Reviewed by Tyler Tice, PT, DPT, OCS, ATC
Article:
Neck Pain: Revision 2017 Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association
Introduction:
The orthopaedic section of the American Physical Therapy Association (APTA) published these clinical practice guidelines in 2017 to give recommendations to clinicians in the differential diagnosis, assessment and treatment of neck pain.
These recommendations are designed to fit into the International Classification of Functioning, Disability, and Health (ICF model) that was introduced by the World Health Organization (WHO) to improve clinician’s ability to appropriately treat and communicate with patients by including pathoanatomical, psychosocial and societal factors when assessing a patient’s wants and needs.
Methods:
Content experts were appointed by the orthopedic section of the APTA to search the current literature for articles relating to the treatment, assessment and diagnosis of neck pain. Articles included were taken from PubMed, Cochrane Library, Web of Science, CINAHL, ProQuest Dissertations and Abstracts, PEDro, ProQuest Nursing and Allied Health Sources, and Embase with dates ranging from 2007 to 2016.
The chosen articles were then categorized based on level of evidence where I represented the highest quality evidence and V represented expert opinion. After the evidence was reviewed and ranked, the experts developed and ranked recommendations utilizing the information. A ranked recommendations were based on strong evidence while F ranked recommendations were based on expert opinion. These recommendations were further categorized into the following content areas; pathoanatomical features/differential diagnosis, Imaging, Examination, Diagnosis/classification, and interventions. These recommendations are further divided based on the type of neck pain the patient is presenting with; neck pain with mobility deficits, neck pain with movement coordination impairments, neck pain with headaches, and neck pain with radiating pain.
Results:
After reviewing the available literature, the authors made the following recommendations:
Clinicians should perform assessments on patients to screen for serious pathology and refer to other providers when necessary.
Clinicians should use validated self-reported outcome measures to assess and track patient pain, status, and physical/psychological function throughout an episode of care.
Clinicians should use easily reproducible activity limitation and participation restriction measures to assess patient function throughout an episode of care.
Clinicians should use assessments of body impairments to determine if a patient has one of the following; (1)neck pain with mobility deficits (cervical active range of motion), (2)neck pain with headache (cervical active range of motion, the cervical flexion-rotation test, upper cervical segmental mobility testing), (3)neck pain with radiating pain (neurodynamic testing, spurling’s test, distraction test, the Valsalva test), (4)neck pain with movement coordination impairments (cranial cervical flexion and neck flexor endurance test.)
To effectively classify patients into one of the 4 neck pain designations, clinicians should use cervical motion limitations, thoracic motion limitations, presence of cervicogenic headache, history of trauma and referred or radiating pain into an upper extremity.
Interventions for neck pain with mobility deficits:
For patients with acute neck pain clinicians should use thoracic manipulation, a program to improve neck ROM, and scapulothoracic and upper extremity strengthening. Clinicians may provide cervical manipulations and/or mobilization.
For patients with subacute neck pain clinicians should use neck and shoulder girdle endurance exercises and may provide thoracic and cervical manipulations/mobilizations.
For patients with chronic neck pain clinicians should employ a multimodal approach including thoracic and cervical manipulations/mobilizations, mixed exercises for the cervical and scapulothoracic regions, dry needling, laser therapy, and intermittent manual or mechanical traction.
Clinicians may provide neck, shoulder girdle and trunk endurance exercises and patient education. Patients should be encouraged to have an active lifestyle and to address psychosocial factors.
Interventions for neck pain with movement coordination impairments
For patients with acute neck pain clinicians should educated their patients on returning to normal, nonprovocative pre-accident activities as soon as possible, minimize the use of a cervical collar, and perform postural and mobility exercises to decrease pain and increase range of motion. Patients should be advised that recovery is expected within the first 2-3 months.
Clinicians should employ a multimodal approach including manual interventions and exercise programs. For patients at low risk of developing chronic symptoms, clinicians may provide a single session consisting of education, a detailed exercise program and TENS treatment. Clinicians should monitor recovery status for signs of chronicity.
For patients with chronic neck pain clinicians may provide manual interventions, patient education focused on encouragement and exercise programs that utilize concepts from cognitive behavioral therapy.
Interventions for neck pain with headaches
For patients with acute neck pain clinicians should provide active mobility exercises as well as C1/C2 self-sustained natural apophyseal glide (SNAG) exercises.
For patients with subacute neck pain clinicians should provide cervical manipulation/mobilization as well as SNAG exercises.
For patients with chronic neck pain clinicians should provide cervical or cervicothoracic manipulation/mobilization combined with exercises for range of motion, strength and endurance.
Interventions for neck pain with radiating pain
For patients with acute neck pain clinicians may provide mobilizing and stabilizing exercises, laser treatments, and short-term use of a cervical collar.
For patients with chronic neck pain clinicians should employ a multimodal approach including mobilization/manipulation, exercise interventions and mechanical intermittent traction. Clinicians should encourage participation in occupational and exercise activities.
Discussion and clinical utility:
This CPG does and excellent job of providing different intervention approaches based on different patient presentations. Neck pain is variable and sometimes inconsistent, therefore it is important to adjust interventions based on a patient’s current presentation.
It is also important to note the emphasis on educating patients to remain active. Many of the stated interventions involve increasing range of motion in the apophyseal joints of the cervical and thoracic spine. The challenge is that when in pain, it can be counterintuitive for patients to continue mobilizing those areas. Encouraging an active lifestyle is a good way of ensuring that benefits introduced during a therapy session continue to have carry over into a patient’s day to day life.
References
Neck Pain: Revision 2017 Peter R. Blanpied, Anita R. Gross, James M. Elliott, Laurie Lee Devaney, Derek Clewley, David M. Walton, Cheryl Sparks, and Eric K. Robertson Journal of Orthopaedic & Sports Physical Therapy 2017 47:7, A1-A83