Neck Pain Best Practice: Treatment-Based Classification

The following is another article written for the online, video-based physical therapy continuing education company MedBridge Education

Among one of the most common musculoskeletal complaints, neck pain has been estimated to effect between 22% and 77% of individuals in their lifetime according to the Neck Pain Clinical Practice Guidelines published by Childs et al. While this pain is typically self-limiting and resolves with time, Bovim et al found that 30% of patients reporting neck pain will ultimately develop chronic symptoms of greater than 6 months in duration. In addition to this study, researchers also found that between 37% (Cote et al) and 44% (Hurwitz et al) of those who experience neck pain will report lingering symptoms for at least 12 months. Unfortunately, even after successful treatment, there has been a reported recurrence rate of 50-85% within the first 1-5 years following resolution of symptoms (Halderman et al). Neck pain is multi-factorial in nature with patients reporting varying symptoms depending on pathology, psychosocial influences/fear-avoidance, and age. Because of the varying clinical presentations of this particular group of patients, an individualized treatment plan developed based on their specific impairments/symptoms should be implemented.

The primary goal of classification is to determine the treatment approach most likely to yield the best clinical outcome for an individual patient and secondarily to determine the patient’s appropriateness for physical therapy. Taking after the treatment-based classification system proposed by Delitto et al for low back pain, Childs et al developed a similar system for disorders of the cervical spine. The first step in this classification scheme is determining the patient’s appropriateness for physical therapy. In general, this stage encompasses screening for ‘red flags’ (cervical myelopathy, cancer, ligamentous instability, fracture, and vascular compromise) as well as non-musculoskeletal causes of neck pain (i.e. cardiac event). This preliminary stage of the process is integral in ruling out significant pathology that needs further radiological imaging and/or surgical intervention prior to beginning a course of physical therapy. During this stage, two specific clinical prediction rules (CPR) can be utilized in order to improve your ability to make the best clinical judgment in this important preliminary stage in the examination process (Cervical Myelopathy and Fracture). After successfully clearing your patient from the presence of serious pathology, the patient’s psychosocial profile should be screened for the presence of any ‘yellow flags’ that may alter your treatment approach (catastrophizing, high fear-avoidance beliefs, ect.). These patients may benefit from a graded exercise, graduated exposure, and/or a pain science education approach in conjunction with the treatment-based classification system groupings.

The final stage of this classification scheme involves determining the correct treatment category for the patient based on their clinical presentation. The classification system for neck pain can be broken into 5 distinct categories (Mobility, Centralization, Exercise & Conditioning, Pain Control, and Headache). The Mobility group receives cervical and/or thoracic manipulative and mobilization interventions in conjunction with cervical exercises (active range of motion, deep cervical flexors, ect.). Identifying these patients can be improved by implementing the CPR for cervical manipulation and the CPR for thoracic manipulation in addition to your clinical expertise and the criteria proposed by Childs et al. Those in the centralization group should receive interventions to create centralization of their symptoms either through the use of their specific directional preference via repeated movements or through the use of manual/mechanical cervical traction. Furthermore, the identification of individuals who will specifically benefit from cervical traction can be aided through the use of the CPR developed by Raney et al. Patients who will benefit from general conditioning and exercise typically display lower pain/disability scores and have a longer duration of symptoms and benefit from targeted strengthening and endurance interventions to improve muscular imbalances and/or deficits. The pain control grouping consists of non-aggravating manual techniques, therapeutic modalities, and activity modification. However, the patient should be progressed to a more active classification category as soon as tolerated. Finally, the headache group is treated with manual therapy techniques directed at the cervical and thoracic spine (manipulation, sub-occipital release, ect.) in addition to upper extremity strengthening. As stated in Chad Cook, PT, PhD, MBA, FAAOMPT’s course, “Manual Therapy for the Cervical Spine: An Evidence-Based Approach”, the process of classification is ongoing, and it is assumed that a patient’s presentation will change with time and treatment. Due to this continual change in presentation, ongoing reassessment is required in order to determine the most appropriate sub-group and subsequent intervention at any point in time during the patient’s course of treatment.

While this is a relatively new classification system, there is some evidence available supporting its effectiveness. In 2007, Fritz et al performed a preliminary investigation into the utility of this particular treatment approach. Baseline patient characteristics and evaluations were performed on 274 patients and subjects were split into two groups (those matched to their classification group and those unmatched). Overall, 113 patients received matched interventions and 161 patients received unmatched interventions. Patients receiving matched interventions showed greater changes in both Neck Disability Index (NDI) scores and pain rating scores compared to their unmatched counterparts. Additionally, 72.5% of patients in the matched group achieved the minimal detectible change in NDI, whereas those in the unmatched group only achieved this feat in 53.8% of patients. Along with this outcome data, the authors found a kappa value of 0.95 for classification determination and 0.96 for the treatment matching decision, both of which are in very strong agreement. In conjunction with this randomized controlled trial, Heintz and Hegedus published a case report of a patient presenting with mechanical neck pain who was successfully treated with the aforementioned treatment-based classification system. Over this patient’s 6-week treatment (38 days), pain was reduced from 4-10/10 to 0/10 with only a complaint of stiffness at end-range and their NDI score decreased from 52% (severe disability) to 6% (no disability). Obviously, this is only one patient, but it does add evidence to the effectiveness of this particular treatment approach. While the research regarding this treatment approach is in its infancy, the current evidence available provides preliminary support to its effectiveness in treating patients presenting with mechanical neck pain.


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