Treatment‐based classification approach to neck pain: Difference between revisions
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== | == Introduction == | ||
Classification provides a general framework for identifying subgroups of patients based on the primary goal of treatment, with the ultimate aim of matching indivuals to specific interventions from which they are most likely to benefit<ref name=":0">Childs MJ, Fritz JM, Piva SR, Whitman JM. [http://www.jospt.org/doi/pdf/10.2519/jospt.2004.34.11.686 Proposal of a classification system for patients with neck pain.] Journal of Orthopaedic & Sports Physical Therapy. 2004 Nov;34(11):686-700.</ref>. | |||
Classification of individuals with neck pain was first proposed by Wells et al in 2001<ref>Wells GA, Tugwell P, Brosseau L, et al. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions: overvi</ref>, their system used symptom 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. The treatment based classification for individuals with neck pain was proposed in 2004 by Childs et al<ref name=":0" />, the system was 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. It was updated in 2009 as part of the APTA Orthopedic section ICF Guidelines with the four current classification categories including: 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: [http://www.physio-pedia.com/index.php5?title=Whiplash_Associated_Disorders Whiplash Disorders]. | |||
It is recognised that additional decision making is necessary within each classification to more specifically guide the application of the selected intervention. However, the first step in the use of a classification system is to direct initial interventions toward the optimal treatment for the individuals presentation. | |||
== Epidemiology/Etiology == | |||
== | 54% of individuals have experienced neck pain within the last 6 months<ref name="Cote">Cote P, Cassidy JD, Carroll LJ, Krisman V.[http://www.ncbi.nlm.nih.gov/pubmed/15561381 The Annual Incidence and Course of Neck Pain in the General Population: A Population-Based Cohort Study].Pain.2004;112: 267-273</ref> 50% have symptoms that persist for greater than 12 months<ref name="Hill">Hill J, Lewis M, Papageorgiou AC, Dziedzic K, Coft P.[http://www.ncbi.nlm.nih.gov/pubmed/15284511 Predicting Persistent Neck Pain a One Year Follow-Up of Population Cohort]. Spine.2004;29(15): 1648-1654</ref> Neck pain increases with age and is most common in women in their fifties<ref name="Cote" /> 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<ref name="Cote" /> | ||
Proposed causes of neck pain include: [[Cervical Spondylosis|degenerative changes]], disc protrusion, [[Cervical Radiculopathy|nerve impingement]] and impaired function of muscle, connective tissue and nervous tissue<ref name="Cote" />. | |||
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<ref name="Cote" /> Therefore, the cervical classification is based on the patient’s presenting signs, symptoms, and impairments rather than pathoanatomical sources of pain. | |||
== Clinical Presentations == | == Clinical Presentations == | ||
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. | |||
<u>'''Neck Pain with Mobility Deficits<ref name="Childs">Childs J, Cleland J, Elliott J, Deydre T, Wainner R, Whitman J, et al. [http://www.ncbi.nlm.nih.gov/pubmed/18758050 Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association]. J Orthop Sports Phys Ther. 2008;38(9):A1-A34</ref>'''</u> | <u>'''Neck Pain with Mobility Deficits<ref name="Childs">Childs J, Cleland J, Elliott J, Deydre T, Wainner R, Whitman J, et al. [http://www.ncbi.nlm.nih.gov/pubmed/18758050 Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association]. J Orthop Sports Phys Ther. 2008;38(9):A1-A34</ref>'''</u> | ||
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# Ergonomic insufficiencies with performing repetitive activities | # Ergonomic insufficiencies with performing repetitive activities | ||
== | == Examination == | ||
Initially individuals with neck pain should be properly screened for potentially [[Serious Cervical Spine Conditions|serious pathology]] such as fracture, instability, CAD, myelopathy, cancer, infection, and visceral disorders. | |||
Factors which are associated with [[The Flag System|Personal and Environmental Factors]] and would perpetuate a patient’s neck pain should also be considered including: | |||
* Psychosocial factors such as fear avoidance beliefs, depression, anxiety, and catastrophizing. | * Psychosocial factors such as fear avoidance beliefs, depression, anxiety, and catastrophizing. | ||
* Environmental factors such as ergonomic considerations, occupation, and recreational activities | * Environmental factors such as ergonomic considerations, occupation, and recreational activities | ||
Once serious pathology has been ruled out and personal and environmental factors have been considered the therapist can continue with the examination that will direct classification. Physical therapists should identify and asterisk sign or something that is reproducible in the clinic that reproduces the patient’s symptoms. It should be associated with activity or participation restrictions and will be a way to measure the patient’s functional progress. What is listed below are the key examination tests that are associated with each treatment based category. | |||
Physical therapists should identify | |||
<u>''' | <u>'''Neck Pain with Mobility Deficits'''</u><sup><ref name="Childs" /></sup> | ||
* Cervical and Thoracic Range of Motion | * Cervical and Thoracic Range of Motion | ||
* Cervical and Thoracic Segmental Mobility | * Cervical and Thoracic Segmental Mobility | ||
Revision as of 10:15, 24 September 2017
Original Editors - Nora Corbett and Jennifer Breithaupt from Temple University's Evidence Based Practice Project
Top Contributors - Nora Corbett, Admin, Rachael Lowe, Jennifer Breithaupt, Kim Jackson, Evan Thomas, Shaimaa Eldib, Simisola Ajeyalemi, Scott A Burns, WikiSysop and Jess Bell
Introduction[edit | edit source]
Classification provides a general framework for identifying subgroups of patients based on the primary goal of treatment, with the ultimate aim of matching indivuals to specific interventions from which they are most likely to benefit[1].
Classification of individuals with neck pain was first proposed by Wells et al in 2001[2], their system used symptom 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. The treatment based classification for individuals with neck pain was proposed in 2004 by Childs et al[1], the system was 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. It was updated in 2009 as part of the APTA Orthopedic section ICF Guidelines with the four current classification categories including: 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.
It is recognised that additional decision making is necessary within each classification to more specifically guide the application of the selected intervention. However, the first step in the use of a classification system is to direct initial interventions toward the optimal treatment for the individuals presentation.
Epidemiology/Etiology[edit | edit source]
54% of individuals have experienced neck pain within the last 6 months[3] 50% have symptoms that persist for greater than 12 months[4] Neck pain increases with age and is most common in women in their fifties[3] 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[3]
Proposed causes of neck pain include: degenerative changes, disc protrusion, nerve impingement and impaired function of muscle, connective tissue and nervous tissue[3].
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[3] Therefore, the cervical classification is based on the patient’s presenting signs, symptoms, and impairments rather than pathoanatomical sources of pain.
Clinical Presentations[edit | edit source]
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.
Neck Pain with Mobility Deficits[5]
- Younger age (< 50 years)
- Acute Neck Pain (< 12 weeks)
- Restricted Cervical ROM
- Segmental hypomobility of the cervical and thoracic spine.
- Symptoms Isolated to the Neck -referred pain may be present
Neck Pain with Radiating Pain[5]
- Neck pain with radiating (narrow band of lancinating) pain in involved upper extremity
- Upper extremity paresthesias, numbness, and, weakness may be present
- May have imaging findings of spondylosis (with foraminal narrowing) or disc herniation
- CPR for Cervical Radiculpopathy
Neck Pain with Headache[5]
3 Main types of headaches:[6] Migraine, Tension and Cervicogenic. Physical therapy is thought to be most effective for cervicogenic headaches and the typical signs and symptoms associated with it are listed below.
- Unilateral headache associated with neck/occipital area symptoms that are aggravated by neck movements or positions.
- Headache produced or aggravated with provocation of the ipsilateral posterior cervical myofascial and joints.
- Restricted cervical range of motion.
- Restricted cervical segmental mobility of the upper cervical spine C0-C2.
- Positive cervical rotation/flexion test for C1-2 mobility.
- Impaired control of the deep neck flexors as found during the cranial cervical flexion test.
Neck Pain with Movement Coordination Impairments[5]
- Longstanding neck pain (greater than 12 weeks)
- Abnormal/Standard performance on the cranial cervical flexion test and deep flexor endurance test
- Coordination Strength and endurance deficits of neck and upper quarter muscles
- Flexibility deficits of upper quarter muscles
- Ergonomic insufficiencies with performing repetitive activities
Examination[edit | edit source]
Initially individuals with neck pain should be properly screened for potentially serious pathology such as fracture, instability, CAD, myelopathy, cancer, infection, and visceral disorders.
Factors which are associated with Personal and Environmental Factors 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
Once serious pathology has been ruled out and personal and environmental factors have been considered the therapist can continue with the examination that will direct classification. Physical therapists should identify and asterisk sign or something that is reproducible in the clinic that reproduces the patient’s symptoms. It should be associated with activity or participation restrictions and will be a way to measure the patient’s functional progress. What is listed below are the key examination tests that are associated with each treatment based category.
Neck Pain with Mobility Deficits[5]
- Cervical and Thoracic Range of Motion
- Cervical and Thoracic Segmental Mobility
Neck Pain with Radiating Pain[5]
- Upper Limb Tension Test (ULTT)
- Spurling’s Test
- Distraction
- Valsalva
- Neurological signs: weakness, sensory loss, reflex changes
Neck Pain with Headache[5]
- Cervical active range of motion
- Cervical segmental mobility
- Cervical flexion rotation test
- Cranial cervical flexion test
Neck Pain with Movement Coordination Impairments
- Cranial cervical flexion test
- Deep neck flexor endurance
- Scapular muscle strength and coordination
- Upper quarter muscle length
Physical Therapy Management[5][edit | edit source]
Fritz et al found that patients receiving interventions matched to their treatment category experienced better outcomes compared to patients receiving unmatched interventions[7].
ICF Guidelines-Childs et al[5]
Neck Pain with Mobility Deficits[5]
Cervical and Thoracic Manipulation combined with exercise
- Evidence: RCT by Walker et al published in 2008[8] - Manual therapy and exercise superior to minimal intervention.
- Evidence:Leaver et al. 2010 - Cervical thrust manipulation and non-thrust manipulation are equally effective with no difference between the two.
- Evidence: 2010 Cleland et al[9] - Thoracic Spine Manipulation and exercise more effective compared to exercise alone.
- Evidence: Cochrane Collaboration Review by Gross et al[10] published in 2004 - High quality evidence for manual therapy combined with exercise.
Neck Pain with Radiating Pain[5] (ICF Guidelines[5], Cleland et al JOSPT Dec 2005[11])
- Cervical and thoracic spine manipulation
- Cervical Lateral Glide non thrust manipulation
- Strengthening Exercises including deep neck flexors and scapular muscles
- Nerve mobilization procedures
- Intermittent Cervical Traction
- Evidence: Young et al 2009[12] - Suggestion that traction + manual therapy and exercise does not improve short-term outcomes in patients with radiating neck pain compared to manual therapy and exercise alone.
- Evidence: Raney et al.
Neck Pain with Headache[13]
- Cervical manipulation
- Thoracic manipulation
- Stretching exercises
- Coordination, strengthening, and endurance exercises
Neck Pain with Movement Coordination Impairments[5]
- Coordination, strengthening and endurance exercises. Effective exercise methods: proprioceptive exercises and dynamic resisted strengthening of neck and shoulder muscles[14]
- Patient education and counseling
- Stretching exercises
Resources[edit | edit source]
Manual Therapy and Exercise for Neck Pain: Clinical Treatment Tool-kit
Should I receive manual therapy and exercise for my neck pain?: A patient decision aid
References[edit | edit source]
- ↑ 1.0 1.1 Childs MJ, Fritz JM, Piva SR, Whitman JM. Proposal of a classification system for patients with neck pain. Journal of Orthopaedic & Sports Physical Therapy. 2004 Nov;34(11):686-700.
- ↑ Wells GA, Tugwell P, Brosseau L, et al. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions: overvi
- ↑ 3.0 3.1 3.2 3.3 3.4 Cote P, Cassidy JD, Carroll LJ, Krisman V.The Annual Incidence and Course of Neck Pain in the General Population: A Population-Based Cohort Study.Pain.2004;112: 267-273
- ↑ Hill J, Lewis M, Papageorgiou AC, Dziedzic K, Coft P.Predicting Persistent Neck Pain a One Year Follow-Up of Population Cohort. Spine.2004;29(15): 1648-1654
- ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 Childs J, Cleland J, Elliott J, Deydre T, Wainner R, Whitman J, et al. Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38(9):A1-A34
- ↑ Jull G.Management of Cervical Headache. Manual Therapy. 1997;2(4):182-190
- ↑ Fritz JM, Brennan GP. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther. 2007;87(5):513-24
- ↑ Walker M, Boyles R, Young B, Strunce J, Garber M, Whitman J, Deyle G, Wainner R. The Effectiveness of Manual Physical Therapy and Exercise for Mechanical Neck Pain. SPINE. 2008;33(22):2371-2378
- ↑ Cleland J, Mintken P, Carpenter K, Fritz J, Glynn P, Whitman J, Childs J. Examination of a Clinical Prediction Rule to Identify Patients With Neck Pain Likely to Benefit From Thoracic Spine Thrust Manipulation and a General Cervical Range of Motion Exercise: Multi-Center Randomized Clinical Trial. Phys Ther. 2010;90(9):1239-1250
- ↑ Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G. Cervical overview group. Manipulation and mobilisation for mechanical neck disorders. Cochrane Database Syst Rev. 2004;(1):CD004249
- ↑ Cleland J, Whitman J, Fritz J, Palmer J. Manual Physical Therapy, Cervical Traction, and Strengthening Exercises in Patients With Cervical Radiculopathy: A Case Series. J Orthop Sports Phys Ther. 2005;35(12):802-811
- ↑ Young I, Michener L, Cleland J, Aguilera A, Snyder A. Manual Therapy, Exercise and Traction for Patients With Cervical Radiculopathy: A Randomized Clinical Trial. Phys Ther. 2009;89(7):1-11
- ↑ 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
- ↑ Sarig-Bahat H. Evidence for Exercise Therapy in Mechanical Neck Disorders. Manual Therapy. 2003;(1):10-20
