Treatment‐based classification approach to neck pain


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 Deficits[3]
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[3]
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 Headache[3]
3 Main types of headaches:[4]

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[3]

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.

Outcome Measures

McGill Pain Questionnaire 

Neck Pain and Disability Index

Patient Specific Functional Scale


Physical therapists should identify an 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
-Cervical and Thoracic Range of Motion
-Cervical and Thoracic Segmental Mobility

Neck Pain with Radiating Pain
-Upper Limb Tension Test (ULTT)
-Spurling’s Test
-Neurological signs: weakness, sensory loss, reflex changes

Neck Pain with Headache[3]
- 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[3]

Evidence: Preliminary Validation of a Proposed Classification System

  • Fritz et al examined the originally proposed treatment-based classification system for patients receiving PT interventions for neck pain[5]
    • The researchers found that patients receiving interventions matched to their treatment category experienced better outcomes compared to patients receiving unmatched interventions.
    • More research to assess the effectiveness of the cervical classification system is needed
Fritz et al. 2007 TBC for Neck Pain

ICF Guidelines-Childs et al[3]


Neck Pain with Mobility Deficits[3]

Cervical and Thoracic Manipulation combined with exercise

  • Evidence: RCT by Walker et al published in 2008[6] - 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[7] - Thoracic Spine Manipulation and exercise more effective compared to exercise alone.
  • Evidence: Cochrane Collaboration Review by Gross et al[8] published in 2004 - High quality evidence for manual therapy combined with exercise.

Neck Pain with Radiating Pain[3] (ICF Guidelines[3], Cleland et al JOSPT Dec 2005[9])

  • 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[10] - 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[11]

  • Cervical manipulation
  • Thoracic manipulation
  • Stretching exercises
  • Coordination, strengthening, and endurance exercises

Neck Pain with Movement Coordination Impairments[3]

  • Coordination, strengthening and endurance exercises
    • Effective exercise methods: proprioceptive exercises and dynamic resisted strengthening of neck and shoulder muscles[12]
  • Patient education and counseling
  • Stretching exercises

Key Research

Heintz MM, Hegedus EJ. Multimodal management of mechanical neck pain using a treatment based classification system. J Man Manip Ther. 2008;16(4):217-24. (FREE full text article)

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 May;87(5):513-24. Epub 2007 Mar 20. (FREE full text article)


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

Recent Related Research (from Pubmed)


  1. 1.0 1.1 1.2 1.3 1.4 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
  2. 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
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 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
  4. Jull G.Management of Cervical Headache. Manual Therapy. 1997;2(4):182-190
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  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
  12. Sarig-Bahat H. Evidence for Exercise Therapy in Mechanical Neck Disorders. Manual Therapy. 2003;(1):10-20