46 Studies
have demonstrated that patients with LBP who are
able to centralize symptoms at baseline return to
work sooner and exhibit greater improvements in
pain and function than patients who are unable to
centralize their symptoms.25,46,59,84,98 Werneke and
Hart97 examined a group of patients with spinal pain
and found the ability to centralize symptoms at the
initial visit, or during the course of treatment, was a
favorable prognostic finding. Only 23% of the sample
in these reports had neck pain, and the results for
these patients could not be distinguished from the
larger group.97 Evidence and clinical experience sug-
gest that achieving centralization is an important
treatment goal for patients with neck pain who have
radiating/radicular symptoms.
The hallmark finding leading to a centralization
classification is, therefore, the achievement of central-
ization during the examination. Patients appropriate
for this classification may be further characterized by
radicular or referred symptoms into the upper quar-
ter or mid-scapular area, particularly when those
symptoms are reported to be affected by neck move-
ments (Table 3). Signs of nerve root compression
such as weakness in a myotomal pattern, decreased
deep-tendon reflexes, and sensor y loss in a
dermatomal pattern may be present. Patients with a
diagnosis of cervical radiculopathy based on imaging
studies will often be classified in the centralization
category. It is important, however, that the clinical
examination be consistent with a centralization classi-
fication before proceeding with treatment. Wainner
et al94 recently developed a CPR to diagnose cervical
radiculopathy. The rule consists of the following 4
clinical examination findings: (1) positive Spurling
test, (2) positive neck distraction test, (3) positive
upper-limb tension test, and (4) the presence of less
than 60° of cervical rotation range of motion to the
involved side. When at least three fourths of these
findings are present, radiculopathy should be strongly
suspected (specificity, 94%; positive likelihood ratio,
6.1).94 If all 4 findings are present, the therapist can
be quite certain the patient has a cer vical
radiculopathy and, thus, may be appropriate for the
centralization classification (specificity, 99%; positive
likelihood ratio, 30.3). The upper-limb tension test
described by Elvey26 was the single best screening test
(sensitivity, 97%; negative likelihood ratio, 0.12)94;
therefore, a negative upper-limb tension test consider-
 ably reduces the likelihood of a diagnosis of cervical
radiculopathy.
For the goal of centralizing symptoms, interven-
tions using manual or mechanical traction are often
recommended.20,75,77 The patient position during
traction may be varied to produce maximal centraliza-
tion.19 Although cervical traction is frequently recom-
mended for patients with neck pain and radicular
pain,74,75,77 its efficacy for this subgroup of patients
has not been adequately studied.17,39,88 Most studies
have consisted of small case series designs,20,65,75 and
have not studied a homogeneous subgroup of pa-
tients thought to be likely to benefit from the
intervention.88 One retrospective study on home
cervical traction reported excellent results.85 It may
be that cervical traction has not shown to be effective
because only a specific subgroup may benefit from it.
Clinical experience suggests that traction can be
beneficial when the appropriate patient is selected.
Another approach to the treatment of patients in
the centralization classification is to instruct patients
to perform repeated active neck movements in a
direction that results in centralization of their symp-
toms. McKenzie61 recommended the use of chin
retraction exercises to promote centralization.
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Abdulwahab and Sabbahi1 studied the effect of chin
retraction on patients with cervical radiculopathy and
reported a significant increase in the H-reflex ampli-
tude after repeated chin retraction exercises. More
importantly, this electrophysiologic change was associ-
ated with a decrease in the patient’s radicular symp-
Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
toms as reported on a visual analog scale. The
authors also observed significant decreases in the
H-reflex amplitude, which was associated with an
increase in radicular symptoms due to assuming a
slumped posture, indicating that postural advice may
also be helpful when the goal of treatment is central-
ization.1 Kjellman and Oberg49 randomized patients
with chronic neck pain to receive either treatment
based on principles advocated by McKenzie, a general
Journal of Orthopaedic & Sports Physical Therapy®
exercise group, or a control group. Patients in the
McKenzie group generally had better outcomes than
those in the control group, but did not show any
superiority over patients receiving general exercise.
The extent to which chin retractions were used in the
McKenzie group was not clear, and the study in-
cluded any patient with chronic neck pain, without
attempting to identify a priori those most likely to
respond to a McKenzie approach.49 Further research
is clearly needed on interventions such as repeated
movements and traction, which are often used with
the intent to centralize symptoms.
Conditioning and Increased Exercise Tolerance
Classification
Some patients with neck pain do not present with
significant mobility restrictions or a need for central-
J Orthop Sports Phys Ther • Volume 34 • Number 11 • November 2004
ization. These patients tend to be further character-
ized by lower disability and pain scores and a longer
duration of symptoms. Patients commonly referred to
as having ‘‘clinical instability’’ may be appropriate for
this classification. Improving motion or achieving
centralization cannot be used to guide treatment for
these patients. Instead, patients fitting this profile
may respond best to treatment with an exercise
approach focusing on strength and conditioning.
Recent RCTs16,27,44,86,100 and systematic reviews17,78
provide evidence for the effectiveness of exercise in
patients with neck pain. In particular, studies examin-
ing exercise programs without manual therapy inter-
ventions appear to indicate that strengthening and
endurance exercises for muscles of the upper quarter,
possibly combined with aerobic conditioning, may be
the most beneficial type of exercise for patients with
chronic neck pain who do not have signs of nerve
root compression.16,27,44,86,100 Intensive strengthening
exercise yields results superior to those of interven-
tions focusing on either manipulation or mobilization
in this subgroup.16,44 One recent RCT100 demon-
strated the effectiveness of both strengthening exer-
cises and endurance training of the deep neck flexor
muscles to reduce pain and disability at a 1-year
follow-up in patients with chronic neck pain. There-
fore, interventions combining strengthening, condi-
tioning, and possibly deep neck flexor exercises may
be most effective for patients in this classification.
Experience also suggests that individual patients
may present with impairments of flexibility of key
muscles related to the lower cervical and upper
thoracic spine, such as the upper trapezius, levator
scapulae, and pectoralis major, which need to be
addressed with stretching exercises. Although re-
search generally does not support the effectiveness of
interventions that focus on stretching and flexibility,
clinical experience suggests that addressing specific
impairments of muscle length for an individual pa-
tient may be a beneficial addition to a comprehensive
CLINICAL
treatment program; however, it appears that the
emphasis should be placed on strengthening and
conditioning activities. Experience also suggests that
many patients in this classification may benefit from
interventions designed to decrease stress on the
cervical spine during daily activities or while at work.
Research focusing on ergonomic interventions is
lacking for patients with neck pain57; however, for a
COMMENTARY
patient whose symptoms are provoked by repetitive
activities, modifications may be useful.
Reduce Headache Classification
Some patients with neck pain present with a chief
complaint of headache that appears to be of cervical
origin. When this is the case, the goal of treatment
focuses on reducing the headache symptoms. Diag-
nostic criteria for cervicogenic headaches have been
the subject of much debate.60 It has been suggested
691
 that the 2 most important diagnostic criteria for
distinguishing cervicogenic headaches from other
headache etiologies are a pattern of symptoms that
start in the neck and progress to the fronto-ocular
area and unilateral headache (sensitivity, 100% for
each finding).7 Other findings common to patients
with cervicogenic headache include pain triggered by
neck movement or position and pain elicited by
pressure on the ipsilateral posterior neck. Symptoms
may fluctuate or be continuous in nature, but are not
typically described as excruciating or throbbing.
Symptoms may also include ipsilateral shoulder and
arm pain of a vague, nonradicular nature.7 Patients
with a predominant complaint of headache that does
not fit this pattern may need to be referred for
further diagnostic testing.
Interventions for patients with a chief complaint of
cervicogenic headache may include manual therapy
for the cervical, and/or thoracic regions, soft tissue
mobilization, strengthening of muscles of the upper
quarter, and postural/ergonomic education. Evidence
from RCTs45,67 and systematic reviews15,90,91 suggests
that mobilization/manipulation is effective for reduc-
ing the duration and intensity of headache symptoms
in these patients, particularly when combined with
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exercise. Other RCTs13 and systematic reviews,8,37
however, question the usefulness of manual therapy
for these patients and suggest that positive findings
may be more related to placebo effects.8 Jull et al,45
in a recent large RCT of patients with cervicogenic
headaches, compared a control group to groups
Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
receiving cer vical mobilization/manipulation,
strengthening of the deep neck flexor and scapular
muscles, and a combined manual therapy and exer-
cise group. The results showed significant reductions
in headache symptoms in all treatment groups versus
the control group and were maintained at a 1-year
follow-up. At shorter-term follow-ups (7 and 12
weeks), the combined exercise and manual therapy
group showed some advantages over the other
Journal of Orthopaedic & Sports Physical Therapy®
groups.45 Hammill et al38 used a combination of
postural education and stretching/strengthening ex-
ercise to reduce the frequency of headaches and
improve disability in a series of 20 patients, with
results being maintained at a 12-month follow-up.
Pain Control Classification
Some patients present with severe neck pain that
dramatically alters activities of daily living. These
patients do not tolerate an examination well, or any
form of manual or movement based intervention.
These findings characterize patients assigned to the
pain control classification (Table 3). It is expected
that patients in the pain control classification will
have higher levels of pain and disability, and will
likely have pronounced active range of motion restric-
tions, possibly with referred or radiating symptoms
into the upper quarter. The onset of symptoms
692 J Orthop Sports Phys Ther • Volume 34 • Number 11 • November 2004
should be acute and likely related to trauma, such as
a motor vehicle accident. Completion of a compre-
hensive examination will be difficult secondary to
symptom exacerbation, and the severity of symptoms
is expected to preclude the performance of interven-
tions to enhance strength or conditioning, promote
centralization, or address specific mobility restric-
tions. Once the patient’s symptoms are reduced, he
or she should be progressed into one of these
classifications, as appropriate. A subset of patients
within this classification may demonstrate more se-
vere symptoms over a longer period of time in
patients with whiplash-associated disorder. Entire clas-
sification systems have been previously proposed just
for patients with whiplash-associated disorder80,81;
thus a detailed discussion of this subset of patients
within the pain control classification is beyond the
purpose of this paper.
The primary aim of treatment for patients in the
pain control classification is to manage symptoms and
facilitate the patient’s ability to tolerate a more active
rehabilitation program. Evidence supports early,
gentle, active range of motion exercise in patients
with acute, posttraumatic neck pain, for whom pain
relief is the primary goal.63,73 McKinney et al18
randomized patients with neck pain due to MVA
within 48 hours after injury to early advice on active
motion, manipulative therapy, or a period of rest and
immobilization. Patients receiving early activity were
less likely to have persistent pain than those receiving
the other interventions. Rosenfeld et al18 compared
early, gentle range of motion exercises to a standard
protocol recommending a soft collar. The active
exercise group had less pain and more range of
motion at 6-month follow-up. Other interventions
recommended for patients in the pain control classifi-
cation have either not been sufficiently studied or
have been shown to be ineffective. Modalities such as
heat/cold, electrical stimulation, and biofeedback
have not been studied sufficiently,18 while interven-
tions such as transcutaneous electrical nerve stimula-
tor (TENS) devices and ultrasound have been studied
and found to be ineffective.17,18,30,89 Gross et al34
reviewed 13 RCTs assessing the effectiveness of vari-
ous physical medicine modalities for patients with
mechanical neck pain and found limited evidence for
their use.
Considering the evidence, the treatment of patients
in the pain control classification should focus on
gentle range of motion exercise, and active exercise
or mobilization to adjacent nonirritable regions (ie,
thoracic spine, shoulder, or rib cage). Physical mo-
dalities (ie, ice, heat, electrical simulation, etc) may
be used if they are helpful for reducing symptoms,
but therapists should attempt to keep patients as
active as tolerated. The patient’s signs and symptoms
need to be closely monitored, and the patient should
 be progressed to a more active classification as soon
as possible.
DISCUSSION
We have proposed a classification system for pa-
tients with neck pain, using published evidence when-
ever possible to support the proposed framework.
The system is based on the goals of treatment and
the interventions used to achieve these goals, rather
than an attempt to classify patients by pathology or
symptom distribution. This approach has proven to
be more effective in improving care in patients with
LBP.28 The only other classification system for pa-
tients with neck pain published to date95 uses symp-
tom location (neck pain only, arm pain with or
without neck pain, or headache) and presumed
pathological mechanisms (radicular versus referred
pain) in the initial subgrouping of patients. Although
classification systems for patients with LBP primarily
based on symptom location and presumed pathology
(eg, the Quebec system79) have generally been shown
to be useful for prognostic purposes,58 their ability to
specifically match patients to interventions has not
been demonstrated.70 Additionally, although Wang et
al95 presented outcomes from a group of patients
Downloaded from www.jospt.org at on February 29, 2020. For personal use only. No other uses without permission.
who received treatment based on the decision points
outlined in their classification scheme, the control
group was untreated. Therefore, the observed
changes in the treatment group may simply be
attributable to the fact that some treatment was
Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
provided, rather than providing validity for the system
itself. Answering questions regarding the best meth-
ods for treatment decision making for patients with
neck pain will ultimately be answered by outcomes
data and controlled clinical trials.
Terms such as exercise, mobilization, etc, are often
used without more specific indications of the tech-
niques used or the intended goals of the interven-
tion, primarily because studies published to date have
Journal of Orthopaedic & Sports Physical Therapy®
generally not been designed to identify the unique
characteristics of patients likely to respond to particu-
lar interventions. Based on the literature and current
practice patterns, it appears that there are at least
some patients with neck pain who will respond to
inter ventions that include mobilization/
manipulation, exercise, and possibly traction. By fur-
ther examining the literature and considering clinical
experience, it appears that the patients likely to
respond to each of these interventions may possess
some unique characteristics that can be used to form
the basis of a classification system. As the evidence
base for the management of patients with neck pain
continues to grow, new classification criteria and
interventions may be identified and will need to be
incorporated.
Therapists who manage patients with neck pain, or
any other musculoskeletal condition, recognize that
an individual patient’s clinical presentation will likely
J Orthop Sports Phys Ther • Volume 34 • Number 11 • November 2004
change as he or she moves through a course of
treatment. If this does not occur, most therapists
would consider the management of the patient to
have failed. It is therefore likely, and indeed ex-
pected, that patients will shift from one classification
to another during an episode of care. For example, a
patient may present with severe neck pain and
referred pain into the arm. If the therapist cannot
find a position, movement, or intervention that will
centralize the symptoms, this patient may be classified
in the pain control subgroup. Once the patient’s pain
has been reduced, the therapist may be able to find a
movement that centralizes the patient’s symptoms,
and the patient would then move into the centraliza-
tion classification. Further, once a patient’s radicular
symptoms centralize, a loss of motion may need to be
addressed, with mobilization/manipulation, for ex-
ample. We believe that the goal for most patients with
neck pain is to arrive at the conditioning and
increased exercise tolerance classification. Neck pain
has high rates of recurrence,12 and although no
research has been conducted on the topic, it is
possible that addressing impairments of strength,
conditioning, and flexibility could reduce the risk of
recurrence.
We recognize that additional decision making is
necessary within each classification to more specifi-
cally guide the application of the selected interven-
tion. For example, detecting a side-to-side discrepancy
in range of motion alone does not provide sufficient
information to guide selection of a particular treat-
ment technique or suggest that treatment be directed
to a specific region of the cervicothoracic spine.
However, the first step in the development of the
classification system is to direct patients toward the
optimal treatment. Future research is necessary to
more specifically guide decision making within each
classification.
Like any aspect of diagnosis or decision making,
classification systems need to be subjected to study
CLINICAL
and scrutiny.17 Various aspects of a system need to be
assessed, including the reliability of individual exami-
nation components as well as the overall reliability of
the classification decision. Most important, however,
is an assessment of the impact of the use of the
classification system on patient outcomes. An effective
classification system must improve the outcomes of
care. Ultimately this is demonstrated by showing that
COMMENTARY
patients in a certain classification have a better
outcome when interventions matched to the classifi-
cation are received versus unmatched interventions.
CONCLUSION
This commentary outlines a general framework for
identifying subgroups of patients based on the pri-
mary goal of treatment, with the ultimate aim of
matching patients to specific interventions from
which they are most likely to benefit. However, the
693
 validity of this classification system will ultimately be
based on the extent to which it improves decision
making and outcomes of care. Therefore, readers are
cautioned to reserve judgment until more definitive
studies are performed and to expect that modifica-
tions will inevitably occur as new evidence emerges.
We hope that this proposal of a classification system
for patients with neck pain will stimulate further
research in this area. The process of refining and
validating a classification system is lengthy; however,
the potential to increase the power of clinical re-
search and increase the effectiveness and efficiency of
rehabilitation for patients with neck pain make these
extended efforts worthwhile.
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a clinical decision-making algorithm. Am J Phys Med
Rehabil. 2003;82:203-218; quiz 219-221.
96. Wells GA, Tugwell P, Brosseau L, et al. Philadelphia
Panel evidence-based clinical practice guidelines on
selected rehabilitation interventions: overview and
methodology. Phys Ther. 2001;81:1629-1640.
97. Werneke M, Hart DL. Centralization phenomenon as a
prognostic factor for chronic low back pain and disabil-
ity. Spine. 2001;26:758-764; discussion 765.
98. Werneke M, Hart DL, Cook D. A descriptive study of
the centralization phenomenon. A prospective analysis.
Spine. 1999;24:676-683.
99. Wright A, Mayer TG, Gatchel RJ. Outcomes of disabling
cervical spine disorders in compensation injuries. A
prospective comparison to tertiary rehabilitation re-
sponse for chronic lumbar spinal disorders. Spine.
1999;24:178-183.
100. Ylinen J, Takala EP, Nykanen M, et al. Active neck
muscle training in the treatment of chronic neck pain in
women: a randomized controlled trial. JAMA.
2003;289:2509-2516.
101. Zimny NJ. Diagnostic classification and orthopaedic
physical therapy practice: what we can learn from
medicine. J Orthop Sports Phys Ther. 2004;34:105-109;
discussion 110-105.
 Invited Commentary
It is timely that a paper proposing a new classifica-
tion system for neck pain is put forward. Whilst
classification systems exist for low back pain, there
have been few attempts made to achieve classification
of neck pain. Evidence is accumulating that demon-
strates neck pain to be a heterogeneous condition
likely involving complex underlying mechanisms of
varying degrees in individual patients. In light of this,
and as the authors of this review point out, treat-
ments directed to neck pain viewed as a homogenous
group are likely to fail and, indeed, this may be one
reason why investigations of treatments for neck pain
have been less than conclusive.
The authors correctly state that a pathoanatomical
classification of neck pain is not useful either in
terms of prognostic capacity or as a guide for
intervention. However, it is more recently emerging
that neck pain may be characterized in terms of both
physical impairments and psychological function.
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Much of this research has been conducted in
whiplash-associated disorders, but it can be seen that
idiopathic neck pain also shows characteristic fea-
tures. Neck pain of both traumatic (in this case,
whiplash injury) and idiopathic origin demonstrate
deficits in motor function, including range of move-
Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ment loss and altered muscle recruitment patterns of
both the cervical spine and shoulder girdle.3,4,6,13
Kinesthetic deficits manifested by increased joint
repositioning errors are also present in both neck
pain groups,10 with patients who report dizziness as a
symptom showing greater loss of kinesthetic aware-
ness.19 Sensory disturbances, including mechanical
and thermal hyperalgesia, allodynia, and heightened
Journal of Orthopaedic & Sports Physical Therapy®
flexor withdrawal responses, have also been found in
whiplash-injured individuals and likely indicate the
augmentation of central pain processing mecha-
nisms.2,12,15,18 Interestingly, preliminary evidence sug-
gests that this sensory hypersensitivity may not be a
feature of idiopathic neck pain,14 but, rather, that it
may be unique to whiplash-associated disorders.
Whilst the research is less extensive than that of low
back pain, psychosocial and psychological factors also
play a role in neck pain.1,11 There is no doubt that
patients with neck pain are psychologically dis-
tressed;11 but, again, it may be useful to differentiate
whiplash injury from idiopathic neck pain, as the
former condition shows a unique psychological reac-
tion in the form of a posttraumatic stress reaction
that has been shown to influence recovery from the
injury.17 Therefore, it can be seen that neck pain is a
multifaceted condition involving varying degrees of
motor and sensory impairments, as well as psychologi
J Orthop Sports Phys Ther • Volume 34 • Number 11 • November 2004
cal factors that will need to be considered in the
assessment and management of these patients.
Classification systems can be devised using a variety
of criteria,21 and the authors of this paper propose a
classification system based primarily on treatment
goals. This is potentially useful for clinicians manag-
ing patients with neck pain. The classification catego-
ries are seemingly based on clinical examination
findings and then interventions proposed to achieve
the particular goal of treatment. The authors ac-
knowledge that each category is homogenous with
respect to the treatment approach that will be of
most benefit to the patient. In broad terms, this may
be the case, but it is possible that there will be
overlap in the treatment approach applied to each
category. For example, whilst the goal of treatment in
the ‘‘mobility’’ group is argued as improving mobility,
this is unlikely to be the only goal of treatment.
Patients with idiopathic neck pain who would be
categorized in the mobility group may also show
deficits in muscle recruitment strategies6,7 and, per-
haps, kinesthetic dysfunction,10 both likely requiring
specific rehabilitation. It has been shown that pain
reduction and movement restoration by themselves
are not sufficient to address the neuromuscular
control deficits in patients with neck pain,9,16 as these
deficits require specific rehabilitation techniques.9
Persistence of motor deficits may render the patient
at risk of developing symptom recurrence. Therefore,
addressing only the lack of mobility in this patient
category may not be the most efficacious approach to
treatment. A similar scenario could be argued for the
other categories. Nevertheless, the classification sys-
tem proposed by Childs and colleagues is a good
starting point to facilitate the concept of considering CLINICAL
neck pain as a heterogeneous condition. It may be
possible to improve the proposed classification by
taking into consideration and including additional
physical (eg, altered muscle recruitment patterns,
kinesthetic deficits, sensory disturbances) and psycho-
logical factors (eg, psychological distress and, in the
COMMENTARY
case of whiplash injury, posttraumatic stress reaction)
shown to be features of neck pain.5,10,15,17
The authors are to be applauded for the inclusion
of a ‘‘pain control’’ category that they suggest will
likely include patients with whiplash injury. This is an
astute clinical observation that is supported by recent
research. Research of whiplash-associated disorders is
demonstrating that a subgroup of those experiencing
a whiplash injury will develop, from soon after injury,
widespread sensory and sympathetic nervous system
697
 disturbances that are indicative of altered central
pain processing mechanisms.15 Whilst Childs and
colleagues suggest that patients in this category may
have symptom onset very soon after injury, it has
been shown that this early sensory hypersensitivity
persists in those who show a poor recovery from the
injury,15 perhaps indicating that not only patients
with acute injuries should be included in this cat-
egory. I also note the authors’ excellent point that
clinicians ‘‘should attempt to keep these patients as
active as tolerated.’’ This is a refreshing change from
the ‘‘act as usual’’ mantra that is often suggested as
management for patients of this sort, and which, in
fact, may exacerbate their condition if such activities
are provocative of pain. It should be noted, however,
that not all patients with whiplash will sit in the ‘‘pain
control’’ category. Most persons with whiplash inju-
ries do not show high levels of pain and disability and
sensory hypersensitivity15 and it is likely these patients
may well be classified into one of the other catego-
ries.
The authors do not specifically include
psychosocial and psychological factors in their classifi-
cation system, except to say that the rehabilitation
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process may need modification should these factors
be identified. The authors draw on the vast expanse
of literature on the influence of psychosocial factors
in low back pain. It is not yet clear whether the same
factors play a similar role in the development of
Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
chronic neck pain. Whilst the literature of
psychosocial factors in cervical spine pain is less
extensive, some studies suggest that the role of
fear-avoidance beliefs, for example, may be less im-
portant than in low back pain.17,20 Perhaps the
temptation to extrapolate from one musculoskeletal
condition to another should be avoided.
The classification system of Childs and colleagues is
a starting point for the classification of neck pain. It
Journal of Orthopaedic & Sports Physical Therapy®
remains to be seen whether or not it will prove to be
useful in terms of improving clinical outcomes for
this patient population. The main difficulty with this
approach is that the interventions proposed for most
of the categories have little evidence of efficacy and,
as outlined previously, there may be some overlap of
treatment goals between the individual categories. It
could be possible to improve the classification system
by the assessment and inclusion of the varied physical
and psychological impairments that have been shown
to be features of those with neck pain.5,10,15,17 The
inclusion of such features are in line with calls to
differentiate mechanisms underlying the patient’s
pain condition20 and to then direct treatment toward
these mechanisms. Physical therapists are in a prime
position to lead the way in this approach to the
assessment, classification, and management of neck
pain conditions.
698 J Orthop Sports Phys Ther • Volume 34 • Number 11 • November 2004
Michele Sterling, BPhty, MPhty, Grad Dip Manip
Physio, PhD
Division of Physiotherapy
The University of Queensland
Queensland, Australia
REFERENCES
1. Ariens GA, van Mechelen W, Bongers PM, Bouter LM,
van der Wal G. Psychosocial risk factors for neck pain:
a systematic review. Am J Ind Med. 2001;39:180-193.
2. Banic B, Petersen-Felix S, Andersen OK, et al. Evidence
for spinal cord hypersensitivity in chronic pain after
whiplash injury and in fibromyalgia. Pain. 2004;107:7-
15.
3. Dall’Alba PT, Sterling MM, Treleaven JM, Edwards SL,
Jull GA. Cervical range of motion discriminates be-
tween asymptomatic persons and those with whiplash.
Spine. 2001;26:2090-2094.
4. Dumas JP, Arsenault AB, Boudreau G, et al. Physical
impairments in cervicogenic headache: traumatic vs.
nontraumatic onset. Cephalalgia. 2001;21:884-893.
5. Falla D. Unravelling the complexity of muscle impair-
ment in chronic neck pain. Man Ther. 2004;9:125-133.
6. Falla D, Bilenkij G, Jull G. Patients with chronic neck
pain demonstrate altered patterns of muscle activation
during performance of a functional upper limb task.
Spine. 2004;29:1436-1440.
7. Falla D, Jull G, Hodges P. Neck pain patients demon-
strate reduced EMG activity of the deep cervical flexor
muscles during performance of the cranio-cervical flex-
ion test. Spine. In press.
8. George SZ, Fritz JM, Erhard RE. A comparison of
fear-avoidance beliefs in patients with lumbar spine
pain and cervical spine pain. Spine. 2001;26:2139-
2145.
9. Jull G, Trott P, Potter H, et al. A randomized controlled
trial of exercise and manipulative therapy for
cervicogenic headache. Spine. 2002;27:1835-1843; dis-
cussion 1843.
10. Kristjansson E, Dall’Alba P, Jull G. A study of five
cervicocephalic relocation tests in three different sub-
ject groups. Clin Rehabil. 2003;17:768-774.
11. Luo X, Edwards CL, Richardson W, Hey L. Relationships
of clinical, psychologic, and individual factors with the
functional status of neck pain patients. Value Health.
2004;7:61-69.
12. Moog M, Quintner J, Hall T, Zusman M. The late
whiplash syndrome: a psychophysical study. Eur J Pain.
2002;6:283-294.
13. Nederhand MJ, Hermens HJ, I Jzerman MJ, Turk DC,
Zilvold G. Chronic neck pain disability due to an acute
whiplash injury. Pain. 2003;102:63-71.
14. Scott D, Sterling M, Jull G. Sensory hypersensitivity is a
feature of chronic whiplash associated disorders but not
chronic idiopathic neck pain. Clin J Pain. In press.
15. Sterling M, Jull G, Vicenzino B, Kenardy J. Sensory
hypersensitivity occurs soon after whiplash injury and is
associated with poor recovery. Pain. 2003;104:509-517.
16. Sterling M, Jull G, Vicenzino B, Kenardy J, Darnell R.
Development of motor system dysfunction following
whiplash injury. Pain. 2003;103:65-73.
17. Sterling M, Kenardy J, Jull G, Vicenzino B. The develop-
ment of psychological changes following whiplash in-
jury. Pain. 2003;106:481-489.
 18. Sterling M, Treleaven J, Edwards S, Jull G. Pressure pain
thresholds of upper limb peripheral nerve trunks in
asymptomatic subjects. Physiother Res Int. 2000;5:220-
229.
19. Treleaven J, Jull G, Sterling M. Dizziness and unsteadi-
ness following whiplash injury: characteristic features
and relationship with cervical joint position error. J
Rehabil Med. 2003;35:36-43.
Authors’ Response
We appreciate Dr Sterling’s insightful commentary
on our proposed classification system for patients
with neck pain. We would like to provide additional
comment on a few of the issues she has raised. First,
we agree with Dr Sterling’s suggestion that it may be
useful to differentiate whiplash injury from idiopathic
neck pain altogether, and we readily acknowledge the
existence of the subgroup of patients with whiplash-
associated disorder (WAD) in our paper. However,
given that entire classification systems have been
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previously proposed unique to this subgroup (includ-
ing Dr Sterling’s own work),4,5 we intentionally omit-
ted a detailed discussion of these patients here in
deference to the existing literature. We also agree
with Dr Sterling that patients suspected to have WAD
may include more than just patients with acute
Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
injuries, based on the poor prognosis associated with
patients who have persistent physical and/or psycho-
logical factors known to interfere with recovery.
Secondly, we readily agree with Dr Sterling’s asser-
tion that psychosocial and psychological factors be
considered in any classification system for patients
with neck pain, and we examine the importance of
these considerations for both prognostic and treat-
Journal of Orthopaedic & Sports Physical Therapy®
ment purposes in our paper. However, we elected not
to more specifically elaborate on detailed screening
and management strategies, because the effectiveness
of biopsychosocial interventions for patients with
neck pain has not been sufficiently studied (com-
pared to the proliferation of evidence supporting the
use of these interventions in patients with low back
pain). Furthermore, evidence in patients with low
back pain suggests that individuals who present with
relevant psychosocial issues may not need to be
considered a unique classification. Rather, these is-
sues can be addressed within the context of an
existing classification system,1 using rehabilitation
strategies that emphasize active rehabilitation, positive
reinforcement of functional accomplishments, graded
exercise programs, gradual exposure to specific activi-
ties that a patient fears, etc.2,3,6
Dr Sterling correctly recognizes the potential for
some overlap to occur in the treatment approach that
J Orthop Sports Phys Ther • Volume 34 • Number 11 • November 2004
20. Woolf CJ, Bennett GJ, Doherty M, et al. Towards a
mechanism-based classification of pain? Pain.
1998;77:227-229.
21. Zimny NJ. Diagnostic classification and orthopaedic
physical therapy practice: what we can learn from
medicine. J Orthop Sports Phys Ther. 2004;34:105-109;
discussion 110-105.
is used for patients in each category. In fact, patients
are expected to shift from one classification to
another, because of underlying changes in the pa-
tient’s clinical presentation over time, which necessi-
tates accompanying changes in management strategy.
Dr Sterling gives the example of patients initially
categorized in the ‘‘mobility’’ group as being ex-
pected to have other impairments, such as alterations
in muscle recruitment strategies, which indeed re-
quires attention during rehabilitation. Nevertheless,
we contend that each patient will have a primary goal
of treatment at a given point during an episode of
care, attesting to the importance of ongoing assess-
ment throughout the episode of care. Clearly, the
goal for most patients with neck pain is to arrive at
the conditioning and increased exercise tolerance
classification, where muscle recruitment consider-
ations and strength and endurance issues can be
examined in more detail. Interventions, such as
aerobic conditioning and strengthening and endur-
ance exercises, can then be matched to these impair-
ments to optimize muscle function and overall
functional recovery.
Finally, Dr Sterling suggests that one difficulty with
this approach is that some of the suggested interven-
CLINICAL
tions within each category lack evidence for their use.
Although we generally agree with this assertion,
attempts to identify subgroups of patients will result
in more homogeneous subsets of patients with neck
pain, increasing the power of clinical research to
identify effective interventions for patients with neck
pain. Ultimately, these efforts should improve deci-
COMMENTARY
sion making for clinicians in matching patients to
specific interventions from which they are likely to
receive the most benefit. We thank Dr Sterling for
her valuable insight and look forward to future
research that will more specifically develop and refine
the framework proposed here.
Maj John D. Childs, PT, PhD, MBA, OCS, FAAOMPT
Senior Physical Therapist and Director of Research
Department of Physical Therapy, Wilford Hall
Medical Center
699
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of a fear-avoidance-based physical therapy intervention
for patients with acute low back pain: results of a
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2. Linton SJ, Andersson T. Can chronic disability be
prevented? A randomized trial of a cognitive-behavior
intervention and two forms of information for patients
with spinal pain. Spine. 2000;25:2825-2831; discussion
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setting. Pain. 2000;88:145-153.
4. Spitzer WO, Skovron ML, Salmi LR, et al. Scientific
monograph of the Quebec Task Force on Whiplash-
Associated Disorders: redefining ‘‘whiplash’’ and its
management. Spine. 1995;20:1S-73S.
5. Sterling M. A proposed new classification system for
whiplash associated disorders—implications for assess-
ment and management. Man Ther. 2004;9:60-70.
6. Vlaeyen JW, de Jong J, Geilen M, Heuts PH, van
Breukelen G. Graded exposure in vivo in the treatment
of pain-related fear: a replicated single-case experimen-
tal design in four patients with chronic low back pain.
Behav Res Ther. 2001;39:151-166.
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Copyright © 2004 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®

700 J Orthop Sports Phys Ther • Volume 34 • Number 11 • November 2004