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 50% have symptoms that persist for greater than 12 months Neck pain increases with age and is most common in women in their fifties 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 Proposed causes of neck pain include: degenerative changes, disc protrusion, nerve impingement, osteophytosis, spondylosis and impaired function of muscle, connective tissue and nervous tissue
Characteristics/Clinical Presentation
Neck Pain with Mobility Deficits
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
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 Main types of headaches:[4]
1. Migraine
2. Tension
3. 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
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
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
Examination
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
-Distraction
-Valsalva
-Neurological signs: weakness, sensory loss, reflex changes
Neck Pain with Headache
- 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
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
• 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
Neck Pain with Mobility Deficits
Cervical and Thoracic Manipulation combined with exercise
• Evidence: RCT by Walker et al published in 2008 - 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 - Thoracic Spine Manipulation and exercise more effective compared to exercise alone.
• Evidence: Cochrane Collaboration Review by Gross et al published in 2004 - High quality evidence for manual therapy combined with exercise.
Neck Pain with Radiating Pain (ICF Guidelines, Cleland et al JOSPT Dec 2005)
• 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 - 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
• Cervical manipulation
• Thoracic manipulation
• Stretching exercises
• Coordination, strengthening, and endurance exercises
Neck Pain with Movement Coordination Impairments
• Coordination, strengthening and endurance exercises
• Effective exercise methods: proprioceptive exercises and dynamic resisted strengthening of neck and shoulder muscles
• Patient education and counseling
• Stretching exercises