Treatment‐based classification approach to neck pain

Original Editors - Nora Corbett and Jennifer Breithaupt from Temple University's Evidence Based Practice Project

Top Contributors - Nora Corbett, Admin, Jennifer Breithaupt, Rachael Lowe, Kim Jackson, Evan Thomas, Shaimaa Eldib, Scott A Burns, Simisola Ajeyalemi, WikiSysop and Jess Bell

Introduction[edit | edit source]

Classification of individuals with neck pain was first proposed by Wells et al in 2001[1], 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[2], 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 2008 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 (radicular), neck pain with movement coordination impairments (WAD), and neck pain with headache (cervicogenic). 

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. 

Classification[edit | edit source]

This classification system is designed to assist the clinician with matching an initial treatment intervention strategy to an individuals presentation.

Is the individual appropriate for treatment[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.

Is the individual ready for treatment?[edit | edit source]

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

Differential Diagnosis[edit | edit source]

Once serious pathology has been ruled out and personal and environmental factors considered and the individual considered as suitable for intervention, the therapist can continue with the examination that will direct classification.

Neck Pain Revision Decision Tree 2017.png

Neck Pain with Mobility Deficits[5]

  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 Pain[5]

  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
  4. 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.

  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 Impairments[5]

  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

Neck Pain with Mobility Deficits[5]

  • Cervical and Thoracic Range of Motion
  • Cervical and Thoracic Segmental Mobility

Neck Pain with Radiating Pain[5]

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].

Fritz et al. 2007 TBC for Neck Pain



ICF Guidelines-Childs et al[5]

Image:ICF_TBC_Neck_Pain.jpg

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. ↑ 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.
  2. ↑ 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.
  3. ↑ 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
  4. ↑ 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. ↑ 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
  6. ↑ Jull G.Management of Cervical Headache. Manual Therapy. 1997;2(4):182-190
  7. ↑ 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
  8. ↑ 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
  9. ↑ 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
  10. ↑ 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
  11. ↑ 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
  12. ↑ 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
  13. ↑ 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
  14. ↑ Sarig-Bahat H. Evidence for Exercise Therapy in Mechanical Neck Disorders. Manual Therapy. 2003;(1):10-20


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