Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association
Authors: Peter R. Blanpied, PT, PhD; Anita R. Gross, PT, MSc; James M. Elliott, PT, PhD; Laurie Lee Devaney, PT, MSc; Derek Clewley, DPT; David M. Walton, PT, PhD; Cheryl Sparks, PT, PhD; Eric K. Robertson, PT, DPT
REVIEWERS: Roy D. Altman, MD; Paul Beattie, PT, PhD; Eugene Boeglin, DPT; Joshua A. Cleland, PT, PhD; John D. Childs, PT, PhD; John DeWitt, DPT; Timothy W. Flynn, PT, PhD; Amanda Ferland, DPT; Sandra Kaplan, PT, PhD; David Killoran, PhD; Leslie Torburn, DPT
Published: Journal of Orthopaedic & Sports Physical Therapy, 2017 Volume: 47 Issue: 7 Pages: A1–A83 DOI: 10.2519/jospt.2017.0302
The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to neck pain.
Pathoanatomical Features/Differential Diagnosis
Clinicians should perform assessments and identify clinical findings in patients with neck pain to determine the potential for the presence of serious pathology (e.g., infection, cancer, cardiac involvement, arterial insufficiency, upper cervical ligamentous insufficiency, unexplained cranial nerve dysfunction or fracture), and refer for consultation as indicated.
Clinicians should utilize existing guidelines and appropriateness criteria in clinical decision making regarding referral or consultation for imaging studies for traumatic and nontraumatic neck pain in the acute and chronic stages.
Examination – Outcome Measures
Clinicians should use validated self-report questionnaires for patients with neck pain – to identify a patient’s baseline status and to monitor changes relative to pain, function, disability, and psychosocial functioning.
Examination – Activity Limitations and Participation Measures
Clinicians should utilize easily reproducible activity limitation and participation restriction measures associated with the patient’s neck pain to assess the changes in the patient’s level of function over the episode of care.
Examination – Physical Impairment Measures
When evaluating a patient with neck pain over an episode of care, clinicians should include assessments of impairments of body function that can establish baselines, monitor changes over time, and be helpful in clinical decision making to rule in or rule out (1) neck pain with mobility deficits, including cervical active range of motion (ROM), the cervical flexion-rotation test, and cervical and thoracic segmental mobility tests; (2) neck pain with headache, including cervical active ROM, the cervical flexion-rotation test, and upper cervical segmental mobility testing; (3) neck pain with radiating pain, including neurodynamic testing, Spurling’s test, the distraction test, and the Valsalva test; and (4) neck pain with movement coordination impairments, including cranial cervical flexion and neck flexor muscle endurance tests. Clinicians should include algometric assessment of pressure pain threshold for classifying pain.
Clinicians should use motion limitations in the cervical and upper thoracic regions, presence of cervicogenic headache, history of trauma, and referred or radiating pain into an upper extremity as useful clinical findings for classifying a patient with neck pain into the following categories:
- Neck pain with mobility deficits
- Neck pain with movement coordination impairments (including whiplash-associated disorder [WAD])
- Neck pain with headaches (cervicogenic headache)
- Neck pain with radiating pain (radicular)
Interventions: Neck Pain with Mobility Deficits
For patients with acute neck pain with mobility deficits:
Clinicians should provide thoracic manipulation, a program of neck ROM exercises, and scapulothoracic and upper extremity strengthening to enhance program adherence.
Clinicians may provide cervical manipulation and/or mobilization.
For patients with subacute neck pain with mobility deficits:
Clinicians should provide neck and shoulder girdle endurance exercises.
Clinicians may provide thoracic manipulation and cervical manipulation and/or mobilization.
For patients with chronic neck pain with mobility deficits:
Clinicians should provide a multimodal approach of the following:
- Thoracic manipulation and cervical manipulation or mobilization
- Mixed exercise for cervical/scapulothoracic regions: neuromuscular exercise (e.g., coordination, proprioception, and postural training), stretching, strengthening, endurance training, aerobic conditioning, and cognitive affective elements
- Dry needling, laser, or intermittent mechanical/manual traction
Clinicians may provide neck, shoulder girdle, and trunk endurance exercise approaches and patient education and counseling strategies that promote an active lifestyle and address cognitive and affective factors.
Interventions: Neck Pain with Movement Coordination Impairments
For patients with acute neck pain with movement coordination impairments (including WAD):
Clinicians should provide the following:
- Education of the patient to:
- Return to normal, nonprovocative preaccident activities as soon as possible
- Minimize use of a cervical collar
- Perform postural and mobility exercises to decrease pain and increase ROM
- Reassurance to the patient that recovery is expected to occur within the first 2 to 3 months.
Clinicians should provide a multimodal intervention approach including manual mobilization techniques plus exercise (e.g., strengthening, endurance, flexibility, postural, coordination, aerobic, and functional exercises) for those patients expected to experience a moderate to slow recovery with persistent impairments.
Clinicians may provide the following for patients whose condition is perceived to be at low risk of progressing toward chronicity:
- A single session consisting of early advice, exercise instruction, and education
- A comprehensive exercise program (including strength and/or endurance with/without coordination exercises)
- Transcutaneous electrical nerve stimulation (TENS)
Clinicians should monitor recovery status in an attempt to identify those patients experiencing delayed recovery who may need more intensive rehabilitation and an early pain education program.
For patients with chronic neck pain with movement coordination impairments (including WAD):
Clinicians may provide the following:
- Patient education and advice focusing on assurance, encouragement, prognosis, and pain management
- Mobilization combined with an individualized, progressive submaximal exercise program including cervicothoracic strengthening, endurance, flexibility, and coordination, using principles of cognitive behavioral therapy
Interventions: Neck Pain with Headaches
For patients with acute neck pain with headache:
Clinicians should provide supervised instruction in active mobility exercise.
Clinicians may provide C1–2 self-sustained natural apophyseal glide (self-SNAG) exercise.
For patients with subacute neck pain with headache:
Clinicians should provide cervical manipulation and mobilization.
Clinicians may provide C1–2 self-SNAG exercise.
For patients with chronic neck pain with headache:
Clinicians should provide cervical or cervicothoracic manipulation or mobilizations combined with shoulder girdle and neck stretching, strengthening, and endurance exercise.
Interventions: Neck Pain with Radiating Pain
For patients with acute neck pain with radiating pain:
Clinicians may provide mobilizing and stabilizing exercises, laser, and short-term use of a cervical collar.
For patients with chronic neck pain with radiating pain:
Clinicians should provide mechanical intermittent cervical traction, combined with other interventions such as stretching and strengthening exercise plus cervical and thoracic mobilization/manipulation.
Clinicians should provide education and counseling to encourage participation in occupational and exercise activities.