Neck Solutions

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

From: J Orthop Sports Phys Ther 2008;38(9):A1-A34

Although the natural history of neck pain appears to be favorable, rates of recurrence and chronicity are high. One study reported that 30% of patients with neck pain will develop chronic symptoms, with neck pain of greater than 6 months duration affecting 14% of all individuals who experience an episode of neck pain. Additionally, a recent survey demonstrated that 37% of individuals who experience neck pain will report persistent problems for at least 12 months. Five percent of the adult population with neck pain will be disabled by the pain, representing a serious health concern. In a survey of workers with injuries to the neck and upper extremity, it was reported that 42% missed more than 1 week of work and 26% experienced recurrence within 1 year. The economic burden due to disorders of the neck is high, and includes costs of treatment, lost wages, and compensation expenditures. Neck pain is second only to low back pain in annual workers’ compensation costs in the United States. In Sweden, neck and shoulder problems account for 18% of all disability payments. It is reported that patients with neck pain make up approximately 25% of patients receiving outpatient physical therapy. Additionally, patients with neck pain frequently are treated without surgery by primary care and physical therapy providers.

A variety of causes of neck pain have been described and include osteoarthritis, discogenic disorders, trauma, tumors, infection, myofascial pain syndrome, torticollis, and whiplash. Unfortunately, clearly defined diagnostic criteria have not been established for many of these entities. Similar to low back pain, a pathoanatomical cause is not identifiable in the majority of patients who present with complaints of neck pain and neck related symptoms of the upper quarter. Therefore, once serious medical pathology (such as cervical fracture or myelopathy) has been ruled out, patients with neck pain are often classified as having either a nerve root compromise or a “mechanical neck disorder”.

In some conditions, particularly those that are degenerative in nature or involve abnormalities of the vertebral motion segment, abnormal findings are not always associated with symptoms. Fourteen to 18% of people without neck pain demonstrate a wide range of abnormalities with imaging studies, including disc protrusion or extrusion and impingement of the thecal sac on the nerve root and spinal cord. However, degenerative changes are still suggested to be a possible cause of mechanical neck pain in some cases, despite the fact that these changes are present in asymptomatic individuals, are non-specific, and are highly prevalent in the elderly. Disorders such as cervical radiculopathy and cervical compressive myelopathy are reported to be caused by space-occupying lesions (osteophytosis or herniated cervical disc). These may be secondary to degenerative processes and can give rise to neck and/or upper quarter pain as well as neurologic signs and symptoms. While cervical disc herniation and spondylosis are most commonly linked to cervical radiculopathy and myelopathy, the bony and ligamentous tissues affected by these conditions are themselves pain generators and are capable of giving rise to some of the referred symptoms observed in patients with these disorders

Because most patients with neck pain usually lack an identifiable pathoanatomic cause for their problem, the majority are classified as having mechanical neck disorders.

Although the cause of neck pain may be associated with degenerative processes or pathology identified during diagnostic imaging, the tissue that is causing a patient’s neck pain is most often unknown. Thus, clinicians should assess for impaired function of muscle, connective, and nerve tissues associated with the identified pathological tissues when a patient presents with neck pain.

Investigatios into the clinical course and predictors of recovery for patients with neck and shoulder pain indicated four hundred forty three patients who consulted their primary care physician with neck or shoulder symptoms were followed for 12 months. At 12 months, 32% of patients reported that they had recovered. Predictors of poor pain-related outcome at 12 months included less intense pain at baseline, a history of neck and shoulder symptoms, more worrying, worse perceived health, and a moderate or bad quality of life. The predictors for a poor disability-related response at 12 months included older age, less disability at baseline, longer duration of symptoms, loss of strength in hands, having multiple symptoms, more worrying, moderate or bad quality of life, and less vitality.

Clinicians should consider age greater than 40, coexisting low back pain, a long history of neck pain, bicycling as a regular activity, loss of strength in the hands, worrisome attitude, poor quality of life, and less vitality as predisposing factors for the development of chronic neck pain.

Approximately 44% of patients experiencing neck pain will go on to develop chronic symptoms, and many will continue to exhibit moderate disability at long-term follow-up A recent systematic review examined the outcomes of nontreatment control groups in clinical trials for the conservative management of chronic mechanical neck pain - not due to whiplash. The outcomes of patients receiving a control or placebo intervention were analyzed and effect sizes were calculated. The changes in pain scores over the varying trial periods in these untreated subjects with chronic mechanical neck pain were consistently small and not significant.

Conversely, there is substantial evidence that favorable outcomes are attained following treatment of patients with cervical radiculopathy. For example, nearly 90% of patients with cervical radiculopathy presented with only mild symptoms at a median follow-up of 4.9 years. It was found that 70% of patients with cervical radiculopathy excellent outcomes after a 2-year follow-up. Outcomes for the patients in the aforementioned studies appeared favorable and suggest that 70-90% of this population can experience improvement without surgical intervention. In contrast, the clinical prognosis of patients with whiplash associated disorder is less favorable. A survey of 108 patients with a history of whiplash requiring care at an emergency department found that 55% had residual pain and disability referable to the original accident at a mean follow-up of 17 years later. Neck pain, radiating pain, and headache were the most common symptoms. Thirty-three percent of the respondents with residual symptoms suffered from work disability, compared to 6% in the group of patients without residual disorders.

Although the cause of neck pain may be associated with degenerative processes or pathology identified during diagnostic imaging, the tissue that is causing a patient’s neck pain is most often unknown. Thus, clinicians should assess for impaired function of muscle, connective, and nerve tissues associated with the identified pathological tissues when a patient presents with neck pain. (Recommendation based on theoretical/foundational evidence.)

Clinicians should consider age greater than 40, coexisting low back pain, a long history of neck pain, cycling as a regular activity, loss of strength in the hands, worrisome attitude, poor quality of life, and less vitality as predisposing factors for the development of chronic neck pain. (Recommendation based on moderate evidence.)

Neck pain, without symptoms or signs of serious medical or psychological conditions, associated with (1) motion limitations in the cervical and upper thoracic regions, (2) headaches, and (3) referred or radiating pain into an upper extremity are useful clinical findings for classifying a patient with neck pain into one of the following International Statistical Classification of Diseases and Related Health Problems (ICD) categories: cervicalgia, pain in thoracic spine, headaches, cervicocranial syndrome, sprain and strain of cervical spine, spondylosis with radiculopathy, and cervical disc disorder with radiculopathy; and the associated International Classification of Functioning, Disability, and Health (ICF) impairmentbased category of neck pain with the following impairments of body function:

• Neck pain with mobility deficits (Mobility of several joints)
• Neck pain with headaches (Pain in head and neck)
• Neck pain with movement coordination impairments (Control of complex voluntary movements)
• Neck pain with radiating pain (Radiating pain in a segment or region)

The following physical examination measures may be useful in classifying a patient in the ICF impairment-based category of neck pain with mobility deficits and the associated ICD categories of cervicalgia or pain in thoracic spine. (Recommendation based on moderate evidence.)

• Cervical active range of motion
• Cervical and thoracic segmental mobility

The following physical examination measures may be useful in classifying a patient in the ICF impairment-based category of neck pain with headaches and the associated ICD categories of headaches or cervicocranial syndrome. (Recommendation based on moderate evidence.)

• Cervical active range of motion
• Cervical segmental mobility
• Cranial cervical flexion test

The following physical examination measures may be useful in classifying a patient in the ICF impairment-based category of neck pain with movement coordination impairments and the associated ICD category of sprain and strain of cervical spine. (Recommendation based on moderate evidence.)

• Cranial cervical flexion test
• Deep neck flexor endurance test

The following physical examination measures may be useful in classifying a patient in the ICF impairment-based category of neck pain with radiating pain and the associated ICD categories of spondylosis with radiculopathy or cervical disc disorder with radiculopathy. (Recommendation based on moderate evidence.)

• Upper limb tension test
• Spurling’s test
• Distraction test

Clinicians should consider diagnostic classifications associated with serious pathological conditions or psychosocial factors when the patient’s reported activity limitations or impairments of body function and structure are not consistent with those presented in the diagnosis/classification section of this guideline, or, when the patient’s symptoms are not resolving with interventions aimed at normalization of the patient’s impairments of body function. (Recommendation based on moderate evidence.)

Clinicians should use validated self-report questionnaires, such as the Neck Disability Index and the Patient-Specific Functional Scale for patients with neck pain. These tools are useful for identifying a patient’s baseline status relative to pain, function, and disability and for monitoring a change in a patient’s status throughout the course of treatment. (Recommendation based on strong evidence.)

Clinicians should utilize easily reproducible activity limitation and participation restriction measures associated with their patient’s neck pain to assess the changes in the patient’s level of function over the episode of care. (Recommendation based on expert opinion.)

Clinicians should consider utilizing cervical manipulation and mobilization procedures, thrust and non-thrust, to reduce neck pain and headache. Combining cervical manipulation and mobilization with exercise is more effective for reducing neck pain, headache, and disability than manipulation and mobilization alone. (Recommendation based on strong evidence.)

Thoracic spine thrust manipulation can be used for patients with primary complaints of neck pain. Thoracic spine thrust manipulation can also be used for reducing pain and disability in patients with neck and neck-related arm pain. (Recommendation based on weak evidence.)

Flexibility exercises can be used for patients with neck symptoms. Examination and targeted flexibility exercises for the following muscles are suggested: anterior/medial/posterior scalenes, upper trapezius, levator scapulae, pectoralis minor, and pectoralis major. (Recommendation based on weak evidence.)

Clinicians should consider the use of coordination, strengthening, and endurance exercises to reduce neck pain and headache. (Recommendation based on strong evidence.)

Specific repeated movements or procedures to promote centralization are not more beneficial in reducing disability when compared to other forms of interventions. (Recommendation based on weak evidence.)

Clinicians should consider the use of upper quarter and nerve mobilization procedures to reduce pain and disability in patients with neck and arm pain. (Recommendation based on moderate evidence.)

Clinicians should consider the use of mechanical intermittent cervical traction, combined with other interventions such as manual therapy and strengthening exercises, for reducing pain and disability in patients with neck and neck-related arm pain. (Recommendation based on moderate evidence.)

To improve recovery in patients with whiplash associated disorder, clinicians should (1) educate the patient that early return to normal, non-provocative pre-accident activities is important, and (2) provide reassurance to the patient that good prognosis and full recovery commonly occurs. (Recommendation based on strong evidence.) Pain and impairment of the neck is common. It is estimated that 22% to 70% of the population will have neck pain some time in their lives. In addition, it has been suggested that the incidence of neck pain is increasing At any given time, 10% to 20% of the population reports neck problems, with 54% of individuals having experienced neck pain within the last 6 months. Prevalence of neck pain increases with age and is most common in women around the fifth decade of life.

Complete neck pain clinical guidelines