Treatment‐based classification approach to neck pain

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Definition/Description

After ruling out red flags, a pathoanatomical diagnosis does not lead the physical therapist to a particular treatment intervention when managing patients with neck pain.  This classification system is designed to assist the clinician with matching an initial treatment intervention strategy to a patient’s presentation. This classification system was originally published in the Journal of Orthopaedic Sports Physical Therapy in 2004 and updated in 2009 as part of the APTA Orthopedic section ICF Guidelines.  The four current classification categories include: neck pain with mobility deficits, neck pain with radiating pain, neck pain with movement coordination impairments, and neck pain with headache.  Neck pain arising from whiplash trauma is not comprehensively covered in the current classification system and is better described separately: Whiplash Disorders .   

Clinically Relevant Anatomy

Beyond identifying serious pathology such as fractures, diagnostic imaging is not often useful in identifying the tissue source of the patient’s neck pain.  Many imaging findings such as spondylosis and herniated discs are found commonly in individuals without pain.¹ Therefore, the cervical classification is based on the patient’s presenting signs, symptoms, and impairments rather than pathoanatomical sources of pain. 

Epidemiology /Etiology

 54% of individuals have experienced neck pain within the last 6 months.¹ 50% have symptoms that persist for greater than 12 months.² Neck pain increases with age and is most common in women in their fifties.¹   Neck pain is the second most common reported workman’s compensation injury second to low back pain and account for approximately 25% of people receiving outpatient physical therapy.¹ Proposed causes of neck pain include: degenerative changes, disc protrusion, nerve impingement, osteophytosis, spondylosis and impaired function of muscle, connective tissue and nervous tissue.¹

Characteristics/Clinical Presentation

Neck Pain with Mobility Deficits³
1. Younger age (< 50 years)
2. Acute Neck Pain (< 12 weeks)
3. Restricted Cervical ROM
4. Segmental hypomobility of the cervical and thoracic spine.
5. Symptoms Isolated to the Neck -referred pain may be present

Neck Pain with Radiating Pain³
1. Neck pain with radiating (narrow band of lancinating) pain in involved upper extremity
2. Upper extremity paresthesias, numbness, and, weakness may be present
3. May have imaging findings of spondylosis (with foraminal narrowing) or disc herniation

Wainner et al. Spine 2004 Test Item Cluster
1. Ipsilateral cervical rotation <60deg
2. + Upper Limb Tension Test
3. + Cervical Distraction Test
4. + Spurling’s Test

Neck Pain with Headache³
3 Main types of headaches:⁵
Migraine
Tension
Cervicogenic

Physical therapy is thought to be most effective for cervicogenic headaches and the typical signs and symptoms associated with it are listed below.
1. Unilateral headache associated with neck/occipital area symptoms that are aggravated by neck movements or positions
2. Headache produced or aggravated with provocation of the ipsilateral posterior
cervical myofascial and joints

3.  Restricted cervical range of motion
4.  Restricted cervical segmental mobility of the upper cervical spine C0-C2.
5.  Positive cervical rotation/flexion test for C1-2 mobility.
6.  Impaired control of the deep neck flexors as found during the cranial cervical flexion test.

Neck Pain with Movement Coordination Impairments³
1. Longstanding neck pain (greater than 12 weeks)
2. Abnormal/Standard performance on the cranial cervical flexion test and deep flexor endurance test   
3. Coordination Strength and endurance deficits of neck and upper quarter muscles
4. Flexibility deficits of upper quarter muscles
5. Ergonomic insufficiencies with performing repetitive activities

 

Differential Diagnosis

Neck Pain Triage:
I: Serious pathology: Fracture, Instability, CAD, Myelopathy, Cancer, Infection, and Visceral Disorders.
II: Cervical Nerve Root Disorder
III: Mechanical Neck Pain (acute or chronic)

Personal and Environmental Factors:
Factors which are associated with and would perpetuate a patient’s neck pain should also be considered including:
Psychosocial factors such as fear avoidance beliefs, depression, anxiety, and catastrophizing.
Environmental factors such as ergonomic considerations, occupation, and recreational activities.

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Physical Therapy Management

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